Integrating Buddhism and HIV Prevention in U.S. Southeast Asian Communities


Journal of Health Care for the Poor & Underserved

Vol. 10 No. 1 Feb.1999


Copyright by Journal of Health Care for the Poor & Underserved

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.) 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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. -------------------