There is sufficient HIV/AIDS research to document the efficacy of education and counseling in HIV prevention; however, for HIV/AIDS prevention interventions to be successful in immigrant communities they must be provided in culturally competent environments. The Enhanced Case Management Plan implemented in the Haitian immigrant community of Boston confirms the importance of understanding the cultural orientation of the target population in designing prevention programs. The intervention is successful in addressing cultural barriers to HIV prevention services by providing a culturally competent environment while at the same time providing HIV prevention education and psychosocial support.
Anthropologists were among the first scientists to discover the cultural relativity of the conceptions and definitions of health and illness (Herzlich and Graham 1973). The early work of anthropologists revealed that how people define illness and health cannot be separated from notions, values, and ideas about the gods, human relationships, and good and evil. Beliefs about the origin of disease, individual response to disease, and the treatment one seeks are interlinked with the culture (Auge and Herzlich 1995). Thus, the representation of illness, the behavior of the sick, and treatment practice vary from culture to culture.
Psychosocial theory also has contributed to an understanding of the cultural dimension of individual health behavior. The health belief theory (Becker 1974, Rosenstock 1974, Rosenstock, Strecher, and Becker 1994), the reasoned action theory (Fishbein and Ajzen 1975) and social cognitive learning theory (Bandura 1977) explain determinants of health behavior. These theories examine rational factors and cognitive processes that shape the isolated individual's decision-making patterns.
The Enhanced Case Management Plan described in this paper incorporates the health belief model in designing a program to change the risk behavior of HIV in infected Haitians living in Boston and its surrounding communities. The ECMP is based on the assumption that cultural barriers to Haitians seeking HIV health care and social services support are individual and systemic, Haitians' individual beliefs about the origin of HIV and appropriate treatment can be a barrier to seeking medical care. The systemic barrier refers to cultural bias in the service delivery system. The delivery system is based on American social values and community norms, with little or no consideration for other cultures, incongruence between American culture and Haitian culture creates a barrier to Haitian immigrants using social and heath care services.
The Greater Boston Haitian Immigrant Community
The Haitian community is one of the fastest growing immigrant communities in the Greater Boston area. Many Haitians have encountered political repression and/or economic deprivation in their native land. As newcomers they often face the challenges of language, literacy, and cultural adaptation that are essential to socioeconomic survival in the United States. Unfortunately, Haitians are also faced with the challenge of being the only ethnic group in the United States to be singled out as an AIDS at-risk group (Centers for Disease Control and Prevention 1983). This stigma has caused fear and discrimination towards the Haitian community, which has exacerbated problems for Haitians who are HIV-infected or who have AIDS.
Besides the complications of immigrant status, Haitians suffer their own intra-community stigmatization that, while often resulting from strong moral ideals based in religion, leads to beliefs that disease is punishment for past sins and is caused by immoral behavior. These beliefs are not unique to the Haitian community, and many non-Haitian religious fundamentalists in the United States and elsewhere share these beliefs. The point made here is that Haitians are not exempted from religion-based moral judgments …