Associations of Self-Silencing and Egalitarian Attitudes with HIV Prevention Behaviors Among Latina Immigrant Farmworkers

Abstract

Latinas in farmworker communities are at particularly higher risk for human immunodeficiency virus (HIV) due to the vulnerable circumstances they experience. However, little is known about the factors infiuencing HIV prevention behaviors in this population. The aim of this study was to examine the associations of self-silencing behaviors and egalitarian attitudes toward women in relation to three HIV prevention behaviors: self-efficacy for HIV prevention, intentions to negotiate safe sex, and HIV-related knowledge. This study is a cross-sectional analysis that used hierarchical multiple regression models to examine these previously mentioned associations, among Latina immigrant farmworkers from Miami-Dade County, Florida (n = 232). Findings indicated that self-silencing behaviors were adversely associated with the three HIV preventive behaviors whereas egalitarian attitudes were positively associated. Findings from this study may help to advance the understanding of sociocultural determinants of HIV prevention behaviors among Latina immigrants.

Background

In the United States (US), Latinas are disproportionately affected by the human immunodeficiency virus (HIV) epidemic, with an HIV diagnosis rate more than three times that of their White counterparts [1]. The most common mode of HIV transmission among Latinas is through heterosexual contact with a male partner [2, 3]. In 2015, 90% of the diagnosed HIV infections among Latinas were attributed to heterosexual contact [2]. Thus, unprotected sex with a male partner is a key behavior to prevent HIV transmission in this subpopulation. Traditional gender roles in the Latino culture (i.e. machismo and marianismo) may make it difficult for Latinas to negotiate condom use and other safer sex behaviors with their male partners; thus, increasing their risk for HIV [3, 4]. One explanation is that Latinas are often imposed restrictive roles and norms for culturally acceptable behaviors (e.g. submissiveness), and, as a result women silence and suppress their feelings, thoughts, and actions to secure and maintain intimate relationships; these are known as self-silencing behaviors [4–6].

Latinas in farmworker communities are at increased risk for HIV due to inadequate HIV knowledge, drug and alcohol abuse, and social isolation, among other factors [7]. Small studies conducted in the 1990s with geographically limited farmworker populations estimate that HIV infection rates range from 5% [8] to 3.5–13% among farmworkers [7, 9]. Nevertheless, little is known about the determinants of HIV and HIV prevention behaviors in this population. The present study will examine associations of self-silencing behaviors and egalitarian attitudes toward women in relation to HIV prevention behaviors that include self-efficacy for HIV prevention, HIV-related knowledge, and intentions to negotiate safe sex with male partners among Latina immigrant farmworkers. Our hypotheses are: (1) higher levels of self-silencing behaviors will be associated with lower levels of HIV prevention behaviors, and (2) egalitarian attitudes toward women will be associated with higher levels of HIV prevention behaviors.

Methods

Participants

The sample included 232 Latina immigrants in farmworker communities in Miami-Dade County, Florida. The mean age was 34.2 years (SD = 7.90; range 18–50 years). Most participants emigrated from Mexico (59.9%) and Guatemala (14.7%). The average years living in the US ranged from 3 to 10 (mean = 7.69; SD = 1.96). The sample was relatively low educated (54.3% did not complete high school), and approximately half of the women (53.9%) were currently employed. Participants reported relatively low-income levels with an average total income for the past 12 months of $22,518 (SD = $9953). Most participants reported having a partner (78.9%).

Data Collection

This is a secondary analysis of baseline data from an intervention study that evaluated the efficacy of Salud/Health, Educación/Education, Prevención/Prevention, y Autocuidado/Selfcare intervention (SEPA) among Latina immigrants in farmworker communities in Miami-Dade County, Florida. The SEPA intervention is a CDC evidenced-based, culturally tailored HIV risk reduction intervention, designed for heterosexual sexually-active Latinas in the US that is based on social cognitive theory [3, 7]. SEPA focuses on building self-efficacy skills through demonstrations, role-playing and other skill building exercises to reduce HIV risky sexual behaviors, domestic violence and substance abuse. The intervention included three sessions of 2.5-h facilitated over a period of 3 weeks (in Spanish) to 22 small groups of 8–10 Latinas. Inclusion criteria were heterosexually sexually-active women, self-identified as Latinas, between the ages of 18–50, that had lived in the US for less than 10 years. More information on the intervention procedures are published elsewhere [7]. The study protocol was reviewed and approved by the Institutional Review Board of Florida International University and informed consent was obtained from all subjects.

Measures

Demographics

The variables age, years in the US, and total income for the past 12 months were continuous. Education was coded as 1 = less than high school diploma, 2 = high school diploma, and 3 = greater than high school diploma. Employment status (currently employed) coded as 0 = no, 1 = yes, 2 = retired. Relationship status as 0 = no partner and 1 = with partner.

Self-Efficacy for HIV Prevention

Self-efficacy for HIV prevention, defined as a woman’s level of confidence in her ability to practice HIV prevention behaviors, was measured using a 7-item scale [3]. Items were rated on a 4-point Likert-type scale and summed scores ranged from 7 to 28. Higher scores represented higher levels of self-efficacy for HIV prevention. The internal consistency was α = 0.62.

Intentions to Negotiate Safe Sex

Four items on a 3-point Likert-type scale were used to measure intentions to negotiate safe sex (adapted from [10] for Hispanic women) [7, 10]. Summed scores ranged from 4 to 12, with higher scores indicating stronger intentions to engage in safer sex. The internal consistency was α = 0.74.

HIV-Related Knowledge

Measured with a 12-item scale to evaluate HIV related knowledge about HIV transmission, prevention, and consequences (responses: true, false and I don’t know) [3]. Summed scores ranged from 0 to 12, with higher scores indicated higher HIV-related knowledge. The internal consistency was α = 0.70.

Silencing the Self Scale

This 31-item scale measured specific schemas about how to build and maintain safe and intimate relationships [6]. Each item was rated on a 5-point Likert-type scale and summed scores ranged from 31 to 155, with higher scores indicating greater self-silencing behaviors. The internal consistency was α = 0.88.

Attitudes Toward Women Scale

Measured with the 15-item modified version of the Attitudes Toward Women Scale, which describes attitudes toward the roles of women in society. One item was omitted (i.e. “Economic and social freedom is worth far more to women than acceptance of the ideal of femininity which has been set up by men”). Each item was rated on a 4-point Likert-type scale with summed scores ranging from 14 to 56. Higher scores indicated higher egalitarian attitudes. The internal consistency was α = 0.73.

Analysis

Three hierarchical multiple regression (HMR) models were tested in SPSS version 25. Self-efficacy for HIV prevention, intentions to negotiate safe sex, and HIV-related knowledge were the outcome variables for each respective HMR model. Predictor variables were entered in the HMR models in two blocks. Block 1 included age, education level, partner status, employment status, total income for the past 12 months, and years in the US. Block 2 included egalitarian attitudes toward women and self-silencing. Two participants that responded to only one of four questions on the negotiation of safe sex scale were excluded from this analysis.

Results

Self-Efficacy for HIV Prevention

Results indicated that Block 1 accounted for 5.7% of the variance in self-efficacy for HIV prevention (R² = .057, F = 2.25, p = .04), and Block 2 added 20.1% (R² = .201, F = 6.97, p = .000) to the explained variance. In the final HMR model, higher scores of self-silencing were associated with lower self-efficacy for HIV prevention (β = − 0.241, p = .001); and higher scores of egalitarian attitudes were associated with higher self-efficacy for HIV prevention (β = 0.210, p = .004) (Table 1).

Table 1.

Results from final HMR models for predictors of HIV prevention behaviors (n = 232)

Predictors	Self-efficacy				Negotiation of safe sex				HIV knowledge
	B	Std. error	β	p	B	Std. Error	β	p	B	Std. error	β	p
Agea	−0.048	0.029	−0.102	0.094	−0.004	0.017	−0.017	0.789	−0.020	0.019	−0.061	0.299
Educationa	0.461	0.313	0.095	0.143	−0.110	0.182	−0.040	0.546	1.096	0.211	0.324	0.000*
Employment status (currently employed)a	−0.334	0.464	−0.045	0.472	−0.553	0.270	−0.132	0.042*	−0.321	0.312	−0.062	0.305
Total income for the past 12 monthsa	1.702E–5	0.000	0.046	0.461	−7.786E–6	0.000	−0.037	0.561	1.389E–5	0.000	0.053	0.372
Years in the USa	−0.118	0.118	−0.063	0.319	−0.157	0.069	−0.147	0.023*	0.095	0.080	0.072	0.236
Relationship statusa	−0.267	0.587	−0.029	0.649	−0.113	0.339	−0.022	0.741	−0.473	0.395	−0.073	0.233
Self-silencing (total score)b	−0.046	0.014	−0.241	0.001*	−0.026	0.008	−0.237	0.002*	−0.019	0.009	−0.142	0.039*
Attitudes toward women (total score)b	0.147	0.050	0.210	0.004*	0.067	0.029	0.172	0.022*	0.096	0.034	0.197	0.005*

^aVariable entered in block one

^bVariable entered in block two

^*Significant results

Negotiation of Safe Sex

Block 1 accounted for 4.7% of the variance in intentions to negotiate safe sex (R² = .047, F = 1.83, p = .09), and Block 2 added 16.7% (R² = .167, F = 5.48, p = .000) to the explained variance. In the final model, higher scores of self-silencing were associated with lower intentions to negotiate safe sex (β = − 0.237, p = .002); and higher egalitarian attitudes were associated with higher intentions to negotiate safe sex (β = 0.172, p = .022). Employment status and years in the US were also significant predictors of intentions to negotiate safe sex (β = − 0.132, p = .042; β = − 0.147, p = .023, respectively) (Table 1).

HIV-Related Knowledge

Results from the HMR model revealed that Block 1 accounted for 17.8% of the variance in HIV-related knowledge (R² = .178, F = 8.08, p = .000), and Block 2 added 26.0% (R² = .260, F = 9.73, p = .000) to the explained variance. In the final model, higher scores of self-silencing were associated with lower HIV-related knowledge (β = − 0.142, p = .039); and higher egalitarian attitudes were associated with higher levels of HIV-related knowledge (β = 0.197, p = .005). Education level was also a predictor of HIV-related knowledge (β = 0.324, p = .000) (Table 1).

Discussion

Understanding the associations of self-silencing and egalitarian attitudes toward women with HIV prevention behaviors among Latinas is important due to the critical role that traditional gender roles and sexual communication with male partners play in HIV prevention. The results of this study suggest that self-silencing and egalitarian attitudes were significantly associated with HIV prevention behaviors. As expected, self-silencing behaviors were adversely associated with the three HIV protective behaviors whereas egalitarian attitudes were positively associated.

Latinas’ HIV risk is embedded in the context of gender roles and culturally acceptable sexual behaviors [4]. Traditional gender norms make it difficult for Latinas to communicate with male partners about sexual behaviors (e.g. condom use), and to negotiate safer sex [5, 11]. Some women consider that expressing themselves and communicating their needs to their male partners is improper [5]. Consequently, they avoid issues that may cause confrontation and conflict to maintain harmony and connectedness in their intimate relationships, thus developing self-silencing behaviors [5]. Perz and Ussher found that offering sexual information and counseling to couples affected by cancer reduced self-silencing by providing a sense of confidence to renegotiate sex and express their sexual needs [12].

New Contribution to the Literature

This is one of the few studies that has examined associations of self-silencing behaviors and egalitarian attitudes toward women in relation to HIV prevention behaviors among Latina immigrant farmworkers. This study provides some insight into specific cultural factors influencing HIV prevention behaviors among Latinas. Although some research has produced interventions specifically tailored to Latina immigrants, there is a dearth of interventions specifically tailored to the cultural constructs of Latinas [3].

Limitations

Some limitations of this study include nonprobability sampling and a cross-sectional design that did not allow for the analysis of temporal relationships. Also, most participants emigrated from Mexico, which could limit the generalizability of these findings. Lastly, the study relied on self-reported data, which is susceptible to recall, and social desirability biases.