Growing problem in Latino community sparks interest
Chicago research concentrates on women
HIV infection continues to rise among Latinos in the United States, particularly among Latino women. While Hispanic women accounted for 18% of the cumulative AIDS cases among Hispanics in 1998, they accounted for 21% of the newly reported AIDS cases that year, according to data collected by the Centers for Disease Control and Prevention in Atlanta.
Among Hispanics in the United States, heterosexual transmission of HIV accounts for 12% of cases, while injection drug use accounts for 28% of cases. CDC researchers say transmission related to substance abuse is a significant problem among Hispanics, especially among those of Puerto Rican descent.
The problem has been that few prevention programs are directed specifically to the Latino community and even fewer to women within that community. This is why a Chicago researcher has targeted this population for a new prevention campaign.
"I started this project because the incidence of HIV among Latino women has been increasing," says Nilda Peragallo, DrPH, RN, FAAN, associate professor at the College of Nursing in the University of Illinois at Chicago.
"Here in Chicago, HIV among women has increased, especially heterosexual transmission among women of color, both African-American and Latino," Peragallo says. "So whatever we’re doing in prevention work is not getting through to that particular population."
With funding from the Washington, DC-based National Institutes of Health and the National Institute of Nursing Research, Peragallo has begun a three-year study to test a culturally tailored intervention that she has designed.
The study will include more than 750 women in Chicago’s Latino communities. Their age range will be 18 to 44 years, and they’ll be of Mexican or Puerto Rican descent. Another criterion is that they have been sexually active within the last three months.
Focus groups helped with model design
"Initially, we had some focus groups in the community, looking at what the issues were in their communities and whether HIV was an issue," Peragallo says.
Focus group participants addressed these questions:
• What are the problems in getting the message out about HIV prevention?
• What areas of prevention are they interested in?
• What do women want from an HIV intervention?
• Where would women want an intervention to be held?
• What sort of program would be more culturally relevant and acceptable to them?
The focus group suggestions were incorporated into the prevention program’s design and were part of a pilot intervention project that has been under way for more than one year.
Here’s how the interventions were designed:
1. Set up intervention sessions.
Two-hour intervention sessions are held once a week for six weeks. The sessions are provided to groups of eight to 12 women, and they have a facilitator nurse who is bilingual and Latino.
"It’s important for the facilitator to understand the context of the culture and to value it," Peragallo says.
Here is a summary of each session:
• First session: This one is about women knowing their bodies. It provides a discussion of anatomy and physiology of both the male and female bodies and the reproductive system. "The women get a chance to ask questions that they have never had the chance to ask before, and that makes them feel very comfortable," Peragallo says.
• Second session: The facilitator talks about HIV and sexually transmitted diseases (STDs) in the participants’ community, bringing the epidemic home to them. "We give participants some very accurate statistics, but provide them in an understandable manner so it makes sense," Peragallo says.
• Third session: This session deals with condoms and teaches participants how to use both male and female condoms.
"We talk about how to properly use them and discuss what has been their experience in using them and why they haven’t used them in the past," Peragallo says. "And we talk about all of the attitudes that are prevalent in our community and what the pros and cons are with using condoms and what our choices are."
• Fourth session: The facilitator teaches the women better communication and negotiation skills, using role-playing techniques. The class is interactive, involving participants in finding solutions to potential communication problems that arise with their partners, their families, and their children.
Women learn to downscale’ conflict
"We teach them how to downscale conflict and not make it bigger," Peragallo says. "We have an exercise in which we say, Tell him what you never dared to tell him,’ and they pick another person in the group to be their partner, and they tell that person whatever it is they have wanted to tell their partner but never had the courage to do so."
For example, one woman in the pilot intervention told the role-playing partner, "I hate to cut your toenails, and I’ve always wanted to tell you that." This exercise gave the women an opportunity to release some of the tension and resentment that had been building up in their relationships, and it provided them with better skills for speaking their minds to their family members.
• Fifth session: This session dealt with how to prevent violence. While this is not a typical HIV prevention intervention, it is an important part of the overall prevention picture, Peragallo says.
"The reason is because we find, and it’s not just in this Latino community, that violence inhibits the communication process or negotiation," she adds. "How can you negotiate with someone about using a condom when you’re not equally in power in the relationship?"
The session includes discussions about gender roles and what these mean. For instance, there’s a discussion about what it means to be "macho" and the positive and negative aspects of this. There’s also a discussion about how the family is valued.
Discussing the effects of violence
"When we talk about violence, we talk about how to prevent it and what the effect of violence is on the family: the women, the perpetrator, and also the children, because a lot of women are not aware of how this affects their children," she says. "With the discussion, they begin to realize how their children’s grades are going down and they’re not doing well at school."
• Sixth session: This session provides a review of all of the previous sessions. Each woman participant is encouraged to present a review of her favorite part. Some women may speak about communication, clarifying certain issues. Their presentations are decided the week before. Also, the last session involves a party with refreshments and cake.
"Then we give them a diploma for their completion, and they come to the session all dressed up," Peragallo says.
After each session, the women do "homework," such as practicing using a female condom or using their new communication skills with a member of their family.
"We always emphasize that the choice is theirs," Peragallo says. "We try to let them know that we value their opinions and their ways of thinking and their experiences, so they know best how to apply these things."
2. Provide follow-up "booster" session.
After three months, the women meet again for a booster session.
"Basically, what we want to do is ask them how they’re doing and what are some things that have been problematic for them," Peragallo explains.
Women give feedback at booster session
The women write a few paragraphs about how they feel, and they talk about the areas that have given them the most difficulty. For example, they might not have liked using the female condom, or maybe they couldn’t get their partners to use the male condom, she adds.
"Then we interview the women because this is a randomized study with a control group," she adds.
3. Analyze the results.
Participants are given HIV pre-tests and post-tests in either Spanish or English. They’re asked demographic questions and questions about their culture identification, such as how long they have lived in this country. Researchers investigate whether the women suffer from depression or self-esteem problems. They also look at partner characteristics and behaviors, because many women’s risk for HIV is more related to their partner’s behaviors than to their own actions, Peragallo says.
"Then we ask them about self-efficacy and their knowledge of HIV and their own behaviors, including the use of condoms and whether they’ve had STDs within the past three months," she adds. "We ask about their drug use and the HIV status of their partner and if they knew or ever asked about that status."
The interview process takes about an hour, and all interviewers are bilingual.
Results from the pilot project have not yet been published. However, analysis from the baseline interviews shows that the women who report a history of violence in their relationships are more likely to be depressed, have low self-esteem, and be at high risk for HIV infection.
"That’s based on 347 baseline interviews, the preliminary results," Peragallo says. "I think that’s important because of the implication that we have to address the topic of violence in designing an intervention for women."
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