targeted approaches to hiv prevention among immigrants living in high- income countries
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Targeted approaches to HIV prevention
among immigrants living in high-
income countries
Tadgh McMahon
Outline of research
Review of HIV prevention interventions at group-
and community-levels with immigrants
Key assumption of cultural appropriateness
What are the ‘best’ mechanisms that contribute to
cultural appropriateness in HIV prevention?
Systematic searches of public health databases -
74 studies included in the review
Key Findings
‘understanding’ and ‘consonance’ – optimise the
use of language and cultural values in
interventions
‘authenticity’ and ‘specificity’ and ‘embeddedness’
– staffing, targeting through ethnicity, and settings
in interventions
‘endorsement’ and ‘framing’ – harness community
endorsement and partner with immigrant
communities
Global migration, mobility and HIV
Migration – a force in the spread of infectious disease (Apostopoulos et al , 2007)
Mobility - unprecedented in volume, speed and reach (Wilson, 2007)
95% of people living with HIV reside in low and middle-income countries (UNAIDS, 2009)
Upward HIV trend among immigrants in high-income countries, alongside evidence of disparities in HIV-related health (NCHECR, 2009)
Immigrants have vulnerabilities to HIV (UNAIDS, 2001)
HIV prevention in Australia
Strengths of targeted approaches with priority
populations
Shift in HIV policy towards immigrants, people
from CALD backgrounds
Limited evidence from Australia of how to improve
HIV prevention with immigrants
What can be learned about ‘what works?’ from
other high-income countries
Theoretical frameworks: intervention ‘chains’ (Weiss, 1997)
Activity -HIV
information resources
in community language
Mechanism -theorised as
’understanding’
Response- immigrants comprehend and act on
HIV messages
Resistance – inaccurate translation
creates confusion and
inaction
Research methods
A realist review of evidence (Pawson, 2006)
Seven theorised mechanisms: –‘authenticity’,
‘understanding’, ‘consonance’, ‘specificity’,
‘embeddedness’, ‘endorsement’ and ‘framing’
Mechanisms tested and refined:
– studies of HIV prevention interventions
– qualitative studies of immigrants views of HIV
prevention
Systematic searches: PubMed; CINAHL; Sociological
Abstracts, ERIC, PAIS, Social Services Abstracts; and
Google Scholar
Searches, culling and appraisal
Intervention studies: 3,300 records 160 full
reports
Qualitative studies of immigrants’ views: 2,700
records 110 full reports
Included if; 65% immigrants from low and middle-
income countries; living in high-income countries;
focus was on HIV/AIDS
74 studies: 34 interventions and 40 qualitative
studies
‘understanding’ mechanism
Activity -HIV
information resources
in community language
Mechanism - theorised as ’understanding’
Response- immigrants comprehend and act on
HIV messages –
‘shared language’
Resistance – inaccurate translation
creates confusion and
inaction
‘consonance ’ mechanism
Activity –
integrating cultural
values and elements into the
intervention content
Mechanism - theorised as ’consonance’
Response-
immigrants understand intervention
in a symbolic sense –‘shared values’
Resistance – dissonance if acculturated or if values are a
source of oppression and
stigma
‘authenticity’ mechanism
Activity – bicultural
staffing (culture=
ethnicity) or use of
imagery
Mechanism - theorised as ’authenticity’
Response– immigrants
trust and credibility
enhanced by peer
interaction–‘shared culture’
Resistance – heterogeneity of ‘culture’ and ‘which culture?’
as well as reluctance
among HIV-positive people
‘embeddedness’ mechanism
Activity – delivery through
immigrant community structures ad settings
Mechanism -theorised as
’embeddedness’
Response- immigrants
encounter intervention
in familiar/local settings –
‘shared place’
Resistance –
marginalising when
immigrants have
withdrawn from ‘ethnic
worlds’
‘specificity’ mechanism
Activity – targeting in terms of ethnicity
Mechanism - theorised as
’specificity ’
Response– sufficiently targeted to respond to
ethnic diversity –
‘shared ethnicity’
and ‘shared difference’
Resistance – stereotyping of ethnicity as primary source of identity and
loss of ‘difference’ implied by
categories such as ‘Africa’, ‘Asian’ and
‘Latino’
‘endorsement’ and ‘framing’ mechanisms
Activities: community consultation processes and framed
within wider social contexts (e.g. racism or homophobia) of
immigrants
Responses:
– intervention is supported, and intended outcomes
match, immigrant community expectations
– ‘shared permission’ and ‘shared decision-making’
Resistances:
– denial of HIV as a priority; migration-related stressors
The mechanisms - a ‘real-life’ example(Carballo-Diequez et al, 2006)
Staffed by Latino gay men- ‘authenticity’
Intervention materials and assessments in Spanish/English – ‘understanding’
Incorporated cultural values and elements (e.g. dichos) – ‘consonance’
Diversity of Latino gay men – ‘specificity’
Community outreach – ‘embeddedness’
Community consultation and focus testing -‘endorsement’
Assumption of dis-empowerment – (lack of) ‘framing’
Key Findings
Pivotal: ‘understanding’ and ‘consonance’ –
optimise the use of language and cultural values in
interventions
Moderate: ‘authenticity’ and ‘specificity’ and
‘embeddedness’ – staffing, targeting through
ethnicity, and settings in interventions
Least critical: ‘endorsement’ and ‘framing’ –
harness community endorsement and partner with
immigrant communities
Implications for HIV prevention with
immigrants
Multiple inter-related mechanisms for
culturally appropriate HIV prevention
Mechanisms complementary to health
promotion practice
Utility of mechanisms dependent on context
Analyse and synthesise evidence from
practice to build the evidence base
Acknowledgements
Prof Paul Ward, Discipline of Public Health, Flinders University; Assoc
Prof John Imrie, NCHSR, UNSW
Expert Reference Group:
– Assoc. Prof. John Chin, Columbia University, USA; Prof. Varda Soskolne, Bar-Ilan
University, Israel ; Prof. Michele G. Shedlin, University of Texas, USA; Georg
Bröring, formerly of the European AIDS & Mobility Project, NIGZ, The Netherlands;
Dr Henrike Körner, NCHSR, Australia
Key Informant Group:
– Phillip Keen, AFAO; Assoc. Prof. Carla Treloar, NCHSR, UNSW; Assoc. Prof. Lisa
Maher, NCHECR; Lisa Ryan, AIDB, NSW Health; Claire Ferguson, HARP,
SESIAHS; Barbara Luisi, MHAHS.
Internship from the Consortium for Social Policy on HIV, Hepatitis C
and Related Disease, NCHSR
Past and present colleagues at Multicultural HIV/AIDS and Hepatitis C
Service
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