Section: Original paper


Abstract: Asian Pacific Islander communities in the United States have
experienced an alarming increase in HIV infection over the past few years,
possibly due to a lack of knowledge and the relative absence of appropriate
educational interventions. The authors propose a new approach to the
development of HIV prevention programs in U.S. southeast Asian communities.
This article reviews the cultural and economic factors that may facilitate
HIV transmission within these communities. Relying on the basic precepts of
Buddhism, the dominant religion of many southeast Asian populations in the
United States, the health belief model is utilized to demonstrate how
recognizable, acceptable religious constructs can be integrated into the
content of HIV prevention messages. This integration of religious concepts
with HIV prevention messages may increase the likelihood that the message
audience will accept the prevention messages as relevant. This nuanced
approach to HIV prevention must be validated and refined through field
research.

Key words: Religion, HIV prevention, ethics, Buddhism.

Recent statistics underscore the urgent necessity for HIV prevention
programs that are both effective in and acceptable to southeast Asian
communities in the United States. Asian Pacific Islanders have experienced
an increase of AIDS cases at a rate greater than that among other ethnic
communities in at least two major urban areas.(n1-n2) Homosexual Asians and
Pacific Islanders experienced a 55 percent increase in new AIDS cases
between 1989 and 1994, compared with 14 percent among homosexual white
men.(n3) Additionally, the HIV infection rate among homosexual Asian and
Pacific Islander men is significantly higher than the rate among white
homosexual men (26.9 and 15.5 percent, respectively).(n4) Although many of
the infected individuals may have been born outside of the United States,
they may have acquired HIV infection within the United States.(n6) Various
theories have been advanced to explain these figures. Asians, and southeast
Asians in particular, may be at increased risk of contracting HIV infection
due to relatively low levels of knowledge regarding HIV and mechanisms of
transmission,(n6-n8) the high prevalence of risky sexual practices,(n9-n12)
and the relative absence of educational interventions designed to reach
these communities.(n13-n15)

The authors of this article propose a new approach to the development of
HIV prevention programs in the southeast Asian communities in the United
States. As background, a review is provided of cultural and socioeconomic
factors that may facilitate HIV transmission within these communities.
Relying on the basic precepts of Buddhism, the dominant religion of a
number of southeast Asian populations in the United States,(n16) the health
belief model is utilized as an example to demonstrate how easily
recognizable and acceptable religious constructs can be integrated into the
content of HIV prevention messages. It is not suggested by this usage that
the health belief model is more appropriate to southeast Asian populations
than are other models of behavior change, although at least one research
group has done so.(n14) The authors suggest that the integration of
religious concepts with HIV prevention messages may increase the likelihood
that a greater proportion of the message audience will accept the
prevention messages as being relevant to them. The suggested approach
emerges not only from a review of the relevant literature, but also from
the direct experience of the research team. Several of the authors have
spent a number of years working in Laos (Loue) and with southeast Asian
communities in the United States to assess the prevalence of HIV and to
develop culturally appropriate HIV intervention programs (Loue, Lane, Loh).
Others on the research team have an extensive background in health
education and communication (Loue, Lane, Lloyd).

Significant cultural differences exist between the various southeast Asian
 communities in the United States, which is defined as encompassing Thais,
Laotians, Cambodians, Burmese, Malaysians, Indonesians, Singaporeans, and
Vietnamese.(n17) Additionally, the practice of Buddhism is characterized by
nuances in ritual, liturgy, and dogma stemming from varied schools of
teaching and the local transformation of basic precepts and traditions,
much as the practice of Christianity varies by denomination, time, and
place. Just as the various Christian denominations share certain common
themes, such as a belief in Jesus Christ and the validity of the New
Testament, so, too, do the various schools of Buddhism share certain basic
beliefs. The aim of this article is to identify key concepts common to the
southeast Asian communities and to the various schools of Buddhist teaching
in the United States as a basis for the development of acceptable and
efficacious HIV prevention messages for these communities. These key
concepts, despite their varied meanings across groups, resonate suffidently
between and among groups to provide the framework for a culturally
sensitive approach to HIV prevention within these communities.

For example, many schools of Buddhism do not believe that merit can be
transferred by one individual to another to better the second person's
karma. (The concept of karma is discussed in greater detail below.) At
least one school of Buddhism, however, recognizes this transference.(n18)
Whether or not an individual or community ascribes to the transference of
merit, the concepts of merit and karma can still be incorporated into HIV
prevention messages, as described below.

The discussion that follows is in no way intended to diminish or ignore the
differences that exist; the authors recognize that such an intervention
carries with it the danger of essentializing a culture and tradition that
is quite heterogeneous. Nevertheless, there is a desperate need for HIV
education interventions that are as finely tuned as possible to local
cultural conditions. The proposed approach seeks a middle way between a
culture-neutral approach and a supernuanced approach that would be neither
cost-efficient nor logistically feasible. It is recognized that the
strategies that are presented here may well require "localization" prior to
adoption and implementation in a specific community. It is further
recognized that the Buddhism-based strategies that are presented here will
most likely not be relevant to non-Buddhist southeast Asians.

Cultural and social factors affecting HIV transmission

Familial and cultural expectations. It is important to recognize that there
is no "typical" Asian family.(n19-n20) Numerous studies, however, have
identified characteristics that appear to predominate across many southeast
Asian families(n16-n21) Some southeast Asian families, and particularly
those from Vietnam, are modeled along Confucian lines, which favor male
descent lines(n19, n22-n23) In such families, a bride often has minimal
status in a household until she produces sons(n24-n26)s Women often expect
to reap rewards in their old age in exchange for their allegiance to this
system.(n27) The family is typically multigenerational, with several
generations living under the same roof. The authority of the grandparents,
which is a function of both age and gender, overrides that of the parents
in many family matters.(n28)

Roles and patterns of communication within many southeast Asian families
tend to be formal, with an emphasis on order and hierarchy. Patterns of
communication between fathers and adolescent children are often more formal
or strained than between the children and their mothers,(n29-n30) and
paternal expectations are often conveyed via the mother,(n29-30) Children
are taught to pay proper respect to their elders.(n31-n33) Although
children are often indulged, they are expected to be well behaved and to
bring honor to the family. Academic excellence is one means of bringing
honor to the family and is generally expected.(n31)

According to Berg and Jaya, interpersonal exchanges are often based on
shame, as in fear of public disgrace, rather than internalized guilt.(n31)
The expression of strong emotion is socially unacceptable.(n31)
Consequently, situations involving strangers are, in some cases, less
anxiety provoking than those involving acquaintances or intimates.(n34)

The strength of the traditional hierarchical relationships within the
family has diminished somewhat among southeast Asian families in the United
States due to the inability of many of the immigrant men to secure any
employment or employment other than low-paying, unstable jobs that are
inadequate to meet the economic demands of their families.(n35-n36) Men who
find themselves in this position may suffer a loss of status and prestige
in their families, regardless of their age. The loss of status may also be
caused or exacerbated by an increase in women's control over the social and
economic resources of the household and the children's relatively more
rapid acquisition of fluency in English.(n37-n38) This loss of status may
result in a loss of the male's traditional power and control, with
consequent intrafamilial conflict. This may be reflected in arguments over
money, children's careers, and lack of wifely obedience. Although
disagreements are often a part of family life, family members may deny the
existence of any intrafamilial conflicts in order not to disgrace the
family.(n39) Great value is placed on preserving harmony(n6) or at least
its appearance, within the family.(n40) Mediation and negotiation are often
employed to resolve any acknowledged conflict, rather than direct
confrontation. The needs of the family are generally considered to take
precedence over those of the individual family member.(n19, n41) Exclusion
from the family is described as the worst imaginable punishment.(n31)

The formality of intrafamilial communication, the fear of bringing shame
and dishonor to the family, and the potential for rejection from the family
may not only discourage communication about HIV infection once it has been
contracted but may even discourage individual family members who may have
been at risk from seeking testing, on the theory that what one doesn't know
can't hurt anyone. Disclosure of HIV infection often carries with it images
of inappropriate sexual behaviors, behaviors that themselves could bring
shame and dishonor to the family due to violation of the community's sexual
norms.

Sexual norms. A number of southeast Asian cultures discourage discussions
about sexual matters. Cambodians, for instance, are reported to believe
that a lack of knowledge regarding sexual matters will prevent behaviors
that can result in pregnancy.(n42) Women, in particular, may be prohibited
from engaging in dialogues about sexual matters, even among
themselves.(n43) Consequently, it is not surprising that one study found
that Asian adolescent girls in the United States had extremely low levels
of knowledge about sexuality and contraception. Despite this lack of
knowledge, or perhaps because of it, many adolescents reported having had
multiple sexual partners.(n44) This sense of modesty extends to the health
care context as well. As an example, Spring and her colleagues found that
Hmong women avoided prenatal care visits because of the unacceptability of
pelvic examinations to both the pregnant women and to their husbands.(n45)

Women are often expected to adhere to traditional sexual norms, such as
remaining with their husbands and refraining from having extramarital
affairs.(n36) Both the Lao and the Thai attribute potentially harmful
powers to female sexuality that is neither contained within the marital
relationship nor circumscribed by appropriate displays of modesty.(n14,
n45) This fear of unrestrained female sexuality is reflected in tales of
phii mae maai, the widow ghost that embodies "the sexually voracious spirit
of a woman" who has met an untimely, and often violent, death. Unexplained
nocturnal deaths of men are not infrequently attributed to attacks of the
phii mae maai.(n46) Cambodians may believe that a daughter's premarital
sexual activity will cause illness to strike another member of her
family.(n41)

Lao and Thai also view female genitalia and bodily fluids as dangerous to
the physical and spiritual well-being of men.(n45) Consequently, numerous
rituals have developed to protect men from these pollutants. Laundry must
be hung so that women's undergarments are separate and on a line below the
men's laundry. Women may not step over food or sit on a cushion that is
usually used as a pillow for the head. Men and women may not touch each
other publicly.

In apparent contrast to the Lao and Thai expectation of female modesty and
the promotion of the concept of the "good" woman, Thai communities, in both
Thailand and the United States, often idealize the beautiful, modem Thai
woman through product advertisements and beauty contests. A fine line
separates those women perceived as glamorous from those viewed as
immoral.(n46)

Within Thai and Vietnamese societies, which are characterized by male
dominance,(n47-n48) the reliance of single and married men on commercial
sex workers is generally tolerated.(n49-n50) Tolerance for these activities
appears to exist within U.S. southeast Asian groups. One study has found
that it is quite common for Vietnamese men living in Southern California to
have sex with Mexican female prostitutes in Southern California and the
border town of Tijuana.(n11) In a recent study of HIV risk behaviors and
knowledge conducted among Asian communities in Southern California,
researchers found that 22.8 percent of the male respondents had utilized
the sexual services of prostitutes. Of these, 84.6 percent were married or
had regular sexual partners. Fewer than 50 percent of those utilizing
prostitutes also utilized condoms during sexual activity.(n51)

Many HIV education programs discuss sexual behaviors quite explicitly. This
is most likely unacceptable to many women within the southeast Asian
communities, in view of the strong expectation of modesty in both speech
and conduct. Even when women are able to identify behaviors such as
prostitution and shared needle usage as risk factors for HIV transmission,
they may fail to perceive that they are at risk of HIV transmission as a
result of their partners' sexual relations with prostitutes.(n52)

Within the Vietnamese community, there is a general denial of
homosexuality, and there is extreme homophobia,(n11) often resulting in
stress in family relationships. Shame ensues at the family level when it is
revealed that a family member is homosexual. There is a belief in the
Vietnamese American community that the homosexual behaviors of Vietnamese
men are a result of their seduction by Anglo American men. Vietnamese
community members, as well as Vietnamese homosexuals themselves, may
believe that homosexuals must be feminine, and they consequently deny
homosexuality among "masculine" men.

Homosexual encounters between Vietnamese men may be facilitated by socially
sanctioned close physical contact between males that is considered normal,
such as holding hands or sleeping in the same bed.(n11) Adolescent gay
behavior appears to be restricted to fellatio or masturbation. Older
Vietnamese gay men in the United States may play the role of patron for
newly arrived younger Vietnamese men willing to participate in gay
encounters. Acculturated homosexual Vietnamese men may be at higher risk
for contracting HIV infection because their sexual partners, which often
include Anglo and Latino partners, have a higher prevalence of HIV.
Additionally, there is a greater likelihood that acculturated Vietnamese
homosexual men will engage in receptive anal intercourse, which carries a
higher risk for contracting HIV infection than do fellatio or
masturbation.(n11)

Gang affiliations. Asian gangs have only recently become a matter of
general concern, in part due to their low visibility in comparison with
other ethnic gangs and their high physical mobility.(n53-n56) Southeast
Asian gangs are also a relatively recent development, having their origin
in the several waves of refugees from Vietnam, Cambodia, and Laos that
began arriving in the United States in 1975.(n55, n57)

Unlike members of other ethnic gangs, members of the southeast Asian gangs
are often still in school. Although some gang members may sell or use drugs
or both,(n58) others may refuse to do so, believing that drug involvement
will be destructive to their families.(n59) Various behaviors encouraged
through gang membership are associated with increased risk of HIV
transmission, including the sharing of injection drug equipment,
unprotected sexual intercourse with gang members or with individuals known
to be HIV positive as a condition of gang membership, and the practice of
becoming "blood sisters," whereby female gang members slit open a portion
of their wrists and exchange blood between them to effect a blood oath and
bond (Personal communication, Arlene Buhain, Asian Pacific Islander
Community AIDS Project, San Diego, California).

Youths' participation in gangs is often problematic for both their
communities and their families. Community members may fear the police due
to their many years of living under coercive regimes in their countries of
origin and may therefore be reluctant to report problems to the
police.(n60) Families often feel that family problems are not to be shared
with outsiders and are to be dealt with internally. The very admission of
juvenile delinquency or drug abuse may constitute an admission of personal
and family failure and bring further disgrace to the family.(n53, n61)
Reluctance to discuss such issues on both a family and a community level
may serve to impede HIV prevention efforts.

Illness beliefs. A discussion of illness beliefs is relevant to HIV
transmission for several reasons. First, if individuals' perceptions and
understandings of HIV infection do not conform to their understandings and
perceptions of disease in general, they will be less likely to recognize
symptoms as either symptoms of a disease or as warranting medical
attention. Consequently, they may be less likely to seek medical care.
Also, if symptoms of HIV infection are similar to symptoms of other
illnesses for which individuals normally rely on alternative forms of
treatment, they may delay seeking appropriate diagnosis and care until they
have first exhausted all other potential remedies. This delay in diagnosis
and care may have direct implications for the transmission of HIV to others
through unprotected sexual intercourse and/or the shared use of injection
equipment. Those who obtain HIV testing presumably receive HIV counseling
on how to avoid contracting HIV if they are found to be HIV-antibody
negative and how to avoid transmitting HIV to others if they are found to
be antibody positive. Although knowledge by itself may be insufficient to
motivate behavior change to reduce risk, it remains a basic component of
HIV reduction efforts.(n62) ses not typically encompassed within concepts
of Western medicine, including a weakness of nerves,(n63-n64) an imbalance
of yin and yang,(n64-n65) an imbalance of the life force chi,(n65) a lack
of harmony with nature,(n65) a curse by an offended spirit,(n64-n68)
punishment for immoral behavior,(n69) exposure to unsuitable food or water
or to changes in the weather,(n70) or loss of the soul within the
body.(n71-n72) Consequently, family members may not seek Western-style
health services, believing instead that other means of healing are most
appropriate for the situation. They may, instead, seek the services of a
religious healer(n63-n64) or a shaman(n32, n63, n68) or rely on home
remedies for minor ailments.(n73-n74) The utilization of Western medical
services may be further delayed in situations in which the patient has
experienced communication problems with the provider,(n75) a situation
frequently encountered when translation and interpretation services are
inadequate. Alternatively, individuals may discourage and avoid any
discussion of HIV or potential illness, believing that such discussions by
themselves will bring about ill health.(n14) Consequently, individuals
experiencing symptoms of HIV may not associate the symptoms with either
previous risk behaviors or with the disease known as HIV, resulting in
delayed treatment and possibly further transmission of the infection during
the interim. Individuals may also believe that one's life span is
predetermined and cannot be altered,(n76) thereby obviating the need for
medicai treatment, even of serious disease.

The popular construction of Buddhism's karma

The popular construction among some southeast Asian subgroups of the
concept of karma is an important belief that may increase the risk of HIV
infection. Stated simplistically, the law of karma dictates that
individuals who perform good actions will earn merit or favorable rebirth,
while those who perform wrong actions will earn demerits or unfavorable
rebirth.(n18) Karma has also been referred to as a "law of causation,"
whereby "every effect has its cause and corresponds with that cause."(n18)
Ultimately, the accumulation of these merits and demerits, in the
individual's present and past lives, will determine the extent to which the
individual must suffer in this lifetime.(n18) The degree of an individual's
economic security, for example, is but a reflection of this accumulation of
merit and demerit. An individual may attempt to change his or her karma by
performing deeds that will earn merit. Such deeds can include supporting
one's family and providing gifts to monks or Buddhist temples. As some
individuals may believe, the more an individual contributes, the more merit
an individual will earn and the less he or she may suffer. Consequently, an
individual may continue to engage in prostitution, prostitution-related
activities, or gang-related crimes to earn the money necessary to
contribute to the family and the temple in order to gain merit so as to
reduce his or her suffering in this lifetime or the next. But the
continuation of such activities necessitates further gift-giving to gain
additional merit in order to avoid the consequences of the demerit
engendered by these activities.(n77)

The popular understanding of karma--that all that happens to an individual
in this lifetime is essentially predetermined and that one can effect one's
suffering in future lives only--also provides justification for engaging in
high-risk behaviors for the transmission of HIV infection.(n78) If one
contracts HIV infection, according to this belief, it is the result of
misdeeds or bad thoughts from prior lifetimes. Because one lacks the
ability to modify the course of the present lifetime, there exists no
incentive to modify potentially risky behavior.

Despite these popular interpretations and applications of Buddhist
doctrine, Buddhist moral precepts may well provide a key to the development
of effective HIV prevention messages for the Buddhist southeast Asian
communities of the United States. The potential impact of such an approach
is by no means small. Approximately 4 percent, or 344,142 of the 8,603,548
Asians currently in the United States, are Buddhists.(n79) Clearly, due to
considerations such as age, this number of persons may not be susceptible
to HIV infection at a given point in time. However, all such persons are
potentially vulnerable as they become sexually active and continue to
remain sexually active, due to their own behaviors or those of their
partners. Various subgroups, such as men having sex with men, may be at
relatively higher risk of HIV transmission, as indicated previously.

Buddhist constructs and HIV prevention strategies

Various behavioral theories have been utilized as the basis for HIV
prevention strategies, including the health belief model,(n80, n81) the
theory of reasoned action,(n82) and the self-efficacy model.(n83) It is
beyond the scope of this article to provide a lengthy discussion of each of
these models, a discourse on the various schools of Buddhism and their
differing texts and tenets, or an integration of Buddhist constructs and
HIV prevention strategies into each of the behavior change models. Instead,
the focus of this article is a discussion of Buddhist constructs and HIV
prevention and their integration in the context of the health belief model.
To emphasize again, the authors are utilizing the health belief model as an
example of this integration process; the authors do not imply that the
health belief model is superior to other behavior change models for
southeast Asian Buddhists in the United States.

The discussion of Buddhist precepts focuses on the teachings of the
Theravada tradition, the older of the two major schools of Buddhism as
practiced in Asia. This tradition, observed in Sri Lanka, Thailand,
Myanamar (Burma), Cambodia, Laos, and Vietnam, claims to possess the
unadulterated word of the Buddha.(n18) The Buddhism of Mahayana, the less
conservative school, predominates in China, Korea, Japan, and the
Himalayas.(n18, n84)

The health belief model

The health belief model focuses on behaviors that are under an individual's
control and that can be changed. The model is premised on the assumption
that individuals will act in their own best interests. Factors significant
to the (non)occurrence of behavior change include: (1) a knowledge of the
health risks involved and behaviors that will promote health; (2) a
perception that one is at risk and that that risk is related to one's
actions;(n85) (3) a perception that a specific illness, here HIV, will
result in serious clinical or social consequences;(n86) and (4) the
perceived effectiveness of a change in behavior and the efficacy of the
response. Social network affiliations and group norms have also been
demonstrated to have an impact on the initiation and maintenance of risk
reduction practices.(n85)

Knowledge. The possession of knowledge about HIV and routes of transmission
is essential to the initiation of behavior change.(n85) It is clear from
previous studies that the level of knowledge regarding HIV and its
transmission is quite low within the southeast Asian populations in the
United States.(n6-n8)

Information relating to HIV transmission and strategies for its prevention
can be integrated into discussions of many Buddhist teachings and concepts,
including suffering and the Five Precepts. A basic tenet of Buddhism is
that all existence is suffering (dukkha), including old age, illness,
death, grief, unification with what is unloved, separation from what is
loved, and the inability to obtain that which is sought.(n18, n87)
Pleasures and pleasant experiences are also a fixed part of life, which
renders worldly existence enticing. Ultimately, however, everything that is
joyful and pleasant ends in suffering because of its transitory and
impermanent nature. Permanence is the true measure of happiness.
Consequently, "every mental attachment to something pleasant leads to
suffering."(n18) Buddhism classifies sufferings into three categories:
dukkha-dukkha, that resulting from pain; viparainama-dukkha, that resulting
from change, including impermanent, although pleasant, emotions; and
sankharadukkha, suffering arising from existence as an individual and the
resultant susceptibility to evils.(n18)

Suffering is engendered through mental identification with any of the Five
Groups of Grasping: body (rupa), sensation (vedana), perception (sanna),
mental phenomena (sankhara), and consciousness (vinnana).(n87) These groups
represent suffering because they are bound to the phenomena of birth,
illness, longing, and death, which are themselves suffering. Additionally,
each of the groups is itself transitory in nature.(n87)

Craving, the central immorality,(n88) can take three forms: craving for
lust, craving for becoming, and craving for destruction. Craving that is
not fulfilled results in suffering. Craving that is fulfilled results in
suffering due to the impermanent nature of the joy that is achieved.
Craving will itself cause the continuation of the birth-rebirth cycle.(n18)

Two conclusions follow from these premises. First, nothing that is
transient in nature can be true happiness. Consequently, any existence as
an individual must be regarded as suffering due to its impermanent nature.
Second, because all is transitory, nothing in man survives death. These
conclusions comprise the Three Marks: impermanence, sorrowfulness, and
nonselfness.(n18) A discussion of the transitory nature of things and the
consequent suffering provides an opportunity to discuss HIV transmission,
the potential increase in suffering that can result from HIV transmission,
and strategies to reduce one's own HIV risk, such as that from unprotected
sexual intercourse with multiple partners.

Suffering may be terminated by following the Noble Truth of the Way: right
view, right resolve, right speech, right conduct, right livelihood, right
effort, right awareness, and right meditation.(n18) Numerous actions are to
be avoided, as their commission will lead to rebirth as a lower form of
life. All Buddhists are enjoined to adhere to Five Precepts: to avoid
destroying life, to abstain from taking what has not been given, to abstain
from "unchastity," to abstain from lying, and to abstain from ingesting
intoxicating drinks. Monks are further enjoined to abstain from eating
after midday; to keep away from activities such as dancing and singing; to
avoid garlands, perfumes, and cosmetics; to refrain from using high
couches; and to refuse gifts of gold and silver.(n18)

The precept to abstain from destroying life refers to all beings that have
life, including insects.(n87) Five conditions comprise the immoral act of
killing: the fact and presence of a living being, knowledge that that being
is a living being, an intent to kill, the act of killing by specified
means, and the resulting death of the living being.(n87) Killing can be
effectuated by six means: killing with one's own hands, causing another to
kill by issuing an order to do so, killing by shooting, killing by
entrapment, killing by occult means, and killing by mantras.(n87)

The precept to abstain from destroying life may be sufficiently broad to
encompass death via transmission of a fatal disease, where intent to kill
is manifested by a complete indifference to the consequences of one's own
actions, and the killing is effectuated via entrapment (misrepresentation,
lying). This precept could, then, apply to a situation in which an
HIV-infected person decided to have unprotected sexual intercourse and
misrepresented his or her HIV status to the potential sexual partner in
order to convince the individual to proceed with unprotected intercourse.
The injunction to abstain from ingesting intoxicating drinks may be related
to the increased likelihood of high-risk behavior associated with drug and
alcohol ingestion.

Perception of personal risk and clinical or social consequences. Knowledge
alone, however, appears insufficient to maintain risk-reducing behaviors
over time? People tend to underestimate their own vulnerability.
Consequently, one's perception of personal risk may actually be more
important than objective knowledge in motivating behavioral change.(n90)
This may be particularly true with southeast Asian communities, which tend
to believe that HIV is a non-Asian epidemic.(n91)

The Order of Interbeing, an order of "engaged Buddhism" founded by
Vietnamese Buddhists in 1964 in response to burgeoning hatred, intolerance,
and suffering, developed 14 precepts as an expression of Buddhist morality
in the context of then-contemporary issues.(n92) Together with the Third
Precept of Buddhism, which teaches the avoidance of unchastity, the
Fourteenth Precept of the Order of Interbeing serves as a vehicle not only
for a discussion of HIV transmission (knowledge), but also as an
opportunity to evaluate the extent of one's own risk taking. The Fourteenth
Precept, which addresses sexual behavior, states in pertinent part: "Do not
mistreat your body. Learn to handle it with respect. Do not look on your
body only as an instrument...In sexual relationships, be aware of future
suffering that may be caused.(n92)

The focus on the body as an instrument may facilitate discussion by
reducing any anxiety that may be associated with a direct discussion of
sexual behaviors only. The discussion, for instance, could examine ways in
which we treat our bodies as instruments in the context of overwork, lack
of sleep, and inadequate diet, to name but a few examples.

Thich Nhat Hanh, a Zen Buddhism teacher and a participant of engaged
Buddhism, has noted that "causing harm to other human beings brings harm to
ourselves."(n93) In the context of HIV transmission, an individual
potentially brings harm not only to another through unprotected sex or the
shared use of injection equipment but also to himself or herself by
increasing the risk of transmission of HIV and other sexually transmitted
diseases, as well as the risk of other infectious diseases such as
bacterial endocarditis.

Perceived effectiveness of change and response efficacy. It addition to the
requisite knowledge and awareness of the risks associated with their own
behavior, individuals must also feel that they are capable of changing
their behaviors and that these changes will actually make a difference to
them.(n85) Individuals who perceive success in behavior change, and
consequent risk reduction, may find future behavioral change easier.(n81)
Sexual behaviors important in HIV transmission have been characterized as
being of "low changeability" because they are often central to individuals'
self-identity.(n89) It has been suggested that individuals who have engaged
in high-risk behaviors over prolonged periods of time may believe that they
are already infected or that they are immune, thereby reducing their
willingness to change their behavior.(n94) Individuals who do test positive
for HIV may feel that there is no need to change their behavior; after all,
they are already infected.(n95)

Clearly, pursuit of the Noble Truth of the Way will not halt the
progression of HIV disease in an infected individual. However, adherence to
the conduct prescribed by right livelihood, right view, right effort, right
awareness, and right meditation could potentially yield benefit to the
individual and to his or her community.

First, the integration of right awareness, with its emphasis on the
interdependency of all things and the nature of suffering,(n18) with
information about HIV transmission may assist individuals to evaluate more
accurately the level of their risk of HIV infection and the consequences of
their conduct on others. The exploration of right livelihood may yield
similar results, as individuals may become more aware of the
interconnectedness of their own or their partners' prostitution- or
drug-related activities and HIV infection.

Second, this integrated discussion of HIV and relevant religious precepts
also serves as an opportunity for the transmittal of knowledge, both about
HIV transmission and about the course of the disease. The practice of right
meditation can be integrated with discussion about disease progression,
pain, and stress. The practice of right meditation may provide infected
individuals with alternative techniques for pain management and their
caregivers with a means of reducing related stress.

The incorporation of the concept of karma, as written in the texts rather
than as commonly understood, into HIV prevention education may reinforce
one's perception that adherence to the behaviors encompassed by the Noble
Truth of the Way can be achieved. These teachings emphasize the
insignificance of the self, the interdependence of all existence
(patticca-samuppada),(n88) and the importance of the process of
becoming.(n87) Our existence in this lifetime is the result of deeds that
we performed in previous existences, the result of karma. Our future form
of existence will be determined by our conduct in the present time.
Understood in the context of praxis, karma represents the functional
equivalent of fate, fortune, or destiny.(n96) Even the happiest rebirth,
however, represents yet another cycle of suffering.(n16)

The principle of karma seeks to explain that each individual essentially
makes himself or herself, which is in contrast to the popular understanding
of karma. Karma is not, however, deterministic.(n88-n97-98) Only the
quality of an existence, such as the physical appearance and mental
abilities of a person, is fixed by the deeds committed by the individual in
a previous existence. Deeds in a previous lifetime are not determinative of
actions in the present existence. The individual may exercise free will
through the choice of alternative moral actions. That free will consists of
four elements: origination (nikkama-dhatu), endeavor (parakkama-dhatu),
strength (thiti-dhatu), and volitional effort (upakkama-dhatu).(n88)

One's karma is, not wholly dependent on one's deeds but is also a function
of both the individual's motive at the time of performing the deed and the
end result of the action.(n88) The law of karma has, as a result, been
interpreted as a psychological law because of this emphasis on motive. A
bad thought will give rise to more bad thoughts and, ultimately, a series
of bad thoughts, which will, in turn, produce anxiety and tension and
consequent suffering. Good thought, however, will produce a series of good
thoughts, leading to happiness and calm.(n88) Only those actions that are
performed in the absence of greed, hatred, and delusion, that is, craving
and ignorance, will not result in consequences that are qualitatively
similar to them. Persons who are no longer bound to the cycle of birth and
rebirth by their actions approach the state of nirvana (extinction).(n88)
The Buddhist concept of nirvana has been compared with the Christian
concept of salvation(n99) in that both represent a form of reward for
proper conduct, albeit quite different ones. Because an individual has the
ability to exercise free will through the choice of alternative moral
actions, there exists the possibility of behavior change. Because an
individual's karma is dependent on both behavior and intent, he or she may
be willing to modify behavior in order to modify the resultant karma.

This framework may provide the basis for discussions of alternative courses
of action in situations that could potentially facilitate HIV transmission.
For instance, pursuant to the law of karma, an individual has the ability
to choose his or her own course of action; it is not predetermined.
Consequently, an individual can choose whether or not to engage in
unprotected intercourse with an unknown partner; neither the behavior nor
the resulting transmission of HIV is predetermined.(n88, n97-98) Engaging
in unprotected intercourse under the delusion that such behavior is safe
and cannot result in harm, or that the attendant risk is unimportant, will
result in consequences that are qualitatively similar to the
action-delusion, that is, harmful. Because this behavior originates from
craving, it will necessarily cause suffering. This reasoning process places
responsibility for the chosen course of action on both individuals
involved. The consequences, then, of unprotected intercourse between
HIV-discordant individuals resulted from the choice of each and is the
responsibility of each, with resulting karma for each.

Social networks and peer norms. Yep has noted the difficulty associated
with HIV prevention outreach to gay and bisexual Asians, who may not be
reachable through the more "conventional channels" in gay and lesbian
communities, such as bars and nightclubs.(n100) The authors agree with Yep
that networks and links must be forged within the Asian communities between
service providers, such as health care agencies, and more traditional
social institutions, such as churches and temples.

According to a monk at a Lao temple in San Diego, California, monks are
increasingly being asked to provide assistance to their temple members on
health and social issues. As an example, there was a young man who came to
tell this monk about his deep depression and his thoughts of suicide; the
youth did not know how to tell his family that he was gay. Parents have
reported to this monk their discovery of guns in their children's bedrooms
and their fear of going to the police. Absent a linkage between the temples
and service providers, monks may not be able to adequately address the
needs of the more troubled members of their temples due to a lack of
knowledge of available services.(n101)

Many Westerners might view this proposed linkage as inconsistent with the
practice of Buddhism. This view is premised on a perception of Buddhism as
a vehicle for escape from the pressures of everyday life and the avoidance
of action.(n102) In actuality, Buddhism has a long history of social
 activism. For instance, Praku Sakorn, a Thai monk, is known for his
assistance to the villagers of his province in developing and marketing
various community projects as a means of combating poverty.(n103) The
Buddhist emperor Asoka (B.C.E. 274-236) is known for his creation of a
"welfare state," which provided medical and veterinary services,
constructed rest houses and hospices for the sick, and emphasized the
importance of education.(n102) Buddha himself condemned the caste system in
India and noted the futility of attempts to suppress crime through
punishment.(n104)

Joint temple-social service prevention efforts will clearly not be
sufficient to reach all members of the southeast Asian communities that
they serve. However, this type of linkage may both increase and diversify
the audience receptive to HIV prevention messages. As an example, HIV
prevention efforts may be more likely to reach older men who frequent
female prostitutes if the messages are delivered in the context of a
temple-sponsored activity rather than at a bar or nightclub. The
temple-related messages and activities may be the only setting in which
prevention information can be imparted to these men's wives. The
development of these linkages and the dissemination of prevention
information must be done sensitively, so as not to frighten or alienate the
potential audience.

An example of a successful health program based in Buddhist temples is a
health education and health-screening program for Cambodian women and their
children in two Buddhist temples in San Diego.(n105) The program was set up
in temples as a means to reach women who are not likely to be reached
through other health outreach methods or in Western health care settings.
While this program originally targeted women, many men attended the health
education sessions and participated in the health screenings. The program
offered sessions on a wide range of topics, including pre- and postnatal
care, birth control, STDs, HIV and AIDS, child safety in the home,
earthquake preparedness, and first aid. In fact, the sessions on HIV and
AIDS were well attended by both men and women. After the first HIV/AIDS
presentation, the program was asked to make the presentation to a group of
Asian teenagers and preteens (8 to 15 years of age). This health program is
ongoing.(n105)

Operationalizing Buddhist-grounded HIV prevention strategies

Figure 1 illustrates how the various elements of the health belief model
can be integrated with Buddhist teachings to focus on specific elements of
an HIV risk reduction strategy, such as avoiding unprotected intercourse.
Again, the health belief model is offered as an example of this process
rather than as a definitive solution. It has been suggested that HIV
prevention messages for Asian communities be provided in a culturally
sensitive and linguistically appropriate manner.(n13) Most preventive
education efforts geared to southeast Asian communities have focused one or
more of the following elements to reach their audiences: the language of
the message, such as Thai or Vietnamese; the ethnicity of the counselors or
educators involved in the program; and the medium of the message (brochure,
video, fortune cookies).(n106) The messages themselves tend to address, but
de-emphasize, issues relating to sexuality and sexual behavior.(n14) Yep
has advocated the use of culture-specific, nonthreatening vocabulary to
refer to sexual behavior as a means of facilitating communication.(n106)

In addition to these strategies, the present authors advocate increasing
emphasis on the language and content of the prevention message. The
language of the message must not only be appropriate in terms of its origin
(English, Vietnamese, Lao, etc.), but must also be appropriate to the
educational level and manner of speech of the intended audience. The health
commercials used in Egypt to convey contraceptive information illustrate
this technique well.(n107)

Poetry and humor are highly valued in Egypt. These qualities were reflected
in the many health education spots that aired on Egyptian national
television and that eventually developed into a series of themes played out
over 5 to 15 television spots. One such series involved a zanana, a
comical, meddling older woman. A well-known Egyptian comedienne played this
role, often offering medically inaccurate advice to her daughter and
son-in-law. Her other family members and the family physician often
corrected her very common misconceptions. The scripted dialogue reflected
linguistic and cultural humor. For instance, in one scene, the zanana
slightly mispronounced a word so that instead of saying "condom," she used
a similar-sounding word for a meddling character, resulting in a pun that
reflected on herself. The value of this message derived not only from its
content but from the way it was delivered through rhymes, puns, and
repetitions, which are all highly valued in Egyptian Arabic.(n107)

A similar strategy can be used to incorporate recognizable Buddhist tenets
and stories into HIV prevention messages, both at the level of primary
prevention of the infection and in the context of caregiving. The following
examples are offered.

The Buddhist admonitions against unchastity and lying, together with the
concept of karma, can be integrated with HIV prevention information in
plays, skits, and stories. A skit could, for instance, depict an
HIV-infected man attempting to convince a woman to have unprotected
intercourse with him. In the process of this exchange, he communicates to
the woman that he is uninfected and to the audience his intent to deceive
her. The woman's response provides an opportunity to communicate basic
facts about HIV transmission to the audience. The man, of course, is
somehow penalized for having lied.

There exists a story in Buddhist teachings about an encounter between
Buddha and a sick monk. The Buddha came upon a monk with severe diarrhea.
No one in the monastic community would care for this monk because he had
never given assistance to anyone in the community. Consequently, the monk
was lying in his own excrement due to lack of care. The Buddha requested
that water be brought to him, and he cleaned and clothed the sick monk
himself. Having done this, he gathered the members of the monastic
community together and admonished them to care for the sick monk, noting
that they no longer had parents to nurse them.

This easily recognizable and widely known story reflects Buddhism's four
central moral virtues: love (metta), compassion (karuna), sympathetic joy
(mudita), and equanimity (upekkha).(n88) A loving mind is thought to make
one calm and relaxed and results in 11 blessings, which include comfortable
sleep, the absence of evil dreams, an individual's endearment to others, an
ability to concentrate mentally, and serenity. This attitude permits one to
say, "May all beings be happy." Compassion as understood in Buddhism
carries with it a "devotion to removing others' suffering."(n88) A
compassionate attitude carries with it the thought "May they be liberated
from these sufferings." Compassion is necessary even toward evil persons.
Compassion does not require that we become sorrowful at others' suffering
but, rather, that we wish only for their freedom from such suffering.(n88)
This concept of compassion has been analogized to Christians' love of
God.(n99) An enactment of a similar story could incorporate messages
relating to the nontransmissibility of HIV through casual contact and
necessary precautions to prevent HIV transmission in the context of home
caregiving. It also provides an opportunity to emphasize the moral virtues
of love and compassion that are central to Buddhism.

Conclusion

The strategy proposed in this article for HIV prevention may reach various
groups in the southeast Asian communities that have heretofore been
overlooked in constructing HIV education programs. Because this strategy
integrates the educational message with recognized and accepted principles,
tenets, and stories, the audience may be more able to understand the
messages and to accept them as being relevant to them. This approach lends
itself to change and modification, both across specific communities and
over time, allowing for variations in both culturally derived practices and
mores and varying interpretations of Buddhist texts. As such, our proposed
strategy reflects a desire for "coculturation," by which health educators
and providers and members of the southeast Asian communities served share
equally the responsibility, opportunity, and power to address HIV
 transmission and to develop appropriate educational strategies. Although
our proposed approach has met with preliminary approval from
representatives of various southeast Asian communities at community
meetings in San Diego County, this nuanced approach to HIV prevention must
now be validated and refined through field research.

DIAGRAM: FIGURE 1; SCHEMATIC REPRESENTATION OF INTEGRATION OF ELEMENTS OF
THE HEALTH BELIEF MODEL, BASIC TENETS OF BUDDHISM, AND HIV PREVENTION
MESSAGES

                                 REFERENCES

(n1.) Department of Health Services, County of San Diego. Description of
the epidemic. San Diego, CA: Department of Public Health, 1994.

(n2.) Toleran DE. Pakikisama: Reaching the Filipino community with AIDS
prevention. Multicultural Inquiry Research AIDS Quarterly Newsletter
1991;5:8-10.

(n3.) Centers for Disease Control and Prevention. Update: Trends in AIDS
among men who have sex with men--United States, 1989-1994. MMWR
1995;44:401-4.

(n4.) Osmond DH, Page K, Wiley J et al. HIV infection in homosexual and
bisexual men 18 to 24 years of age: The San Francisco Young Men's Health
Study. Am J Public Health 1994;84(12):1933-7.

(n5.) Metier R, Hu DJ, Fleming PL, Ward JW. AIDS among Asians & Pacific
Islanders (A/PI) reported in the USA. Presented at the Tenth International
Conference on AIDS, Yokohama, Japan, August 7-12,1994 [Abstract PC0325].

(n6.) Murase K, Sung S, Vuong VD. AIDS knowledge, attitudes, beliefs and
behaviors in Southeast Asian communities in San Francisco. San Francisco:
Center for Cross-Cultural Research and Social Work Practice, San Francisco
State University, 1991.

(n7.) Siegel D, Lazarus N, Krasnovsky F, Dubin M, Chesney M. AIDS
knowledge, attitudes and behavior among inner city, junior high school
students. J Sch Health 1991; 61(4):160-5.

(n8.) Strunin L. Adolescents' perceptions of risk for HIV infection:
Implications for future research. Soc Sci Med 1991;32(2):221-8.

(n9.) Choi K, Coates TJ, Catania JA, Choi P. High HIV risk among gay and
Asian Pacific Islander men in San Francisco (letter). AIDS
1995;9(13):306-8.

(n10.) Gellert GA, Moore DF, Maxwell RM, et al. Targeted HIV seroprevalence
among Vietnamese in Southern California. Genitourin Med 1994;70(4):265-7.

(n11.) Carrier J, Nguyen B, Su S. Vietnamese American sexual behaviors &
HIV infection. J Sex Res 1992;29(4):547-60.

(n12.) Cochran SD, Mays VM, Leung L. Sexual practices of heterosexual
Asian-American young adults. Implications for risk of HIV infection. Arch
Sex Behav 1991;20(4):381-91.

(n13.) Asian/Pacific Islander AIDS Coalition. U.S. National Asian and
Pacific Islander HIV/AIDS Agenda. San Francisco: Author, 1993.

(n14.) Aoki B, Ngin CP, Mo B, Ja DY. AIDS prevention models in
Asian-American communities. In: Mays VM, Albee GW, Schneider SF, eds.
Primary prevention of AIDS: Psychological approaches. Newbury Park, CA:
Sage, 1989.

(n15.) Choi K, Lew S, Vittinghoff E, Catania JA, Barrett DC, Coates TJ. The
efficacy of brief group counseling in HIV risk reduction among homosexual
Asian and Pacific Islander men. AIDS 1996;10(1):81-7.

(n16.) Min PG. An overview of Asian Americans. In: Min PG ed. Asian
Americans: Contemporary trends and issues. Thousand Oaks, CA: Sage, 1995.

(n17.) Leitch LePoer B, ed. Thailand: A country study. Washington, DC:
Library of Congress, Federal Research Division, 1989.

(n18.) Schumann HW. Buddhism: An outline of its teachings and schools
(trans. G. Feuerstein). Wheaton, IL: Quest Books, 1973.

(n19.) Fong R. Family preservation: Making it work for Asians. Child
Welfare, 1994;73(4):331-41.

(n20.) Lin-Fu JS. Population characteristics and health care needs of Asian
Pacific Americans. Pub Health Rep 1988;103(1):18-27.

(n21.) Barringer HR, Gardner RW, Levin MJ. Asians and Pacific Islanders in
the United States. New York: Russell Sage Foundation, 1993.

(n22.) Keyes CF. The golden peninsula. New York: Macmillan, 1977.

(n23.) Marr DG. The 1920's women's rights debate in Vietnam. J Asian Stud
1976;35:3.

(n24.) Johnson KA. Women, the family and peasant revolution in China.
Chicago: University of Chicago Press, 1983.

(n25.) Lamphere L. Strategies, cooperation and conflict among women in
domestic groups. In: Rosaldo MR, Lamphere L, eds. Women, culture, and
society. Stanford, CA: Stanford University Press, 1974.

(n26.) Wolf M. Women and the family in rural Taiwan. Palo Alto, CA:
Stanford University Press, 1972.

(n27.) Wolf M. Chinese women: Old skills in a new context. In: Rosaldo M,
Lamphere L, eds. Women, culture and society. Palo Alto, CA: Stanford
University Press, 1974.

(n28.) Boman B, Edwards M. The Indochinese refugee. Aust New Zealand J
Psychiatry 1984;18(1):40-52.

(n29.) Dinh KT, Sarason BR, Sarason IG. Parent-child relationships in
Vietnamese immigrant families. J Fam Psychol 1994;8:471-88.

(n30.) Cooper CR, Baker H, Polichar D, Welsh M. Values and communication of
Chinese, Filipino, European, Mexican, and Vietnamese American Adolescents
with their families and friends. In: Shulman S, Collins AW, eds.
Father-adolescent relationships. San Francisco: Jossey Bass, 1993.

(n31.) Berg IK, Jaya A. Different and same: Family therapy with
Asian-American families. J Marital Family Ther 1993;19(1):31-8.

(n32.) Rairdan B, Higgs ZR. When your patient is a Hmong refugee. Am J Nurs
1992; 92(3):52-5.

(n33.) Way RT. Burmese culture, personality, and mental health. Aust New
Zealand J Psychiatry 1985;19:275-82.

(n34.) Zane NWS, Sue S, Hu L, Kwon JH. Asian-American assertion: A social
learning analysis of cultural differences. J Couns Psychol
1991;38(1):63-70.

(n35.) Yee BWK. Elders in southeast Asian refugee families. Generations
1992;16:24-7.

(n36.) Kibria N. Power, patriarchy, and gender: Conflict in the Vietnamese
immigrant community. Gender and Society 1990;4(1):9-24.

(n37.) Kibria N. Family tightrope: The changing lives of Vietnamese
Americans. Princeton, NJ: Princeton University Press, 1993.

(n38.) Ima K, Rumbaut RG. Southeast Asian refugees in American schools: A
comparison of fluent-English-proficient and limited-English-proficient
students. In: Nakanishi DT, Nishida TY, eds. The Asian American educational
experience. New York: Routledge, 1995.

(n39.) Detzner DF. Life histories: Conflict in southeast Asian refugee
families. In: Gilgun JF, Daly K, Handel G, eds. Qualitative methods in
family research. Newbury Park, CA: Sage, 1992.

(n40.) Fukuyama MA, Greenfield TK. Dimensions of assertiveness in an
Asian-American student population. J Counsel Psychol 1983;30:429-32.

(n41.) Yee BWK. Gender and family issues in minority groups. Generations
1990;14:39-42.

(n42.) Kulig JC. Sexuality beliefs among Cambodians: Implications for
health care professionals. Health Care for Women International
1994;15(1):69-76.

(n43.) Tung T. The Indochinese refugees as patients. J Refugee Resettlement
1980;1(1):53-60.

(n44.) Moore DS, Erickson PI. Age, gender, and ethnic differences in sexual
and contraceptive knowledge, attitudes, and behaviors. Faro Comm Health
1985;8(3):38-51.

(n45.) Spring MA, Ross PJ, Etkin NL, Deinard AS. Sociocultural factors in
the use of prenatal care by Hmong women, Minneapolis. AJPH
1995;85(7):1015-17.

(n46.) Mills MB. Attack of the widow ghosts: Gender, death, and modernity
in northeast Thailand. In: Ong A, Peletz MG, eds. Bewitching women, pious
men: Gender and body politics in Southeast Asia. Berkeley, CA: University
of California Press, 1995.

(n47.) Flaskerud JH, Nyamathi AM. An AIDS education program for Vietnamese
women. NY State J Med 1988;88(12):632-7.

(n48.) Pongpaichit P. From peasant girls to Bangkok masseuses. Geneva:
International Labour Organization, 1982.

(n49.) Weniger BG. Experience from HIV incidence cohorts in Thailand:
Implications for HIV vaccine efficacy trials. AIDS 1994;8(7):1007-10.

(n50.) Havanon N, Bennett A, Knodel J. Sexual networking in a provincial
Thai setting. Monograph Report. 1992.

(n51.) Loue S, Phoombour E, Mirano R, Lloyd L, Project HAPI Working Group.
Use of prostitutes as a risk factor for HIV infection among Asian/Pacific
Islander men in San Diego County: Preliminary findings. Presented at the
15th Annual Scientific Sessions of the Society of Behavioral Medicine,
Boston, Massachusetts, April 13-16,1994.

(n52.) Maticka-Tyndale E, Kiewying M, Haswell-Elkins M, et al. Knowledge,
attitudes and beliefs about HIV/AIDS among women in Northeastern Thailand.
AIDS Educ Prev 1994;6(3):205-18.

(n53.) Joe KA. Getting into the gang: Methodological issues in studying
ethnic gangs. NIDA Research Monograph 1993;130:234-57.

(n54.) Mydans S. For Vietnamese, a wave of gang terror. NY Times, Apr.
8,1991, p. A11, col. 4. 55. Vigil JD, Yun SC. Vietnam youth gangs in
Southern California. In: Huff CR, ed. Gangs in America. Newbury Park, CA:
Sage, 1990.

(n56.) Thompson M. The untouchables. Far Eastern Economic Rev 1989;31-32.

(n57.) Ima K. A handbook for professionals working with Southeast Asian
delinquents and at-risk youth. San Diego, CA: SAY San Diego, Inc., 1991.

(n58.) Sanders WB. Gangbangs and drive-bys: Grounded culture and juvenile
gang violence. Hawthorne, NY: Aldine de Gruyter, 1994.

(n59.) Joe KA. The new criminal conspiracy? Asian gangs and organized crime
in San Francisco. J Res Crime Delinquency, 1994;31(4):390-415.

(n60.) Chin S, Furillo A. Viet gangs a growing threat in U.S. San Francisco
Examiner, Apr. 28,1991 pp. Al, Al0.

(n61.) Joe K. California's runaway scene. Presented at the California
Association for Criminal Justice Research, Sacramento, California, April
4-5,1991.

(n62.) Becker MH, Joseph JG. AIDS and behavioral change to reduce risk: A
review. Am J Public Health 1988;78(4):394-410.

(n63.) Thao X. Southeast Asian refugees of Rhode Island: The Hmong
perception of illness. RI Med J 1994; 67(7):323-30.

(n64.) Moon A, Tashima N. Help seeking behavior and attitudes of southeast
Asian refugees. San Francisco: Pacific Asian Mental Health Research
Project, 1982.

(n65.) Lin KM, Inui T, Kleinman A, Womack W. Sociocultural determinants of
help-seeking behavior of patients with mental illness. J Nerv Ment Dis
1982;170(2):78-85.

(n66.) Brainard J. Changing health beliefs and behaviors of resettled
Laotian refugees. Soc Sci Med 1989;29(7):845-52.

(n67.) Muecke M. In search of healers---Southeast Asian refugees in the
American health system. West J Med 1983;139(6):835-40.

(n68.) Egawa J, Tashima N. Indigenous healers in southeast Asian refugee
communities. San Francisco: Pacific Asian Mental Health Research Project,
1982.

(n69.) Aronson L. Traditional Cambodian health beliefs and practices. RI J
Med 1987;70(2):73-8.

(n70.) Bliatout B. Hmong beliefs about health and illness. Hmong Forum
1990;1:40-5.

(n71.) Rice PL, Ly B, Lumley J. Childbirth and soul loss: The case of a
Hmong woman. Med J Aust 1994;160(9):577-78.

(n72.) Thao P, Hmong perspectives on health and illness. Presented at Forms
of Healing: Diverse Cultural Perspectives, University of Minnesota Medical
School, Minneapolis, April 1991.

(n73.) Gray E, Cosgrove J. Ethnocentric perception of childrearing
practices in protective services. Child Abuse Neglect 1985,9(3):389-96.

(n74.) Yeatman GW, Shaw C, Barlow NJ, et al.. Pseudo-battering in
Vietnamese children. Ped 1976; 58(4):616-17.

(n75.) Uba L. Cultural barriers to health care for southeast Asian
refugees. Pub Health Rep 1992;107(5):544-48.

(n76.) Cheon-Klessig Y, Camilleri D, McElmurry B, Ohlson V. Folk medicine
in the health practices of Hmong refugees. West J Nuts Res
1988;10(5):647-60.

(n77.) Muecke MA. Mother sold food, daughter sells her body: The cultural
continuity of prostitution. Soc Sci Med 1992;35(7):891-901.

(n78.) Ford N, Koetsawang S. The socio-cultural context of transmission of
HIV in Thailand. Soc Sci Med 1991;33(4):405-14.

(n79.) World Factbook. McLean, VA: Brasseys, 1994.

(n80.) Petosa R, Jackson K. Using the health belief model to predict safer
sex intentions among adolescents. Health Educ Q 1991;18(4):463-76.

(n81.) Kirscht JP, Joseph JG. The health belief model: Some implications
for behavior change, with reference to homosexual males. In: Mays VM, Albee
GW, Schneider SF, eds. Primary prevention of AIDS: Psychological
approaches. Newbury Park, CA: Sage, 1989.

(n82.) Fishbein M, Middlestadt SE. Using the theory of reasoned action as a
framework for understanding and changing AIDS-related behaviors. In: Mays
VM, Albee GW, Schneider SF, eds. Primary prevention of AIDS: Psychological
approaches. Newbury Park, CA: Sage, 1989.

(n83.) Bandura A. Perceived self-efficacy in the exercise of control over
AIDS infection. In: Mays VM, Albee GW, Schneider SF, eds. Primary
prevention of AIDS: Psychological approaches. Newbury Park, CA: Sage, 1989.

(n84.) Florida RE. Buddhism and the four principles. In: Gillon R, ed.
Principles of health care ethics. New York: John Wiley, 1994.

(n85.) Johnson RW, Ostrow DG, Joseph J. Educational strategies for
prevention of sexual transmission of HIV. In: Mays VM, Albee GW, Schneider
SF, eds. Primary prevention of AIDS: Psychological approaches. Newbury
Park, CA: Sage, 1989.

(n86.) Rosenstock IM. The health belief model and preventive health
behavior. Health Education Monographs 1974;2:27-59.

(n87.) Saddhatissa H. Buddhist ethics: The path to nirvana. London: Wisdom,
1987.

(n88.) Dharmasiri G. Fundamentals of Buddhist ethics. Antioch, CA: Golden
Leaves, 1989.

(n89.) Joseph J, Montgomery S, Emmons C, et al. Magnitude and determinants
of behavior risk reduction: Longitudinal analysis of a cohort at risk for
AIDS. Psychol Health 1987;1(1):73-96.

(n90.) Weinstein N. Reducing unrealistic optimism about illness
susceptibility. Health Psychol 1983;2:11-20.

(n91.) Jue S. Identifying and meeting the needs of minority clients with
AIDS. In: Leukefeld CG, Fimbres M, eds. Responding to AIDS: Psychosocial
initiatives. Silver Spring, MD: National Association of Social Workers,
1987.

(n92.) Eppsteiner F. In the crucible: The precepts of the Order of
Interbeing. In: Eppsteiner F, ed. The path of compassion: Writings on
socially engaged A NAME="M27">Buddhism. Berkeley, CA: Parallax, 1988.

(n93.) Hanh TN. The individual, society, and nature. In: Eppsteiner F, ed.
The path of compassion: Writings on socially engaged Buddhism. Berkeley,
CA: Parallax, 1988.

(n94.) McKusick L, Wiley J, Coates T, et al. Reported changes in the sexual
behavior of men at risk for AIDS, San Francisco, 1982-84--The AIDS
Behavioral Research Project. Pub Health Rep 1985;100(6):622-29.

(n95.) Ostrow DG. Medical and psychological implications of HTLV-III
antibody testing. In: Ostrow DG, ed. Biobehavioral control of AIDS. New
York: Irvington, 1987.

(n96.) Spiro M E. Cultural relativism and the future of anthropology.
Cultural Anth 1986; 1:259-286.

(n97.) Kalupahana DJ. Causality: The central philosophy of Buddhism.
Honolulu: University of Hawaii Press, 1993.

(n98.) Ratanakul P. Bioethics in Thailand: The struggle for Buddhist
solutions. J Med Phil 1988;13:301-12.

(n99.) Satha-Anand S. Religious movements in contemporary Thailand:
Buddhist struggles for modem relevance. Asian Survey 1990;30(4):395-408.

(n100.) Yep GA. First Asian/Pacific Islander men's HIV conference, Los
Angeles, California. AIDS Education Prev 1993;5:87-8.

(n101.) Rev. Benton Pandito. Presentation to IMAA Violence Prevention
Collaborative, San Diego, CA, 1995.

(n102.) Jones K. The social face of Buddhism: An approach to political and
social activism. London: Wisdom, 1989.

(n103.) Sivaraksa S. Buddhism in a world of change: Politics must be
related to religion. In: Eppsteiner F, ed. The path of compassion: Writings
on socially engaged Buddhism. Berkeley, CA: Parallax, 1988.

(n104.) Aitken R. Taking the path of Zen. San Francisco: North Point, 1982.

(n105.) Pickwell SM. Health screening and health education for Cambodian
women and children. San Diego, CA: Alliance Healthcare Foundation, 1994.

(n106.) Yep GA. HIV/AIDS education and prevention for Asian and Pacific
Islander communities: Towards the development of general guidelines. AIDS
Educ Prev 1994;6(2):184-6.

(n107.) Lane SD. Television mini-drama: Social marketing and evaluation in
Egypt. Med Anth 1997; 11(2): 1-19.

Received March 26, 1997; revised September 19, 1997; accepted October 27,
1997.

~~~~~~~~

By SANA LOUE, JD, PhD, MPH; SANDRA D. LANE, PhD, MPH; LINDA S. LLOYD, DrPH
and LENG LOH, BA

Adapted by JD, PhD, MPH , PhD, MPH , DrPH and BA

DR. LOUE is Associate Professor, Department of Epidemiology and
Biostatistics, Case Western Reserve University, School of Medicine,
MetroHealth Medical Center 2500 MetroHealth Drive, Rammelkamp Building
R-213A, Cleveland, 0H44109-1998; DR. LANE is formerly Assistant Professor,
Department of Anthropology, Case Western Reserve University, and is
Behavioral Scientist, Onandaga County Health Department, 421 Montgomery
Street, Syracuse, NY 13202; DR. LLOYD is Vice President, Programs, Alliance
Health Care Foundation, 9325 Skypark Court, Suite 350, 92123, San Diego, CA
92123; and LENG LOH is Technical Assistant, Asian/Pacific Islander
Community AIDS Project, P.O. Box 89174, San Diego, CA 92138.
                            -------------------