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Culturally Competent HIV Prevention
With by Kurt C. Organista Occasional Paper No. 47
The author wishes to acknowledge the expert guidance of Dr. Barbara VanOss Marin, director, and staff of The Collaborative HIV Prevention Research in Minority Communities program at the Center for AIDS Prevention Studies (CAPS), University of California, San Francisco.
About the Author: Kurt Organista Kurt C. Organista, PH.D., is an Associate Professor of Social Welfare at the University of California, Berkeley, and a clinical psychologist. He conducts research in the areas of HIV prevention with Mexican farmworkers and culturally competent applications of cognitive behavioral therapy to depressed Latinos. Organista teaches courses such as the following: psychopathology, stress and coping, race relations, ethnic minority mental health, and social work with Latinos.
SUGGESTED CITATION Organista, Kurt C., (Ph.D.) "Culturally Competent HIV Prevention With Mexican/Chicano Farmworkers," JSRI Occasional Paper #47, The Julian Samora Research Institute, Michigan State University, East Lansing, Mich., 1998.
Table of Contents
Mexican farmworkers are among the poorest, most marginalized, and exploited Latinos in America. Although they are part of a century-and-a-half old tradition of supplying essential, labor-intensive work to multi-million and billion dollar industries and corporations, they struggle and toil at the bottom of the U.S. stratification system, where they are extremely vulnerable to numerous life-compromising problems and circumstances. Severe and neglected health problems have already been documented for migrant laborers (Rust, 1990). A recent review of the literature on HIV risk and migrant laborers (Organista and Balls Organista, 1997) adds the imminence of an AIDS epidemic further complicating the lives of migrant laborers in general, and Mexican farmworkers in particular, who comprise the majority of migrant laborers in the United States. The purpose of this chapter is to provide sociodemographic and HIV risk profiles for Mexican/Chicano farmworkers, followed by a discussion of culturally competent HIV/AIDS research with this unique population, and finally, recommendations for both future research as well as culturally appropriate HIV prevention strategies. It is worth mentioning that the frequency with which Mexican migrant laborers eventually settle in the U.S. blurs the distinction between Mexican and Chicano farmworkers. In the most thorough survey of migrant laborers in America, the U.S. Department of Labor (1990) estimates that there are between 2.7 and 4 million migrant laborers (the higher figure includes an estimation of family members). Mexican migrants comprise 57% of all migrant laborers, while U.S.-born Chicanos comprise another 9% for a two-thirds Mexican descent work force. Mexican migrant laborers are extremely poor, with annual incomes of approximately $6000, an average of 4-7 years of education, and a 10% illiteracy rate (Organista and Balls Organista, 1997). In terms of gender breakdown, Mexican migrants remain predominantly about 70% male, but this figure indicates the steadily increasing presence of women in migratory labor, which used to be virtually all male. About 25% of Mexican migrants are undocumented. Inherent in this sociodemographic profile are many formidable obstacles to conducting HIV research with Mexican farmworkers and to provide them with the numerous health and human services that they need, including HIV prevention services. Yet, it is time to begin to struggle with these obstacles in order to prevent an AIDS epidemic in this new high risk group. Introduction | Sociodemographic Profile | HIV Infection/Risk Profile | Major HIV Exposure Categories for Farmworkers | Prostitution Use in the United States | Sex Between Men | Needle Sharing | Gender and HIV Risk | HIV/AIDS-Related Knowledge, Attitudes, Beliefs, and Behaviors | Predictors of Condom Use | Notes On Culturally Competent HIV Research | Implications for Future HIV Research with Mexican Farmworkers | Implications for HIV Prevention Services for Mexican Farmworkers | Conclusion | References HIV screening with migrant laborers is currently infrequent and sporadic. However, the few screenings that have been conducted indicate an AIDS epidemic in progress for Black farmworkers in the Southeastern states, and the making of such an epidemic in Mexican farmworkers. For example, HIV testing in labor camps in Florida and the Carolinas revealed infection rates ranging from 3.5% to an alarming 13% in Black farmworkers from both the U.S. and Caribbean; Blacks comprise about 27% of the migrant labor population (Organista and Balls, 1997). While the results of three HIV screenings with Mexican farmworkers have only found infection rates of less than 2% (CDC, 1988; Lopez and Ruiz, 1995; Carrier and Magaña, 1991), these studies also document the presence of significant precursors to an AIDS epidemic in this population. For example, in Lopez and Ruiz's (1995) HIV screening of 176 Mexican farmworkers in Northern California, they report a 9% history of STDs, two active cases of syphilis, and note that 9% of female respondents reported having sex with a partner using injection drugs. Also, in their screening of 2,000 migrant laborers, Carrier and Magaña (1991) note that epidemics of syphilis and chancroid had recently occurred in migrant laborers and prostitutes in the Orange County area. Major HIV Exposure Categories for Farmworkers Previous survey research by the author and associates, and reviews of the literature, indicate that there are at least four major HIV exposure categories that render farmworkers vulnerable to infection. These categories are related to both migratory labor and Mexican culture. Prostitution Use in the United States Worldwide, prostitution use is a common part of the migrant labor experience for men far away from home for extended periods of time (Hulewicz, 1994). With regard to Mexican migrants, Organista et al. (1997a) found that 44% of 342 male respondents reported sex with prostitutes while working in the U.S. Interestingly, married men in the survey were as likely as single men to use prostitutes, but less likely to use condoms, underscoring significant risk to wives. With regard to the complex ways that culture and migratory labor influence behavior, it was also found that 13% of the men surveyed reported participating in a male bonding ritual in which several migrant men have sex with the same prostitute in succession. After such an experience, these men refer to themselves as Hermanos de Leche [Milk Brothers], presumably for sharing sperm. The Hermanos de Leche ritual was also documented by Magaña (1991) who interviewed 50 male Mexican migrants and 38 injection-drug using female prostitutes. Magaña reported that the prostitutes actively solicited the men at the labor camps, bars, and other locations where they congregated, especially on payday. Ironically, low condom use was reported by both the migrants and the sex workers in this study because members of each group believed that suggesting condom use would insinuate that they had AIDS or another STD. Efforts to promote condom use with prostitutes will need to take into consideration the complex nuances of this salient HIV exposure category. Introduction | Sociodemographic Profile | HIV Infection/Risk Profile | Major HIV Exposure Categories for Farmworkers | Prostitution Use in the United States | Sex Between Men | Needle Sharing | Gender and HIV Risk | HIV/AIDS-Related Knowledge, Attitudes, Beliefs, and Behaviors | Predictors of Condom Use | Notes On Culturally Competent HIV Research | Implications for Future HIV Research with Mexican Farmworkers | Implications for HIV Prevention Services for Mexican Farmworkers | Conclusion | References Surveys of Mexican migrants inquiring about sex between men report rates ranging from 2% to 3.5% (Lafferty, 1991; Lopez and Ruiz, 1995; Organista, et al. 1997a). Although these survey interviews were private and conducted by male interviewers, the figures most likely underestimate this taboo behavior. For example, when the author conducted pre-survey focus groups with migrant men to discuss sex between men, all participants acknowledged the common practice of heterosexual "macho" men occasionally having sex with other men when women are unavailable. But when asked directly if any of them had had such experiences, all said no, given the non-private and social nature of focus groups. Private interviews are needed to learn more about the complexities of this pertinent HIV exposure category. Carrier (1985, 1995) wrote extensively about the construction of (homo)sexuality in Mexico vs. the U.S. in ways that are informative to HIV prevention research and services. Consistent with the above focus groups, Carrier has long noted that masculine Mexican men that occasionally play the active inserter role with passive, effeminate men may continue to identify as heterosexual, and lead predominantly heterosexual lifestyles. Such culture-based sexual behaviors are bound to be influenced by the experience of migratory labor in which sex between men is not uncommon. For example, Bronfman and Minello (1992) conducted in-depth, qualitative interviews with Mexican migrants and concluded that homosexual contact increases with migration, due to factors such as extended periods of loneliness, isolation, emotional deprivation, as well as greater sexual freedom in the U.S. Obviously the different constructions of sex between Mexican men need to be considered for maximally effective HIV prevention messages. Needle sharing is an interesting HIV exposure category for Mexican migrants for many culture-related reasons, such as the frequent practice of lay "therapeutic injections" of vitamins and antibiotics. In Mexico, it is legal and common for people to purchase and use hypodermic needles to medicate themselves and family members. This practice continues in the U.S., especially given the low access to affordable health care. For example, Lafferty (1991) found that 20% of 411 Mexican farmworkers reported self-administered lay therapeutic injections, including 3.5% who reported sharing the needle with family members. In contrast, only 2.9% of the sample reported illegal injection drug use. More recently, McVea (1997) found that 12% of 532 Mexican farmworkers surveyed admitted to lay injection with antibiotics or vitamins. Thus, HIV prevention messages aimed at needle sharing must not be confined to illegal drug use. While not documented in the literature, there is currently discussion in the labor camps about the practice of young migrant men who share needles while placing tattoos on their bodies. This would be yet another example of HIV risk related to a rather distinct form of needle sharing. As mentioned earlier, Mexican migrant women, as well as the wives of migrant men back in Mexico, are at risk for HIV due to the risky behaviors of their male sex partners, which include IV drug use (Lopez and Ruiz, 1995), prostitution use without condoms (Organista, et al. 1997), sex between men, and needle sharing as discussed above. Unfortunately, risk for these women is exacerbated due to their lack of knowledge regarding STDs (Schoonover Smith, 1988) and cultural prohibitions that are obstacles to HIV prevention strategies such as condom use. For example, Organista, et al. (1997a) found that migrants in general - and female migrants in particular - believed that women would be seen as promiscuous for carrying condoms. As a result, 75% of the 159 women surveyed reported "never" carrying condoms as compared to 41.4% of men. Hence, there are considerable culture and gender-related obstacles to initiating protective behaviors in female migrants. One way of skirting the issue is to focus on the risk behaviors of migrant men that place their female partners at risk. However, female focused strategies warrant equal attention. Amaro (1988) has advocated the obvious starting place of conducting empowering focus groups with Latinas in which discussions would focus on their beliefs about realistic and effective prevention strategies. Introduction | Sociodemographic Profile | HIV Infection/Risk Profile | Major HIV Exposure Categories for Farmworkers | Prostitution Use in the United States | Sex Between Men | Needle Sharing | Gender and HIV Risk | HIV/AIDS-Related Knowledge, Attitudes, Beliefs, and Behaviors | Predictors of Condom Use | Notes On Culturally Competent HIV Research | Implications for Future HIV Research with Mexican Farmworkers | Implications for HIV Prevention Services for Mexican Farmworkers | Conclusion | References HIV/AIDS-Related Knowledge, Attitudes, Beliefs, and Behaviors HIV Transmission Considering the high risk status of Mexican farmworkers documented
above, what do we know about HIV/AIDS-related knowledge in this
population? Survey research conducted by the author and his associates
have documented that, contrary to popular belief, Mexican migrant
laborers have high knowledge about the major modes of HIV transmission
(e.g., blood, unprotected sex) (Organista, et al. 1997a). However,
they simultaneously hold many misconceptions about contracting
HIV from casual modes such as mosquito bites, public bathrooms,
kissing on the mouth, being coughed on, giving blood, etc. A
full 50% of the 501 migrant laborers surveyed believed that they
could contract HIV from the HIV test, a misconception that promises
to be a surefire deterrent to getting people tested. The safer sex strategy of carrying and using condoms is particularly relevant to migrant laborers given the transient and geographically isolated nature of their work and lifestyles. Unfortunately, research on condom use reveals poor condom knowledge and inconsistent use. For example, Organista, et al. (1997a) found that between half and two-thirds of their sample either answered incorrectly or reported that they did not know the answers to questions such as "Is Vaseline good lubricant for condoms?" or "Should you unroll condom before putting it on penis?". When condoms are used by Mexican migrants, they are used far more often with secondary or occasional sex partners as compared to primary sex partners. In pre-survey focus groups, the following reasons were given for not using condoms with intimate, regular sex partners: it would suggest infidelity, female partner already using (non-barrier) birth control, couple's desire to have children. Consequently, only 21% of sexually active migrants reported "always" using condoms with regular sex partners during the past year, as compared to 71% with secondary sex partners. Culture-related condom use by sex partner patterns clearly need to be considered in condom promotion strategies. In view of the low and inconsistent use of condoms on the part of Mexican migrant laborers, it is important to explore predictors of condom use. Analyses of data from a small pilot survey of 87 Mexican migrant laborers, revealed that condom use with both occasional and regular sex partners, as well as carrying condoms, were all most strongly predicted by the perception that friends carry and use condoms or "condom social norms" (Organista, et al. 1997b). Pilot study findings also showed that personally knowing someone with AIDS was a significant predictor of both carrying condoms and condom use with occasional sex partners. In addition, worry about contracting AIDS was found to predict carrying condoms. Thus, while secondary to the social norm variable, items tapping perceived risk were noteworthy predictors. Predictors of condom use were also analyzed in a large follow-up survey of 501 Mexican migrant laborers (Organista, et al. 1998). The purpose of this larger predictor study was threefold: first, we were interested in replicating the pilot study findings on a larger and more representative sample of Mexican migrant laborers; second, we examined the effects of additional demographic and lifestyle control variables on the replication analyses. The larger sample size gave us the opportunity to more stringently control variables well-known in AIDS literature for their influence on condom use (e.g., age, education, number of sex partners, etc.); finally, we explored the added effects of several additional pertinent variables on the results of the above controlled analyses. For example, the sample we examined included the variable "condom efficacy" which is designed to assess how confident respondents feel about negotiating condom use with sex partners in a variety of challenging situations (e.g., subjects were asked how capable they would be of insisting on condom use if a prospective sex partner were to: get angry; not want to use a condom; threaten to leave, etc.). Other items assessed condom use capability with a sex partner that the respondent was in love with, that was using another form of birth control, that wanted to have a baby, etc. This variable was included in the larger predictor study because previous research on U.S. Latinos showed that it predicts condom use with occasional sex partners (Marin, et al. 1993). In fact, Marin, et al. (1998) recently validated a full 20-item scale of condom efficacy on a large, ten state sample of over 1,100 U.S. Latino men and women. This particular scale was used to assess condom efficacy in our larger predictor study. Results revealed that while we were able to replicate our pilot study finding, condom use with occasional and regular sex partners, as well as carrying condoms, were all predicted by condom social norms, and the addition of condom efficacy as a predictor factor greatly altered the final results as described below. Condom Use With Occasional Sex Partners In the case of condom use with occasional sex partners, condom social norms were rendered nonsignificant (as well as all other predictors) when condom efficacy was added to the final regression model. This finding indicated that the omission of condom efficacy as a variable in predictor studies overestimates the influence of condom social norms on condom use with occasional sex partners. Thus, condom efficacy appears to be a central factor in understanding condom use with occasional sex partners in Mexican migrants whose work and lifestyle accentuate this major HIV exposure category. For example, 82% of single men and 27% of married men in the survey reported multiple sex partners during the past year (Organista, et al. 1997a) Condom Use With Regular Sex Partners Condom use with a regular sex partner appears to be more complex and multi-determined than condom use with occasional sex partners. The addition of condom efficacy to the final regression model again displaced condom social norms as a significant predictor factor, but carrying condoms and low negative attitudes towards condoms remained significant predictors. Thus, for migrants to increase their condom use in presumably intimate, ongoing sexual relationships, it appears that they must feel both efficacious and positive regarding condoms and must also keep condoms readily available. Carrying Condoms The regression model predicting carrying condoms was the most
complex and suggests that promoting this behavior is a crucial
first step that requires attention to a wide variety of factors.
This is because the addition of condom efficacy and negative
attitudes towards condoms to the final regression model revealed
no confounding with previously significant predictors. That is,
carrying condoms was a function of condom efficacy as well as
condom social norms, perceived vulnerability about contracting
AIDS, and low negative attitudes towards condoms. Taken together, results from the predictor studies indicate three very important forms of condom use, each with its own distinct set of predictors. In sum, our results suggest that carrying condoms is an imperative - albeit currently infrequent - first step in preventing AIDS in Mexican migrants that can be increased by interventions enhancing condom-related social norms, attitudes, and efficacy, as well as instilling a sense of vulnerability to contracting HIV. While condom efficacy is only one of several factors needed to increase the frequency of carrying condoms, it appears to be the central factor in condom use with occasional sex partners and must be stressed in this important context. Finally, while condom use with regular sex partners is secondary to occasional sex partners in the target population, our findings suggest that even this infrequent and interpersonally sensitive form of condom use might be enhanced by increasing condom efficacy, positive attitudes, and carrying condoms. Introduction | Sociodemographic Profile | HIV Infection/Risk Profile | Major HIV Exposure Categories for Farmworkers | Prostitution Use in the United States | Sex Between Men | Needle Sharing | Gender and HIV Risk | HIV/AIDS-Related Knowledge, Attitudes, Beliefs, and Behaviors | Predictors of Condom Use | Notes On Culturally Competent HIV Research | Implications for Future HIV Research with Mexican Farmworkers | Implications for HIV Prevention Services for Mexican Farmworkers | Conclusion | References Notes On Culturally Competent HIV Research Before discussing the implications of the above research for future HIV prevention research and services for Mexican farmworkers, it is instructive for the purpose of this report to share the considerable effort that went into making this research project culturally sensitive. Hence, the deliberate inter-penetration of culture and research methods that guided this project are briefly highlighted below. Collaboration The idea for this research emerged from discussions with Dr. Javier Garcia de Alba G., Director of the Regional Institute of Public Health at the University of Guadalajara (UG) in Mexico, who was concerned about cases of AIDS beginning to appear in some of the remote "sending towns" of Jalisco, Mexico, with long histories of out-migration to the United States. Indeed, research has documented a strong link between AIDS cases in Mexico and migration to the U.S. For example, Bronfman, et al. (1989) found that of the 165 registered AIDS cases in Mexico in 1988, 10.4% had lived in the U.S. and 33% of the cases were from states with the highest out-migration to the U.S. (e.g., of the AIDS cases in Baja California, 20% had lived in the U.S.). From 1983 to 1995, UG and the School of Social Welfare at the University of California, Berkeley (UCB), co-sponsored an annual Intercambio Academico [academic exchange] program in which students and faculty visited each other's institutions for a three-week period, in order to receive didactic instruction and field experience in the areas of social work and public health. This innovative program was developed by UCB's pioneering Chicano social work faculty member, Joe Solis, whose vision was to enrich Latino curricula and inspire collaborative research. When I joined the UCB faculty in 1990, my ability to speak Spanish, as well as my Chicano background, enabled me to use the Intercambio Academico as a vehicle for conducting collaborative, cross-cultural, international research with Mexico. Research Approach The information in this manuscript is based on seven years of labor intensive qualitative and quantitative survey research. The state of the art in social science HIV research has now shifted to blending qualitative and quantitative research methods in ways that inform each other in an illuminating, bi-directional fashion. Such an approach is consistent with current critiques of the intervention literature that urge researchers to carefully tailor AIDS prevention programs to the sociocultural and ethnic realities of specific at-risk groups (Marin, 1995; Wyatt, 1994). But while blending qualitative and quantitative research represents an optimal approach, few researchers possess balanced skills in both of these distinct sets of research methods. As such, interdisciplinary collaboration is imperative, as well the willingness on behalf of the researchers to transcend their typically 1-sided research training, not to mention the considerable biases built into such narrow training. As with most projects, the first step was to thoroughly review the literature in order to summarize and critique the state of current knowledge. Given the paucity of research in this area, and the need to develop a knowledge base, a comprehensive review of the literature was compiled and published (Organista and Balls Organista, 1997). Mishra, Connor, and Magaña (1996) have similarly expanded this knowledge base with their pioneering book AIDS crossing borders: the spread of HIV among migrant Latinos. The next step was to identify and/or design instruments in order to conduct an HIV/AIDS "knowledge, attitudes, beliefs and behaviors" or "KABB" survey with Mexican migrant laborers. The plan was to survey a prototypical "sending town" in the state of Jalisco, Mexico, during the Christmas season when migrant laborers in the U.S. return home for the holidays. Mexican colleagues were crucial in providing access to the town given their work with the medical school at UG in establishing satellite health clinics and conducting health campaigns in such poor, rural communities. The town selected had an average of two family members per household who had lived and worked in the U.S. Barbara VanOss Marin and associates at the Center for AIDS Prevention Services (CAPS) at the University of California San Francisco (UCSF) have been at the forefront of conducting large behavioral epidemiological HIV-related surveys with Latinos in the U.S. (e.g., Marin, Gomez, and Tschann, 1993). I requested a copy of Marin's Hispanic Condom Questionnaire (HCQ) - a fully back-translated KABB questionnaire developed for U.S. Latinos. My research team modified the HCQ based on our literature review, consultations with experts, and pre-survey focus groups with members of the target population at the selected study site. Please note that it would have been easier, and less culturally sensitive, to simply impose the HCQ "as is" on the initial, pilot study sample. Next, I flew to Mexico and visited the study site with Dr. Marco Antonio Castillo Moran, a trusted UG medical doctor who had previously lived and worked in the town as their medical provider for a period of one year during his required "servicio social" [social service]. Introduced as the doctor's colleague, we first met with an important community leader or "gate keeper" who ran the local hardware store. He offered me pitayas (a regional small red prickly pear) to eat while I shared with him my family's roots in Jalisco noting that many of my cousins currently lived in Guadalajara. When I accepted his second offering of pitayas, I'll never forget how he smiled and exclaimed "So, you really are Mexican!" From that moment on, I was able to request his assistance with helping me to organize focus groups with adult migrant men and women who had lived and worked in the U.S. since the early 1980's (the beginning of U.S. AIDS epidemic). The hardware store owner took out a megaphone, climbed to the roof of his store and broadcasted to the town my presence, title, and the requested focus groups (he also mentioned that eggs had arrived and could be purchased at his store). I marveled as his amplified voice echoed off the rooftops and nearby cliffs and marveled even more when I saw the focus group participants gathered at the designated locations at mid-day. The above interpersonal exchange is highlighted to illustrate the necessity of understanding and using a Latino-based relationship protocol to build confianza or trust on the basis of salient values such as respecto [respect] and personalismo, or a personalized approach to collaboration in which the personal dimension predominates over the task dimension of the relationship. That is, to begin such an exchange by requesting assistance with a task (as in the American style of "not mixing business with pleasure") generally runs counter to traditional Latino communication protocol, and can be perceived as rude. During the focus groups, I facilitated discussions about HIV/AIDS designed to reveal what the migrants knew, believed, and how they behaved sexually with respect to the disease. Discussions were recorded and reviewed afterward with research team members. Ultimately, the information obtained was used to tailor the HCQ for use with Mexican migrant laborers from the town. New items were back-translated by our bilingual research team members. Next, Mexican medical students from UG were trained to administer the survey instrument by a Mexican HIV expert with years of experience training HIV agency personnel how to administer such highly personal questionnaires. Only those students evaluated to be competent by the trainer were included in the interview team. It was also imperative for myself to participate on the team as both interviewer and daily team convener in order to process the ongoing experience. We were successful in surveying every household in the town and in publishing a series of reports focusing on KABB results for the entire sample (Organista, et al. 1996), as well as a woman's sample (Balls Organista, Organista, Soloff, 1998), and finally the aforementioned exploration of predictors of condom use (Organista, et al. 1997b). The pilot study was most informative for ascertaining how to further modify and refine our survey instrument in preparation for a planned, 5-site, state-wide survey in Jalisco. For example, we decided to drop our measure of depression, because it revealed little statistical variance and elicited a negative response bias from participants. Conversely, pilot study findings that illuminated HIV risk or protection resulted in the creation, expansion, or adoption of scales in such areas as prostitution use, condom social norms, and condom efficacy. However, these survey modifications were proceeded by yet another round of pre-survey focus groups at prospective study sites - this time stratified by age (younger and older migrants) and gender. Again, this qualitative dimension of the research required a trip to Mexico and careful study of focus group tape recordings, but the resulting collection of scales yielded sound psychometric properties illuminating measures of HIV risk and protection for the target population. Reports from the larger survey include KABB findings (Organista, et al. 1997a) as well as the well-controlled and expanded analysis of predictors of condom use (Organista, et al. 1998). Findings from these reports have implications for the next phase of HIV prevention research and for informing HIV prevention strategies with a target population. Introduction | Sociodemographic Profile | HIV Infection/Risk Profile | Major HIV Exposure Categories for Farmworkers | Prostitution Use in the United States | Sex Between Men | Needle Sharing | Gender and HIV Risk | HIV/AIDS-Related Knowledge, Attitudes, Beliefs, and Behaviors | Predictors of Condom Use | Notes On Culturally Competent HIV Research | Implications for Future HIV Research with Mexican Farmworkers | Implications for HIV Prevention Services for Mexican Farmworkers | Conclusion | References Implications for Future HIV Research with Mexican Farmworkers Objectives While prior research suggests several possible future research directions, it seems optimal to pursue the objective of increasing proper and consistent condom use with secondary sex partners on part of Mexican male farmworkers. This particular objective addresses most of salient interacting factors framing the problem of HIV risk in Mexican farmworkers. Framing the Problem Figure 1 serves as a working model that depicts salient characteristics of both migratory labor in the U.S. (e.g., lonely and transient work, social marginality) as well as Mexican culture (e.g., traditional gender roles, machismo) in the attempt to portray how these two major overlapping dimensions frame a wide variety of risk scenarios. Such scenarios are, in turn, a function of different interactions between subgroups of farmworkers (e.g., age group, gender), different HIV exposure categories (e.g., prostitution use), and situational factors (e.g., geographical isolation, heavy drinking at local bars, etc.). This model is used to plan a pilot study to assess the feasibility of pursuing the research objectives, given the formidable obstacles that this complex problem area presents to conventional social science research methods.
Pilot Feasibility Study The proposed pilot study will consist of two phases: 1) gather pertinent information from key informants, to better understand the farmworker situation, and subsequently work out prevention service delivery issues and refine HIV prevention program content; and 2) pilot test the preliminary HIV prevention service delivery program on a small scale, complete with a plan for evaluating intervention effectiveness. Both study phases will be carried out in collaboration with community-based migrant health service providers currently serving members of the target population. A recent survey of 181 California agencies that provide AIDS prevention services to Latinos showed that community-based agencies are more effective than federal, state, and private agencies due to greater numbers of bilingual staff and volunteers, and to more culturally sensitive approaches to service delivery (Castañeda and Collins 1995). Qualitative Groundwork Qualitative research methods in the form of a series of private, individual interviews with farmworkers, and focus groups with health outreach workers will be used to: 1) obtain basic, descriptive information about the farmworker experience at potential study sites (e.g., number and different types of labor camps in Northern California counties; labor migration seasons and patterns; migrant population estimates, etc.); 2) obtain information on current HIV/AIDS, and other health and social service delivery models currently available to farmworkers (e.g., sponsored by the federal government, state, non-profit, or community grass roots agencies); and 3) obtain input on perceptions of barriers and facilitators to HIV prevention with the target population. Innovative Interventions Qualitative data will also be used to develop a preliminary version of the HIV prevention program and to assess the feasibility of program delivery and evaluation. This phase of the study will be important for building upon prior research. For example, while condom efficacy predicts condom use with occasional sex partners, what inhibits and promotes condom efficacy with different types of sex partners such as other men, local women, and sex workers? Thus, qualitative data will also be used to modify and refine variables from previous research believed to mediate condom use. For example, the understanding of condom efficacy as assessed in prior research may not take into consideration challenging sexual situations specific to farmworkers at potential study sites in Northern California. Qualitative data will also help to make decisions about different
intervention methods that can be tried (e.g., actively involving
farmworkers in the HIV prevention service versus a more traditional
didactic approach). With regard to innovative approaches, Magaña,
et. al (1992) have advocated circulos de salud [health circles]
for promoting HIV prevention with Latinos based on the empowering
and progressive work of Brazilian educator Paulo Friere. Such
health circles begin by teaching participants the technical basics
of HIV transmission and prevention, but then involve the participants
in an active problem-solving discussion after posing relevant
hypothetical risky situations relevant to their lives. The assumption
here is that participants want to prevent HIV and know much more
about their reality than researchers and service providers. Finally, methods of data collection for assessing intervention program effectiveness, including strategies for conducting follow-up evaluation (e.g., six month post-intervention) with the transient target population, will also be explored. One piece of advice on this matter, provided by a consulting health agency, is to focus on government labor camps where documented farmworkers are easier to track. Obviously, the exclusion of undocumented farmworkers has numerous tradeoffs to consider. Introduction | Sociodemographic Profile | HIV Infection/Risk Profile | Major HIV Exposure Categories for Farmworkers | Prostitution Use in the United States | Sex Between Men | Needle Sharing | Gender and HIV Risk | HIV/AIDS-Related Knowledge, Attitudes, Beliefs, and Behaviors | Predictors of Condom Use | Notes On Culturally Competent HIV Research | Implications for Future HIV Research with Mexican Farmworkers | Implications for HIV Prevention Services for Mexican Farmworkers | Conclusion | References Implications for HIV Prevention Services for Mexican Farmworkers While research efforts continue, people continue to become infected with HIV. Hence, it is necessary at any point in time to use state of the art knowledge to inform prevention strategies as best as possible. General Recommendations Basic HIV/AIDS information must be communicated to Mexican farmworkers in Spanish (e.g., 81% of our survey sample spoke only or mostly Spanish). Written literature must be geared to the appropriate reading level (average years of education = 4-7 in survey sample). It's imperative to do HIV prevention outreach where migrants live and work (e.g., labor camps). It is also important to develop and deliver focused, single-session interventions given the transient nature of farmwork. Finally, the delivery of intervention messages needs to be done separately for men and women given the sexual conservatism of traditional Mexican people (de la Vega, 1990). Male Focused Interventions (Married and Single) Condom promotion efforts with male Mexican farmworkers must begin by providing basic instructions on proper condom use, including "hands on" practice with phallic replicas. Men should be urged to carry or keep condoms handy in the spirit of being hombres preparados [prepared men], a term that carries the connotation of being learned in addition to prepared. HIV transmission with different types of sex partners should be discussed. For example, the common practice of using prostitutes while in the U.S., including the occasional practice of the hermanos de leche ritual, should be addressed in detail (e.g., can men still be hermanos de leche if condoms are used? Isn't it important for real hermanos to protect each other? Are there less risky forms of male bonding?) The topic of sex between men (and specifically unprotected anal sex) must not be restricted to homosexuals, but should acknowledge the occasional participation of heterosexual or bisexual men, as well as the need for men to protect their female partners by using condoms with occasional male sex partners. In a study of 190 recent Mexican immigrants, Mikawa, et al. (1992) found that using condoms to "protect the woman" predicted condom use while using condoms to protect one's own health did not. Because of the apparent central role of condom efficacy in predicting condom use with secondary sex partners, sufficient discussion and role playing should be used to practice insistence on condom use in challenging sexual situations encountered by Mexican male migrants (e.g., being solicited by prostitutes in bars while drinking with encouraging co-workers on pay day). Female Focused Interventions Female migrants in our surveys were extremely low in acculturation and thus presumably high in traditional Mexican culture and adherence to conservative gender roles. Working within traditional gender roles could involve urging Mexican women to protect themselves in order to prevent the congenital transmission of HIV to children. Similarly, because Mexican women are central to their family's health and well being, they could be reminded that their family health is closely linked to their own. However, working outside of traditional Mexican culture is also necessary, and may not be as difficult as often presumed given the changing nature of gender roles in migrant and immigrant women. Guendelman (1987) noted that Mexican migrant and immigrant women experience "gender role expansion" as a result of wage earnings. This enhanced purchasing power often leads to a more pro-active role in family decision making, more help with household chores from husbands, and a greater feeling of autonomy. Hence, empowering and proactive prevention strategies to be initiated by women need to be considered (e.g., assertively negotiating sexual matters). Introduction | Sociodemographic Profile | HIV Infection/Risk Profile | Major HIV Exposure Categories for Farmworkers | Prostitution Use in the United States | Sex Between Men | Needle Sharing | Gender and HIV Risk | HIV/AIDS-Related Knowledge, Attitudes, Beliefs, and Behaviors | Predictors of Condom Use | Notes On Culturally Competent HIV Research | Implications for Future HIV Research with Mexican Farmworkers | Implications for HIV Prevention Services for Mexican Farmworkers | Conclusion | References Culturally competent HIV prevention research and direct services are urgently needed to prevent the high probability of an AIDS epidemic among the Mexican/Chicano farmworkers who comprise the majority of migrant labor in the United States. Within the large overlapping dimensions of migratory labor and Mexican culture exist a number of pertinent HIV exposure categories and risk scenarios that need to be carefully considered and targeted. The development of culturally appropriate research and service approaches is imperative despite the extra work required, and despite the growing "diversity fatigue" in both society and the social sciences. The contribution of Chicano psychology to decreasing HIV risk in campesinos can be considerable given the emerging emphasis on interdisciplinary collaboration, combining qualitative and quantitative research methods, and seeking to inter-penetrate cultural and experiential variables with research and service variables. This publication seeks to explicate these otherwise abstract notions of Chicano psychology research. Amaro, H. 1988. "Considerations for prevention of HIV infection among Hispanic women." Psychology of Women Quarterly, 12, 429-443. Balls Organista, P., K.C. Organista, and P.R. Soloff. 1998. "Exploring AIDS-related knowledge, attitudes, and behaviors of Female Mexican migrant workers." Health & Social Work, 23(2), 81-160. Bronfman, M. and N. Minello. 1992. 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Revista Latino Americana De Psicologia [Latin American Journal of Psychology], 24(1-2), 97-108. Marín, B.V. 1995. Analysis of AIDS prevention among ethnic minority populations in the United States. Washington, D.C.: Report for the Office of Technology Assessment, U.S. Congress. Marin, B.V., C. Gomez, and J.M. Tschann 1993. "Condom use among Hispanic men with multiple female partners: A nine-state study." Public Health Reports, 25, 742-750. Marin, B.V., J.M. Tschann, C.A. Gomez, and S. Gregorich. 1998. "Self-efficacy to use condoms in unmarried Latino Adults." American Journal of Community Psychology, 26(1), 53-71. McVea, K.L.S.P. 1997. "Lay injection practices among migrant farmworkers in the age of AIDS: Evolution of a biomedical folk practices." Social Science Medicine, 45(1), 91-98. Mikawa, J. K., P.A. Morones, A. Gomez, H.L. Case, D. Olsen, and M.J. Gonzales-Huss. 1992. "Cultural Practices of Hispanics: Implications for the prevention of AIDS. Hispanic Journal of the Behavioral Sciences, 14(4), 421-433. Mishra, S.I., R.F. Conner, and J.R. Magaña. 1996 (Eds.). "AIDS crossing borders: The spread of HIV among migrant Latinos." Boulder, Colo.: Westview Press. Organista, K.C., and P. Balls Organista. 1997. "Migrant laborers and AIDS in the United States: A review of the literature." AIDS Education and Prevention, 9, 83-93. Organista, K.C., P. Balls Organista, J. Bola, G. Garcia de Alba, J.E., and M.A. Castillo Moran. 1998. Predictors of condom use in Mexican migrant laborers. Unpublished manuscript. School of Social Welfare, University of California, Berkeley. Organista, K.C., P. Balls Organista, G. Garcia de Alba, J.E., and M.A. Castillo Moran. 1997b. "Psychosocial predictors of condom use in Mexican migrant laborers." Interamerican Journal of Psychology, 31(1), 77-90. Organista, K.C., P. Balls Organista, G. Garcia de Alba, J.E., M.A. Castillo Moran, and H. Carrillo. 1996. "AIDS and condom-related knowledge, beliefs, and behaviors in Mexican migrant laborers." Hispanic Journal of Behavioral Sciences, 18, 392-406. Organista, K.C., P. Balls Organista, G. Garcia de Alba J.E., M.A. Castillo Moran, and L.E. Ureta Carrillo. 1997a. "Survey of condom-related beliefs, behaviors, and perceived social norms in Mexican migrant laborers." Journal of Community Health, 22(3), 185-198. Rust, G. S. 1990. "Health status of migrants farmworkers: A literature review and commentary." American Journal of Public Health, 80(10), 1231-1217. Schoonover Smith, L. 1988. "Ethnic differences in knowledge of sexually transmitted diseases in North American black and Mexican American farmworkers." Research in Nursing and Health, 11, 51-58. U.S. Department of Labor. 1990. Findings from the national agricultural workers survey (NAWS), 1990: a demographic and employment profile of perishable crop farmworkers. Washington, D.C.: U.S. Department of Labor, 89, 97-98. Wyatt, G. E. 1994. "The sociocultural relevance of sex research: Challenges for the 1990's and beyond." American Psychologist, 49(8), 748-754. Introduction | Sociodemographic Profile | HIV Infection/Risk Profile | Major HIV Exposure Categories for Farmworkers | Prostitution Use in the United States | Sex Between Men | Needle Sharing | Gender and HIV Risk | HIV/AIDS-Related Knowledge, Attitudes, Beliefs, and Behaviors | Predictors of Condom Use | Notes On Culturally Competent HIV Research | Implications for Future HIV Research with Mexican Farmworkers | Implications for HIV Prevention Services for Mexican Farmworkers | Conclusion | References JSRI Home | JSRI Research & Publications | Occasional Paper Series |
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