1. Proyecto de Salud Para Latinos: Understanding the Sexual and Reproductive Health Needs of Young Latino Men and Women Residing in Rural Oregon Moderator: Marie Harvey OPHA Panel Presentation: October 18, 2010

2. Latino Health Project Why?? Latinos disproportionately high rates of unintended pregnancy and STIs Sexual health disparities only have the potential to grow Non-traditional settlement areas experienced rapid and dramatic increases in the number of Latino residents with large numbers migrating to rural areas Oregon has experienced a striking 52.7% growth in Latino population between the years 2000-2008 Relatively little known about sexual risk profile of Latino men and women who live in rural Oregon.

3. Latino Health Project Proyecto de Salud Para Latinos 5-year funded CDC study that examined the relational and contextual determinants of contraceptive use and sexual risk behavior among young adult Latinos in rural Oregon Project Period: 9/30/2007 – 9/29/2011

4. Latino Health Project for Men Proyecto de Salud Para Hombres Latinos 3-year DHHS Office of Population Affairs funded study designed to improve delivery of sexual and reproductive health services to heterosexual Latino men in rural areas. Project Period: 9/30/2007 – 9/29/2011

5. It Takes a Village… Research Team S. Marie Harvey, DrPH, MPH – Principal Investigator Ann P. Zukoski, DrPH, MPH - Co-Investigator Donna Champeau, PhD – Co-Investigator Jocelyn Warren, PhD, MPH – Post Doctoral Fellow Liana Winett – DrPH, MPH – Research Associate Meredith R. Branch, MPH - Project Coordinator Deanne Hudson, RN, MPH - Project Coordinator Marit Bovbjerg, MS – Research Assistant Antonio Torres, B.A. - Field Coordinator/Interviewer Leslie Salas Karnes - Graduate Research Assistant Doris Cancel-Tirado – Graduate Research Assistant Brennan Beauchesne - Undergraduate Student Intern

6. It Takes a Village… Field Staff Recruiter/Interviewers/Translators Yazmin Brambila Victor Elias Javier Fernandez Salvador Jasmin Guerra Jazmin GonzalezAlonso Oliveros Mario Rosales Patricia Robleto Elio Cacerras

8. Community Partners Tuality Salud Virginia Garcia Clinics Radio Movimiento Planned Parenthood Benton County Health Department Centro Latino Farmworker Housing Development Corporation Linn-Benton Hispanic Advisory Committee Woodburn Public Library Chemeketa Community College

9. Proyecto de Salud Para Hombres Latinos: Immigrant Latino Men Residing in Rural Communities in the Northwest: Exploring Physical and Social Environments Antonio Torres, Marie Harvey, Liana Winett, Deanne Hudson, & Meredith Branch OPHA Panel Presentation: October 18, 2010

10. Goals Of the study: to increase understanding of sexual and reproductive health needs of heterosexual immigrant Latino men residing in rural areas of Oregon Today: to provide a snapshot of the lives of Latino men working and living in rural Oregon to describe how contextual factors might interact to increase men’s risk for HIV/STIs

11. Latinos in Rural Communities Largest & fastest growing minority group in US, particularly in “new settlement areas” Face unique challenges that may influence sexual behavior and health service utilization that increase risk of exposure to HIV/STIs, unintended pregnancy Migration disrupts social, familial, sexual relationships The percent increase in Latino population over the last decades has been dramatic in Oregon, Washington and Idaho.

12. % Increase Hispanic Population 1980-2000 [US Census 2000] 268% 318% 178% 81% 29%

13. Disparities Facing the Latino Community High rates of unintended pregnancy, STIS & HIV/AIDS among U.S. Latinos 2007 AIDS case rate among Latinos was 3.3 times higher than for Whites In 2008, Latinos had highest syphilis rate and second highest chlamydia and gonorrhea rates among minority populations in OR

14. Contextual Determinants Amaro and Raj (2000) called for including individually-based factors within the context of the larger social dynamics of gender, race/ethnicity and class oppression Our focus: how individual and interpersonal risk factors interact with sociostructural variables that place Latino men at increased risk

15. Target population Heterosexual men who self-identify as Latino Immigrated to the U.S. in past 10 years 18-30 years old Live in rural Oregon Report intercourse within past 3 months Not seeking to get partner pregnant Not HIV +

16. Challenges Trust Immigration Issues Legitimacy of Project Building a Presence Finding Participants Cultural Norms-Talking about Sexual Issues Perceived Discrimination Issues

17. Recruitment and Networking Strategies Building community presence Outreach locations Marketing Face to face/Engaging participants

18. Community Partners Tuality Salud Virginia Garcia Clinics Radio Movimiento Planned Parenthood Benton County Health Department Centro Latino Farmworker Housing Development Corporation Linn-Benton Hispanic Advisory Committee Woodburn Public Library Chemeketa Community College

19. Study Methods Individual, semi-structured interviews 60-90 minutes long Bilingual, bicultural staff members conducted interviews in English or Spanish

20. Analysis Interviewed 49 Latino men Audio-recorded, translated & transcribed NVIVO 8 qualitative data analysis software Ethnographic content analysis SPSS 17.0 to create frequency distributions of structured survey responses Content analysis using NVIVO8

21. RESULTS…

22. Participant Characteristics Average age 24 years 92% from Mexico Average 6 years living in the US; 4.3 years in OR 57% unemployed Mean household income $13,621 Mean 9.1 years of education completed

23. Sexual Risk Profile Average age first intercourse 16 years Mean of 8.2 lifetime sexual partners 10% tested for STIs in past month 49% ever tested for HIV 45% ever had sex with prostitute 29% never used condoms during sex 46% report binge drinking

24. Social and Physical Environment Living in Oregon Came to Oregon for increased opportunity Came to Oregon because of friends/family Cultural differences Working in Oregon Employment/unemployment Workplace conditions

25. Social Relationships Family and sexual partners Social support Committed relationships

26. Sexual Relationships Sex outside of committed relationship Loneliness Sexual experimentation Sexual needs Engaging with prostitutes Cultural differences

27. Implications Risky environments + migration-driven factors = increased prevalence of HIV/STIs Social network dynamics, social isolation Address substance use Source, availability & social economy of prostitution

28. Proyecto de Salud Para Latinos: Para Hombres Perceived Structural Barriers to Sexual and Reproductive Health Services Deanne Hudson, Marie Harvey, Antonio Torres, Meredith Branch OPHA 2010 Annual Meeting October 18, 2010 Corvallis, Oregon

29. Purpose of the Presentation Characterize structural and service delivery factors that affect utilization of services Explore the preferred context for services and strategies to promote access and utilization of services Discuss implications of findings

30. Greatest Concerns about Health and Sexual Health Overall Health: –Sexual health was fourth Sexual Health: –Over half had no concerns –About two fifths were concerned about STIs

31. Utilization of Services Almost half had ever used services - US –Community/Public Clinic: 52% –Emergency Department: 17% –HMO: 13% –Private Doctor: 9% Utilization of SRH services - Oregon –Used STD Services: 31% –Received HIV Testing: 37% A few used Family Planning services - US

32. Health Insurance 88% Lacked health insurance –Few had employer-provided coverage

33. Structural Factors Affect Access & Use of SRH Services Lack of knowledge Cost Time Clinic Staff Characteristics - Language Privacy – Confidentiality - Trust

34. Factors Affect Access/Use of Family Planning Services Few men ever used US family planning services Self and Cohort: lack of knowledge Cohort –Lack of interest and services not valued Self –No need for FP services –Not ready for a family

35. Factors Affect His Ability to Get Birth Control Now Too much waiting time at clinics 76% It is hard for me to get time off work or school53% I have transportation problems getting to a clinic 45% Takes too long to get an appointment41% I have no one to watch my kids33% No clinic close to where I live30% Clinic hours are not convenient for me30%

36. Experiences with Discrimination in Oregon Over half reported ever having been discriminated against or made to feel unwelcome in Oregon.

37. Perceived Discrimination in US Health Care Services About half who received health care in the US perceived: –Been treated with less courtesy than others –Been treated with less respect than others –Received poorer service than others Scale adapted from Bird ST, Bogart LM, 2001.

38. Preferred Context: How Men Want to Be Treated About three fourths described the importance of having trust in your provider. About two thirds wanted to be treated respectfully. About half wanted equality and fair treatment.

39. Preferred Delivery Setting for SRH Services Prefer to receive services at Community/Public Health Clinics Prefer to see a private doctor or clinic Preferred Involvement in Decisions to Prevent Pregnancy –Talk with my partner and me together

40. Strategies to Increase Use of SRH Services: What Can Clinics Do? Increase Awareness and Knowledge Reduce Cost Efficient use of Time Clinic Staff Characteristics - Language Promote Privacy - Confidentiality - Trust

41. Discussion Results are consistent with the literature Informs practice, policy and research

42. Factors Influencing Effective Contraceptive Use Among a Sample of Latinos Residing in Rural Communities in the Northwest Jocelyn T. Warren, S. Marie Harvey & Marit Bovbjerg Oregon Public Health Association 2010 Annual Meeting Corvallis, Oregon

43. Background Unintended pregnancy high among Latinos Use of contraception low – Inconsistent use – Reliance on less effective methods

44. Previous Research Individual factors identified –self-efficacy, perceived vulnerability, etc. Cultural factors explored –machismo, familismo, marianismo –acculturation Partner and relationship factors? –women’s pregnancy intention varies depending on partner –men often not included in contraceptive research Include individual factors in larger context

45. Study Purpose Describe effective contraceptive use Determine whether contextual factors are related to effective contraceptive use Discuss significance of findings for reproductive and sexual health programs

46. Latino Health Project Proyecto de Salud para Latinos Multi-method study to increase understanding of social, cultural factors that influence condom use, sexual risk behavior, HIV/STI prevention among Latinos living in rural Oregon Participants included young Latino heterosexual men and women and health care providers who serve Latinos in rural areas Young adult participants recruited from clinics and community locations

47. Methods Eligibility criteria for study: – Ages18-25 – Current sexual partner – Not planning pregnancy – No sterilization within couple Data derived from computer-assisted quantitative surveys with trained interviewers lasting ~1 hr

48. Participants Over 60% born outside the US One quarter spoke only Spanish Just over half completed high school Almost half were married or living with partner Median income was $15,000 and average household size was 3.5

49. Effective Use of Contraception Three groups defined: Female-controlled= use of LARC (IUDs, injections, rings, etc.) or regular use of pills Male-controlled=male condom used at every sex in past three months Others= non-use, use of ineffective methods, and inconsistent use of effective methods

50. Other Variables Sex (female/male) At least HS graduate Married and/or cohabitating Acculturation Scale Machismo Scale Birth control use self- efficacy scale Perceived vulnerability to pregnancy with partner Relationship commitment scale Contraceptive decision- making scale Perceived partner support for birth control

51. Effective Contraceptive Use Women % (N=243) Men % (N=233) TOTAL (N=476) Female-controlled methods 46%27% 36% Male-controlled method 12%22% 17% Other42%51% 47%

52. Results: Risk Ratios from Multinomial Logistic Regression Variable Female Control vs. Other Male Control vs. Other Female Control vs. Male Female 1.15.721.60 HS graduate.75.92.81 Married/cohabitating 1.82*.41*4.48*** Acculturation.72*.78.92 Machismo.79.94.84 BC self-efficacy 1.58**1.351.17 Perceived vulnerability 1.251.39.90 Commitment 1.071.041.02 BC decision-making 1.272.12**.60* Partner support for BC.61**1.04.59 *p<.05; **p<.01; ***p<.001

53. Discussion Over half of the sample practiced effective use, with female-controlled methods more common Factors related to effective use varied by method Importance of married/cohabitating—more likely for female controlled, less likely for condom users Lower acculturation finding consistent with previous studies of contraceptive use Partner factors important across methods Self-efficacy related only to female-controlled methods vs others, but greater decision-making predicts condom use