THE ROLE OF SPIRITUALITY PREVENTING EARLY SEXUAL BEHAVIOR

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Abstract: Many African American girls begin pubertal development very early and run the risk of engaging in early sexual behavior and its harmful consequences. Health and educational programs are attempting to provide them with the help they need to avoid inappropriate sexual behaviors at such a young age. However, local and national statistics indicate that oral and vaginal sexual intercourse are occurring in rising numbers among this group. Spirituality may be an important variable in health promotion to prevent early sexual behavior. The purpose of this paper is to examine the role of spirituality in preventing early sexual behavior among these girls.

Adolescence is a time of transition, change, and heightened vulnerability (Chamberlain & Hall, 2000) during which adolescents feel pressured by and caught up between internal needs and societal demands. Breast development, onset of menstruation, pubic hair growth and growth spurts occur in all adolescents, but are occurring earlier among African American girls (Doswell, 2000; Feldman, 1998; Herman-Gidden et al., 1997). Despite the decline in teen pregnancy in urban African American adolescent girls, early sexual activity remains high. Many African American adolescent girls, especially those from lower income, mother-headed or disrupted families may be at high risk for early sexual behavior. Oral sex, with its concomitant adverse outcomes of sexually transmitted infections, including HIV/AIDS, is rising among African American adolescent girls (Kaiser Family Foundation, 2002). A review of the literature shows multiple underlying factors leading to early sexual behavior. These factors include the explicit and generally permissive sexual behavior of the larger society, the influence of peers who are sexually active, the media's heavy focus on sex, and adolescent girls' own inner urge for sex (Brown and Steele, 1995; Doswell, 2000; Emerson, 2002). Intervention research to delay or reverse the onset of early sexual behavior has been successful in the short term, but none has been confirmed to be a long-term solution. As in other high-risk behaviors, an inner unmet need may be the underlying motivating factor behind sexual appetites expressed early and in risky behavior.

This inner unmet need, more likely spiritual in nature, has not yet been explicitly addressed by previous intervention research. Spirituality may be especially important to adolescents' search for self-identity, life purpose, life direction and meaning in life. Spirituality based on everyday life needs and concerns is gradually altering American spiritual landscape (Wuthnow, 1998). This view of spirituality is consistent with a more general literature commonly known as self-regulation theory (Bouffard and Vezeau, 1998; Bouffard-Bouchard, Parent & Lavalée, 1993). Lerner (2002) defines self-regulation as one's ability to anticipate, control, and direct one's life through strategies to develop life goals and coping skills. Self-regulation also involves the quality of one's relationship with one's family, peers, school, and neighborhood. Although similar, there is a difference between spirituality and self-regulation. Self-regulation is a point of interface between one and some or all aspects of one's behavior. For example, one may be a total success in some areas of life, but a total failure in others. In contrast, spirituality is a commitment to a life purpose, a life direction, and a life meaning. It is about the person as a whole genuinely engaged to contribute to the well being of self and others. A girl who exhibits spirituality will be a girl in touch with herself and her community, and a girl able to self-regulate in the presence of peer pressure, temptations, and unwise choices. In this paper we will examine the potential influence of spirituality in preventing early sexual behavior among African American adolescent girls.

SPIRITUALITY: MEANING, ROLE AND CHALLENGES IN HEALTH PROMOTION
We define spirituality as one's ability to keep centered no matter how severe one's life circumstances and how conflicting the messages coming from one's personal, family and community related issues. Spirituality is an ever-increasing search for and commitment to a life purpose, a life direction and a life meaning. Spirituality comprises the values by and through which we construe our worldview, organize our day-to-day living and assess our way of life. Our spirituality determines, guides and controls each and every decision, action, interaction and reaction we make or refuse to make. It is a disposition to achieve a deeper, fuller, and better life. Spirituality is about who we are: our individuality, identity, sense of social interconnectedness, and of being a part of something greater than us and larger than life. Spirituality is characterized by a balance between two end points of a continuum. One endpoint involves being spiritually integrative or "connected," and the opposite endpoint involves being spiritually disintegrative or "disconnected" (Jackson-Lowman, Rogers, Zhang, Zhao & Braithewaite-Tull, 1996).

Spirituality is becoming an important variable in understanding body-mind relationships, in providing care to client as whole persons and in preventing and/or healing whollistically. Chatters (2000) states that spirituality and spiritual concerns are particularly important for understanding health-related behaviors, attitudes and beliefs for individuals whose health is compromised or who are most vulnerable. According to a poll by Gallup and Jones (2000), teens say they believe in God (95%), they pray when alone (74%), and have a great interest in discussing the existence of God (64%). However, there was no indication of the percentage of African American teens in this sample, nor their beliefs in relation to issues of spirituality.

The role of spirituality in delaying or reducing early and risky sexual behavior has not been empirically examined, especially among African American adolescent girls, certainly at greater risk because of their earlier physical maturity, and more frequent fatherless homes. Health promotion strategies based on culturally relevant theories are needed to take into account the role of spirituality in preventing early and risky sexual activity. Health care professionals should give careful consideration to the role and importance of spirituality in health promotion in general and in early sexual behavior risks prevention in particular (Thoresen & Harris, 2002). Mattis & Jagers (2001) see spirituality as one of the defining features of African American life. To them, spirituality guides and affects positively the affective, cognitive, and behavioral mechanisms that shape African American individuals, family and communal relationships. Community as practical goal and highest good, coupled with reciprocal relationships between persons and invisible spirits, signal according to Paris (1995), the pragmatic nature of all African thought in relation to each of the realms of life: spirit, history and nature.

Trying to link spirituality to health promotion presents some challenges. On one side, spirituality seems to be too broad and abstract a concept, too close to one's own personal belief system, and too far apart from what health care providers believe their role to be. On the other, health science deals more with and relies much on empirical data, hard facts, and well-constructed and replicable methods and techniques. Trying to incorporate one with the other may seem working outside the traditional rigor of the scientific path based on valid facts and reliable evidences drawn from well-controlled studies (Thoresen & Harris, 2002). Any attempt to link spirituality to health promotion may then be thought of as difficult and misleading (Lawrence, 2002).

BACKGROUND AND SIGNIFICANCE OF SPIRITUALITY
One of the ultimate functions of spirituality is to assist the individual to achieve self-control and self-mastery skills, important in the prevention of early sexual behavior. The inclusion of spirituality as an important variable in health promotion research is gaining wider acceptance. Empirical studies on religion, spirituality and health are proliferating the scientific literature (Sloan and Bagiella, 2002; Larimore, Parker & Crowther, 2002). Many major medical, psychiatric and behavioral medicine journal have published on the topic (Underwood & Teresi, 2002). But what is examined seems to vary from one study to another. Some studies are more focused on church attendance and religious activities (frequently labeled as "religiosity"), while other studies focus more on coping skills (labeled as spirituality based on everyday life needs). Others focus more on life meaning--a blend of faith and daily life based spirituality--which we consider to be the most important aspect of spirituality. Beyond these conflicting foci, the main issue is the impact of spiritually integrated or disintegrated ways of being on how people, families and communities live. Horney (1950) viewed self-destruction tendencies as results of deep-rooted feelings of inferiority and an overwhelming sense of failure in meeting societal expectations. Jung (1964) echoed Horney's view and went deeper to see self-destruction tendencies as an expression of intolerable living situations and a longing for spirituality.

Spirituality, a lens through which we view mind and body relationships, reflects life's deepest longings: a purpose, a direction and a meaning. Deep-rooted feelings of inferiority, overwhelming sense of failure, and yearning for life meaning are daily components of many African Americans in the inner cities. Taylor, Obiechina & Harrison (1998) described this situation as a spiritually disintegrated way of being or loss of bearing. They characterized it as an acute or chronic diminution in one's sense of purpose and meaning. Spiritual disintegration reinforces one's desire to engage in risky palliative self-absorption behaviors such as early and risky sexual activity. It also decreases one's ability to access to personal and social resources that may help one finds adaptive solutions to poor decision-making, risky behaviors, and unwise activities. Subsequently, preventing early sexual behavior among African American adolescent girls may require more than the usual health promotion training strategies: abstinence, single partner, protective, safe and healthy sex. It may require a spiritual component, or commitment to a life purpose, direction, and meaning, which can help young girls enhance their coping skills and resistance to the risk of early sexual behavior.

There are empirical studies that suggest a positive impact of spirituality on African American youth's health and overall well being. McCree (2002) emphasized the importance of integrating religiosity into motivational and self-help programs for African American adolescents. An adolescent's private religious devotion, an indicator of their spirituality, is more of a protective factor against early sexual debut than their public religious behaviors. A study by James (2002) suggested that adolescents' level of religiosity alone is not a predictor of self-control, abstinence and early sexual behavior mastery. Therefore, intervention programs aimed to improve the quality of life of African American youth should incorporate proactive racial socialization messages and spirituality (Jamie, 2000). Gladding (1977) found that adolescents who reported positive feeling about school and/or religious belief had significantly lower anomie. He stated that adolescents' connection with school and a system of belief reinforced by the community is very important to adolescent self-identity. The National Study of Youth and Religion (Smith & Faris, 2002) found 12 graders' religiosity to be significantly linked with fewer of the following behaviors compared to non religious adolescents: smoking, going to bars, drinking, shoplifting, stealing, and skipping school. To Pelletier (1994), health promotion is achieved through an inner disposition to a healthy lifestyle potentially present in each of us. Spirituality constitutes both the nature and nurture of this disposition.

There is scientific evidence that living a spiritual and positive life improves brain function (Amen, 2002). According to Amen, focusing on values enhances prefrontal cortex function, and calms the emotional area of the brain crucial to decision-making and planning for the future. When the prefrontal cortex works properly, we are no longer driven by pure instinct or desire, key issues in early sexual behavior. Spirituality is also fundamental to one's quality of life. To be successful in any line of endeavor, we first have to decide what we want out of life, which is a spiritual question.

However, the research literature on spirituality shows conceptual and methodological weaknesses (Chatters, 2000). The sample sizes are too large and too general to specify characteristics of specific subpopulations such as racial/ethnic minority adolescents. Further, sample size is too specifically focused on specific religious denominations, multivariate statistical approaches that don't take into account differing set of statistical controls. There is also a limited development of theoretically based conceptual definitions of the terminology and instruments that focus on developmental and chronological age. Chatters concludes that greater clarity in conceptual definitions of spirituality and its multidimensionality, specification of explicit theoretical linkages connecting religion and health, and the development of conceptually valid instruments are essential steps.

HISTORICAL PATH OF TODAY'S ADOLESCENT SEXUALITY
Between the 1960's and the 1970's, the Baby Boomers, caught up in difficult transition to adulthood, were asking: "What does it all means?" Their children, known as the "latchkey" kids or Generation Xers', were generally left alone home because both parents worked (Gallup & Jones, 2000) to achieve the American dream: two cars, a house and other material comfort. Television sets became babysitters and pop culture part of the nurture that shaped their lives, values and character. The children of the 1980's and 1990's have been characterized as "hurried" children (Elkind, 2001). They found themselves pressured to take on adult clothing, to listen to music with sexual content, watch adult television shows and movies. They spent summers in computer or space camps and attended academic enrichment programs. Such socio-cultural pressure to achieve a decent living at any cost including that of a meaningful life forced little girls to cast aside playing dolls before the age of 10 and boys to engage in competitive sports that parallel the intensity of the professionals. As result, many adolescents experienced a sort of alienation from both mainstream culture and religious organizations. Their spiritual malaise became a fertile ground to permissive and promiscuous sex, tobacco addiction, drug use, alcohol abuse accompanied by violence turned against other adolescents (Doswell, 2000; Taylor, Obiechina and Harrison, 1998).

Since 1993, sexual infection has been found to be the largest risk category for African American women (Hetherington, Harris, Bausell, Kavanaugh, & Scott, 1996). The U.S. Surgeon's General report on sexual behavior (2001) and other research on African American population show that African American adolescent girls report early sexual experience, unprotected sexual intercourse and its adverse health outcomes (Michael, Gagnon, Laumann, & Kolata, 1994). A summary of sexually transmitted diseases between 1996-2000 in Allegheny County, Pennsylvania, made by the Pittsburgh Urban League (2001) indicated that African American adolescent girls ( 15-19years old) are respectively 18.6% and 43.6% times more infected by chlamydia and gonorrhea than their Caucasians counterparts. For the year 2000 alone, Allegheny's countywide statistics unadjusted for population indicated that 80% of female reporting chlamydid and 90% reporting gonorrhea were African American women. HIV infection rates also show dramatic shifts with 54% of new infection occurring among Blacks, and 19% among Hispanics despite the fact that they represented respectively only 13% and 12% of the total population (CDC, 2001). AIDS is now the leading cause of death of Blacks men and minority women between the age of 25 and 44 (CDC, 2001).

Why do STI's persist in the African American community despite the availability of 'successful' prevention and treatment programs and health policies? Why is that intervention research on early sexual risk behavior has only been effective for the short-term? Answers to these questions may be related to many different factors such as: absence of cultural components, design flaws, dosage and implementation issues, accessibility to health services, and confidentiality. We also believe that part of the problem lies in the following three areas:

• Interventions are often more ailment than strength driven.

• Interventions may fail to accommodate individuals' racial, communal and cultural specific needs and challenges.

• Interventions tend to be more focused on treating STI's than developing preventive strategies based on the target communities' context and needs.

Our claim is that African American adolescent girls need to develop a disposition to integrate their spirituality and daily life experiences into an inner set of core beliefs fostering self-control. Delaying or reversing early sexual behavior is a fundamental yet often missing piece in health promotion interventions. Integrating spirituality into intervention design may be the most effective approach for understanding and addressing the diversity and complexity of issues related to early sexual behavior prevention. Spirituality sharpens our ability to predict with greater clarity the consequences of our daily actions and interactions. Adolescents, new to decision-making and its consequences, may be among individuals who think, act and behave as if they have no responsibility to maintain their own health. To some of these individuals, health and life span, here and thereafter, have long been decided by predestination. All they have to do is to follow the path of their already predicted health and life destiny. Belief systems such as this one may hinder spirituality in their day-to-day life, health promotion, and personal growth.

THE RATIONALE OF EARLY SEXUAL BEHAVIOR PREVENTION PARADIGM SHIFT
Our paradigm shift is a new way of seeing and dealing with early sexual behavior prevention. The newness of our approach is the split of the early sexual prevention role into two function of equal importance: communal function and individual function. The first function is to promote in depth social connectedness and interdependence. The second function is to ensure self-regulation and independence. Both functions are instrumental to early sexual behavior prevention. Our approach is to combine communal (family, peers, school, church, and public care) input and early adolescent girls' personal input. Previously, input was essentially from the community. It has worked and will as long as individuals' ways of being reflect communal expectations. Because of the rising conflict between individual and communal values and the sexual messages from the mass media, we believe that an effective way of dealing with early sexual behavior prevention is to:

• design approach that deepens and promote communal input where it still exists.

• inspire adolescent girls to combine and harmonize social and personal resources at their disposal in order to become the very agent of their early sexual behavior prevention.

Figure 1 symbolizes our understanding and beliefs about the role and importance of spirituality in people's daily lives, health promotion and early sexual behavior prevention The figure shows that the integration of social norms (interdependence) and individual need (independence) respectively contribute to the development of a spiritually integrated way of being that results in skills of self-control, self-mastery and self-navigation.

Research on social and cultural integration shows interesting differences between independent and interdependent people (Landrine, 1992; Markus & Kitayama, 1991). Independent people are described as having personal abilities, preferences, needs, desires, and a life style of their own without any reference to others or to a context. Independent people tend to think about themselves in isolation. Interdependent people have a self that exists in the context of relationships. These individuals have no enduring characteristics, traits or desires, in isolation from their relationships and contexts (Landrine, 1992). Both of these groups are missing a fundamental aspect of spirituality. Independent people are missing enrichment acquired from associating with others. Interdependent people are missing the uniqueness of one's own inner life and resources. We contend that spirituality is a bridge-building process between independence and interdependence that will enable African American early adolescent girls to develop personal and external resources to control their growing sexual desires.

A COMMUNITY PROGRAM FOR GIRLS BASED ON SPIRITUALITY
The NIA Girls' self-development program, an after school program for young women of color (ages 8-10), was developed out of requests from a local inner city school developmental counselor, a local health clinic social worker, and the nursing director of the health clinic. As young girls came to the clinic for health care, parents indicated there was no after school activities for their daughters. The NIA program was created at the clinic to fulfill that need. The program's name, NIA, is derived from one of the seven principles of the African American cultural holiday, Kwanzaa, which in Swahili means, "having a sense of purpose" (Karenga, 1977). Begun in 1994, this after school program, coordinated by the previously mentioned individuals, and the primary author, consists of weekly 45- minute sessions year round. Some of the activities and topics covered are a health jeopardy game, videos on African American culture, teaching of decision making and conflict resolution skills, etiquette, nutrition, hair design and care, skin and nail care, table games to teach cooperation, miming, talks about puberty and care of our bodies, and outdoor physical exercise. The NIA group also has a read around where books by African American authors about African American girls are read and discussed--sometimes led by the author. As the girls reached middle school, a NIA Girls-2 group was created, and this past summer a NIA Girls-3 group, as some original participants entered high school in the fall of 2002.

From its inception, the NIA program included an implicit, if not explicit spirituality component. The program strives to harmonize the community's need for order, stability, and well being, and each adolescent girl participant's need for self-identity, inner autonomy and healthy growth. Teaching NIA girls about African American culture, conflict resolution, and cooperation is teaching the interdependent aspects of a spiritually integrated way of being. Teaching them about decision-making, hair, skin, and nail care, aspects of puberty and care of their bodies, is teaching them the independent aspects of a spiritually integrated way of being. Integrating and harmonizing societal demands with individual needs of adolescent girls constitutes a unique opportunity to familiarize them with the first two of our 3 components of spirituality--a life purpose and life direction.

The last step, life meaning, is a personal journey that they will learn as they mature and encounter life experiences. To help these girls fully understand and navigate these components of spirituality may take a new model of learning comprised of four levels: 1) objective learning; 2) active learning; 3) meaningful learning; and 4) mindful learning. Objective learning exposes the girls to measurable aspects of early sexual behavior risk through knowledge imparted by their parents or health care providers. Active learning means engaging girls in learning by using personal stories, and lived experiences from significant others to assist them to understand and internalize what is being taught. Meaningful learning is teaching girls to embrace what is learned and applying the learning to address and solve real life issues that matter to them. Mindful learning encourages girls to use the first 3 types of learning to question, analyze, and evaluate their behavior and select a more health-promoting behavior when encountering life situations and circumstances that are potentially harmful.

CONCLUSION
This paper has reviewed the meaning and potential role of spirituality in health promotion and prevention of early sexual behavior in African American adolescent girls. Spirituality is an important but often neglected component of early sexual behavior prevention. Spirituality is a self-regulatory process that may enable these girls to anticipate, control, and deal constructively with each aspect of their daily life, including the control of their sexual desires. The absence of spirituality in health promotion strategies, specifically early sexual behavior prevention, is probably due to the confusion surrounding the meaning, role, and importance of spirituality in daily life. Spirituality is a self-righting and self-directing influence we need to incorporate into health promotion strategies if we are to be able to prevent early sexual behavior among our young girls. The NIA Girls' Group provides an opportunity for exploring the inclusion of spirituality components as part of its program of early sexual behavior prevention. As a first step, we are currently designing a Spirituality and Sexual Behavior Questionnaire that will examine adolescents' perceptions of the linkage between spirituality and their own sexual behavior within the NIA program.

Address all correspondence to Willa M. Doswell, Ph.D., Assistant Professor, Department of Health Promotion and Development, School of Nursing, University of Pittsburgh, 460 Victoria Building, Pittsburgh, PA 15261, PHONE: 412.624.8977, E-MAIL: wdo100@pitt.edu.

HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY ADDRESSED
Responsibility X - Advancing the Profession of Health Education

Competency A - Provide a critical analysis of current and future needs in health education.

Subcompetency 1 - Relate health education issues to larger social issues.

DIAGRAM: Figure 1. Early Sexual Behavior Prevention Paradigm Shift.

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By Willa M. Doswell, Ph.D.; Malick Kouyate, Ed.D. and Jerome Taylor, Ph.D.

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