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. Author manuscript; available in PMC: 2022 Oct 10.
Published in final edited form as: Arch Sex Behav. 2022 Jun 28;51(5):2399–2412. doi: 10.1007/s10508-021-02237-9

A Relational Framework for Engaging Latino Sexual Minority Men in Sexual and Behavioral Health Research

Audrey Harkness 1, Brooke G Rogers 2,3, Daniel Mayo 4, Rosana Smith-Alvarez 4, John E Pachankis 5, Steven A Safren 4
PMCID: PMC9549688  NIHMSID: NIHMS1837541  PMID: 35763160

Abstract

Latino sexual minority men (LSMM) experience sexual and behavioral health disparities. Yet, LSMM are underrepresented in sexual and behavioral health research, creating scientific inequity. There is, therefore, a need to identify the barriers and facilitators to LSMM’s participation in sexual and behavioral health research, which is the gap that the current study sought to fill. We interviewed LSMM (n = 28; age 18–40, 57% US born) and key informants (n = 10) regarding LSMM’s barriers and facilitators to participating in sexual and behavioral health research and suggestions for increasing participation. The research team coded the data via thematic analysis. We found that relational factors are central to understanding LSMM’s participation in sexual and behavioral health research. Some relational experiences (e.g., interpersonal stigma) interfered with participation, whereas others (e.g., altruistic desires to contribute to community well-being) facilitated participation. The findings are consolidated within a new relational framework for understanding LSMM’s participation in sexual and behavioral health research. Study findings highlight the centrality of relational factors in influencing LSMM’s participation in sexual and behavioral health research. Relational factors can be used to inform the development of culturally relevant recruitment strategies to improve representation of LSMM in sexual and behavioral health research. Implementing these recommendations may address scientific inequity, whereby LSMM are disproportionately impacted by sexual and behavioral health concerns yet underrepresented in related research.

Keywords: Latino sexual minority men, Community research engagement, Relationships, Health disparities, Thematic analysis, Sexual orientation

Introduction

Latino sexual minority men (LSMM) face HIV disparities compared to non-Latino White sexual minority men (CDC, 2019). Latino men represent about 9% of the US population (National Center for Health Statistics, 2018), yet accounted for nearly a quarter of new HIV diagnoses in 2016, with the majority of diagnoses (88.3%) among LSMM. Although HIV incidence among sexual minority men (SMM) stabilized or declined from 2010 to 2016, LSMM experienced a 27.1% increase (CDC, 2019; Guilamo-Ramos et al., 2020). Migrants experience over a third of new HIV diagnoses among LSMM (CDC, 2018; Guilamo-Ramos et al., 2020). Although there is a nationwide increase in HIV diagnoses among LSMM, HIV is also regionally concentrated. For example, Miami-Dade County leads the US in HIV incidence, with LSMM most impacted (CDC, 2020; Florida Department of Health [FLDOH] in Miami-Dade, 2019). Accordingly, the Ending the HIV Epidemic initiative, launched in 2019, calls for research to scale up and disseminate evidence-based HIV-prevention services to LSMM (Fauci et al., 2019).

Simultaneously, Latino/a/x sexual minority communities experience behavioral health disparities (Gattamorta et al., 2019; Martinez et al., 2017; Rodriguez-Seijas et al., 2019), including depression, anxiety, and suicidal ideation (Cochran et al., 2007; Díaz et al., 2001; Sandfort et al., 2007) compared to their heterosexual and non-Latino/a/x White peers.1 These disparities are attributed to “minority stress,” the added stress marginalized communities face (Meyer, 2003; Schmitz et al., 2019; Shangani et al., 2020).

The co-occurrence of behavioral health and HIV disparities, along with structural factors that negatively impact health, is called “synergistic epidemics, or “syndemics” (Singer & Clair, 2003; Singer et al., 2006). Among SMM in general and LSMM in particular, mental health and substance use, along with other psychosocial, interpersonal, and structural challenges converge to increase the likelihood of HIV acquisition through sexual behavior (Martinez et al., 2016; Mimiaga et al., 2015). Therefore, there is a great need to engage LSMM in sexual and behavioral health research to develop and evaluate interventions that address these disparities, enhancing health and scientific equity. To achieve this, LSMM must be recruited to participate in sexual and behavioral health research.

Yet, LSMM are underrepresented in HIV-related sexual health and behavioral health research (Castillo-Mancilla et al., 2014; Du Bois et al., 2012; Harkness et al., 2019; Sullivan et al., 2011). For HIV-prevention intervention studies, LSMM are less likely to complete an online eligibility screener than non-LSMM (Du Bois et al., 2012). LSMM are also less likely to provide informed consent and enroll in online or in-person HIV-prevention and behavioral health interventions compared to non-LSMM (Grov et al., 2016; Harkness et al., 2019; Madkins et al., 2018). Finally, LSMM are less willing to participate in online follow-up study visits than non-LSMM, even when compensated (Grov et al., 2019; Khosropour & Sullivan, 2011).

Although it is clear LSMM are underrepresented in sexual and behavioral health research, the factors driving this underrepresentation are less clear. Prior work suggests LSMM may avoid participating in research due to concerns that staff could hold prejudiced attitudes about their ethnicity (Castillo-Mancilla et al., 2014; Murray et al., 2018), fears that participation could bring unwanted attention to sexual orientation (Murray et al., 2018; Zea et al., 2003), perceiving a lack of direct benefit (Zea et al., 2003), or concerns that participation could jeopardize US residency (Rhodes et al., 2010; Zea et al., 2003). These concerns may also be underscored by Latino/a/x communities’ mistrust of both research and the medical system (Blair et al., 2013; García et al., 2017; Sewell, 2015; Svensson et al., 2012), which are based in both historical and lived experiences of multilevel (e.g., interpersonal, structural) racist and ethnocentric bias and mistreatment (Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, 2003; Oakley et al., 2019; Sage et al., 2018). More broadly, Latino/a/xs may not be as aware of research opportunities due to a lack of outreach directed toward the Latino/a/x community (Castillo-Mancilla et al., 2014). Further research is needed to understand specific factors driving underrepresentation of LSMM in sexual and behavioral health research. Such research is needed for addressing persistent sexual and behavioral health disparities and may be driven by common and/or unique factors given the stigmatization of mental health and sexual minority identities within Latino/a/x communities (Bruce et al., 2008; Schmitz et al., 2019).

Relational factors and relevant cultural values may affect LSMM’s participation in sexual and behavioral health research. Relationships are central in Latino/a/x culture, exemplified by cultural values such as familismo (familism), respeto (respect), personalismo (personalism), simpatía (congeniality), and confianza (trust) (Andrés-Hyman et al., 2006; Kim et al., 2009). Compared to passive recruitment, face-to-face interactions with Latino/a/xs yield greater success as research staff establish meaningful relationships and provide an accurate understanding of the research (García et al., 2017; Kelley et al., 2020). Alternatively, video conference technology can allow Latino/a/x participants to familiarize themselves with research staff and develop a sense of trust (Cowan et al., 2007; Hendrickson, 2007). Collaborating with community leaders also helps to promote trust and willingness to participate in research (Reidy et al., 2012; Vincent et al., 2013). Relatedly, individuals who are referred to a study by a current participant or receive encouragement from their peers and family members are more likely to enroll than those who lack this type of support (García et al., 2017; Villarruel et al., 2006). Relational factors such as these may also specifically inform LSMM’s participation in behavioral and sexual health research.

Underrepresentation of LSMM in sexual and behavioral health research limits the development, evaluation, and dissemination of tailored sexual and behavioral health interventions that equitably benefit LSMM to overcome long-standing sexual and behavioral health disparities. The objective of the current study was to utilize a community-centered approach to examine factors that impede and facilitate LSMM’s participation in sexual and behavioral health research, and recommendations for ensuring equitable representation. The current study focuses on LSMM in South Florida, a region that leads the US in HIV incidence, with LSMM greatly impacted (CDC, 2020; FLDOH in Miami-Dade, 2019). Furthermore, the study focuses specifically on LSMM’s participation in sexual and behavioral health research, as sexual and behavioral health disparities are persistent among LSMM. The findings highlight barriers and facilitators, as well as culturally relevant recruitment strategies to promote engagement of LSMM in sexual and behavioral health research.

Method

Participants and Procedure

Participants included 28 LSMM and 10 key informants, defined as individuals who provide behavioral health or HIV-prevention services to LSMM in South Florida. LSMM were recruited from individuals who were eligible for one of two HIV-prevention and behavioral health (i.e., mental health/substance use) trials and participated (“engagers;” n = 15) or did not participate (“non-engagers;” n = 13). Most participants were recruited from ESTEEM, a trial evaluating an LGBTQ-affirming mental health treatment that addressed behavioral and sexual health concerns among young gay and bisexual men (Pachankis et al., 2019). Additional participants were recruited from project IMPACT, a trial evaluating a behavioral intervention to reduce stimulant use and sexual behavior that could lead to HIV acquisition among men who have sex with men (Mimiaga et al., 2019). We purposively recruited both “engagers” and “non-engagers” to achieve representation of individuals who participated and did not participate in prior research. Recruitment of LSMM was purposively stratified by nativity to achieve representation of US born and non-US born LSMM. LSMM who were screened for either of the two prior trials and provided their contact information for future studies were contacted by our study team and invited to be screened for the current study.

We also included key informants in the current study. Although LSMM may have the most direct access to information about why they and their peers do or do not engage in behavioral and sexual health research, the inclusion of key informants allowed us to assess the research question more fully from another, complementary, perspective. As researchers who often partner with key informants who serve the LSMM community (e.g., requesting support from key informants in referring LSMM to research studies and partnering with key informants to carry out research studies with LSMM), we sought their insights to enrich our understanding of potential barriers and facilitators. Our goal was to reach saturation in themes (Guest et al., 2016) across all types of participants, including key informants. We recruited key informants through our network of partners in South Florida who provide sexual and behavioral health services to LSMM. We invited individuals from these organizations to participate and sent email recruitment messages through professional networks. All interested individuals were screened by phone to confirm their eligibility, scheduled for an interview if eligible and interested, and remunerated $50.

Eligible LSMM were (1) gay, bisexual, or a man who has sex with men, (2) Latino/Hispanic, (3) self-reported HIV-negative or unknown HIV status, (4) South Florida residents (5) 18–60 years old (although, of note, the final sample of participants included LSMM between the ages of 18 and 40 years old). Key informants who worked with LSMM in South Florida and were 18 years or older were eligible. Participant demographics are provided in Table 1. All procedures were reviewed and approved by the Institutional Review Board at University of Miami.

Table 1.

Participant characteristics

Latino SMM N = 28 Key informants N = 10
Age (M/SD) 28.64 (5.21) Age 39.90 (12.51)
18–23 4 (14.3%) 28–36 6 (60.0)
24–28 13 (46.4%) 37–45 1 (10.0)
29–33 5 (17.9%) 46–54 1 (10.0)
35–40 6 (21.4%) 55–62 2 (20.0)
Race Race/ethnicity
White 19 (67.9%) White Non-Latino/a/x 1 (10.0)
Multiracial 7 (25.0%) White Latino/a/x 5 (50.0)
Indigenous 2 (7.1%) Multiracial Latino/a/x 4 (40.0)
Sexual orientation Sexual orientation
Gay 23 (82.1%) Heterosexual 3 (30.0)
Bisexual 4 (14.3%) Gay 5 (50.0)
Other 1 (3.6%) Bisexual 1 (14.3)
Queer 1 (14.3)
Native language Native language
English 12 (42.9%) English 2 (20.0)
Spanish 16 (57.1%) Spanish 7 (70.0)
German 1 (10.0)
Preferred language Preferred language
English 25 (89.3%) English 8 (80.0)
Spanish 3 (10.7%) Spanish 2 (20.0)
Highest level of education Highest level of education
High school or equivalent 3 (10.7%) Some college/university 1 (10.0)
Some college/university 7 (25.0%) College/university degree 9 (90.0)
College/university degree 18 (64.3%)
Country of birth Country of birth
United States 16 (57.1%) United States 5 (50.0)
Colombia 2 (7.1%) Colombia 2 (20.0)
Cuba 3 (10.7%) Cuba 2 (20.0)
Ecuador 1 (3.6%) Venezuela 1 (10.0)
Jamaica 1 (3.6%)
Panama 1 (3.6%)
Peru 1 (3.6%)
Puerto Rico 1 (3.6%)
Venezuela 2 (7.1%)
Monthly income Gender
US$200–$499 1 (3.6%) Male 7 (70.0)
US$500–$999 1 (3.6%) Female 3 (30.0)
US$1000–$1999 5 (17.9%)
US$2000 + 18 (64.3%)
Declined to Answer 3 (10.7%)
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Measures

Semi-structured Interviews

Participants completed semi-structured interviews with study staff in English (n = 36), Spanish (n = 1), or both (n = 1). Interviews were designed to last approximately 60 min; however, the range of interview lengths was approximately 30 to 90 due to variability in participants’ elaboration on their responses and subsequent probes (i.e., most interviews were 45–60 min, with few exceptions that were shorter or longer). The full interview probed participants’ experiences and perceptions of LSMM’s engagement in behavioral health services, HIV-prevention services, and research related to these services. (The latter was the focus of the current study.) Participants were asked open-ended questions about what led them to/stopped them from participating in the prior trial, factors that affected other LSMM’s participation in sexual and behavioral health research, and suggestions for engaging LSMM in sexual and behavioral health research.

Our team was diverse with respect to race/ethnicity, gender identity, and sexual orientation, as well as professional experience and training (e.g., students/faculty in psychology and public health). All members of the team shared LGBTQ and Latino/a/x affirming views. Team members received an initial training in qualitative research, study objectives, and health disparities impacting Latino/a/x and LGBTQ communities, with ongoing meetings following the initial training.

Data

Interviews were recorded and transcribed for thematic analysis (Braun & Clarke, 2006) in NVivo 12 by a team of five. The first author reviewed the data and developed an initial codebook. Two individuals independently coded each transcript. After each “batch” of coding, the lead author reviewed their coding. If the two coders agreed on the code, this code was finalized unless there were questions warranting further discussion. If the two coders disagreed on the code, the next coding meeting allowed for discussion to consensus. Discussions involved sharing interpretations of the codebook, allowing codebook revisions for consistency and clarity. Meetings facilitated researcher reflexivity to increase self-awareness of assumptions and achieve “fairness” in our representation of participants’ viewpoints (Morrow, 2005). Reflexivity involved discussing how team members’ subjectivities impacted their interpretations and striving to remain “close to the data.” We continued enrollment until coding saturation was reached (Guest et al., 2006).

After all data were coded, we sorted the codes into themes and sub-themes (Braun & Clarke, 2006), presented below and in Fig. 1 as a new relational framework. The authors reviewed and agreed on the accuracy of the findings, including the framework, themes, and sub-themes.

Fig. 1.

Fig. 1

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Relational model for understanding Latino sexual minority men’s engagement in sexual and behavioral health research. This figure presents a new relational framework for understanding Latino sexual minority men’s engagement in sexual and mental health research, based on the themes and sub-themes identified in the current study. As shown here, relational factors were central (i.e., one of the main themes from the current study). Relational factors had an influence on both individual and structural factors. All, in turn, influenced Latino sexual minority men’s engagement in sexual and behavioral health research

Results

We identified 60 codes which fit into three overarching themes (and corresponding sub-themes). Themes included: (1) the centrality of relationships, (2) individual-level factors, and (3) structural-level factors. Relational factors were central to LSMM’s decisions to engage in sexual and behavioral health research. Therefore, we also present the themes and sub-themes within Fig. 1, which articulates a new relational framework that is based on the findings from the current study. The relational framework integrates the three overarching themes from the current study, articulating the centrality of relational factors in impacting LSMM’s decisions to participate in sexual and behavioral health research. Recommendations for research recruitment based on the themes are presented in Table 2.

Table 2.

Recommendations based on study findings for engaging Latino sexual minority men in sexual and behavioral health research

Recommendation Example quote
1.Appeal to altruistic desire to help LSMM peers and community I always want to help out the community in any way possible, whether it’s providing a personal opinion about what kind of problems are being risen up... being a part of something that is related to my identity
2. Build trust with LSMM communities through emphasizing confidentiality and privacy and being transparent about the research Knowing what’s happening with the information after helps I think... what exactly you’re helping, why is this being collected? Why is this being studied? What’s the end goal? That helps. I guess, transparency
3. Undo stigmatizing messages by showing warmth and affirmation I got 10 sessions here [as part of a research study] and I mean just coming here and again, safe space, no judgment. I’m comfortable
4. Leverage LSMM’s relational networks to share information about research opportunities, encourage prior participants to “vouch” for the team Definitely if the individuals that participated in the study, they don’t mind sending it out, that’s free, so that might get a lotta people through the door
5. Build community relationships via partnering with organizations/events that cater to the LSMM for social events and recruitment I would say a community leader, and also just partnering with a gay club. I would say going to Twist or Palace and being like, “Hey, we’re conducting this study...”
6. Address transportation/access issues through compensating for transportation and offering non-traditional ways of participating (e.g., online, field offices, after hours) Bring it to them. You got to bring it to them sometimes. Set up an office in Hialeah [∼ 95% Latino/a/x city near Miami]
7. Partner with LSMM communities and organizations to build trust specifically with immigrant LSMM communities and ensure equitable representation Sometimes they might think it’s a set-up if their immigration status isn’t correct
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The recommendations articulated here are intended to translate the study findings into active, behavioral recruitment strategies that researchers can use to develop culturally relevant recruitment strategies

Centrality of Relationships

Relationships were central to LSMM’s decisions to participate in sexual and behavioral health research. Some relational factors, such as wanting to contribute to one’s peers and community or feeling a sense of trust and safety with the research team, facilitated participation. Others, such as interpersonal stigma, impeded participation. Sub-themes are described below.

Helping Peers and Community

Participants described wanting to contribute to the LSMM community through participating in sexual and behavioral health research, exemplified here:

For me, it wasn’t even about the money, again…it was my experiences [are] going to shape a system that will help people make things easier for people, for Latino gay and bisexual men…people naturally want to be part of something that’s bigger than themselves, so I think that’s something, that’s one way you can engage them…and a lot of time just gay and bisexual or LGBTQ people in and of themselves are you know active in being part of a cause—especially one that benefits their community (27 year-old White Latino bisexual man, US born, engager).

Participants suggested leveraging altruism by making HIV disparities affecting the community known to prospective participants and articulating how LSMM could help their community through participating in sexual health research:

Let people know if we have—this is the highest population of…Latino homosexual and bisexual men, we have the highest HIV, and we’re trying to lower that. You can help lower it. That’s what you should do. That’s how you should market it, I think…People are not gonna participate if they don’t know what it is. Not just a study—just let them know we’re helping this by bringing this down [HIV rates]. Right now it’s the highest in the country. We’re working on bringing it down. They’ll be, “Oh, sure. I wanna be a part of that” (40 year-old White Latino gay man, non-US born, non-engager).

Confidentiality and Trust

Participants described concerns about their social networks discovering their participation in sexual and behavioral health research, both of which were stigmatized, or their private information being inadvertently disclosed (i.e., a barrier to participation). Therefore, establishing confidentiality and trust were critical and could serve as a participation facilitator:

It’s also feeling like what are you gonna discover about me? Am I gonna have to divulge my HIV status, that’s very nerve-wracking. Like that’s very personal, you don’t want to share that with everybody and that’s kind of like rule #1. Here you kinda, the first question you ask, “Are you [HIV] positive or negative?” Like what’s gonna happen if I’m positive, what’s gonna happen, are you gonna use that information against me? It’s very like sensitive topic to talk about. Anything sexual health is very sensitive topic, I think, especially about that. Yeah a lot of fear goes into that and you know how 100% confidential like, “Who’s this person I’m talking to? Are they gonna talk about me once I leave the office? Who are they sharing this with?” Yeah definitely privacy might be a factor (28 year-old White Latino gay man, non-US born, engager).

Participants described factors that could lead LSMM to mistrust researchers. Some described a general sense of mistrust, not wanting to be a “guinea pig.” Mistrust was sometimes learned in LSMM’s families:

Participant: “Research in general has a negative connotation. I think, for some reason, the population—and I’m gonna put myself in it—research is like, ‘Oh, you’re gonna do that? Don’t take that pill ‘cause you’re gonna die. You’re just gonna be a lab rat.’ I don’t know. I think our community has that negative connotation about research.”

Interviewer: “Where do you think it comes from?”

Participant: “It’s kind of like it’s passed down. I know, for example, in my life, my mother would say, ‘Don’t participate in those things, because—’ especially with something medical or something like that, because, ‘My friend died of this.’ It’s that word-of-mouth, like, ‘Don’t do that.’” (Key Informant, Behavioral Health Provider).

Participants encouraged building trusting relationships with the LSMM community to address mistrust as a barrier and facilitate participation. They emphasized the importance of the research study being affiliated with a trustworthy institution, being transparent about what the study involves and its purpose, and making confidentiality standards clear.

Experiencing Stigma from Others

Participants described intersecting stigma related to their sexual orientation, sexual behaviors, use of HIV-prevention services, substance use, and mental health. Interpersonal stigma impeded LSMM’s willingness to participate in sexual and behavioral health research. One participant highlighted that LSMM may feel a heightened sense of sexual orientation stigma from family or the Latino/a/x community, creating hesitancy about participating in research focused on their sexual behaviors or health:

I would think that they are not willing to participate as much as, maybe, Caucasian. Maybe more or less so African American because they also have that similar stigma that comes with being gay or bisexual or having sex with men, in their own community. It’s just verbalized differently than the Hispanic community. I think, maybe, minorities in a sense, have a harder time participating just because of the culture (26 year-old multiracial Latino gay man, non-US born, engager).

Another described the dual impact of feeling stigmatized about both being a sexual minority man and having mental health concerns. In his case, mental health stigma was an initial participation barrier; once in the trial, sexual orientation stigma led him to conceal his participation:

Well, yeah, that’s the Latino culture, yeah. Yeah, it’s that preconception, prejudice of that you only get a psychologist or a psychiatrist if you have a serious problem, but really serious. I mean, people are aware that depression is serious, but they don’t know how common it is. Like in my case, sometimes you are depressed and you don’t really know it. When it gets to a really bad point is when they seek for help, which it should be the other way around. If you think something’s wrong, try to get help before it gets to that point where it’s gonna be more complicated to treat it or to resolve the problem … I think it’s a cultural thing. For some reason we are ashamed. We’re ashamed of talking our problems even with professionals. In the gay community, there’s all that stigma about—well, in my case, I’m still in the closet with my family, so that’s an important issue for me, and I think that happens in many cases. For example, the whole time that I was [getting mental health treatment through the prior trial], my family didn’t know. I have a binder with all of the material and all of that and I have it hidden (35 year-old White Latino gay man, non-US born, engager).

Another described stigma related to language, indicating that LSMM who are not English speaking may feel unwelcome and underscored the need for researchers to be linguistically affirming:

I think the majority of Latino men only know Spanish or they’re not fluent in English. They get hesitant. Even coming to…this area isn’t really too friendly. Let’s say someone asks someone for help on the street. Someone would probably just walk on by and not even assist them (28 year-old Indigenous Latino gay man, US born, non-engager).

Personalism and Affirmation

Personalismo refers to being warm and friendly, showing genuine caring, and relating as a human being and is an important value in Latino/a/x culture (Añez et al., 2005; Barrera & Longoria, 2018; Flores, 2000), the importance of which may be underscored for LSMM who have experienced substantial stigma, as described above. One participant commented on the importance of feeling welcomed and attended to when participating in a study. He explained what it would take to feel welcomed:

When people greet you, and you don’t feel like you’re just forgotten about in some waiting room somewhere, just – or if they don’t check in with you and things like that, then you don’t feel like maybe you’re just a number to them. (36 year-old multiracial Latino gay man, US born, non-engager)

Affirmation refers to explicitly supporting LGBTQ and Latino/a/x people. The need for affirmation was exemplified by one participant who described the prior trial as a rare chance to have an honest, safe conversation about his sexual and behavioral health, as well as his identity:

“It was nice just to have conversations with somebody else about these kind of things. We don’t typically – I don’t know – have these conversations. In fact, I felt safe and secure and it was good” (31 year-old White Latino gay man, US born, engager).

This desire to be affirmed and engage in authentic self-expression facilitated participation in the prior trial:

That was why when I found the study I was like, “This is perfect, because it’s something that I can do myself. It’s tailored specifically to me – gay Latino men; that’s me.” Obviously, my parents would have no part in that. Yeah. That was one of the big things (25 year-old White Latino gay man, US born, engager).

Another explained that the research team’s affirming attitudes and behavior promoted his participation:

“You guys are showing us that, you—I mean, I would assume that most of you guys are not even LGBTQ but we have allies in the world” (36 year-old multiracial Latino bisexual man, non-US born, engager).

Participants described occasions where they felt unseen or misunderstood by researchers, undermining engagement efforts and suggesting that the absence of personalism and affirmation could serve as a participation barrier. A key informant explained that sometimes researchers do not understand the heterogeneity of LSMM, inaccurately believing that “American” LGBTQ references (e.g., RuPaul’s drag race) would be equally compelling as a marketing tool for immigrant LSMM. They later commented: “You’re gonna use the Spanglish. Because this is Miami, you don’t speak English or Spanish, you speak Spanglish.”

Another described the need to show understanding by “thinking in Spanish” when developing outreach materials: “When you present things to the Spanish-speaking culture, make sure that they are thought in Spanish, not translated from English, so that they do not feel like a translation. Otherwise, it is just more gringo bullshit. We have a lot of gringo bullshit to deal with already,” (Key Informant, PrEP Coordinator). These examples highlight the importance of researchers knowing the LSMM communities with whom they work and developing relationships to improve their understanding of relevant and compelling recruitment.

Participants recommended building relationships with LSMM-serving community partners to build trust with the LSMM community and develop community-driven recruitment efforts. For instance, one participant suggested working with local gay bars:

Maybe have people at the bars and clubs. Although, maybe that’s not the best place cuz people don’t really wanna talk about that when they’re out. They wanna drink and hookup, basically but innovative ways like “Pillow Talk” [a social event that our lab co-hosts with a local bar]. I mean, I know that’s really cute. I hope it works or it’s working (36 year-old multiracial Latino bisexual man, non-US born, engager).

Leveraging Relational Networks to Enhance Participation and Trust

Participants explained that LSMM can be reached and engaged through their relational networks, a theme that overlapped to some degree with the “Confidentiality and Trust” theme described above. For example, they described the importance of someone within their relational networks “vouching” for the researchers to enhance participation and trust of the research team. One key informant, who identified as LSMM, explained: “I didn’t hear of this through a flyer. If I did, I probably would have walked right past it. My friend told me about it and then someone else told me about it,” (Key Informant, HIV Test Counselor).

Many participants indicated they either became engaged in research through social or sexual networking sites and apps (e.g., Facebook, Instagram, Grindr, Scruff) or believed these would be effective tools to recruit LSMM. Many viewed these as virtual spaces where LSMM “hang out:”

The internet, any kind of—I love the Grindr idea and those dating service apps. Where are they spending time? Is it a Facebook thing? Is it an Instagram thing? If it’s investing into social media outreaches, I think is…yes, I think those would be your top three gay choices (31 year-old White Latino gay man, US born, engager).

Individual-Level Factors

Participants discussed individual-level factors that can impact LSMM’s participation: their knowledge about research opportunities and their perceived needs/anticipated benefits related to participating in a sexual or behavioral health study. Individual-level factors could be addressed to some extent by leveraging the relational factors described above.

First, participants indicated that LSMM may not know about research opportunities and therefore were less likely to participate. As described above, they recommended disseminating such knowledge through LSMM’s relational networks.

Participants also described LSMM as not identifying as having sexual and behavioral health needs that merit intervention and therefore not anticipating direct benefits from research:

“People think like, ‘Oh, no. Why? I don’t have a problem. Why do I need to go talk to somebody?’” (26 year-old White Latino gay man, US born, engager).

Participants attributed a lack of perceived need to mental health stigma, interwoven with gendered expectations (e.g., machismo). Participants suggested emphasizing the direct benefits of research:

I think just reframing the study as, “Hey, you can play a part in,” blah, blah, blah. Great things. It might make people more likely to do it, and then obviously highlighting the personal benefits for them, too. Obviously, you get compensated, but you might learn about yourself. You might get access to some resources and some information. Just having that more positive reframing of it, rather than just saying, “Here’s a research study for gay people with mental health problems.” That isn’t necessarily the most, “All right. I want to delve into that.” (36 year-old multiracial Latino bisexual man, non-US born, engager)

Structural-Level Factors

Finally, participants described structural factors that can affect LSMM’s participation. Structural factors included transportation and accessibility as well as immigration concerns. Again, structural factors were linked in some ways to the relational factors described above.

Transportation and accessibility were frequently cited problems. Participants explained that LSMM often live in areas not accessible to downtown research sites. They reported difficulties participating in research due to the times at which the research office was open and inconveniences of in-person studies. Although transportation and access issues were sometimes “stand-alone” challenges, they intersected with relational factors, as LSMM may share resources, such as a car, with their family, making it difficult to conceal participation:

“…because maybe they might be reliant upon their family members, and their family members are like, ‘Where are you going? Why are you doing this?’” (Key Informant, PrEP Pharmacist).

Participants recommended making the study convenient (e.g., remote participation, satellite offices in communities LSMM live) and maintaining flexible hours. Participants described these options as a way of engaging LSMM in research who might otherwise not participate in a study in “some weird office” where they might feel uncomfortable. Participating remotely might be a way of building trust with LSMM without asking them to put themselves in situations where they feel at risk of interpersonal stigma and loss of privacy.

Finally, LSMM’s immigration fears, particularly if undocumented, could be a deterrent to participation. One participant indicated:

“Sometimes they might think it’s a set-up if their immigration status isn’t correct,” (28 year-old Indigenous Latino gay man, US born, non-engager).

Participants emphasized relational strategies for overcoming this barrier, such as building trust with immigrant LSMM communities and organizations that serve them.

Discussion

This study contributes a new relational framework for understanding LSMM’s engagement in sexual and behavioral health research and strategies that leverage the centrality of relationships in LSMM’s lives. This new relational framework organizes the themes and sub-themes from the current study into one unified framework. Many of the identified themes intersect with relationally oriented cultural values, echoing prior research with Latino/a/x communities (García et al., 2017). For instance, LSMM’s concerns about stigma because of participating, as well as their needs for confidentiality and trust suggest that confianzia (trust) is a key cultural value to consider when seeking to engage LSMM in sexual and behavioral health research. Similarly, LSMM’s need for personalism and affirmation in the context of research participation underscored the role of personalismo to reach LSMM for research. Strategies based on this relational framework could be used to promote equitable representation of LSMM in sexual and behavioral health research. Building on prior findings that LSMM are underrepresented in research (Castillo-Mancilla et al., 2014; Du Bois et al., 2012; Harkness et al., 2019; Sullivan et al., 2011), this study articulates how relational experiences can undermine or promote sexual and behavioral health research participation among LSMM.

Many of our findings converge with and build upon prior research. For example, the importance of stigma (as a barrier) and affirmation/personalism (as a facilitator) is consistent with prior research that LSMM’s participation can be thwarted by anticipated racism and ethnocentrism (Castillo-Mancilla et al., 2014; Murray et al., 2018) and sexual orientation stigma (Murray et al., 2018; Zea et al., 2003). Concerns of participating in research studies due to immigration fears also converge with prior research with LSMM (Rhodes et al., 2010; Zea et al., 2003). Prior research with Latino/a/x communities has also identified research and medical mistrust (Sewell, 2015; Svensson et al., 2012) as a barrier to research participation, which we found is also of high importance of LSMM in particular. Relatedly, prior work has shown the importance of relationship building, trust, community partnerships, and familiarity, to promote Latino/a/x individuals’ participation in research (Cowan et al., 2007; García et al., 2017; Hendrickson, 2007; Kelley et al., 2020; Reidy et al., 2012; Vincent et al., 2013). Our findings suggest that the importance of these factors extends to the LSMM community.

Although many of our findings converge with prior research with Latino/a/x communities in general, this is the first research to the authors’ knowledge to articulate LSMM’s barriers and facilitators to participating in sexual and behavioral health research within a relational framework. Some of the specific themes within the proposed relational framework are unique to LSMM’s participation in sexual and behavioral health research. For example, the stigmatizing interpersonal experiences participants cited as participation barriers were unique to individuals who identify as sexual minorities or in need of sexual or behavioral health services. However, stigma as a barrier could apply to LSMM’s participation in other types of research, or Latino/a/x individuals’ participation in research. For example, Latino/a/x individuals’ stigmatizing perceptions about research may impede participation (Ceballos et al., 2014; Martinez et al., 2012).

Conversely, some themes within this framework may not, at first glance, seem specific to LSMM’s participation in behavioral and sexual health research. However, community-specific factors may enhance the impact of these factors for LSMM. For example, transportation is a widely cited participation barrier for Latino/a/x communities (Hildebrand et al., 2018; Woodall et al., 2010). The current study articulates how this barrier may manifest uniquely for LSMM participating in sexual and behavioral health research. For instance, shared transportation with family could present an issue of privacy and disclosure concerns about their sexual orientation identity, sexual behaviors, or mental health. Some relational factors identified in the current study are addressable through culturally relevant approaches to recruitment. Tailored recruitment efforts may be enhanced through appealing to LSMM’s altruism by naming specific ways participants would contribute to the LSMM community through participating. Altruistic views can promote sexual minority men’s engagement in safer sexual behaviors to protect their sexual partners (O’Dell et al., 2008) and participation in biomedical HIV research (Chin et al., 2016; D’Angelo et al., 2019). Latino individuals may be particularly committed to helping other LSMM, potentially rooted in interdependent self-construals (Moua, 2010; Segal et al., 2011). Although prior research has shown that altruism is a motivating factor for other populations and health conditions (Chin et al., 2016; George et al., 2014), the current findings suggesting altruistic views may be especially motivating for LSMM given the alignment with altruism and Latino/a/x cultural factors and particularly useful to leverage through tailored recruitment.

Stigma learned and experienced in LSMM’s relationships negatively impacted LSMM’s participation in sexual and behavioral health research. Although consistent with prior work (Castillo-Mancilla et al., 2014; Murray et al., 2018; Zea et al., 2003), our findings articulate both how interpersonal experiences of stigma may serve as a barrier to engagement and, conversely, how affirming relationships and building trust can overcome stigma through tailored recruitment efforts. Participants suggested overcoming stigma by “getting to know” the community and bringing LSMM and trusted organizations into the sexual and behavioral health research enterprise. Stigma related to sexual and behavioral health research may also be addressed by leveraging LSMM’s relational networks, such as presenting examples of LSMM participating in the same type of research, disseminating study information through social networks, and inviting LSMM who participate to “vouch” for the study within their networks.

Participants also discussed structural barriers, such as concerns about participating in research due to immigration laws. This is consistent with prior work highlighting concerns about US residency status as a barrier for migrants to participate in research (Rhodes et al., 2010; Zea et al., 2003). Although it may be difficult for researchers to immediately address fears related to immigration laws and documentation status in the U.S. at a structural level (i.e., changing policy), an immediately actionable strategy is to ensure safety in every way possible. Ensuring safety may also involve leveraging the relational factors described above to allay prospective participants’ concerns and promote engagement of immigrant LSMM. For instance, participants encouraged researchers to acknowledge the heterogeneous experiences and cultural references of LSMM, particularly those born outside the US. They encouraged researchers to “think in Spanish” instead of translating English recruitment materials to Spanish, which may not retain the intended meaning. For example, a recruitment flyer in English, if translated literally to Spanish, may convey a different message than intended, whereas if the recruitment flyer was created in Spanish, translation issues would not arise. Although this is ideal, others have shown the feasibility of using a workflow involving multiple bilingual translators to create an acceptable multilingual health education program (Shah & Diaz, 2021). Participants also encouraged building trust with undocumented LSMM communities, recognizing the historical and current mistreatment that LSMM who are undocumented face, partnering with trusted organizations that serve immigrant LSMM, and emphasizing privacy and confidentiality protocols.

These strategies, grounded in a relational framework, may facilitate LSMM’s participation in sexual and behavioral health research. LSMM face sexual and behavioral health disparities (CDC, 2019; Gattamorta et al., 2019; Guilamo-Ramos et al., 2020; Martinez et al., 2017; Rodriguez-Seijas et al., 2019), yet are underrepresented in related research (Castillo-Mancilla et al., 2014; Du Bois et al., 2012; Harkness et al., 2019; Sullivan et al., 2011). This combination of disproportionate public health burden and underrepresentation in research is referred to as “scientific inequity” (McNulty et al., 2019; Perrino et al., 2015). Scientific inequity occurs when research yields the most knowledge about groups least impacted by health disparities, and the least knowledge about groups most impacted by disparities. Culturally tailored recruitment strategies such as those highlighted by participants in this study are needed to advance scientific equity, yielding equitable knowledge of evidence-based approaches to advance the sexual and behavioral health of LSMM. Without equitably engaging LSMM in this research, it is impossible to develop, evaluate, and disseminate evidence-based, culturally relevant and affirming sexual and behavioral health interventions that can mitigate disparities.

Another contribution of the current study is the simultaneous contributions of both LSMM and key informants to the themes described. Notably, all data sources including both sets of LSMM (engagers and non-engagers) and key informants all contributed to every theme. In other words, there was consensus between non-engaging and engaging LSMM and key informants regarding the barriers and facilitators to LSMM’s participation in sexual and behavioral health research. This suggests that the relational framework we have presented is applicable to both LSMM who did and did not engage in sexual and behavioral health research. However, we caution over-interpretation of this finding, given that all LSMM were asked what helps and gets in the way of both their own and other LSMM’s participation. As such, we are not able to fully disentangle LSMM’s personal versus perceived community-level barriers and facilitators.

Relatedly, some of the identified themes and sub-themes reflect barriers, others reflect facilitators, and others are a mixture of both. For instance, “helping peers and community” was a facilitator to LSMM’s participation and was cited by both engagers and non-engagers as something that either did or would help them or their peers to participate. In contrast, “experiencing stigma from others” was a barrier to LSMM’s participation, again cited by both non-engagers and engagers. Finally, although “structural-level factors” generally reflected barriers (e.g., related to transportation and immigration status), they could also be facilitators to LSMM’s participation if they were well-addressed by the research team. The findings from the current study suggest that addressing barriers and leveraging facilitators within our relational framework would increase the engagement of LSMM in sexual and behavioral research. Future research could further evaluate this by comparing the effect of recruitment efforts that are grounded in this relational framework to non-tailored recruitment approaches in terms of LSMM’s representation in research studies.

The strengths of this study must be considered in the context of its limitations. One area of consideration is the degree to which the findings generalize beyond LSMM in South Florida. We focused on LSMM in South Florida due to the impact of the HIV epidemic on LSMM in South Florida. Furthermore, although all LSMM (engagers and non-engagers) contributed to all themes, all were asked about their own barriers and facilitators, as well as their perceptions of the barriers and facilitators for participation among other LSMM in the community. Although the benefit of this decision was to add more in-depth responses to our data, the limitation was that it prevented us from disentangling the degree to which each theme applies to each type of participant. We also chose to focus on LSMM’s participation in both sexual and behavioral health research due to the disproportionate impact of HIV and syndemic behavioral health concerns on LSMM. Additionally, although nearly half the participants were born outside the US, most had not moved to the US recently. We also note the variability in the interview length; although the interviews were meant to last approximately 60 min, they ranged from approximately 30–90 min, due to variability in participants’ depth of responses to initial and probing questions. As with all qualitative research, we recognize that the findings do not extend beyond those included, but rather, lay the groundwork for generalizable quantitative inquiry into the extent to which the proposed relational framework affects LSMM’s engagement in sexual and behavioral health research more broadly.

The purpose of the current study was to articulate themes related to LSMM’s participation in behavioral and sexual health research, with all participant data informing the development of the relational model presented here. Although the current study achieved this aim, it also lays the groundwork for further research. For instance, future studies could utilize the current findings to develop tailored recruitment practices to reach LSMM for sexual and behavioral health research and systematically evaluate the extent to which such practices are efficacious in improving representation of LSMM in sexual and behavioral health research. Such a study could also evaluate the degree to which tailored recruitment strategies’ effects on LSMM’s participation may be moderated based on LSMM’s individual differences (e.g., immigration status, acculturation, perceived stigma).

The strengths of this study should also be noted. We used community member and key informant input to develop a community-centered understanding of factors that impact research engagement among LSMM. This approach centers and amplifies the voices of the community. Additionally, interviewers had shared experience with participants: those who interviewed LSMM were both bilingual and bicultural, allowing us to conduct interviews in English and Spanish. We reached important segments of the LSMM population who provided unique insights, including non-US born LSMM and non-engagers from prior trials. As such, the current study provides community-centered guidelines for researchers seeking to engage LSMM in sexual and behavioral health research.

Conclusions

This study identified a new relational framework for understanding LSMM’s engagement in sexual and behavioral health research. The study also highlights recruitment strategies based on this framework to promote LSMM’s engagement in sexual and behavioral health research. Researchers can utilize the findings to extend the reach of sexual and behavioral health research to LSMM who have often been underrepresented. Such engagement is essential for advancing scientific and health equity for LSMM.

Funding

Data collection for this study was supported by P30 AI073961 (Pahwa). Additional research support was provided by U54 MD002266 (Behar-Zusman), P30 MH116867 (Safren), and R01 MH109413 (Pachankis). Some of the author time was supported by K24DA040489 (Safren) and K23MD015690 (Harkness). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Conflict of interest The authors have no conflict of interest to disclose.

Ethics Approval All procedures performed involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Approval was granted by the Institutional Review Board at University of Miami.

Informed Consent Informed consent was obtained from all participants.

1

Note that we are using language regarding ethnicity recommended by del Río-González (2021), which is that when referring to the whole community, we use the term “Latino/a/x” whereas when we are referring to a specific gender (e.g., men), we use the corresponding gendered term (e.g., “Latino”).

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