“You Still Got to See Where She’s Coming From”: Using Photovoice to Understand African American Female Adolescents’ Perspectives on Sexual Risk

Abstract

African Americans have the highest rate of new HIV infection in the United States. This photovoice study explored the perspectives and experiences of African American female youth and sought to understand how adolescent development impacts HIV risk. This study used the photovoice methodology with seven African American or Biracial female youth, in Grades 8 through 12, residing in North Carolina. Study findings indicate that African American female adolescents struggle to navigate adolescence, specifically in coping with race- and gender-related stressors. The photovoice study demonstrated that African American early adolescent females face unique challenges that influence sexual health and HIV risk. There is a need for HIV prevention programs that support positive racial and gender identity development and teach early adolescents how to cope with race- and gender-related stressors. Our findings suggest it is important for youth to be sources of positive support for their peers.

Keywords

HIV adolescent health African American early adolescence race-related stress

In 2009, African American adolescents aged 13 to 19 accounted for 14% of the U.S. population but 65% of all HIV diagnoses (Centers for Disease Control and Prevention [CDC], 2011). Among African American females aged 13 to 29, the incidence rate is 11 times higher than the rate of Hispanic and White young women of the same age (CDC, 2011). Research has shown that African American youth report a higher number of sexual partners and initiate sex at an earlier age than their White and Hispanic peers—key risk factors for HIV transmission (CDC, 2011). To address the HIV epidemic among young Black women, researchers have called for a greater focus on HIV prevention programs that address the unique factors that put African American female adolescents at risk for HIV transmission (Crosby et al., 2001; DiClemente et al., 2004). In addition, because early adolescence is a particularly vulnerable time for the emergence of sexual risk behavior, there is a need for research that examines risk factors particularly among early adolescents (Ali & Dwyer, 2011; M. T. Wang & Eccles, 2012).

Although there is strong evidence for gender-tailored and culturally relevant HIV prevention interventions for African American adolescents (DiClemente et al., 2004; Wingood & DiClemente, 1992), less is known about how stressors encountered during early adolescence influence African American females’ risk behavior. African American girls must navigate race-related stressors such as racial stereotypes and experiences of discrimination (Brown, White-Johnson, & Griffin-Fennell, 2013; Evans et al., 2012; Rivas-Drake et al., 2014; Thomas, Hacker, & Hoxha, 2011), which can lead to depletion of coping resources negatively impacting mental health (Clark, Anderson, Clark, & Williams, 1999).

In addition, African American female adolescents must navigate gender-related stressors such as gender discrimination and socialization (Cooper, Guthrie, Brown, & Metzger, 2011; Raiford, Seth, & DiClemente, 2013). Past studies have shown that African American female adolescents may experience discrimination differently than males (Oyserman, Harrison, & Bybee, 2001). Researchers have hypothesized that gender socialization may create a greater need for social approval and relationships among adolescent females making them more likely to experience adverse mental health effects from discrimination (Cogburn, Chavous, & Griffin, 2011; Oyserman et al., 2001) and report higher levels of sexual risk behavior (Raiford et al., 2013).

During early adolescence, African American females also experience developmental-related stress such as navigating the transition from middle to high school and being exposed to or directly experiencing bullying (Soriano, Rivera, Williams, Daley, & Reznik, 2004). Bullying is particularly prevalent in early adolescence (Nansel et al., 2001), and research has shown that African American adolescents are uniquely impacted by developmental-related stressors, which can be exacerbated by discrimination-related stress (Soriano et al., 2004).

Although there is empirical evidence to support the relationship between race-, gender-, and developmental-related stress on African American adolescent females’ sexual risk behavior, further qualitative research is needed to uncover the processes through which this occurs. There is a heightened importance for understanding how stress impacts the sexual risk behavior of early adolescents. A better understanding of these unique factors during early adolescence can enhance the developmental relevance of gender-tailored and culturally relevant HIV prevention. To enhance this understanding, this qualitative research study used photovoice methodology to explore the perspectives and experiences of African American female youth and gain an understanding of how early adolescent development impacts their HIV risk.

Method

Study Design and Population

Photovoice is a qualitative research process that enables participants to document their community’s assets and challenges through photography (C. C. Wang, 1999; C. Wang & Burris, 1997). Using a community-based participatory research (CBPR) approach, a community-based organization (CBO) in central North Carolina (NC) partnered with academic researchers to pilot an evidence-based HIV prevention intervention, Focus on Youth (FOY) + Informed Parents and Youth Together (ImPACT) with African American youth aged 12 to 15 in faith settings (Lightfoot et al., 2012). Focus groups conducted with youth prior to implementation of the intervention highlighted risk factors in the community that the community-academic team decided to explore via photovoice. This photovoice project engaged seven young women aged 13 to 17 ( $\bar{X}$ = 14.42, SD = 1.62) who were members of the community served by the CBO. Five of the young women identified as African American/Black and two identified as Biracial (African American and another race). The project was facilitated by four graduate students in public health.

The aim of the photovoice project was to understand African American female adolescents’ experiences with and perceptions of gender, race, and the developmental period of early adolescence and how those experiences influence HIV risk. Prior to data collection, human subject research approval was obtained from the University of North Carolina at Chapel Hill’s Institutional Review Board (IRB).

Participant Recruitment and Data Collection

The seven female adolescents who participated in the photovoice project were recruited from CBOs in the community by the FOY study’s project coordinator. Additional information on recruitment can be found in Woods-Jaeger et al. (2013). The facilitators provided a thorough orientation to the photovoice process and obtained informed consent, including parental permission and youth assent for participation. The orientation included training on photo ethics, including how to protect participants’ privacy by not including identifiable features or by having a participant in the photo complete a consent form. The photovoice participants had the freedom to take candid or staged photos and were encouraged to be creative in thinking about how to take photos where individuals could not be identified.

During orientation, the facilitators worked with the young women to brainstorm ideas for photo-assignments. The four photo-assignments generated by the youth for this study were as follows: (a) Why is HIV/AIDs an epidemic in the Black community? (b) How do the people around us influence our risk behavior? (c) How can our community support people in making healthy decisions about sex, and what challenges do they face? and (d) What challenges does the Black community face in addressing HIV/AIDS? The youth were provided with a disposable camera at each session and asked to take photos that represented the selected photo-assignment for that week. The young women were asked to drop the cameras off at the CBO before the next meeting, so facilitators could have the film developed (at no cost to the participants) and ready for the subsequent week’s discussion session. The prints of the photographs were returned to the participants in sealed envelopes at the start of each session. The young women received a US$10 gift card for each session attended as well as copies of each photo they took.

The photo sessions were facilitated using the SHOWED (See, Happening, Our, Why, Empowerment/Evaluation, Do) method (C. Wang & Burris, 1997), which facilitates a discussion that leads participants from an individual-level interpretation of a social problem to social analysis and policy action (Table 1). The discussions began with each participant selecting one photograph from their collection and describing how their photograph represented the photo-assignment. After these discussions, the youth voted on one photo to serve as the “trigger” photograph for the SHOWED discussion process. At the end of each SHOWED session, the youth brainstormed and selected a topic for the following week’s photo-assignment.

Table 1.

Questions to Facilitate and Move Discussion From a Personal- to Social-Level Analysis and Action.

S	See	Naming the issue. What do we literally SEE in the photograph?	Start with the concrete. Literally describe what you see in the photograph.	Concrete questions
H	Happening	What is HAPPENING in the photograph?	Begin to identify different elements of a story—what’s going on in the photograph? How do people feel about what is going on?	Concrete questions
O	Our	How do these issues relate to OUR lives and how do we feel about them?	Expand to the personal and emotional level. Discuss how our lives are similar or different.	Personalizing questions
W	Why	WHY have these issues arisen (on an individual, family, and societal level)?	Expand to the analytic. Question the root causes of these issues.	Analytic questions
E	Empower	Explore how we can become EMPOWERED with our new social understanding.	Bring understanding back to the individual. Examine the individual and social connection.	Problem-posing process questions
D	Do	What can we DO about these issues in our lives?	Expand to action at both the personal, group, and community levels.	Problem solving

Qualitative Analysis

All photovoice discussions were audio-recorded and transcribed verbatim for data analysis. Using Atlas.ti 5.0 (Muhr & Friese, 2004), the transcripts were systematically analyzed according to the principles of thematic analysis (Braun & Clarke, 2006). The first phase of the analysis involved reviewing transcripts. The facilitators reviewed the transcripts and memoed on their perspective of the photovoice discussions. Memoing allowed the team to reflect on the accumulation of ideas and record concepts and relationships that emerged while reading the transcript. Next, each member created codes that represented emerging concepts and themes based on the photovoice discussions. Once the team approved a standard definition for each code, the first and second author coded all data. Once the transcripts were coded, the entire team reviewed the documents and began to identify recurring themes in the photovoice sessions. The facilitators presented the codes, themes, and the initial analysis of the photo discussions to the youth, allowing them to provide feedback on the findings. The participants’ feedback was incorporated and the graduate team further explored relationships between linkages and themes. Themes that emerged from the analysis and member-checked discussion are presented below.

Results

During the photovoice sessions, the young women discussed the challenges of navigating early adolescence as African American women. The participants felt that African American early adolescents are subject to negative expectations and often feel invisible in comparison with their White peers. The participants described the contradictory societal pressures that young women face that strain their relationships with male and female peers. The participants also explained that young women must figure out how to establish their independence and navigate new freedoms as they grow older and transition from early to late adolescence. According to the young women, female early adolescents who are unable to successfully navigate such stressors are more likely to engage in sexual risk behavior putting them at risk for sexually transmitted infections such as HIV.

Navigating Developmental-Related Stressors

During the photovoice discussions, the youth described how it is challenging to navigate the transition from early to late adolescence with increased exposure to new risks and challenges. They felt the high school environment exposes adolescents to heightened risks such as peer pressure and bullying. The older youth in the group, who had already entered high school, cautioned the younger participants in the group about the transition from middle to high school.

You’re going to be exposed to different kinds of things cause I know from my 8th grade year to now I have learned so much about so many different things including sex, HIV, drugs and all that and why people do this peer pressure, depression all that kind of stuff.

The youth also described increased pressure to compete with peers in high school. One youth said,

It seems like more competition for the popularity thing everybody’s going to try to dress a certain way. “Oh there are new shoes out so everybody’s going to get them and wear them on the same day” and I mean, it’s just stuff like that.

One participant took a photo (Figure 1) of the schoolyard after classes were out to reflect the social groups and peer pressure of the high school environment. During the discussion about the high school environment, one young woman described how bullying occurs in high school and can lead youth to feel unsafe.

You have these adults in school because they say school is the safe place but really it isn’t to me because, like, the other day some girl was supposed to fight some girl but the girl got on the bus and they was calling her punk and she came today and she was crying . . . so that’s why I say school is kind of like not safe.

Figure 1.

Students released from school at the end of day, this image was used to illustrate social groups and peer pressure among high school students.

In addition to dealing with increased peer pressure and bullying, which becomes particularly prevalent in early adolescence (Nansel et al., 2001), as adolescents grow older, they must learn how to establish their independence and define themselves as young adults. According to participants, some youth use sexual experiences to define their independence and young adulthood. As one young woman explained, “Growing up, you’re trying to look like adults, . . . like I’m grown now cause I didn’t use a condom, it’s like I’m grown now, cause I’m more independent cause I had sex.” Because adolescents are trying to establish their independence, the participants explained that some adolescents rebel against the advice of adults. For example, one participant said, “People don’t want to use protection because everyone wants to do the opposite of what the older person says.”

Navigating Race-Related Stressors

Throughout the photovoice project, the young women discussed navigating the successes and challenges of their daily realities as members of the African American racial group. They described being subject to the negative expectations that are commonly held for Black youth and feeling invisible in comparison with White youth. The youth described that adolescents vary in their responses to such stressors, either internalizing or externalizing racial situations. The youth felt that internalizing racial situations could contribute to an adolescent’s HIV risk.

Several of the youth explained that the negative expectations that are experienced by Black youth can contribute to early adolescents’ HIV risk behavior. During the first photovoice discussion, the youth discussed reasons why HIV/AIDS is an epidemic in the Black community in response to a photograph staged by one of the participants showing the word “life” being thrown into a garbage can. For her, the photo represented that “Black people do not care about their life.” When asked why, she explained,

They think that since they already have a name then why should they care? I just feel like, if you already have a name, then why would they care. They call Black people nasty or . . . . (Participant 2)

Ignorant (Participant 4)

Yeah, so they’re going to nasty and ignorant (Participant 7)

The participants discussed their reactions to this, explaining that such negative expectations for Black females can make them more likely to engage in sexual risk behavior. For example, one participant described,

I think a lot of people look at black people and they’re like oh, they must want to have sex, they must want to start a family. I hear people say we will automatically not make it in life or label us as teen moms.

In addition to negative expectations, the youth described that African American female adolescents often feel invisible compared with White peer groups, which limits progress on addressing HIV/AIDS in Black communities. As part of the fourth photovoice discussion, the youth selected a photograph of clouds to symbolize the lack of action taking place to address HIV/AIDS in the Black community. The young woman who took the photo explained that nothing is really going on in the Black community to prevent HIV/AIDS. She went on that “Because no one is standing up for it” and another girl mentioned “people don’t practice what they preach.” Similarly, the youth described how the challenges that African American youth face are often omitted. As an example, they discussed television shows such as MTV’s “Teen Mom,” commenting on how African Americans do not appear on the show even though they have higher rates of teen pregnancy. One girl said, “I think teen pregnancy is more in the Black community but we are not on the show . . . they do not want to show how Black people really suffer or what we go through compared to Caucasians.”

Navigating Gender-Related Stressors

During the photovoice project, the young women discussed the challenges of navigating early adolescence as a female and the competing pressures they face. The youth explained that young women feel pressured to engage in sex as a way to gain attention and popularity from males. At the same time, the participants explained that female adolescents who engage in risk behavior are subject to gossip and blame from their female peers. This sets up a challenging dynamic where young women feel they cannot discuss this pressure with their female peers, resulting in feelings of social isolation. Ironically, the combination of this pressure and corresponding lack of peer support, the youth contend, promotes risky sexual behavior among their peers.

During the second photovoice session, the young women selected a photo (Figure 2) of a teenager covering her ears with her hands to convey the many and complicated pressures faced by young women. She explained, “They [young women] have so many influences around them—one person telling you not to do this isn’t going to stop you from doing it.” Some participants discussed how they felt the pressure to conform to social norms regarding dressing more promiscuously, while others expressed they did not agree with their female peers who conformed. During our conversations, many of the youth blamed their female peers for their sexual risk behavior. One of the girls, for example, described how one of her peers was letting a boy pull down her shirt during class. She explained, “That just made me look at her a whole other way. I mean, I’m not friends with her, but it does not make me think any better of her.”

Figure 2.

A female student covers her ears in order to represent the pressure and conflicting advice she encounters on a daily basis.

In addition to blaming their female peers, the youth described distancing themselves from peers engaging in risk behavior. One youth described not being friends with a girl in her class because of her promiscuity. She remarked, “I don’t really talk to her anymore. When I’ve talked to her, I’m like, I’m younger than you and I have more common sense. If you’re gonna do that, that’s your fault, that’s your problem.” For young women experiencing relationship problems, the participants explained that fear of gossip prevents many from reaching out for support from their female peers. For example, one young woman stated,

You can trust this guy to keep it a secret that you’re you know, doing oral sex with him, but you don’t think you can tell a friend or maybe a counselor or maybe your principal or teacher to go sit there and tell them about you feel. Cause you know, you don’t want to have like a bad road, and all the girl has to do is just talk about it.

The young women explained that they contributed to the lack of support among female peers. One participant said,

I feel like, me myself, I contribute to it because sometimes I’m like, she need to take that off or she’s a skank or she’s a slut. I’m not speaking right about that person and everyone’s contributing to it because no one is trying to lift her up.

Discussion

The primary aim of this photovoice project was to understand how the experiences and perspectives of African American female early adolescents impact their HIV risk. The design of the project allowed the facilitators to build a trusting relationship with the youth and establish a safe environment to discuss sensitive topics such as sexual behavior. Our findings suggest that African American early female adolescents experience unique challenges during their developmental years such as race-, gender-, and developmental-related stress. The following discussion will consider the results of the photovoice project in relation to current literature.

Targeting Racial Stressors in HIV Prevention Programs

The young women participating in the photovoice project discussed how racial stereotypes and discrimination can cause African American female early adolescents to develop negative outcome expectations and often feel invisible in comparison with White youth. As a consequence, youth can develop a negative racial identity putting them at greater risk for engaging in sexual risk behavior. These findings are consistent with past research suggesting that racial discrimination is a stressor that negatively impacts youth well-being and adjustment such as academic and behavioral functioning and sexual risk behavior (Clark, Coleman, & Novak, 2004; Stevens-Watkins, Brown-Wright, & Tyler, 2011). This study builds upon the literature by highlighting two unique stressors caused by racism that impact adolescents—negative outcome expectations and feelings of invisibility—that could be leveraged in future HIV prevention research. Past research with adults has suggested that strong ethnic identity and developing collective coping strategies may mitigate race-related stress (Constantine & Sha’Kema, 2002; Franklin, Boyd-Franklin, & Kelly, 2006). Future research is needed to test strategies for reducing race-related stress, such as fostering ethnic identity and developing collective coping strategies, in adolescents. Past identity research has suggested that need for affiliation is particularly salient during early adolescence (Kroger, 2006), suggesting that HIV prevention programs that foster race-related affiliation could be particularly effective for this age group.

Supporting Positive Gender Identity Development in HIV Prevention Programs

Consistent with the double jeopardy hypothesis (Reid & Comas-Diaz, 1990), the youth in this study described additional stressors that African American adolescents may face as a result of the intersection of racial and gender discrimination. The participants, for example, described the prevalence of stereotypes regarding African American female adolescents’ risk of pregnancy and how such stereotypes impact female youth’s self-value and sexual risk behavior. Although young people typically identify with many social groups, race and gender are two of the most prominent social identities in the United States (Ashmore, Deaux, & McLaughlin-Volpe, 2004). The youth in this project recognized the connection between being female and African American and described negative expectations for both identities. Past studies have shown that African American adolescent females who define their identity based on stereotypes experience decreased self-esteem (Buckley & Carter, 2005). These findings suggest that young women need opportunities to develop positive expectations of the Black community and for Black women. Further research should explore programs that support positive gender identity development for African American female youth as a strategy for reducing sexual risk behavior.

Reducing Bullying Through HIV Prevention Programs

Our study findings suggest that early African American female adolescents experience heightened stress associated with development. As youth transition from early to late adolescence, they may experience bullying increasing their risk for HIV. Youth who are victims of bullying may be stigmatized, socially isolated from their peers, and lack social support—factors that increase an adolescent’s likelihood of engaging in sexual risk behavior (Holt, Matjasko, Espelage, Reid, & Koenig, 2013). Research has identified social distancing and gossip behaviors as a form of relational bullying—bullying that is indirect and more common among female than male adolescents (Crick & Grotpeter, 1995; J. Wang, Iannotti, & Nansel, 2009). Researchers have also suggested that African American adolescents who are victims of bullying may be at increased risk of adverse health outcomes because discrimination-related stress may exacerbate the stress associated with bullying (Soriano et al., 2004). Future studies should examine how bullying experiences may be different among Black youth, such as the relationship between discrimination- and bullying-related stress, and how such stressors influence early adolescents, who are more vulnerable to internalizing bullying-related stress (Peskin, Tortolero, Markham, Addy, & Baumler, 2007). To design effective HIV prevention programs for early African American adolescents, future research should investigate the bullying context among African American adolescents to discern how it relates to sexual risk behavior.

Limitations

A few limitations should be noted when considering the results of this photovoice study. Due to the small sample size of this photovoice group, generalizability is limited. Similarly, because of the small sample size, it was not possible to compare and contrast the experiences of the African American and biracial adolescents included in the study. Future research should specifically examine how adolescent development impacts the HIV risk of biracial adolescents. This study was also conducted in an urban area in the Southeastern United States where youth’s experiences of race and gender may be different from other geographic locations. Future research should examine how geographic location, such as rural versus urban or other regions of the United States such as the Midwest, impacts HIV risk.

Conclusion

African American early adolescent females face increased exposure to stressors that impact sexual risk behaviors and ultimately HIV risk. A unique approach is required to help mitigate these factors as young women navigate adolescence while working to understand the role their race and gender plays in who they are and where they are coming from. It is critical to focus on programs that address the specialized needs of this population. The CBPR method of photovoice utilized in this study was a first step in empowering these young women to discuss the challenges they face as African American early adolescent females. The photovoice process gave them a voice and an opportunity to express what they believed would be valuable in helping sexual health risk and HIV vulnerability. Our findings provide critical insight into the perspectives and experiences of young African American women and have important implications for researchers and practitioners as they work to develop effective interventions to reduce sexual risk in early adolescence for minority youth populations.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Turquoise Sidibe is a former master’s of public health student at the University of North Carolina at Chapel Hill. She is particularly interested in program planning and evaluation, public health policy, health literacy, and understanding the psychosocial determinants of African Americans’ mental and physical health across the life-course.

Kea Turner is a former master’s of public health student and a current doctoral student at the University of North Carolina at Chapel Hill. Her research interests include implementation research, health care innovation, and health inequities.

Alicia Sparks is a doctoral student at the Johns Hopkins Bloomberg School of Public Health. Her research focuses on youth access to alcohol and environmental strategies to reduce underage alcohol consumption. She has an MPH in Health Behavior from the University of North Carolina at Chapel Hill.

Briana Woods-Jaeger is an assistant professor in the Department of Community and Behavioral Health at the University of Iowa, College of Public Health. Her research interests include African American adolescent health, co-occurring traumatic stress and health risk behaviors, community-based participatory research (CBPR), health inequities, and implementation research.

Alexandra Lightfoot is director of the Community-Based Participatory Research Core at the Center for Health Promotion and Disease Prevention, a CDC-funded Prevention Research Center at the University of North Carolina at Chapel Hill. She promotes the use of community-engaged approaches to address health disparities and provides trainings, workshops, and technical assistance to strengthen community-academic research partnerships through a consulting model, CBPR Charrettes.

References

Ali

Dwyer

D. S.

(2011). Estimating peer effects in sexual behavior among adolescents. Journal of Adolescence, 34, 183-190.

Ashmore

R. D.

Deaux

McLaughlin-Volpe

(2004). An organizing framework for collective identity: Articulation and significance of multidimensionality. Psychological Bulletin, 130, 80-114.

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101.

Brown

D. L.

White-Johnson

R. L.

Griffin-Fennell

F. D.

(2013). Breaking the chains: Examining the endorsement of modern Jezebel images and racial-ethnic esteem among African American women. Culture, Health & Sexuality, 15, 525-539.

Buckley

T. R.

Carter

R. T.

(2005). Black adolescent girls: Do gender role and racial identity impact their self-esteem. Sex Roles, 53, 647-661.

Centers for Disease Control and Prevention. (2011). HIV among youth. Retrieved from http://www.cdc.gov/hiv/group/age/youth/

Clark

Anderson

N. B.

Clark

V. R.

Williams

D. R.

(1999). Racism as a stressor for African Americans: A biopsychosocial model. American Psychologist, 54, 805-816.

Clark

Coleman

A. P.

Novak

J. D.

(2004). Brief report: Initial psychometric properties of the everyday discrimination scale in Black adolescents. Journal of Adolescence, 27, 363-368.

Cogburn

C. D.

Chavous

T. M.

Griffin

T. M.

(2011). School-based racial and gender discrimination among African American adolescents: Exploring gender variation in frequency and implications for adjustment. Race and Social Problems, 3, 25-37.

10.

Constantine

M. G.

Sha’Kema

M. B.

(2002). Black adolescents’ racial socialization experiences their relations to home, school, and peer self-esteem. Journal of Black Studies, 32, 322-335.

11.

Cooper

Guthrie

B. J.

Brown

Metzger

(2011). Daily hassles and African American adolescent females’ psychological functioning: Direct and interactive associations with gender role orientation. Sex Roles, 65, 397-409.

12.

Crick

N. R.

Grotpeter

J. K.

(1995). Relational aggression, gender, and social-psychological adjustment. Child Development, 66, 710-722.

13.

Crosby

R. A.

DiClemente

R. J.

Wingood

G. M.

Harrington

Davies

Malow

(2001). Participation by African-American adolescent females in social organizations: Associations with HIV-protective behaviors. Ethnicity & Disease, 12, 186-192.

14.

DiClemente

R. J.

Wingood

G. M.

Harrington

K. F.

Lang

D. L.

Davies

S. L.

Hook

E. W.

III . . . Robillard

(2004). Efficacy of an HIV prevention intervention for African American adolescent girls: A randomized controlled trial. Journal of the American Medical Association, 292, 171-179.

15.

Evans

A. B.

Banerjee

Meyer

Aldana

Foust

Rowley

(2012). Racial socialization as a mechanism for positive development among African American youth. Child Development Perspectives, 6, 251-257.

16.

Franklin

A. J.

Boyd-Franklin

Kelly

(2006). Racism and invisibility: Race-related stress, emotional abuse and psychological trauma for people of color. Journal of Emotional Abuse, 6(2-3), 9-30.

17.

Holt

M. K.

Matjasko

J. L.

Espelage

Reid

Koenig

(2013). Sexual risk taking and bullying among adolescents. Pediatrics, 321, e1481.

18.

Kroger

(2006). Identity development: Adolescence through adulthood. Thousand Oaks, CA: Sage.

19.

Lightfoot

A. F.

Woods

B. A.

Jackson

Riggins

Krieger

Brodie

. . . Howard

D. L.

(2012). “In my house”: Laying the foundation for youth HIV prevention in the Black Church. Progress in Community Health Partnerships: Research, Education, and Action, 6, 451-456.

20.

Muhr

Friese

(2004). User’s manual for ATLAS.ti 5.0. Berlin, Germany: ATLAS.ti Scientific Software Development GmbH.

21.

Nansel

T. R.

Overpeck

Pilla

R. S.

Ruan

W. J.

Simons-Morton

Scheidt

(2001). Bullying behaviors among US youth: Prevalence and association with psychosocial adjustment. The Journal of the American Medical Association, 285(16), 2094-2100.

22.

Oyserman

Harrison

Bybee

(2001). Can racial identity be promotive of academic efficacy? International Journal of Behavioral Development, 25, 379-385.

23.

Peskin

M. F.

Tortolero

Markham

C. M.

Addy

R. C.

Baumler

E. R.

(2007). Bullying and victimization and internalizing symptoms among low-income Black and Hispanic students. Journal of Adolescent Health, 40, 372-375.

24.

Raiford

J. L.

Seth

DiClemente

(2013). What girls won’t do for love: Human immunodeficiency virus/sexually transmitted infections risk among young African American women driven by a relationship imperative. Journal of Adolescent Health, 52, 566-571.

25.

Reid

Comas-Diaz

(1990). Gender and ethnicity: Perspectives on dual status. Sex Roles. 22, 397-408.

26.

Rivas-Drake

Seaton

E. K.

Markstrom

Quintana

Syed

Lee

R. M.

. . . Yip

(2014). Ethnic and racial identity in adolescence: Implications for psychosocial, academic, and health outcomes. Child Development, 85, 40-57.

27.

Soriano

F. I.

Rivera

L. M.

Williams

K. J.

Daley

S. P.

Reznik

V. M.

(2004). Navigating between cultures: The role of culture in youth violence. Journal of Adolescent Health, 34, 169-176.

28.

Stevens-Watkins

Brown-Wright

Tyler

(2011). The number of sexual partners and race-related stress in African American adolescents: Preliminary findings. Journal of Adolescence, 34, 191-194.

29.

Thomas

A. J.

Hacker

J. D.

Hoxha

(2011). Gendered racial identity of Black young women. Sex Roles, 64, 530-542.

30.

Wang

Burris

M. A.

(1997). Photovoice: Concept, methodology, and use for participatory needs assessment. Health Education & Behavior, 24, 369-387.

31.

Wang

C. C.

(1999). Photovoice: A participatory action research strategy applied to women’s health. Journal of Women’s Health, 8, 185-192.

32.

Wang

Iannotti

R. J.

Nansel

T. R.

(2009). School bullying among adolescents in the United States: Physical, verbal, relational, and cyber. Journal of Adolescent Health, 45, 368-375.

33.

Wang

M. T.

Eccles

J. S.

(2012). Social support matters: Longitudinal effects of social support on three dimensions of school engagement from middle to high school. Child Development, 83, 877-895.

34.

Wingood

G. M.

DiClemente

R. J.

(1992). Cultural, gender, and psychosocial influences on HIV-related behavior of African-American female adolescents: Implications for the development of tailored prevention programs. Ethnicity & Disease, 2, 381-388.

35.

Woods-Jaeger

B. A.

Sparks

Turner

Griffith

Jackson

Lightfoot

A. F.

(2013). Exploring the social and community context of African American adolescents’ HIV vulnerability. Qualitative health research, 23(11), 1541-1550.