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Abstract

African Americans, particularly men, are disproportionately affected by the HIV epidemic. Inconsistent condom use and concurrent sexual partnerships are risk factors; there is limited investigation on how these factors influence HIV risk engagement in young, heterosexual, African American men. To identify contextual risk factors that place young men (18-24 years) at risk for HIV infection, one focus group was conducted with 13 men, and questionnaires were administered to 48 men. Participants were 18 to 24 years old and were recruited from local barbershops. The majority engaged in noncondom use (83%) and had multiple sexual partners (64%). Qualitative themes revealed noncondom use “when in the moment” and enhanced condom use with casual partners. This study provided an understanding of participants’ attitudes, intentions, and behaviors as they related to HIV risk and revealed the need for culturally relevant, theory-based HIV prevention programs to reduce HIV transmission among this population.

Keywords

adolescent men HIV/AIDS qualitative research sexual health men of color

Background

HIV/AIDS remains a serious health problem for African American men. Although African Americans make up 13% of the U.S. population, they disproportionately account for 52% of HIV diagnoses (Centers for Disease Control and Prevention [CDC], 2011a). African American men account for 31% of all new HIV infections in the United States and 47% of diagnoses of HIV infection among males (CDC, 2011a). The primary modes of HIV transmission among African American adult and adolescent males are male-to-male sexual contact (68%), followed by high-risk heterosexual contact (20%) and injection drug use (9%; CDC, 2011a). In 2009, the estimated rate of diagnoses of HIV infection among African American males (122.2) was more than 8 times as high as the rate for Whites (14.8) and approximately 2.5 times as high as the rate for Hispanics/Latinos (48; CDC, 2011a). Similar disparities are also found among African American adolescents and young adults. Among youth aged 13 to 24 years, African Americans accounted for 60% of all reported HIV infections between 2006 and 2009 (CDC, 2011b). Of the approximate 19,000 adolescent and young adult males living with a diagnosis of HIV infection, 64% are African American (CDC, 2011b).

According to 2010 data from the Philadelphia, PA, Department of Public Health (PDPH), nearly 30,000 residents have HIV or AIDS (PDPH, 2011). African Americans comprise approximately 44% of the population in Philadelphia, PA (U.S. Census Bureau, 2011) and account for 66% of new HIV diagnoses (PDPH, 2011). Majority of the new HIV cases are among men (73%), and adolescents and young adults (13-29 years of age) comprise 36% of newly diagnosed individuals (PDPH, 2011). Heterosexual transmission accounts for the majority (43%) of HIV/AIDS cases followed by male-to-male sexual contact (42%) and injection drug use (10%; PDPH, 2011).

Heterosexual males are a forgotten population in the development of HIV prevention programs, despite the fact that HIV/AIDS rates are on the rise among this group (Noar, Morokoff, & Redding, 2002). Targeting heterosexually identified men is critical as heterosexual transmission is the primary mode of HIV infection for women in the United States (Karon, Fleming, Steketee, & DeCock, 2001). According to Bowleg (2004), African American men in heterosexual relationships are virtually invisible in the theoretical and empirical psychological HIV/AIDS literature. Elwy, Hart, Hawkes, and Petticrew (2002) conducted a systematic review of the literature on the effectiveness of interventions to prevent sexually transmitted infections (STIs) and HIV in heterosexual men. Of the 27 studies meeting their criteria, 12 (44%) focused on men exclusively, and only 4 (30%) targeted racial minority groups (Elwy et al., 2002). Although this deficit in interventions was identified almost 10 years ago, there are still few HIV/STI prevention interventions specifically targeting heterosexual men. The importance of filling this gap is critical, as heterosexually identified men may be the key to limiting the spread of HIV and STIs (Elwy et al., 2002). Furthermore, the insufficient number of intervention programs directed at young African American men has hindered the ability to make definitive conclusions about how to combat men’s attitudes and beliefs concerning HIV risk–related sexual risk behaviors. The purpose of this study was to examine the (a) attitudes, (b) beliefs, (c) intentions, and (d) sexual behaviors in relation to HIV risk among young African American males (aged 18-24 years) and to explore the feasibility of developing a culturally tailored HIV prevention program to be implemented in local barbershops.

Social Factors, Sexual Networks, and Risk Behavior

Individuals are continually influenced by their social environment. This is reflected in the formation of sexual networks that lend to the spread of STIs, including HIV. Sexual networks include people who are linked directly or indirectly through sexual contact (Adimora & Schoenbach, 2005). Sexual networks also influence behaviors that occur among the members. Among adolescents, sexual intention is linked to peer norms (DiClemente et al., 2008; Wallace, Miller, & Forehand, 2008); among those sexually active, when individuals identify a peer who is a condom user, this is associated with a significant reduction in odds of having unprotected sex at last intercourse (Rice, 2010; Rice, Milburn, & Rotheram-Borus, 2007). Similar behavior is found among men, as those who perceived their networks (friends and acquaintances) supportive of condom use were more likely to engage in low –HIV risk behaviors (Peterson, Rothenberg, Kraft, Beeker, & Trotter, 2009).

Sexual partner concurrency (having sexual relationships with more than one person that overlap in time) is found to increase rates of STIs among African Americans (Adimora & Schoenbach, 2005). Concurrent sexual partnerships are linked to HIV risk because individuals who engage in sexual concurrency often have sex with people who are close in proximity, from the same networks (Hallfors, Iritani, Miller, & Bauer, 2007). Among African Americans, more frequent sexual contact occurs between those with many partners and those with few partners (Laumann & Youm, 1999). Also, researchers demonstrate that African Americans have more racially segregated sexual networks than those of other racial ethnic backgrounds (Laumann & Youm, 1999). In a study of heterosexual transmission of HIV among African Americans, a higher prevalence of concurrent relationships was found among African American men (53%) when compared with African American women (31%; Adimora, Schoenbach, Bonas, Martinson, & Donaldson, 2002; Adimora, Schoenbach, Martinson, Donaldson, & Stancil, 2004). For African American men, studies have found that social network norms are associated with choices about sexual risk engagement. Some African American men feel that manhood is defined by partner concurrency and that partner concurrency is normative (Bowleg et al., 2011; Carey, Senn, Seward, & Vanable, 2010).

Research has also demonstrated a relationship between masculinity ideology and health-related attitudes and beliefs among men (Courtenay, 2000). Men who endorse traditional masculinity are less likely to engage in health promoting behaviors and have greater health risks than men who do not endorse traditional masculinity. Courtenay (2000) found that traditional masculinity ideology was the strongest predictor of a risk-taking behavior style (i.e., smoking, drug and alcohol abuse, sex conquests) among African American men when compared with their White counterparts. Among adolescent males, a traditional conception of manhood (i.e., competitiveness, physical prowess, restricted emotionality, physical and sexual violence, and restricted affectionate behavior between men) is associated with engagement in sexual risk behaviors (Pleck, Sonenstein, & Ku, 1993). Cultural and social factors, including notions of manhood and sexual networks, influence behaviors that may facilitate HIV/STI transmission among young African American men.

HIV Risk–Related Sexual Behaviors Among Young African American Men

HIV risk–related sexual behaviors are more prevalent among young African American males compared with their White or Latino counterparts. African American males have the highest rate of sexual intercourse of all racial/ethnic groups in high schools (Eaton et al., 2010). Furthermore, African American male students are more likely than Hispanic and White students to have initiated intercourse before age 13 (25% vs. 10% and 4%, respectively; Eaton et al., 2010). Nationwide, 14% of adolescents have had sexual intercourse with four or more persons during their lifetime, yet 39% of African American males reported more than four sexual partners (Eaton et al., 2010). Among adolescents, approximately 21% of African American males reported drinking alcohol or using drugs before their last sexual encounter (Eaton et al., 2010).Young adults under the influence of alcohol or drugs are more susceptible to earlier sexual initiation, unprotected sexual intercourse, multiple partners, contracting STIs, and unintended pregnancy (Kaiser Family Foundation, 2002).

Although much of the literature shows that African American men are at increased risk for HIV/STIs, particularly through behaviors such as concurrent partnering (Bowleg et al., 2011), studies have also found that African Americans engage in normative behavior patterns (i.e., few sexual partners and low substance abuse) when compared with their White counterparts (Hallfors et al., 2007). The high concentration of HIV in African American sexual networks (Adimora, Schoenbach, & Doherty, 2007; Lane, Rubinstein, & Keefe, 2004), in addition to the higher prevalence of HIV in communities with low socioeconomic status (Denning, DiNenno, & Wiegand, 2011) may explain discordance between behaviors and infection rates. In other words, despite engagement in behaviors similar to other racial and ethnic groups, members of the African American population are exposed to HIV at a much higher rate (Adimora et al., 2007; Lane et al., 2004). These disparate findings highlight the need for continued research on social and structural factors that contribute toward HIV transmission.

Sexually Transmitted Infections

In general, inner-city African American males have disproportionately higher rates of syphilis and gonorrhea (PDPH, 2008). The Chlamydia rate among African American males was 12 times higher than that among White males (CDC, 2008). Although much less common than Chlamydia, syphilis cases among men are also on the rise. In 2008, the syphilis rate among African American men 15 to 19 years of age was 22 times higher than the rates of White males (CDC, 2008). A high incidence of gonorrhea has been found in inner-city urban African American populations. In 2008, African American males ages 15 to 19 years had a gonorrhea rate of 488.6 cases per 100,000 males—40.7 times greater than the rate among White males of the same age (CDC, 2008). In Philadelphia, one study found that 4% of Medicaid-eligible high school students had been treated for an STI, with Chlamydia being the most commonly diagnosed STI (Mandell et al., 2008). Understanding factors that prevent or encourage safer sexual practices among young African American males would prove useful toward the development of prevention programs for this group. The combination of HIV risk–related sexual risk behaviors and elevated STI rates suggest the urgency of interventions for young African American men.

Barbershops as Health Promotion Sites

Barbershops are unique among the African American community for numerous reasons. The barbershop has been termed the African American men’s “country club” (Releford, Frencher, & Yancey, 2010), as they are places of cultural exchange (Alexander, 2003). They have a history as public spaces for African American men to socialize without the intrusion of outsiders. There is communication about personal and social issues (E. Friedman, 2001), and information is transferred among elders and young men (Alexander, 2003). Barbershops regularly attract large numbers of African American men and provide an environment of trust and an avenue to disseminate health education information. African American men specifically have reported acceptance of receiving health messages in barbershops (Biro, 2004). Several health promotion projects have used barbershops and salons in the African American community as a location for recruitment (Hendricks, 2000; Royal et al., 2000; Weinrich et al., 1998) and on a range of health issues, including asthma, diabetes, cancer, heart health, sexual health, smoking, and nutrition (Browne, 2006; Brown et al., 2006).

Projects have used barbers or stylists to implement interventions with clients, as they have been shown to be effective change agents (Lieberman & Harris, 2007; Linnan, Ferguson, & Wasilewski, 2005; Sadler, Thomas, Gebrekistos, Dhanjal, & Mugo, 2000). Two projects have used barbershop or beauty salons to deliver health promotion messages related to reducing risk for STIs, including HIV. One program in North Carolina consisted of local barbers and beauticians providing condoms, education materials, and education to their clients about HIV (Lewis, Shain, Quin, & Turner, 2002). A community-based organization, “Us Helping Us,” has used barbershops as venues to disseminate HIV risk reduction information (Anonymous, 2011). In light of the role of the barbershop as a cultural institution in the African American community and providing an atmosphere of trust for disseminating health information, it may be an ideal setting to reach young men to deliver HIV/STI prevention programs.

Framework

Ample evidence indicates that theory-based interventions can decrease sexual risk behaviors among men (Herbst et al., 2005; Johnson et al., 2002). However, a dearth of theory-driven interventions exists specifically for African American heterosexually identified men (Elwy et al., 2002). This study used the Theory of Planned Behavior to provide a structure to understand attitudes toward behavior (Ajzen, 1991). The theory posits that behavioral intentions (the immediate antecedents to behavior) are a function of salient information (beliefs) about the likelihood that performing the behavior will lead to a specific outcome (Madden, Ellen, & Ajzen, 1992). Another important determinant of an individual’s behavior is said to be his behavioral intent. Thus, intentions are a combination of one’s attitude toward performing the behavior and his subjective norm (the perception that those important to him approve/disapprove of the behavior; Ajzen, 1985). What this highlights is that persons are not only motivated to implement the behavior because of their attitudes and subjective norms but also their feelings about their ability to perform said behavior. Azjen and Fishbein (1980) have noted the necessity of elicitation procedures prior to the development of assessment instruments and interventions. The elicitation work described below was used to identify men’s (a) attitudes toward safe sex engagement; (b) relevant referent groups, which might influence their engagement in safer sex behaviors; (c) facilitators and barriers to safer sex; (d) characteristics and qualities they believe influence/can influence safer sex; and (e) their thoughts on alternatives to safe sex engagement (Fishbein, 1995).

Methods

Location and Recruitment

In 2008, the project director approached African American barbershop owners (n = 13) in West Philadelphia to gauge their interest in the study. In a 1-week period, the project director conducted face-to-face appointments with each barbershop owner to provide detailed information about the study. Of the 13 owners approached, 7 (54%) agreed to participate in the study and to allow the project staff members to post recruitment flyers in their barbershops. Interested men were screened for eligibility by telephone. Eligibility criteria included self-identifying as African American, heterosexual, and between 18 and 24 years of age. One barbershop owner who had previous experience with community health programs was very enthusiastic about the study. Thus, he offered his barbershop as the location for the focus group session. Following informed consent, 13 men participated in one focus group and another 35 men completed a short questionnaire (n = 48). All study activities took place at the barbershop where the men were recruited. The institutional review board of the University of Pennsylvania approved the study.

Questionnaire

The eight-page, self-administered paper-and-pencil questionnaire included items on sociodemographics (including barbershop attendance), as well as items from previously used measures about sexual experiences, drug use (Metzger et al., 1993), HIV/AIDS knowledge (Cederbaum, Coleman, Goller, & Jemmott, 2006; Jemmott, Jemmott, & O’Leary, 2007), and partner sexual communication (El-Bassel et al., 2010). Sample questions specific to the barbershop participants attended included length of time they had been getting their hair cut at the barbershop, frequency of haircuts, average length of time in the barber’s chair, and whether they thought their barber was a reliable, trustworthy source for health information. Questionnaires were all written at an eighth-grade reading level. Reading the survey aloud was presented as an option for anyone who desired assistance; however, this was not requested by any of the participants. Questionnaires were completed in approximately 15 minutes prior to the start of the focus group.

Semistructured Focus Group Guide

The focus group was conducted using a semistructured focus group guide. Ajzen and Fishbein (1980) have noted the necessity of elicitation procedures prior to development of assessment instruments, including focus groups. Specifically, the elicitation work is used to identify (a) perceived outcomes, (b) relevant referent groups, (c) facilitators and barriers, (d) characteristics and qualities, and (e) alternatives to said action (Fishbein, 1995). Thus, in the creation of the focus group guide, tenets of the Theory of Planned Behavior were incorporated. The structured script was developed as a guide for both the facilitator and the group participants (Krueger & Casey, 2009).The final script (see Table 1 for selected questions from the focus group guide) incorporated questions related to attitudes, beliefs, intentions regarding sexual relationships with female partners, as well as to get preliminary information on the design of a culturally relevant, theory-based HIV/STI prevention program for young heterosexual African American men.

Table 1.

Sample Items From the Focus Group Guide

Do you think that HIV is something that African American men in Philadelphia should be concerned about?

How can African American men prevent themselves from contracting HIV and other STIs?

Would you be willing to be tested via urine samples for [STIs]? What are barriers to being tested via urine samples? What are some solutions to these barriers?

What is good/bad about using condoms?

What makes it easy/hard to use condoms?

Who would approve/disapprove of using condoms?

Why do young men have more than one partner?

Which type of partner (steady, casual, or paying) is it easier/harder to use condoms with and why?

Do you think that a barbershop is a good place to have this program? Why or why not?

Do you think barbers are the right people to provide the education?

If someone gave you some money to design an HIV/STD prevention and health promotion program for African American men, what would you like to make sure it included? Now, think about the messages and themes. What messages and themes would you want to make sure it included?

Note. STI = sexually transmitted infection.

Procedure

Focus Group

The focus group was conducted in a barbershop in Southwest Philadelphia. A project staff member provided the men (n = 13) name tags and consent forms on their arrival to the session. Before the focus group began, the facilitator read the consent form aloud to all the participants and signatures were obtained. Prior to the focus group session, all participants completed the brief, self-administered questionnaire. Two African American male facilitators moderated the discussion. Along with being audio-recorded, two note takers (both female) were present to record the session and take detailed notes about the main themes that arose during the group. The facilitators had extensive training in qualitative research methods.

Throughout the focus group session, the facilitators ensured that all individuals had the opportunity to share their thoughts. Two hours were given (more than the traditional 1.5 hours for a focus group) to allow enough time to hear all the voices of the 13 men who participated. The facilitators were positioned in two locations in the room so as to have varied perspectives during the group. For individuals who inserted their thoughts less often, the facilitators asked them more directed follow-up questions.

When a concept was raised, the facilitators would ask the group how many persons agreed with the comment. This was then recorded by the note takers, whose purpose was to count and aggregate these data. The focus group was transcribed, and the project manager verified that the amounts recorded were correct based on the group conversation. The participants were assured that all documents (including the recordings) would be destroyed after the transcription of the focus group. Each participant received $50 compensation at the end of the discussion.

Questionnaires

To complement the in-depth focus group data, cross-sectional survey data were collected on attitudes, beliefs, intentions, and practices regarding HIV risk–related sexual behaviors among young African American men. Inclusion criteria for the survey were identical to the focus group criteria: self-identifying as (a) African American, (b) heterosexual, and (c) between 18 and 24 years. Beyond the 13 surveys completed by the men in the focus group, trained data collectors recruited men (n = 35) from the remaining six barbershops that agreed to participate in the study. The men completed the same self-administered questionnaire as the men in the focus group session. Participants were provided $10 for completing the questionnaire. Including the men in the focus group, 48 men completed the questionnaire.

Data Analysis

The focus group was tape-recorded and notes were taken by project staff members during the groups. All audio files were transcribed. These transcripts were triangulated with notes taken by note takers during the focus group session. The project director reviewed all transcribed files, analyzed the data, and created code lists. To ensure reliability and validity, two independent coders coded the data. Discrepancies between the codes were brought to the research team for final determinations. The transcripts were verified with the original recording for accuracy, and notes taken during the group were also verified with the transcript to make sure none of the details were missed. Qualitative software program Atlas ti (Muhr, 2005) was used to organize the data and during the coding process. Data were examined to identify themes. Purposeful profiles were created using an inductive method: transcripts were coded into specific and general themes (Padgett, 2008). Themes were evaluated and further refined by the project director. Specific quotes are used to highlight themes presented. Survey data were analyzed in SPSS version 17.0. Descriptive statistics and frequency counts were used to describe the study samples, as well as their attitudes, beliefs, and intentions.

Results

Table 2 describes participant demographics. Focus group and questionnaire-only participants were an average of 19 ± 2 and 20 ± 2 years of age (M ± SD), respectively. Questionnaire-only participants had higher levels of education and reported a higher frequency of having ever been married (12%, n = 4, vs. 8%, n = 1), having children (26%, n = 9, vs. 15%, n = 2), being employed full-time (57%, n = 20, vs. 31%, n = 4), and having ever spent time in jail or prison (29%, n = 10, vs. 8%, n = 1). The majority of participants in both groups had been getting their hair cut at their regular barbershops for more than a year and went at least every 2 weeks. The average length of time in the chair for a haircut was 23 ± 12 and 24 ± 17 minutes for focus group and questionnaire-only participants, respectively. Most believed that their barbers were reliable and trustworthy sources for health information.

Table 2.

Demographic Characteristics of Participants (N = 48)

Focus Group (n = 13), % (n)		Questionnaire-Only (n = 35), % (n)		Total Sample (N = 48), % (n)
Age in years, mean (SD)	19 (2)	Age in years, mean (SD)	20 (2)	20 (2)
Educational attainment		Educational attainment
No formal schooling	0	No formal schooling	0	0
Less than a high school diploma	15% (2)	Less than a high school diploma	20% (7)	19% (9)
High school diploma or GED	77% (10)	High school diploma or GED	46% (16)	54% (26)
Some trade school or finished trade school	0	Some trade school or finished trade school	3% (1)	2% (1)
Some college or a 2-year degree	0	Some college or a 2-year degree	11% (4)	8% (4)
4-year college degree	0	4-year college degree	6% (2)	4% (2)
Postgraduate work	0	Postgraduate work	6% (2)	4% (2)
Marital status		Marital status
Never married	92% (12)	Never married	83% (29)	85% (41)
Married	0	Married	9% (3)	6% (3)
Separated	0	Separated	3% (1)	2% (1)
Divorced	8% (1)	Divorced	0	2% (1)
Widowed	0	Widowed	0	0
Have living children		Have living children
Yes	15% (2)	Yes	26% (9)	23% (11)
No	85% (11)	No	74% (26)	77% (37)
Employed full-time		Employed full-time
Yes	31% (4)	Yes	57% (20)	50% (24)
No	69% (9)	No	43% (15)	50% (24)
Employed part-time		Employed part-time
Yes	46% (6)	Yes	23% (8)	29% (14)
No	54% (7)	No	71% (25)	67% (32)
Ever spent time in jail or prison		Ever spent time in jail or prison
Yes	8% (1)	Yes	29% (10)	23% (11)
No	85% (11)	No	71% (25)	75% (36)
Length of time getting hair cut at regular barbershop		Length of time getting hair cut at regular barbershop
Less than 1 year	15% (2)	Less than 1 year	20% (7)	19% (9)
1-2 years	39% (5)	1-2 years	17% (6)	23% (11)
3-5 years	8% (1)	3-5 years	29% (10)	23% (11)
More than 5 years	39% (5)	More than 5 years	34% (12)	35% (17)
Frequency of haircuts at regular barbershop		Frequency of haircuts at regular barbershop
Once every week	31% (4)	Once every week	49% (17)	44% (21)
Once every 2 weeks	39% (5)	Once every 2 weeks	40% (14)	40% (19)
Once every 3-4 weeks	23% (3)	Once every 3-4 weeks	6% (2)	10% (5)
Once every other month	8% (1)	Once every other month	3% (1)	4% (2)
Less than four times a year	0	Less than four times a year	3% (1)	2% (1)
Average length of time in the chair for a haircut (in minutes), mean (SD)	23 (12)	Average length of time in the chair for a haircut (in minutes), mean (SD)	24 (17)	60% (29)
Barber is a reliable and trustworthy source for health information		Barber is a reliable and trustworthy source for health information
Yes	85% (11)	Yes	71% (25)	75% (36)
No	8% (1)	No	23% (8)	19% (9)

Focus Group Findings

The young men shared their attitudes and beliefs regarding HIV/STIs, condom use, multiple sexual partners, and HIV/STI prevention programs targeted toward African American men aged between 18 and 24 years. All of the men’s accounts were given in the context of their daily lives. The notion of sexual pressure to have sex and/or have unprotected sex from actual or potential female partners was prevalent. The men described how they had more than one sexual partner because “it’s easy,” “it’s out there,” “it’s given to you,” and “there’s [sic] so many females out here tempting you.” The discussion centered on women making sexual relationships readily available to them, and pursuing them, even if the women knew the men were already in another relationship.

The impact of HIV/STIs in the heterosexual African American male community

At the beginning of the focus group, the men were asked, “What is the most important health concern affecting African American men, like you, in your community?” The resounding answer was HIV and STIs. “Blood pressure,” “cancer,” and “diabetes” were also mentioned; however, the men were keenly aware of the impact of HIV/STIs in their community. For HIV, in particular, one participant shared, “Yes it kills you. It change [sic] over to AIDS and you ain’t getting saved after that.” Several others believed that HIV was the “number one cause of death” for African American men because “once you have it you’re done.”

Most of the participants agreed that HIV was primarily spread through unprotected sex and acknowledged risks associated with tattoos, anal sex, sharing needles, and having sex with a promiscuous girl (“smashin’ a dirty chick”). The men also correctly identified gonorrhea, “claps” [Chlamydia], “trich” [Trichomoniasis], syphilis, and genital herpes as other STIs of concern. Several HIV/AIDS-related myths were also expressed, however, as the men discussed “smoking after somebody” and “tongue kissing” as HIV risk–related behaviors. Having sex with only one partner, using “Trojans,” and “using two condoms” were identified as ways for African American men to prevent contracting HIV and other STIs. Condom use, however, was projected by this group to be low among African American young men. When asked whether or not men in their demographic always used condoms, participants shared, “no, never, everybody slips up a couple of times,” “some people can’t remember the last time they used a condom,” and “some people say, ‘that’s my girl so I don’t have to use one’, or, ‘you go to the clinic together and you know she doesn’t have anything.’” The group conjectured that 1 to 6 out of every 10 African American young men consistently use condoms.

Behavioral beliefs regarding condom use

Participants’ responses to the elicitation questions about condom use revealed several salient beliefs. Condoms were viewed as easy to use with “a girl reminding you, asking to see one,” “knowing that you have to protect yourself,” being “consistent with one partner,” and “thinking about what everybody else went through.” One participant shared that he could “relax because it [wearing a condom] doesn’t feel like anything.” Female sexual partners were seen as a primary barrier to condom use as the men shared that some women did not like to use condoms: “it depends on the girlfriend, [she might say] ‘I don’t like the way it feels’ or ‘I’m allergic.’” We also asked the men about the impact of being high on drugs or alcohol on condom use decision making. Based on their own experiences, this group of men highlighted how being high made it harder to use condoms because “you’re not in your right mind” and that having sex while high was “probably how a lot of people get diseases . . . they get high and don’t think.”

Partner differences: Steady versus casual

The men also indicated that condom use varied by the type of partner they were having sex with (i.e., steady partner vs. casual partner). They stated, “Yes, you’re more careful with your casual partner,” “You got to creep ‘cause you can’t take anything home,” and “It’s very different, you need a condom with your side jawn [partner] because you don’t want to get caught up with your main chick, bringing something home.”

In steady relationships, pregnancy prevention was seen as the primary positive factor for using condoms. On the other hand, the men strongly believed that their steady partners would lose trust in them or think they were cheating if they tried to use condoms in those relationships. As one participant shared, “She might think you’re doing something because you hadn’t been using one, she might think you have something.” All the men also agreed that condoms had to be used with casual partners because they didn’t want any “slip-ups” [getting someone pregnant or getting an STI]. Additionally, they believed their casual partners had “other side jawns [partners] and [were] sleeping with other people.” Though the men acknowledged the benefits of using condoms with casual partners, they also noted that it was easier to use condoms if they weren’t “real sexually attracted to her,” because a greater sexual attraction would make it more difficult to negotiate condom use.

The men were in consensus regarding the notion that African American men have multiple sexual partners and the reasons why. Half of the group believed that African American men in their age demographic have sex with more than one partner; some even estimated that 70% to 90% of the men have multiple sexual partners, with projections of 2 to 28 partners over a 3-month period. When asked to explain why young men have more than one sexual partner, the group provided answers including “temptation,” “it’s easy,” “being greedy,” and “it’s [sex is] out there/easily given to you.” Additional barriers to monogamous relationships included “always into somebody who looks better than your girl,” “it’s boring,” and monogamous men “don’t get the wide experience.” Factors that made it easy to be in monogamous relationships included “love,” “less stress,” “less chance of catching something [an STI],” “better time management,” “less complaining,” and “less money you have to spend.” Referent females in the men’s lives (i.e., female sexual partners, mothers, and grandmothers), as well as friends in monogamous relationships, were viewed as individuals who would approve of the men having sex with no more than one sexual partner. “Homies” [friends] who have multiple sexual partners, however, were viewed as individuals who would disapprove of the men having sex with no more than one sexual partner.

Ideas for barbershop program

Participants shared that “everyone” comes to the barbershop. It is a place to not only “get a cut” but also to catch up on sports, talk about relationships, and gossip about community happenings. They identified barbers as strong males in their lives. The men also indicated that female barbers could effectively deliver HIV/STI information to their male clients, without a partiality for whether they preferred to receive the information from a male or female barber. “It doesn’t matter whether it’s a man or a woman, as long as there’s an open conversation,” one participant shared. They saw access to information, condoms, and STI testing (and treatment if they tested positive) as beneficial and believed the barbershop would be the most convenient setting. Young men expressed their interest in the program being delivered in a group setting, with a realistic time commitment (3 hours was deemed acceptable) and spoke about their compensation needs. Specifically, the men paralleled the time they would spend in the group intervention to time being taken away from their ability to “make money.” The themes and messages they wanted to see included were “don’t do drugs,” “protect yourself by any means necessary,” “strap up,” “survival,” and “teaching all the ways you can get an STI.”

Questionnaire Findings

AIDS/STI knowledge and testing history

Most (64%, n = 30) had been tested for HIV in their lifetimes; none reported having tested positive for HIV. Twenty-four percent (n = 9) had been diagnosed with an STI in their lifetime. Among the nine men with STI histories all had been diagnosed with Chlamydia, followed by fewer diagnoses of Trichomoniasis (22%, n = 2), HPV (11%, n = 1), and Herpes (11%, n = 1). On average, the men answered 74% of the AIDS/STI knowledge questions correctly. Of the questions that were answered incorrectly, 38% (n = 18) did not know that anal intercourse increases the chances of transmitting HIV/AIDS, and 40% (n = 19) believed that STIs always have symptoms. This highlights that HIV/STI prevention knowledge may also be a factor in engagement in HIV risk–related sexual behavior among this sample. See Table 3.

Table 3.

AIDS/STI Knowledge and Testing History (N = 48)

	M (SD)	% (n)
AIDS/STI knowledge (average correct out of 100)	74 (19)
% Answered correctly
The HIV/AIDS virus is present in blood, semen, and vaginal fluid		92% (44)
Anal intercourse (i.e., penis in a person’s behind/anus) increases the chance of transmitting HIV/AIDS		62% (29)
Condoms can help protect you from transmitting or becoming infected with HIV		85% (41)
If you placed a condom on the penis in the wrong way, you should start over with a new condom		73% (35)
If a person has an STI, he or she is at greater risk of becoming infected with HIV		71% (34)
STIs always have symptoms		60% (29)
Ever been tested for HIV		64% (30)
Never received an HIV-positive diagnosis		100% (48)
Ever had an STI		24% (9)
Chlamydia		100% (9)
HPV		11% (1)
Trichomoniasis		22% (2)
Genital herpes		11% (1)

Note. STI = sexually transmitted infection; HPV = human papillomavirus.

Attitudes and beliefs toward condom use and multiple sexual partners

Overall, participants reported favorable attitudes toward condom use and limiting sexual partners to one in the next 3 months. Most reported that it would either be good (27%, n = 13) or very good (54%, n = 26) to use condoms. More than half (54%, n = 26) believed that condom use would be enjoyable or very enjoyable. Having no more than one sexual partner was also viewed as a good (38%, n = 18) or very good idea (25%, n = 12), but more participants were in the middle on how enjoyable (ranging from very “enjoyable” to very “unenjoyable”) this would be (23%, n = 11). Most (64%, n = 30) strongly agreed that referent others would want them to use condoms. Fewer (21%, n = 10) strongly agreed that these individuals would not want them to have multiple sexual partners. Seventy percent indicated that they planned to use condoms every time they have sex, and 57% planned to have sex with no more than one partner. See Tables 4 and 5.

Table 4.

Selected Attitudes, Beliefs, and Intentions Toward Condom Use

	% (n)
Using a condom every time during sex in the next 3 months would be
Very bad	2% (1)
Bad	6% (3)
In the middle	10% (5)
Good	27% (13)
Very good	54% (26)
Using a condom every time during sex in the next 3 months would be
Very unenjoyable	6% (3)
Unenjoyable	8% (4)
In the middle	31% (15)
Enjoyable	35% (17)
Very enjoyable	19% (9)
Most people who are important to me would want me to use a condom every time I have sex in the next 3 months
Disagree strongly	4% (2)
Disagree	8% (4)
In the middle	8% (4)
Agree	17% (8)
Agree strongly	64% (30)
It would be easy/hard to use condoms every time during sex in the next 3 months
Very hard	2% (1)
Hard	10% (5)
In the middle	21% (10)
Easy	33% (16)
Very easy	31% (15)
I am sure that I can use a condom every time I have sex in the next 3 months
Disagree strongly	0%
Disagree	13% (6)
In the middle	13% (6)
Agree	40% (19)
Agree strongly	35% (17)
I plan to use condoms every time I have sex in the next 3 months
Disagree strongly	4% (2)
Disagree	2% (1)
In the middle	23% (11)
Agree	35% (17)
Agree strongly	35% (17)
My goal is to use a condom every time I have sex in the next 3 months
Disagree strongly	6% (3)
Disagree	6% (3)
In the middle	10% (5)
Agree	42% (20)
Agree strongly	35% (17)

Table 5.

Selected Attitudes, Beliefs, and Intentions Toward Multiple Sexual Partners

	% (n)
Having no more than one sexual partner in the next 3 months would be
Very bad	4% (2)
Bad	6% (3)
In the middle	27% (13)
Good	38% (18)
Very good	25% (12)
Having no more than one sexual partner in the next 3 months would be
Very unenjoyable	4% (2)
Unenjoyable	8% (4)
In the middle	23% (11)
Enjoyable	48% (23)
Very enjoyable	17% (8)
Most people who are important to me would want me to have no more than one sexual partner in the next 3 months
Disagree strongly	6% (3)
Disagree	4% (2)
In the middle	17% (8)
Agree	52% (25)
Agree strongly	21% (10)
It would be easy/hard to have no more than one sexual partner in the next 3 months
Very hard	10% (5)
Hard	13% (6)
In the middle	23% (11)
Easy	31% (15)
Very easy	23% (11)
I am sure that I can have no more than one sexual partner in the next 3 months
Disagree strongly	2% (1)
Disagree	13% (6)
In the middle	27% (13)
Agree	33% (16)
Agree strongly	25% (12)
I plan to have sex with no more than one sexual partner in the next 3 months
Disagree strongly	4% (2)
Disagree	19% (9)
In the middle	21% (10)
Agree	40% (19)
Agree strongly	17% (8)
My goal is to have sex with no more than one sexual partner in the next 3 months
Disagree strongly	2% (1)
Disagree	17% (8)
In the middle	23% (11)
Agree	38% (18)
Agree strongly	21% (10)

Sexual risk behaviors

Participants reported a number of sexual behaviors that placed them at risk for HIV and other STIs. Majority (75%, n = 36) had vaginal intercourse, and 42% (n = 20) had anal intercourse with a female in the past 3 months. Eight percent (n = 4) also reported that they had sexual intercourse with a man in their lifetimes. However, only eight men (17%) reported using a condom during every sexual encounter in the past 3 months. Participants reported 31 ± 82 vaginal sexual encounters within the past 3 months, of which nearly half (13 ± 29) were unprotected. Thirty-five percent (n = 17) did not have main or steady partners, and participants had an average of 4 ± 6 sexual partners in the past 3 months. See Table 6.

Table 6.

Sexual Behaviors Among Study Participants (N = 48)

	M (SD)	% (n)
Number of vaginal sex partners in the past 3 months	4 (6)
Number of times had vaginal intercourse in the past 3 months	31 (82)
Number of times had vaginal intercourse without a condom in the past 3 months	13 (29)
Ever had vaginal intercourse		88% (42)
Had vaginal intercourse in the past 3 months		75% (36)
Steady or main sex partner in the past 3 months		60% (29)
Frequency of condom use during vaginal intercourse in the past 3 months
I did not have vaginal intercourse in the past 3 months		10% (5)
Never		21% (9)
Sometimes		14% (6)
Often		9% (4)
Almost every time		35% (15)
Every time		19% (8)
Ever had anal intercourse with a female		42% (20)
Ever had any kind of sex (vaginal, anal, or oral) with a man		8% (4)

Note. For frequency of condom use during vaginal intercourse in the past 3 months, participants who reported “I did not have vaginal intercourse in the past 3 months” (n = 5) were excluded from the sample in the subsequent descriptives for the other categories. The denominator for the proceedings statistics is therefore 43.

Discussion

Despite the enormity of HIV/STI disparities among African Americans, and the rise of HIV/STI diagnoses among heterosexually identified men, few HIV/STI risk-reduction intervention trials have focused specifically on African American heterosexual men (Henry, Williams, & Patterson, 2010). Evidence shows that when HIV/AIDS knowledge exists among African American men, it does not guarantee engagement in safer sexual practices (Williams & Sallar, 2010). Research has shown that independent behaviors are not the only risk factors for HIV infection (Hallfors et al., 2007). African American men also continue to be at increased risk because of two explicit cultural ideologies: men should have sex with multiple female partners (often concurrently) from whom they should never decline sex, even if it bears risk for HIV/STIs, and that men should not have sex with men (Bowleg et al., 2011). Sexual concurrency norms and behaviors increase the risk for HIV/STIs in geographically and socially constrained social networks (Adimora & Schoenbach, 2005; Adimora et al., 2004; Hallfors et al., 2007). Furthermore, the latter ideology is particularly concerning when conceptualizations of same-sex sexual relationships facilitate negation of HIV/STI risks associated with anal sex with female partners. These norms and behaviors are influenced by structural factors such as poverty, racial discrimination, and incarceration that act as catalysts to low male-to-female ratios, which may encourage African American men to engage in sexual concurrency (S. R. Friedman, Cooper, & Osborne, 2009). As HIV and STI rates continue to rise among young heterosexual African American males, culturally tailored HIV risk-reduction interventions are direly needed. The results of this study demonstrate a pressing need to develop successful programs to reduce HIV and STI transmission and morbidity among young heterosexually identified African American men.

This study provides a snapshot of sexual practices among young African American men who leave themselves vulnerable to HIV/STI infection. Qualitative results demonstrated that overall the men held positive attitudes about condom use and limiting the number of sexual partners. The men expressed overall positive beliefs about condoms with regard to protection from HIV/STIs and unwanted pregnancies. However, with regard to actual behavior, quantitative data revealed that the majority of men did not use a condom every time they had sex (81%) and on average had four sexual partners in a 3-month period. Engagement in concurrent sexual relationships puts not only the men at risk for HIV/STI infection but also their sexual partners. The focus group provided an opportunity to explore the reasons why attitudes and knowledge did not translate to actual behavior and to understand the barriers the men faced to engaging in safer sexual practices.

Similar to the quantitative findings, the men expressed knowledge of the benefits of condom use and limiting sexual partners in the focus group. However, when discussing their actual sexual practices the men acknowledged engaging in concurrent sexual relationships with main and casual sexual partners. Some African American men believe that they should have sex with several women and that they should have many sexually uninhibited experiences—which often involves concurrent sexual partners. In our study, concurrent sexual partners were tied to themes of wanting to have the best looking female, not being able to turn down multiple solicitations from easily available women, and wanting “sexual favors” that main female partners were unwilling to provide. This is similar to findings from Carey et al. (2010) who found that some African American men choose to have concurrent sexual partnerships because multiple partners fulfill different sexual needs. In addition, some believed that African American men are often respected and admired for having many women, especially by those men who did not (Carey et al., 2010).

Condom use beliefs and intentions varied for main partners when compared with casual partners. The men expressed notions of ease and necessity of condom use with casual partners but difficulty in negotiating condom use with their main, steady partners. Initiation of condom use with primary partners can be associated with infidelity (Eyre et al., 2011).These attitudes often lend to condom use with casual partners but not with primary partners. Similar attitudes were held among our sample, as the men expressed strong beliefs about using condoms consistently with casual partners in an attempt to keep their steady partners protected from HIV/STI infection. In contrast, they expressed difficulty in negotiating condom use with their main partners in fear of losing their trust particularly when their partners did not want to use condoms. It is important to note that several participants expressed that even when they intended to use condoms, their female sexual partners refused condom use; this directly contrasts predominant literature that men are the only ones resistant to condom use. Data also reveal that sexual partner concurrency is linked to other sexual risk behaviors, such as having sex under the influence of drugs and alcohol, exchanging sex for money, and having a greater overall number of sexual partners (Adimora et al., 2007). Participants in this study also suggested that condom use could be more difficult when under the influence of substances, particularly marijuana.

Implications for Research

The results of this study elucidate the HIV/STI prevention program needs of young heterosexual African American men in Philadelphia. The dearth of available sexual health education and reproductive health services, combined with engagement in sexual networks, cultivate sexual behaviors that foster transmission of HIV/STIs among adolescents (Adimora & Schoenbach, 2005; Rice, 2010). The juxtaposition of elevated HIV/STI rates in certain populations also suggests the urgency of intervening with young African American men between the ages of 18 and 24 years. For these reasons, a further model of intervention research is needed with this particular population. In this study, the men shared the need for skills to (a) increase their HIV/STI knowledge, (b) negotiate condom use with different types of partners (e.g., main and casual), and (c) limit their number of sexual partners. Findings from this limited sample of men suggest that intervention programs will need to enhance knowledge, target negative beliefs about condom use (e.g., less pleasure and reduced spontaneity), and provide negotiation skills to equip young males to effectively protect themselves and their sexual partners from HIV/STIs. As suggested by Essien, Meshack, Peters, Ogungbade, and Osemene (2005), interventions for men should include issues of condom use, condom availability, condom-use skills, and eroticizing condoms. Given high rates of partner concurrency, interventions can also focus on limiting the number of sexual partners and enhancing the positive aspects of monogamy (i.e., reduced risk HIV/STI transmission, save money, less conflict with partner, etc.).

In addition, these participants highlighted that interventions need to target heterosexually identified men through gender-specific interventions in settings that are appealing and culturally relevant, such as barbershops. In this study, there was resounding enthusiasm to hold HIV/STI intervention programs in barbershops. Participants had long-standing ties to their respective barbershops, getting their hair cut on a weekly to biweekly basis for more than 1 year. They also spent almost half an hour in their barbers’ chairs. In the survey, three quarters of the men reported that their barbers were a reliable and trustworthy source for health information. This indicates that barbershops may be an appropriate way to engage a captive audience, with barbers serving as trusted facilitators. The men saw access to information, condoms, and STI testing (and treatment if needed) as positive. In the focus group, barbers were deemed as trusted, “strong male role models” who would be effective facilitators. With regard to the desired gender of facilitators for an HIV/STI program (male vs. female), the men did not have a preference. They expressed being comfortable and receptive to a female barber because “in the shop you’re a barber and there is a relationship.” They suggested that barbers could recruit participants for the program and that incentives such as money, free haircuts, and condoms would result in participation.

Men in our sample, and other heterosexually identified men in the literature, report engaging in sexual acts with other men; in the questionnaire, we did not probe these reports to determine whether the acts were forced or coerced (i.e., what is sometimes seen in incarcerated populations) or mutually consensual. It should not be assumed that heterosexually identified men have never had sex with a man, particularly given the notions of masculinity and unacceptability of same-sex orientation among some men. Sexual identity and behavior are two different concepts and accordingly need to be addressed separately in interventions. The men in our sample were clear that discussing sexual acts regarding men having sex with other men was unacceptable and would result in lack of community participation and engagement. The data, however, show that individuals may not identify as having same-sex relationships or sexual encounters but still engage in same-sex sexual behaviors. Interventions, therefore, should focus on the behaviors that increase risk for HIV transmission (i.e., anal sex) regardless of who they occur with rather than tying the behaviors within a context of sexual identification/alignment.

Study Limitations

The study consisted of a small (N = 48) convenience sample. Thus, the results are not generalizable to all heterosexual African American males aged 18 to 24 years. Self-reported data have the potential for response bias and limited recall. Additionally, the high standard deviations for some of the reported statistics indicate high variability in the participants’ responses and should therefore be evaluated with caution. Finally, the cross-sectional design limits the ability to imply causality. Despite these limitations, the results demonstrate the need for research aimed at developing and implementing HIV sexual risk-reduction interventions for African American young men.

Conclusion

African American men continue to be disproportionally affected by HIV/AIDS. Barbershops are an ideal location to engage hard-to-reach, inner-city young heterosexual African American men for implementation of evidence-based HIV/STI prevention programs. This population has long been neglected in the development of HIV/STI prevention programs. As a result, the public health response to the HIV epidemic among heterosexual African American men has been hampered by the lack of targeted sexual risk reduction interventions with solid evidence of efficacy. This study highlighted attitudes, knowledge, and risk behaviors that prevent young males from engaging in safer sex practices. Culturally situated interventions have the potential to target hard-to-reach, historically underserved populations by meeting the participants where they are and in their own colloquial language. Efforts to reduce risk among African American men may have the secondary benefit of reducing risk among African American women.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Barbershops as Venues to Assess and Intervene in HIV/STI Risk Among Young,Heterosexual African American Men

Abstract

Keywords

Background

Social Factors, Sexual Networks, and Risk Behavior

HIV Risk–Related Sexual Behaviors Among Young African American Men

Sexually Transmitted Infections

Barbershops as Health Promotion Sites

Framework

Methods

Location and Recruitment

Questionnaire

Semistructured Focus Group Guide

Procedure

Focus Group

Questionnaires

Data Analysis

Results

Focus Group Findings

The impact of HIV/STIs in the heterosexual African American male community

Behavioral beliefs regarding condom use

Partner differences: Steady versus casual

Ideas for barbershop program

Questionnaire Findings

AIDS/STI knowledge and testing history

Attitudes and beliefs toward condom use and multiple sexual partners

Sexual risk behaviors

Discussion

Implications for Research

Study Limitations

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

References