School Nurse and More

The Church of the Incarnation in Dallas hosts mission trips to Belize and Honduras every year. There are also many service days that take place, especially in support of the schools in the area. As a school nurse, I have had the opportunity to serve several times in Honduras. I feel the work is especially appreciated because there are limited resources, poverty, and governmental issues that cannot be resolved.

In 2004 and 2005 I served in the village of Santa Cruz Arriba in the mountains outside of Tecugigalpa. The village initially had no water or sewage system and our construction team helped build a water cistern and then a septic system for the village. We had a small medical clinic set up inside the church and a dentist working down the road in a small home. There was a great need for a dentist to extract the teeth of the many who had pain related to their decayed teeth. Since safe water was not always available, soda was a safer and sometimes a cheaper alternative causing tooth decay even in the small children. Many of the medical issues we saw revolved around the family structure. The husbands, including the village mayor, left the village family every week to work in a larger town where they typically had a second family. The women were left with the children with no other options. My concern was communicable disease such as HIV and STDs that went untreated. Condoms and birth control were distributed and lessons were taught. Other lessons were taught concerning women's rights and abusive behavior. The women were taught to embroider and "Honduras Threads" was established. This cottage industry eventually spread to some of the surrounding villages with the help of M'Lou Bancroft. It was also during this time that we gathered around the murdered father of one of the girls in the sewing co-op. He had been shot in the head over a disagreement about a cow that day. This type of violence was also not uncommon.

In 2006 and 2007 I served in the village of Santa Cruz Abajo in a farming community. There was not a church in this village and lack of a spiritual connection was felt. The families seemed more stable, but there was a larger number of very young women who came into the clinic with their babies. This seemed to be the typical lifestyle with minimal education for most of the people. The multi-generational living arrangement, with many living in one small home, was a way of life. The small children played in the dirt and seemed destined to a bleak future. When the children were given soap, tooth brushes, and toothpaste, we got word they were eating the toothpaste. This can be toxic, so we immediately started lessons on how to used the soap and toothpaste in a safe way. There was no governmental regulation for trash, so the flies and trash were everywhere. Eventually the trash would be piled up and burned which then polluted the air. Many suffered from respiratory illnesses. Most of the construction efforts included painting and refurbishing the classrooms of a school. While this work was in progress one of the missioners fell off a ladder and sustained a head injury. He was stabilized and carted down the mountain in the back of a flatbed truck. He stayed in the hospital there even after we retuned home, but continued to have residual effects of this for many years. I never took for granted the risks that such a trip as this could bring.

In 2008 and 2009 I served in the community of San Bartolome on the outskirts of Siguatepeque. This was a strong religious community with a higher level of education and resources. The needs were the same, but not as urgent as they had been in the mountainous villages. The people were more joyful and resourceful. The construction team assisted with building a community center next to the church with cinder blocks and rebar. The women missioners on the construction team were not initially allowed to assist, so there was an ongoing battle of how the women could help. That is the only time that I ever saw any resentment; eventually the women were able to prove their worth. This church group was unique in that the agenda for the week was done according to the desires of the people and that made all the difference. It was during this time that the President of Honduras decided to change the Constitution and serve for an additional term. Choas broke out and he was kidnapped and put on a plane to Costa Rica. There was military in the streets. We were on our way out of the country, but the next day the airport was shut down- we barely made it home.

In 2011 I served in the mountain area of La Laguna at San Matias outside of Siguatepeque. This community was a strong religious farming community. When we first arrived, three boys from a family in a neighboring village had died from drinking bad well-water. The fourth boy died two days later. When the grandfather eventually visited our clinic, all we could offer were words of encouragement and sorrow. We were on alert during this time for other victims with dysentary or dehydration. We saw many families through the clinic, but no additional cases were found. We did see many large families, sometimes with 15 and 16 children, who were struggling to survive. We had no condoms or birth contol to offer this year and I felt very frustrated for the women who were seeking options to this predicament. In previous years there was a Honduran doctor or facility for follow-up for the medical cases. In this case, there was nothing available for the 21 year old gunshot victim with a colostomy and infection or the bedridden 26 year old mother of two who was dying from what was a diagnosis of "arthritis". Our doctors were able to treat the young mother with antibiotics and Vitamin B which resulted in some improvemnent. On the last day there was a torrential downpour. Our bus was on dirt roads typical of the area. The previous government did little to help with road construction and repair. We got down the mountain on a river of mud. In a previous year, the high school students in Tegucigalpa rebelled when they were unable to get to school due to mud slides. They sat in the middle of the highway and would not allow any traffic to pass. After coming on board our bus, they let us pass to do our medical work. One can only hope the new government will do its job and better roads and a better life will be in the future.

Name: Valerie King
Title/Position: School Nurse
Places of work: RISD-North Junior High and DCCCD-Richland College
# years as a nurse: 23 years
Degree held and field of specialty: BSN, RN
School Nursing, Medical Missionary
Why Nursing? Nursing is full of surprises. I love research, travel, and foreign language. Nursing, as a career, has allowed me to experience all of this. I try to be culturally sensitive in helping meet the needs of my students who come from many different places.
Being named a Great 100 Nurse is a dream come true. Some of the best nurses I know have received this award, so I am honored to be chosen to stand beside them.
I have had many memorable experiences in my nursing career; however, I feel most rewarded using all my training to make a small difference for others as a Medical Missionary. I travel each summer with a Missionary team from the Church of the Incarnation to Honduras to serve. In learning how to work as a nurse in a third world country, I am able to come back with renewed strength, hope, and ideas for how to be a better nurse in my own community.
It is interesting, but Missionary work allows for a connection that is hard to find in other ways. Through the eyes of others, I have grown spiritually. In many cases, when a person is sick, that is all that can be offered- a few words of encouragement or a listening ear. Dr Courtney Cowart wrote An American Awakening: from Ground Zero to Katrina the People We are Free to Be. She spoke recently about her experiences in both the 9/11 crisis and Katrina. She mentioned that she came away from that with the mantra “only people matter.” I also believe that people matter and it is up to each one of us to try to make a difference even if it is just one person at a time.
I remember working in Honduras, I am always impressed how many of the villagers walk hours to seek medical attention and visit our clinic. We offer some medications, but are limited with respect to treating chronic illness such as high blood pressure or diabetes. Although we screen for these things, there would be no way to continue the prescribed medications, so we can only discuss diet and exercise as ways to prevent complications. The nutritious foods are not always available either, so I find myself saying many times, “vaya con Dios” or “go with God. “ This would seem all too inadequate to say in our country, but the people there seem to be lifted up by these words. In these hard economic times, I wonder if many here will now be seeking to live a more caring and compassionate lifestyle. Our own community may suffer due to the inability to afford health insurance, medication, or treatment options. These are real concerns for the medical community as well, but I still hold onto the lessons learned as a Medical Missionary. We pray that God will provide and while this means sometimes waiting longer than we would like, at least we can reach out to one another with a word of encouragement. Sometimes that is the best medicine of all.

Our staff, at the local junior high where I work, had a concern for a number of years that our Hispanic girls were deficient in the areas of health, personal safety, and general self esteem issues. In an effort to fill in these gaps, an after school program was developed just for these girls. The unique thing about this program is that the information is taught and then discussed in Spanish with the assistance of an ESL aide. The weekly sessions are scheduled from 3:30-5:00 on Tuesday afternoons. Approximately 50 girls attend this program with an average of 25 girls on any particular day.

Our objectives include:
1. Education of the Hispanic girls with respect to healthly lifestyle and personal safety with classes on nutrition, skin care, and sexuality
2. Improvement of confidence and self-esteem through group work and support
3. Explore roadblocks to academic success such as pregnancy and substance abuse issues
4. Establish friendships and social connections within the school

Some of the fun activities included: a fashion show by their teachers to demonstrate appropriate and inappropriate dress, a make-over for skin and makeup, an edited version of the movie "Real Women Have Curves" that has Spanish subtitles and demonstrates some of the roadblocks which exist for these girls, a weekly drawing for a teddy bear, and planning the music and food for their celebration days. This year the girls attended the SMU Visioneer program and won an award.

The outcome and results have been very rewarding with the older girls helping the younger ones with personal, family, and school issues. The girls also expressed their goals for the future and how they think they could attain these goals. There has also been evidence of improved self-esteem and healthier lifestyle choices.

The objectives, as previously stated, were developed to present information in Spanish with fun activities to assist the girls in choosing to make healthier decisions as well as improved self esteem and success in school. When families come for school conferences and express concern for their daughters' welfare, this programn is sometimes recomemended by the staff. The staff had also recommended individual girls for this program that have been identified as at risk for pregnancy or substance abuse. In many cases the girls find some support within the Just For Girls class as they struggle with their personal decisions.

One important factor missing for these girls is the lack of a positive role model. The staff assists them when possible with some of the lessons, such as the fashion show, to demonstrate what it takes to be successful on a personal level as well as in the school and work environment. The girls are exposed to these adults on an ongoing basis during the school day. These adults make an impact by not only giving their time to demonstrate a caring attitude, but by supporting their program to be a better person.

The "Just For Girls" program was developed to assist the native speaking girls in developing self confidence and a healthy, safe lifestyle. It is not uncommon for a girl to become involved with an older boy and then become pregnant at an early age and/or drop out of school. These girls typically come from lower income homes and in many cases where the parents have limited educational and work opportunities.

Our school has approximately 550 students enrolled with many special programs. The students who are enrolled into the English as a Second Language (ESL) program are allowed three years to develop enough skills to then be scheduled into regular classes. Some of these students do not have the support at home, although the school has offered parent education programs in Spanish to try to assist in this. Our ESOL aides make home visits to bridge the gap between home and school. In many cases the staff communicates the student's needs through an interpreter. Approximately 30% of our students are bused here from Hispanic neighborhoods. We have at least 35% of our students on free or reduced lunch. In some cases students miss school when they are required to baby-sit or care for younger siblings. There are also some issues of truancy, substance abuse, and gang related activity that impedes the learning process. There are limited resources for many of these students due to lack of insurance and social security status.

Our Hispanic girls are especially at risk. They have a difficult time with the academics and struggle with their school work. They feel socially isolated and discouraged. They are also given mixed messages on how to fit in. They tend to grow up too fast and become enamored with the older boys who seem to offer an easy answer to school frustrations, a bad home situation, and/or security. The families are ignorant in many cases of the dangers involved. They too, struggle with feelings of isolation and discouragement. It is our hope that their sons and daughters will develop a greater understanding and appreciation for a healthier, more secure lifestyle.

The program we would like for these girls and their mothers to attend next year would cost $75/person. The SHARP program (Sexual harassment assault rape prevention) would greatly improve assertive behavior and teach the individual rape avoidance. The research indicates that girls younger than 14 years that become pregnant have been forced into early sexual activity. This could be prevented if the girls and their mothers could learn some techniques to avoid an assault and improve assertive behavior. The cost of this program would be well worth the results. Our program now functions as a club that is entitled to limited financial support. Our T-shirts were donated. It is our hope that we can secure funding for this program.

There are many benefits obtained from anyone choosing to be a corporate sponsor for this group. The Hispanic parent meetings are held monthly and the parents are updated with respect to the activities that take place at the school. These parents are most supportive of the Just for Girls program that was started three years ago. We will continue to promote this after school program for the school year at the Hispanic parent meeting, PTA, and through the newsletter.


Volunteer Activities:
Our school staff and community support make a big difference in the success of this type of program. These are some of the things they have done to support these girls:

Staff members dressed in very sexually suggestive ways for a fashion show to depict appropriate/inappropriate dress.

A Mary Kay representative volunteered two years in a row to supply and teach the girls basic skin care and make-up. She brought free samples and treats for the girls.

The 8th grade counselor presented a program on peer pressure and put the girls "in the hot seat".

The mother of one of our girls brought a cake and decorations for a celebration day.

One of our ESL teachers arranged for her Hispanic doctor to visit with the girls and answer health related questions.

The School Librarian assisted in getting stories and books to read with the girls.

The Administrators have supported the special activities that were planned with additional money for snacks and pizza.

The school designated money for a bus for a field trip in 2003-2004 to attend the UTD LULAC program and lunch.

A parent purchased our group T-shirts for the 2004-2005 school year.

The Go Van Go program from The Dallas Museum of Art presented a program in Spanish for the girls on Aztec art and culture in November 2004.

The community at large contributed to the Veronica benefit fund (see letter) and benefit dance which raised $600 for the family during December 2004.

The girls attended and won an engineering award at the SMU Visioneer program in Feb 2005.

The PTA sponsors Cinco de Mayo and contributes money for decorations.

Region X School Nurse of the Year award for 2005-2006. A special day celebrated with my children.

Working for a week in the mountains outside Tegucigalpa Honduras can be awe inspiring. For the third summer, I will be traveling with an Episcopal mission group to volunteer with other doctors and nurses in a small medical clinic designed to help families with preventative and
non-urgent care. The adults get blood pressure checks, blood sugar tests, birth control, and referral to Honduran doctors for followup. The children get weighed and measured, vitamins, anti-parasitic meds, and treatment for respiratory illnesses, among other things. I also teach classes on HIV/AIDS awareness and Domestic Violence. Educational materials are posted on High blood pressure, Diabetes, Hepatitis A, and Hepatitis B. My question is what else should we be doing to make a difference for these people? We also take a dentist, pharmacist, and some years an ophthalmologist. The other groups with us are assisting with the school, church, and construction projects such as water and septic tank. The most life changing project for the women has been the establishment of a sewing co-op. What has made a difference in other communities to combat the rising numbers of HIV, drug abuse, and limited options for education and progress?

Factors Relating to Choices of the Latina Adolescent and the Risk of HIV:
Many Americans care about the spread of Human Immunodeficiency Virus (HIV) when it touches their own family or costs them more of their taxpayer dollars to subsidize the victims of this plague. Although the virus is known to affect mostly men who have unprotected sex and use IV drugs, within the last several years, women are also becoming infected in increasing numbers. Women of color are especially at risk due to such complex issues as cultural norms, religion, gender roles, poverty, discrimination, and limited access to health care (Scott, Gilliam, and Braxton 2005). The following review of literature helps to clarify the issues of risk factors, predictors, and considerations with respect to young women at risk of HIV infection. This review specifically attempts to determine why young women of color, particularly Latinas, are disproportionately at risk for HIV and what could be done to make a difference.

Minority women represent almost 25% of the U.S. population and make up 79% of cumulative cases of Acquired Immunodeficiency Disease (AIDS) according to the Center of Disease Control and Prevention (CDC 2003). As reflected in the current research, the education level, economic status, and self-efficacy of these women helps to predict to what degree they practice safe sex and protect themselves with consistent condom use (Scott et al. 2005). The predictors indicate women of color are at increased risk for transmission of HIV, which causes AIDS. They are the fastest growing group in the nation. Young Latinas are found especially at risk as this review shows. AIDS is the third leading cause of death for Latinas between the ages of 25-44 years of age. In fact, young Hispanic women represent one in four new HIV cases of infection identified in people less than 22 years of age (CDC 2003). Adolescence is a traditionally difficult time of experimentation and defining identity. The challenges of the immature Latina adolescent attempting to navigate these issues and avoid HIV infection can be summarized as follows.

Adolescent Risk Issues
According to one study, fewer than 50% of European Americans and Latino teens choose to use contraception. Barriers to condom use include: lack of knowledge, cost, availability, interference with pleasure, and negotiations with partner. By the time a teen reaches the twelfth grade, 32% are as sexually active as the average adult. In this sample, Latinas specifically have the highest rate of sexual activity, which places these girls at greater risk for teen pregnancy, sexually transmitted disease, and HIV infection than any other gender and ethnic group (Farza 2000).

There might be cultural and attitudinal influences on gender roles that also complicate this case. In traditional Latino culture, a woman is not supposed to know about sex. It might be considered inappropriate for a Hispanic woman to talk about HIV or condom use; therefore, she might be less informed about attitudes, HIV behavior, sexual behavior, and safe sex practices (Newcomb, Locke, and Goodyear 2003). The Latina must negotiate conflicts between traditional cultural values of parents and church and popular cultural values of media and peers. Traditional values support abstinence where as popular culture shows unprotected and frequent sexual activity and substance use, although substance use might increase due to the increased anxiety present in trying to maintain this cultural balance (Farza 2000).

Another area of risk behavior pertains to drug use at this age. With substance abuse comes a decreased likelihood of condom use and increase in sexual risk behavior; an increase risk in HIV is due to an increase in the number of partners involved, needle sharing, and ethnicity. In fact, five out of eight Latinos have behaviors that are identified as strong predictors of risk for HIV: alcohol use, cigarette use, marijuana use, illicit drug use, and drunk driving (The Measurement Group 2003). A difficult problem, especially for Latinas, concerns the tendency for older men in their twenties who have greater prevalence of HIV, to seek out the younger teenage girls. Young Latinas are at increased risk for several reasons: male to female vaginal intercourse, since the vaginal mucosa is thinner in younger women, lower condom use, more sexual activity, and more partners (Farza 2000).

A National Demonstration Program of Adolescent HIV and AIDS Care Projects funded ten programs that delivered HIV and AIDS services to ethnically diverse adolescents and youth in 1993. Those adolescents with HIV or who were at risk of HIV were provided with whatever services were most needed. Two risk factors for the men were identified as sexual intercourse with men and a general risk factor and three factors for women were identified as sexual intercourse with men, substance abuse, and a high-risk sex behavior factor. This study shows there is an increased risk for those from an ethnic minority background who are disproportionately affected by HIV and AIDS (The Measurement Group 2003).

Predictors of HIV Risk
Predictors of HIV risk are as varied as the risk factors themselves when reviewing the literature. According to one study, predictors of HIV risk behaviors among minority adolescents include: gender, self-efficacy, knowledge, attitude, and beliefs as well as ethnicity. Ethnicity proves to be the more significant risk factor and therefore theoretical models for behavior change must include a dimension of culture, diversity, and ethnic identity(Farza, 2000:1).

In another study predictors include childhood experiences such as family abuse, neglect, sexual abuse, parent alcohol problems, and perceived childhood quality. Mediators such as attachment, drug use, psychological distress, age of first intercourse, cultural pride, self-efficacy, and a belief that the threat of AIDS is "over-estimated" should be taken into consideration. Some outcome variables related to HIV include the number of sexual and steady partners, frequency of intercourse, the number of pregnancies, condom use and abstinence, HIV related attitudes and behaviors, and HIV testing (Newcomb et al. 2003).
At risk teenagers traditionally have been rebellious and difficult to direct. In establishing their identities they sometimes push away from the very people that could help them (Hubbard, Barbieri, and Power 1998).

Sandra Cisneros writes about a beautiful Latin girl named Marin "who is singing the same song somewhere waiting for a car to stop, a star to fall, someone to change her life "(Cisneros 1984: 27). Marin portrays the girl who grew up too fast. Many of Cisneros characters In the House on Mango Street are tragic, lost, or rebellious. An important factor in growing up capable and secure has to do with being able to believe in oneself (Hubbard 1998). In the world of sociology, this could be call self-efficacy.

Self-Efficacy and HIV Risk
Self-efficacy refers to what a person believes he or she could do regardless of knowledge of skills. In this case, use of condoms for protection could make a difference. The strongest predictor of condom use is having asked a partner to use one (Farza 2000). Despite the fact that many studies have included self-efficacy as a risk indicator for HIV and AIDS, some argue that self-efficacy theory does not apply to women because the women do not control the use of the male condom. (Bowleg, Belgrave, Reisen 2000).
According to another study, building communication skills with a partner is central to increasing HIV prevention practice. A multiethnic study of 427 high school students uses a self-efficacy scale to determine HIV risk among adolescents, their relationships with parents, and an evaluation of an AIDS education component designed for multicultural youth. Self-efficacy theory is based on a model of behavior change for improved health. Belief in abilities prove more predictive of reducing risk than knowledge or skills (Farza 2000).
One interesting study rates Hispanic women the highest level of condom use; however, they have lowest condom related communication comfort levels and self-efficacy scores. These contradictory results reflect a high adaptability to the environment. One possibility implies these women use an indirect method to negotiate condom use in order to remain within the constraints of the machismo mentality of the culture (Soler et al. 2000).

Cultural Norms
Understanding the Hispanic community at large incorporates many variables, especially with respect to family and tradition; this in turn impacts the values and mores of young Latinas. Raffaelli and Ontai (2001) speculate that family practices related to sexuality have important implications. Women who conform to parental restrictions on sexual experimentation report later relationship difficulties due to inexperience whereas women who rebel against parental restriction describe feelings of guilt(Raffaelli and Ontai 2001:306)

This study suggests that more often Latinas have limited romantic and sexual experience prior to leaving home and then may be ill equipped to negotiate sexual encounters (Raffaelli and Ontai, 2001).
Cultural scripts also complicate acceptance of any HIV education. The Hispanic family values the non-confrontational, close relationship. Simpatia means politeness and discourages confrontation. Personalismo refers to Hispanic Americans preference for relationships that reflect warmth and familiarity. This study suggests an approach congruent with Hispanic American participants beliefs and expectations facilitate the development of trust through a personal, respectful presentation (Scott et al. 2005). Agreement among researchers concerning cultural values of the Hispanic population include the following concepts: the term familismo means the family is the primary source of support and identity and respecto means the need to maintain respectful hierarchical relationships(Raffaelli, Ontai 2001, p. 296). Within the Hispanic population, many women approach contraception from a familismo perspective in that men would be responsible for protecting their families (Solar et al. 2000).

Traditional family and religious beliefs serve to protect young women against risk taking behaviors. The traditional Hispanic family protects their daughters, keeping them close to home. In fact, daughters are not encouraged to date while living at home and 43% said they are expected to wait until after they turn fifteen. The traditional coming of age ceremony, the quincenera, is held at that time (Raffaelli and Ontai 2001). The Latino men continue to be protective of their women; however, the quincenera signals the woman is no longer a child which puts her at greater risk for a mature sexual relationship and HIV/AIDS.
Cultural beliefs affect sexual risk taking behaviors due to the existence of cultural prohibitions against sexual communications and negotiation. It is possible that a woman who suspects her male partner of infidelity chooses to remain silent, even though by doing so she places herself at risk for HIV/AIDS. "Such things as the perception that requesting condom use from partners is unfeminine and the belief that condoms interfere with natural and spontaneous sex contribute to lack of protection" (Koniak-Griffin et al. 2003).

The Latina typically fulfilled the role of caretaker and is responsible for the health of the family. Once she is educated in HIV prevention, she can teach her family members and better protect her home from the virus. Addressing the cultural context of Latinas lives is an important component because cultural norms are dictated by patriarchy, traditional and religious values (Scott et al. 2005). Prior research identifies specific cultural values and norms related to sexuality among Latino families, but the way that these beliefs influence the sexual socializations of adolescents need further study (Raffaelli and Ontai 2001).

Religion
Roman Catholicism poses a different set of problems for Hispanic women. On New Years Eve 1930, the Roman Catholic officially banned any artificial means of birth control that included condoms, diaphragms and cervical caps. Eventually, the church also banned the birth control pill (PBS online 1999-2001). The Catholic Church has maintained the historic Christian teaching that deliberate acts of contraception are gravely sinful.

Pope Paul IV stated, "let them consider, first of all, how wide and easy a road would thus be opened up towards conjugal infidelity and the general lowering of morality"(Catholic Answers 2004:1). The Church continues to play an important role in legislating birth control and preventative condom use. The election of German Cardinal Joseph Ratzinger, in April 2005, is another reason for concern in this battle for HIV prevention. The Pope, clearly conservative in his proceedings, left no doubt that he disapproves of any relaxation of the churchs opposition to birth control (CBC News Indepth 2005). The church virtually put married and unmarried women at risk, for unwanted pregnancy as well as protection from sexually transmitted disease, HIV/AIDS.

The Church teachings disapprove of contraception, including condoms; it also encourages strong family bonds, or familismo, and child rearing. Hispanic women are faced with the challenge of balancing family values and protecting the family and themselves from sexually transmitted diseases and HIV. Through scriptural interpretation the church also reinforces gender roles, which encourage a male dominant household and the male as head of the family. The concept of machismo exaggerates the importance of the male in society while marianismo means that women should play a submissive role. This puts the Latina at greater risk for HIV since she is unable to legislate the sexual decisions made on her behalf. She is required to play the role of the naive, submissive female who may even be reluctant to discuss sex or condom use with her male partner fearing that it may suggest she is too knowledgeable or even promiscuous (Scott et al.2003).
Gender Issues
Some researchers have found higher levels of acculturation in U.S. society to be associated with less traditional gender roles for Latinas. In one study gender-related issues are relevant to whether women would take an active or passive role in sexual situations including, "initiating discussions with a sexual partner about safer sexual practices, deciding when safer practices occur, using strategies to negotiate or assert power to protect their own health, or refusing to engage in risky sexual practices" (Bowleg et al. 2000). Although there are mixed results, Latinas typically choose the traditional feminine gender role orientation. Most studies show that those women "with more traditional concepts of womanhood, such as passivity and selflessness, would be more likely to hold less power in their relationships and therefore have less choice about sexual decisions " (Bowleg et al.2000).

Gender and power issues often create imbalances in sexual decision-making that directly influence condom use. "Fear or experience of abuse by partners is an important factor in women's inability to carry out safer sexual negotiations. A major goal in the lives of many pregnant adolescents and young mothers is maintaining a harmonious relationship with their steady partner who generally is the father of their baby. Promoting safer sex practices among women who are involved in a steady couple relationship is particularly difficult" (Koniak-Griffin et al.2003). One study reveals condom use is higher in new relationships than in established ones (Koniak-Griffin et al. 2003).

Another study validates the previous one in finding women with high levels of relationship power that are five times more likely to report consistent condom use than are women with low levels of relationship power. For Latinas in the USA, issues of power and gender roles emerge as a central barrier to HIV risk reduction in three-fourths of the groups since women must rely on their partners to use male condoms (Pulerwitz et al. 2002).

Hubbard, Barbieri, and Powers (1988 )write in We Want to be Known-Learning from Adolescent Girls about girls identities and the forces of society that dictate gender roles. This book is written for and by teenage girls and is filled with their hopes and dreams, poetry, and strategies used by those who work with them in their daily lives. The authors feel that much of the research on gender issues is based on survey information or impersonal reporting; however, much could be learned through the articles written by their teachers and in some cases the girls themselves (Hubbard et al. 1998). The girls write about frustration and growing up in a world that does not always understand their struggles. Perhaps the most effective research on understanding the structural effects or societal pressure on young girls would be to question the girls themselves and clarify those issues that put them most at risk for a sexual relationship, unwanted pregnancy, and sexually transmitted disease including HIV/AIDS.

Findings
The findings of one study suggests that childhood experiences play an important role in predicting several HIV risk domains for Latinas. Adverse early experiences such as child maltreatment have widespread influence and many negative effects. The psychological distress, drug use and general self-efficacy are mediators of early experiences on later HIV risk. Treatment and prevention that reduce the impact of childhood maltreatment, reduce psychological distress and drug use, and increase attachment capability, are likely to decrease the risks of HIV acquisition and transmission in young Latina women (Newcomb et al. 2003).

Sexual abuse incidents and physical abuse in childhood and adulthood result in additional risk for HIV infection. Coercive and abusive relationships limit a woman's option for negotiating safer sex. Other risks include involvement with multiple partners or survival sex for financial stability. Greater economic dependence on partners limit a woman's personal control over HIV risk practices (G.Wyatt et al. 2002).

A positive change in behavior results from increasing the women's self-esteem, self-efficacy, and awareness of the cultural, economic and political constraints of their lives. Successful prevention efforts must be based on the realities that Latinas face in their daily existence; for Hispanic women, addressing the cultural context of their world is an important component of culturally competent HIV prevention programs. The reality of the lives of Hispanic women differs from other populations due to patriarchy and religious influence. Cultural competence must address the cultural norms governing interpersonal interaction, gender roles specific to the culture, and diversity of sub groups (Scott et al. 2003:23).

As mentioned previously, Hispanic women rely on indirect methods to resolve some of these issues. For example, an indirect method of protection might be used so as to remain within constraints imposed by machismo. In one study, Hispanic respondents are as likely as the other groups to use contraceptive methods, which suggest condoms supplemented rather than replaced more effective methods (Solar et al. 2000). While supplemental methods reduce the odds of pregnancy, only male or female condom use or abstinence prevent the risk of HIV and other sexually transmitted diseases.

Strategies
The Center for Disease Control and Prevention recommend four strategies for reducing the spread of HIV and AIDS among Hispanic women: "making HIV testing a routine part of medical care, implementing new models for diagnosing HIV infections outside medical settings, preventing new infections by working with HIV infected person and their partners, and further decreasing perinatal HIV transmission. Examples of CDC-funded programs that focus on Hispanics include a community-based free health clinic offering bilingual, bicultural HIV/AIDS programs in Washington, DC; one-on-one interventions for transgender people in various California urban areas; and a food bank in east Los Angeles that serves persons living with HIV/
AIDS " (CDC 2004).

One study maintains that HIV prevention programs that target Latinas should include: respect of privacy, pose prevention as the shared responsibility of both men and women, use machismo in a positive context such as to be the protector of the family, demand that bilingual/bicultural workers examine their own value judgments, develop trust between provider and clients, use anonymous questionnaires, conduct multiple education sessions that promote sharing of experiences and follow-up, use support groups with role models from the Latino community, consider the reality of the need for basic survival, create materials that are attentive to cultural norms (Scott et al. 2003).

Considerations
In working with adolescent Latinas, one area that presents as an ongoing concern has been the rush to grow up, date older boys, and become wives and mothers. The research mentions this as a contributing factor to increase risk of HIV in the Hispanic community. Some of the research indicates these girls mature early and perhaps the older boys think they are older than they are. The Mexican girls also have their quincenera party at fifteen years of age and this also seems to contribute to the process (Farza 2000). Once the young girl becomes fifteen she sees herself as almost grown and ready for a sexual relationship and the posible consequences of that which include the risk of HIV/AIDS.

Much of the research concerns risk factors for HIV, self-efficacy issues, culture, and gender issues.
Other research mentions the fact that some Latin groups acculturate or assimilate into American society with less difficulty than other groups. They learn to speak English, succeed in school, and become acclimated to a new way of life. Other young women seem to have a difficult time acclimating to new ways because they have strong family ties to the traditional cultural values. Still others do not wish to acclimate and prefer to be recognized as a strong representative of their culture such as with the women serving in the League of United Latin American Citizens (LULAC).

This would appear to present a difficult balancing act of maintaining connections with culture and attempting to grow-up surrounded by different expectations. There would appear to be two choices here. First, young Latinas must choose between traditional family ways and the popular American ways. Second, they must choose to be traditionally submissive or assertive in their behavior. The issues become complicated in all four combinations: if a young woman chooses to be traditional/submissive and cope with limited options, traditional/assertive and fight for her rights, Americanized/ submissive and again cope with limited options, or Americanized/assertive and takes a stand against the family and tradition. It seems more research might be needed in clarifying the Risk Factors of the Adolescent Latina with respect to HIV and AIDS from these four perspectives. The results would indicate what combination and combinations of behaviors put these young women most at risk.

One study validates this in recommending that to understand the sexual behavior of U.S. Latinas, researchers must examine more closely sexual socialization within the family of origin and take parents culturally influenced beliefs and practices into account (Raffaelli and Ontai 2001). There are other implications from one study for future research on gender, power and HIV/AIDS that recommend: theoretical models that predict women's self-protection should be specific to the circumstances of the relationship, recognizing how class and race biases cause researchers to overlook important variables such as motivation to use condoms, focusing on cultural norms, relationship factors when developing conceptual models of women's risk, and determining the factors and conditions that determine whether a woman will be concerned about contracting the disease ( Bowleg et al. 2000).

Several recommendations for developing programs for Latina adolescents to promote reproductive and sexual health according to the Advocates for Youth include: making programs culturally and linguistically appropriate, involving teens and their social support networks, addressing culturally defined gender roles, and involving communities (Schuster 2003). One author suggests policy or responses that could range from "reducing the concentration of poverty and idle youth through the law and wage policies or youth employment programs or providing role models for adolescents in disadvantaged communities "
(Cubbin et al. 2005).

These studies present excellent recommendations for the future; however, the U.S government recently attempted to produce new immigration laws that erupted into a re-focusing on the Hispanic community and their rights. Hopefully through this process, some positive decisions affecting the economy and education result in some new programs and benefit for the young Latinas and their families. These women need support and encouragement to become successful, productive adults while making responsible decisions about their sexuality and avoiding the risk of HIV/AIDS. They have a right to protection even though the right to life, liberty, and the pursuit of happiness is sometimes elusive.