ETAC Multi-site Qualitative Evaluation Plan Update

1. ETAC Multi-site Qualitative Evaluation Plan Update Andrés Maiorana and Sophia Zamudio-Haas

2. Our presentation today • Overview of qualitative evaluation • Concepts about Latino/a identity and minority status that will inform the evaluation • Dialogue and critical thinking about concepts that will shape the interventions

3. Objectives • To describe the interventions and the barriers and facilitators that affect their implementation • To identify best practices regarding community engagement, testing, linkage, and retention in care • To better understand the experiences of patients related to testing, linkage, and engagement in care • To assess perspectives of interventionists on core components tailored for the appropriate transnational population

4. Timeline

5. Domains to explore • Experiences participating in the interventions, barriers and facilitators to engagement in care • Perceptions related to living with HIV, being in HIV care, ongoing service needs • Health seeking experiences (beliefs, behaviors and structural barriers) • Self-identity in relationship to health care: ethnicity, gender, sexual orientation, minority status and level of acculturation)

6. Transnational Framework • Transnationalism is a conceptual theory that explains and describes the cross-border interconnections between people, groups and businesses

8. How are the interventions grounded in self-identity, ethnicity, and understanding of minority status for persons of Mexican and Puerto Rican origin?

9. Cultural elements guiding engagement-in-care interventions • How do the interventions connect with persons of Mexican and Puerto Rican origin newly diagnosed or out of care? • How are cultural elements operationalized to make the interventions culturally competent? • What cultural factors are most effective to make the interventions relevant and effective?

10. Cultural elements guiding engagement in care interventions • Content is culturally bound • Core values, beliefs, norms and lifestyles • Form of delivery of intervention • Ex. Promotore/as • Characteristics of the interventionists

11. Identity • Self-identity is the organized structure of cognitions or thoughts that we have about ourselves, including perceptions of our social identities and personal qualities, and generalizations about the self based on experience. • Identity is the meanings attached to the self by one's self and others Michener, H. Andrew, John D. DeLamater, and Daniel J. Myers. 2004. Social Psychology. 5th ed. Belmont, CA: Wadsworth/Thompson Learning

12. Self-Identity • A set of beliefs and perceptions about oneself • Multiple layers: • Personal identity (Not fixed and stable but mutable and plural) • Ethnicity • Social identity (perceived by others) • Identity, community and ethnic boundaries

13. Ethnicity “Aspects of relationships between groups which consider themselves, and are regarded by others, as culturally distinct.” HyllandEriksen, T. “Ethnicity and Nationalism: Anthropological Perspectives”. Pluto Press, 2002.

14. Latino Ethnicity • Defined by a shared or common identity from Spanish-speaking countries of North, Central and South America, and the Caribbean • Shared identity expressed through a sense of belonging and place • Solidarity and reciprocity ties in social relationships • Common history • Spanish as the native language of origin

15. Concept of Latinidad The concept of Latinidad is mainly defined in the context of Latinos in the U.S. being a minority sharing historical, political, and cultural processes, united by race and language, and facing particular challenges such as stigma, racism, and immigration-related issues. Miguel, Guadalupe San. "Embracing Latinidad: Beyond Nationalism in the History of Education." Journal of Latinos & Education 10.1 (2011): 3-22. Price, P. L. "Cohering Culture on CalleOcho: The Pause and Flow of Latinidad." Globalizations 4.1 (2007): 81-99

16. Concept of Latinidad in U.S. “As Latinos living in the U.S., we have a truly multicultural experience. In this nation, through good fortune and necessity, the lines along country of origin that normally distinguish one Latino from the other are softened even as our common heritage is highlighted. While we still form strong organizations based on our home country, we also form very powerful and strategic alliances as well as deep personal relationships with a diverse group of Latin American peers.” “Como latinos radicados en Estados Unidos, nos desenvolvemos en un ambiente multicultural. En este país, por fortuna y necesidad, las líneas nacionales que nos pueden distinguir el uno del otro se hacen más suaves a la vez que nuestra herencia común se destaca. Eso nos lleva a construir fuertes lazos profesionales y sentimentales con personas de diversos países latinoamericanos” -NEXXOS, American Airlines Magazine, May, 2014

17. Balancing Intersecting Identities Minority Status Latino Self-Identity

18. Intersecting or Overlapping Identities • Mexican Americans • Nuyoricans • Puerto Ricans of African descent • Indigenous migrants from Mexico • LGBT

19. A Queer Latinidad • View into the life experiences of gay, bisexual, transsexual, and queer Latino/as at the confluence of race, ethnicity, and gender and sexual orientation. • Localized in a time-space framework, in which the identities, history and desire of Latino/a LGBTQ are expressed through political, social , cultural and linguistic interactions, including activism and HIV prevention. Foster, D. W. El Ambiente Nuestro, BilingualPress, Tempe, Arizona, 2006. Rodriguez, J. M. Queer Latinidad: Identity Practices, Discursive Spaces, 2003.Lima, L., Picano, F. (ed.) Ambientes, New Queer Latino Writing, Univ. of Wisconsin Press, 2011.

20. Factors that shape the experience of first generation Latino/as • Personal characteristics (ex.SES, agency, and ideology) • Reasons for living in the continental U.S. • Language • Length in the US • Sending community/place of origin (urban/rural) • Receiving community in the U.S • Neighborhood and social and gender networks of support • Political climate

21. Language

23. Spanish Language and Latino/as in the U.S • Communicate in native language • Underline a representation of the world • Protect an identity against the acculturating and homogenizing effects of English Foster, D. W. El Ambiente Nuestro, BilingualPress, Tempe, Arizona, 2006.

25. Language • Ability to communicate in English reflects levels of acculturation and easiness of functioning in mainstream U.S. society. • Interplay and switching between English and Spanish an expression of two different worlds with which they are familiar. • Spanish used to express a nostalgia for real or idealized roots. Foster, D. W. El Ambiente Nuestro, BilingualPress, Tempe, Arizona, 2006.

26. Latino Cultural “Ismos” • Machismo/Caballerismo • Familismo • Personalismo • Confianza (trust) • Marianismo How much do they apply to a specific individual?

27. Other cultural elements • Mistrust of the system and authority • Passive aggressiveness • “Si pero no” How do the “Ismos” and other cultural elements need to be considered as part of the interventions to engage persons of Mexican and Puerto Rican origin in care?

28. Minority Status • Historical processes result in differential power dynamics • Economic, political and social inequities • Dwellings in inner cities with social and environmental ills • Social and economic isolation

29. Signifiers of Ethnic Identity and Markers of difference • Socioeconomic Status • Language • Skin color • An “ethnic” name • Social, cultural and political factors

30. Markers of Difference • Perceptions of the “foreign” as a threat • Perceptions of the “alien” as outside the community of “Americans” • Stigma and discrimination Maiorana, A.; Rebchook, G.; Curotto, A.; Galindo, G.; Susan Kegeles, S. “Adaptation of the Mpowerment Project to YoungLatino MSM.” www. mpowerment. org

31. Markers of Difference “My mind does not have an accent, my speech does” Maiorana, A.; Rebchook, G.; Curotto, A.; Galindo, G.; Susan Kegeles, S. “Adaptation of the Mpowerment Project to YoungLatino MSM.” www.mpowerment.org

32. Common Structural Barriers • Lack of financial resources • Limited job opportunities • Access to health services • Legal status • Lack of insurance How does the interplay of barriers and cultural elements impact health care utilization and health seeking behaviors?

33. Concept of Citizenship/Concepto de Ciudadanía • Vastly used in Latin America • Framework of social justice • Achievement of equal political, economic, social, cultural, sexual rights • Access to health services as a basic right • Full participation in a democratic and plural society Dagnino, E. “Citizenship in Latin America: An Introduction.” Latin American Perspectives 2003 30: 211

34. Concept of Citizenship Cáceres, Frasca, Pecheny, Terto. Ciudadanía sexual en América Latina: abriendo el debate. Lima” Perú. 2004.

35. To be continued • Health seeking behaviors • Acculturation processes • Stigma