Social Support Networks:An Underutilized Resource for the Prevention of HIV and other Sexually Transmitted Diseases among Hispanic/Latino Migrants and Immigrants
Hispanic/Latino migrants and immigrants are vulnerable to infection by HIV and other sexually transmitted diseases (STDs). Participation in social support networks helps them cope with circumstances in the U.S. Studies of Hispanic/Latino migrants suggest that participation may also be protective against HIV/STD infection. However the studies do not satisfactorily explain how participation leads to protective actions, and recommend externally-induced interventions for HIV/STD prevention rather than incorporating the spontaneously occurring forms of social support they describe. Given the potential protective effects of support networks, a database search was conducted to ascertain the extent to which published HIV/STD prevention interventions for these populations incorporate their support networks. Very few interventions were identified and fewer still incorporate support networks. This commentary calls for research to understand more fully how support networks affect HIV/STD risks among Hispanic/Latino migrants and immigrants and identifies potential benefits of incorporating these networks in HIV/STD prevention for these vulnerable populations.
Hispanics, Latinos, migrants, immigrants, HIV/AIDS, sexually transmitted diseases, social support, social support networks
Hispanic/Latino migrants and immigrants from Mexico and other Latin American countries number nearly nine million in the U.S.1,2 Most seek income-earning opportunities; others flee oppression and violence in their countries of origin. Hispanic/Latino migrants and immigrants have long used mobility as a strategy for locating opportunities and addressing risks that affect their and their families' livelihoods in their countries of origin, doing so within social fields or spaces that cross national borders.3,4 Once in the U.S., they may encounter additional risks, including those of infection by HIV and other sexually transmitted diseases (STDs). Hispanics/Latinos in the U.S. are disproportionately affected by HIV/AIDS and other STDs, and have been identified by The U. S. Office of National AIDS Policy as a population at elevated risk for HIV infection.5 In 2013, Hispanics/Latinos accounted for almost one quarter of new [End Page 44] HIV diagnoses in the U.S. and six dependent areas.6 Among Hispanics/Latinos who are also migrants or immigrants, several factors characteristic of their circumstances can affect their HIV/STD infection risks. Individual actions by males that can increase their risks of transmitting or being infected by HIV and other STDs include unprotected sex with heterosexual partners, particularly sex workers,7,8 sex with other men,9,10 heavy alcohol consumption and other forms of substance use.11,12 For female Hispanic/Latino migrants and immigrants, the greatest infection risk may be unprotected sex with a regular partner, including their husbands.13,14 Migrants' and immigrants' circumstances can also affect their HIV/STD risks. These include social and geographic isolation and loneliness in their U.S. destinations,13,15 disrupted family relationships,13,16,17 and attenuated or missing family-based or community-based social controls (social norms and sanctions) that can moderate risk behaviors.18 These factors may be amplified among migrants and immigrants in southern and Midwestern states where many Hispanic/Latino communities are relatively recent, often dating from the 1990s.13,19,20
Studies have demonstrated that HIV infection among foreign-born persons in the U.S., including Hispanics/Latinos, is more likely to occur in the U.S. than in their countries of origin,21,22 and prospective studies of Hispanics/Latinos before and after migration to the U.S., point to a causal link between participation in the migration process and increased HIV/STD risk behaviors.8,23,24 Research suggests that HIV-infected Hispanic/Latino migrants may be spreading HIV in their communities of origin. In Mexico, the source of most Hispanic/Latino migrants in the U.S., the spread of HIV infection is increasingly rural and heterosexual in nature due to the return of infected men from the U.S.25,26
Social Support Networks: Coping Mechanisms for Migrants and Immigrants in Second-Country Destinations
Studies of Hispanic/Latino migrants and immigrants in the U.S.13,18,27 and Central America,28 and migrants and immigrants in other world areas, for example, African migrants and immigrants in Africa,29 Europe,30 and the U.S.,31 have described social support networks that can facilitate their coping with risks and challenges they encounter in their second-country destinations. In general, social support networks among migrants and immigrants result from social affinities based on common nationality, co-residence in the same hometown or area of their countries of origin, shared ethnic or religious backgrounds, kinship, or friendship affiliations. Social support networks are social structures that result from these kinds of affinities and linkages and that enable persons in the networks to access a range of resources. Social support networks result from social networks (that result in turn from social links or connections), but differ by virtue of the specific content—social support—that they make available to members. As such, social support networks may be described qualitatively in terms of specific kinds of relationships among members (e.g., co-membership in church group or a co-residential or co-ethnic community in a destination country) and their functions for members (e.g., providing moral and emotional support to members in time of need, or facilitating access to housing or jobs). A recent effort to measure social support in relationship to HIV/STD risk behaviors among Hispanic/Latino migrants [End Page 45] and immigrants has been reported. However, the authors stress the importance of not collecting quantitative information only, as doing so may provide an unsatisfactory picture concerning the quality of social support that support networks afford members. They argue with respect to HIV/STD risks, that research is needed to examine both the quality and quantity of social support.32 Studies of Hispanic/Latino migrants and immigrants have described social support networks as facilitating access by members to material resources such as loans, housing, transportation, and access to jobs, and to non-material resources, including emotional support during times of hardship, and information about sources of loans, housing, and jobs.13,18,33,34
Protective Effects of Social Support Networks Relative to HIV/STD Risks
Several studies13,27,32,35 illustrate how accessing social support from networks of relationships within their communities can affect HIV/STD infection risks among Hispanic/Latino migrants and immigrants. In their study of male migrants from Michoacán, Mexico in Atlanta, Hirsch et al.13 observed that those who had more contacts with friends and family members in their social networks (defined as the people they could count on) reported fewer sex partners than men who did not have as many such contacts. A study by Kissinger et al.27 of mostly Honduran male migrants in New Orleans found that those who had family members in their households and who belonged to social organizations (church-related groups, Alcoholics Anonymous, soccer clubs, journalism, and worker's rights clubs) were less likely to patronize female sex workers and more likely to be sexually abstinent than men who did not. In contrast, men who reported inconsistent condom use with casual sex partners were less likely to belong to social organizations. The authors identify social connectedness as a potentially protective factor. A follow-on study by Althoff et al.32 also found that increased social support, assessed in terms of both quantity and quality, reported by the migrants in New Orleans was associated with fewer HIV/STD risk behaviors. In a study of male Mexican migrants in Tijuana, Mexico who were returning from the U.S. voluntarily or due to deportation, Martinez-Donate et al.35 observed that the negative effects of men's experiences of discrimination and stress caused by language barriers and their undocumented status in the U.S. on their self-reported sexual HIV risks were not as strong among men who had more support than among those with less social support. The studies do not describe the reach of the social support networks in their samples; i.e., the extent to which community members were included in the social support networks they describe.
Use of Social Support Networks by HIV/STD Prevention Interventions for Hispanic/Latino Migrants and Immigrants
The potentially protective effects of social support and participation in social support networks among Hispanic/Latino migrants illustrated by the descriptive studies referred to above raises a question about the extent to which behavioral HIV/STD prevention interventions for Hispanic/Latino migrants and immigrants incorporate [End Page 46] these support networks. To answer this question, a search was conducted to identify published reports of evidence-based behavioral HIV/STD prevention interventions for Hispanic/Latino migrants and immigrants. The search used the Prevention Research Synthesis database of the Centers for Disease Control and Prevention (CDC). The database contains more than 79,000 HIV-related publications and is periodically updated based through scans of the CINAHL, EMBASE, MEDLINE, PsychINFO, and Sociological Abstracts bibliographic databases.36 The search focused on peer-reviewed publications and book chapters published from 1990 to August 2014, describing HIV/STD prevention interventions designed for Hispanic/Latino migrants and immigrants that had been evaluated and reported behavioral or biologic outcomes. Studies that examined HIV/STD prevention interventions for migrants and immigrants other than Hispanics/Latinos were not included because they were beyond the scope of the analysis for this paper.
Seven prevention interventions were identified for the nearly 25 years covered by the search. Three interventions were designed for migrants: male migrant farmworkers,37 male urban-based day laborers,38 and male and female migrant farmworkers.39 Two interventions were designed for male immigrants40,41 and two for female immigrants.42,43 The intervention studies described participants' self reports concerning behavioral outcomes only: all described condom use; two described HIV testing. The interventions did not describe participants' participation in health care services. Because this commentary is concerned primarily with the extent to which the prevention interventions incorporated migrants' or immigrants' social support networks, the intervention outcomes are only briefly described below. Details on all interventions can be obtained from the author or the authors of the individual intervention studies. Of additional interest from a public health point of view is the extent to which the interventions identified by the search are available for actual use by organizations that provide HIV/STD prevention-related services to Hispanic/Latino migrants and immigrants.
Interventions for Hispanic/Latino migrants
The Tres Hombres sin Fronteras (Three Men without Borders) small-group intervention used fotonovelas (photo story books) and condom demonstrations to promote condom use by male Mexican migrant farmworkers with female sex workers, and was evaluated in San Diego County, California migrant farmworker camps. At one month post-intervention, more intervention than comparison participants who reported sex with female sex workers also reported using condoms.37 A unnamed small-group pilot intervention used poster-size loteria (lottery) cards, story vignettes, and condom demonstrations to promote condom use by male Mexican migrant day laborers, and was evaluated in Berkeley, California. At one month post-intervention, with no comparison condition, intervention participants reported reductions in any sex and unprotected sex with female sex workers.38 The Adapted Stage-Enhanced Motivational Interviewing (A-SEMI) intervention promoted condom use among male and female migrant farmworkers in southern Miami-Dade County, Florida. At nine months post-intervention, intervention participants were more likely than comparison participants to report consistent condom use and less likely to have never used condoms during their last sexual encounter.39
None of the three published interventions used migrants' social support networks in their design. Tres Hombres sin Fronteras and the migrant day laborer intervention [End Page 47] are not available for use.44 The A-SEMI intervention has been listed by CDC as a Good Evidence group level behavioral intervention in the Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention; however its use by service provider organizations appears to be limited (J. Sánchez, personal communication). A separate search of the CDC database for descriptions of unevaluated HIV/STD prevention approaches identified Hombres Preparados (Men who are Prepared), an educational toolkit that promotes condom use and HIV testing by unaccompanied male Hispanic/Latino migrant agricultural workers.45 Although the toolkit has not been evaluated for effectiveness, it has been packaged with supporting materials and is available for use from the National Center for Farmworker Health (E. Orozco, personal communication).
Interventions for Hispanic/Latino immigrants
The community-level HoMBReS (Hombres Manteniendo Bienestar y Relaciones Saludables—Men Maintaining Wellbeing and Healthy Relationships) intervention for male Hispanic/Latino immigrants, used soccer team members trained as lay health advisors (navegantes) to promote condom use and HIV testing by fellow team members, and was evaluated in central North Carolina. Eighteen months after completion of the health advisor trainings, more soccer team members who participated in navegantes' activities, compared with those who did not, reported consistent condom use and HIV testing.40 The two-session small group HoMBReS-2 intervention is based on HoMBReS, is delivered by Hispanic/Latino men trained as peer educators (compañeros de salud), and was also evaluated in central North Carolina. At three months post-intervention, HoMBReS-2 participants were more lik1ly than comparison participants to report consistent condom use and HIV testing.41 Mujeres Unidas y Activas (United and Active Women) is an empowerment program for Hispanic/Latino immigrant women, promotes condom use by their male sexual partners, and was evaluated in the Mission District of San Francisco, California. Six months after completing the intervention, with no comparison condition, participants reported slight increases in their partners' ever-using condoms and condom use at last sex.42 The HIV-intensive prevention program (HIV-IP) uses Freirian participatory education strategies with female immigrant Hispanic/Latino participants to promote condom use by their male sexual partners, and was evaluated in Boston, Massachusetts. At three and six months post-intervention, women in the HIV-IP and a general health promotion comparison condition were more likely than participants in a third arm wait-list comparison condition to report increased condom use with their main male sex partners.43
Only the above-mentioned HoMBReS40 and HoMBReS-241 interventions describe efforts by developers to tap into potentially supportive social relationships that can occur among Hispanic/Latino immigrants for purposes of intervention design and delivery. The authors describe the HoMBReS intervention navegantes as "natural leaders" who implemented the intervention by "working within the naturally existing social networks of a rural soccer league."40[pp.106–107] In similar manner, they describe the compañeros de salud (peer educators) who delivered the HoMBReS-2 intervention as "peer leaders" and "natural helpers."41[p.1772] HoMBReS has been packaged in English by the Sociometrics Corporation; a Spanish version is available (S. Rhodes, personal communication). The intervention is listed by CDC as a Best Evidence-based community-level intervention in the Compendium of Evidence-Based Interventions and [End Page 48] Best Practices for HIV Prevention. HoMBReS-2 has not been packaged; however the Spanish language curriculum can be obtained (S. Rhodes, personal communication). No information is available concerning the availability of the Mujeres Unidas y Activas program. The HIV-intensive prevention program curriculum is available in Spanish and English (A. Raj, personal communication).
A Partial Picture of How Social Support Networks Affect HIV/STD Risks among Hispanic/Latino Migrants and Immigrants; Some Implications for HIV/STD-related Research and Prevention
The illustrative studies by Hirsch et al.,13 Kissinger et al.,27 Althoff et al.,32 and Martinez-Donate et al.35 describe associations between greater social support or social connectedness among Hispanic/Latino migrants and lower levels of HIV/STD risks. These are important studies and provide useful insights. However, they provide limited detail concerning how the associations they describe are produced and reproduced over time and affect HIV/STD risks and protective actions among the migrants in their study samples. Hirsch et al. do not suggest reasons why the primary relationships they describe were protective against HIV/STD infection risks, and they acknowledge the need to better understand these issues through further research. Kissinger et al. suggest that social connectedness was protective against HIV/STD risks among male migrants in their study, but do not explain how norms, values, and interpersonal relationship processes that underlie the social connectedness affected the men's HIV/STD risk behaviors. Althoff et al. also observe a positive association between social support and reduced HIV/STD risk behaviors, yet argue that more research is needed to better understand the relationship between the quantity and quality of social support and HIV/STD risks. I take this to mean in part that we need to better understand the social dynamics and relationships that underlie and produce measured differences in quantity and quality of social support. Martinez-Donate et al. observe that the negative effects of various types of stress on HIV risk behaviors by the male Mexican migrants they studied were stronger among those men who reported less social support, but the reasons for this are not detailed in their preliminary report of study findings. Future analysis by the authors may clarify the issue.
Of interest is that most recommendations from these studies for HIV/STD prevention initiatives based on study findings focus on exogenous strategies—introducing or mobilizing social support from outside Hispanic/Latino migrant and immigrant communities, through the use of interventions or initiatives. Hirsch et al.,13 for example, recommend integrating migrants into social movements; Kissinger et al.27 and Althoff et al.32 recommend initiatives to foster a sense of community, social networks, and healthy social connections among Hispanic/Latino migrants; and Martinez-Donate et al.35 suggest that interventions to increase and mobilize social support may help counter the potential contribution of stress and discrimination to HIV risks.
These recommendations merit serious consideration and follow-up by HIV/STD prevention researchers and potentially as pilot efforts by HIV/STD prevention programs. However, they do not appear to consider, or consider to a limited degree, the possibility that the social foundations for developing the social support and shared [End Page 49] sense of community they call for may already exist among Hispanic/Latino migrants and immigrants in the form of spontaneously occurring relationships of social support. They do not focus on potential strengths or social capital that can occur within Hispanic/Latino migrant and immigrant communities that can contribute to HIV/STD-related resilience among them, and that may be tapped into for purposes of HIV/STD prevention and health promotion with these vulnerable populations.
In contrast, Rhodes et al.40,41 demonstrate the feasibility and provide some evidence suggesting the effectiveness of using trained Hispanic/Latino immigrants drawn from pre-existing social support networks to effect changes in their peers' HIV/STD risk behaviors. However, the authors provide few details concerning the supportive relationship structures, processes, and shared values and norms that underlie the naturally existing social networks to which they refer, and that contributed to observed reductions in intervention participants' HIV/STD risk behaviors. Greater clarity on these issues would be useful. Rhodes and colleagues acknowledge that this topic requires further study.40,46,47,48,49
Potential Benefits of Incorporating Social Support Networks in HIV/STD Prevention for Hispanic/Latino Migrants and Immigrants
The limited attention that the prevention interventions described above give to social support networks in their design and implementation is noteworthy in light of suggestions by researchers who have studied Hispanic/Latino13,20,27,44 and non-Hispanic/Latino migrants and immigrants alike29,50 that incorporating spontaneously occurring social support processes that can occur among these populations may be useful in the design of HIV/STD prevention programs for them. Doing so may build on community-based strengths (social assets) rather than focusing largely or solely on individual-level, risk-related deficits. Current HIV/STD prevention approaches frequently aim, as Herrick et al.51,52 have observed, to "identify risk factors that lead to deficits, disparities, and disease, and work toward removing these risks."52[p.2] Individuals targeted by behavioral interventions, for example, may be considered to lack sufficient HIV/STD-related self-efficacy and skills to negotiate condom use, so interventions are designed to strengthen these attributes and skills. Continued efforts are needed to ensure that behavioral prevention interventions address individual-level deficits of this kind. However, research is also needed to better characterize and understand spontaneously occurring social support structures and processes among Hispanic/Latino migrants and immigrants that may encourage and sustain HIV/STD-protective actions by these mobile populations, and to incorporate where feasible, these support networks in HIV/STD prevention and health promotion practice for them. Doing so may offer several potential benefits:
• Greater socio-cultural congruence of interventions and health promotion strategies with Hispanic/Latino migrants' and immigrants' circumstances, social relationships and processes, and shared values and norms.
• Greater acceptability by Hispanic/Latino migrants and immigrants because of a closer alignment with values shared by social support network members concerning members' well-being. [End Page 50]
• Increased program reach through the use of social structures and processes that Hispanic/Latino migrants and immigrants routinely use for sharing information about opportunities and risks, and through support for Hispanic/Latino migrants' and immigrants' coping strategies.
• More cost-effective approaches to HIV/STD prevention and health promotion among Hispanic/Latino migrants through the use of existing social support relationships in migrant and immigrant communities rather than relying solely on externally introduced, potentially unsustainable intervention processes.
• Reduced HIV/AIDS-related stigma through the creation of safe social spaces and opportunities for Hispanic/Latino migrants and immigrants:
○ To learn and share information about HIV/STD risks, prevention, and options for obtaining screening, care, and treatment.
○ To discuss openly and clarify issues that migrants frequently misunderstand concerning HIV/STD transmission and prevention.
○ To clarify how values and associated norms that are commonly considered to be pan-Hispanic/Latino in nature (e.g., machismo, familismo, and marianismo) can shape migrants' HIV/STD risks and protective actions.
• Changes in shared values and social norms among network members concerning HIV/STD prevention and health promotion, resulting in increased levels of community support and collective efficacy among Hispanic/Latino migrants and immigrants and their sex partners to take protective actions and seek needed care in a timely manner, thereby contributing to reduced morbidity.
• Reduced HIV/STD infection among Hispanic/Latino migrants and immigrants and their sex partners in the U.S. and in their countries of origin.
Given the large number of Hispanic/Latino migrants and recent immigrants in the U.S., persistent reports concerning their vulnerability to HIV/STD infection, evidence suggesting that they may be spreading HIV infection in their countries of origin, and a shortage of efficacious behavioral prevention interventions designed specifically for and available for use with them,40,41,53 innovative approaches are needed to increase or improve prevention options for these populations in the U.S. Improved understandings of how Hispanic/Latino migrants' and immigrants' social support networks can positively or negatively affect their HIV/STD infection risks, and of the potential value of incorporating these support structures in a range of behavioral and biomedical approaches for preventing HIV/STD infection and promoting access to HIV-related care54,55,56 may respond to this need for additional, culturally competent prevention resources. Furthermore, studies that describe the prevalence or salience of social support networks in Hispanic/Latino migrant and immigrant communities to better understand the nature and scope of community-based resources for potential support of HIV/STD protective actions would be useful. Of course, social support networks among Hispanic/Latino migrants and immigrants do not occur in a vacuum. We also need to better understand how social, economic, and political factors can shape the [End Page 51] circumstances within which social support networks form and function. Economic recession and resulting losses of employment opportunities, for example, can negatively influence the ability of social support network members to facilitate access by other members and would-be members of the support networks, to leads for gainful employment. Aggressive implementation of immigration policies and procedures by local, state, and federal authorities may constrain the stability and effectiveness of these support networks. Nevertheless, social support networks merit greater attention by HIV/STD prevention researchers and programs. They may are a potentially useful, albeit underutilized community-based resource for use in HIV/STD prevention and health promotion among Hispanic/Latino migrants and immigrants.
THOMAS M. PAINTER is affiliated with the Prevention Research Branch, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at the Centers for Disease Control and Prevention.