Peaks and Valleys of Building Community Rapport: Lessons Learned Through an Investigation of Adolescent Sexual Health

On my graduate school journey in medical anthropology at the University of Alabama, I became curious about HIV risk while conducting fieldwork in Mobile, Alabama. There, I worked on my thesis on intergenerational body image beliefs of working class African American mothers and daughters. Mothers in my study revealed that they could tell someone had HIV by looking at them. These insights solidified my interests in determining what African American adolescent girls in Alabama knew about HIV and how social ecological factors influence both knowledge and sexual health behaviors. Alabama is an abstinence only sex education state (Minimum Contents to be Included in Sex Education Program or Curriculum, Alabama State Code Section 16-40A-2). Sexual health education is focused on abstinence until marriage, and prevention of sexually transmitted infections, including HIV/AIDS, and teen pregnancy.

The Youth Risk Behavior Surveillance reports that while risky sexual activity is decreasing among adolescents, condom use among African American high school teens during last sexual intercourse declined from 70 percent in 1999 to 65 percent in 2011. Alabama is ranked lowest in rates of condom use among high school students (Eaton et al. 2012). African Americans represent 26 percent of the state’s population, but 64 percent of reported HIV infections are from this group. Adolescents in Alabama aged 13-24 comprise 5 percent of existing HIV infections, and 32 percent of new cases reported in 2014 (Alabama Department of Public Health, 2015).

When I embarked on my journey toward this project, I was driven by anthropological theory as a way to address a public health concern. Although I did not consider a strengths-based approach to lead my inquiry regarding sexual health, I understood and respected the importance of addressing community needs as a participant observer and researcher. I recognize that dismissing assets used to address sexual health concerns is problematic. However, given the taboo nature of what I wanted to explore, I believe acknowledging these assets pose additional challenges and would not have changed the peaks and valleys experienced in my community engagement and research. Following is a brief, partial list of lessons learned through my experiences working with an anonymous African American community in Alabama. It is my hope that the suggestions put forth will prove valuable to those committed to community engagement and scholarship.

  1. Find community members supportive about what you want to learn.

Two years prior to beginning my research, I met with many community members. Among them was a school board member who worked for many years as a nurse. She developed and implemented a health initiative program where I happened to volunteer one summer prior to meeting her. Because of this established rapport through familiarity of her program, she provided me with beneficial information about health issues, community life and how to effectively engage with other members. She recommended members and organizations, as she ended many of our conversations saying, “Tell them I sent you.” This type of advocacy was essential to discovering where my skills could be used in the community while simultaneously researching sexual health issues among teen girls.

  1. Understand that what scholars, governmental institutions, and non-profit organizations view as important, community members may not judge similarly.

When establishing rapport in the early stages of my research, a professor suggested I meet a pastor amenable to research. This pastor was extremely welcoming, although, early on in our conversation, he stated that his church members do not really talk about HIV or believe it is a major problem in the community. In addition, I attended a high school parent meeting provided by a local health organization discussing sexual health and sexually transmitted infections. Notably, only two school administrators and myself attended this meeting, even though parents were given advanced notice of the seminar.

I discovered early on that difficulty in trying to research a stigmatizing topic is the strong desire for community members to separate themselves from the issue through attempting to achieve mainstream social norms, values, and conduct. This also creates difficulty in using a strengths-based approach, since assets may not be used for the purpose of addressing a proscribed issue that community members approach in denial.

  1. Find a place where you fit in and build community relationships.

After explaining my project to numerous community members, I had a difficult time having people take me seriously, return my calls, or acknowledge me in public. Initially, I spoke with middle class community members to gain entrée into the community, establish where I could assist with community needs, and determine the best way to learn what young teenage girls knew about HIV risk. For example, I approached another pastor who was willing to assist, but was ultimately too busy to accommodate me in his church. This early acceptance and eventual rejection happened frequently. While this pastor was too occupied to assist me, he introduced me to the director of a neighborhood center centrally located in a working class community, and this introduction proved to be extremely valuable.

The neighborhood center resulted in collaboration with the director where I fulfilled both community engagement and research roles. The center provides residents with numerous services including computer classes, GED classes, a Chess Club, and after-school and summer programs for youth. Upon my introduction to the community, the director asked if I would be interested in teaching GED. classes. I jumped at the chance to serve this community that was welcoming to my presence and could utilize my academic skills. I taught math GED classes weekly for a fall and spring semester to men and women in the community.

The women I taught were extremely helpful to my understanding of community dynamics. Understanding community interactions was useful given that I took a social ecological perspective to HIV risk in my research. Women shared that conflict centered on arguing over men who were unfaithful in not only the local community where the center was centrally located, but also in an adjacent governmental housing area. Remarkably, one of the women revealed that higher sexual risk was associated with a woman’s male partner having a concurrent relationship with someone outside of the immediate neighborhood. If their boyfriend had a sexual relationship with a woman in the governmental housing neighborhood or beyond the immediate community, it was believed that sexual health risk increased greatly because the sexual partners that their boyfriend was concurrently dating was unfamiliar. Given that the women were aware of gossip regarding illnesses that other women in the local community held, it was viewed as a higher risk situation when information about the health of potential sex partners outside of the community was not readily available, whether this information is true or not.

After spending some time in the community, I interviewed younger girls in the neighborhood who shared various characteristics and behaviors associated with HIV risk which highlighted socio-ecological factors important to this topic. High risk was associated with lack of parental investment, hanging out in the neighborhood, running away from home, and transactional sex. In contrast, low risk was associated with parental investment, staying at home, interest in academic pursuits and future goals, and involvement in church.

  1. Do not take it personally when you run into a person or people who are unsupportive. Avoid flattery and move on to someone willing to assist.

A school administrator that worked closely with the students shared some of the experiences of the girls that attended the community high school where I observed. At the outset, she was forthcoming about issues faced by female students including domestic violence, sexual abuse, teenage pregnancy and abortions. Through this first conversation, this administrator mentioned that she mentored and advised two in-school programs for girls that experienced these concerns. I looked forward to observing these programs, hoping to get a sense of how these students understood sexual health through their lived experiences. Afterwards, the administrator noted that she would have to ask permission to allow me to gain access to these programs and observe students.

After a great deal of effort to contact her in the days and weeks following our conversation, I emailed her to see if I would be more successful in contacting her in that manner. This approach worked, with a brief email returned almost immediately. Unfortunately, the administrator noted that aside from the Principal of the school, she also answered to another supervisor at the department of education. Her supervisor advised that she was not under any responsibility to assist me in understanding issues related to sexual health, and wished me the best in my endeavors.

I was not surprised by the eventual demise of our communication, although the situation was extremely discouraging. After the dust settled, I asked some colleagues in anthropology and the school board member (see lesson #1 above) for advice on the situation. My colleagues thought I should try to establish rapport with her by finding out what she liked and buying it for her. This was not bad advice from anthropologists since we are trained that participant observation “involves getting close to people and making them feel comfortable enough with your presence so that you can observe and record information about their lives. […] Only by confronting the truth about participant observation—that it involves deception and impression management—can we hope to conduct ourselves ethically in fieldwork“ (Bernard 2006:342). With this training, it makes sense that fellow anthropologists would advise me to build rapport using this method.

In contrast, when I met with the school board member over lunch one afternoon, she stated that there would always be someone who does not approve of the work being done in the community, and that people would stand in the way. She advised that I should simply go around the school administrator and find someone able to help with what I need—a suggestion that really spoke to who I am personally. I could not imagine having a disingenuous relationship with this woman who is extremely busy with her own responsibilities. Eventually, I became grateful for the little time where we sat together and she shared valuable information about the girls that she serves through her employment at the school. Fortunately, I did bypass this school administrator and found allies with amazing teachers and other administrators who supported my observation in the school.

To conclude, this journey to understand sexual health concerns and risks among African-American teenagers taught me a great deal. I learned the value of community engagement on a level of incorporating my skills to meet the needs of those who valued my presence, even though they may have thought I was strange for asking about community dynamics or why some girls were viewed as high or low risk of HIV. One of the most valuable things I learned is that if there is sincerity in your desire to assist in what the community deems important, community members will value that goodwill and add to your scholarship by revealing more about their lives than initially hoped.


Tina Thomas (PhD, University at Alabama, 2016) is a Postdoctoral Fellow in Anthropology at Juniata College. She studies the intersection of culture, social ecology, and health in the U.S.

Finding the Culture in Acculturation

Author, Courtney Andrews, and her daughter

Author, Courtney Andrews, and her daughter

“Juana,” a Mexican immigrant who lives in Birmingham, Alabama, is a native of a small ranching village in Jalisco. Fifteen years ago, her husband lost his job in Mexico. They had no money saved, and she was scared for the safety of her children because of drug-related crime in their community there. Her husband convinced her that they needed to move to the U.S. where he could find work, they could get their kids in good schools, and they could have better lives. He went first, and, a little while later, Juana paid a “coyote” to take her across the border. After a month-long, treacherous journey, during which she was arrested and sent back, attacked by wild animals, left behind in the desert without food or water, and was constantly scared, she finally made it across the border and eventually to Alabama where her husband was living. He found steady work, and they sent for their three kids, who are now participants in the Deferred Action for Childhood Arrivals program. Juana and her family have achieved all the things they set out to achieve in moving to the U.S. Yet her health has suffered considerably, both physically and mentally. Unfortunately, this is not an uncommon experience for people like Juana.

The typical framework used to study what happens to individuals who developed in one sociocultural context when they attempt to live in another is called “acculturation.” In my work with Mexican immigrant women in Alabama, I’m trying to figure out what the acculturative process looks like and why typical measures of acculturation are associated with a dramatic decline in health outcomes, particularly diabetes and depressive symptoms. To understand how cultural meaning systems change and the effects of such meaning on human lives, we need to have a clear concept of what culture is, how it works, and ways to measure it. A cognitive definition of culture is a good place to start because it moves culture out of the realm of abstraction and allows for it to be measured in concrete terms. As Dressler point out in a previous post, culture is the information needed to think and behave appropriately in certain situations and to interpret the behavior of others correctly. This knowledge is encoded in overarching cultural models, which we draw on to structure our understanding of how we ought to live. Once we have an idea of what a cultural model looks like in a certain context, we can measure individuals against it and see how well they stack up. That stacking up is termed “cultural consonance“—the ability to live up to the shared cultural expectations of the group—and it affects health.

So, what’s going on with women like Juana? We know they tend to be in better health upon arrival than their U.S.-born counterparts, despite tremendous suffering before and during immigration. However, as they carry out their lives in the U.S.—even as their standard of living improves and they gain access to better health care—their health often gets worse. Researchers haven’t been able to explain the underlying cultural mechanism responsible for this. I’m interested in using cultural consonance as an intervening variable between measures of acculturation and health outcomes to determine if the pathway by which acculturation leads to declining health is, at least in part, in its effect on the ability to achieve a culturally valued lifestyle.

I focus on four cultural domains—lifestyle, family life, Mexican immigrant identity, and life goals. Using a technique called free listing, I asked my informants to list as many items as they could in response to these four questions:

  1. What kinds of things are important or necessary to have a good life?
  2. How would you describe a loving family?
  3. What are the qualities or characteristics of Mexican immigrant women?
  4. What are your goals in life? This gives me a glimpse into how cultural realities are changing in a new context

The next step is to understand what kinds of things go together and why as well as which items are most highly valued and sought after. This is analyzed using cultural consensus analysis, which measures the extent to which cultural knowledge is shared among informants and provides the best representation of how the collective thinks about a particular domain.

In general, people act in ways that correspond to cultural influences and expectations. I believe that, as Mexican immigrant women carry out their lives in the U.S., they internalize a new cultural model for how one ought to live, and, as they do this, their positions in the cultural landscape change. The further away they find themselves from living a collectively valued lifestyle in their new U.S. cultural context, the greater risk their risk for declining health. For Juana, adapting to a new culture has been difficult. For example, speaking Spanish in the home and celebrating Mexican traditions is very important to her, but she struggles to get her children to do this, which is a source of family discord. Another thing is that she is scared to drive, so she can’t get around easily and has lost her sense of independence.

Reasons for cultural dissonance among immigrants may range from economic constraints, structural or interpersonal violence and abuse, or lack of interest in engaging with a new culture. I hope to improve understanding what role culture plays in immigrant health outcomes as well as what social and institutional factors may limit the achievement of a culturally valued lifestyle. Such limitations may simply produce new stress that contributes to poor health outcomes.


Biocultural Systematics is written by members of the University of Alabama Biocultural Medical Anthropology program.

Courtney Andrews is a doctoral candidate in the department who has conducted research in Fiji and Peru and is currently studying Mexican immigrants in Alabama.