the development, implementation, and assessment of a culturally innovative hiv/aids intervention for...

The Development, Implementation, and Assessment of a Culturally Innovative

HIV/AIDS Intervention for Hispanic Drug Injectors

The Development, Implementation, and Assessment of a Culturally Innovative

HIV/AIDS Intervention for Hispanic Drug Injectors

Antonio L. Estrada, Ph.D., MSPHAntonio L. Estrada, Ph.D., MSPH

DirectorDirector

Mexican American Studies & Research CenterMexican American Studies & Research Center

And ProfessorAnd Professor

Mel & Enid Zuckerman Arizona College of Public HealthMel & Enid Zuckerman Arizona College of Public Health

The University of ArizonaThe University of Arizona9th Annual Summer Public Health Videoconference on Minority Health

June 12, 2003Support for this research was provided by the National Institute on Drug Abuse, Grant #

R01-DA10162, National Institutes of Health

BackgroundBackground

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).


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.


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 Increasing disparity is seen in the percent of those infected with HIV; 42% among Non-Hispanic infected with HIV; 42% among Non-Hispanic Whites compared to 58% among minorities (CDC, Whites compared to 58% among minorities (CDC, 2001).2001).

05

1015202530354045505560

93 94 95 96 97

Year

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00

Popu

latio

n

Non-HispanicBlack

Hispanic

Non-HispanicWhite

Non-HispanicAmerican Indian

Non-HispanicAsian & PacificIslander

Trends in Age-Adjusted* Annual Rates of Death from HIV InfectionBy Race/Ethnicity, USA**, 1993-1997

*Using the age distribution of the projected year 2000 US population as the standard. **Excluding data from Oklahoma, where Hispanic ethnicity was not recorded on death certificates until 1997.


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.).

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.

Adult/adolescent AIDS cases among Hispanics, by exposure category and place of birth, reported in 2000, United States

EpidemiologyEpidemiology

Male Hispanic AIDS Cases by Exposure Category Reported through December 2001, U.S.Male Hispanic AIDS Cases by Exposure Category Reported through December 2001, U.S.

42%

35%

7%0%6%

1%9%

MSMIDUMSM and IDUHemophiliaHeterosexualBlood ProductsOther

Note: Cases are for adults and adolescentsSource: Center for Disease Control, HIV/AIDS Surveillance Report, December 2001

Female Hispanic AIDS Cases by Exposure Category Reported through December 2001, U.S.Female Hispanic AIDS Cases by Exposure Category Reported through December 2001, U.S.

40%

0%47%

2%

11%

IDUHemophiliaHeterosexualBlood ProductsOther

Note: Cases are for adults and adolescentsSource: Center for Disease Control, HIV/AIDS Surveillance Report, December 2001

Pediatric Hispanic AIDS Cases by Exposure Category Reported through December 2001, U.S.Pediatric Hispanic AIDS Cases by Exposure Category Reported through December 2001, U.S.

92%

5%

1%2%

Hemophilia

Mother at Risk forHIVBlood Products

Other

Source: Center for Disease Control, HIV/AIDS Surveillance Report, December 2001

HIV/AIDS Risk BehaviorsHIV/AIDS Risk Behaviors


Injection-Related/Syringe-Mediated Risk BehaviorsInjection-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)


Sexually Related Risk BehaviorsSexually 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)

HIV Prevention Models and TheoriesHIV Prevention Models and Theories

Methods for Chronic Disease Prevention and Control (Public Health Model)Methods for Chronic Disease Prevention and Control (Public Health Model)

Primary prevention

Prevention strategy

SusceptiblePopulation’s disease status

Reduced disease incidence

Effects

Secondary prevention

Asymptomatic

Reduced prevalence/ consequence

Tertiary prevention

Symptomatic

Reduced complications/ disability

Four Major Theoretical Models Used in HIV/AIDS Four Major Theoretical Models Used in HIV/AIDS PreventionPrevention

Four Major Theoretical Models Used in HIV/AIDS Four Major Theoretical Models Used in HIV/AIDS PreventionPrevention

I.I. The Health Belief Model (Becker)The Health Belief Model (Becker) Relevant health motivation and knowledge Relevant health motivation and knowledge

(importance of health)(importance of health) Vulnerability to diseaseVulnerability to disease Disease perceived as threateningDisease perceived as threatening Efficacy and feasibility of behavior changeEfficacy and feasibility of behavior change Cues to actionCues to action Barriers to actionBarriers to action

Four Major Theoretical Models Used in HIV/AIDS Four Major Theoretical Models Used in HIV/AIDS Prevention (contd.)Prevention (contd.)


II.II. Social Cognitive Theory (Bandura)Social Cognitive Theory (Bandura)

Observation and modeling of behaviors in a social Observation and modeling of behaviors in a social groupgroup

Normative behaviors that are valued/endorsed Normative behaviors that are valued/endorsed Perceived Self-efficacyPerceived Self-efficacy Social network influencesSocial network influences Role modelsRole models



III.III. Theory of Reasoned Action/Planned BehaviorTheory of Reasoned Action/Planned Behavior

(Fishbein and Ajzen)(Fishbein and Ajzen) Behavioral intentionsBehavioral intentions Subjective normsSubjective norms Behavioral and normative beliefsBehavioral and normative beliefs Attitudes toward behaviorsAttitudes toward behaviors Perceived behavioral controlPerceived behavioral control



IV.IV. Transtheoretical Model (Stages of Change)Transtheoretical Model (Stages of Change)

(Prochaska and DiClemente)(Prochaska and DiClemente) Pre-contemplativePre-contemplative ContemplativeContemplative Ready for actionReady for action ActionAction MaintenanceMaintenance RelapseRelapse

NIMH Theorists WorkshopNIMH Theorists WorkshopConsensus on Eight AreasConsensus on Eight Areas

NIMH Theorists WorkshopNIMH Theorists WorkshopConsensus on Eight AreasConsensus on Eight Areas

1.1. BehavioralBehavioral IntentionsIntentions

2.2. Environmental ConstraintsEnvironmental Constraints

3.3. Ability (skills)Ability (skills)

4.4. Anticipated Outcomes or AttitudesAnticipated Outcomes or Attitudes

5.5. Normative InfluencesNormative Influences

6.6. Self-standardsSelf-standards

7.7. Emotion (positive or negative Emotion (positive or negative attitudes toward behavior change)attitudes toward behavior change)

8.8. Perceived Self-efficacyPerceived Self-efficacy

Designing and Implementing a Culturally Innovative Intervention

Designing and Implementing a Culturally Innovative Intervention

Cultural Sensitivity Versus Cultural CompetencyCultural Sensitivity Versus Cultural CompetencyCultural Sensitivity Versus Cultural CompetencyCultural Sensitivity Versus Cultural Competency

Cultural SensitivityCultural Sensitivity Translation of materials into SpanishTranslation of materials into Spanish Hiring of bilingual/bicultural staffHiring of bilingual/bicultural staff Delivering the intervention within the targeted Delivering the intervention within the targeted

community (community-based)community (community-based) Recognizing cultural differencesRecognizing cultural differences Creating a culturally appropriate environmentCreating a culturally appropriate environment All of the aboveAll of the above

Cultural Sensitivity Versus Cultural CompetencyCultural Sensitivity Versus Cultural CompetencyCultural Sensitivity Versus Cultural CompetencyCultural Sensitivity Versus Cultural Competency

Cultural CompetencyCultural Competency

Similar to cultural sensitivity, but differs by Similar to cultural sensitivity, but differs by building the overall intervention on cultural building the overall intervention on cultural concepts, normative/cultural beliefs, or the essence concepts, normative/cultural beliefs, or the essence of the culture itselfof the culture itself

Defining Culturally Appropriate InterventionsDefining Culturally Appropriate Interventions

Marin, G. (1993): Culturally Appropriate Marin, G. (1993): Culturally Appropriate InterventionsInterventions

Based on the cultural values of the groupBased on the cultural values of the group Strategies that comprise the intervention reflect the Strategies that comprise the intervention reflect the

subjective culture (attitudes, expectations, norms) subjective culture (attitudes, expectations, norms) of the groupof the group

The components that make up the strategies reflect The components that make up the strategies reflect the behavioral preferences and expectations of the the behavioral preferences and expectations of the group membersgroup members

Singer, (1991): Various forms/approaches for Singer, (1991): Various forms/approaches for interventionsinterventions

““Culturally sensitive” approaches attempt to be Culturally sensitive” approaches attempt to be socioculturally empathetic, in that they recognize socioculturally empathetic, in that they recognize the importance of training staff to be cognizant of the importance of training staff to be cognizant of racial/ethnic issues and sensitivitiesracial/ethnic issues and sensitivities

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.


“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.


“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.

Hispanic Cultural Concepts That Were Identified for Possible Use to Derive the “Culturally Innovative”

Intervention


Intervention

Acculturation:Acculturation: The degree to which Mexican Americans are more The degree to which Mexican Americans are more “traditional” in their orientation to Hispanic or Anglo “traditional” in their orientation to Hispanic or Anglo culture.culture.

La Vida Loca:La Vida Loca: The lifestyle characteristics of Mexican American The lifestyle characteristics of Mexican American injection drug users.injection drug users.

Familism:Familism:The significance of family to the individual.The significance of family to the individual.

Simpatia:Simpatia: The smooth/non-confrontational context of social The smooth/non-confrontational context of social interactions.interactions.

Personalismo:Personalismo: The preference for relationships with same-ethnic The preference for relationships with same-ethnic members in a social group.members in a social group.


Intervention


Intervention

Machismo: Machismo: Machismo of the streets vs. Machismo of the Machismo of the streets vs. Machismo of the home.home.

Respeto:Respeto: The need to maintain one’s personal integrity and that The need to maintain one’s personal integrity and that of others.of others.

Controlarse:Controlarse: The degree of self-control an individual has over The degree of self-control an individual has over certain certain behaviors and feelings.behaviors and feelings.

Confianza:Confianza: The establishment of a trusting, safe and open bond The establishment of a trusting, safe and open bond between two people.between two people.

Traditionalism:The degree to which one adheres to traditional beliefs Traditionalism:The degree to which one adheres to traditional beliefs and customs (e.g., gender roles).and customs (e.g., gender roles).

Deriving and Validating Cultural and Subcultural ConceptsDeriving and Validating Cultural and Subcultural ConceptsElicitation Research:Elicitation Research: Used this approach to identify and define Used this approach to identify and define

cultural concepts with Hispanic IDUscultural concepts with Hispanic IDUs Forty in-depth interviews and four focus Forty in-depth interviews and four focus

groups with Hispanic IDUs were conducted groups with Hispanic IDUs were conducted in the first year of the studyin the first year of the study

Several cultural and subcultural concepts Several cultural and subcultural concepts were identifiedwere identified

Deriving and Validating Cultural and Subcultural ConceptsDeriving and Validating Cultural and Subcultural ConceptsMachismo:Machismo: For me being macho means always having drugs.For me being macho means always having drugs. Being macho is an important part of who I am.Being macho is an important part of who I am. A woman should give in to her husband in almost A woman should give in to her husband in almost

all matters.all matters. It is a man’s right to drink and use drugs if he It is a man’s right to drink and use drugs if he

wants to.wants to. For me, being macho is controlling my drug use.For me, being macho is controlling my drug use.

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

Deriving and Validating Cultural and Subcultural ConceptsDeriving and Validating Cultural and Subcultural ConceptsReligiosity:Religiosity: I am a very religious person.I am a very religious person. Healing comes only from God.Healing comes only from God. My faith in God has guided my life and My faith in God has guided my life and

helped me through personal crises I have helped me through personal crises I have had.had.

I go to church regularly.I go to church regularly.

Deriving and Validating Cultural and Subcultural ConceptsDeriving and Validating Cultural and Subcultural Concepts I want my children to have a religious I want my children to have a religious

background.background. Good health and happiness happens to Good health and happiness happens to

people who obey God’s commandments.people who obey God’s commandments. I have a lot of faith in the power of God.I have a lot of faith in the power of God. I pray every day.I pray every day.

Deriving and Validating Cultural and Subcultural ConceptsDeriving and Validating Cultural and Subcultural ConceptsFamilism:Familism: More parents should teach their children to More parents should teach their children to

be loyal to the family.be loyal to the family. I rely on my family for help when I need it.I rely on my family for help when I need it. No matter what the cost, dealing with my No matter what the cost, dealing with my

relatives’ problems comes first.relatives’ problems comes first.

Deriving and Validating Cultural and Subcultural ConceptsDeriving and Validating Cultural and Subcultural Concepts It is important to me to be respected by my It is important to me to be respected by my

family.family. In spite of my drug use, I always try to take In spite of my drug use, I always try to take

care of my family.care of my family. My family is very important to me.My family is very important to me.

Deriving and Validating Cultural and Subcultural ConceptsDeriving and Validating Cultural and Subcultural Concepts Traditionalism:Traditionalism: I prefer to live in a small town where I prefer to live in a small town where

everyone knows each other.everyone knows each other. Husbands and wives should share equally in Husbands and wives should share equally in

child rearing and child care.child rearing and child care. It is hard to meet and get to know people in It is hard to meet and get to know people in

large cities.large cities.

Deriving and Validating Cultural and Subcultural ConceptsDeriving and Validating Cultural and Subcultural Concepts

You should know your family history so You should know your family history so you can pass it along to your children.you can pass it along to your children.

Adult children should visit their parents Adult children should visit their parents regularly.regularly.

We should make time for friends and We should make time for friends and others.others.

Deriving and Validating Cultural and Subcultural ConceptsDeriving and Validating Cultural and Subcultural Concepts Children should be taught to always be close to Children should be taught to always be close to

their families.their families. We are in such a hurry sometimes that we forget to We are in such a hurry sometimes that we forget to

enjoy life.enjoy life. When making important decisions in my life, I When making important decisions in my life, I

like to consult members of my family.like to consult members of my family. Tradition and ritual serve to remind us of the rich Tradition and ritual serve to remind us of the rich

history of our institutions and our society.history of our institutions and our society.

One to One Intervention GuidelinesOne 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.

Stages of HIV/AIDS Risk Management

LABELINGWhat is HIV/AIDS?What is HIV risk?

SALIENCESusceptibility to HIV.

How am I at risk?

COMMITMENTI will reduce my risk.I am ready to changemy risky behavior.

ACTIONWhat have I done to

reduce my risk?

MAINTENANCEI am maintaining my

risk reductionbehavior.

Progress

Relapse

Stages, Influences, Assessments and Interventions for HIV/AIDS Risk ManagementStages, Influences, Assessments and Interventions for HIV/AIDS Risk Management

Stage Influences Assessments Interventions Labeling Transmission knowledge

Perceived risk AIDS knowledge Perceptions of HIV/AIDS risk Identification of behaviors

“What is HIV/AIDS and risk?” Core Session 1 Identify characteristics of client Top 10 daily concerns Knowledge/skills Set risk management strategies

Salience Severity of HIV/AIDS Susceptibility to HIV/AIDS Perceived ability to help self Self esteem Skill building Barriers to change Denial

Self efficacy Self esteem Religiosity Family values Peer influences Traditionalism

“How am I at risk?” Core Session 2 Cycle of drug use Client identification of own risk Addiction management

Commitment Perceived benefit of change Social influences Barrier reduction Communication skills

Perceived benefit of change Commitment to changing Barriers to change Respect for self and others Machismo

“I am ready to change my risky behavior.” Core Session 2 Identify and review risk management

strategies Identify Module 1

Action Communication skills Self efficacy Self esteem Social support

Past risk reduction Social support Drug treatment HIV testing Health and STDs Arrests

“I am changing my risky behaviors.” Modules 1-3 Attend individualized Modules Identify and review risk management

strategies

Maintenance Self efficacy Self esteem Skills Social and cultural context

6 and 12 month assessments “I am maintaining my risk reduction behaviors.” Modules 1-3 Attend individualized Modules Identify and review risk management

strategies


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


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)

Assessment of the Culturally Innovative Intervention

Assessment of the Culturally Innovative Intervention

HIV Behavioral Risk Reduction Model for Hispanic Injection Drug Users

External Factors Attitudes, Beliefs Intentions and Risk Reduction and Behaviors Self-Efficacy

Demographics Age Education Income Employment Homelessness Marital Status

Cultural Factors Machismo Familism Acculturation Traditionalism Respeto Religiosity

Psychosocial Factors Self Esteem Social Support

Perceptions of Risk

Peer Influences

AIDS Knowledge

Attitudes/Beliefs

Benefits of Risk Reduction

Intentions to reduce HIV Risk

Self-Efficacy Overall Injection Sexual

Behavioral Factors IDU Risk Sex Risk STDs

HIV Risk Reduction

Correlations between Cultural Factors with Behavioral Intentions and Perceived Self Efficacy to Reduce HIV Risk Behaviors (n=406)

Correlations between Cultural Factors with Behavioral Intentions and Perceived Self Efficacy to Reduce HIV Risk Behaviors (n=406)

Behavioral Behavioral IntentionsIntentions

Overall Overall Self-Self-EfficacyEfficacy

Syringe Syringe Self- Self- EfficacyEfficacy

Condom Condom Self- Self- EfficacyEfficacy

AcculturationAcculturation -.025-.025 .072.072 -.016-.016 .065.065

MachismoMachismo -.095-.095 -.101*-.101* -.159**-.159** -.084-.084

FamilismFamilism .264**.264** .294**.294** .370**.370** .235**.235**

ReligiosityReligiosity .126*.126* .138*.138* .247**.247** .100*.100*

TraditionalisTraditionalismm

.253**.253** .227**.227** .289**.289** .234**.234**

* p < .05; ** p < .005; 2-tailed test

ImplicationsImplications


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.


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.


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.

DiscussionDiscussion

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?

What are the risk behaviors you would like to What are the risk behaviors you would like to reduce? reduce?

What is their prevalence? What is their prevalence? How do they contribute to disease causation?How do they contribute to disease causation?

How To Develop a Culturally Competent InterventionHow To Develop a Culturally Competent Intervention

What are some of the factors (social, What are some of the factors (social, demographic, psychological, demographic, psychological, psychopharmacological, cultural) that may psychopharmacological, cultural) that may contribute to these risk behaviors? contribute to these risk behaviors?

What are some of the socio-cultural What are some of the socio-cultural characteristics of the target population? characteristics of the target population?

What are some of the sub-cultural What are some of the sub-cultural characteristics? characteristics?

How are these characteristics related to the risk How are these characteristics related to the risk behaviors you want to reduce?behaviors you want to reduce?


What are some cultural strengths that you think What are some cultural strengths that you think could be used to facilitate risk reduction in the could be used to facilitate risk reduction in the target population?target population?

What are some cultural barriers that you think What are some cultural barriers that you think could interfere with risk reduction in the target could interfere with risk reduction in the target population?population?

What behavior change models come to mind What behavior change models come to mind when you think about interventions to reduce when you think about interventions to reduce these risk behaviors?these risk behaviors?


What are some of their key components? What are some of their key components? How could they be adapted to the target How could they be adapted to the target

population?population? How could you infuse these models with cultural How could you infuse these models with cultural

factors?factors? How would you develop a culturally competent How would you develop a culturally competent

intervention based on how you answered the intervention based on how you answered the above questions?above questions?


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