Promotion of Latina Health

Abstract

Latina women in the United States are vulnerable to two intersecting public health concerns: intimate partner violence (IPV) and subsequent risk for HIV/AIDS infection. Examination of the cultural and contextual life factors of this understudied population is crucial to developing culturally relevant HIV interventions. Focus groups with Latinas (15 monolingual; 10 bilingual) who have experienced IPV were conducted. Monolingual and bilingual Latinas endorsed that they were concerned about HIV infection, naming partner infidelity and experiences of forced and coerced sex as primary reasons for their concern. However, monolingual participants had lower levels of HIV knowledge, spending much time discussing myths of HIV infection, whereas bilingual participants spent more time discussing specific prevention techniques, including challenges related to the violence in their relationships. These findings suggest that HIV/AIDS prevention programs for Latinas need to pay close attention to the different historical, contextual, and cultural experiences of this at-risk group of women.

Keywords

Latinas HIV/AIDS prevention HIV/AIDS risk-reduction interventions intimate partner violence

Latina women in the United States are vulnerable to two intersecting public health concerns: intimate partner violence (IPV) and HIV/AIDS infection. According to the National Intimate Partner and Sexual Violence Survey, 37% of Latinas have been a victim of IPV at some point in their lives (Black et al., 2011). Women who experience IPV are at an increased risk of contracting HIV/AIDS (Davila, Bonilla, Gonzalez-Ramirez, & Villarruel, 2007; El-Bassel, Gilbert, Wu, Go, & Hill, 2005; Gielen et al., 2007; Wingood, DiClemente, & Raj, 2000). They are more likely to experience sexual coercion (Murdaugh, Hunt, Sowell, & Santana, 2004) and less likely to practice consistent condom use or attempt to negotiate safe sex with their intimate partners (El-Bassel et al., 2005; Raj, Silverman, & Amaro, 2004). Male abusive partners are more likely to engage in risk-taking behaviors such as unprotected sex and sexual infidelity relative to their non-abusive male counterparts (Raj et al., 2006). Furthermore, women who have experienced abuse are more likely to engage in risky behaviors, such as using drugs and alcohol (Johnson, Cunningham-Williams, & Cottler, 2003) and having sex with multiple partners (Champion, Shain, & Piper, 2004).

The association between IPV and HIV is a concern that must be addressed, especially in the context of the rising number of HIV/AIDS cases among women. In the United States, women now comprise more than a quarter of the newly reported HIV/AIDS cases (Centers for Disease Control and Prevention [CDC], 2008), and racial and ethnic minority women are disproportionately at risk compared with their White counterparts. African American women and Latinas make up 82% of all HIV/AIDS cases among women, although they only make up 26% of the United States’ female population (Kaiser Family Foundation, 2008). Although African American women have the highest rates of HIV/AIDS cases among U.S. women, Latinas have the fastest growing rate. From 2006-2009, there was a 2% decrease in the rate of cases among African American women as well as White women. In contrast, rates of HIV/AIDS cases among Latinas increased by 2% during the same 3-year period (Kaiser Family Foundation, 2008). Given this trend, and the association between HIV and IPV, special attention needs to be paid to HIV/AIDS prevention among the Latina population, particularly Latinas who have survived IPV (Moreno, 2007; Wyatt et al., 2002).

Risk of HIV Among Latinas: The Role of IPV

Among women, the most common mode of HIV transmission is through heterosexual contact (CDC, 2008). Of particular concern are women who are in abusive relationships as partner abuse increases women’s vulnerability to HIV (Gonzalez-Guarda, Peragallo, Urrutia, Vasquez, & Mitrani, 2008; Moreno, Morrill, & El-Bassel, 2011). Given that Latinas are more likely than Whites to be exposed to IPV (Caetano, Field, Ramisetty-Mikler, & McGrath, 2005) and Latinas who experience IPV are less likely to leave the relationship and seek help (i.e., utilize shelters and services; Ingram, 2007) relative to non-Latina women, IPV is a significant risk factor for HIV among Latinas. According to Klevens (2007), there are many barriers that prevent Latinas from accessing domestic violence services, including language barriers, having limited education and knowledge of available services, being foreign-born, and fearing authority figures. Latina survivors of IPV also experience multiple oppressions based on race, class, gender, and sexuality that present unique challenges for this population to get the help that they need (Murdaugh et al., 2004; Raj et al., 2004).

Acculturation and the degree to which Latinas adhere to traditional gender roles affect Latinas’ perceptions of IPV and thus how they cope with these experiences. In the Latin culture, women are often viewed as the most integral part of the home. Latinas are expected to put the needs of their family above their own, to endure many sacrifices or “sufrimiento” in the name of the family (Murdaugh et al., 2004). This traditional female role in the Latin culture is referred to as “marianismo.” Latinas who value and strive to uphold the cultural tradition of marianismo often feel strong and brave for the suffering they are willing to endure on account of their family. However, they also tend to lack control in their relationship and live according to their husband’s wishes (Kasturirangan & Williams, 2003). Research indicates that Latinas return to their abusers more often than their White counterparts (Klevens, 2007), perhaps due to these values of sufrimiento and marianismo. Kelly (2009), for example, found that Latinas stayed with their abusive partners for concern for their children’s well-being, fear of losing custody of their children, and a desire to keep the family intact. Thus, culture-specific sex role attitudes indirectly influence risk of HIV among Latinas (Moreno, 2007).

Culture-specific sex role attitudes can also directly affect HIV risk among Latinas (Collins, von Unger, & Armbrister, 2008; Moreno, 2007; Scott, Gilliam, & Braxton, 2005; Zambrana, Cornelius, Boykin, & Lopez, 2004). Zambrana et al. (2004) hypothesize that religious and cultural beliefs regarding women’s sexuality, including the ideals of virginity and sexual abstinence outside of marriage, are related to a lack of discussion and, therefore, knowledge about sexuality. These beliefs make it difficult for women to discuss condom use; they would be stepping outside of the gender norm in which they are supposed to be naive about sexuality (Scott et al., 2005).

HIV Prevention Among Latinas

Effective HIV prevention for Latinas requires a tailored risk-reduction strategy, perceived by the women as addressing their needs (Peragallo et al., 2005). It must also be reflective and responsive to their lived reality (Trickett, 2002). Davila and colleagues (2007) explored the HIV-IPV prevention needs of monolingual, Spanish-speaking Latinas from the perspective of survivors and health and service providers. Consistent with the existing literature (Amaro & Raj, 2000; Davila, 2005; Davila & Brackley, 1999; Peragallo et al., 2005; Wu, El-Bassel, Witte, Gilbert, & Chang, 2003), Davila and colleagues found that cultural norms, gender roles, and inability to access services due to the language were barriers to HIV prevention. This study also found that IPV, partner control, and financial dependence upon partners interfered with Latinas engaging in HIV prevention methods. These additional findings provided new exploratory insights into the development and implementation of a HIV-IPV prevention intervention program. However, it is important to note that these findings may not generalize to bilingual or monolingual English-speaking Latinas. It is likely that there are many differences in the experiences (e.g., structural, cultural) of monolingual Spanish-speaking Latinas and bilingual or monolingual English-speaking Latinas.

The purpose of the current study was to further illuminate the cultural and contextual experiences of monolingual and bilingual Latinas who have experienced IPV as a vehicle in the development of HIV/AIDS prevention interventions. We implemented a mixed-methods design, collecting data through focus group interviews and questionnaires, to gain a more nuanced understanding of the experiences of these Latina women. One thing we were particularly interested in was exploring the degree to which these Latinas, who are seemingly similar, may have very different lived experiences of sexual abuse or rape and thus differ in knowledge on HIV/AIDS, transmission, and risk-reduction behavioral strategies and perspectives on developing a contextually and culturally relevant HIV/AIDS risk-reduction intervention for Latina IPV survivors.

Method

Sample and Recruitment

Participants included 25 Latinas aged 26-40 years who were residents of a domestic violence shelter or transitional housing program in the southern region of the United States (monolingual, n = 15; bilingual, n = 10). Recruitment was targeted at these locations to identify females who had experienced physical and sexual violence and were at prominent risk for HIV infection. Education level was relatively low in this sample: five (28%) had a high school diploma, one (6%) had a college degree, and one (6%) had a graduate degree. Nearly half of the participants were divorced (n = 8; 42%). All but two of the women reported having children (average of 2.4 children). None of the participants had a monthly income of more than US$2,000. In fact, five participants (26%) had no income and 13 (69%) had monthly income less than US$1,000.

Purposive sampling was used to identify participants who met the necessary criteria: females who were identified as Latina, were above the age of 18, and had experienced rape or sexual abuse or had sex unwillingly with a male partner in their relationship. While purposive sampling is non-random and thus technically biased, this method of sampling is used when researchers are looking for specific information that is only held by certain informants (Bernard, 2002). Because the purpose of this study is to understand the cultural and contextual life factors that influence the intersection of IPV and HIV/AIDS risk among Latinas, it was essential that Latinas who had experienced IPV be interviewed. Two strategies were used for recruitment: (a) Participants saw English and Spanish posted flyers and directly contacted the principal investigator or (b) the shelter staff identified participants. All participants were given an overview of the study, an assurance of confidentiality, and a grocery store gift certificate worth US$25 at the end of the focus group to compensate them for their time. Choosing not to participate in the study did not impinge on services provided by the shelter. This study was approved by the institutional review board.

Procedures

We used a mixed-methods design in which we collected qualitative and quantitative data from one sample of Latinas who had experienced IPV, and all the data were collected at the same time point. We conducted two focus groups with Latinas who had experienced IPV, and following the focus group, participants were asked to complete two questionnaires that also assessed issues related to IPV, condom beliefs and practices, and HIV/AIDS prevention knowledge.

For the focus group interviews, one group was conducted with only monolingual Spanish-speaking Latinas (n = 15) and the other was with bilingual English- and Spanish-speaking Latinas (n =10). Individuals who met the inclusion criteria and gave informed consent to participate and to be audio recorded were escorted by one of the group facilitators into a private meeting area at the shelter. There was one facilitator for each group and one note-taker. Both facilitators and note-takers were trained by the principal investigator. The bilingual facilitators were licensed social workers and had the same ethnic background as the participants. Given the sensitive nature of the discussion, groups were not video recorded. Instead, groups were audio recorded, and facilitators took notes throughout the session.

Facilitators used an interview protocol with open-ended questions to guide the focus groups, including the following questions: (a) What are the influences of sexual abuse or rape on risk for HIV infection? (b) What are the beliefs and practices concerning HIV/AIDS prevention knowledge among Latina women who have experienced IPV? (c) Are there differences in knowledge, beliefs, and practices concerning HIV/AIDS prevention among monolingual and bilingual women? (d) What information can inform the design of a culturally and contextually grounded HIV/AIDS risk-reduction intervention for Latina women who have experienced IPV? The sequence of questions began with topics less related to the research topic and moved toward the more sensitive questions related to the research topic based on participants’ responses and level of comfort. Focus groups continued until each theme from the interview guide was saturated, which lasted approximately 90 min.

After the focus group, participants were asked to complete two questionnaires that assessed issues related to IPV (e.g., “Women who have experienced sexual assault/ rape or had sex in their relationship when they have not wanted to are at a higher risk of HIV/AIDS infection than women who have not experienced intimate partner violence. True or False”), condom beliefs and practices (e.g., “Latex condoms and dental dams provide the most protection against HIV infection. True or False”), and HIV/AIDS prevention knowledge (e.g., “Unprotected oral sex with someone who is HIV infected IS a way to be infected by HIV. True or False”).

Measures

Sociodemographic information (e.g., age, income, education) was collected at the beginning of the study. Participants completed an abridged version of the HIV Knowledge Questionnaire (HIV-KQ-18; Carey & Schroder, 2002), an 18-item measure assessing understanding of disease transmission and self-protective behaviors (e.g., condom use). The HIV-KQ-18 has been shown to have good internal consistency with stable coefficients ranging from .76 to .94 (Carey & Schroder, 2002). Focus group participants also answered a 14-item questionnaire that was created by the research team based upon the synthesis of the literature in the areas of IPV and HIV/AIDS and in consultation with IPV and HIV/AIDS practitioners and consumers, to investigate perceptions of risk for infection, safe sex practices, experience of condom negotiation, and the provision of HIV/AIDS resources and referrals from the domestic violence shelter. All forms were available in English and Spanish.

Data Analysis

The main method of data analysis was triangulation. First, data from the focus groups were analyzed using basic thematic content analysis. Initial analysis was based on a priori themes that were chosen from the focus group interview guides. However, as themes emerged, they were included in the analysis. Special attention was paid to emergent and divergent themes across the focus groups. Data from the questionnaires were then analyzed to further explore the experiences, understanding, and knowledge of Latinas who had experienced IPV. Specifically, these data provided descriptive information about the participants and allowed us to explore any potential differences between monolingual and bilingual Latinas.

This type of analysis allowed us to triangulate our findings: to compare findings from the thematic content analysis with the findings from the questionnaires to determine if (a) findings were consistent and (b) reliable. Conventional standards for reliability and validity do not pertain to qualitative studies (Padgett, 1998). However, using triangulation affords us the opportunity to ensure transferability: We were able to verify themes observed from the focus groups by examining data from questionnaires and seeing how well they matched findings from the focus group data analysis. We also tried to ensure transferability by employing a community advisory board comprising Latina community members who had been victims of IPV and HIV/AIDS service providers throughout the study. The community advisory board members gave feedback at various points to ensure that participants’ worldviews were being addressed throughout the research study.

Analysis of the focus group data started with transcription of audio recordings. The Spanish-speaking group recordings were translated to English by a native Spanish speaker, and then transcribed. The main method of data analysis used was thematic content analysis. The goal of this type of analysis is to reduce the data from large amounts of text into a few, mutually exclusive themes. First, the transcribed data were coded using the qualitative software Atlas.ti v6.0 (2005). Three coders analyzed the data concentrating on template coding using priori themes based on the interview protocol (e.g., ways you have heard about avoiding HIV, ways you protect yourself from transmission, ways to have conversations about practicing safer sex, substance abuse or drug use an impediment to avoiding transmission, experiences of risk for HIV as a survivor of IPV, components of a contextually and culturally tailored HIV/AIDS risk-reduction intervention). Thematic content analysis is an iterative process; therefore, the data were read through repeatedly, as new themes emerged, old themes were modified or discarded.

To examine data from the questionnaires, particularly looking at differences between monolingual and bilingual Latinas who experienced IPV, we used Fischer’s exact tests in Stata 11.2 (2002). Typically, when comparing categorical data from two groups (i.e., 2 × 2 contingency table), chi-square analysis is sufficient. However, chi-square analysis only gives an approximation, and this approximation is only meaningful when the sample size is relatively large. Given the small sample of the current study, we utilized Fischer’s exact test, which is designed for comparisons of categorical data using small samples and provides an exact measurement of difference (Corcoran, Senchaudhuri, Mehta, & Patel, 2005).

Results

Results from the survey and focus group are organized and reported by theme rather than data collection method. This structure affords the opportunity to examine consistency in response across data collection method and allows for a more nuanced understanding of Latinas’ knowledge and experiences regarding HIV/AIDS and IPV. Specific themes include (a) knowledge of HIV/AIDS, transmission, and risk-reduction strategies; (b) safe sex practices and perceptions of risk; (c) cultural perspectives; and (d) key ingredients for culturally and contextually appropriate prevention.

Knowledge of HIV/AIDS, Transmission, and Risk-Reduction Behavioral Strategies

Monolingual and bilingual Latinas were knowledgeable of the prevalence of HIV/AIDS, how the disease is transmitted and treated, and the impact of HIV/AIDS on the body (see Table 1). They were also aware of the intersecting nature of HIV/AIDS risk and IPV, with 80% of bilingual and 67% of monolingual Latinas endorsing that they agree with the following statement: “Women who have experienced sexual assault/ rape or had sex in their relationship when they have not wanted to are at a higher risk of HIV/AIDS infection than women who have not experienced intimate partner violence.”

Table 1.

Participants’ Knowledge of HIV/AIDS, Transmission, and Risk-Reduction Behavioral Strategies: Comparison of Correct Response Rates Between Monolingual (n = 15) and Bilingual Latinas (n = 10).

	Bilingual Latinas	Monolingual Latinas	Fischer’s exact test
	% (n)	% (n)	Fischer’s exact test
Knowledge: HIV/AIDS
Women represent the most rapidly increasing category of individuals with HIV/AIDS.	90% (9)	27% (4)	.004
Compared with adult and adolescent rates of female HIV/AIDS infection, infant females account for the highest number of female HIV/AIDS cases.	30% (3)	67% (10)	n.s.
Among women of color, African American and Latina women are the fastest growing infected population.	90% (9)	73% (11)	n.s.
Women who have experienced sexual assault/ rape or had sex in their relationship when they have not wanted to are at a higher risk of HIV/AIDS infection than women who have not experienced intimate partner violence.	80% (8)	67% (10)	n.s.
Transmission: HIV/AIDS
Coughing and sneezing DO NOT spread HIV.	70% (7)	47% (7)	n.s.
A person can get HIV by sharing a glass of water with someone who has HIV.	90% (9)	67% (10)	.079
Pulling out the penis before a man climaxes keeps a woman from getting HIV during sex.	90% (9)	73% (11)	n.s.
A woman can get HIV if she has anal sex with a man.	60% (6)	87% (13)	n.s.
Showering or washing one’s genitals/private parts after sex keeps a person from getting HIV.	80% (8)	93% (14)	n.s.
All pregnant women infected with HIV will have babies born with AIDS.	60% (6)	33% (5)	n.s.
People are likely to get HIV by deep kissing (putting their tongue in their partner).	100% (10)	40% (6)	.004
A woman cannot get HIV if she has sex during her period.	90% (9)	73% (11)	n.s.
There is a female condom that can help decrease a woman’s chance of getting HIV.	50% (5)	60% (9)	n.s.
A natural skin condom works better against HIV than does a latex condom.	90% (9)	100% (15)	n.s.
A person will not get HIV if she or he is taking antibiotics.	80% (8)	73% (11)	n.s.
Having sex with more than one partner can increase a person’s chance of being infected with HIV.	70% (7)	93% (14)	n.s.
Taking a test for HIV 1 week after having sex will tell a person if she or he has HIV.	70% (7)	87% (13)	n.s.
A person can get HIV by sitting in a hot tub or a swimming pool with a person who has HIV.	80% (8)	80% (12)	n.s.
A person can get HIV from oral sex.	90% (9)	93% (14)	n.s.
Using Vaseline or baby oil with condoms lowers the chance of getting HIV.	80% (8)	80% (12)	n.s.
Unprotected sexual intercourse (either vaginal or anal) with someone who is HIV infected DOES NOT put a person at risk for becoming infected.	50% (5)	73% (11)	n.s.
Unprotected oral sex with someone who is HIV infected IS a way to be infected by HIV.	90% (9)	93% (14)	n.s.
Sharing needles or syringes with someone who is HIV infected IS NOT a way to be infected with HIV.	50% (5)	53% (8)	n.s.
Effect on the body
People who have been infected with HIV quickly show serious signs of being infected.	60% (6)	73% (11)	n.s.
Cure: HIV/AIDS
There is a vaccine that can stop adults from getting HIV.	90% (9)	80% (12)	n.s.
E. Reduce risk: Infection
Lambskin products provide little protection against HIV infection.	20% (2)	7% (1)	n.s.
Latex condoms and dental dams provide the most protection against HIV infection.	100% (10)	53% (8)	.013
Water-based lubricants are the most effective against HIV infection.	20% (2)	13% (2)	n.s.

Note. Percentages reflect only responses that were correct. n.s. = non-significant.

Participants reported less knowledge in specific risk-reduction strategies, with less than 20% answering correctly on items related to the effectiveness of using lambskin products as barrier protection, choosing water-based lubricants, and bleaching needles/syringes. Although non-significant, it is important to note that the correct response rates for those items were higher for bilingual Latinas relative to monolingual Latinas.

On several questions, there were significant differences in correct response rates between bilingual and monolingual Latinas. Among bilingual Latinas, 69% knew that women represented the most rapidly increasing category of individuals with HIV/AIDS, compared with 31% of monolingual Latinas (p < .01, Fischer’s exact test). All bilingual Latinas (100%) knew that deep kissing was not a mode of HIV transmission compared with 40% of monolingual Latinas (p < .01, Fischer’s exact test), and 100% of bilingual Latinas knew that latex condoms and dental dams provide the most protection against HIV infection, compared with 53% of monolingual participants (p <.05, Fischer’s exact test).

Data from the focus groups also indicated that monolingual Latinas have less knowledge about HIV/AIDS, as many had questions and uncertainties about HIV/AIDS and its transmission.

I wanted to ask what is AIDS? If it’s like cancer or what? I also wanted to ask . . . what it is or what it’s like. I’ve just heard about AIDS and AIDS . . . but I don’t know what it is.

Well, I’ve heard of it (HIV/AIDS), but I don’t know how AIDS is transmitted.

Participants in the monolingual group consequently spent more time discussing the many ways they had been told HIV/AIDS was transmitted. Some knew that it was transmitted through blood, yet many had misconceptions of transmission methods:

You can also get it from your eyebrows . . . see since it comes from a root . . . and it can be infected . . . if you have AIDS . . . when you are plucking your eyebrows . . . if you are infected . . . that is contagious . . . just like a nail cutter and such is what they taught me.

If you have a blister in your mouth or an infected molar and you are sharing in your home with someone who has AIDS, try not to share . . . to drink from the same glass, eyebrow tweezers and personal things like that.

By contrast, bilingual Latinas did not ask questions regarding the nature of HIV/AIDS or the modes of transmission. Many of the bilingual Latinas stated that they learned about HIV/AIDS in school or from knowing someone who had the disease. Overall, bilingual Latinas seemed to have a clear understanding of the disease, and thus the discussion about these topics was rather brief; instead, bilingual Latinas were more interested in discussing the factors that put them at risk for HIV/AIDS.

Safe Sex Practices and Perceptions of Risk

Safe sex practices

Seventy percent of bilingual Latinas reported using a condom every time they had sex compared with only 27% of monolingual Latinas (p < .05, Fischer’s exact test). Despite these differences, condom use was a prominent point of discussion in both focus groups. In particular, participants emphasized that negotiating condom use with their partners was a difficult process.

The condom is sometimes difficult because the man . . . Latino, Mexican American man they might say why do you want to use condoms? They laugh because maybe you have this other person or something. You don’t want to get children or something. So I think it’s difficult and awkward to use condoms.

As depicted from the participant’s comment above, many Latinas stated that when they tried to get their partners to use protection, their partners would accuse them of having sexual affairs outside of the relationship:

Well, in my home that’s what they’ve told me. You have someone else . . . surely it’s the neighbor, the landlord, the milkman, the butcher, my cousin that forgot something and ended up chatting with you . . . or whatever. Or if you go to the store and you take longer than you allegedly should, then see, there you go. You were having relations with someone.

Participants also indicated that substance use interfered with their ability to engage in safe sex practices. Specifically, they said that when their partners were under the influence they were less likely to use protection: “Someone that is drugged doesn’t have a conscience. He just wants to satisfy himself.” They further noted that their partners were more likely to be aggressive under the influence, highlighting how IPV can impede a woman’s ability to protect herself from HIV/AIDS infection.

In both the monolingual and bilingual focus groups, Latinas spoke directly about how being in an abusive relationship—or, in their words, an “unhealthy” relationship—contributed to their lack of sexual self-efficacy. They were often unable to negotiate condom use and unable to refuse sex when they did not want it.

In my case, it’s very difficult to say no and if you say “no, no and no” it’s very ugly . . . I mean, they can hit you and such . . . they verbally abuse you . . . and all that.

Because when you say no, they grab your hair and force you.

My ex-husband too . . . He used to travel on the weekends to the border and I don’t know what. And I didn’t want to be with him because I know he would go. But he would grab me by force . . . like she said . . . he’d punch me and hit me . . . and I had to do it so that he wouldn’t hurt me.

The third quote emphasized that being in an abusive relationship interfered with safe sex practices and compounded the risk for HIV. In addition to having sex outside of his primary relationship, this Latina’s partner was coming home and forcing her to have sex with him, an explicit example of how HIV and sexually transmitted disease (STD) are transferred to women by their abusive intimate partners.

For some women, practicing safe sex was not a priority while in an abusive relationship or when leaving or recovering from one:

When you’re out there you’re not thinking about STDs. You’re thinking about my spouse, the love. You’re dealing with emotional abuse, the physical abuse and then when you’re not safe you can think about all the other things that come intact with the decisions you’re made to just get your immediate needs met.

Perceptions of risk

The majority of participants were aware of the intersecting nature of IPV and HIV/AIDS risk. Table 2 shows that 80% of bilingual Latinas and 60% of monolingual Latinas knew that experiencing IPV increased a woman’s risk of HIV/AIDS (see Table 1). However, only bilingual Latinas seemed to apply this to their own situation. Among bilingual Latinas, 50% reported that they had experienced IPV and 50% reported that they thought they were at risk of being infected with HIV/AIDS (see Table 2). Among monolingual Latinas, 67% reported that they had experienced IPV and only 27% reported that they thought they were at risk of being infected with HIV/AIDS.

Table 2.

Perceptions of HIV Risk and Safe Sex Practices: Comparison of Endorsed Responses (“yes”) Between Monolingual (n = 15) and Bilingual Latinas (n = 10).

	Bilingual Latinas	Monolingual Latinas	Fischer’s exact test
	% (n)	% (n)	Fischer’s exact test
Protective factors: HIV/AIDS
Have you experienced sexual violence (rape, sexual assault) or having had sex when you did not want to within your abusive relationship?	50% (5)	67% (10)	n.s.
Do you think you are at risk of being HIV/AIDS infected?	50% (5)	27% (4)	n.s.
Do you worry about getting infected with HIV/AIDS?	80% (8)	60% (9)	n.s.
Do you protect yourself every time you have sex from being infected with HIV/AIDS?	70% (7)	40% (6)	n.s.
Have you ever been diagnosed with a sexually transmitted disease (chlamydia, gonorrhea, etc.) during your abusive relationship?	4 (40%)	27% (4)	n.s.
Have you ever been diagnosed with more than one sexually transmitted disease (chlamydia, gonorrhea, etc.) during your abusive relationship?	2 (20%)	13% (2)	n.s.
Do you use a condom every time you have sex?	70% (7)	27% (4)	.049
Have you ever asked a male partner to use a condom?	90% (9)	80% (12)	n.s.
If you have asked your male partner to use a condom, did he respond negatively?	40% (4)	47% (7)	n.s.
If you have asked your male partner to use a condom, has he responded positively?	60% (6)	33% (5)	n.s.
Has the shelter offered you information on referrals to be tested for a sexually transmitted disease, including HIV/AIDS?	20% (2)	33% (5)	n.s.
Has the shelter offered you information on referrals for treatment for a sexually transmitted disease, including HIV/AIDS?	30% (3)	33% (5)	n.s.
Has the shelter offered you information on how to protect yourself from HIV/AIDS infection?*	40% (4)	53% (8)	n.s.

Note. Percentages reflect only responses that were in the affirmative.

Significance Level .0.049

Although there was some discussion about increased risk of being infected with HIV/AIDS when raped by one’s partner, the focus of the conversation about risk was more on infidelity than on IPV.

You think with some ladies that are faithful to their men and they’re stay at home moms. She does everything for the man but it’s the man that’s out there doing wrong.

And doing things wrong and then coming home to you.

And bring it to you.

Among monolingual Latinas, the discussion of infidelity was solely focused on the male as the perpetrator. Bilingual participants also talked about female infidelity:

I think a lot of us, because we’re hurt by our spouses, we tend to stray off and cheat and want to find somebody else to confide in and believe that we’re loveable and that we’re cared for and needed. So, we’re also inclined to having multiple partners.

And a lot of us, because we’re been abused, tend to jump from man to man. I haven’t met hardly anybody that’s just been with one person, you know, in our situation where we’re at.

Bilingual Latinas mentioned that low self-esteem and unhealthy family upbringing were two additional risk factors, aside from the abuse, that increased their risk for HIV:

If you not have your self-esteem high . . . then you’re looking for the love. . . . You continue to have many uh, couples (partners).

You can come from a home that you weren’t shown no love. You weren’t shown how to respect people. You weren’t shown how to respect yourself. You weren’t shown morals or values because you had no one there to do it.

These Latinas felt that having low self-esteem and not being raised in a good home led to poor decision making (i.e., hanging with the wrong crowds, looking for love in all the wrong places), which put them at high risk of HIV/AIDS.

In both groups, participants mentioned that limited resources increased their risk of HIV/AIDS. Because they did not have money, “papers” (documentation of citizenship), or insurance they were unable to get tested or receive proper treatment for their sexual health or for things related to being a victim of IPV.

Cultural Perspectives

Significant discussion included components of cultural and familial experiences that shaped the participants’ perspectives of HIV/AIDS risk and healthy relationships. Primarily, the “Latino macho man” attitude played a major role in their partners’ resistance to condom use. In their cultural context, men control the sexual decision making; thus, women are not supposed to request using condoms during sex. According to participants, when a woman crosses that gender line she is humiliated (e.g., “They laugh because maybe you have this other person or something”) and accused of being unfaithful in the relationship.

Second, there was discussion about the role of women in the family and the importance of mother–daughter relationships:

. . . there are women that . . . have had the support of a mother or family that have talked of the importance of self-esteem and how important it is that you talked about morals and values and respecting yourself and respecting the role of mother to your children and what you teach your children. And some have had that opportunity.

Finally, conversations focused on spirituality and morality, and religion and faith were healthy ways women expressed themselves and worked through their history of abuse, as portrayed in the following three quotes:

The morality, I think, is a foundation of values, fears, your love, your hate.

I feel like [God] was my source to make me stronger . . . that was my source that gave me the power not to go back [to the abusive relationship]. Not to put up with that no more.

I think a lot of, looking at women in particular, there’s a strong connection between religion, faith and spirituality in our culture.

Culturally and Contextually Relevant HIV/AIDS Prevention Intervention

Monolingual and bilingual participants engaged in a conversation about what they would want to see included in an HIV prevention program. Both groups said that practicing abstinence and having more information about HIV/AIDS, safe sex practices, and sexual health (e.g., visits to the gynecologist, pap smears) would be helpful. Monolingual Latinas felt that they needed more education, whereas bilingual Latinas were more concerned about increasing knowledge and awareness among their peers and children.

Bilingual Latinas provided several recommendations for prevention programs that were not discussed among monolingual Latinas. They agreed that prevention programs should provide access to female condoms so that females do not have to rely on males to use protection and could protect themselves. They also mentioned that there should be more focus on teaching women, particularly Latinas, about the importance of being in a “healthy relationship” and having higher self-esteem. They mentioned the importance of including religion in prevention programs and suggested attending to many logistical details, including reaching diverse women, holding classes in a safe, unsuspicious location, and providing assistance with transportation and child care.

Discussion

This study is unique in the use of mixed methodology to explore the HIV/AIDS knowledge, experiences, and perceptions among monolingual and bilingual Latinas. Congruent with existing research on domestic violence and HIV/AIDS risk (El-Bassel et al., 2005; Raj et al., 2004), participants in this sample reported that experiences of domestic violence inhibited their ability to practice safe sex and put them at risk for HIV/AIDS infection. Members of both the English-speaking and Spanish-speaking focus groups discussed an inability to use condoms and openly shared situations of forced sex and childhood sexual abuse. While they had little to no locus of sexual control in their abusive relationships, some expressed that they did not even think about prioritizing their sexual health until after leaving their violent situations; even then, it was not always a priority.

Race, ethnicity, and culture played an intricate role in HIV/AIDS knowledge and prevention practices among the women in this sample. First, they noted the growing rate of HIV/AIDS-related death among Latinos in the United States. At the same time, however, they asserted that HIV does not discriminate and affects all people equally. Thus, there seems to be a separation between these two concepts: Participants noted that “too many” Hispanic people are dying of AIDS, but there was no discussion of possible reasons for this disparity. The participants did talk indirectly, however, about structural barriers. For example, many participants did not have the financial resources, insurance, or documentation to get the medical care they need in regard to HIV and other STD testing.

Participants articulated fear and silence about HIV/AIDS. Because of the fear and silence, the focus group participants expressed a strong desire to know more about HIV/AIDS basics. Not only did they want to know more ways of protecting themselves, but also several participants in the Spanish-speaking group wanted an answer to the question “What is AIDS?” An important prevention tool, then, is alleviating clients’ fears of HIV by dispelling HIV-related myths. It is clear that myths regarding HIV were disempowering. The participants in this study expressed fear in areas they cannot control (e.g., blood transfusions), which distracted them from focusing on areas in which they could make positive changes (e.g., using condoms). Dispelling the myths about HIV infection through education would help women evaluate their actual risk levels and then determine the most appropriate steps to protect themselves.

The strong cultural expectations of gender roles plays a significant part in the worldview of the participants, their relationships, and their HIV risk. The male gender role “machismo” results in situations in which men control sexual decision making and women cannot negotiate condom use. However, participants in this study discussed a positive, healthy view of women’s gender roles in which mothers teach their daughters the importance of self-esteem. When seen in conjunction with literature indicating that “marianismo” prevents Latinas from having sexual self-efficacy, there appears to be a duality: Female gender roles may increase self-esteem in the case of strong mother–daughter relationships, but they may also perpetuate silence around sex, which creates an environment in which sexual decision making is left to the men rather than to the women and can increase risk of HIV. All treatment, counseling, and intervention models need to explore both positive and negative aspects of Latin cultural influence when it comes to HIV prevention for Latina women. One essential component, as observed in the focus groups, is to consider the family as an integral part of life among Latino Americans. For the women we interviewed, family was an active part of everyday living and pivotally influenced their decision making—protecting themselves from HIV is a way they can protect their children and their family. HIV prevention must happen at the family level rather than at the individual level for it to be effective and sustainable for this population.

Limitations

There are several limitations in this study which must be attended when interpreting the findings. First, given the non-random, small sample of this study, we cannot generalize the results. Furthermore, broad claims about the impact of ethnicity on HIV and IPV cannot be made due to the lack of information about participants’ ethnic identity. Specifically, Latina/os are not a homogeneous group. In fact, according to the U.S. Census there are more than 20 different Latina/o subgroups just within the United States (U.S. Census Bureau, 2007). Although these subgroups have some similarities (e.g., being of Latin descent, centrality of family), there are also many distinctions (Gutierrez, Yeakley, & Ortega, 2000). Most of the participants in our study were influenced by a Mexican-Latino cultural background, meaning that results may not apply to Latinas from other Latina/o subgroups (e.g., Cuban, Puerto Rican, Nicaraguan, Chilean).

Another limiting factor is that we only talked to Latinas who were residing at a domestic violence shelter. These females are already seeking help and may have already received education about HIV/AIDS. Thus, they may be distinctly different from other Latinas who are experiencing IPV or those who are not experiencing IPV but are still at risk of HIV/AIDS for other reasons.

Conclusion and Implications

Findings illustrate that when providing a HIV prevention intervention for Latinas, it is important to emphasize HIV prevention basics as a primary focus. While covering HIV/AIDS basics is a clear priority, it is also evidently not enough. Given the complex nature of abusive relationships and cultural factors, the participants provided valuable information for consideration in designing a specialized prevention program, such as sexual health information, self-esteem, healthy relationships, identifying types of abuse, and ways to get help in abusive situations.

Footnotes

Appendix

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Michele A. Rountree is an associate professor with the University of Texas at Austin School of Social Work, and her scholarship focuses on the areas of health promotion, disease prevention, and health disparities as it relates to meeting the needs of marginalized populations. Much of her research has involved the examination of HIV/AIDS risk-reduction interventions for women who have experienced intimate partner violence. In addition, scholarship efforts include the development and evaluation of evidence-based HIV/AIDS interventions and prevention strategies tailored to populations with alarming rates of infection such as African American and Latina women.

Teresa Granillo is dedicated to improving the mental health and well-being of Latina adolescents and young adults, helping them to successfully obtain their education, have a better quality of life, and ultimately be a contributing member of our society. She is currently the executive director of Con Mi Madre, a nonprofit providing services to Latinas and their mothers that increase preparedness, participation, and success in post-secondary education.

Meredith Bagwell-Gray, MSW, graduated from the University of Texas at Austin School of Social Work and is currently pursuing her PhD at the Arizona State University School of Social Work. One particular area of research interest is the correlation between risk for HIV infection and women’s experiences of intimate partner violence, particularly as it relates to sexual safety.

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