Cultural Competence & Field Instruction: working with US-Mexico - - PowerPoint PPT Presentation

Cultural Competence & Field Instruction:

working with US-Mexico transnational populations in Southern California: Substance Use and increased risk for poor health outcomes, specifically HIV.

María Luisa Zúñiga, Ph.D.

Associate Professor School of Social Work, San Diego State University

School of Social Work Field Instructor Continuing Education May 7, 2014

Learning Objectives

I. Identify relationships between substance use and risk of poor health outcomes among transnational Latinos

• II. Discuss opportunities for improving delivery of

culturally-competent care to transnational populations

• III. Discuss Implications for field instruction and

interventions with Latino populations

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“To live on the border is to live in the center: to be at the entrance and the exit; to inhabit two worlds, two cultures and to accept both” José Antonio Burciaga

Binational barriers to care study: Proyecto Acceso Mexican indigenous migration study: Sending community Migration study receiving community

Human Immunodeficiency Virus (HIV) remains a formidable threat to Latino health

CDC estimates that in the U.S., ~ 1.2 million persons aged 13 years and older are living with HIV infection,

• 18.1% do not know they are infected

Latinos represent ~16% of the U.S. population but account for 21% of new HIV infections (CDC 2010) Latinos face multiple barriers to HIV testing and care: they are more likely than any other ethnic/racial group to delay HIV testing & care entry after their diagnosis, and frequently fall

• ut of care (Keesee, Natale, Curiel, 2012)

These barriers prevail in the US and California, especially in our demographically booming border region

http://www.cdc.gov/hiv/surveillance/resources/reports/2010supp_vol17no3/index.htm

California has the second largest number HIV/AIDS cases in the U.S.; San Diego county has the third largest number of HIV and AIDS cases in California

• 14,805 cumulative AIDS cases 1981-2011, roughly ½ currently alive
• 43,501 cumulative cases of HIV (not AIDS) 2006-2011 (name-based)
• Latinos in San Diego’s southern region account for 66% of HIV cases

and Comprise ~56% of pop. in region

(County of San Diego, HIV/AIDS Epidemiology Report, 2012)

• Among Mexico’s 31 states, Baja CA ranks 5th in cumulative HIV cases
• 1,562 Cumulative cases from 1985-2011

http://www.censida.salud.gob.mx/descargas/2011/NUMERALIA_SIDA_2011.pdf http://www.censida.salud.gob.mx/descargas/epidemiologia/RN_CIERRE_2013.pdf

HIV infection risks

Individual risk behaviors

• Injection drug use
• Unprotected sex

Environment

• Availability of

alcohol and drugs

Policies

• Drug policies/

incarceration

• Lack of harm

reduction policies (e.g. poor access to clean needle exchange) Communities at increased risk:

Men who have sex with men (MSM), Sex workers , substance users HIV infection

HIV transmission risks among individuals living with HIV

Individual risk behaviors

• Injection drug use
• Unprotected sex
• Lack of access to care, poor care

engagement & low adherence to antiretroviral therapy

Environment

• Availability of

alcohol and drugs

Policies

• Drug policies/

incarceration

• Poor access to

harm reduction

• Immigration
• Insurance and

health care policies Communities at increased risk:

MSM, Sex workers , substance users HIV transmission

Cross-sectional study binational recruitment Field sites Social & clinical service agencies in Tijuana & San Diego Mixed Methods Quantitative survey: 283 HIV+ Latinos Qualitative: 19 in-depth interviews (clinical HIV providers) 4 patient focus groups Binational IRB approval UCSD & Tijuana General Hospital Bioethics Committee Study period June 08- May 2011 Funded by NIMH 1R21MH084266 (PI: Zúñiga) NCCAM R21AT00467601A1 (PI: Zúñiga)

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Proyecto Acceso

Study to understand barriers to care and care utilization among HIV+ Latinos in the US-Mexico border region

Study research questions

• Are there differences between the profile of

patients who receive HIV care in Tijuana vs. San Diego?

• What factors affect a patient’s ability to adhere

to their medication therapy?

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This study found that HIV-positive patients who had their most recent HIV appointment in San Diego had:

• 1. Significantly higher educational attainment,
• 2. Were more likely to make MORE changes to their antiretroviral therapy regimen (not able to take as

prescribed),

• 3. Were less likely to have been deported (than patients in Tijuana), and
• 4. Were less likely to feel socially isolated….meaning that Tijuana patients were LESS likely to make ART

changes but MORE likely to have been deported and feel socially isolated

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What factors are associated with increased odds of making changes to antiretroviral therapy?

Outcome variable: Self-reported changes to ART: “During the past 4 weeks how often did you make small or large changes from the antiretroviral drugs your doctor prescribed?”

Characteristics AdjOR (95%CI)

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* Fair/poor/very poor vs. excellent/very good/good

Female gender 2.15 (1.03, 4.48) Having one sex partner (ref=0 sex partners) 2.42 (1.21, 4.83) Having 2 + sex partners (ref=0 sex partners) 3.33 (1.47, 7.53) Living ≤ 6 years with HIV (ref= >6 years) 1.99 (1.08, 3.60) Rate health as fair in the last 6 months (ref=good)* 2.50 (1.32, 4.72)

Factors independently associated with patient self-initiated ART regimen changes

Clinician Perspectives

“…Substance abuse, alcohol or other type of substance… some patients are using crystal meth… its making them fail in their treatment because sometimes they don’t even know if they took it [ART] or not.” – Female provider, San Diego “… Substance abuse including alcohol, is the most common reason why people just disappear from the clinic, because substance abuse is

• ccasionally treated by the judicial system, it’s a medical condition that is

treated by judges also, sometimes some of my patients disappear because they are incarcerated.” – Male provider, San Diego

Servin AE, Muñoz FA, Zúñiga ML. Healthcare provider perspectives on barriers to HIV-care access and utilisation among Latinos living with HIV in the US-Mexico border . Cult Health Sex. 2014 Mar 5. [Epub ahead of print]

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“Don’t ever forget how you got here”

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Compounded risks for poor health outcomes: HIV+ , substance use, deportation, stigma, social isolation, unhealthy environment

Study implications:

HIV+ Latinos at high risk for poor care engagement and low adherence to ART

“Don’t ever forget how you got here”

Funding: Health Initiative of the Americas-University of California, Research Program on Migration and Health PI’s Zúñiga, ML and Lewin-Fischer, P Funding Period 03/01/12-08/31/13

Study of substance use and mental health among indigenous migrants

Municipality of Tunkás State of Yucatán Mexico

• Pop. ~3,500

Cross-sectional study design Mixed Methods Quantitative: Cross-sectional study Qualitative: In-depth interviews IRB Approval: UC San Diego HRPP and DIF Yucatán Field work conducted January – March 2012 Sample size: 650 Tunkaseños

• 583 in Tunkás
• 67 in Anaheim & Inglewood, California
• Average age 40 years
• 56% have a history of migration, internal and transnational
• >75% speak Maya (a little, well)

Internal migration and correlates of substance use in a community of indigenous Maya from Yucatán, Mexico Pinedo, M, Kang Sim, E, Espinoza, RA, Zúñiga, ML.

Field ACTions Science Reports Accepted, February 2013

Factors associated with lifetime substance use (n =45)

Is migration destination associated with increased

• dds of lifetime substance use?

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Foto from Cancún http://www.poresto.net/squintanaro

• .php?idSeccion= 1

Alcohol Use Behaviors Among Indigenous Migrants: a Transnational Study of Communities of Origin and Destination

Pinedo M, Campos Y , Leal D, Fregoso J, Goldenberg SM, Zúñiga ML. Alcohol Use

Behaviors Among I ndigenous Migrants: A Transnational Study on Communities of Origin and

• Destination. J Immigr Minor Health. 2013

Dec 24. [Epub ahead of print]

Alcohol Use Disorders Identification Test (AUDIT) screening instrument

► developed by World Health Organization ► Identified risky alcohol consumption by drinking category (self-reported, in last year, n = 650)

Low risk drinkers (score 0 to 7, reference category) 508 78% At-risk drinkers (score 8-15,

90 14% hazardous drinking /alcohol abuse)

High-risk drinkers (score ≥ 16, dependence)

52 08%

Sample question:

• 1. How often do you have

a drink containing alcohol? (0) Never (1) Monthly or less (2) 2 to 4 times a month (3) 2 to 3 times a week (4) 4 or more times a week

Taking into account our socio-demographic variables of interest, is duration of migration (domestic & U.S.) associated with increased

• dds of risky alcohol consumption?

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Factors independently associated with at-risk and high-risk drinking*

Structural factors and social networks related to mental health and substance use among indigenous migrants from Yucatán

Pedro Lewin-Fischer, Isabel Haviland, Teresa Rocha, María Luisa Zúñiga Manuscript in prepration for Migraciones Internacionales In-depth interview with Male international migrant who returned to his Yucatán home community

“Why do migrants consume alcohol? Because firstly it is the isolation, there are many who are alone. The majority of people who go there [U.S.] Go alone. “alone” I am referring to without their wife or mother. .. Then having this feeling when you arrive, it is what makes you grab the nostalgia and the beer and everything is abundant…there are times when they even get into drugs.”

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Substance use among indigenous migrants from Yucatán

• Migration destination matters, as does

duration of residence in receiving community

• Amount of available substance in receiving

community matters

• Social isolation directly linked to substance

use

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Translational Research: Taking research findings back to the community to promote community engagement in developing interventions

What study findings add: Implications for serving border-dwelling individuals and families

Individual risk

• Mental health (isolation & stigma)
• Risky alcohol & drug consumption
• poor medication adherence
• deportation

Environment

• Border dynamics
• Tourism destinations
• Availability of alcohol

and drugs

Policies

• Drug policies/

incarceration

• Immigration &

deportation policies

• Insurance and

health care policies Communities at increased risk:

►HIV+ Latinos receiving care in San Diego ► HIV+ Latinos in Tijuana ►Transnational migrants ► Domestic migrants ► Deportees

HIV transmission

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Environmental, Structural, Policy ►Border region dynamics ► Drug trafficking route: Availability alcohol/drugs ► Drug policies (incarceration/deportation harm reduction) ► Lack of rehabilitation services Community ► alcohol consumption norms ► drug consumption norms ► gender/sexual norms I nterpersonal ► Family ties strained homophobia/stigma/discrimination long distance, limited resources to send, few visits, partner exposure risk I ndividual ► Mental health – depression/social isolation/stigma ► Medication adherence ► Cross-border mobility ► Documentation/deportation risk ► Risky consumption alcohol/drugs ► Risky sex ► HIV/STI transmission ► Poor care access

Implications for Field Training: Helping to increase student awareness

Implications for delivery of clinical care and services

• Cross-cultural communication (language, delivery of

culturally-effective care)

• Sensitivity to family immigration status (one member

may be undocumented, stress of potential deportation for family)

• Binational & transnational mobility
• Harder to engage in care
• Vulnerability to dropping out of care
• Comprehensive/Patient-centered medical home
• Others?

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Acknowledgements…

• Fátima Muñoz
• Justine Kozo
• Argentina Servin
• Yvette Longduriyang
• Estela Blanco
• Rosana Scolari
• Carolina González
• Karla Liliana Torres
• Isela Martínez
• Remedios Lozada
• Enrique Gomez
• Steffanie Strathdee
• Jorge Luis Martínez
• Rosario Mancillas
• Sergio Rivera
• Hector Miguel Corral

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The extraordinary community partners

and study participants

MMFRP students from UC San Diego & Universidad Autónoma de Yucatán

Partner Agencies

Patronato Pro - COMUSIDA Tijuana, A.C.

County of San Diego, Health and Human Services Agency Public Health Services

Gracias!

ADDITIONAL REFERENCE SLIDES

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Border health is big…opportunities are plentiful

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• Binational health-

care behavior

• Changing climate of

care provision & insurance

• Opportunities for

improved binational coordination of care

Future directions for applied research

Design and test culturally-effective interventions for HIV+ Latinos and Latino immigrants (intersection of both)

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► Alcohol and substance use interventions I ntervention sites: criminal justice, detention

centers, community clinics

► Care engagement & retention interventions

(medication adherence interventions)

► Access to care interventions in climate of ACA exclusivity and rise in deportation

Factors associated with deportation from the United States to Mexico among HIV-positive Latinos living in the U.S.-Mexico border region (Muñoz, F , et al., 2013, in preparation)

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Of 283 participants, 71 (25%) reported having been deported at

• ne time

No significant differences between participants recruited in Mexico and U.S.

Socio-demographics:

• Mean age 41 yrs. (SD:10)
• Male (77%)
• Born in Mexico (93%) & preferred speaking Spanish (84%)
• Did not complete high school or equivalent (60%)

US-Mexico border-crossing activity

• 54% made at least one-round trip border crossing in the last 6 months;

average # of trips was 15 (SD= 33)

• Of border crossers, 66% had crossed for health care & 64% had crossed

for medications

• 32% reported being concerned about crossing with medications
• 24% Have been deported from US to Mexico

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Results (N= 230)

Opportunities for community-engaged research

Researcher develops idea, contacts community agencies to collaborate Community with characteristic or health condition

• f interest is

contacted and invited to participate Data collected by research team Data analyzed Data disseminated: Conferences Journals Reports Advocacy Clinical practice

COMMUNITY

Community mobilization

Co-generate idea, inform

• n underlying

resources and challenges Community support in locating study population Train members of community to support data collection, provide critical feedback Discuss priority analyses Validation of findings, access to data, advocacy, co- authorship?

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US-Mexico Border Region

Source: Pan American Health Organization Border Region ~3000 km (1,863 miles) North/South 100 km (62 miles) CA/Baja CA 322 km (200 miles)

Challenges & Strengths

• Joint Appointment
• Community-Based

Participatory Research

• US-Mexico Collaboration
• Research $$
• Mentorship opportunities
• Growing understanding of

health care delivery in

• ur border region