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The Development, Implementation, and Assessment of a Culturally Innovative HIVAIDS Intervention for

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Title: The Development, Implementation, and Assessment of a Culturally Innovative HIVAIDS Intervention for


1
The Development, Implementation, and Assessment
of a Culturally Innovative HIV/AIDS Intervention
for Hispanic Drug Injectors
  • Antonio L. Estrada, Ph.D., MSPH
  • Director
  • Mexican American Studies Research Center
  • And Professor
  • Mel Enid Zuckerman Arizona College of Public
    Health
  • The University of Arizona
  • 9th Annual Summer Public Health Videoconference
    on Minority Health
  • June 12, 2003
  • Support for this research was provided by the
    National Institute on Drug Abuse, Grant
    R01-DA10162, National Institutes of Health

2
Background
  • In 2000, the rate of AIDS cases among Hispanic
    males was more than 3 times the rate found among
    non-Hispanic white males (47.2 per 100,000 vs.
    14.0 per 100,000).
  • Moreover, the rate of AIDS cases among Hispanic
    females was more than 6 times the rate found
    among non-Hispanic white females (13.8 per
    100,000 vs. 2.2 per 100,000).

3
Background
  • The transmission mode of injecting drug use (IDU)
    has shown a dramatic increase in AIDS cases from
    1990-2000. During the last decade, IDU increased
    by over 400 percent.
  • For Hispanic males, injecting drug use as a
    transmission mode increased by a factor of 7.
  • For Hispanic females, injecting drug use and sex
    with an injecting drug user as transmission modes
    increased by a factor of 8.

4
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5
Background
  • Hispanics, as well as African Americans, tend to
    have higher case-fatality rates from AIDS than
    non-Hispanic whites due to a lack of health care
    access, early detection, and treatment costs.
  • Increasing disparity is seen in the percent of
    those infected with HIV 42 among Non-Hispanic
    Whites compared to 58 among minorities (CDC,
    2001).

6

7
Background
  • Previous studies have shown that AIDS rates among
    Hispanics vary markedly depending on the specific
    Hispanic sub-group examined (e.g., Mexican
    American, Puerto Rican, Central/South American,
    Cuban, etc.).

8
Adult/adolescent AIDS cases among Hispanics, by
exposure category and place of birth, reported in
2000, United States
1. Excludes persons born in U.S. dependencies,
possessions, and independent nations in free
association with the United States. Ancestry data
for U.S.-born Hispanics are not collected. 2.
Includes 234 Hispanics born in locations other
than those listed, and 1,193 Hispanics whose
place of birth is unknown.3. See Technical
Notes.
9
Epidemiology
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12
Male Hispanic AIDS Cases by Exposure Category
Reported through December 2001, U.S.
Note Cases are for adults and adolescents Source
Center for Disease Control, HIV/AIDS
Surveillance Report, December 2001
13
Female Hispanic AIDS Cases by Exposure Category
Reported through December 2001, U.S.
Note Cases are for adults and adolescents Source
Center for Disease Control, HIV/AIDS
Surveillance Report, December 2001
14
Pediatric Hispanic AIDS Cases by Exposure
Category Reported through December 2001, U.S.
Source Center for Disease Control, HIV/AIDS
Surveillance Report, December 2001
15
HIV/AIDS Risk Behaviors
16
HIV/AIDS Risk Behaviors
  • Injection-Related/Syringe-Mediated Risk Behaviors
  • Frequency of injection
  • Type of drug injected (Cocaine, Methamphetamine,
    Heroin)
  • Common drug purchases (pooling money)
  • Multi-person reuse of needle/syringe
  • Lack of appropriate bleaching of needle/syringe
  • Sharing the cooker, cotton, rinse water
  • Front-loading (syringe mediated drug dispersal)
  • Back-loading (syringe mediated drug dispersal)

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19
HIV/AIDS Risk Behaviors
  • Sexually Related Risk Behaviors
  • Sexual relations under the influence of
    drugs/alcohol
  • Exchanging sex for money or drugs
  • Sexual bingeing
  • Unprotected sex with an HIV individual
  • Unprotected sex with an HIV IDU
  • Hierarchy of risk in sexual relations (oral,
    vaginal, anal)

20
HIV Prevention Models and Theories
21
Methods for Chronic Disease Prevention and
Control (Public Health Model)
Primary prevention
Prevention strategy
Secondary prevention
Tertiary prevention
Asymptomatic
Symptomatic
Susceptible
Populations disease status
Reduced disease incidence
Effects
Reduced prevalence/ consequence
Reduced complications/ disability
22
Four Major Theoretical Models Used in HIV/AIDS
Prevention
  • I. The Health Belief Model (Becker)
  • Relevant health motivation and knowledge
    (importance of health)
  • Vulnerability to disease
  • Disease perceived as threatening
  • Efficacy and feasibility of behavior change
  • Cues to action
  • Barriers to action

23
Four Major Theoretical Models Used in HIV/AIDS
Prevention (contd.)
  • II. Social Cognitive Theory (Bandura)
  • Observation and modeling of behaviors in a
    social group
  • Normative behaviors that are valued/endorsed
  • Perceived Self-efficacy
  • Social network influences
  • Role models

24
Four Major Theoretical Models Used in HIV/AIDS
Prevention (contd.)
  • III. Theory of Reasoned Action/Planned Behavior
  • (Fishbein and Ajzen)
  • Behavioral intentions
  • Subjective norms
  • Behavioral and normative beliefs
  • Attitudes toward behaviors
  • Perceived behavioral control

25
Four Major Theoretical Models Used in HIV/AIDS
Prevention (contd.)
  • IV. Transtheoretical Model (Stages of Change)
  • (Prochaska and DiClemente)
  • Pre-contemplative
  • Contemplative
  • Ready for action
  • Action
  • Maintenance
  • Relapse

26
NIMH Theorists WorkshopConsensus on Eight Areas
1. Behavioral Intentions 2. Environmental
Constraints 3. Ability (skills) 4. Anticipated
Outcomes or Attitudes 5. Normative
Influences 6. Self-standards 7. Emotion (positive
or negative attitudes toward behavior
change) 8. Perceived Self-efficacy
27
Designing and Implementing a Culturally
Innovative Intervention
28
Cultural Sensitivity Versus Cultural Competency
  • Cultural Sensitivity
  • Translation of materials into Spanish
  • Hiring of bilingual/bicultural staff
  • Delivering the intervention within the targeted
    community (community-based)
  • Recognizing cultural differences
  • Creating a culturally appropriate environment
  • All of the above

29
Cultural Sensitivity Versus Cultural Competency
  • Cultural Competency
  • Similar to cultural sensitivity, but differs by
    building the overall intervention on cultural
    concepts, normative/cultural beliefs, or the
    essence of the culture itself

30
Defining Culturally Appropriate Interventions
  • Marin, G. (1993) Culturally Appropriate
    Interventions
  • Based on the cultural values of the group
  • Strategies that comprise the intervention reflect
    the subjective culture (attitudes, expectations,
    norms) of the group
  • The components that make up the strategies
    reflect the behavioral preferences and
    expectations of the group members

31
Defining Culturally Appropriate Interventions
  • Singer, (1991) Various forms/approaches for
    interventions
  • Culturally sensitive approaches attempt to be
    socioculturally empathetic, in that they
    recognize the importance of training staff to be
    cognizant of racial/ethnic issues and
    sensitivities

32
Defining Culturally Appropriate Interventions
  • In addition to the above, culturally
    appropriate approaches also incorporate a
    specific awareness of the cultural and linguistic
    patterns of the target community. To help people
    feel at home and to build a rapport quickly.

33
Defining Culturally Appropriate Interventions
  • Culturally innovative approaches incorporate
    features of the other types but in addition
    struggle to consciously mobilize and enhance
    cultural beliefs, symbols, concepts, values and
    roles as core elements of the intervention
    process. They intentionally attempt to find ways
    to use culture therapeutically to both reach
    participants and to assist them in making
    behavioral changes.

34
Defining Culturally Appropriate Interventions
  • Socioculturally congruent approaches, while
    including elements of the other approaches, are
    especially concerned with establishing congruence
    between program work and community efforts in the
    struggle for self-determination and
    self-development. The ultimate goal is to assist
    participants to view their culture as an
    empowerment tool.

35
Hispanic Cultural Concepts That Were Identified
for Possible Use to Derive the Culturally
Innovative Intervention
Acculturation The degree to which Mexican
Americans are more traditional in their
orientation to Hispanic or Anglo culture. La
Vida Loca The lifestyle characteristics of
Mexican American injection drug
users. Familism The significance of family to
the individual. Simpatia The smooth/non-confronta
tional context of social interactions. Personal
ismo The preference for relationships with
same-ethnic members in a social group.
36
Hispanic Cultural Concepts That Were Identified
for Possible Use to Derive the Culturally
Innovative Intervention
Machismo Machismo of the streets vs. Machismo
of the home. Respeto The need to maintain
ones personal integrity and that of
others. Controlarse The degree of self-control
an individual has over certain behaviors and
feelings. Confianza The establishment of a
trusting, safe and open bond between two
people. TraditionalismThe degree to which one
adheres to traditional beliefs and customs
(e.g., gender roles).
37
Deriving and Validating Cultural and Subcultural
Concepts
  • Elicitation Research
  • Used this approach to identify and define
    cultural concepts with Hispanic IDUs
  • Forty in-depth interviews and four focus groups
    with Hispanic IDUs were conducted in the first
    year of the study
  • Several cultural and subcultural concepts were
    identified

38
Deriving and Validating Cultural and Subcultural
Concepts
  • Machismo
  • For me being macho means always having drugs.
  • Being macho is an important part of who I am.
  • A woman should give in to her husband in almost
    all matters.
  • It is a mans right to drink and use drugs if he
    wants to.
  • For me, being macho is controlling my drug use.

39
Deriving and Validating Cultural and Subcultural
Concepts
  • It is macho to get high on any drug available.
  • Drug use makes my friends think I am macho.
  • It is macho to have lots of money and drugs.
  • To be macho you can never let your guard down.
  • To be macho is not to be addicted.
  • Those who sell drugs are macho.

40
Deriving and Validating Cultural and Subcultural
Concepts
  • Religiosity
  • I am a very religious person.
  • Healing comes only from God.
  • My faith in God has guided my life and helped me
    through personal crises I have had.
  • I go to church regularly.

41
Deriving and Validating Cultural and Subcultural
Concepts
  • I want my children to have a religious
    background.
  • Good health and happiness happens to people who
    obey Gods commandments.
  • I have a lot of faith in the power of God.
  • I pray every day.

42
Deriving and Validating Cultural and Subcultural
Concepts
  • Familism
  • More parents should teach their children to be
    loyal to the family.
  • I rely on my family for help when I need it.
  • No matter what the cost, dealing with my
    relatives problems comes first.

43
Deriving and Validating Cultural and Subcultural
Concepts
  • It is important to me to be respected by my
    family.
  • In spite of my drug use, I always try to take
    care of my family.
  • My family is very important to me.

44
Deriving and Validating Cultural and Subcultural
Concepts
  • Traditionalism
  • I prefer to live in a small town where everyone
    knows each other.
  • Husbands and wives should share equally in child
    rearing and child care.
  • It is hard to meet and get to know people in
    large cities.

45
Deriving and Validating Cultural and Subcultural
Concepts
  • You should know your family history so you can
    pass it along to your children.
  • Adult children should visit their parents
    regularly.
  • We should make time for friends and others.

46
Deriving and Validating Cultural and Subcultural
Concepts
  • Children should be taught to always be close to
    their families.
  • We are in such a hurry sometimes that we forget
    to enjoy life.
  • When making important decisions in my life, I
    like to consult members of my family.
  • Tradition and ritual serve to remind us of the
    rich history of our institutions and our society.

47
One to One Intervention Guidelines
  • Theoretical Model
  • Eclectic, primarily derived from the Theory of
    Reasoned Action/Planned Behavior, Cognitive
    Social Theory, and the Health Belief Model. The
    intervention model is similar to the AIDS Risk
    Reduction Model (ARRM), in that it has several
    stages - labeling, salience, commitment, action,
    and maintenance. The model was guided by an
    empowerment philosophy using a case management
    approach.

48
Stages of HIV/AIDS Risk Management
49
Stages, Influences, Assessments and Interventions
for HIV/AIDS Risk Management
50
One to One Intervention Guidelines
  • Psychosocial and Behavioral Measures
  • Perceived Risk of HIV/AIDS
  • Facilitators and Inhibitors to taking preventive
    action
  • HIV/AIDS knowledge
  • HIV/AIDS risk behaviors (injection and sexual)
  • Normative influences
  • Perceived Self-efficacy
  • Response Efficacy (perceived benefits of behavior
    change)
  • Behavioral Intentions to perform preventive
    behaviors

51
One to One Intervention Guidelines
  • Cultural and Subcultural Measures
  • Machismo (Derived from IDU subculture)
  • Familism (Derived from Hispanic culture)
  • Respeto (Derived from IDU subculture)
  • Acculturation (Arizona Acculturation Scale)
  • Traditionalism (Derived from Hispanic culture)
  • Religiosity (Derived from Hispanic culture)

52
Assessment of the Culturally Innovative
Intervention
53
HIV Behavioral Risk Reduction Model for Hispanic
Injection Drug Users
54
Correlations between Cultural Factors with
Behavioral Intentions and Perceived Self Efficacy
to Reduce HIV Risk Behaviors (n406)
p lt .05 p lt .005 2-tailed test
55
Implications
56
Implications
  • Theoretical Models
  • It is important to assess the specific
    contributions of theoretical elements in using
    any behavior change model. In the psychosocial
    model developed for this study, key theoretical
    concepts were measured and identified as
    important factors contributing to self-efficacy
    and intentions to perform HIV risk reduction.
  • The examination of core theoretical elements must
    have congruence and salience with the subgroup
    targeted injection drug users, men who have sex
    with men, women, etc.
  • Interventions should be theoretically driven.

57
Implications
  • Cultural Elements
  • Interventions targeting HIV risk reduction among
    Hispanics must be culturally tailored to meet the
    specific issues of the particular Hispanic
    subgroup (IDU, MSM).
  • The inclusion of cultural factors like familism,
    traditionalism, and machismo are important in
    elucidating cognitive impacts on HIV risk
    reduction.
  • The absence of cultural factors in behavioral
    models of HIV/AIDS risk reduction will lead to an
    incomplete picture of HIV risks and associated
    cultural factors/influences.

58
Implications
  • Cultural Elements
  • Cultural competence is necessary not only in the
    delivery of the intervention but also in the
    development of the theoretical model of behavior
    change employed.
  • Cultural measures should always be included in
    behavior change models targeting Hispanics.
    Cognitive referents of the acculturation process
    are particularly important (e.g., familism,
    traditionalism, religiosity) and can be used to
    trigger behavior change among Hispanics.

59
Discussion
  • Does ethnic culture matter in the development and
    implementation of HIV/AIDS interventions?
  • How does ethnic culture and subcultures of risk
    (e.g., IDU, MSM) intertwine? Which may have
    precedent?
  • What aspects of ethnic culture can be used in the
    intervention to trigger motivation to change
    behaviors?
  • To what extent can models of behavior change
    include cultural concepts as influences on
    cognition (values and beliefs) and behaviors?

60
How To Develop a Culturally Competent Intervention
  • What are the risk behaviors you would like to
    reduce?
  • What is their prevalence?
  • How do they contribute to disease causation?

61
How To Develop a Culturally Competent Intervention
  • What are some of the factors (social,
    demographic, psychological, psychopharmacological,
    cultural) that may contribute to these risk
    behaviors?
  • What are some of the socio-cultural
    characteristics of the target population?
  • What are some of the sub-cultural
    characteristics?
  • How are these characteristics related to the risk
    behaviors you want to reduce?

62
How To Develop a Culturally Competent Intervention
  • What are some cultural strengths that you think
    could be used to facilitate risk reduction in the
    target population?
  • What are some cultural barriers that you think
    could interfere with risk reduction in the target
    population?
  • What behavior change models come to mind when you
    think about interventions to reduce these risk
    behaviors?

63
How To Develop a Culturally Competent Intervention
  • What are some of their key components?
  • How could they be adapted to the target
    population?
  • How could you infuse these models with cultural
    factors?
  • How would you develop a culturally competent
    intervention based on how you answered the above
    questions?

64
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