Rhonda Bohs, Ph. D Spectrum Programs Inc. Miami Behavioral Health Center

1. Moving Beyond the Comadres/CompadresModel Rhonda Bohs, Ph. D Spectrum Programs Inc. Miami Behavioral Health Center Vice-President of Research and Clinical Development Maria Elena Villar, Ph.D. Florida International University Assistant Professor School of Journalism and Mass Communication ACKNOWLEDGEMENTSThis study was supported by award number P20MD002288 from the National Institute on Minority Health and Health Disparities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Minority Health and Health Disparities, or the National Institutes of Health .

2. Spectrum Programs Inc. and Miami Behavioral Health Center • MBHC located in Miami, Florida has conducted their services with SPI since 2003 predominantly serving the Hispanic/ Latino community. • SPI located in Miami-Dade and Broward County is the oldest and largest non-profit substance abuse treatment provider in South Florida. • MBHC has served the Latino community (children, adults, and severely mentally ill and substance abusing) since 1977 providing both mental health and substance abuse services.

3. Latinos and HIV Testing • Latinos are more likely than other ethnicities to be tested for HIV late in their illness. • Latinos are more likely to be public insured or uninsured when compared to other groups. • Latinos are more likely to report postponing medical care due to transportation or being too sick to go to doctor. • Latinos are more likely to under-utilize services due to socio-economic challenges, poverty.

4. Our focus: Behavioral Health Clients and their Risks • More prone to homelessness and poverty as well as lack access to health care and other basic necessities. • More likely to present cognitive deficiencies and reduced social and interpersonal skills (Parry, Blank, & Pithey, 2007), leading to increased risk-taking behavior and probability of ending up in risky situations. • In addition, multiple sex partners; unprotected sex, and engaging in injection drug use. • Individuals with co-occurring mental health and substance use disorders appear to experience the most severe risks relative to engaging in these behaviors (Parry et al, 2007)

5. HIV Stigma and Peer Interventions • Social stigma of HIV & drug use may decrease perceived susceptibility and social support for screening and treatment • Research is lacking on the effectiveness of peer health advisors/community health workers for HIV & substance abuse • Peer interventions have been used to challenge health related cultural beliefs • There is a need for further study on the specific attitudes and beliefs associated with testing and other screening/prevention behavior

6. Why assess stigma? Previous research describes participants reporting lower testing intentions for a stigmatized disease than for a non-stigmatized disease • participants were found to diminish their perceived risk for contracting the disease when they were informed it could be transmitted through unprotected sex in addition to other non-sexual means, and their intentions to be tested for the disease were consequently reduced. • The study indicates that when a disease carries moral stigma, people are increasingly unwilling to test for it so as to uphold a good moral image (Young, Nussbaum, & Monin, 2007).

7. HIV Attitudes and Beliefs Previous studies show that HIV testing behavior is negatively related to • misinformation • misguided beliefs about HIV • stigmatized attitudes towards HIV

8. Comadres/ Compadres • Literally means: godmother/godfather because Latinos extend respect and loyalty to comadres/compadres. • Focus on linking people to primary and secondary prevention on substance use and HIV. • Objectives: • Document the County’s HIV/AIDS and Substance Abuse Prevention and Treatment Resources • Recruit, Select, and Train Comadres/Compadres • Collect Participant Surveys for information on: (1)knowledge of HIV/Substance use consequences; (2) actual HIV and substance use risk behaviors; (3)needs for connection to prevention and treatment services; (4) knowledge of HIV/AIDS and substance abuse service providers • Participant Focus Groups

9. Health Educator Model • Link and connect individuals to services in the community. • Community Health workers live in the same neighborhoods as the individuals they serve. • Use community empowerment as a tool to reduce health care burdens. • Outreach, education and follow-up of underserved populations. • Model can be used for breast cancer, diabetes, or HIV education.

10. Training Training: • 5 sessions over 5 weeks; trained by Spectrum staff • Curriculum was modified from “Community Voices: Healthcare for the Underserved Project” • Included modules on (a) role of community health coaches, (b) Latino health disparities, HIV & substance abuse, (c) Coaching skills & (d) community resources.

11. The Intervention • Developed a curriculum based on the principles of Community Voices. • Consists of Four Modules • Module 1: Identify the roles of community health coaches • What are the values guiding the work of community health coaches? • Module 2: Educate Comadres and Compadres on Latino health disparities • HIV/AIDS • Substance Abuse

12. The Intervention • Module 3: Provide the trainees with coaching skills necessary to conduct outreach, education, and advocacy activities in their clinic • Communication and Presentation skills • Problem solving skills • Team Building skills • Setting goals and objectives

13. The Intervention • Module 4: Identify Community Resources • HIV/AIDS • Substance abuse • Recognition: Certificate of Accomplishment • Supervision: Weekly meetings with supervisors to discuss accomplishments, challenges, and to provide peer support.

14. Data Collection Sites • Intervention was pilot-tested at a Community Behavioral Health Center • 2 Control sites were included in survey: a Latino Residential Program and an Outpatient Clinic • Control sites were exposed to standards of state mandated HIV education Data Collection • 140-item knowledge & attitude questionnaire • Items addressed: (a) knowledge of existing services, (b) unmet service needs, (c) attitudes & beliefs toward HIV & substance abuse, (d) intent to be tested for HIV and/or substance use, (e) reasons for intention to be tested. • 3 point scales (agree-neutral-disagree) • Post test was administered 5 months after intervention

15. Participant Demographics • N= 72 pre; 62 post • Pre-test demographics • Mean age: 44.9, SD=13.8 • 58.3% male; 41.7% female • 40.8% single; 18.3% married; 28.2% divorced; 5.6% widowed • 15.5% college grad or grad school; 21.1% high school grad; 26.7% trade school or some college; 25.3% elementary or middle school only • 77.5% born outside US; mean yrs in US=18.8, SD=12.01 • 83.8% identify as white; 7.4% as black; 8.8% mixed race • 45.8% identified as Hispanic; 33.3% as Latino; 5.6% as Hispanic Latino; 6.9% as American • 75.7% speak Spanish at home; 12.9 English; 11.4 Spanglish

16. Summary of Pre-Test HIV/AIDS: Knowledge • Knowledge on the nature of HIV was high • Knowledge on the transmission of HIV was comparatively low. • Prevalent misconceptions about • Transmission of HIV • Ability to identify people with HIV by looking at them. HIV/AIDS: Attitudes & beliefs • Attitudes towards people living with HIV was somewhat negative, but not across the board. • Most participants did not blame homosexuals for transmitting HIV, and did not consider it a punishment from God.

17. Summary of Pre-Test • There were differences in attitudes and beliefs between testing behavior groups • Greater stigmatized beliefs among those not interested in testing • Greater misinformation about those never tested and not willing to be tested • Reasons for testing or not testing related to perceptions of personal risk and exposure.

18. Results Pre/Post AttitudesAIDS Knowledge

19. Results: Pre/Post AIDS Attitudes

20. Results: Pre-Post AttitudesIntervention vs. control Paired Samples t-tests

21. Results: Pre-Post AttitudesIntervention vs. control Chi Square Analysis

22. Discussion • Misconceptions about HIV transmission overestimate the risk of transmission, but this did not make participants more likely to be tested. • May be explained by the effect of stigma. • Misconceptions about who is affected lead to reduced perceptions of risk • Increasing knowledge by reinforcing accurate beliefs about transmission of HIV and HIV risk may increase willingness to be tested among Latino behavioral health clients. • While no causal relationships can be inferred between beliefs, stigmatized attitudes and HIV testing, findings need for experimental research to determine whether modifying these beliefs and attitudes would influence testing intent.

23. Lessons Learned • Latinos still report engaging in risky unprotected sex contributing to health disparities and disproportionate HIV/AIDS and substance abuse prevalence and incidence rates. • Hispanics do not perceive to be “at risk” or are not aware of having a problem • Latinos have a disproportionate rate of substance use (alcohol, marijuana, cocaine) • Low levels of perceived risk may be contributing to “pre-contemplative stance” and resistance towards change

24. Future Steps • Use of Stages of Change Model to increase Hispanics’ readiness to seek treatment and prevention services. • Through Stages of Change motivate individuals to be well informed about getting tested and results. • Increase awareness of risk factors • Individualized one-on-one home interventions to dispel erroneous beliefs that contribute to stigmas attached to those individuals

25. Question / Answer