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 2

“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

Migration study receiving community Binational barriers to care study: Mexican Proyecto indigenous Acceso migration study: Sending 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 out 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 Communities at increased risk : Men who have sex with men (MSM), Sex workers , substance users HIV infection Policies - Drug policies/ Environment incarceration - Lack of harm - Availability of reduction alcohol and drugs policies (e.g. Individual risk poor access to behaviors clean needle exchange) - Injection drug use - Unprotected sex

HIV transmission risks among individuals living with HIV Communities at increased risk : HIV MSM, Sex workers , substance transmission users Policies - Drug policies/ Environment incarceration - Poor access to - Availability of harm reduction alcohol and drugs Individual risk - Immigration behaviors - Insurance and health care - Injection drug use policies - Unprotected sex - Lack of access to care, poor care engagement & low adherence to antiretroviral therapy

Proyecto Acceso Study to understand barriers to care and care utilization among HIV+ Latinos in the US-Mexico border region 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) 9 NCCAM R21AT00467601A1 (PI: Zúñiga)

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? 10

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 11

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 12 the antiretroviral drugs your doctor prescribed?”

Factors independently associated with patient self-initiated ART regimen changes Characteristics AdjOR (95%CI) Female gender 2.15 (1.03, 4.48) 2.42 (1.21, 4.83) Having one sex partner (ref=0 sex partners) 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) 13 * Fair/poor/very poor vs. excellent/very good/good

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 occasionally 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. 14 [Epub ahead of print]

Study implications : HIV+ Latinos at high risk for poor care engagement and low adherence to ART “Don’t ever forget how you got here” “Don’t ever forget how you got here” Compounded risks for poor health outcomes: HIV+ , substance use, deportation, stigma, social isolation, 15 unhealthy environment

Study of substance use and mental health among indigenous migrants 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

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 odds of lifetime substance use? Foto from Cancún http://www.poresto.net/squintanaro 23 o.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 Sample question: 1. How often do you have ► Identified risky alcohol consumption by a drink containing alcohol? drinking category (0) Never (self-reported, in last year, n = 650) (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 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%

Taking into account our socio-demographic variables of interest, is duration of migration (domestic & U.S.) associated with increased odds of risky alcohol consumption? 26

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