Health Care Research
Among Diverse
Communities
Nilda (Nena) Peragallo, DrPH, RN , FAAN
Rosa Maria Gonzalez-Guarda, PhD, RN
University of Miami
School of Nursing and Health Studies
Objectives
• Discuss program of research on
HIV with Latino diverse
communities
• Analyze future opportunities and
challenges in research with diverse
communities
The Primary Mission of El Centro
• To advance the scientific development and
evaluation of culturally-tailored interventions in
a constellation of behaviorally-rooted health
conditions that disproportionately affect
Hispanics:
– Substance abuse
– HIV/AIDS and sexually transmitted infections
– Family and intimate partner violence
– Co-occurring mental health conditions that
impact and are impacted by these other
conditions
Why Culturally-Tailored
Interventions?
• Hispanics have unique values, beliefs, behaviors
and histories that directly impact health and the
efficacy of interventions.
• Few intervention research studies have sufficiently
large Hispanic sub-samples to evaluate the efficacy
of interventions for Hispanics.
• Interventions that have not been designed for or
adequately tested on Hispanics are probably not
ready for widespread utilization for Hispanics.
Other El Centro Aims
• To develop knowledge on the
mechanisms of culture-related
processes
• To train the next generation of health
disparities researchers.
Common Cultural Measures
• Hispanic Stress Scale (Cervantes, Padilla, &
Salgado de Snyder, 1990)
• Bidimensional Acculturation Scale (Marin
& Gamba, 1996)
• Familism Scale (Sabogal, Marin, Otero-Sabogal,
1987)
• El Centro Demographic Form
–
–
–
–
Birthplace, years in US
Immigration-related separations
Religious observance/influence
Health practices/access
Research Studies
• Two Randomized Multi-Year Trials
– “CIFTA” – D. Santisteban, PI
– “SEPA” – N. Peragallo, PI
• Pilot Studies Program: 2 studies/yr ($40k
each)
– Year 01 Pilot Studies:
• “VIDA” – E. Vasquez, PI
• “SET-Prenatal” – V. Mitrani, PI
– Year 02 Pilot Studies:
• “Attitudes About Circumcision” – J. Castro,
PI
• “HISPACARE” – M. Lopez, PI
“The future health of the nation will be
determined to a large extent by how
effectively we work with communities
to reduce and eliminate health
disparities between non-minority and
minority populations experiencing
disproportionate burdens of disease,
disability, and premature death.”
~ CDC, Office of Minority Health (2006)
How Big is the Problem?
Conditions that disproportionately
affect racial/ethnic minority groups:
• Cardiovascular
Disease
• Cancer
• Infant Mortality
• Diabetes
• Lack of
Immunization
• HIV/AIDS
Women at Increased
Risk of HIV
Percentage of total new AIDS diagnoses:
- In 1985, 8% were female
- In 2006, 27% were female
Percentage of new AIDS diagnoses among
heterosexual women:
- 65% African American
- 15% Latina
- 17% White
Kaiser Family Foundation. (2009). The HIV/AIDS epidemic in the United States.
HIV/AIDS Rates in the
Latino Community
In 2006 Latinos comprised:
- 15% of the population
- 19% of new HIV diagnoses
Latinos account for a growing share of
AIDS diagnoses from 15% in 1985 to
19% in 2006
Aids estimated prevalence among Latinos
increased 27% between 2002 and 2006
Kaiser Family Foundation. (2009). Latinos and HIV/AIDS
Factors that Increase
HIV Risk for Latinas
• Unequal access to health care
• Language barriers
• Cultural characteristics
- Gender roles, “machismo” and
“marianismo”
- Conceptualization of male sexual roles
- Religiosity
Peragallo, N. (1996). Latino women and AIDS risk.
Public Health Nursing, 13(3), 217-222.
HIV Risk Reduction in
Latino Communities
SEPA Project
DYVA Project
SEPA II Project
Salud/Health
Educación/Education
Prevención/Prevention
Autocuidado/Self-Care
Drogas/Drugs
Y/and
Violencia en las/Violence in the
Americas
Salud/Health
Educación/Education
Prevención/Prevention
Autocuidado/Self-Care
Funded by NIH / NINR
R01 NR04746
Multicentric Pilot Project
Funded By OAS/CICAD
Funded by NIH/NCMHD
1P60MD002266
(P.I. Peragallo)
(P.I. Peragallo)
(P.I. Peragallo)
Objectives
Project SEPA
Project DYVA
Evaluate a
randomized culturallytailored intervention
to prevent high-HIVrisk sexual behaviors
for Mexican and
Puerto Rican women
living in urban areas
Explore the collective
and individual
experiences of
Latinas with
substance abuse,
violence and risky
sexual behaviors
Project SEPA II
Evaluate the
effectiveness of a
culturally-tailored
specific intervention
to increase HIV
prevention behaviors
for Hispanic women
living in South
Florida
Participants in SEPA, SEPA II &
DYVA
Project SEPA:
Project DYVA:
Project SEPA II:
•
•
•
•


•
•
(n=657)
Mexican and PuertoRican Latinas residing
in the urban Midwest
Ages 18 to 44
Sexually active within 3
months prior to
enrollment
•
(n=82)
Heterogeneous
sample of Latinas in
the Broward/MiamiDade area
Ages 18 to 60


(n=540)
Diverse Latina
population residing
in Miami-Dade and
Broward Counties
Ages 18 to 50
Sexually active
within 3 months
prior to enrollment
BASELINE DATA for SEPA, SEPA
II and DYVA
Variables
Age
Nationality
Language
interview
SEPA (n=454)
( %)
DYVA (n=82)
( %)
SEPA II (n=464)
(%)
18-20
8
2
1
21-25
22
11
8
26-30
27
10
11
31-39
32
34
30
40+
11
43
50
South Amer
0
76
50
Mexico/PR
100
6
8
Central/Carib
0
16
34
Other
0
2
8
Spanish
81
96
95
English
19
4
5
BASELINE DATA for SEPA, SEPA
II and DYVA
Variables
Years in
USA
Education
(yrs)
SEPA (n=454)
( %)
DYVA (n=82)
( %)
SEPA II (n=464)
(%)
<2
8
24
18
3-5
16
26
19
6-10
35
28
26
11-20
20
12
21
21+
21
10
16
<6
20
7
4
7-11
42
7
24
High School
19
15
20
Beyond HS
19
71
52
BASELINE DATA for SEPA, SEPA
II and DYVA
Variables
Employed
Insurance
SEPA
(n=454)
( %)
DYVA
(n=82)
( %)
SEPA II
(n=464)
%
Yes
28
40
32
No
72
60
68
Yes
39
35
39
No
61
65
61
6
29
40
Hispanic
(high)
67
100
97
High on both
24
38
37
Acculturation United States
(high)
Common Findings from SEPA &
DYVA Focus Groups
•
•
•
•
•
•
Physical, psychological violence
Cultural norms and acculturation
Machismo and male infidelity
Alcohol and drug use
Social discrimination amongst peers
Barriers to accessing healthcare
Violence
SEPA
DYVA
“…when I had been married only
a short while he used to beat
me. He wanted me to get
pregnant and well I
miscarried my first child, and
he used to blame me and say
that I had taken something
and this and that. He wanted
me to get pregnant and I
couldn’t...”
“…because the abusive man
always knows how to prepare
the scene and starts by
diminishing your self-esteem”
“…he hit me and I’m not gonna
hit him because you’re gonna
get hit worse. A man, no
matter how bad and how big
you are, a man is stronger
than a woman. Okay?”
“…sometimes the abuser is so
intelligent controlling and
manipulative what he does is
shows a different external
face and it makes you feel like
the one that is doing
something wrong is you not
him…self-esteem falls so low,
so low that you lose your
sense of value”
Violence
SEPA
DYVA
“…he hit me and I’m not
gonna hit him because
you’re gonna get hit
worse. A man, no matter
how bad and how big
you are, a man is
stronger than a woman.
Okay?”
“…because the
abusive man always
knows how to prepare
the scene and starts
by diminishing your
self-esteem”
Machismo and Marianismo
SEPA
•
“…we used to see our mother get
beat up by our father. Only because
my mother took it, but my mother
didn’t know any better. Cause my
mother grew up in an environment
where there were like, you know,
antique, in Puerto Rico, come on, you
stay there you are my wife you marry
me, you take whatever comes. No,
it’s not like that anymore...”
•
“…I used to be embarrassed to say
that he had an affair, because you
know, we as women are so,
especially Latina, we are proud for
women, we have the best marriages
and we have everything best, but I
say it because he’s come a long way.
And, for him to be Latino man...”
DYVA
•
“…women need to change their
machista beliefs because there is
no one more machista than a
woman, not even men themselves…
because without realizing it we
repeat the same pattern of our
mothers and grandmothers, and the
generational curse repeats”
•
“(Latino men say) ‘I’m a man and I
can have sex with 10 women
without a condom’. American men
won’t have sex with a woman who
doesn’t want any protection, but
our machos go to bed with
anybody”
Comparisons of SEPA/DYVA/SEPA II
Experiences w/ Violence
Variable
SEPA
(n=454)
%
DYVA
(n=82)
%
SEPA II
(n=464)
%
Reported experiencing physical
or child abuse before 18
32
26
13
Reported sexual abuse before 18
22
34
12
“Any” violence during adulthood
Physical- sexual
Psychological
Non-P
Partner
45
52
70
31
38
14
25
Reported being physically
abused
41
46
24
12
Reported being forced into sex
22
26
5
6
Non-P = Non current partner; Partner = Current or most recent partner
SEPA
Intervention
and Results
Conceptual Framework
Random
Group Assignment
Personal
Factors
Intervention
Experiences
Relationship
Factors
Intermediate
Outcomes
HIV/AIDS
Prevention
Outcomes
Community-Based Intervention
SEPA
Six weekly sessions for
two hours:
–
–
–
–
Know your own body
Risk awareness/ risk management
Skill training on condom use
Sexual communication / negotiation
and problem solving
– Violence prevention /conflict
management
– Peer support for change efforts
SEPA II
Six weekly sessions for
two hours:






Know your own body
Risk awareness/ risk
management
Skill training on condom use
Sexual communication /
negotiation and problem solving
Violence prevention /conflict
management
Peer support for change efforts
SEPA group at one of the community sites
Comparisons of intervention and control group for baseline
(N=454), 3-month (N=394), and 6-month (N=422) outcome data for
Condom Use (always)
Intervention
Control
Results Using Multiple Linear & Logistic Regression
Adjusted by Baseline score of each dependent variable,
acculturation, ethnicity, poverty, insurance, lived with partner
Group
OR
Condom Use
CI
p
3 months
2.018
1.021, 3.985
.043
6 months
2.044
1.292, 3.234
.002
Comparisons of intervention and control group for baseline
(N=454), 3-month (N=394), and 6-month (N=422) outcome data for
HIV Knowledge ≥ 9
Intervention
Control
Comparisons of intervention and control group for baseline
(N=454), 3-month (N=394), and 6-month (N=422) outcome data for
Safer Sex Peer Norms >13
Intervention
Control
Comparisons of intervention and control group for baseline
(N=454), 3-month (N=394), and 6-month (N=422) outcome data for
Perceived Barriers to Condom Use >13
Intervention
Control
Comparisons of intervention and control group for baseline
(N=454) 3-month (N=394), and 6-month (N=422) outcome data for
Communication ≥ 7
Intervention
Control
Comparisons of intervention and control group for baseline
(N=454), 3-month (N=394), and 6-month (N=422) outcome data for
Behavioral Intention ≥ 13
Intervention
Control
Effect Size
Overall Generalized Estimating Equations Results
(N=454; Intervention=263, Control=191)
Conclusions & Implications
• Project SEPA was highly successful in
increasing condom use, HIV health
protective communication, and HIV
knowledge and decreasing risk behaviors
among low income, primarily Spanish
speaking Latinas.
• This study provided evidence that
HIV/AIDS prevention interventions must
be culturally tailored to the targeted
population of the intended program.
Recommendations Based on
SEPA
• Community-based and culturally-tailored
• Strong referral system established (e.g.
mental health, domestic violence,
housing)
• Sustained contact and booster sessions
• Critical to address violence,
discrimination, lack of access to
healthcare
• Interventions must target non-English
speaking populations
SEPA group showing off diplomas
Successes with HIV
Prevention in the U.S.
• HIV testing and donor deferral have
increased the safety of the nation’s blood
supply
• Perinatal transmission of HIV has been
greatly reduced
• Reduction in needle-sharing has resulted in
decreasing HIV transmission among
injection drug users
Challenges in HIV Prevention
• Racial and ethnic disparities have
increased during the past 25 years
• Disparities e.g. poverty, homelessness,
racism, homophobia, violence and gender
inequalities all affect HIV risk and affect
directly the delivery of prevention
programs to these populations
• More people living with HIV/AIDS (without
knowledge of diagnosis)
Challenges in HIV Prevention
• Changes in belief regarding disease
severity
• Increase in Methamphetamine use and
STDs
• Other factors associated are: HIV stigma,
discrimination causing individuals to
delay seeking health care, fear of
disclosure of their HIV status to others
Must incorporate biomedical advances
like pre and post-exposure prophylaxis ,
microbicides, male circumcision, vaccine
development, effects of antiretroviral
therapy on infectivity
Challenges in HIV Prevention
• New interventions and improve effectiveness of
successful interventions are needed for
disparities populations e.g. African American,
Latinos
• Include disparities population that may have
decreased access to care and linguistic issues
• Must have researchers who are from the
disparities population and that understand health
disparities and cultural issues that influence HIV
prevention
• CBO and health departments need to be ready to
implement interventions at the community level
• Thank you very much
• Gracias
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Figure 1. Project SEPA: Random assignment into groups