Initial acculturation and HIV risk among new Hispanic immigrants.

Abstract

Research on the initial stage of acculturation of new immigrants is crucial for identifying AIDS prevention policies and priorities for this vulnerable population.
This study employed an exploratory approach and qualitative data collection methods to identify and describe social and behavioral factors influencing risk for HIV infection among recent Hispanic immigrants (<3 years in the United States). Immigrants from Guatemala, El Salvador, Honduras, the Dominican Republic and Mexico were interviewed in urban, suburban and semirural settings in the New York Metropolitan Area. Data were collected through ethnographic fieldwork, in-depth interviews (N=51), focus groups (N=11; total number of participants=86) and individual interviews with health and social service providers (N=26).
Initial stages of acculturation for immigrants reflect both retention and change in attitudes and behaviors involving their mental health, gender role norms, social and sexual behavior, and alcohol and other drug use. Current living environments may introduce conditions affecting HIV risk and prevention, while sustained connections to countries of origin may support retention of attitudes and behaviors with positive and negative risk implications.
Specific epidemiological, environmental, economic, social and psychosocial factors are identified that provide the context for risk and prevention. The challenges and opportunities faced by these new communities must be distinguished from those of more acculturated immigrant populations if culturally appropriate interventions are to be developed.

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Initial Acculturation and HIV Risk among
New Hispanic Immigrants
Michele G. Shedlin, PhD; Carlos Ulises Decena, PhD; and Denise Oliver-Velez, PhD Candidate
New York, New York
Purpose: Research on the initial stage of acculturation of
new immigrants is crucial for identifying AIDS prevention
policies and priorities for this vulnerable population.
Methods: This study employed an exploratory approach and
qualitative data collection methods to idenfify and describe
social and behavioral factors influencing risk for HIV infection
among recent Hispanic immigrants (<3 years in the United
States). Immigrants from Guatemala, El Salvador, Honduras,
the Dominican Republic and Mexico were interviewed in
urban, suburban and semirural seltings in the New York Metro-
politan Area. Data were collected through ethnographic
fieldwork, in-depth interviews (N=51), focus groups (N= 1;
total number of participants=86) and individual interviews
with health and social service providers (N=26).
Results: Initial stages of acculturation for immigrants reflect
both retention and change in attitudes and behaviors
involving their mental health, gender role norms, social and
sexual behavior, and alcohol and other drug use. Current liv-
ing environments may introduce conditions affecting HIV risk
and prevention, while sustained connections to countries of
origin may support retention of attitudes and behaviors with
positive and negative risk implications.
Conclusions: Specific epidemiological, environmental, eco-
nomic, social and psychosocial factors are identified that pro-
vide the context for risk and prevention. The chollenges and
opportunilies faced by these new communities must be distin-
guished from those of more acculturated immigrant popula-
fions if culturally approprate interventions are to bedeveloped.
Key words: acculturation * immigrant health U HIV/AIDS U
Hispanic communities
© 2005. From Center for Drug Use and HIV Research, Institute for AIDS
Research, National Development and Research Institutes Inc. (Shedlin,
Decena) and the Graduate Center, City University of New York (Oliver-
Velez), New York, NY. Send correspondence and reprint requests for J Natl
Med Assoc. 2005;97:32S-37S to: Michele Shedlin, University of Texas at El
Paso, 1 101 N. Campbell St., El Paso, TX 79912; e-mail: mshedlin@utep.edu
INTRODUCTION
Hispanics are disproportionately represented in the
HIV/AIDS epidemic in the United States.' In 2002, the
estimated AIDS rate among adult and adolescent His-
panic men was 39.7 per 100,000, more than three times
the rate for non-Hispanic white men (12.3).2 The dis-
crepancy is larger among Hispanic women, with rates
of 11.3 per 100,000 compared to 2.1 for white women.2
Hispanics are also more likely than whites to be con-
currently diagnosed with HIV and AIDS,3 receiving
medical care later in the course oftheir illness.
Although priority setting and policy for HIV pre-
vention are often tied to the umbrella category "His-
panic," immigrants from Latin America and the
Caribbean, in fact, embody differences in migration
experiences, health status, educational levels, lan-
guage and other areas that are obscured in this cate-
gory. Because ofthese differences and because they
are in the initial stage ofacculturation, HIV risks for
new immigrants set them apart from those oflonger-
term residents and frequently from each other. These
communities at risk should be considered a high pri-
ority for prevention and education efforts, especially
in light ofresearch indicating that most immigrants
living with HIV were infected in the United States.4'5
Hispanic Immigrants in the
Metropolitan New York Area
Although data on immigration status are not col-
lected through existing HIV surveillance mecha-
nisms, documented and undocumented immigrants
who settle in high seroprevalence areas, such as the
New York Metropolitan Area, are thought to be at
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INITIAL ACCULTURATION AND HIV RISK
increased risk for HIV because oflanguage and cul-
tural barriers, economic difficulties and insufficient
knowledge about HIV and AIDS.69 In addition, data
from the Department ofHealth indicate that in 2002,
over 11% of people with AIDS in New York City
were foreign-born.'0
New York City (NYC) and its surrounding areas
accounted for 91% of New York State's total
increase in foreign-born population from Central
America between 1990 and March of 2000."1
Approximately 136,000 Central Americans reside in
NYC and the surrounding counties.""2 Of these,
98,000 (72%) were born in El Salvador, Guatemala
or Honduras.'2 In addition, more than 600,000 indi-
viduals classified as Hispanic in the New York Met-
ropolitan Area report their native countries as Mexi-
co or the Dominican Republic.'2 Demographers
argue that U.S. Census figures underestimate the
size ofthese populations due to the undercount of
undocumented residents.'3
We
conducted
a
exploratory study ofnew immigrants in urban, sub-
urban and semirural locations in the NewYork Met-
ropolitan Area from the Dominican Republic,
Guatemala, El Salvador, Honduras and Mexico. The
objective ofthe research was to investigate not only
the cultural factors that influence risk ofHIV and
sexually transmitted infections (STIs) but also the
environmental factors that provide the context for
risk and prevention. In addition, the study included
an exploration ofrisk and protective factors embed-
ded to varying degrees in immigrants' multiple cul-
tures and subcultures.
short-term,
qualitative,
METHODS
Qualitative data collection involved:
1) semistructured, in-depth individual interviews;
2) focus groups;
3) key informant interviews and a focus group with
advocates and providers in health and social
services; and
4) ethnographic observation in the communities.
Interview instruments were designed to explore:
individual and collective living conditions; continu-
ities and changes in attitudes, behaviors, and interac-
tions with existing social networks and environments;
attitudes and behaviors related to HIV and other STIs;
and access to health and other social services.
Data were collected in New York State in 2002
and 2003 in two field sites:
1) the contiguous counties ofWestchester and
Putnam, composed ofurban, suburban and semi-
rural areas; and
2) the semirural North Fork ofSuffolk County,
Long Island.
Participants were recruited at each site using a
snowball approach initiated by community leaders
and providers. Because ofnew immigrants' fear of
immigration authorities, the research team began
field activities by establishing contacts at each site
with the assistance oftrusted community advocates
and leaders. Criteria for recruitment for interviews
and focus groups were: a) aged .18; b) born in one
ofthe target countries; and c) having arrived from
the country oforigin <3 years before their participa-
tion in the study. Key informants included social
workers, nurses, county officials, immigrant advo-
cates, outreach workers, business owners, religious
leaders and HIV/AIDS educators.
Data included ethnographic field notes, inter-
viewer comments and transcripts of interviews and
focus groups. Other sources ofinformation included
print media coverage oflocal issues regarding immi-
gration and census data. Atlas.ti (Scientific Software
Development, Berlin, Germany) and Folioviews
(Folio Corporation, Provo, UT) qualitative software
programs facilitated the identification of patterns
and themes within and across groups.
RESULTS
Sample
Men and women (n=5 1) from each of the target
countries participated in individual interviews. Eleven
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INITIAL ACCULTURATION AND HIV RISK
focus groups were conducted (n=86), organized by
nationality, sex and site. Overall, the average age of
respondents was 31, with a length ofresidence in the
United States of<2 years. One focus group and indi-
vidual interviews (n=26) were conducted with key
informants.
Immigrant Characteristics and
Realities
New immigrants from the target groups were gen-
erally young single men. Single women immigrated
to join family members, to accompany p&rtners
and/or children or tojoin partners already living in the
areas. Educational attainment was generally between
fifth and sixth grade, and most had only partial ele-
mentary schooling. While Mexicans were present in
all locations (urban, suburban and semirural), Central
Americans were more visible within the smaller
towns and semirural areas. Dominicans were most
visible in urban and suburban locations in Westch-
ester County. Interviews revealed a lack ofdocumen-
tation for most interviewees, although the question
was not asked directly. Most respondents stated that
they were in the United States for the first time. Not
speaking English was identified as the key obstacle in
their lives, along with the scarcity and cost ofhous-
ing. Single men in particular reported difficulty find-
ing housing and sharing rooms in overcrowded and
expensive apartnents and houses in poor condition.
Obligations to relatives in their countries oforigin,
the urgency to repay coyotes (individuals who provide
illegal transportation across borders) and the need to
survive made work the focus of new immigrants'
lives. Because employment options were limited, sea-
sonal or irregular, many respondents reported long
workdays and long periods without income.
Health and Mental Health Issues
Immigrants'
long-standing
emerged frequently during interviews and focus
groups. HIV and other health providers in these areas
reported serious pre-existing health conditions among
these groups, including: malnutrition, anemia, dia-
betes, asthma, toxoplasmosis, STIs (syphilis and gon-
health
concerns
orrhea), parasitic infections, hypertension, cardiovas-
cular problems/high cholesterol (especially among
Dominicans), malaria, tuberculosis and dental decay.'4
The lack ofcommunication skills and the urgency of
generating income, however, resulted in a lack ofatten-
tion to their health unless the ability to work or care for
families was threatened.
Most interviews revealed the salience ofmental
health issues as well. Participants perceived "stress"
and "depression" as consequences ofthe "suffering"
they endured while migrating as well as from leav-
ing families and increasing debts. Central American
men spoke of "desperation" and expressed feelings
of social isolation as well as frustration at not know-
ing U.S. and local laws or acceptable behaviors and
expectations. Mexican women discussed the nega-
tive effects of disillusionment with their new lives
along with perceived discrimination toward them
and their families.
Domestic Violence
Men and women reported physical mistreatment of
womenby male partners. However, laws against domes-
tic violence appeared to support women in protecting
themselves, including calling police evenwhen deporta-
tion was a risk. The resource of 911 was seen as an
important benefit ofliving in the United States. Never-
theless, women and providers reported that family vio-
lence was still a serious issue withinthese communities.
Social and Sexual Behavior
Geographic location emerged as an important
factor in immigrants' interactions with social venues
and networks. In less urban areas, men appeared to
have few opportunities to socialize in local bars.
They met men from other ethnic/national groups
through work or sports activities. Women with chil-
dren in school had more social contact with other
women than those without children. Young women,
some with infants, without employment or social or
family networks, were frequently isolated in small
apartments or rooms with almost no social contacts
other than their partners.
Central American men reported a scarcity of
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INITIAL ACCULTURATION AND HIV RISK
women as potential sex partners, especially in rural
locations. Some male respondents also alluded to
their involvement with sex workers for this reason.
As one participant explained:
Isee a lot ofHispanic men on the street, but to see a
Hispanic woman, Ihave to go into a restaurant, to a
Hispanic bar to see a woman. So we have a more dif-
ficult time finding a woman, conquering her. She
becomes more important than in our country. So
manyguys useprostitution.
Employers were said to permit or even arrange for
sex workers on payday for the "use" of dormitory-
housed farm workers. The use ofalcohol with sex and a
reliance on the sex workerto provide condoms were also
reported to be common practices. Ifthe sex worker did
not provide condoms, men said that theywouldhave sex
anyway, especially ifthey were "drunk or not thinking
clearly." Some stated feeling "forced" to use condomsby
"prostitutes," especially since most men came from
countries without a condom culture and where HIV
infection was not perceived as a personal threat. Having
a sefiora (partner/wife) was said to help control risk as
well as having sex only with women deemed "clean" or
"safe" regardless ofwhetherthey were wives, girlfiiends
in either country or women they dated for weeks or
months. In addition, Mexican men explained that they
did not associate condoms with "pure love" and thus
would not use them with long-term partners or spouses.
Women, however, reported perceiving a risk of
HIV/AIDS from their partners. Some women said they
immigrated to protect themselves and their families
from diseases by keeping their men from having sex
with other women. Mexican women were especially
reluctant to discuss condoms in a group. They did not
agree onwhethermen woulduse them ornot. Otherthan
for contraception, there was little expectation among
female respondents from all groups that partners would
use condoms.
The subject ofmen having sex with other men was
difficult to broach with immigrant men, although
women were generally more aware and willing than
the men to discuss same-sex sexual behavior among
men. Most male respondents denied knowledge of
MSM behavior in their community. Key informants,
nonetheless, reported hearing about MSM behavior
within some ofthe all-male households.
Alcohol and Other Drugs
Respondents and key informants cited alcohol as
the drug of choice, particularly for Mexican and
Central American men. While drinking was reported
to be the basis ofmost socializing, men and women
suggested that socializing frequently took place in
their houses. Women reported heavy drinking by
men on weekends and that men were frequently
jailed locally because they were drunk in public or
were driving drunk. Respondents also perceived
alcohol consumption as part ofthe process ofmeet-
ing women and having sex. Men and women saw
alcohol as an outlet for men who were alone,
depressed and coping with stresses of a new envi-
ronment. Although occasional drinking among
women in the sending countries was noted
cially among women from the larger cities-it was
suggested that women "consume more [alcohol]
than normal" after migration. "Here, they are not
ashamed ofgoing out already drunk."
Most respondents said they came from communi-
ties where drug use other than alcohol and marijuana
was rare. They agreed that new immigrant involve-
ment in use and sale of drugs was initiated in the
United States. Men's discussions ofdrug availability
in their communities suggested that decisions of
whether or not to use drugs might be influenced
more by finances than by social norms or health
concerns. As one Salvadoran respondent explained:
espe-
When Iarrived at thatplace to buyfood, at 11 in the
evening, they [drug dealers] would say, they would
come close to me and they would ask me ifIwanted
and they would say, "25 ... " I would say, "$25for
this? No." I would say, "I will eatfive lunchesfor
that amount."
Participants also suggested that generational dif-
ferences exist in immigrants' attitudes towards drugs,
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INITIAL ACCULTURATION AND HIV RISK
with younger men being more likely to use marijuana
and cocaine, while older men continue alcohol use,
including beer binge drinking.
Knowledge of HIV/AIDS and
Perception of Risk
Many rural male respondents illustrated only a
superficial knowledge of HIV/AIDS. The hispano
(Hispanic), they agreed, was not aware ofthe preva-
lence ofAIDS, the risk ofinfection, symptoms or con-
sequences. Mostmen and women did notknow the dif-
ference between HIV andAIDS. Women appeared to
know more about HIV/AIDS than men, although with
many gaps in their information. Exceptions were
indigenous Mexican women, who did not appear to
have even a basic understanding ofthe virus or epi-
demic. Some acknowledged their concern about HIV
risk because oftheir partners' other relationships. Oth-
ers discussed risks from their partners' use ofsex work-
ers andthe "behavior ofmen alone."Women sawthem-
selves at risk even if in a monogamous relationship
with husbands and boyfriends, and believed they could
be infected more easily being in the United States. But
even women who knew little about HIV/AIDS
believed they knew more than men because they were
more likely to get information from prenatal/maternal
and child health clinics and services, children's schools
and fromwatching television.
DISCUSSION
Although it would be inappropriate to generalize
about national and ethnic groups based on the small
and nonrepresentative study sample, the identifica-
tion of a range of sociodemographic and contextual
factors can inform institutional and community-based
action as well as directions for future HIV prevention
research. Findings illustrate the urgency ofreaching
these communities as their new residents begin the
process of adaptation and acculturation. Such efforts
must be guided by current and in-depth information
on the strengths and resources of these immigrant
groups as well as their vulnerabilities within the U.S.
epidemic. Furthermore, providers, including U.S. and
native Spanish-speaking professionals, have expressed
their need for information on these new groups from
largely rural and indigenous communities whose
beliefs and behaviors can be significantly different
from other, more established, Spanish-speaking com-
munities in their areas.'4
The risks ofHIV/AIDS can be better identified
and addressed by building on the strengths of
emerging immigrant communities, developing part-
nerships with trusted leaders, mentoring and sup-
porting potential leaders, and bringing community
members into the process of creating prevention
strategies that address new immigrant realities.
ACKNOWLEDGEMENTS
This research was supported by grant #HD042970,
fundedby NICHD. We thank the agencies and individ-
uals whose generous contributions informed this study.
We are grateful to Angela Martinez and Carol Tobkes
fortheir interviewing and insights andto Sherry Deren,
Milton Mino, DorlineYee and theJNMA reviewers for
their comments on earlier versions ofthis article.
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