Abstract
This study explored factors that affect access to and use of sexual and reproductive health services including family planning among immigrant Latino men residing in rural Oregon communities that have experienced a high growth in their Latino population. In-depth interviews were conducted with 49 sexually active men aged 18 to 30 years who recently immigrated to the United States. Findings from content analysis identified multiple overlapping individual-level barriers, including lack of knowledge, perception of personal risk for unintended pregnancy and STIs, and fear of disease. On a service delivery level, structural factors and the importance of confianza when interacting with providers and clinic staff were dominant themes. The majority of these themes were grounded in a cultural context and linked to men’s cultural background, beliefs, and experiences. Examining the needs of immigrant Latino men through this cultural lens may be critically important for improving access and use of sexual and reproductive health services.
Keywords
Latinos in the United States experience disproportionately high rates of unintended pregnancy, sexually transmitted infection (STIs) and HIV/AIDS (Centers for Disease Control [CDC], 2011; Finer & Henshaw, 2006; James et al., 2009). The unintended pregnancy rate for Latinas aged 15 to 44 years is almost 2 times the rate for non-Latino White women (Finer & Henshaw, 2006). In 2009, the HIV infection rate among Latinos was nearly 3 times higher than for Whites (CDC, 2011). It is particularly noteworthy that during this time period, Latino men accounted for 79% of all new HIV infections among Latinos; heterosexual contact continues to be the primary source of HIV infection for Latina women, whose rate of infection was more than 4 times that of White women in 2009 (CDC, 2011). Disparities in other STI infections also affect Latinos, particularly those in the younger age bracket. For example, in 2009, young Latino men and women aged 20 to 24 years had gonorrhea and chlamydia rates that were twice as high as those among non-Latino Whites (CDC, 2010).
These sexual health disparities only have the potential to grow as Latinos continue to be the largest and fastest growing minority in the United States (Ennis, Rios-Vargas, & Albert, 2011). As part of this growth, nontraditional settlement areas in the Southeast and Northwest experienced rapid and dramatic increases in the number of Latino residents with large numbers migrating to rural areas (Kandel & Cromartie, 2004). In the Pacific Northwest, Oregon experienced a 144% increase in Latinos from 1990-2000, with another 63.5% increase through 2010 (Ennis et al., 2011). In 2009, 11% of the state’s population was Hispanic, 84% of who were of Mexican origin (Pew Hispanic Center, 2009). These new immigrants are more likely to be poor, male, young in age (aged 14-39 years) and move into communities unaccustomed to seeing large numbers of foreign-born residents and without established Latino communities (Fry, 2008; Lopez & Cohn, 2011; Painter, 2008). These circumstances combined with the reality that most immigrants have low-paying jobs, inconsistent access to employment, low levels of literacy, and low access to health services create challenges that may influence sexual risk behaviors and their use of sexual and reproductive health services (SRHS), putting them at greater risk of acquiring STIs (Parrado, Flippen, & McQuiston, 2004).
Several studies have identified factors that affect Latino immigrants’ access to and utilization of health care services including the high cost of services (Kalmuss & Austrian, 2010; Maternowska et al., 2010; Peak, Gast, & Ahlstrom, 2010), the lack of health insurance (Cristancho, Garces, Peters, & Mueller, 2008; Kalmuss & Austrian, 2010; Peak et al., 2010), communication difficulties (Cristancho et al., 2008; Holbert, Rumptz, & Drach, 2009; Peak et al., 2010; Rhodes et al., 2007), fears of discrimination and stigma (Bowden, Rhodes, Wilkin, & Jolly, 2006; Holbert et al., 2009; Kalmuss & Austrian, 2010; Maternowska et al., 2010; Rhodes et al., 2007), the lack of time to seek services (Holbert et al., 2009), the prevalence of misinformation (Rhodes et al., 2007), and lack of knowledge about available services (Bowden et al., 2006; Holbert et al., 2009; Rhodes et al., 2007). Few studies have specifically examined the challenges to serving immigrant Latino men’s SRHS needs. Of those, one was limited to men’s use of family planning services in a medium-sized Midwestern community (Sable, Campbell, Brandt, & Dannerbeck, 2006), whereas another included barriers to care in their exploration of determinants of HIV risk among Latinos in urban North Carolina (Rhodes et al., 2007). A third study (Bowden et al., 2006) looked at determinants of SRHS for men living with HIV, also in urban North Carolina. No studies to our knowledge have addressed issues faced by immigrant Latino men related to access and utilization of SRHS in rural communities in the Pacific Northwest.
The present study is part of a larger project, Proyecto de Salud Para Latinos Para Hombres (Latino Health Project for Men). The purpose of this article is to explore factors that affect utilization of SRHS by immigrant Latino men in four rural Oregon communities that have experienced a high growth in their Latino population. Because this study was intended to provide initial information about topics on which little is currently known for this specific group, both open-ended questions and quantitative measures were included to provide a fuller picture of participants’ experiences and perceptions. This article reports findings from in-depth interviews with Latino men from the target population and explores from their perspective: (a) use of health care services including SRHS and (b) factors that affect the use of SRHS, including family planning.
Method
Participants
The sample consisted of 49 sexually active Latino men (aged 18-30 years) from four rural counties in the Northwest. Participants were recruited from farms, health clinics, health fairs, and other community locations in each county using both passive and active strategies. Passive recruitment consisted of placing printed English and Spanish language recruiting materials (e.g., posters, flyers, brochures) at various community locations and radio ads on Spanish language stations. The printed materials and ads described the project and asked interested persons or those who wanted more information to call a 1-800 phone number. Active recruitment was accomplished by male bilingual/bicultural staff members approaching, recruiting, and possibly screening potential participants at various community locations (e.g., parks, grocery stores, bus stops, libraries). Project staff adhered to a specific script that included information about the project. Each person approached was given an easy-to-read brochure that described the study at the fifth-grade reading level in both Spanish and English. Individuals who were interested in participating were asked to complete the screening interview in a private setting. Those who were interested but could not complete a screening interview at that time were scheduled for a more convenient time.
To be eligible for the study, participants had to be men between the ages of 18 and 30 years, self-identify as Latino, immigrate to the United States in the past 10 years, report vaginal intercourse within the past 3 months, and report that they are not planning to get a sexual partner pregnant within the next year. Men were excluded if they had tested positive for HIV/AIDS, had a partner who was pregnant, were unable to understand informed consent or other aspects of the project description, and were not fluent in either English or Spanish. Of the 99 individuals screened, 50 (50.5%) met the eligibility criteria. A total of 49 participants (98% of eligible individuals) completed an interview.
As a result of the eligibility criteria described above, all of the men were Latino. The average age was 24.0 years and the vast majority (45, 91.8%) of them were natives of Mexico. The participants had been in the United States for an average of 6.0 years and in Oregon for 4.3 years. Levels of acculturation among this group were relatively low with a mean score of 1.97 on the Short Acculturation Scale for Hispanics (G. Marin, Sabogal, Marin, Otero-Sabogal, & Perez-Stable, 1987). Fifty-seven percent (28) of the men reported that they were currently unemployed and the majority were living well below the poverty threshold (U.S. Census Bureau, 2009). These men reported a mean of 9.1 years of education.
Participants cited an average age at first intercourse of 15.9 years, and a mean of 8.2 lifetime sexual partners to date. Just fewer than one half (22, 44.9%) said that they had ever had sex with a prostitute or sex worker, with 22.7% (11) of these reporting that they had done so within the past 3 months. Additional risk behaviors among this group included using recreational drugs (13, 27.1%) and/or binge drinking, with 37.5% (18) consuming ≥5 drinks at one time in the past month. Although a majority (31, 63.3%) said that they were aware of men in their communities having sex with other men, none of the men in our sample reported that they, themselves, had done so.
Data Collection
Participants were recruited and enrolled in the study over an 8-month period between November 2008 and June 2009. Bilingual, bicultural male staff members conducted individual semistructured interviews lasting approximately 60 to 90 minutes. Participants could choose to have the interview conducted in Spanish (n = 41) or English (n = 8). Interviewers referred to a standard interview guide for all interview questions. Interviews were audio-recorded and responses to close-ended questions were noted on hard copies of the guide. Participants were paid for their time and compensated for travel and/or child care costs. Institutional Review Board approval was obtained and each participant signed an informed consent form after the study was fully explained.
Measures
Development of the interview guide was informed by an earlier study conducted in rural Oregon involving Latino men and women (Zukoski, Harvey, Oakley, & Branch, 2011). The interview guide included open-ended as well as structured questions. To collect open-ended data men were asked where they went if they had concerns about sexual health issues, how they decide to see a doctor, and what they would do if they got an STI. They were also asked about their experiences using sexually transmitted disease services in Oregon, where they would go to get STI testing/treatment, and barriers and facilitators to accessing and using STI services. This set was followed with a similar series of questions about both HIV testing and family planning services. Last, men were asked how they would like to be treated when getting health care.
Although the focus of this analysis was on the qualitative data, responses were examined to quantitative questions regarding demographic characteristics, sexual risk behaviors, and men’s use of health care services to further describe the sample. Men were asked if they had health insurance coverage, if they had ever seen a health care provider, the number of times they had seen a provider in the past year, the usual places they sought health care, and their level of satisfaction with their care. Participants also reported whether they had ever seen a provider for SRHS, if they had ever had an HIV test, and if they had had an HIV and/or STI test in the past 3 months.
Analysis
Audio recordings of the interviews were transcribed, and interviews conducted in Spanish were concurrently translated. The transcripts were entered into the software program NVIVO 8 (QSR International) for coding, sorting, and quantifying thematic content of interest. The data were analyzed using ethnographic content analysis (Altheide, 1987), a “reflexive” process in which coded categories are permitted to surface from the textual data, allowing for unanticipated or emergent meanings, as well as continuous negotiation of, and refinements to, the analytic structure. After initial reading of the transcripts, two teams of coder pairs constructed and operationalized an initial system of codes reflecting the structure of responses to the open-ended survey. On second and ongoing readings of the transcripts, coders further developed and expanded on the coding structure to fully capture the contours of participants’ narrative responses, including anticipated and unanticipated response categories and expressions of sentiment. A minimum of two coders analyzed each survey section. Items on which there were differing opinions were discussed, issues were resolved, and any necessary alterations were made to the coding structure. With the transcripts fully coded, quotations were selected as exemplars to illustrate individual themes. Coded categories that were most frequent, and those that were striking even in their infrequency, were noted.
For the structured questions from the in-depth interviews, frequency distributions of participants’ responses were examined using SPSS 15.0 and STATA 10.1.
Results
Use of Services
Men in our sample were largely uninsured (43, 88%), with only 47% (23) reporting that they had ever seen a health care provider for services when they were sick or needed a checkup (Table 1). Of those who had seen a health care provider, the mean number of visits in the past year was 1.4. More than half (12, 52%) had visited a community clinic, whereas equal numbers (5, 22%) had either gone to a hospital clinic/emergency room or private doctor. Nearly all (22, 96%) men who had seen a provider reported being moderately, very, or extremely satisfied with their care. The majority of men (43, 88%) had never seen a provider for SRHS. Relatively small numbers of men reported being tested for HIV and other STIs in the past 3 months (6.1% [3] and 10.2% [5], respectively), although 49% (24) reported ever being tested for HIV.
Men’s Use of Health Care Services (n = 49)
Note. HMO = health maintenance organization; SRHS = sexual and reproductive health services; STI = sexually transmitted infection.
Factors That Influence the Use of SRHS
Several themes emerged from this exploratory study and were grouped into two broad categories: (a) individual-level factors and (b) perceived service delivery-level factors. Despite this organizational division, all themes were grounded in an overarching cultural context and were, in many cases, closely related and overlapping.
Individual-Level Factors
Knowledge and perceived risk
Many men cited a lack of basic information about reproductive health and family planning among their cohort. They described themselves and other Latino men as not having a great deal of knowledge about sexual and reproductive health or family planning, and a quarter of the men were unfamiliar with the term family planning. Accordingly, when asked what would make it easier to get family planning services, nearly three quarters responded that having “more information” or “knowing more about it” would facilitate access and utilization. As one man stated,
Well, as I said before, the majority of Latino men, we are ignorant or uneducated [about family planning] and it is not about how aggressive we are, but it is that we never received the education of knowing that we [men] have options on how not to get a woman pregnant.
The need for more information also included access issues. Men discussed not knowing where to find clinics, whom to ask for information or what services were available. In a response typical of the larger sample, one man commented, “Well, I think that there are indeed clinics . . . I don’t know what service they may offer.” This point was reiterated by another man: “Umm, I just think its lack of information is the main deal. It’s that they don’t know about it and they don’t want to ask about it.”
When men were asked where they would go if they needed family planning services, only four men in our sample named specific clinics. Excluding men who were unfamiliar with the term family planning, more than a quarter of participants said that they did not know or had “no idea” where they would go to get services, whereas the remainder said that they would go to “a clinic,” “a hospital” or “a place” without providing any further details.
When asked how clinics could promote their services and improve access for Latino men, more widespread dissemination of sexual and reproductive health information was a predominant theme. As one man shared, “Having pamphlets or brochures, in the places where the Latinos frequent a lot, telling about free or low cost . . . or about birth control methods and all of that.” Another man concurred, and added that materials should be placed “Not only in clinics . . . but also in laundromats, in Latino stores and all of that.” Media campaigns on television and radio, newspaper ads, posters, flyers, and mass mailings were also mentioned repeatedly by respondents. Some men noted that these channels could serve a dual purpose of informing men about reproductive health and family planning topics as well as notifying them about clinic locations, hours, available services, and cost.
Overall, men appeared to be most familiar with STI/HIV testing and related services. The vast majority not only said that they would go to a clinic or doctor’s office, but listed a specific place that they knew of or had used in the past. Although one third still cited a need for general information about STIs and HIV, they voiced specific needs and concerns around prevention, disease symptoms, treatment, and testing options.
Not surprisingly, information and knowledge about sexual and reproductive health and family planning were significant factors in shaping men’s perceptions of risk and need for services. This interplay was evident when men were asked about STI/HIV testing, and almost two thirds reported no personal need for seeking such services. One of the most common sentiments in this category was the certainty that they did not have an STI because they were asymptomatic and felt good. When men were asked why they do not seek testing for STIs and HIV, one man simply stated, “Well, I don’t think I have it. And if I don’t think that I have it, for what [would I go in for testing]?” Several other men tied their reasoning to their perceived state of health: “Well, because I . . . feel well, healthy, I feel I don’t need it.” “Well, I am well; the way I am right now, then why?” “Why? I’ve never thought of taking a test because no, I mean I don’t feel any discomfort or anything like that.”
Other reasons for inaction included that they had been tested before, they used condoms, or they did not engage in what they considered to be high risk behavior. Some men classified “high risk” as having sex with prostitutes, and otherwise felt safe. As one man stated, “No, I would not get tested because I haven’t had such intimate relations with people from the street.” Several men equated risky behavior with multiple sex partners, although each person had differing ideas about the number of partners and the frequency of encounters that made someone vulnerable to STIs. The following quotations illustrate these varied perceptions of personal risk:
Well I have not done it [STI/HIV test] because I have had sexual relations with women but not too many, and I didn’t consider it necessary . . . I haven’t had multiple partners, that’s why I didn’t consider it necessary. If I felt not well or so or I were a drunk and dealing with different women and very often, then yes, then I indeed would get worried and I would go to get a test done.
In contrast, more than two fifths of our sample presented cohesive ideas about why STI-related services should be important to men. Several felt that testing was important for protecting sexual partners and not spreading disease. Many participants also stated that they wanted to ensure that they were healthy or “clean.” Others would get checked if they had engaged in sex with multiple partners in the past, had not always used condoms, and were experiencing symptoms of a disease.
Men’s perceived need for family planning services also varied, and was clearly influenced by their lack of knowledge about family planning and the availability of services. Despite the fact that all participants were sexually active, almost a quarter of our sample expressed that they were not at risk for unintended pregnancies because they were not the right age for family planning services or already had children so they did not need such services. It was clear that many men were unaware of and lacked knowledge that family planning services were available for people wanting to prevent pregnancy as well as plan for it. One such man remarked that he was not interested in family planning “because most of the time I have been single.” Another man explained that he had not looked into family planning services at all “since I am not thinking about having a family yet.”
Despite the perceived lack of need for family planning services, more than two fifths of participants did report personal value in being able to prevent pregnancy and plan their children and families. Men in this group typically responded that they would use family planning services because they were “not ready for a kid” or a family, or did not want to have too many children. Many of these men also mentioned the importance of planning and ensuring that they had adequate resources to raise a child. As one man explained,
Right now, the reason that I use them [family planning services] is because I don’t want to have another baby, I can’t. Or we don’t want to have one now because we have plans; we have dreams for the child we already have; we want to focus on giving him all our attention and love and give him the necessary things so he lives comfortably with us.
Men frequently referenced their cultural background and beliefs as an explanation for their lack of knowledge and perceptions about SRHS and family planning in particular. For example, many men attributed their lack of knowledge to cultural constraints surrounding sexuality. Almost half of the men reported that they had never discussed sexual and reproductive health topics with their parents while growing up, a commonality that more than one attributed to their country of origin. As one man explained, “Unfortunately we come from a country that, I don’t know, they never want to talk about that. They keep it quiet and one grows up ignorant about that subject.” Another man confirmed this statement: “Well no, in Mexico you hardly talk about that. One gets shy to talk with your parents about sex.” Moreover, in many rural areas men were not exposed to family planning ideas or services. One man explained,
Well, more than anything one comes like this from Mexico. In Mexico, in a ranch, in a small town there are not clinics. One grows up saying, well, I grew up like my grandpa. That is what one says, that’s what one is based in.
Similarly, another man clarified, “. . . I feel that it is part of one’s own culture because in Mexico, nothing is planned.” This viewpoint was reiterated by several men who noted that their culture was not traditionally supportive of family planning. As one man stated,
It is that we are very reserved; we don’t want to see the things like—like, the things of the past didn’t allow that one be seeking that [family planning services] in order not to have children. That, that was not seen so well. And we have these beliefs.
Almost a fifth of the sample elaborated on this theme by making a connection to machismo-related beliefs about male behavior. According to one man, “Well, I think that one feels due to machismo one doesn’t want to go to such places.” This belief was corroborated by another participant, who noted that men don’t seek family planning services because “. . . there is machismo and all of that, like a man should not be getting that stuff.” Men’s comments about culture and machismo illustrate how these beliefs may be closely linked with a lack of interest in seeking SRHS including family planning. Although machismo is not inherently a Latino male characteristic, it clearly has implications for behavior. When combined with a cultural history that has not embraced the male role in sexual and reproductive health, the cultural belief of machismo perpetuates the idea that Latino men do not have to be responsible for their own sexual health or that of their partner.
Fear of disease
Many men also attributed a fear of being diagnosed with a disease as affecting Latino men’s use of services for HIV and STI testing. Despite the fact that almost two thirds perceived no personal need for services, almost half of the participants reported being afraid of the prospect of a positive diagnosis. Some equated a positive HIV or STI diagnosis with death, perhaps because they lacked knowledge about treatment options. Others were fearful of what an HIV or STI diagnosis would mean for their future. As is illustrated in the following quotes, many of these men dealt with their fears by avoiding them:
Well, in this case Latinos are very—How I tell you! They are very afraid—How is it said, which is this word! They are very reserved. It’s like they are afraid of that. They are afraid of going to a clinic and getting tested for AIDS. That’s the reason they never go. The fear. . . . the other [reason] about “why not?” [get tested] because of just being afraid about what one can have, and better not to take any action. Concerns? Concerns, as I can tell you, yes, there are concerns, because I had sex with other women and I also don’t know with whom they were dealing with before . . . Yes, I do have this concern; why would I tell you that it’s not! And yes, I have had this idea to go to get tested. And as I can tell you—at the same time, I don’t want to get tested because I don’t want to know.
Finally, several men expressed fear and concern about the effects of being diagnosed with HIV or an STI on their morale, their role as a provider for their family, and future relationships. As one man explained,
. . . there’s a shame behind the STD infection. The shame of you are not clean, and for a man to have an STD and all the women know about is like, well, you probably never get laid or have sex because none of those women want to get infected also, so it’s quite shameful.
Perceived Service Delivery Factors
Themes that emerged from an exploration of factors that affected men’s access to and use of SRHS were clustered into two broad categories: (a) confianza, a term that encompasses trust, respect, level of communication, and confidentiality and (b) structural barriers to SRHS. Themes within these categories are discussed below.
Confianza
Men’s culturally based need for confianza emerged as an overarching theme that connected men’s concerns about privacy, confidentiality, and communication when interacting with and receiving services from health care providers. The need for privacy when seeking or receiving SRHS was a recurrent theme and discussed by nearly half the men. Several noted that without a sense of privacy between the provider and patient, there can be no trust, or confianza, resulting in no honest and open discussion about sensitive health issues. As one man explained,
Confianza in our society is everything. Having trust in another human person makes that human connections. So if the gain, so if I’m able willing to give this health care provider my trust, I’m trusting him with my body, with my whole self, so it means everything. It’s everything pretty much.
An important aspect of this theme was trusting providers to be nonjudgmental and true to their professional ethic not to disclose information about patients. Respondents repeatedly said that men need to feel they can speak honestly with their provider and without embarrassment in order to seek and receive appropriate treatment. As one man explained, “Well I think that the confianza is very important because one is embarrassed, with fear of what they might think what are they going to say about me?” Another man elaborated,
Well, it’s important to trust on your doctor and the doctor try to trust on you because you are going to tell him, truly, why you have the disease, if you have this disease or what you are doing sexually or what you are not doing sexually. Because even if they tell you, “You know what, all you tell me I won’t tell anyone else”—you know, this is—about these kinds of things it is natural that someone feels distrustful. So it is important that someone don’t judge you just because you are a patient, rather he or she should try to understand. They should tell you, “You are not alone, there are many people, here we have information about places you can go to speak, to share time with someone like you; you are not alone, nor are you the worst thing because having contracted this disease.”
The importance of privacy extended beyond the provider level to the front-office staff and how they handled appointments and communicating test results. One man said that his fear of disclosure by clinic personnel prevented him from getting an HIV test. Several men who had HIV tests were reassured that the clinics kept the purpose of their appointment private. One man described his testing experience as pleasant “because they didn’t put right there a sign that says, ‘here he comes to get tested for AIDS.” Another man corroborated his experience:
I was treated right. It was confidential also, so there is not like, you know, they are not in front of people saying, you getting tested for HIV or anything like that. It was, it was just good.
The importance of being treated respectfully emerged as another significant theme. More than two thirds of the men talked about basic elements of respect such as kindness, sincerity, and honesty. As one man explained,
Well, I think [respect] means that they look at you as a human being, not as a person that committed a mistake of being with a prostitute and that contracted these diseases. I believe that we all have the necessity of socializing and maybe that person has no one and he decided to go to be with a prostitute looking for some warm human affection or friendliness. So nobody knows why he is where he is. So before judging a book by his cover, one should try to read it a little bit.
Similarly, almost half of the respondents described respect as equality in treatment and being treated fairly or “just like everyone else” regardless of color, race or income. As one man summarized, “Treat me equally; treat me equally to others. You know just because my color is brown and the people around here are White, Caucasian . . . Just because of the color they shouldn’t be judging people.”
Nearly three fifths of the men discussed the importance of honest communication with a provider. The ability to converse and feel that the provider is listening to what you say was heard repeatedly in our interviews; some men took it a step further and noted that they wanted an open discussion of the problem and treatment options. One man commented,
Ummm, I guess, I probably like them making me feel comfortable like telling me like, ok you have this option and you have this other option. You know, if I tell them what’s going on, I would like to know more than just, “oh you have this option and that’s it.” Because I would think that there is more than one thing they can do about my, whatever situation I was in.
A providers’ ability to establish rapport through collaborative and friendly communication was noted by almost a quarter of the men. One man explained that “. . . there are good conversations with the doctors about your health and there are others that just fill out a questionnaire. They don’t ask you the reason or anything, simply what do you have, what is wrong, that is all.” This sentiment was confirmed by another man who noted that
The most important is to converse. To start a conversation where he would say, you know what, don’t be afraid, there are not problems; I am here to help you out, and all of that. Make you feel like you are his friend. I would say that this is the only way that I would have more confianza of saying, you know what! This is what I have, doctor. And also I would say, a smile let’s say, a good conversation, and good advice too.
Another man added that he would like providers to approach him:
As a human being, with a smile. Having them telling us, “Good morning! Good afternoon! How are you doing? How do you feel?” A little brief conversation, just before they say, “To take down your pants, let me check you!” Just something like that.
Structural barriers
Men’s perceptions of structural factors related to service delivery appeared to be strongly influenced by their cultural background and experiences, and in many ways overlapped with individual-level factors previously identified. For instance, knowledge affected economic factors such as actual or perceived costs of SRHS, which were mentioned as a deterrent by a third of those interviewed. One man said, “I have the idea, well they charge a lot, right?” Another man replied: “I feel [men] don’t use [SRHS] because they think it is very expensive.” Concerns about cost for services were exacerbated by lack of knowledge about available services, unemployment, lack of health insurance, and concerns about legal documentation. Several men commented on cost in conjunction with men’s lack of information about low-cost services that are available. As one man explained,
Well, because what is it called . . . like all of us Latinos know that it’s expensive, the medical health is expensive and we are not aware that there is [help] from the government. I was not aware until today
Other concerns included lack of health insurance and their perception that documentation of legal status would be required to receive free or low-cost services. As one man described his situation, “Because we don’t have, one has no papers, one has no good insurance, one can only go to the hospitals. One can’t go to a clinic because you know they will charge you a lot.” Another man elaborated on this theme:
Not, not having the papers [legal documents] from here, from the United States. That’s why they usually don’t see us [in the hospitals, clinics]. Because one is not a citizen here. This is the only problem. Not having a good health insurance, not having a Medical [Medicare]. Those are the problems, a big problem.
More than two thirds of our sample listed provider characteristics that would facilitate men’s access to SRHS. Several men expressed a preference for male providers while others expressed a need for bilingual providers. One man explained that a past experience with a health care provider could have been improved simply by “having bilingual people there to approach you as a human being.” The majority of comments in this theme focused on the interconnection between language and patient-provider rapport. Another man elaborated,
It doesn’t matter who he is, as long as he or she is a person who understands that el calor humano [warm human affection or friendliness] is needed for any person that is in trouble and if he or she is bilingual then it is easier.
Several men commented that at the very least, having translators present during appointments would facilitate communication. One man described his concerns:
They could have Latino people there that—I mean, someone who can explain you well about the birth control methods and all of that. Because one speaks English with difficulties and they put you with someone who only speaks English and he speaks to you very fast and you don’t know anything about what he said.
Although men generally agreed that clear communication between providers and patients was important, a few expressed reservations about the presence of a translator. One man noted his embarrassment when he “had to go to the doctor, and they speak only English and I had to go with someone, a girl, to help me with the translation.” Another man explained his feelings about having a third party present:
Sometimes one has a problem . . . or wants to talk but they get embarrassed to tell the translator because he’s going to tell the doctor and how embarrassing . . . what will he say, and he is going to say that I am very nasty and this and that. They are going to think–I think this is maybe the case–the embarrassment, that [the translator] is going to hear and what does it matter to him, my body?
Clinic-related factors also affected access to SRHS, and participants reported that having convenient clinic hours, reduced waiting time and living or working in close proximity to a clinic would make it easier to receive SRHS. Several men described time pressures because of time spent working or searching for work, or that clinics were closed when they were not working: “Well, I think, indeed, there is some sort of impediment. There are times when one is working and by the time one leaves work all the offices are already closed.” Another man described how men’s lack of time is simply one more barrier that contributes to an overall web of effects that prevents men from accessing services:
Here in Oregon, maybe the lack of information or the language too [stops men from seeking SRHS]. I think there are many that want to know something but that it is only in English and I can’t, I don’t understand this and also the lack of decision, oh I’ll go later, oh later . . . any way I don’t have time right now, I have a lot of work.
Several men also reported that time spent waiting to be seen within the clinic was a barrier to using services: “I think because sometimes one does not have patience; one arrives in the clinic and they leave you there waiting for 2 or 3 hours there and they don’t pay attention to us.” Two men suggested having more personnel would reduce the wait for appointments and at the clinic: “I think that—to make it more comfortable? Having more doctors available because there are times that there are not enough of them. Then [there is] a long wait.” Another man voiced having a good experience, “They didn’t keep me waiting forever and ever so, I thought . . . I had good experiences with them.”
Discussion
This study explored factors that affect access to and utilization of SRHS by young immigrant Latino men in four rural Oregon communities that have experienced a high growth in their Latino population. Using open-ended questions and listening to our participants allowed for complex and contextual themes to emerge among a group of men who are generally silent about sexual and reproductive health topics. Many of the themes men identified parallel those from the small body of research done thus far with immigrant Latino men (Bowden et al., 2006; Peak et al., 2010; Rhodes et al., 2007; Sable et al., 2006). Most notable, however, was the way in which nearly all these themes were grounded in a cultural context. In our interviews, men went beyond simply identifying factors related to SRHS; they gave context to these themes, and linked many of their perceptions and actions to their cultural background, beliefs, and experiences. Examining the sexual and reproductive health needs of immigrant Latino men through this cultural lens may be critically important for improving access and use of SRHS (Diaz, 1998; B. V. Marin, 2003; Maternowska et al., 2010).
Information, knowledge, and perceptions are important predictors of behavioral intentions and can erect formidable barriers to men seeking and accessing SRHS (Holbert et al., 2009; Rhodes, Hergenrather, Wilkin, Alegria-Ortega, & Montano, 2006). Yet as Diaz (1998) points out, whether or not a person follows through with those intentions depends on a multitude of contextual, cultural, and social variables. For many men in our sample who originated from rural Mexican towns, SRHS for men were unheard of, unavailable, and generally considered outside the accepted scope of masculinity. Men’s opportunities for gaining accurate information and knowledge were further hampered by the lack of discussion of reproductive health topics in their formative social and familial networks.
This concept of “sexual silence” in the Latino culture is well documented in the literature (Diaz, 1998; Gilliam, 2007; B. V. Marin, 2003) and describes the high level of discomfort many Latinos report in talking openly about sex. In a culture where family harmony is highly valued, remaining silent may be preferable to broaching potentially embarrassing topics (Diaz, 1998). Compared with parents from other ethnic groups, research has consistently shown that Latino parents discuss sex with their children less often (Hutchinson, 2002; O’Sullivan, Meyer-Bahlburg, & Watkins, 2001). More recent studies, however, reveal that although newer generations of Latino families in the United States are more open to discussing values and beliefs about sexual relationships, the primary deficit in these discussions is the provision of sex-specific information about topics such as birth control and STIs (Guilamo-Ramos et al., 2006; Raffaelli & Green, 2003). These findings support the accounts from many of our interviewees who reported little to no parental education about sexuality, STIs, or pregnancy. This lack of discussion in turn can lead to misinformation and knowledge gaps that are difficult to identify and correct (Bowden et al., 2006). Sexual silence has, therefore, direct implications for men as they seek and access SRHS.
Men’s reluctance to communicate about sexual and reproductive health issues can also prompt fear of STIs and HIV as well as social stigma (Diaz, 1998; Holbert et al., 2009). In our own sample, these feelings were strong enough to dissuade some men from seeking any kind of SRHS for fear of being seen in their community as having a sexual disease or problem. For other men, remaining ignorant of any condition they may have was far preferable to receiving a diagnosis and having to contend with the result. These events appear to contribute to and reinforce the cycle of inaction. As Holbert et al. (2009) point out, being secretive or in denial about their risk factors or disease status isolates Latino men from their normal support structures and prevents them from clarifying misinformation. For many health issues, the Latino family is often considered one of the primary sources of information as well as social support (Diaz, 1998; Livingston, Minushkin, & Cohn, 2008). However, Diaz (1998) points out that paradoxically, it is the family that can deter men from taking charge of their sexual and reproductive health in the first place. The importance of maintaining family harmony, the threat of social stigma, and the culture of sexual silence are all factors that can affect how Latino men interpret and react to sexual health issues (Diaz, 1998).
Machismo, a term used by participants to justify a wide range of male behaviors, highlights the role of norms and expectations of masculinity on risk behavior. Masculinity is typically associated with proven courage, fearlessness and strength; the need to prove leads to the more perverted displays of masculinity that gives machismo its tainted reputation (Diaz, 1998). In turn, these norms erect masculinity-related barriers that can have a negative effect on health-seeking and preventive behavior (Kalmuss & Austrian, 2010; Peak et al., 2010). Men’s insecurities about their place in the paradigm of masculinity could help explain why more than half our sample saw no need for seeking SRHS, or avoided them because such services do not fit within the realm of what is traditionally considered “masculine.”
Our findings also corroborate a number of studies that have identified common structural barriers to health-seeking behaviors among Latinos, including long waiting time (Ransford, Carrillo, & Rivera, 2010), cost (Cristancho et al., 2008; Heyman, Nunez, & Talavera, 2009; Rhodes, Hergenrather, Zometa, Lindstrom, & Montano, 2008), concern about confidentiality (Rhodes et al., 2008), and language barriers (Britigan, Murnan, & Rojas-Guyler, 2009; Holbert et al., 2009; Moreno & Morales, 2010; Ransford et al., 2010; Rhodes et al., 2008). Individually, such barriers may not be enough to prevent someone from accessing services. Taken together however, individual, systems and cultural factors interact to reinforce each other and ultimately constrain access (Heyman et al., 2009).
Despite these barriers that constrain Latino immigrant men from being proactive in seeking SRHS, men in our study were forthcoming with their appeals to health care providers for confianza, respectful treatment and honest communication. For many new immigrants who are not fluent in English, the ability to communicate with their provider influences access to services as well as their satisfaction with their visit. Adding an overlay of language and cultural differences to an office visit that is already too brief could facilitate mistrust and avoidance of the health care system, particularly where STI/HIV testing and other preventive SRHS are concerned (Britigan et al., 2009; Cristancho et al., 2008; Nachtigall et al., 2009; Julliard et al., 2008). Medical translators add yet another barrier. As in our study, the lack of availability of trained medical translators has been widely noted as a deficiency in providing care to Latinos (Cristancho et al., 2008; Nachtigall et al., 2009; Flores, 2005, 2006; Timmins, 2002). However, men in our study had mixed feelings about the presence of translators; although they could ensure an accurate exchange of health information between patient and provider, having a third party present—potentially a female member of their own community—also introduced a fear of stigma and violated men’s strong need for privacy.
Some potential limitations should be noted. First, this was a qualitative study that used convenience sampling. Participants were recruited at locations throughout the region to increase the likelihood of capturing a wide spectrum of viewpoints. Our relatively small sample size and limited geographic area, however, means that findings may not be generalizable to the Latino population in the region. In addition, all data were self-reported and, therefore, subject to recall and social desirability bias. To minimize underreporting of behaviors that may be socially undesirable or stigmatized, interviewers and participants were matched by gender and ethnicity. Finally, due to concerns about the legality of their status in the United States, it is possible that some potential respondents declined participation out of fear that engaging in the study would make them more visible and potentially vulnerable. As a result, our sample may not be representative of undocumented immigrants and biased toward documented and more acculturated Latinos. However, because project staff were known and trusted in the communities from which sampling occurred, and because participants were not asked about immigration status, these effects were likely mitigated.
Despite these limitations, our findings coupled with previous research provide insights for public health efforts to enhance new immigrant Latino men’s access to and use of SRHS. First, many participants had limited knowledge about reproductive health topics, particularly pregnancy prevention. Although simply possessing knowledge does not imply a corresponding change in behavior, it is nonetheless a necessary component. The men in this study offered many of their own ideas about how to best disseminate information about reproductive health and SRHS, such as airing public service announcements on Latino radio or television stations, placing articles about reproductive health or ads for services in Latino newspapers, or distributing pamphlets in locations where Latinos frequent, such as Laundromats or Latino stores. Men also emphasized the importance of providing information in Spanish, a proposition that has received support from numerous other studies (Becker et al., 2009; Branch, Harvey, Zukoski, & Warren, 2010; Britigan et al., 2009; Hunter, Fernandez, Lacy-Martinez, Dunne-Sosa, & Coe, 2007). Britigan et al. (2009) also suggest that language problems can be circumvented by turning to computers and the use of the Internet as a way to access health information in a user’s native language. Given the upward trajectory of Internet and computer use in this population (Livingston, 2011), future research should closely examine the possibilities for improving health literacy among immigrant Latino populations through computer applications.
Second, although the use of Latino lay health promoters and peer health educators is widely advocated, men’s fears about privacy and stigma cast doubt on the ability of bilingual, bicultural members of the Latino community to effectively convey messages about topics as personal as sexual and reproductive health. Although Latino peer education has been notably successful in tackling issues on chronic disease and general health and lifestyle (e.g., Balcazar et al., 2006; Elder et al., 2006; Garvin, Cheadle, Chrisman, Chen, & Brunson, 2004; Townsend, Johns, Shilts, & Farfan-Ramirez, 2006), there is some evidence in the literature to suggest that expert interventionists or nonpeer deliverers (e.g., health care providers, counselors) may be more effective in promoting protective sexual behaviors than trained lay community members (Durantini, Albarracin, Mitchell, Earl, & Gillette, 2006; Herbst et al., 2007). More research is needed, however, to better understand effective delivery methods of sensitive sexual and reproductive health messages to immigrant Latino male populations.
Third, health care providers and clinic staff might consider assuming a slightly different demeanor with their Latino clients. Dispensing health information and expecting subsequent behavior change may be unrealistic, as men’s cultural background and life experiences often reinforce just the opposite. Given what is known about the influence of culture, background and experience on sexual behavior, providers might benefit by approaching men’s behaviors as rational actions within their particular sociocultural context (Diaz, 1998). Moreover, connecting with Latino male clients may require a unique balance of friendliness and professionalism. Bolstering findings from other studies (Cristancho et al., 2008; Ransford et al., 2010), men in our sample preferred a provider and a clinic setting where interactions are respectful, professional yet conversational, where they can speak honestly about their health issues and options, and can establish a sense of partnership. Diaz (1998) corroborates the importance of this client–provider partnership as a mechanism for Latino men to gain a sense of control over their own health by acting collaboratively in the construction of their own behavioral intentions.
Such a relationship should also facilitate frank discussions about the intersection of culture and sexual health. For instance, it is imperative that providers engage Latino men in conversations regarding their beliefs and fears about HIV testing and possible seropositive status and treatment. Previous studies have also advised that providers tap into machismo-related beliefs by emphasizing the need for men to be responsible for their families, protecting their wife, and in general building positive images of manhood (Herbst et al., 2007; Sable et al., 2006). At the same time, however, providers should be aware of the possible connotations implicit in machismo-related sexual behavior (Diaz, 1998). As providers learn more about their clients’ beliefs and background, the more effectively they will be able to apply this tenet.
Last, it was clear that the men in this study valued discretion when seeking and accessing SRHS. Clinic staff who are discrete, professional, and preferably bilingual can help Latino men feel secure in their ability to enter a clinic despite the specter of social stigma. Once men are inside the office, frank assurances of privacy and confidentiality are essential in all client–provider interactions, particularly if a translator is present.
Our study provides important insight into how recent male Latino immigrants in rural Pacific Northwest communities integrate perceptions and beliefs about their cultural background into their experiences in seeking and accessing SRHS. As an increasing number of immigrants move to this area, understanding factors that affect their selection and use of the health care system will become even more critical. General barriers to health care have been researched elsewhere and in many instances parallel the experiences of our population. However, the use of qualitative data has allowed us to better understand the interaction of those barriers with cultural beliefs held by this understudied population. Only by placing barriers into a cultural context that resonates with immigrant Latino men will it be possible to implement a more effective array of solutions.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Grant No. 44 FPRPA006029 from the U.S. Department of Health and Human Services, Office of Population Affairs to S. Marie Harvey, College of Public Health and Human Sciences, Oregon State University.