Role of health belief model on sexual communication among African immigrants.
Abstract: Background: The purpose of this study was to use health belief model (HBM) and acculturation to assess sexual communication behaviors among African immigrants. Methods: A 47-item cross-sectional survey administered to a purposive sample of 412 African immigrants in Ohio. Results: The study revealed that the HBM constructs as a set significantly predict sexual communication behaviors. The study found that cues to action (OR=1.22), perceived benefits (OR=1.45), perceived susceptibility (OR = 1.29), and acculturation (OR = 1.08) were significantly predict sexual communication behavior (p < 0.05). Discussion: Future HIV/AIDS prevention programs among African immigrants can be designed based on HBM constructs.
Article Type: Survey
Subject: Immigrants (Surveys)
HIV (Viruses) (Prevention)
AIDS (Disease) (Prevention)
AIDS treatment
Authors: Asare, Matthew
Sharma, Manoj
Pub Date: 03/22/2012
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Spring, 2012 Source Volume: 27 Source Issue: 2
Product: Product Code: E198450 Immigrants
Accession Number: 308741506
Full Text: BACKGROUND

African immigrants in the US face enormous health challenges, and one such health need is HIV/ AIDS risk reduction. Available data confirmed that HIV/AIDS is prevalent among African immigrants (Kerani et al. 2008). A few studies on the African immigrant population in the US and Europe indicate that African immigrants could potentially experience differential impact of HIV/ AIDS disease. In Europe for instance, Gras, van Benthem, Coutinho, & van den Hoek's, (2001) study among Surinamese, Antillean, and sub-Saharan African immigrants in Holland confirmed that most participants in the study engaged in sex with multiple sexual partners, and there was more incidence of HIV among immigrant population than among the native Dutch. In the 1990s the prevalence of HIV/AIDS among African immigrants was high in Sweden (Bredstorm, 2009). Two senior Swedish physicians observed in 1993 that among African immigrants community in Sweden there was "a pattern of promiscuous sexual relations, non-monogamy, resistance to condom use and a denial of illnesses such as AIDS" (Bredstrom, 2009, p. 62). The United Kingdom (UK) Collaborative Group for HIV/STI Surveillance (2004) indicated that African immigrants form the second largest social group affected by HIV in the UK. By the year 2000, HIV/ AIDS diagnosis in African immigrants accounted for 51% in France, 20% in Spain, approximately 56% in Germany, nearly 25% in Sweden, and almost 65% in UK (Del Amo, Broring, Hamers, Infuso, & Fenton, 2004). Health Protection Agency (2006) indicated that "In the UK most HIV cases reported between 2004 and 2006 involved migrants from Sub-Saharan Africa ..." (p.46).

Given the staggering figures about the rates of HIV/AIDS incidence among African immigrants in Europe, one would expect similar trend of HIV cases among African immigrants in the US. However, there are no specific data about HIV/AIDS cases among the African immigrant population in the US because nationwide data on HIV/AIDS diagnosis in most cases omit the birth place of the people (Kerani et al. 2008). Although the foreign born African immigrants and the native born African Americans shared some commonalities, there are distinct historical, cultural and traditional beliefs, educational attainment, gender, socioeconomic status, and religious beliefs within the black population. These differences directly influence their health and sexual behaviors (Beatty et al., 2004). However, the current available health care data and studies on HIV/ AIDS use the term "black" and do not distinguish between foreign born African immigrants and native born African Americans. This failure to distinguish between the Africans and African Americans does not only hinder accurate identification of HIV/ AIDS risk factors but also can prevent formulation and implementation of culturally appropriate HIV/ AIDS intervention programs in the black population (Beatty et al., 2004). This study therefore seeks to tease out sexual behavior of African immigrants with specific emphasis on sexual communication.

The few available HIV surveillance data in the US, for example, revealed a widespread distribution of HIV/AIDS cases among African immigrants in California, Georgia, Massachusetts, Minnesota, New Jersey and in King County, Washington, New York City, and the portion of Virginia included in the Washington, DC metropolitan areas (Kerani et al. 2008). Johnson, Hu, & Dean, (2010) concluded that between 2001 and 2007 there were 11,700 HIV cases reported among black immigrants in 33 states in the US and out of those reported cases, approximately 42% were African immigrants. In Urban Washington State, African immigrants accounted for 40% of HIV/AIDS cases reported between 2000 and 2003 (Eteni & Wood, 2003).

A few research studies had concluded that sexual partners' ability to communicate and negotiate condom use and other protective measures with one another is necessary for practicing safer sex (Cline, 2003; Noar, Carlyle, & Cole, 2006) and an important HIV and STDs risk-reduction strategy (Noar & Edgar, 2008; Faulkner & Lannutti, 2010). Sexual communication helps provide an avenue for an "individual to select their potential partners for sexual relations, through which the meanings, functions and effects of sexual relations are negotiated" (Metts & Spitzber, 1996, P. 49). Meta-analyses by Allen, Emmer-Sommer, and Crowell (2002) and Noar, Carlyle, and Cole (2006) confirmed that there is an association between partners' ability to communicate about their sexual behaviors and safer sex practices. However, sexual communication or sexual negotiations are scarcely practiced by African immigrants and Africans in general because such practices are considered taboo by some Africans. Makau and Nyong'o (2010) summarized Africans' reactions toward sexual communication in the following words:

"Mention sex in most places on the African continent and you are likely to be met with questioning glances. Most quietly wonder "what is this person up to?" Venture into speaking about controversial sexual rights and you are likely to cause a furor. The most common reaction will ostensibly focus on their immoral or un-African nature. You will be lucky to leave the conversation unscathed, physically or otherwise" (p.1)

Flomo's (2009) study supported the fact that some African immigrants do not want to introduce condom use or talk about condom use in their stable relationship because of fear that the partner might misconstrue it to be unfaithfulness or lack of trust. One African immigrant (a woman) in Flomo's (2009) study succinctly described ambivalent feelings most African immigrants have about sexual communication and condom use in this way: "I will like to use condom but I'm kind of afraid that my husband will not agree, and he might think that I do not trust him or that I think that he is cheating. So, even though I tell other people to use condom, I find it very difficult to even talk to my husband about using it myself." (p. 71).

Knowing the factors that influence African immigrant sexual communication behaviors could help in the design of effective sexual communication programs for African immigrants. Unfortunately, there is paucity of literature about African immigrant sexual communication behaviors, and there is the need to close that gap. Therefore, the purpose of this study was to the relationship of Health Belief Model (HBM) constructs and acculturation with sexual communication behaviors among African immigrants.

THEORETICAL FRAMEWORK HEALTH BELIEF MODEL:

In the 1950s a group of social psychologists at the U.S. Public Health Services developed the HBM based on social and psychological theories. The HBM has been one of the most widely used theoretical frameworks in individuals' health behavior change (Janz, Champion & Strecher, 2002). The HBM constructs are perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. A few studies have utilized HBM constructs to guide research studies among African immigrants. Mitha and colleagues (2009) utilized the constructs of risk perception and perceived susceptibility to predict HIV susceptibility among Ethiopian immigrants in San Francisco. Manirankunda, Loos, Alou, Colebunders, & Nostlinger, (2009) used perceived susceptibility and perceived barriers to evaluate Sub-Saharan African migrants in Belgium perceptions about HIV counseling and testing. Mohamed's (2007) on the other hand utilized the HBM to predict the role of cultural practices and transmission of HIV among African immigrants in Minnesota. Simbiri, Hausman, Wadenya, & Lidicker, (2010) used a perceived barrier construct to access impediments to health care and social services among Francophone and Anglophone African immigrants in Philadelphia. However, HBM constructs have not been used to examine the sexual communication behaviors among African immigrants, therefore the current study seeks to bridge that gap in the literature.

ACCULTURATION AND HIV/AIDS AMONG IMMIGRANTS

Acculturation is a change in the culture of a group or change in the psychology of individuals who continuously interact with dominant cultures or other cultures (Redfield, Linton, & Herskovits, 1936; Berry, 1997; Ryder, Alden, & Paulhus, 2000). Through acculturation individuals adapt to a new culture, often considered to be the dominant culture within their host countries. Burnam and his colleagues (1987) argued that "Differences in levels of acculturation play a crucial role in many areas of psychological functioning, including cognition, personality, and the expression of psychopathology" (p. 106). Cooper, Loue, and Lloyd (2001) also concluded in their study that individuals' acculturation levels could mediate the relationship between their risky behaviors and perceived susceptibility of contracting a disease. Rojas-Guyler, Ellis and Sanders (2005) study found a significant correlation between higher non-Hispanic acculturation level and higher sexual communication among the participants in their study. Newcomb et al. (1998) found that acculturation, age, and marital status were the most powerful predictors of risky sexual behaviors of the sampled Latinas. Suffice to say, there is overwhelming evidence that acculturation has been utilized to understand immigrants' risky behaviors that predispose them to contracting HIV/ AIDS virus. Notwithstanding this documented evidence, there is a paucity of acculturation study among African immigrants regarding their sexual behavior and HIV/AIDS and, hence the need of this study.

METHODS

PARTICIPANTS AND RECRUITMENT PROCESS:

A sample size of 394 was needed for this study based on an alpha of 0.05 and power of 0.80 with an estimated population correlation coefficient of 0.20 (Polit & Hungler, 1999, p. 495). A cross sectional design was utilized to collect one point in time data (Baltes, Reese, & Nesslroade, 1988) from the participants. The cross-sectional design was utilized in this study because African immigrants are hard to reach and therefore a snapshot study among the available ones was a good start. The study used a purposive sample and a randomized snowball method called binomial (Goodman, 2004) in the recruitment process. The participants were asked to sign an informed consent form to indicate their willingness to take part in the study. The questionnaires were hand delivered to participants in African churches, African shops, and African social gatherings. When a participant completed the questionnaire, the researcher asked the participants if they would like to refer any friends or family members to take part in the study. Goodman's (2004) study has indicated the randomized snow ball sampling can significantly improve the representativeness. The study was approved by University Cincinnati Institutional Review Board (IRB). A $5.00 gift card was given to each participant upon completion of the survey.

MEASURES:

A 47-item instrument was developed based on the constructs of the HBM and acculturation. The participants' sexual communication behaviors were measured by Yes =1 or No =0questions. For example a question, "In the past 30 days, did you talk to your partner about safe sex?" Where talking about safe sex was defined as communicating to one's sexual partner about their sexual history, HIV/ AIDS and STDs risk reduction, HIV testing and condom use. For measuring participants' perceived benefits of sexual communication a two-item Likert-type self-reporting scale which had response choices ranging from strongly disagree (1)to strongly agree (5) was used. An example of the questions was "If I talk with my partner about safer sex it will help us to reduce our risk of getting HIV/AIDS and other STDs." The rating scores of the two items were summed to achieve a possible range of 2-10 with the higher score reflecting greater perceived benefits in engaging in sexual communication.

For assessing the participants' past sexual communication experience with their family members (parents), a five-item Likert-type self-reporting rating scale which had response choices ranging from never (1)to very often (5)was utilized. An example of the items used was "When you were growing up, how often did your family (parents) talk to you about sexual abstinence?" The rating scores of the past sexual communication experience items were summed to achieve a possible range of 5 to 25 with the higher score reflecting strong background in sexual communication.

The participants' perceived barriers to sexual communication were evaluated with a five-item Likert-type self-reporting rating scale which had response choices ranging from strongly disagree (1) to strongly agree (5) was used. An example of the items used was "Because of my cultural beliefs, I find it difficult to talk about my sexual behavior with my partners." The rating scores of the five items were summed to achieve a possible range of 5-25 with the higher score reflecting perceived greater barriers to participants' ability to communicate about the sexual behavior.

The participants' cue to action about sexual communication were evaluated with a three-item Likert-type self-reporting rating scale which had response choices ranging from never (1)to very often (5) was used. An example of the items used was "In the past 6 months, I heard about the benefits of talking to your partner(s) about safer sex on the radio." The rating scores of were summed to achieve a possible range of 3-15 with the higher score reflecting greater force in influencing participants' sexual communications.

For measuring the participants' self-efficacy about sexual communication a three-item Likert-type self-reporting rating scale which had response choices ranging from strongly disagree (1)to strongly agree (5) was used to measure the participants' self-efficacy about sexual communication. An example of the question used was "I am confident that I can discuss condom use with my partner before sexual intercourse." The rating scores of the three items were summed to achieve a possible range of 3-15 with the higher score reflecting participants' greater confidence to communicate about safer sex with their partners.

In this study, the participants' levels of acculturation were measured by an eight-item Likert-type self-reporting rating scale which had response choices ranging from strongly disagree (1)to strongly agree (5). An example of the questions used was "I adhere strictly to American cultural values more than those of Africans." The rating scores of the eight items were summed to achieve a possible range of 8-40. The low score represented low acculturation level and the high score represented high level of acculturation of the participants.

The face and content validity of the instrument was established by a panel of six experts in a two round review process. Test-retest reliability and internal consistency were used to test the reliability of the instrument. For the purpose of test-retest reliability, 30 participants filled out the questionnaire twice in two week intervals. The correlation coefficients for perceived benefits (0.93), perceived barriers (0.80), self-efficacy (0.77), cues to action (0.78), sexual communication with family (0.80) and acculturation (0.77) were all greater than the 0.70 (Polit & Hungler, 1999) level established a priori. The correlation coefficient for perceived susceptibility (0.67) and perceived severity (0.66) were lower than the 0.70 acceptable standard; however those scales were retained. For internal consistency, the Cronbach's alphas for all six subscales were found to be more than 0.70, the a priori standard set for study. Structural Equation Modeling was used to conduct a Confirmatory Factor Analysis (CFA) for the construct validity of the instrument. The HBM variable had six latent variables (six constructs), and there were three items each for perceived severity, barriers, susceptibility and self-efficacy. Perceived benefits had only two items and perceived barriers had five items. The structural equation model analysis revealed that the overall model, measuring sexual communication among the participants was significant, [chi square] (137, n=412) = 340.21, p<.001. A non-significant chi-square is desired for the model to be fit. However other index such as comparative fit index (CFI) = 0.92, goodness-of-fit index (GFI) = 0.92, mean square error of approximation (RMSEA) = 0.06, showed that the model fit well. The acculturation variable had one latent variable with eight items. The overall model was significant, [chi square] (20, n=412) = 79.1, p<.001. A non-significant chi-square is desired for the model to be fit. However other index such as CFI = .94, GFI = .94, RMSEA = .05 showed that the model fit well. The confirmatory factor analysis confirmed acceptable factor loadings greater than 0.30 (Tabachnick & Fidell, 2007) for each item on the instruments. The residuals were also examined after evaluation of the model fitness and the results for each of the subscales confirmed that the model fit the data because none of the residual values exceeded 2 (Amos Development Corporation, 2010).

Data Analysis: Basic statistical tests were utilized to analyze the responses. Descriptive statistics, such as frequencies and means were computed on the demographic data to describe the sample. Binary Logistic regression analyses were carried out for the constructs of HBM and acculturation to account for the variance in sexual communication behaviors. All data were analyzed by the IBM SPSS Statistics 19.0 for Windows[R]

RESULTS

DEMOGRAPHICS

A total of 412 participants were included in the study. About 60.4 % (n = 249) of the participants were males and the female participants comprised about 39.6% (n = 163). The average age of the participants was 36.59 (SD = 9.27) years old. The majority (62%) of the participants were married, and the singles (25%) and the remaining 13% were those living together with their partners, widows, divorced, and separated. About 22% of the participants had graduate or higher degree and another 22% had undergraduate degree. Demographics were summarized in Table 1.

Approximately 59% (n = 241) of the participants reported that Ghana is their country of origin, 18.9% (n = 78) reported that Nigeria is their native country, 3.4% (n =14) were from Senegal, 3.2% (n = 13) were from Cameroon, 2.7% were from Kenya and the remaining 12.8% was from twenty other African countries. About 49% (n = 204) of the participants had engaged in sexual communication behavior while about equal number, 50% (n = 208), of the participants indicated that they did not engage in sexual communication with their partners. Table 2 summarizes the distribution of means and standard deviations for HBM constructs and acculturation.

MAJOR ANALYSIS

A test of full model with all the predictors against constant only model was statistically significant, [chi square](5, n=412) = 72.41, p<.001, indicating that the predictors as a set, reliably predicted sexual communication behaviors among the participants (see Table 3). The Nagelkerke R2 results showed the constructs as whole accounted for 29% of the variance in sexual communication behavior. The classification was very impressive, with 33.9% of no sexual communication and 98% of sexual communication correctly predicted, for an overall success rate of 89%. This means the model is about 90% correctly predicting sexual communication among the participants. The Hosmer & Lemeshow test for the model was not significant (p>.05) which shows that the model is a good fit.

TESTS OF INDIVIDUAL VARIABLES:

The logistic regression results for the statistical significance of the Wald statistic, odds ratio (OR) and 95% confidence interval for each of the independent variables were presented in Table 4. The study found that cues to action were a significant predictor of sexual communication behavior, [chi square] (1) = 8.07, p < .05. (OR=1.22). Perceived benefits was a significant predictor of sexual communication behavior, [chi square](1) = 29.07, p < .05 (OR=1.45) Perceived susceptibility was a significant predictor of sexual communication behavior, [chi square](1) = 15.79, p < .05 (OR = 1.29). Acculturation was a significant predictor of sexual communication behavior, [chi square] (1) = 6.15, p < .05 (OR = 1.08) Age was a significant predictor of sexual communication behavior, [chi square](1) = 14.04, p < .05, (OR = 0.49).

Further Chi-square analyses for the acculturation variables indicated that there was a significant relationship between the number of years the participants had lived in the US and their willingness to talk about protecting themselves against, pregnancy, STDs and HIV/AIDS. [chi square] (12) = 4.06, P<.05. However, there wasn't any significant difference between the number of years the participants had lived in the US and their willingness to talk about condom use. There was a significant difference between participants' sexual communication and other acculturation variables such as: the type of entertainment or music they preferred [chi square] (4) = 12.93, p<.05; the kind of friendship they had, [chi square] (4) = 23.20, p<.05; their comfort level of speaking native languages when American friends are around [chi square] (4) = 9.77, p<.05; and their identity [chi square] (4) = 13.47, p<.05. However, there was no significant difference in participants' response in relation to sexual communication and the type of social support system they sought and their comfort levels about the people who were around them at any given time.

DISSCUSSION

The purpose of this study was to determine the relationship HBM and acculturation with sexual communication behaviors among African immigrants. The findings of the present study were consistent with the study by Lin, Simoni, & Zemon, (2005) that the health belief model constructs as a whole was a reliable predictor of sexual behavior of the participants. The present study concluded that perceived susceptibility has a positive correlation with the participants' condom use and sexual communication behaviors. The respondents who believed that they were likely to get HIV because of their past and current sexual behaviors were more likely to engage in conversation with their partners about their sexual history. Most of the participants found it necessary to talk to their partners about condom use and how best they could protect themselves against HIV/AIDS and STDs. This finding supports various studies that perceived susceptibility was a significant predictor of condom use (Southerland, 2003) and HIV testing (Cooper, Loue, & Lloyd, 2001). The study revealed that cues to action were a significant predictor of participants' sexual communication behaviors. This means that when the participants heard their friends discuss the benefits of sexual communication behaviors, it encouraged them to practice safe sex and talk to their partners about HIV risk reduction, condom use, and their sexual history. Perceived benefits were significant in predicting sexual communication among the participants. Respondents who perceived that sexual communication with partners was important in preventing HIV and pregnancy were more likely to talk about their sexual behavior with their partners.

In the present study, acculturation was a significant predictor of sexual communication among the participants. As more and more African immigrants become exposed to American culture, they begin to communicate about their behaviors. This finding is consistent with the results of Rojas-Guyler, Ellis & Sanders, (2005) study. The current study revealed that sexual communication had a direct association with condom use among the participants. Again, this result supports Rojas-Guyler and colleagues' conclusion that sexual communications have an association with frequency of condom use. The participants' gender, however, had no association with sexual communication among sexual partners. More male (52%) respondents than female (45%) respondents engaged in sexual communication behavior such as condom use, discussions about partners' sexual history, and protection against STDS and HIV/AIDS in the past three months. The result concurs with participants in Flomo's (2009) research that African immigrant females are unwilling to talk about their sexual history with their partners. There was a significant association between the participants' marital status and their sexual communication behavior. Those who identified themselves as singles (61%) were more likely to engage in sexual communication behavior. Those participants who lived together with their partners (74%) had sexual communication in the past three month. Those respondents who were married were less likely (41%) to engage in sexual communication with their partners. This finding goes to support the fact that there is a tenuous sexual communication among African immigrant married couples (Flomo, 2009).

The participants' age has significant association with their sexual communication behavior. Those participants between the ages of 21--40 years (75%) compares to those who were 41 years and above (25%) engaged in sexual communication behavior. In other words, participants who were more likely to talk about their sexual behaviors were the young adults. Although the binary logistic regression did not show that the participants' sexual communications in past with their family or parents have a significant relationship with their present sexual communication behavior, the respondents who had sexual communication with their parents or family about: abstinence (n =56); condom use (n = 26); and HIV/AIDs (n = 55) were more likely to practice safe sex. The study revealed that the majority, about 74.8%, of the participants did not have sexual communication with their family about abstinence, 88.6% did not have any sexual communication experience with their family or parents about condom use, and 74.3% did not have any sexual communication about HIV/AIDS with their family or parents. These results are consistent with Morisky et al., (2006) and Scott (2009) that African parents feel uncomfortable talking about sex with their children. However, studies have shown that adolescents who had sexual communication experiences with their parents were more likely to practice safe sex (Powell & Segrin, 2004; Dilorio, Dudley, Lehr, & Soet, 2000; Shoop & Davidson, 1994). African immigrant parents should be encouraged to educate their children, especially adolescents, about sexual negotiation strategies and skills, the need to engage in sexual communication with their future partners about their sexual history, HIV testing, and how to protect themselves against HIV and STDs.

LIMITATIONS

Like any other study, this study is not without limitations. The following were the limitations in this study. First, the instrument used in this study was a self-reported questionnaire and responses might include participants' bias and dishonesty, desirability, and potential recall problems. This would introduce measurement bias in the study. Second, the study used a convenience sample based on the snowball method, which could introduce sampling bias and did not use a random selection of subjects. This study could not use random selection because no list of names or directory was available on the target population.

Third, there were not enough useful data on the target population and as such the data utilized in this study were based on deduction from other data. For example, there was no specific data on the number of HIV/AIDS cases among African immigrants; therefore, the study relied on general data available on Africans and African immigrants. The use of cross sectional design in this study is also a limitation because it cannot establish temporality and since it is only a snapshot a time sequence cannot be established. Another limitation was that the correlation coefficients for perceived susceptibility (.67) and perceived severity (.66) were lower than the .70 acceptable standard, therefore any analyses and discussions based on those variables should be interpreted with caution. Finally, since the study was limited to African immigrants who could read and write English, the results could not be generalized to those African immigrants who cannot speak English.

IMPLICATIONS FOR PRACTICE

The implication for practice is that interventions to promote sexual communication skills and strategies for sexual negotiations should be implemented among the African immigrant participants. The HBM constructs such as cues to action, perceived benefits, and perceived susceptibility could be used to guide any programs aimed at promoting sexual communication among the participants. Educational methods like lecture, phone calls, personal reminders, small group discussion, and video could be utilized to facilitate the cues to action, perceived benefits, and perceived susceptibility of the participants. The other implication similar to the partner sexual communication is that the participants (especially parents) should be encouraged to educate their adolescent children about engaging in sexual communication with their new and future partners. This will not only break the vicious cycle of lack of sexual communication among Africans but also would help the adolescent to protect themselves against HIV/AIDS and STDs. In conclusion, since some of these sexual behaviors (i.e. lack of condom use and lack of sexual communication) are engrained in the culture of the people, health education practitioners who want to promote condom use and sexual communication among African immigrants should be cognizant of the culture of the people so that they (health practitioners) can design culturally sensitive programs.

RECOMMENDATIONS FOR FUTURE RESEARCH

Future study should attempt to increase the sample size and incorporate more African immigrants from different countries like South Africa, Liberia, Uganda, Kenya, etc. There should be more attempts to replicate this study among African immigrants in different settings to validate or debunk the findings. Future research should improve upon the instrument by operationalizing the constructs of HBM to include more items and be clearer on perceived benefits and perceived barrier items. Intervention programs to promote Parents-Adolescent-child sexual communication should be done among African immigrants to break the myths around lack of sexual communication among African immigrant children. Finally, health education efforts should be made to increase the participants' self efficacy, their sexual communication skills and strategies in order to promote healthy sexual communication among the participants.

REFERENCES

Allen, M., Emmers-Sommer, T., & Crowell, T. L. (2002). Couples negotiating safer sex behaviors: A meta-analysis of the impact of conversation and gender. In M. Allen, R. W. Preiss, B. M. Gayle, & N. A. Burrell (Eds.), Interpersonal communication research: Advances through meta-analysis (pp. 263-279). Mahwah, New Jersey: Erlbaum.

Amos Development Corporation (2010). Amos 19 reference guide.

Baltes, P. B., Reese, H. W., & Nesselroade, J. R. (1988). Introduction to research methods, lifespan developmental psychology.Hillsdale, NJ: Lawrence Erlbaum Associates, Inc

Berry, J. W. (1997). Immigration, acculturation, and adaptation. Applied Psychology: An International Review, 46(1), 5-8.

Bredstrom, A. (2009). Sweden: HIV/AIDS policy and the 'crisis' of multiculturalism. Race & Class, 50(4), 57 - 74. doi: 10.1177/0306396809102998

Burnam, M. A., Hough, R. L., Karno, M., Escobar, J. L., & Telles, C. A. (1987). Acculturation and lifetime prevalence of psychiatric disorders among Mexican Americans in Los Angeles. Journal of Health and Social Behavior, 28, 89-102.

Cline, R. J. W. (2003). Everyday interpersonal communication and health. In T. L. Thompson, A. M. Dorsey, K. I. Miller, & R. Parrot (Eds.), Handbook of health communication(pp. 285--313). Mahwah, NJ: Lawrence Erlbaum Associates.

Cooper, M. Loue, S., & Lloyd, L. S. (2001). Perceived susceptibility to HIV infection among Asian and Pacific Islander women in San Diego. Journal of Health Care for the Poor and Underserved, 12(2), 208-223.

Del Amo, J., Broring, G., Hamers, F.F., Infuso, A., & Fenton, K. (2004). Monitoring HIV/AIDS in Europe's migrant communities and ethnic minorities. AIDS, 18(14), 1867-1873.

Dilorio, C., Dudley, W. N., Lehr, S., & Soet, J. E. (2000). Correlates of safer sex communication among college students.Journal of Advanced Nursing, 32, 658-665.

Eteni ("Das"), L. & Wood, R. (2003). African immigrants project. Retrieved from www.kingcounty.gov/ healthservices/.../African_Immigrant_Project.ashx

Faulkner, S. L. & Lannutti, P. J. (2010). Examining the content and outcomes of young adults' satisfying and unsatisfying conversations about sex. Qualitative Health Research, 20(3), 375-385.

Flomo, N, S (2009).Acquired immune deficiency syndrome and immigrant: A look at HIV knowledge and risk behaviors among African immigrants in Guilford County. (Doctoral dissertation). Retrieved from ProQuest. UMI Number: 3352333

Goodman, L. A. (2004). The snowball sampling. The Annals of Mathematical Statistics, 32(1), 148-170. Gras, M. J. van Benthem, B. H. B., Coutinho, R. A., & van den Hoek, A. (2001). Determinants of high-risk sexual behavior among immigrant groups in Amsterdam: Implications for interventions. JAIDS Journal of Acquired Immune Deficiency Syndromes, 28(2), 166-172.

Greene, S. L., & Lannutti, P. J. (2010). Examining the content and outcomes of young adults' satisfying and unsatisfying conversations about sex. Qualitative Health Research 20(3) 375-385. doi: 10.1177/1049732309354274

Health Protection Agency UK (HPA) (2006). Migrant health: Infectious diseases in non-UK born populations in England, Wales and Northern Ireland. A baseline report 2006. HPA: London

Janz, N. K., Champion, V. L., & Strecher, V. J. (2002). The health belief model. In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds).Health behavior and health education: Theory, research and practice(pp. 45 -47). San Francisco, CA: Jossey-Bass.

Johnson, A. S., Hu, X., & Dean, H. D. (2010). Epidemiologic differences between native-born and foreign-born black people diagnosed with HIV infection in 33 U.S. States, 2001-2007. Public Health Report, 125, 61-69.

Kerani, R. P., Kent, J. B., Sides, T., Dennis, G., Ibrahim, A. R., Cross, H., ...Golden, M. R. (2008). HIV among African-born persons in the United States: A hidden epidemic? Journal of Acquired Immune Deficiency Syndrome, 49(1), 102-106.

Lin, P., Simoni, J. M., & Zemon, V. (2005). The health belief model, sexual behaviors and HIV risk among Taiwanese immigrants. AIDS Education and Prevention, 17(5), 469-483.

Makau, K. & Nyong'o, Z. (2010). Africa: Sexuality, discourses- between patriarchy, pornography and pleasure. Retrieve from allafrican.com

Manirankunda, L., Loos, J., Alou, T. A., Colebunders,R., & Nostlinger, C. (2009). "It's better not to know': perceived barriers to HIV voluntary counseling and testing among sub-Saharan African migrants in Belgium. AIDS Education and Prevention, 21(6), 582-593.

Metts, S., & Spitzberg, B. H. (1996). Sexual communication in interpersonal contexts: A scripts-based approach. In B. R. Burleson (Ed.), Communication Yearbook 19 (pp.49-91). Thousand Oaks, CA: Sage.

Mitha, K., Yirsalign, M., Cherner, M., McCutchan, A., & Langford, T. D. (2009). Risk perception and beliefs regarding HIV Infection among Ethiopian immigrants. AIDS Education and Prevention, 21(5), 484-494.

Mohamed, S. M. (2007). The role of culture in the transmission of HIV/AIDS among Minnesota's African-born residents: Applicability of the health belief model(Unpublished master's thesis). Minnesota State University, Minnesota.

Morisky, D. E. W., Jacob, J., Nsubuga, U. K., & Hite, S. J. (2006). Overcoming AIDS: Lessons learned from Uganda. Connecticut: lAP--Information Age Publishing, Inc.

Newcomb, M. D., Romero, G. J., Wyatt, G. E., Wayment, H. A., Tucker, M. B., Carmona, J. V.,... Mitchell-Kernan, C. (1998). Acculturation, sexual risk taking, and HIV health promotion among Latinas. Journal of Counseling Psychology, 45(4), 454-467.

Noar, S. M., Carlyle, K., & Cole, C. (2006). Why communication is crucial: Meta-analysis of the relationship between safer sexual communication and condom use. Journal of Health Communication, 11(4), 365-390.

Noar, S. M., & Edgar, T. (2008). The role of partner communication in safer sexual behavior. In T. Edgar, S. M. Noar, & V. S. Freimuth (Eds.), Communication perspectives on HIV/AIDS for the 21st century(pp. 3-28).New York, NY: Lawrence Erlbaum Associates.

Polit, O. F., & Hungler, B. P. (1999). Nursing research: Principles and methods.(6th ed.). Philadelphia: Lippincott Williams & Wilkins.

Powell, H. L., & Segrin, C. (2004). The effect of family and peer communication on college students' communication with dating partners about HIV and AIDS. Health Communication, 16, 427-449. Redfield, R., Linton, R., & Herskovits, M. J. (1936). Memorandum for the study of acculturation. American Anthropologist, 38, 149-152.

Rojas-Guyler, L., Ellis, N., & Sanders, S. (2005). Acculturation, health protective sexual communication, and HIV/AIDS risk behavior among Hispanic women in a large Midwestern city. Health Education and Behavior, 32,767-779.

Ryder, A. G., Alden, L. E., & Paulhus, D. L. (2000). Is acculturation unidimensional or bidimensional? Ahead to head comparison in the prediction of personality, self identity, and adjustment. Journal of Personality and Social Psychology, 79(1), 77-88.

Simbiri, K. O. A., Hausman, A., Wadenya, R. O. & Lidicker, (2009)Access impediments to health care and social services between Anglophone and Francophone African Immigrants living in Philadelphia with Respect to HIV/AIDS. Journal of Immigrant and Minority Health, 12(4), 569-579. doi: 10.1007/ s10903-009-9229-8

Scott, S. (2009). HIV/AIDS: Understanding socio-cultural factors and their influence on sexual behavior and decision making in Africa. Journal o/the Manitoba Anthropology Students Association. Retrieved from umanitoba.ca/publications/openjournal/index.php/mb-anthro/

Shoop, D. M., & Davidson, P. M. (1994). AIDS and adolescents: The relation of parent and partner communication to adolescent condom use. Journal of Adolescence,77,137-148.

Simbiri,K. O. A., Hausman, A., Wadenya, R. O., & Lidicker, J. (2010). Access impediments to health care and social services between Anglophone and Francophone African immigrants living in Philadelphia with respect to HIV/AIDS. Journal of Immigrant and Minority Health, 12,569-579. doi: 10.1007/ s10903-009-9229-8

Southerland, S. M. (2003). Factors related to condom use among sexually active African American female using health belief model constructs and potential cues to action with a mass communication/interpersonal communication approach. (Doctoral dissertation) University of Tennessee, Knoxville.

Tabachnick, B. G, & Fidell, L. S (2007). Using multivariate statistics(5th ed.) Boston: Pearson.

United Kingdom Collaborative Group for HIV and STI Surveillance (2004). Focus on prevention. HIV and Other Sexually Transmitted Infections in the United Kingdom in 2003. Retrieved from Health Protection Agency website: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1203496898848

Matthew Asare, PhD, MBA, CHES

Manoj Sharma, MBBS, MCHES, PhD

Matthew Asare, PhD, MBA, CHES, Assistant Professor, Department of Kinesiology & Health, Northern Kentucky University, 116 HC, Nunn Dr, Highland Heights, KY 41099, (859) 572-5196 (Phone), (859) 572-6090 (Fax), asarem1@nku.edu (E-mail). Manoj Sharma, MBBS, MCHES, PhD, Professor, Health Promotion & Education Program, University of Cincinnati, Cincinnati, OH 45221-0068, (513) 556-3878 (Phone), (513) 556-3898 (Fax), manoj.sharma@uc.edu (E-mail)
Table 1. Summary of Demographic Characteristics of the participants
(n = 412)

Variables            Frequency   Percent

Gender

Male                    249       60.4
Female                  163       39.6

Age

  21-30 years           116       28.2
  31-40 years           168       40.8
  41-50 years           99         24
  51-60 years           25         6.1
  61 years and           4          1
    above

Marital status

  Separated              8         1.9
  Living together       23         5.6
    with partner
  Single                105       25.5
  Widowed                4          1
  Divorced              16         3.9
  Married               256       62.1

Education

  None                   5         1.2
  Less than             22         5.3
    High School
  High School           101       24.5
    Diploma/GED
  Associate Degree      64        15.5
  Some                  40         9.7
    undergraduate
    course taken
  Undergrad degree      90        21.8
  Graduate              90        21.8
    degree/Higher

Table 2. Distribution of range, means and standard
deviation of HBM constructs, sexual communication
experience with family and Acculturation (n = 412)

Variable               n     Possible Range   Observed Range

Perceived benefits     412   2.00-10.00       2.00-10.00
Perceived barriers     412   5.00-25.00       5.00-25.00
Self-efficacy          412   3.00-15.00       3.00-15.00
Sexual comm & family   412   5.00-25.00       5.00-25.00
Cues to action         412   3.00-15.00       3.00-15.00
Acculturation          412   8.00-9.00        8.00-39.00

Variable               Mean     Std. Deviation

Perceived benefits     7.502    2.236
Perceived barriers     10.418   4.280
Self-efficacy          11.435   2.953
Sexual comm & family   13.000   5.235
Cues to action         7.461    3.069
Acculturation          15.953   5.678

Table 3. Summary of log-likelihood and Chi-Square distribution
for full model of predictors of sexual communication
behaviors (n=412).

Variable          -2 Log       -2 Log       [chi      df   Sig.
                  likelihood   likelihood   square]
                  (Constant    (Full
                  only)        model)
Predictors of     327.533      255.119      72.414    5    .000
  Sexual
  Communication

Note: Cox & Snell R2 = .161 (sexual communication);
Nagelkerke R2 = .294 (sexual communication);
Classification: No sexual communication =33.9,
sexual communication = 98.0, overall % = 89.3;

Table 4. Summary of parameters of HBM constructs,
acculturation, and demographics predicting sexual
communication behavior among the participants
(n = 412)

Variables            Sig.    OR     95% C.I. for OR

                                    Lower   Upper

Family Sex Com       .509   1.025   .953    1.103
Cues to action       .005   1.220   1.064   1.400
Perceived benefits   .000   1.452   1.268   1.663
Perceived barrier    .159   1.059   .978    1.148
Self-efficacy        .143   1.080   .974    1.198
Perceived            .000   1.290   1.138   1.463
  susceptibility
Perceived severity   .812   1.016   .890    1.161
Acculturation        .013   1.081   1.016   1.150
Education            .235   .900    .756    1.071
Marital status       .253   .871    .687    1.104
Age                  .000   .490    .338    .712
No. of yrs           .580   .921    .688    1.233
  lived in US
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