Drugs, Women and Violence in the Americas: U.S. Quantitative Results of a Multi-Centric Pilot Project (Phase 2)

Drogas, mujeres y violencia en el continente americano: resultados de un proyecto piloto multicéntrico en Estados Unidos (Fase 2)

Rosa María González-Guarda¹

Nilda Peragallo²

Ami Lynch³

Susanna Nemes³

¹ Ph.D., M.PH., R.N., C.PH. School of Nursing and Health Studies, University of Miami. Coral Gables, FL, USA.

² Dr PH, RN, FAAN. School of Nursing and Health Studies, University of Miami. Coral Gables, FL, USA.

³ Ph.D. Social Solutions International, Inc. Silver Spring, MD, USA.

Correspondencia Susanna Nemes Social Solutions International Suite 201 8070 Georgia Avenue Silver Spring, MD 20910 Estados Unidos snemes@socialsolutions.biz

Recibido para evaluación: 16 de mayo del 2010 Aceptado para publicación: 5 de agosto del 2010

Abstract

Objectives: To explore the collective and individual experiences that Latin American females in the U.S. have with substance abuse, violence and risky sexual behaviors. Methods: This study was conducted in two phases from July 2006 to June 2007 in south Florida. This paper covers Phase 2. In Phase 2, questionnaires were provided to women to test whether there is a relationship between demographics, acculturation, depression, self-esteem and substance use/abuse; whether there is a relationship between demographics, acculturation, depression, self-esteem and violence exposure and victimization; whether there is a relationship between demographics, acculturation, depression, self-esteem, HIV knowledge and STD and HIV/AIDS risks among respondents; and whether there is a relationship between substance abuse, violence victimization and HIV/AIDS risks among respondents. Results: Participants reported high rates of alcohol and drug abuse among their current or most recent partners. This is a major concern because partner alcohol use and drug use was related to partner physical, sexual and psychological abuse. Only two factors were associated with lifetime drug use: income and acculturation. Over half of the participants reported being victims of at least one form of abuse during childhood and adulthood. A substantial component of abuse reported during adulthood was perpetrated by a currently or recent intimate partner. Conclusions: The results from this study suggest that substance abuse, violence and HIV should be addressed in an integrative and comprehensive manner. Recommendations for the development of policies, programs and services addressing substance abuse, violence and risk for HIV among Latinos are provided.

Key words: Substance abuse, violence victimization, STDs, HIV, Hispanic, women

Resumen

Objetivo: Explorar las experiencias colectivas e individuales que mujeres latinomaericanas tienen en los Estados Unidos en cuanto al abuso de sustancias, violencia y conductas sexuales de riesgo. Métodos: El estudio se realizó en dos fases entre julio de 2006 y junio de 2007, en el sur de Florida. En la Fase 2, se dieron cuestionarios a las mujeres para comprobar si existe una relación entre: características demográficas, grado de aculturación, depresión, autoestima, uso/abuso de sustancias, exposición a la violencia y conocimiento de los riesgos del VIH y el sida. Resultados: Los participantes reportaron altos índices de abuso de alcohol y drogas. Sólo dos factores se asociaron con el uso de drogas de por vida: ingresos económicos y aculturación. Más de la mitad de los participantes informaron haber sido víctimas de al menos una forma de abuso (físico, sexual y/o psicológico) durante la infancia y la adultez. Un componente importante de los abusos reportados durante la edad adulta es que fueron perpetrados por un compañero íntimo. Conclusiones: Los resultados de este estudio sugieren que el abuso de sustancias, la violencia y el VIH deben abordarse de manera integradora y global.

Palabras clave: Trastornos relacionados con sustancias, violencia, enfermedades de transmisión sexual, VIH, mujeres.

Introduction

Methods

This pilot project was part of a multicentric research project including various countries in Latin America and the U.S. The study was conducted in two phases and utilized both qualitative (phase one) and quantitative methods (phase two) to gather data on the experiences Hispanic women in the U.S. have with substance abuse, violence and risky sexual behaviors. This paper reports on the results from the second, quantitative phase of the project, which sought to accomplish the following: To examine the relationship among acculturation, depression, self-esteem, substance abuse, violence exposure and victimization, and intimate/sexual relationships; To examine the interrelationship between substance abuse, violence, and intimate/sexual relationships.

a. The data collected from these questionnaires were used to test the following hypotheses:

b. There is a relationship between demographics, acculturation, depression, self-esteem and substance use/abuse.

c. There is a relationship between demographics, acculturation, depression, self-esteem and violence exposure and victimization.

d. There is a relationship between demographics, acculturation, depression, self-esteem, HIV knowledge and STD and HIV/ AIDS risks among respondents.

There is a relationship between substance abuse, violence victimization and HIV/AIDS risks among respondents.

Numerous statistical analyses were used to describe the relationships hypothesized above. Details about the quantitative analysis are described in the methodology section.

Sample and Setting

In order to be eligible for the study, participants had to be women of Hispanic/Latino decent, Spanish, English or Portuguese speaking (according to country) and between the ages of 18 and 60. Non-Brazilian study participants (n=81) were primarily recruited from a community agency in Broward County, where they were recruited with flyers. Additional participants from the Dade and Broward counties were recruited through an article in the local newspaper that described the study and provided readers with contact information and through snowballing sampling methods in where participants encouraged their friends and relatives to also participate. CICAD/ OAS (Inter-American Drug Abuse Control Commission, Office of American States) and SENAD (National Anti-Drug Organization in Brazil) required that we purposely recruit and enroll 10 Brazilian women into the study. This component of the sample (n=10) was recruited by a Brazilian research assistant who placed flyers in Portuguese at Brazilian grocery stores and businesses and approached perspective participants in these areas.

Phase Two Methodology

In second phase of the study, individual face-to-face in-depth interviews were used to collect data on the individual experiences that participants have with substance abuse, violence victimization and sexual relationships. Data on the respondent's demographics, level of acculturation, self-esteem and depression were collected using general demographic questions, the Bidemensional Acculturation Scale (2), the Rosenberg Self-Esteem Scale (3), and the CES-D Scale for depression (4) respectively. Although these are not the main outcome variables, they have been identified as being related to the main outcomes of interest (substance abuse, violence victimization and risky sexual behaviors).

Substance abuse was assessed using the TWEAK and the Psychoactive Drug History Questionnaire. The TWEAK, is a five-item questionnaire (7-point scale) that assesses alcohol abuse. The acronym stands for T (tolerance), W (worry), E (eye-openers), A (amnesia) and K (cut down) (5). This is one of the few alcohol abuse instruments that has been developed for and validated among women as well as Hispanics in the U.S. (6,7). The Psychoacti-ve Drug History Questionnaire, a widely used drug use inventory, measured the type of drugs that were used, the amount of years they were used for, if these drugs were injected, and the frequency of used during the last six months (5). An additional column was added to this questionnaire to assess drug use during the last three months.

Exposure to violence was assessed in various sections of the questionnaire. Violence victimization questions are included in the partner table (see description below) and a violence history that assesses exposure to community violence as well as physical, sexual and verbal/psychological abuse during both child and adulthood. The researchers on this team developed these questions. A psychological violence victimization scale, the PMWI-F (short version) (8) was used to further explore verbal/ psychological abuse among Latinas. This is a 15-item tool that assesses psychological abuse within intimate relationships. Additional questions relating to this specific area of abuse were added because women are often unfamiliar with this type of abuse and are therefore presumably less likely to report these in an abuse history.

Risky sexual practices and risk for STDs and HIV/AIDS were assessed in the sexual history portion of the questionnaire. The research team developed the questions included in this section, most of which have been used before (9). These questions will assess the risk for STDs and AIDS/HIV. Questions about contraception use and sexual practices were included, as well as an in-depth history of the lifetime partners of the respondent (partner table). Respondents were asked to identify the number of lifetime partners and trace their partners from their current or most recent partner to their first. Data on their sexual practices, exposure to violence and substance abuse during the time they were intimately involved with each partner were documented on the questionnaire. General knowledge about HIV and its prevention were assessed using the HIV Knowledge Questionnaire developed by Heckman et al. (10).

Study participants were required to sign an additional consent form prior to administrating the face-to-face questionnaire (Phase 2). The principal investigators and coinvestigators trained train bilingual, bicultural graduate students from the University of Miami to assist with conducting the interviews in English and Spanish and the Brazilian research assistant to conduct the interviews in Portuguese. Participants completing this phase of the study were also paid $50 to compensate them for their time, travel and child care expenses.

Analytical Methods, Phase 2 (Quantitative Data)

Data collected from the questionnaires were analyzed using SPSS (v.14.0) for Windows. Analyses included descriptive statistics of demographic characteristics, acculturation, self-esteem and depression. The proportion of participants reporting drug and alcohol use, violence exposure and risky sexual practices were also described by category and classification (i.e. cocaine use, sexual harassment, never using condom during vaginal intercourse). Simple, multiple and logistic regression analysis and chisquare analysis was used to explore relationships between demographics, acculturation, depression and self esteem and the outcomes of interest (substance abuse, violence and STD/HIV risks) and to explore relationships between the outcomes themselves. Finally, t-tests were used to explore differences between the Brazilian and non-Brazilian (Hispanic) sub-groups of the sample in regards to the outcomes of interest.

Results and Analysis, Quantitative Results

Demographics

Latino women participating in the study were diverse in respect to their age, country of origin, socioeconomic situations and other socio-demographic variables (See Tables 1 and 2). The average age of participants was 39 years of age (SD=10.73) and had spent an average of 9 years in the U.S (SD=9.30). Participants represented almost all countries in Latin America, with the largest proportion of participants coming from Colombia (42.4%), Venezuela (12.0%), Brazil (10.9%) and Ecuador (7.6%). All participants had a high level of non-U.S. acculturation (100%), while many were highly acculturated to the U.S. (41.3%) and were therefore, also considered bicultural according to the Bidemensional Acculturation Scale (2). As typically found within Latino cultures, the majority of participants reported being Roman Catholic (60.9%) and being influenced at least somewhat by their religious beliefs (83.7%). A large proportion of participants were married (57.6%) and currently living with a partner (6 2. 0%). They had an average of 1.65 children (SD=1.26). The majority of participants were also not employed (56.5%). Consequently, they had an average monthly income of less than $1,000 (M=955.54, SD=1316.07). Their household monthly income was little higher (M=2,554.18, SD=1735.13), but still low considering that an average of 3.46 people (SD=1.26) lived off of this money. Although they had a low income, participants had a relatively high level of education. In fact, 89.1% had either graduated from high school or had obtained their GRE. The average years of education of participants was over 14 years (M=14.25, SD=3.75), signaling that the majority of participants had obtained at least some years of college level education. Only 23.5% of the sample had access to private or public insurance. The remainder of the participants paid their health care out of pocket (28.3%), had not access health care in the U.S. (17.4%), found a health center where they gave them reduced prices because of their no insurance status (10.9%) or returned to their countries of origin when they needed to access care (2.2%).

Psychological Variables

Participants scored high on the CES-D scale. The mean score for participants was 14.90 (SD=11.83), which was very close to the clinical depression cut-off point of a score equaling 16 and above. When this variable was dichotomized to separate those above and below the clinical cut-off point, 39.1% of the participants had probable clinical depression. Despite high rates of depression, they had relatively high levels of self-esteem according to the results of the Rosenburg Self-esteem Scale. In a scale ranging from 10 to 40, in where 10 is the poorest self-esteem and 40 is the greatest, participants scored an average of 34.79 (SD=4.52). The relationship between demographics, acculturation, depression and self-esteem and the outcomes of primary interest (substance abuse, violence and HIV risks) will be described in the following sections. This will be followed by the results of the analysis testing relationships between the primary outcomes and differences identified between Non-Brazilian and Brazilian sub-groups.

Substance Abuse

Alcohol use and lifetime and 3 month drug use were relatively low among the sample of participants. The majority of participant reported either never drinking alcohol or only drinking on special occasions, once or twice a year (58.7%). Fewer drank once a month or once a week (17.4% each), various times a week (4.3%) or once a day (2.2%). Participants also reported drinking few alcoholic beverages during occasions when they did drink (M=1.32, SD=1.30). Wine (37.0%), mixed drinks (15.2%) and beer (14.1%) were the most common alcoholic beverages participants drank during these occasions. Less than a third of the sample (28.3%) reported using/ experimenting with any illicit or non-illicit drug (excluding alcohol) included in the Psychoactive Drug Inventory during their lifetimes, while few reported any drug use during the last three months (5.4%). Among the illicit drugs included in the inventory, cannabis (8.7%) and cocaine/crack (4.3%) were the most frequently abused drugs participants reported abusing during their lifetimes. Among the non-illicit drugs, benzodiazepines (17.4%) were the most frequently used drugs participants reported using during their lifetimes. A very small proportion of these lifetime users reported also using these drugs during the past three months (all less than 2.2%). Reported alcohol and substance abuse rates were much higher among participant's current or most recent partner. In fact, 10% of participants reported that their partners were almost always drunk and 4.4% reported that they were almost always high on drugs. Occasional use was even greater (See Table 3).