The Role of Settings in Family Based Prevention of HIV/STDs
3.3 Settings or Physical and Social Environments
3.3.3 Neighborhood
Disease Control 2009 ; Kirby et al. 2007 ) . Moreover, embedding family based interventions in the schools may be an effective means of reducing HIV/STD risk, by bolstering parent–child communication processes and parent/teacher collabora-tion in monitoring of children, and by educating parents about HIV/STD risk factors and thus facilitating more consistent HIV/STD preventive messages across settings (Coyle et al. 1999 ) .
employment, and low collective effi cacy or monitoring of adolescents’ activities by adults (Sampson et al. 1997, 1999 ) .
Any attempt to decrease the occurrence of HIV/STD risk behaviors must address additional problems that may co-occur in resource-poor communities, such as high crime, low collective effi cacy, and/or undesirable built (physical) environmental characteristics, any one of which may contribute to HIV/STD risk for individuals in a family. The following subsections will address each of these additional facets of neighborhoods in relation to HIV/STD risk.
3.3.3.2 Neighborhood Crime
Several studies have attempted to address the role of neighborhood crime in the chain of causality for HIV/STD risk. For example, neighborhood crime has been found to be related to the presence of visible drug sales and drug use at the neigh-borhood level (Ford and Beveridge 2006 ) . Possible interpretations of this fi nding are either that crime encourages drug dealing or else that the presence of drug deal-ing in a neighborhood attracts other types of criminal behavior. Both drug dealdeal-ing and other types of crime may signify a degree of social disorder and a lack of social control (Ford and Beveridge 2006 ) , which may lead to an increased risk for the development of risk behaviors in adolescents (see Sect. 3.3.3 ).
The presence of gangs, organized groups with a criminal affi liation, is an addi-tional contextual infl uence that tends to increase crime and violence in a neigh-borhood (Herrenkohl et al. 2000 ; Rosenfeld et al. 1999 ) , which in turn may be related to increases in HIV/STD risk behaviors (Lane et al. 2004 ; Seal et al. 2003 ) . Gangs are particularly infl uential to adolescents, who are at a developmental stage where they may be especially vulnerable to peer infl uence (Gifford-Smith et al.
2005 ; Henry et al. 2001 ) and who may join a gang in a search of establishing an identity apart from parents or other authority fi gures (Henry et al. 2001 ) . Gang presence has been shown to increase adolescent likelihood of participating in risky sexual behavior (Walker-Barnes and Mason 2004 ) . Relative to those not involved in gangs, gang members have been shown to exhibit earlier age of sexual debut, higher rates of sexual activity, sex while under the infl uence of drugs or alcohol, and lower rates of condom use (Brooks et al. 2009 ; Voisin et al. 2004 ; Wingood et al. 2002 ) .
A longitudinal study using an ethnically diverse sample of 300 ninth-grade stu-dents suggests that parenting variables (i.e., behavioral control, psychological con-trol, parent–adolescent confl ict, and warmth) may moderate the relationship between gang involvement and problem behavior (Walker-Barnes and Mason 2004 ) . Thus, structural interventions using a multilevel approach to address neigh-borhood crime and gang involvement – including embedding family based preven-tion within communities at high risk for crime and gang activity – may be a potentially effective means of preventing HIV/STD-related behaviors, given the likelihood of a multifaceted etiology being at play with regards to HIV/STD risk in crime-ridden communities.
3.3.3.3 Neighborhood Social and Physical Environment
Protection or risk for HIV/STDs in the neighborhood social environment may be understood through collective effi cacy. Collective effi cacy is a construct that refers to social cohesion among neighbors and their willingness to intervene on each other’s behalf (including supervision of each other’s children; Sampson et al. 1997, 1999 ) . An initial study in this area examined the relationship between collective effi cacy and vari-ations in violence across 343 neighborhood clusters in the city of Chicago (Sampson et al. 1997 ) . Sampson et al. ( 1997 ) found an association between collective effi cacy and variations in violence between neighborhoods, when controlling for individual characteristics, measurement error, and prior violence. Moreover, both race and con-centrated poverty were signifi cantly associated with collective effi cacy. However, with race removed as a confounding factor (e.g., limiting the analysis to African American neighborhoods), collective effi cacy continued to explain variations in neighborhood violence. Further analysis suggested that collective effi cacy may be viewed as partially mediating the association between these neighborhood socioeconomic characteristics and violence. However, there was substantial variation in collective effi cacy among low-SES neighborhoods, suggesting that high levels of collective effi cacy may be pro-tective against risky adolescent behaviors even among low-SES neighborhoods.
Follow-up analyses suggested that, even accounting for differences in physical charac-teristics of neighborhoods (e.g., graffi ti; litter), collective effi cacy accounted for sub-stantial variation in neighborhood level violence (Sampson and Raudenbush 1999 ) . A third study found that collective effi cacy was related to collaboration of neighbors in parenting of children, including monitoring of children in the neighborhood (Sampson et al. 1999 ) . These fi ndings suggest that crime and other dangerous activity in the neighborhood may create an environment of fear, detracting from the sense of collec-tive effi cacy by neighbors, including monitoring of adolescent activities which may put the adolescent at risk for HIV/STDs (Sampson et al. 1997, 1999 ) .
Recent studies have indicated that neighborhood collective effi cacy may reduce the likelihood of highrisk sexual behavior among adolescents. For instance, collective effi -cacy has been linked to age of initiation of fi rst sexual intercourse among urban adoles-cents in Chicago (Browning et al. 2005 ) . Findings suggest that adolescents residing in neighborhoods low in collective effi cacy were 64% more likely to experience sexual onset by age 16 compared to adolescents residing in neighborhoods high in collective effi cacy. Follow-up research suggests that low levels of neighborhood collective effi cacy are associated with an increased number of sexual partners (Browning et al. 2008 ) , which may in turn increase HIV/STD risk (Rosenberg et al. 1999 ) . Thus, family based prevention interventions which foster collective effi cacy at the neighborhood level may serve as a mechanism for reducing HIV/STD risk for individuals in a family.
3.3.3.4 Example of HIV/STD Family Based Preventive Interventions in Neighborhood Settings
The Collaborative HIV Adolescent Mental Health Program (CHAMP) intervention has emphasized the role of family in HIV prevention and targets preadolescents (fourth
and fi fth grade), in an effort to reach youth before they transition to adolescence (McKay et al. 2004 ) . The CHAMP program was implemented in the USA (Chicago:
McKay et al. 2000 ; McKay and Paikoff 2007 ; New York: McKay et al. 2007 ) and adapted for sites in Trinidad and Tobago (Baptiste et al. 2007 ) and South Africa (Bell et al. 2008 ) . CHAMP highlights the role of community involvement and cultural sen-sitivity in implementation of its curriculum. Community members play a role in the direction, facilitation, and evaluation of the program. The intervention is then admin-istered to small groups of families and their “preadolescent” by trained program leaders.
Group workshops are designed to increase HIV knowledge, increase family commu-nication skills, increase parental monitoring, decrease neighborhood disorganization, and increase social cohesion and control (Bell et al. 2008 ) . CHAMP participants in the USA showed improvements in family functioning and comfort in parent–child com-munication, which are thought to be protective factors against adolescent HIV risk (McKay et al. 2004 ) . Similarly, CHAMP participants in the South Africa study had signifi cantly more knowledge regarding HIV transmission at postintervention and greater caregiver communication comfort and frequency in discussing sensitive top-ics, compared to a nonintervention control group (Baptiste et al. 2006 ; Bell et al.
2008 ) . This study was also successful in strengthening primary support networks (i.e., the caregiver or parent–child relationship; Bell et al. 2008 ) . Strong primary support networks are essential for social capital which can lead to larger social networks (Carpiano 2006 ) . Social networks are the basis for the development of more socially cohesive communities which, in turn, harbor a greater collective effi cacy, creating safer environments and strengthening the “community protective shield” for youths (Bell et al. 2008 ) .
3.3.3.5 Summary of Neighborhood Characteristics and HIV/STD Risk Epidemiologic studies suggest that multiple neighborhood characteristics (e.g., poor socioeconomic conditions, high crime, and undesirable built environment characteristics such as dilapidated buildings and alcohol outlets) may increase HIV/
STD risk behaviors. On the other hand, neighborhoods high in collective effi cacy and desirable physical environments (e.g., shops near homes, few liquor stores, well-kept homes and apartments) may be protective against these risk behaviors.
Intervention studies suggest that collaboration with community-based partners may be an effective means of disseminating HIV preventive messages and fostering col-laboration among community members in monitoring of adolescents’ activities, particularly in low-SES, crime-ridden neighborhoods.