Network-, Setting-, and Community-LevelHIV Prevention Strategies for Asian / Pacific Islanders:
Data from Peer Educators at theAsian/Pacific Islander Coalition on HIV/AIDS
Hirokazu Yoshikawa, Ph.D.
File in PDF Format
December 1999
I would like to thank JoAnn Hsueh, Elisa A. Rosman, and Patrick Wilson for both research assistance and co-facilitation of focus groups and workshops associated with this project. In addition, I would like to thank John Chin, Jen Haejin Kim, C.N. Le, Therese Rodriguez, and the Coordinators of the Education Department projects (Lance Dronkers, Li Ma, Javid Syed, and Bert Wong) at the Asian / Pacific Islander Coalition on HIV/AIDS for their generosity and help with organizing the data collection. Above all, thanks to the peer educators who took part in the study for sharing their expertise and for their dedication to the health of Asian / Pacific Islander communities in New York City.
Please contact Hirokazu Yoshikawa with any comments or suggestions: Department of Psychology, New York University, 6 Washington Place, Room 279, New York, NY 10003; e-mail hiro@psych.nyu.edu; phone (212) 998-7826; fax (212) 998-7781.
TABLE OF CONTENT
- Introduction
- The Organizational Context: Primary Prevention of HIV Infection at The Asian and Pacific Islander Coalition on HIV/AIDS (APICHA)
- Methodology
- Success Stories and Their Underlying Prevention Principles
A. Tailoring Prevention Strategies to API Cultural Norms
B. Targeting Social Networks for Prevention
C. Targeting Settings for Prevention
D. Community-Building for Prevention - Predictors of HIV Risk Specific to the Experience of Immigration
A. Factors in the Country of Origin Pre-Immigration
B. Acculturation Factors Post-Immigration - Predictors of HIV Risk Common to Multiple Segments of the Asian / Pacific Islander Communities
- Predictors of HIV Risk Specific to Particular Segments of the Asian / Pacific Islander Communities
- Implications and Suggestions for Prevention Practice
- References
- Appendix 1. Focus Group Interview Protocol
Introduction
This report presents results from a focus group study of all of the peer educators in the Education Department at the Asian / Pacific Islander Coalition on HIV/AIDS (APICHA). The aims of the project were: 1) to identify the full range of prevention activities engaged in by peer educators, and the theories of change, or principles of prevention, which guide the different kinds of work; 2) to accomplish the first aim by identifying success stories from the work of the peer educators at APICHA, or stories of instances in which they felt behavior change occurred or may have occurred; and 3) to identify factors in the area of immigration, acculturation, and culture which affect the prevention work of APICHA peer educators working with different Asian / Pacific Islander communities in New York City.
Through this study, it is hoped that a range of culturally specific theories of change, or principles of prevention, have been identified which may help APICHA further clarify and refine its prevention efforts. To accomplish this goal, the process of collaboration in conceptualizing, implementing, interpreting, and disseminating the study and its results was carried out as much as possible in a capacity-building manner (see Methodology section below for information on how this collaboration developed).
It is also hoped that this report may prove useful to other AIDS service organizations working with Asian / Pacific Islander populations in the U.S. Finally, the resulting data are intended to add to the scant knowledge base concerning effective HIV prevention strategies for API communities.
The Organizational Context: Primary Prevention of HIV Infection at APICHA
The following section presents the mission statements of the Education Department at APICHA, as well as those of the four component projects which make up the department. This part of the agency carries out most of the work of APICHA in primary prevention of HIV infection.
The mission of the APICHA Department of Education is to educate and empower individuals, groups, and community organizations in the API community by outreaching to then on HIV/AIDS and related issues, which can include but is not limited to discussions surrounding virus transmission, sexuality, risk reduction strategies, general health wellness, substance use, cultural understanding and anti-discrimination, mental health, and community empowerment. The Department seeks to accomplish this through street outreach, counseling, advanced education, workshops, seminars, training, recreational and social events, and other means deemed to be appropriate and effective. The Department also strives to engage in community development initiatives and collaborative projects with other AIDS-service organizations and community-based organizations that provide health and social services to the API community in an effort to strengthen our organizational ties with them and our prevention education efforts.
The Mission and Philosophy of Each Education Department Project
The Lesbian, Gay, Bisexual, and Transgender project seeks to educate and empower LGBT API about HIV/AIDS and its related issues such as immigration, homophobia, classism, etc. The prevention philosophy combines community organizing with HIV/AIDS education. The HIV education follows a health-belief model that acknowledges that people do not practice healthier behaviors until they see themselves at risk and this is addressed through the community organizing aspect of the philosophy. Through community organizing, HIV/AIDS is framed in the larger context of API queer lives. Thus community organizing is not only often the first step in creating an API queer community in which we can do our HIV prevention outreach, but it is also an important way in which HIV-related issues of racism, classism, homophobia, and immigration can be addressed more consistently within these communities. All of the prevention efforts within this project are also informed by the harm-reduction model and as such, work with the current realities of the communities, and attempt to work with them to manage and reduce their risks.
The Prevention Case Management project seeks to reduce the transmission of HIV/AIDS and improve the living and working conditions of API communities. This goal is accomplished by conducting culturally- and ethnically-sensitive outreach and education on HIV/AIDS prevention; developing and conducting workshops that correspond to communities needs; providing risk reduction counseling for members of API communities to reduce the risk of HIV/AIDS transmission; and providing referrals for clients to other social and health services in the New York City area.
The Young People’s Project seeks to educate and empower young API people about HIV/AIDS and its related issues (homophobia, ageism/youth empowerment, immigration, classism, racism, sexism, general health, gender image, self-esteem, etc.). The prevention philosophy combines HIV/AIDS education with community organizing and youth empowerment. The HIV education follows a health-belief model which acknowledges the reality that young people do not practice healthier behaviors until they see themselves at risk. Young people often feel immortal because of their youth and may behave brashly or impulsively, sometimes ignoring the long-term effects of their actions. They can also feel frustrated and discontent with the responsibilities that family and community place on them and disempowered by the lack of trust by adults. Through community organizing, HIV/AIDS is framed in the larger context of their lives. In this way, community organizing becomes the vehicle for youth empowerment and organizing in which HIV prevention work can be accomplished, along with an acute awareness for the social and health issues that face young people and their families.
The Women’s Project seeks to educate and empower API women in the New York City area on safe sex, economic oppression, and immigration issues as well as other women’s related issues through dissemination of information, training, and organizing. It also strives to provide a forum or safer space for API women to share their experience and to support each other, with the understanding that prevention education is important and is the best method of combating and avoiding HIV/AIDS transmission and other STDs.
Methodology
Initial discussions with the coordinators of the Education Department projects and other staff at APICHA led to the formulation of the main questions of this study, as well as the decision to use focus groups as the data collection strategy. Initial drafts of a resulting protocol were shared with the staff and coordinators, and subsequently revised. See Appendix 1 for the final protocol used in the focus group interview. In addition, human subjects approval was obtained from the Institutional Review Board at New York University.
All peer educators at APICHA who had worked for the agency for over six months were invited to participate in focus group interviews in the spring of 1999. Of 44 invited, 36 accepted. The focus groups were 90 minutes in duration; each participant was paid immediately following the interview. The focus groups were conducted within project, so for example one focus group each was conducted for peer educators from the Youth project, the Men’s project, the Women’s project, and the GLBT project. Five focus groups were conducted in total (with two focus groups in the Women’s project, one conducted in English and one in Bengali). The focus group in Bengali was translated on the spot. Two interviews were conducted as individual interviews, due to time conflicts.
Immediately preceding the focus group, a short questionnaire collecting demographic information was administered. All participants signed informed consent forms. Rules for discussion were presented to the participants (e.g., exclusion of certain topics such as potential undocumented status of target clients or peer educators, or staff / administration issues within the agency; the need not to speak at once).
All focus groups were audiotaped, and then transcribed. The quotes included below are drawn from the transcriptions. Any information that might identify an individual peer educator has been changed.
The results of the focus groups were presented to APICHA staff and peer educators in two workshops conducted in the fall of 1999. In these workshops, examples of success stories and their associated principles of prevention were presented by the research team from New York University. In addition, further examples of success stories were distributed to workshop participants, who developed their own interpretations of the stories and drew implications for their prevention work during small-group discussions. The results presented here are thus co-constructed interpretations, with input in many cases from both researchers and agency staff.
Results will be presented in five sections, with the first two sections subdivided further:
I. Success Stories and Their Underlying Prevention Principles
A.Tailoring Prevention Strategies to API Cultural Norms
B. Targeting Social Networks for Prevention
C. Targeting Settings for Prevention
D. Community-Building for Prevention
II. Predictors of HIV Risk Specific to the Experience of Immigration
A. Factors in the Country of Origin Pre-Immigration
B. Acculturation Factors Post-Immigration
III. Predictors of HIV Risk Common to Multiple Segments of the Asian / Pacific Islander Communities
IV. Predictors of HIV Risk Specific to Particular Segments of the Asian / Pacific Islander Communities
V. Implications and Suggestions for Prevention Practice
Many of the efforts in HIV prevention in the United States have historically consisted of one-on-one street outreach, and small-group interventions (National Institutes of Health Consensus Panel, 1997). Theories of behavior change used to guide HIV prevention efforts have accordingly been primarily individual-level theories, describing individual-level processes. Examples of such theories include the health belief model, the theory of reasoned action, and theories about self-efficacy to engage in safer sex or other HIV protective behaviors (Ajzen & Fishbein, 1980; Bandura, 1986; Kirscht, 1988). These theories have proven useful in guiding small-group interventions.The individual-level theories of behavior change, however, have limited relevance for other kinds of prevention work, such as those which target social networks, settings such as bars, social organizations, and stores, or entire communities. In addition, many have argued that these theories do not take into account the diversity in cultural values, beliefs, and attitudes regarding HIV in racial/ethnic minority groups in general, and Asian / Pacific Islander populations, in particular (Chng, Sy, Choi, Bau, & Astudillo, 1998; Choi et al., in press; Marín, 1995; Nemoto et al., 1998; Wong, Chng, & Choi, 1998).
The results of the current study, based on focus groups conducted at APICHA, suggest that the theories, or principles, driving prevention work among the peer educators in APICHA’s Education Department are much more wide-ranging. They differ from the mainstream theories mentioned above in their emphases on 1) cultural norms among API immigrant communities, and 2) contexts, such as networks, settings, and communities.
Cultural norms, beliefs and values among Asian / Pacific Islander populations shape the kinds of prevention which peer educators undertake. Many examples were found in which prevention strategies were tailored to such cultural norms; for example, the use of strategies which respected the value of privacy concerning sexual matters in many East Asian and South Asian cultures; the targeting of settings congruent with health goals (pharmacies) in Chinese immigrant communities; outreach materials for South Asian lesbian communities which incorporated information about the history of lesbianism in India.
In addition, some instances were found in which peer educators targeted entire settings, networks and communities for prevention efforts. Such work moves beyond the traditionally one-on-one street outreach process to engage contexts. Although research has begun to document the value of such contextual approaches in HIV prevention for other communities (Kegeles, Hays & Coates, 1996; Kelly et al., 1998), these approaches have rarely been tried in racial/ethnic minority communities or immigrant communities. They may be especially relevant to Asian / Pacific Islander communities in that immigrant social networks among API’s are tight-knit, with information traveling quickly within them. Information and norms concerning HIV prevention could potentially be diffused among the networks.
The following sections present "success stories" of the peer educators as they illustrate cultural and contextual approaches to HIV prevention, specifically those which A) Tailor prevention strategies to cultural norms; B) Target social networks; C) Target settings, and D) Target entire communities through community-building processes.
A. Tailoring Prevention Strategies to API Cultural Norms
Respecting South Asian norms of privacy by beginning house party with non-HIV discussion
WE 378 - 387 (House Parties with South Asian Women)
[Prevention Principle: Emphasis on Privacy re: HIV and sex in South Asian cultures influences risk behavior and communication about risk; Social networks influence risk behavior;Participant: We set up an appointment. For instance let’s say [name] calls one person and she’s going to call me saying [name] we have to go this person’s house. So we make a group and we go there so [name] knows someone and that lady brings other friends her friends at her house. First we come in. We don’t suddenly start. We talk about different issues going on in family, we relax and we get hospitable. They offer us tea. And then we get on with discussing about HIV and AIDS and they ask us questions and then we talk about their own personal lives that affect them – immigration issues, sexuality issues. This is how we start.Facilitator: Why was this a success?
Participant: It’s like simple psychology. If you’re going to talk about something very private you’re not going to ask a stranger you’re not going to ask anyone, you’re going to ask someone you know. And that’s where networking comes in and that’s why I’m doubtful about street outreach.
Implication for Prevention Strategy: work with naturally occurring social networks and start with non-HIV issues of concern to population]
Incorporating Cultural and Historical Factors Explicitly into Prevention Materials for API Queer Populations
Example from SLAAAP (Sexually Liberated Asian Arts Activists People) project, in which prevention materials were developed for API queer people by a coalition of prevention activists and artists:
Facilitator: How were those links made on the actual materials between those kinds of other factors like exoticism or immigration issues or those kinds of things and HIV risk?
[Prevention Principle: Incorporating issues of identity, history and culture explicitly in prevention materials may increase their relevance to API communities;Participant: One card was on exoticism. And these two guys are in this bar and this White guy is trying to pick up on him and he says something to them like, "So which one of you fly dragons is going to take me on the Orient Express tonight," you know, and then they look at each other, these two Asian men, and they say, "Oh, it's exhausting to be exoticized," and the back says you don't have to be disempowered, you can connect with other people of color, queer groups, so you can find support through community, and if you're a stronger more energized person, then you're more able to take care of yourself physically, so those are the connections we made. And then one of the cards had to do with just isolation, and this woman who can't find anything, can't find any information on being a lesbian. And so then she finds a book not only on being lesbian, but on being South Asian and lesbian, and the history of lesbianism in India, you know, and so she's able to inform herself and empower herself that way.
Implications for Prevention Practice: Incorporate culture-specific topics into outreach materials for each particular API community being targeted]
Respecting Norms of Privacy in Choice of Workshop Strategies
GM 217 (Prevention Workshop with API Gay Men)
[Cultural Factor: Emphasis on privacy re: HIV and sex in East Asian and South Asian cultures influences risk and communication about risk among API gay men;I found that to be the case when I did my first workshop, which was with the Long Yang club and hardly anyone asked questions, and it's a mixed group as far as Asians and non-Asians, and it was primarily non-Asians who were asking questions. Ummm, when I did the workshop with GAPIMNY, we actually had them write out the questions on cards, index cards, which allow people to ask more questions, and that seemed to work a lot better.
Implication for Prevention Strategy: Use media strategies in which privacy is retained]
Culturally Specific Packaging of Condoms and Brochures
SM 114 (Packaging of Condoms and Brochures)
[Prevention Principle: Cultural norms are related to receptivity to prevention materials.Participant: Before we distribute condoms always by pink paper or purple paper. Wrapped. A lot of people are not interested. After, when we use red box, like the Chinese New Year. Distribute the condom.Facilitator: Then people took them?
Participant: Yeah. Give them good luck.
Implications for Prevention Strategy: Utilize within-ethnicity cultural norms in social marketing of HIV prevention]
Cultural Norms Respecting Doctors for Medical AdviceSM 722 (Outreach at clinics)
[Prevention Principle: API cultural emphasis on trusting medical authorities indicates suitability of doctors for diffusing HIV prevention messages;Facilitator: You said something about more recent immigrants might be more willing to listen to doctors?Participant 1: Just that everybody will listen to a doctor. Because, a doctor has the education, so they know.
Participant 2: They are not in Asian, only Guyanese, so when I give them the English brochures, and, sometimes they ask me to leave the condoms. And sometimes they call me, "Mr. Doctor, give me some condoms." They are calling me as a doctor.
Facilitator: So they think you're a doctor?
Participant: Yes. One of them I went 3 or 4 times in neighboring hospital clinic in Manhattan in 14th Street or something like that, you know, over there, and he's calling me the doctor, how are you? Come, I have to go in the doctors. He call me the doctor, and he has to go to the doctor. I said, "I am not doctor." And he say, "No, I know that you are not doctor, but you are doing like doctor."
Implications for Prevention Strategy: educate API doctors, doctors working with API populations to communicate prevention messages, or highlight other health-promoting functions of peer educators]
Appeal to Norms of Protecting Family and Community as a Prevention Strategy
WB 206 (Workshops for South Asian Women)
[Prevention Principle: Protecting family and community may be compelling reason to reduce risk among API immigrant communities;She explain the same thing, sex is not only the reason, there could be a different ways to get this virus, at that point they became interested. When she attended workshops so then woman deny a little bit they don't want to hear it, but then at the end they understand this is for their family their own community, so they think that we should [?] This kind of outreach keep going on people with experience should be doing the same thing over and over again, then the community may be ready even more. They learn it more.
Implication for Prevention Strategy: Appeal to protecting family and community in prevention activities]
Becoming an Insider to Social Networks Prior to Prevention WorkB. Targeting Social Networks for HIV Prevention
GM 352 (Prevention with Transgender Sex Workers)
[Cultural Factor: Strong boundaries of social networks exist among networks of TG sex workers;I'm talking about TG sex workers, but they basically, I think for them to really, you know, come to me and to start asking is, I have to become their friend first. You know, I have to step into their group setting situation. You know, I'm sure there's like Filipino groups and Thai and all that groups is there, I know that, but I have to kind of be part of them. And then they will start talking to me, by the way, how's that, how's this. And that, if I could create that, probably that would be the best situation I can create to talk to them.
Prevention Principle: Social Networks in Communicating Prevention Messages;
Implication for Prevention Strategy: Infiltrate social networks, perhaps by recruiting members of a variety of networks to become prevention activists]
Becoming Known to Social Networks Through Repeated Contact: Example 1
[Prevention Principle: Social networks influence risk behavior among API women; Implication for Prevention Strategy: become known to social networks personally, rather than having one-time interactions with individuals on the street] Becoming Known to Social Networks Through Repeated Contact: Example 2I think networking is really really important. And not just follow-up. When you present let's say hi my name is Sonia or whatever, they connect you with APICHA. It's more effective so when they actually want to ask about safer sex / HIV / AIDS or if they want to be referred somewhere else for testing or for whatever reason the name sticks. It's not just I'll call APICHA.
GM 15 (Prevention with Bangladeshi Cabdrivers)
[Prevention Principle: Social familiarity facilitates communication of prevention messages;But, I mean like, there are times when I do see them again, and then they'll tell me that they are having, like, safer sex or got tested or something like that. And, there's a behavior change. Because I do the same areas everyday, and sometimes you do meet them again. And, they'll tell you or they'll ask, they'll come up and ask for condoms and say, you know, that they read the materials or, you know, you talked to them and they had. They thought about it, it's something they didn't think about before, they had like a behavior change, like where they started using condoms, one, or like maybe two, started using say water-based lube, things like that.
Implication for Prevention Strategy: Repeated contacts with same group]
Utilizing Friendship Networks in HIV Prevention for API Youth
YT 26 (Outreach near High Schools)
[Prevention Principle: Social networks (friendship networks) influence risk behavior among youth;Participant: I agree with them because it's like okay if I was going out there to give out pamphlets and stuff, they would like take it, but you don't know what they're going to do with it, but if I was speaking to my friend at school, like a genuine concern they understand they know that I'm out there look out for them, so I think they will look more into what I'm telling them, instead of a stranger giving them stuff on the street, it's like they're just doing this because it's their job you know they're getting paid. But if it's like with my friends they know it's my genuine concern.
Implication for Prevention Strategy: target social networks, rather than individuals on the street]
Building Trust in Relationships with Social Networks for HIV Prevention
YT 244 (Outreach near High Schools)
[Prevention Principle: Social networks (friendship networks) characterized by trust influence risk behavior among youth;Participant: I've made friends and they are interested in working for APICHA, we give them the number and stuff and yeah.Facilitator: And so when they come back and talk to you, you think you've really made an impact, like can you tell from...
Participant: Yeah, I think that we're on that level where there is trust, where if I were to tell them something and such, it's not like I'm getting paid for that. I care for you, that's why I'm telling you, so we've gone to that next level.
Facilitator: How do you build that trust? Is it because you see them over and over again?
Participant: It's a friendly face, you know we see each other everyday, not everyday, but usually...[laughter], yeah it's a friendly face, we hold different conversations, it's not about sex. We talk about other things first and then it all leads down to what I do and what I can do for you and if you have any questions, you can ask one of us.
Implication for Prevention Strategy: target friendship networks, rather than individuals on the street]
Empowerment as a Prevention Strategy: Example 1
WE 206 (Workshop for API Women):
[Prevention Principle: Empowerment for women and increasing their communication skills in their families may influence HIV protective behavior;I don't directly say "Come I will now be doing a presentation on HIV." Nobody will come. But if you say it will be something like this like that presentation about awareness program you first do things which you think are very interesting to them. Like now we have the Census 2000. I present that first. So I go to that one I deal with empowerment. Until later on what is empowerment in your family? What is empowerment between the wife and the husband? What is empowerment among the children, if you have more than one or two children? So later on they will be gaining a lot of things about empowerment how a woman can say no if she really does not like it. Because you have already given them a background on communication skills.
Implication for Prevention Strategy: Start with other kinds of empowerment before addressing empowerment in the context of negotiating condom use]
Empowerment as a Prevention Strategy: Example 2WE 97-120 (House Parties for Bangladeshi Women)
[Prevention Principle: Empowerment for women in the context of their relationships can affect their HIV protective behavior;I conducted a workshop seminar in one of the houses of a peer educator (Bangladeshi). The husband also is a peer educator among the men. Now what they did was to invite husbands and wives to attend the workshop seminar. But what they did with [name] was we separated the men from the women. Thinking that there will be some reservations from one party or from the men or they won't talk because the husband is there or the wife is there. And so we had a very interesting discussions. . .Now after that then we had the dinner then there was interaction between the husbands and the wives! And after a lot of interactions we said next time we'll have a workshop seminar where both the husband and the wife will be there.[At the workshop for husbands and wives together:] I tried even role playing. On how to use condoms for protection, how do you to convince your husband so you will be protected. I had a contest for how to use the condom and how to put on the condom. And the pair who first demonstrated rightly will get a prize! We did it so nicely -- it's motivation!
Implication for Prevention Strategy: work on empowering women with men present]
Addressing Parenting Concerns to Facilitate HIV Prevention within Family Networks
WB 472 (Prevention with South Asian Mother)
[Prevention Principle: Parents’ communication skills shape their ability to affect risk behavior of children;Participant: I talk to her: be free with them, be free talk to them with the subject, what they're doing, what they're going, how our society get the disease, then they will not hide from you, if something happen she is going to do something, this way she is okay. Because I know myself I used to, I have kids, from childhood, I didn't know about AIDS, I didn't know about because I make them build them up that way that so that they have something to hid, but they don't want to hid, when I am going to be frank with them I explain to them I talk to them any topic any subject I told them if anything happen, you can ask him, don't hesitate, so this way children will be frank.Facilitator: So that woman that you were talking to did she then now she talks to her
children about it.
Participant: Yeah, now she's talking, now they are good shape, they're very happy.
Implication for Prevention Strategy: Incorporate work on parenting skills in prevention work with parents]
Effects of Peer Education on Peer Educators’ Own Families and Social Networks
WB 464
[Prevention Principle: Becoming a change agent influences peer educators’ approach to HIV prevention in their personal networks and families;No I talk to my son about one day when we finish the training, then one day, I tell him, do you know what kind of job I just finish, he said no, so I told him each and everything about HIV virus, how this thing spread out, after that he is really thinking something oh my god, and he feel shame, because I talk to him each and every way, like anal sex, like everything, and he I saw he feel shame, because my mother can talk like this, oh my god. And after that I told him because he's a big boy now maybe sometime you fall in love with other girls, but if I told you don't go for too many girls, you never listen to me. But try to do the safe sex.
Implications for Prevention Strategy: Have peer educators share these personal experiences, as role models, in their outreach work]
- Targeting Settings for HIV Prevention
SM 6 (Outreach in front of pharmacies in Chinatown)
[Prevention Principle: The match between setting’s goals and HIV prevention goals influences its suitability for prevention activities in Chinese communities;I use the outreach and first of all, I have to talk about, it really depends on the environment. It could be a pharmacy store in Chinatown would be different from the grocery store in Chinatown because, the pharmacy, the people come in with tendency to rely on the pharmacist because they have a tendency to come to the pharmacist needing some kind of medication, so if you're doing outreach in front of the pharmacy or inside the pharmacy, people pay much more attention than if you do it in the grocery store.
Implication for Prevention Strategy: Target settings associated with health]
Targeting Asian dance clubs as settings for HIV PreventionYT 142 (Outreach in Asian clubs popular with youth)
[Prevention Principle: Degree of saturation of a setting influences ability to bring about risk reduction in all members of the setting;Participant 1: No you know I think that APICHA went a really long way because APICHA is a really familiar name in the Asian community, because we go clubbing and stuff, and everybody's there in clubs, we don't just go to one specific club, we go to all the Asian clubs, so we're very known in the Asian community. . .I think that club outreaches are really effective. I mean basically when they're coming in, give them brochures and condoms and by the time everybody gets in, I pretty sure everyone has a condom. . .Participant 2: It's good that we give everybody condoms at clubs, because usually they get laid afterwards, [inaudible] and the condoms come in handy.
Implication for Prevention Strategy: Employ methods that ensure that majority of target population in a setting receives prevention message]
Targeting Apartment Buildings as Settings for Prevention
WB 141 [Networking among Bangladeshi Women in Multiple Settings]:
[Prevention Principle: Targeting Entire Residential Buildings for Prevention May Lower Levels of Risk Across the Entire Setting;Translator: So she is living in this area about five years in Elmhurst right here, very near, so when start working at APICHA, there were a lot of neighbors in her apartment, a lot of Bengali people, so they start talk ask her where to do you work. So when she said that I work at APICHA and I works on HIV/AIDS, and then their children were prevented to come to her apartment. . . They were saying that she works with AIDS, so she should not be living at that apartment at all. That kind of thing. . .So she keep on working and explaining them, several woman she took into another workshop, the person was here, she had a workshop and she took those woman to there, and assured them, I really do not work with the HIV/AIDS patients, I work, I try to [inaudible] so that the virus will not spread. Then they used to come and took the condoms, some of them.Facilitator: And these were women in the building?
Translator: Yes. She took the womans invite here different parties, marriage parties, restaurants, so she used to go there and with her flyers and condoms, and they also learned that way.
Facilitator: So your friends were helping you in a way.
Participants: Yes. [Agreement]
Facilitator: And then did that spread to other people in the building?
Translator: Yes. . . They understanding that by touching you cannot get that, you know hearing it over and over going to some workshops, then they got a little bit less scared.
Facilitator: And then did any of the people in that building, do you think their risk behavior changed? For instance, did they start to use condoms?
Translator: Yes, she thinks several of them. Whatever I know from talking to them, and whatever they told me, I think some of them have started to use condoms.
Implication for Prevention: Saturate settings which are associated with high levels of risk behavior before moving on to next setting]
Targeting Groups of Settings for HIV Prevention: Example 1
WE 290 - 317 (Work with Network of Sex Work Establishments)
Participant: I worked with [name] and I go to my clubs I go my places. You do not go there early in the evening, but you go there late in the evening. And the managers call me Mrs. Condom.Facilitator: Are they welcoming? Do they welcome you?
[Prevention Principle: Role of multiple levels of organization in influencing risk behavior; Implication for Prevention Strategy: work with multiple levels of organizations of which target population are members Targeting Groups of Settings for HIV Prevention: Example 2Participant: Yeah because first what I did was I worked with the managers. I talk with them. I talk with the managers. I introduce myself what I do. I know that you have some women who belong to the Asian communities working with you, and I want to help them and to help also your business. . . The manager is interested because there's no need for him to buy the condoms and give to these women. So they say OK. Just put something there and maybe you can come back a couple of days and I'll tell you what transpire there after leaving brochures and phone numbers.Facilitator: And were there any cases where the sex workers started to use condoms more or demand that clients use condoms?
Participant: Yeah. . .Because they are into the prevention the education, they're not doing it. They stopped the work already.
SM 33 (Work with Network of Bangladeshi Grocery Store Owners)
[Prevention Principle: Diffusion of prevention messages through leaders in community settings;Participant: Reason is, they are scared from their friends, their relatives, their society, so they don't like to take the condoms in open. That's why, I put some condoms in different stores so owners and they are taking from the owners. Sometimes they are not taking from us, okay, I have family members, or I am not family members, please give me. But, mostly we are distributing in Bangladeshi community through the stores' owners.Facilitator: So when you go back to the stores and you've put condoms or brochures there, you find that the, you go back maybe a week later and some people have taken those?
Participant: Yes. The condoms I put in 37th Avenue, one grocery store, and I put in ten condoms, and yesterday I went over there and I find only one condom.
Facilitator: So, you educated the owners first?
Participant: Yes. First I'm going in the different stores and asking the owners and, the same time, who are coming to buy materials, goods, shopping. So, they are asking me, what are you doing, why, and then I explain that our organization we are helping to the people about the HIV prevention and AIDS, if anybody infected, we are trying to help them. And, they are listening, and we are distributing the brochures.
Implications for Prevention Strategy: Identify settings in which diffusion can take place while retaining privacy]
4. Community-Building for HIV Prevention
Community-Building Through the Creation of New Social Settings:Persimmon Space
Participant:So, she and some other people started doing a lot of community building, and, which is extremely effective, you know, and what we discovered was that there was an interest in discussing HIV and STDs and general wellness among queer women.
Facilitator:
[Prevention Principle: Creating Social Settings and Spaces for Community Building Facilitates HIV Prevention;Could you give me some examples of how the community building happened?Participant:
Well, first I guess by sort of piggybacking with other organizations like Kilawin Kolektibo, which is the Pacific Islander Filipino Lesbian organization. . .So, to start with, Persimmon Space started outreaching to people in these organizations, and then started holding events for queer Asian/Pacific Islander women, which were incredibly well received. I mean, it was one of those things where they decided to see if there was interest, and it was shocking how much interest there was.. . .Most of the events in the past year and a half have been held just in spaces where we can find spaces, in galleries or one of the women works for, I don't know what it is, I guess it's some artist's space, a photographer's space, and so we've had a series of gatherings there. And, they just kind of take shape as they happen, you know, there's food provided, and there's generally music, and people just having the chance to come and mingle is really exciting, and then Persimmon Space and APICHA make announcements, make sort of a presentation, and then the different groups can make their announcements and then, like, the last one, there' s a woman who works at APICHA who's made some movies, and they showed those movies, and then they hung out and they played games, and they sort of turn into these informal focus groups, as well, to get more information.
Implications for Prevention: Create spaces, settings, and events which have a social and community-building focus]
Community-Building Through the Establishment of Prevention Activist Coalitions
SLAAAP (Sexually Liberated Asian Arts Activists People)
Participant: so this group of people came together, and we tried to figure out a time that we could meet. And we had long meetings. I think we had 4 hour meetings to start with, and then they became like 6 hour meetings and more frequent, you know. It was basically just a thinking group, and we would come together and put issues on the table and work through them and figure out what we wanted SLAAAP to do and what we, what holes we felt there were in the kind of education that was being done amongst queer Asians. And what we discovered was that HIV, we felt, was just one of many issues. And that there were all these other things that kept people form thinking about HIV, you know, that it can't be a concern, for example, if your immigration status is in the way or it can't be a concern if you're really really upset about breaking up with someone at that time. You know, that all these other things had to be addressed. And I think the way SLAAP was most productive for me was that that whole process changed the way I thought about doing HIV prevention outreach. And I think that was the case for everyone.
Community-Building Through Increasing Contacts with API Queer Communities Among Men Who Have Sex with MenIt was really more towards the end, you know as we were actually laying out what we wanted to talk about that [name] kept reminding us, this is HIV work, you know, don't forget we have to focus on ethnic diversity and all these things. And, I think at that time, I was surprised at least to find that the connection to HIV/AIDS was not too far way.
GM (Ind) (Prevention Case Management with Korean MSM)
[Prevention Principle: Complex process of connection to Korean gay community – beginnings of gay identity formation – changes in self-esteem – access to sources of information re: HIV/AIDS -- may lead to changes in risk behavior.Participant: I usually had worked on Wednesday from 3 to 5 o’clock for 2 hours – almost every week he called me and then he just talking about his life and his relationship with his wife and other questions about safer sex and HIV because he was a little bit afraid of going out to gay bar or other so-called gay place because he might be known by some other people. So he was very scared to go to open gay place. So he only hang out at cruising park – Astoria or Central Park. He usually just do sexual acts – masturbation or oral sex in the park. He asked a lot of questions about his life – kind of divorce, then sexuality, then gay community, and Asian gay man, then safer sex, HIV and STD. Actually we asked him to come to [CBO] office to just get a more accurate information about HIV and STD. So he came to [CBO] and then [name] and I had a meeting more than 1 hour. [Name] gave him general information, safer sex guide, STD guide. After he was very relieved after hearing about HIV/AIDS. He learned that mutual masturbation and oral sex could be risky for STD or HIV so after the meeting he said he started to use condoms when he did oral sex and he became more careful about mutual masturbation because there are some kind of STD that are transmitted by mutual masturbation.Interviewer: Do you feel that the benefit he got from talking to you was in part the connection not only to information about HIV but also connection to the gay Korean community?
Participant: Sure. To see other Korean gay people, just living in New York City. It’s a very simple fact but it’s really hard for people – for those live in the closet – they really want to see Korean gay people but usually it’s very difficult to get into the person and the gay community.
Interviewer: How do you think for him learning about being gay and Asian / Korean was related to changes in risk behavior?
Participant: Yeah I think so because he said he used to feel like when he saw people in the park seems like people hanging there have kind of low self-esteem kind of dirty. Seems kind of not healthy situation. But when he saw healthier or more out gay community- gay people – whenever he had questions he could connect. Because he now had access to the gay community. That was important in terms of support – network – peer counseling.
Implications for Prevention Strategy: Increasing involvement with API gay community over time may reduce risk]
Community-Building Through Peer EducationYT 429
[Prevention Principle: Becoming a change agent influences peer educators’ sense of empowerment;I think that peer education is a great experience, I think that what we know, I think that a person who has to be in a situation as a peer educator would understand. I'm so for safe sex and these things, I'm so for it. We have workshops, and everything. I think that most of the teens out there, I think that they should apply for a peer education job cause that's a great experience, you got a lot out of it. Well I did, so.
Implications for Prevention Strategy: Recruit more of target population to become prevention activists]
Community-Building Through HIV Prevention on the World Wide Web
[Prevention Principle: Social networks on the Web provide privacy which can facilitate diffusion of prevention messages;YT 269Oh, I had that experience, but not physically outreach. I do it hook on email, it was funny because one time my friend just wrote me a basic question about STD and I just pretty much pick up a brochure that APICHA has and I typed it to her. And she forward it to couple of people, and those people that she forward to, ask me question. Which is funny, they don't really know me. They don't see me as this person who is providing them with health info. I think that there is a safe, I can get the information without seeing the person's face. And I still keep in contact with the people who she forward it to, I don't know who they are, and I don't know what they look like. All I know that they go to different university in upstate and that's all I know, and basically sometimes, I identify [?] but they just ask, HIV prevention work.
Implications for Prevention Strategy: Take advantage of rapid connections between social networks on the Web]
II. PREDICTORS OF HIV RISK SPECIFIC TO THE EXPERIENCE OF IMMIGRATION
One major way in which HIV prevention models for API communities must differ from those developed for other groups in the U.S. is in consideration of the diversity of API immigration experiences. Some evidence suggests that recency of immigration is associated with lower levels of HIV knowledge among API populations. However, there has been little work which takes into account factors which may be specific to different stages of the immigration process, such as factors in the country of origin pre-immigration, and acculturation to multiple communities post-immigration. The populations targeted by APICHA are distinguished by a huge range of experiences pre-immigration related to HIV/AIDS and more general health outcomes, as well as predictors of such outcomes. They are also characterized by great diversity in acculturation to multiple communities in New York City, including the various API post-immigrant communities, women’s communities, ethnicity-specific queer communities, mainstream queer communities, and geographically defined communities. Each of these kinds of communities has their own set of social norms of HIV-related knowledge, attitudes, and behaviors.It is likely that experiences post-immigration in the U.S. interact in a complex manner with experiences pre-immigration to influence present HIV risk and protective behaviors. However, there are virtually no data available concerning the influence of immigration-specific factors on HIV risk or protective behaviors on any API immigrant populations. The current study presents some of the first qualitative data on both pre- and post-immigration experiences, as they may relate to HIV risk and protection. The following portion of the report presents this data, in two sections: one detailing factors in the country of origin (pre-immigration), and one detailing acculturation factors in the U.S. (post-immigration).
Urban vs. Rural OriginA. Factors in the Country of Origin Pre-Immigration
Among South Asian women (WE 475):
Participant 1: Women coming from urban areas they are different from those that came from the rural areas. . .The rural women who are coming from the countryside it takes time for them to open their mouth and say something about condoms about sexuality. Most of the time they are just sitting down they are just listening [in workshops].Facilitator: Why do you think that is? Why the difference between urban and rural women?
Participant 2: Education.
Among Bangladeshi men (SM 706):Participant 1: It's not exactly education -- it could be exposure to the environment. Because the urban cities are more exposed to nightclubs to activities over there. Over there in the city [Manila] they were more advanced in disseminating information about this and at the same time they are more exposed to a more busy environment.
Among Cambodian men (SM 714):Difference is, like in our country [Bangladesh], the capital, it is in lot of different countries, people are living in over there. The village people only [inaudible] local people. So that, doesn't know what the contact with the foreigners. The capital, there are lots of countries that have embassy office, missionary office, any other NGO office, and charity organization, they are coming, a lot of foreigners come and they are talking, and they know the people. Number two is, they are educated, they are serving, either government or commercial or whatever. But the village people, they are in solitary in limited area.
You know, I read the newspaper from Cambodia and, most people, they got AIDS in the city. But, now, more people they got AIDS in the countryside, because in the countryside they don't get educated about AIDS, so it's easy for them to get AIDS.
Educational Attainment in the Country of Origin
WE 528 (Women’s Project)
As far as I know in the Chinese community it depends on the education level. The higher the education level the more easier you can discuss. Because I think it's more understandable for them. But for people from rural areas from for example Fujian whatever they not legally come to this country those people seem not well educated. But anyhow what I encountered I feel that most of the people I encounter through my church they are mostly well educated. I feel the more education level, it's very easy to communicate with them.
- Acculturation Factors Post-Immigration
SM 646
Retention of norms from country of origin re: unsafe sexSometimes in our country [Bangladesh], people, just say, "HIV, they are disease." They are making mistake, because that say that HIV is a disease. I say, "No, HIV is a virus. It is not a disease. AIDS is a disease." So, like in the same, when they are coming over here, they are confused, because their own country, the government or organization, they are not probably forecast about what is the difference between HIV and AIDS. When they heard about the AIDS, one kind of disease. But, doesn't know, how it is infected. So, when they are coming over here, one or two or three years later or in six months or three months they could know it. Because they read the paper or radio news or television news. They watch it and they could realize how is infected.
Among Japanese gay men (GM 689):
Retention of norms from country of origin regarding HIV/AIDS and sexualityParticipant: Japanese are not well educated in that sense. When it comes to the using a condom, especially, you know, young ones. They really don't know.Facilitator: And these are men who did start having sex in Japan?
Participant: Yeah, and then coming here. . .Scarily, but a lot of them not using the condoms. There especially. It's like almost like a taboo to use it. It's more like, their mentality is like using a condom is like telling the other person that you have something.
Among Korean gay men: (GM 2:220)
Among South Asian immigrant adults (SM 671):Education system in Korea is very bad we don't have any sexuality education in Korea. There's a lot of incorrect information about HIV/AIDS and just that's too bad because Korea only 20% of people in HIV are homosexual but still the Korean government say HIV is a gay disease. So they don't care about 90% heterosexual population, they're only targeting the gay population. HIV/AIDS as gay issue. Also they don't know how to use condoms. Just so sad in Korea. People who've grown up there in Korea and immigrate to the U.S. when they have communication or relationship with American people, whether Asian American or other American people, I guess they might have difficulty in communicating with them in terms of sexuality or HIV.
Acculturation to mainstream gay community’s norms re: safer sexWhen someone comes from their own country in the United States or in some Western countries, they are looking about the teenager or in man or woman, older, or in middle age or, whatever, they are giving the kiss, but that does not happen in their own country. Kiss, like in the subway or somewhere. They watch that one. Like one student he came from another country he will see that, oh, the two teenager, they are holding each other and giving kiss. That does not happen in his own country. . . and the parents, even if his parents are over here, he think, it will take time to change his mind. It is not accepting his culture. When he coming over here, it is in open, it is free, so he is confused. That's why the new person when comes, he doesn't know nothing. He step by step and slow and steady, he knows something.
GM 760
Entry into different social settings as part of acculturation processesYou asked a little earlier as far as like whether there's a difference between foreign born and American born. I do think there is, especially for, I came out as part of like an American -European gay identity and system. And, me & my peers that are, I have found to be much more willing to use condoms and to carry them around with us, and, because of the whole drive in the 80s to make condoms and safer sex a community standard within the gay community. And now, I want to make it clear I'm talking specifically about the gay community, which is not necessarily the Asian gay community, but the gay community in general, and not an MSM community, if there is such a thing. . .That's not to say that there haven't been breakdowns in that community standard, especially in recent years, but at least a lot of us know what the community standard is, even if they then choose not to follow it.
YT 309
There are certain things that one would do, like going to Asian clubs, I didn't know until much later, until high school, I didn't know the whole notion of going to Asian clubs existed until I started hanging out with more like either they born here or first generation. I think a lot have to do with this difference with recent immigrant group and API group that had been here for longer, just in terms of what we do socially.
III. PREDICTORS OF HIV RISK AND PROTECTION COMMON TO MULTIPLE SEGMENTS OF THE ASIAN / PACIFIC ISLANDER COMMUNITIES
The following two sections present findings from the focus groups concerning potential predictors of HIV risk which arose in multiple projects, and may therefore be common to multiple API communities, and predictors which arose only in certain projects, and may be specific to particular communities. There is little information in the field regarding predictors of either kind (for examples of such data, see Choi et al., 1998; Jemmott, Maula, & Bush, 1999; Nemoto et al., 1998). Such studies concur that, across many API communities, norms of silence regarding sexuality and HIV/AIDS exist which make open discussions of such issues difficult. Such findings are replicated here. However, in addition, the current data show that, across multiple API communities, including both gay- and non-gay-identified adults, and youth, a cultural norm equating the use of condoms with promiscuity represents an additional barrier to HIV prevention efforts. Levels of HIV knowledge and awareness are low among recent API immigrantsSM 326 (South Asian adults)
API doctors speaking API languages may be less likely to bring up AIDS during routine health visits than other doctorsYeah, I told them, you don't be scared. They suggest me stop your job, very dangerous. Not for you, for your family, don't continue work for APICHA. A lot of them suggest to me. Even on the road or when we contact the people. They think is very dangerous because we contact with them, the HIV positive person or the AIDS people. I explain with them that, don't scared. The transfer the HIV positive by the sex or the drug or the needles. After, they understand, because we have a lot of experience. A lot of people, contact all together, play all together, then they understand.
SM 773
Cultural norms of silence surrounding HIV and sexAlso, it's about what type of doctor you go to. For example, you're Chinese, you speak Chinese, you go to a Chinese doctor, they might not mention [HIV]. It know it's U.S., but if you're like American, go to an American doctor who speaks English, normally they'll tell you, when you're getting medication or whatever, they'll tell you something. Like, if you're getting a certain shot, they'll tell you, well, it's to prevent that and that, you know, diseases and to help you and that but still, safer sex, it won't do that. So, they'll try to talk about AIDS indirectly, but, you know, they're trying to tell you.
WE 355-362 (South Asian Women)
SM 553 (Cambodian adults)Facilitator: What is it about the culture or about the cultures that makes street outreach maybe more difficult?Participant: Especially people who are from Bangladesh Pakistan and India they have a big taboo about sex and sexuality and HIV carries that. The whole baggage about HIV and AIDS carries sex and sexuality. . .That those are bad and taboo let's brush it under the carpet. It's very private matter especially for Indian and Bangladeshi cultures. Let me give you an example during the month of Ramadan people don't even talk about sex. They do not talk about sex.
YT 69 (Youth)Yeah, me too, I do outreach in Cambodian store. . .Especially in my culture, it's hard to talk about sex, so I just tell them "Oh, I work in this place for health and HIV, and just take it and look and read it, and if you have any question you can come back and ask or call this number."
YT 337 (youth)Asian background we're not allowed to speak about sex and sex is probably not even a word, we don't have a word for sex in some cultures. And it's only if you're married you have sex, so it's like you know, it's how we're brought up.
YT 89Facilitator: So what's that like when you're doing the outreach and the messages in an API language, how does that feel different?Participant: It seems harder because that language that we use, like [Southeast Asian] language we don't speak about sex and it just seems so forbidden to speak in that language about sex to that person.
Facilitator: So, it's hard to find the words?
Participant: Yeah, there's no words to describe it. We have to go behind the bushes and speak about something else, [laughter] oh the birds flew in...[laughter], yeah stuff like that.
YT 369Do you know what's weird, if I go to like my friend's house, they would watch pornos together. It would be okay, but if it was in my house, in they were holding hands we flick over a channel, everybody is getting hot and heavy and I got to go take care or the kids, I got to go take a shower, it feels so uncomfortable, it is so awkward, sitting in a room watching a sex scene together the whole family. It's like it's an awkward feeling, so we just don't talk about sex in the house.
Participant 1: And usually on the weekends a lot of youths are with their parents and sometimes we are like oh should we go and give it to the youth or not because they are with their parents and that's because...
Participant 2: And usually we don't because it's we get mixed reactions from parents because some parents might be really open about it, because maybe they're really Americanized or whatever. And some parents they would take it really offensively. They be like, my daughter does not have sex or whatever and they take it to a different level.
Cultural norms equating the use of condoms with promiscuity
GM 493-497 (Gay Men)
SM 244 (Bangladeshi Adults)Participant 1: I don't know what, who they are having sex with or who they're eroticizing, but how the Western culture eroticizes East Asian, South Asian as submissive, pure, especially in the gay community as like not virginal, whatever. I think a lot of that, a lot of that has to come into play with that.Facilitator: You mean those kinds of internalized stereotypes?
Participant 2: So having a condom when you're having sex before hand, tell you you're not pure.
Participant 1: Yeah, or you're promiscuous, or, I don't know, all those kind of things...
YT 204 (Youth)Participant: In Ditmar, the one I put in boxes, and I put in some brochures and, I ask the owners to put the condoms and, he said, "Okay, not in the stores." I ask why. He said, "Our community, are not like to put the condoms and brochures in the same boxes. I could distribute it, if you have no objection. If you give me 50 or 30 or 100, I could give it. A lot of people comes in over here, I could give it." I said, "Okay, I'll give it to you." The reason is so sensitive to us they think about the religion, the family, so all the combines, they are not like to take the condoms in the street or in one-one-on or in front of any other persons. . .Usually, the religious is not accepting about free sex. That's why the people who are in conservative or the religious-minded, they are..Facilitator: Muslim?
Participant: Yes, Muslims or Hindu or whatever. It is not accepting the free sex.
Perceptions that HIV is a White diseaseOne thing that I notice during outreaches, when we do give out the brochure to heterosexual couple, they usually don't take it. I think that you know, I don't know if anybody in the group experience this, but just in terms of like I experience it, where I try to give out to heterosexual couple, they usually don't take it . . .Yeah because they want to make it look like they're so faithful, we're together we don't need that, you know we're monogamous, you know what I mean.
GM 251
And most of the Chinese population, even though if do outreach, they don't believe in this kind of things. "Oh, HIV," they throw away,. "Oh, my husband would never do that." Or, "my son never do this." But, in real life, her husband has affair with another girl and unprotected sex and bring HIV back to her, whatever. So it really feel like, I mean in Asian way of the thinking, they think that HIV is just something that's bad, and they don't want to know about it. It's a White guy disease, and it won't happen in Asian community ever, so they think.
IV. PREDICTORS OF HIV RISK AND PROTECTION SPECIFIC TO PARTICULAR SEGMENTS OF THE ASIAN / PACIFIC ISLANDER COMMUNITIES
Data from the focus groups suggest that factors related to HIV knowledge attitudes and behavior are often specific to particular communities, such as youth, South Asian women, or queer communities. These factors may need to be particularly emphasized in targeted prevention efforts. For example, power, financial independence, and gender role ideology issues emerged far more often in the focus groups in the Women’s Project than in those within the other projects. Other research on HIV prevention for women suggests that these factors are crucial in influencing HIV risk for women across a range of racial/ethnic groups in the U.S. (Amaro, 1995; Gillespie, 1997; Ickovics & Yoshikawa, 1998). Prevention efforts for API women must continue to develop ways to integrate discussions and actions around these issues, linking efforts to fight systemic oppression with health behaviors and self-care.Lack of the kind of access to condoms for youth that retains privacy
YT 463
Political awareness and consciousness among womenJust in terms of having access to resources and condoms. One thing that I notice in Chinatown, when you go into pharmacy, a lot of the condom is behind the counter. And I'm like hello, it took me like probably until I was 17, I was not feel embarrassed to buy maxi pads for my period, and let's talk about, I get just in terms of like, I can't imagine like it's hard oh can I have the condom. You know like that pack. I'm not putting an equivalent of getting a maxi pad is like getting a condoms, but in terms of like, you have to ask for it.
WE 611-619
I just want to add one thing and it’s backtracking but when [name] was saying about who's easier to talk to? You mentioned education but it's also whatever is more politicized. I know a lot of the women have masters degrees and it's beyond class and it's beyond education it's how cautious you are and how aware you are of issues because there are so many women who have masters degrees and doctorate degrees and they think it's not really affecting their lives. . .Like for instance this woman I met she was a writer. She's gone through so much of her own experience -- she was an abused woman and where she's now divorced and living by herself. She learned through own experience she joined other programs such as SAKHI where they deal with domestic violence and abuse and HIV/AIDS sex and sexuality.
Power imbalance between men and women
WB 108
Gender role ideologyBecause in our community women are very shy, they can not raise their voice to the husband, they cannot give them ideas suggestion or something like this, so we should work on the man actually, somebody, not women, maybe men worker, men worker can work or what I mean, yeah. So that they can come for more actually. Women, wife, most of the time they can not talk to their husband, they don't express their opinion suggestion or something she wants or this is the man dominated society in our county male dominated. Whatever they want this and that, oh I want this, you have to do that, so man should come forward let them understand that this is good for their health, good for their family, good for not that we are suspecting somebody, that somebody is bad.
YT 415
Financial Independence Among WomenYeah I think that it's funny because you just mentioned something that I just remembered doing outreach with you in Chinatown where this guy who's 30 and two women friends, there was this incident and the guy took the condom and his two female friends were just giggling. And I think a lot have to do with just sexism it's more acceptable and it's more okay for guy to take a condom than a female. And also I think that it implies a lot of internalized how people are brought up not just in the API community, but just in terms of how we see sex in general. Like that might be how come more guys are more receptive to taking the condom.
WB 285
Role of involvement in gay community and gay identity in reducing risk behaviorParticipant: That is why I say, they do not have courage, or they are not empowered to ask their husbands.Facilitator: How do you empower them to ask their husbands?
Participant: So if that woman is financially independent, then she will have courage to ask.. And outside to work.
GM 2:178
Role of families in HIV prevention for gay menTo me, it's like in the gay community of New York City, safer sex and HIV prevention is very well organized. But those persons who are living in the closet who are MSM they are afraid of being in contact with gay community that promotes safer sex and HIV prevention. So they might have some kind of guilty or shame in terms of sexuality so that might make them not think about safer sex. Sometimes kind of a depressed or isolated person they're just going out to bars and have a lot of drinks and substance abuse and they just want to have 1-night stand not thinking about anything at all just having sex. I mean I guess that makes them not have safer sex.
GM 2: 200
Facilitator: You mentioned that for Korean gay men whose families are here that they're more likely to have come out?
Perceptions that HIV is a gay disease among API non-gay-identified MSMParticipant: To friends and to family.Facilitator: Than among those who are here without their families. Then do you think the men who have families here also differ in their risk behavior?
Participant: I think so because for example when they come out to their family their family member might ask them about safer sex and HIV/AIDS and usually someone who comes out to family member they may have strategy to talk about safer sex and HIV/AIDS. So they might kind of share or collect information. At that time the parents talk "Please use safer sex" that kind of support I really feel positively working. Because my parents accept my sexuality my parents told me to practice safer sex.
GM 247
No, I just want to say that maybe I think South Asian or API most of the time will try to relate HIV with gay and gay with something that is negative side for them. So, sometimes if they're still in closet, or they don't want people to know it, and if they read the pamphlet about HIV, they're afraid that people are going to assume that you are gay or whatever.
5. IMPLICATIONS AND SUGGESTIONS FOR PREVENTION PRACTICE
The main suggestions which follow from the above findings are presented below.Limited Usefulness of the Traditional Approach to Street Outreach
A consistent finding across all of the focus groups was that peer educators find traditional street outreach to be unfulfilling and rarely successful. The traditional street outreach strategy involves short, one-on-one contacts, often on a one-time basis, in which peer educators approach potential target clients on the street and hand out information and/or condoms. Peer educators reported several reasons why this technique may not be very successful. First, many API cultures frown on exchanging information having anything to do with sexuality with strangers. HIV and AIDS are associated with sexuality, and therefore any indications that materials are about HIV/AIDS were usually met with a blank or negative response. Second, peers noted that condoms are equated with promiscuity and so when it is clear to target clients that condoms are being handed out, they tend not to accept them for fear of being perceived as promiscuous. Many peers observed that this effect was worsened when potential target clients were with family members, friends, or partners. Third, peer educators have reported fatigue and dissatisfaction following such traditional outreach trips.
Modifications of Traditional Models of Street Outreach: Identifying Social Networks and Settings Associated with Higher Risk
Staff and peer educators in the Education Department have devised ways to modify traditional approaches to street outreach in order to maximize their relevance to API communities. For example, peers in the Youth Project noted that when materials were introduced as health materials, target clients were much more likely to accept them than when they were presented in the context of HIV/AIDS. Condom packaging has been modified to appeal to certain API communities (e.g., red packaging with gold letters to imitate Chinese New Year gift packaging).
However, perhaps the most important modification of street outreach engaged in by peer educators consists of a complete reframing of the process to include 1) identification of new social networks and settings in which specific API community members gather; 2) saturation of those settings with materials; and 3) diffusion of new norms concerning HIV risk and protective behaviors, through a series of workshops.
In the first step, some peer educators have identified and assessed social networks and settings which may be associated with elevated risk. For example, in two separate initiatives, peer educators identified Bangladeshi grocery stores and restaurants as informal social support settings for immigrant Bangladeshi men and cabdrivers, respectively. Many of these men appear to engage in unprotected sex with men. In both these initiatives, repeated contacts were made with members of these settings (in one case, owners of grocery stores, and in the other the cabdrivers who regularly congregate in a small number of restaurants on their breaks).
In the second step, some peer educators have made attempts to saturate settings with outreach materials. For example, peers in the Youth project have "blanketed" Asian youth clubs with materials, distributing condoms and brochures to virtually all youth entering clubs. These are settings that are associated with elevated HIV risk. Similar efforts have been carried out in the GLBT project in bathhouse or club settings. In the grocery store example mentioned above, attempts were made to saturate the settings with outreach materials: Owners were recruited to distribute materials and have them available at all times. These efforts may result in setting-wide reductions in HIV risk.
In the third step, attempts have been made to diffuse new norms concerning HIV risk and protective behaviors among tightly knit social networks. A series of house parties in South Asian communities have made use of the high levels of cohesion in networks of Bangladeshi women to diffuse awareness about HIV/AIDS. In a typical scenario, an initial house party will generate interest among friends of women who attended, and that group is then invited to a subsequent party. Using this method, peers have presented multiple workshops in the same apartment building or residential area. Such a method may potentially result in reductions in HIV risk across the given setting (e.g., apartment building or area), through a process of diffusion of new information and norms for risk behavior in existing social networks. This process, in which new behaviors spread through social networks, has been termed "diffusion of innovation" (Rogers, 1995). Interventions based on this model have proven effective across a range of public health goals. The process is facilitated in situations where the change agent (the person introducing the new behavior) is similar in demographics to the persons being targeted, and in social networks where communication and influence travel quickly. Both these conditions are met in the current example of house parties for Bangladeshi women.
Anecdotally, peer educators involved in this initiative in the Women’s project report some changes in HIV risk behavior among at least a subgroup of Bangladeshi women who have attended such house parties. The parties integrate discussion of HIV and AIDS into more general discussion of topics of concern to the women, including immigration issues and parenting. Similarly, other peers in the Women’s project have presented workshops about HIV/AIDS following English as a Second Language classes for Chinese immigrants.
Further Development of Diffusion of Innovation Models of HIV Prevention: Integration with Community-Building Approaches
As described above, peer educators in the various projects at APICHA have begun to identify and work with social networks and entire settings, not just individuals. This work could be expanded further, in keeping with approaches which research in HIV prevention has proven effective.
First, systematic approaches could identify particularly high-risk settings among API communities. Within each of the four projects in the Education Department, assessments could be made of settings and populations which may represent particularly high risk for HIV infection. Many settings have already been identified in this way (e.g., parties at clubs are potentially high-risk situations because, in the words of one peer educator, "people get laid afterwards," often under the added influence of substances). However, there has never been a systematic risk assessment carried out within projects to determine rates of risk behavior in different ethnic, geographic, or sexual communities (this is a shortcoming among API AIDS service organizations in general; Sy, Chng, Choi, & Wong, 1998; Wong, Chng, & Lo, 1998). Such information could guide targeting of intensive prevention strategies to communities at risk.
Second, studies have found that diffusion of new norms concerning safer sex can be facilitated through identification and recruitment of natural leaders (often termed "opinion leaders") in social networks (Kelly et al., 1997; Miller, Klotz, & Eckholdt, 1998). Coalitions of such leaders could be created, resulting in new cadres of prevention activists. Initiatives at APICHA have developed such coalitions. For example, the SLAAAP (Sexually Liberated Asian Arts Activists People) project brought together a group of artists and prevention activists to develop a small-media campaign for queer API men and women around issues of queer API identity, exoticization, and HIV prevention (see examples from SLAAAP above under the Community-Building section). This group met for 6 months, engaging in an intensive group process to discuss approaches to media-based prevention strategies, conceptualize a campaign, and produce materials to be distributed during Pride weekend and at other events.
Third, some studies have found that creating new social spaces and settings where none existed before can both serve a community organizing function and create new norms for HIV protective behavior (Kegeles, Hays, & Coates, 1996; Kegeles, Hays, Pollack, & Coates, in press). As an example of this, APICHA initiated a project for queer API women called Persimmon Space, which created the first social spaces in New York City devoted to bringing together this group. HIV prevention and other health-related efforts were integrated into the popular social events sponsored by Persimmon Space. Those involved with this project report community-building effects of Persimmon Space. One advantage of such an initiative is that the new social setting is not identified primarily with HIV, and can therefore draw people who would not normally attend an HIV-related workshop.
Despite the success of these projects, similar kinds of strategies involving coalition formation (bringing together groups of activists) or the creation of new social spaces and settings are not a widespread practice in the agency. In addition, other kinds of community coalition-building have not been explored. Future efforts could work with existing informal social organizations, for example, to create inter-organization coalitions addressing HIV and other related concerns of API communities. Many of the informal social organizations among API communities are ethnicity-specific; therefore, such work could develop coalitions across cultural and linguistic divides for the common purposes of empowerment, health promotion and HIV prevention.
Expansion of the goals of prevention activist coalitions could also be implemented. The SLAAAP coalition-building project was focused on one kind of HIV prevention (development of outreach materials); other coalitions could potentially engage in a variety of activities, including identification of social networks, implementation of small-group interventions, creation of new social settings, and outreach, as well as media initiatives. Such approaches have been proven to result in community-wide reductions in HIV risk among other populations (Kegeles et al., 1996; Kegeles et al., in press).
This study suggests a rich array of factors related to HIV knowledge, attitudes and behavior among the many communities targeted by APICHA. Integration of such factors into HIV prevention models is an ongoing practice among peer educators at the agency. The current findings suggest potential future directions which may prove effective. For example, the findings concerning contexts of HIV risk in countries of origin suggest that discussion of these factors may be important in working with immigrant API communities. Norms of unsafe sex from mainstream and gay or lesbian API communities in countries of origin appear to be retained, at least among certain subgroups of recent immigrants. Prevention activities could integrate discussion of such topics, ranging from assessment of clients’ perceptions of risk in their countries of origin to exploring what they perceive to be changes in contexts of seroprevalence and risk in New York City or their particular circle of contacts.
Certain findings pertaining to specific subgroups suggest implications for targeted prevention efforts. For example, participants in the youth group noted a lack of the kinds of access to condoms which insures privacy. Initiatives could potentially be developed which increase access to condoms for API youth in neighborhoods where they live, through youth organizations, Web-based outreach and other modes of delivery which retain their privacy. To take another example, findings concerning the need for empowerment among South Asian women suggest the potential of a community coalition-building intervention, which integrates HIV prevention with discussion of power, considered as both a relational and economic issue.
Other suggestions for prevention practice were made by the peer educators themselves. They are presented in the following final section.
Develop Prevention Materials from Within-Group Cultural Norms
Recruit Community Leaders to Raise Awareness About HIV PreventionAlong with that, I think a lot of the outreach material that we do have, a lot of it just seems to be, like, there's nothing really that makes it so much Asian specific. As far as what (name) was saying about like, there are a lot of cultural nuances, and that could be really done more in the actual materials themselves, is make, is to really target specific populations and make, instead of translating the same brochures, like the men together brochure into Japanese, Chinese, Tagalog, and all these other languages, create specific brochures for each language population. Start from within. Because if you just translate the same one, all you're doing is, you're not making it specific, you're just, you're making it accessible as far as language, but you're not making it specific to that population.
Improve Printing Quality and Design of Media MaterialsAnd also, if more like community leaders from within the community incorporated our, you know, somehow they sponsor HIV/AIDS awareness and education or are, somehow, brought into the fold, I think people from those communities will listen to them a lot more...like, for South Asians communities, maybe the religious leaders, somehow could be brought in. Because like a lot of people listen to them, you know. And people who are doing political work within those communities, you know, others, doctors, lawyers, who they respect and who they listen to a lot more. Because it's just not, it's not a problem of just the gay men, just the MSM men and how, especially in terms of the MSM men, how to reach them without being specific about their sexuality. You know if they get those materials in ways which do not label them as MSM or gay they're more likely to access them and read them and you know, take the message home than, say, if we're doing outreach in like MSM specific areas or just gay specific areas.
Use WorldWide WebSome, like in APICHA brochures, the printing is not clear, that's one thing.The most important to our community that information plus pictures are designed. It should be attractive, and to give new information, new things to the community.
Or maybe have different brochures, because every time we pass out the brochures, they say we already have gotten one. Because they see the cartoon characters, and they've seen them already. They automatically know they have received one already.
Larger Workshops / Town MeetingsI think a website's a good way of promoting. 'Cuz over a million people are on-line every day. And, they could just search it, and if they want to read about it, it'll come it. Rather than getting something from someone on the street.
YT 715
Full or Permanent Staff Status for Peer EducatorsI don't think giving out pamphlets are effective, I think that it should be more of a workshop to get youths together and have a whole town meeting.
Better Tasting IncentivesExample 1:Each of us is technically hired for 6 months, and then evaluated. And then they can keep you longer doing outreach. I don't know how effective for the people in APICHA, after 6 months you're not gonna be involved with APICHA. I think that it would be more effective to hire permanently staff to keep momentum going.
Example 2:
Facilitator: Because what you found was when you go door-to-door only what small percent come to your rap session.
Participant: Small percent and it was only for six months, that was her point, we did it for six months, I don't know how much I could have reached her own son couldn't be very easy to talk, she learned a lot of things new, but she cannot tell her son.
YT 719
Oh the thing you said about the town meeting, I think funding is the issue there. Because what is gonna induce kids to come. Free advice? No it's gotta be free food and stuff.
References
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Choi, K., Kumekawa, E., Dang, Q., Kegeles, S.M., Hays, R.B., & Stall, R. (in press). Risk and protective factors affecting sexual behavior among young Asian and Pacific Islander men who have sex with men: Implications for HIV prevention. Journal of Sex Education and Therapy.
Chng, C.L., Sy, F.S., Choi, S.T., Bau, I., & Astudillo, R. (1998). Asian and Pacific Islander American HIV community-based organizations: A nationwide survey. AIDS Education and Prevention, 10 (Supplement A), 48-60.
Choi, K., Yep, G.A., & Kumekawa, E. (1998). HIV prevention among Asian and Pacific Islander American men who have sex with men: A critical review of theoretical models and directions for future research. AIDS Education and Prevention, 10 (Supplement A), 19-30.
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Appendix 1. Focus Group Interview Protocol
Introduction
As you read on the flyer, the purpose of this group interview is to learn more about factors that affect HIV prevention among Asian and Pacific Islander populations. Since there is so little systematic information known about this topic, we thought that a good first step would be to gain the perspectives of the experts – peer educators like yourselves who are on the front lines in communities doing HIV prevention. This information will be of great benefit not only to other peer educators at community-based agencies like APICHA, but to the field of HIV prevention as a whole, which has only started to address the prevention needs of ethnically and racially diverse groups.
Before we start, I’d like to lay a couple ground rules for our discussion.
First, the focus of this discussion will be on factors that affect your HIV prevention work with different communities. However, we’d like to ask that you not talk about administrative issues within APICHA, or about conflicts with each other. These include issues like conflicts with supervisors or other staff at APICHA, or tensions with other peer educators.
Secondly, we’d like to ask that you not interrupt each other and that not more than one person speak at once. It makes it very difficult for us to hear what was said if two or more people are talking at the same time.
Finally, we’d like to ask that you not reveal undocumented immigrant status of yourself or of any of the people you may be talking about.
I’d like to give you a chance to opt out of this focus group, if what you’ve heard makes you feel uncomfortable or if what you’ve read on the consent form makes you feel uncomfortable.
As it says on the consent form, the project coordinators and others at APICHA have agreed that participation in the focus group will have no effect on their perceptions of the quality or commitment of your work at APICHA.
Questions:
1) We’d like to first ask you to think back to all of the HIV prevention work you’ve done for APICHA – on the street, in stores, at parties, in social organizations, in bars, in bathhouses, or in other places. We’d like you to think more specifically about the interactions and conversations you’ve had with people in these places that have lasted longer than simply giving out materials. Interactions where you had some significant conversation, particularly those where you developed a relationship with them over time.
When you think of these interactions you’ve had, you must have a sense of some that went better than others.
I’d like you to take a few minutes to remember and think of the 4 or 5 most successful relationships / interactions you’ve had in your prevention work at APICHA. [take 5 minutes]
What about those relationships made them successful?
Reductions in the long-term, or short-term?Probe: Do you think those particular interactions might have led to reductions in HIV risk behaviors?
[If necessary:] Can you give an example?
How do you think the interactions differed depending on their immigration status?Probe: What about the interactions might have led to change in their risk behavior?2) Now we’d like you to think not just about the most successful interactions, but about all of them, including the ones that didn’t go so well.
We’d like you to think about specific aspects of the people in these interactions.
Probe: What aspects of their immigration status?
[prompt if needed]:
Documented / Undocumented status?
Length of residency?
3) How do you think the interactions were different depending on their ties to different immigrant organizations and communities?
4) How do you think the interactions were different depending on their ties to their families?For example, how were interactions with people who are very involved with their particular immigrant community different from those with people who weren’t very involved?Probe: What about interactions with people mainly involved in non-API, mainstream American organizations / communities?For example, how were interactions with people who are very involved with their families different from those with people who weren’t very involved?
5) How do you think the interactions were different depending on their ties to [depending on nature of focus group] gay / queer / TG spaces / organizations / communities; women’s spaces / organizations / communities; lesbian spaces / organizations / communities; youth organizations / spaces / communities;]?
For example, how were interactions with people who were very involved with the [gay or queer; women’s; youth] communities different from those with people who weren’t very involved?
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