Transnationalism and HIV care among Mexican and Puerto Rican immigrant populations Ronald Brooks, Ph.D., John Sauceda, Ph.D., Carlos Rodríguez-Díaz, Ph.D. and Pedro Goicochea, MSc, MA
Outline of presentation Defining transnationalism Transnational: Social spaces Life Identity Practices Influences on transnational practices Impact of transnationalism on health Suggestions for integrating transnationalism Hector Carrillo s Additional suggestions for integrating a transnational approach into HIV care interventions Using the Transnational Exploration Session/Tool
Transnationalism Defined as the processes by which immigrants forge and sustain multi-stranded social relations that link together their societies of origin and settlement. The form, frequency, and intensity of transnationalism largely hinges on the nature of the relationship between sending and receiving countries Basch et al., 1994, p. 6, Duany, 2011, p. 7; Levitt et al., 2007
Transnationalism and the Mexican migrant
Transnational social spaces/fields Transnational migration takes place within fluid social spaces that are reworked through migrants simultaneous embeddedness in more than one society. Levitt 2001; Levitt & Glick Shiller, 2004; Levitt et al., 2007; Pries, 2005; Smith, 2005
Transnational life Transnational life is used to include practices and relationships that link migrants and their children with their country of origin, where such practices have significant meaning and are regularly observed. Immigrants use their transnational connections as a primary point of reference that informs their cultural understandings Transnational connections and activities also compel immigrants to deeply assess the cultures that exist in their country of origin and compare them with those that they perceive as the prevailing culture of the host country. Carrillo, 2012; Levitt et al., 2007; Smith, 2006
Transnational identity The volume and intensity of their economic, political, and social engagement with the country of origin led transnational researchers to argue that immigrants' lives and their identities may be developed in relation to more than one nation. Tamaki, 2011
Transnational Identity Cont. Puerto Rican Transnational Identity The interaction between mainland-born and island-born Puerto Ricans brings to light other processes of identity formation and issues of belonging that demonstrate how Puerto Ricanness is constantly negotiated in the migration experience. The construction of a Puerto Rican identity within the migrant community is based on various notions of differences where place of origin and the ability to speak Spanish are important markers. Furthermore, the presence of numerous Puerto Rican institutions in the US is helping create a unique community landscape, a new Puerto Rico. Sánchez, 2009
Transnational Identify cont. Puerto Rican Transnational Identity Although Puerto Ricans are US citizens, they cross significant geographic, cultural, and linguistic borders when they migrate between the Island and the mainland, and this displacement helps to reconfigure their national identities. Duany, 2003, p. 424; Duany, 2011, p. 103
Transnational practices Transnationalism is best identified by the cross-border activities, practices and attachments of immigrants. Transnational practices can include informal and formal social, political, economic, cultural and religious practices. Migrants will engage in selective transnational practices, usually in response to particular life events. Most migrants are occasional transnational activists. Levitt, 2014; Levitt et al., 2007;
Transnational practices Cont. Communication One of the basic ways in which immigrants maintain ties with their home countries is through contact with relatives and/or friends and associates. Technologies and social media (e.g., email, Skype, Facebook) have helped to increase the intensity of this activity. Murphy, 2004
Transnational practices Cont. Travel Maintaining social ties may also involve traveling back home to visit family and friends, or providing assistance to family and friends to visit. Murphy, 2004
Transnational practices Cont. Economic and Social Remittances Money send by migrants to their homeland may be used individually or collectively. They may support family members who stay behind; fund small and large businesses; support public works and social service projects in sending communities. Social remittances (e.g., ideas, norms, practices, and identities) may flow back from place of settlement to place of origin Levitt et al., 2007
Transnational practices Cont. Politics Migrants political transnational practices can include a variety of activities such as electoral participation, membership in political associations, parties or campaigns in two different countries. Levitt et al., 2007
Transnational practices Cont. Puerto Rico: Migration and Politics Transnational colonial state is exemplified by Puerto Rico s relationship with the U.S. In this case, the sending and receiving nations share the same citizenship, but migrants from the dependent territory to the metropole are treated as foreigners in the mother country. Due to the political status of Puerto Rico with the US, diasporic communities often develop different representations of identity from the US canon by stressing their broad kinship, cultural, and emotional ties to Puerto Rico, rather than its narrow linguistic and territorial boundaries. Duany, 2003, 2011
Transnational practices Cont. Social Transformation Transnational migration influences transformations in family structure that inform constructions of class, gender and race. Research in this area has focused on living arrangements, finances, and generational reproduction in the everyday lives of transnational families. Levitt et al., 2007; Viruell-Fuentes, 2006
Influences on transnational practices Length of time in the U.S. Greder et al. (2009) found that Latino immigrants who most engaged in transnational activities were also those who had lived in the United States for the least amount of time. Those Latinos who had lived in the U.S. for the longest amount of time had the lowest amounts of engagement in transnational activities.
Influences on transnational practices? Cont. Generational impact Transnational practices and attachments have been and continue to be widespread among the first generation, but few researchers think these ties persist among subsequent generations. Transnational activities will not be central to the lives of most of the second or third generation, and they will not participate with the same frequency and intensity as their parents. Levitt et al., 2007; Pries, 2004
Impact of transnationalism on health and well-being A growing number of studies are examining the impact of transnationalism on the health and mental health of immigrant populations: A 2009 study of Latino immigrant mothers in California, Oregon and Iowa found no association between their level of transnationalism (high vs. low) and health. A 2010 study of Haitians in Miami-Dade, Florida, showed evidenced that transnationalism positively influenced immigrants psychosocial well-being but had a negative effect on their self-management of hypertension because of the need to send economic remittances back home. Greder et al., 2009; Sanon et al., 2014
Impact of transnationalism on health and well-being cont d A 2013 study of migrant women in Denmark found that their struggles to maintain their transnational ties (i.e., emotional and financial obligations to family in country of origin) left little room for concerns about breast cancer and appeared to contribute to lower participation in breast cancer screening among these women. A 2004 study of West Indians in the U.S. found that transnationalism was associated with depression, but it also found transnationalism to be associated with improved life satisfaction. Kessing et al., 2013; Murphy and Mahalingam 2004
Hector Carrillo s suggestion for integrating transnationalism Location of migrants cultural points of reference sources of information sources of emotional and practical support sources of discrimination and social stigma sources of beliefs about health access to health care and health practices
Integrating a transnational approach into HIV care interventions What are participants level of transnational identity? What are the points of reference for participants regarding their health beliefs and health care seeking behaviors? Who in the lives of HIV+ participants knows their status? Do they disclose to family/friends from their place of origin? Help participants access their transnational connections to support their current HIV health care behaviors (e.g., accessing herbal supplements only available in place of origin).
Integrating a transnational approach into HIV care interventions Cont. Help participants address the issue of HIV disclosure with transnational social support members (e.g., family and friends in place of origin). Help participants adapt their health care beliefs and behaviors to the available U.S. HIV health care model when a participant s point of reference about health care is their place of origin (e.g., participant does not feel respected or understood by U.S. medical providers and believes he or she would receive better care in place of origin, or there is a mismatch between U.S. providers and immigrant consumers expectations of health care provision).
Transnational Exploration Session and Tool
Case example: David David is a 24 year old HIV+ male sex worker from Guadalajara, Mexico. He came to the U.S. four years ago because he was uncomfortable being out as a gay man in his hometown. He has been HIV+ for only two years and is in good health. David turned to sex work to supplement his part-time job as a male dancer at a local Latino gay night club. Since being in the U.S., he has tried to send money to his family in Mexico on a regular basis. He remains close with his younger sisters and mother and communicates with them weekly. They know that he is gay but they do not know that he is HIV+. David finds it difficult to communicate with his HIV medical care team because he is embarrassed about what he does for a living and feels he will be judged. Because he needs to work so much to send money back home, he regularly misses medical appointment and is non-adherent to his medications because he does not feel like he is sick.
Transnational Exploration Session/Tool To Explore to learn about or familiarize oneself with: an individual s (project participant s) Transnational Profile Purpose: To use their Transnational Profile as a source of information. You can incorporate this information into your intervention (in any way you would like) as a new way of understanding facilitators and barriers to linkage and engagement in HIV care, ART adherence and clinical outcomes. Note: Transnationalism = TN
Transnational Exploration Session/Tool Cont. An example: Step 1: Client is eligible and consents to participate. Step 2: At intake, interventionist and client work through the Transnational Exploration Checklist. Step 3: Interventionist summarizes client s profile in their own words, adds to their notes, and uses this information through their contact with the client to problem solve.
Transnational Exploration Session/Tool Cont. Key Points 1.Anyone eligible for the study can engage in transnational activities (not bounded by generation status), or engage in zero Transnational activities. 1.Transnationalism is a process, you want to understand this process to better understand client s experience and how it affects HIV care, ultimately. 1.People can engage in Transnational practices/activities/behaviors unintentionally or intentionally, which are categorically different experiences. For a richer level of detail, noticing the two would be helpful.
Transnational Exploration Session/Tool Cont. Key Points 3. Transnationalism is NOT the ismos (e.g., personalismo, familismo, machismo) also known as Latino cultural elements. Integrating Transnationalism is an innovative approach. You are not required to use the ismos but if you choose to, they must be viewed as supplemental to and not replacing the Transnational approach that you are integrating into your interventions. (The ismos likely interact with Transnationalism, but the focus should be on Transnationalism).
Transnational Exploration Checklist Guide to systematize how an interventionist could potentially go through the entire TN approach as described. Again, you are the designers of these interventions and can choose to utilize this tool or your own methods (as some have done). Mexico Mexican National, Mexicano Mexico Local mercado where I send money that I made the previous night at work back to my family in guadalajara Mexico Mexicano
Transnational Exploration Checklist How does being from Mexico, or viewing yourself as Mexicano, influence: A. How you think about your 1) health, 2) HIV status, and 3) medical status? B. The actions you make about your 1) health, 2) HIV status and 3) medical status? Response from client: A. I came to US because I was afraid of being rejected by everyone in my hometown, and I didn t want to shame my family my family relies on my financial support I need to send them money back home so I can t afford to miss work I work really late and end up sleeping all day and missing my appointments and forget to take my medication I know I should but I feel perfectly healthy I am afraid to of what my doctor might say if they found out what I did for a living and they always ask me what I do for work when I check-in with the receptionist Comment from interventionist: A. Client has concerns around stigma related to his sexual orientation, occupation, embarrassing his family and disclosing his HIV status to his mother and sister. B. Client sends money home (economic remittances) and works very late into the night. C. Client thinks he does not need to be adherent to medication because he feels fine D. Perpetual cycle afraid of people around him finding out what he does for a living, which may be associated with missed appointments because of stigma and the fact that he feels healthy, stresses that in the U.S. he would have to disclose his occupation to his provider and is avoiding this interaction medical staff is unaware of true reasons for missing appointments + stigma
References Basch L, Glick Schiller N, Blanc-Szanton C, eds. 1994. Nations Unbound: Transnational Projects, Postcolonial Predicaments, and Deterritorialized Nation-States. London: Gordon & Breach. Duany, J. (2003). Nation, migration, identity: The case of Puerto Ricans. Latino Studies, 1, 424-444. Duany, J. (2011). Blurred borders: Transnational migration between the Hispanic Caribbean and the United States. Chapel Hill: The University of North Carolina Press. Greder K, et al. (2009). Exploring relationships between transnationalism and housing and health risks of rural Latino immigrant families, Family & Consumer Sciences Journal, 34(2), 186-206 Kessing L L, Norredam M, Kvernrod A, et al. (2013). Contextualising migrants' health behaviour - a qualitative study of transnational ties and their implications for participation in mammography screening. BMC public health, 13, 431-.
References Cont. Levitt P, Glick Schiller N. 2004. Conceptualizing simultaneity: a transnational social field perspective on society. Int. Migr. Rev. 38:1002 39. Levitt P. 2001. The Transnational Villagers. Berkeley: Univ. Calif. Press. Levitt P. 2004. I feel I am a citizen of the world and of a church without borders: the Latino religious experience. Presented at Lat. Past Influence, Future Power. Conf. Tomas Rivera Policy Inst., Jan. 31 Feb. 1, Newport Beach, CA. Levitt, P & Jaworsky N. (2007). Transnationalism migration studies: past developments and future trends. Annual Review of Sociology, 33, 129-156. Menjıvar C. 2002a. Living in two worlds? Guatemalan-origin children in the United States and emerging transnationalism. J. Ethn. Migr. Stud. 28:531 52.
References Cont. Murphy, E J, & Mahalingam, R. (2004). Transnational ties and mental health of Caribbean immigrants. Journal of immigrant health, 6(4), 167-78. Parrenas RS. 2001. Servants of Globalization: Women, Migration and Domestic Work. Stanford, CA: Stanford Univ. Press Pries L. 2004. Determining the causes and durability of transnational labour migration between Mexico and the United States: some empirical findings. Int. Migr. 42:3 39 Pries L. 2005. Configurations of geographic and societal spaces: a sociological proposal between methodological nationalism and the spaces of flows. Global Netw. 5:167 90 Sánchez, L. (2009). The new Puerto Rico?: Identity, hybridity and transnationalism within the Puerto Rican diaspora in Orlando, Florida. VDM Verlag.
References Cont. Sanon, M, Spigner, C, & McCullagh, M C. (2014). Transnationalism and Hypertension Self-Management Among Haitian Immigrants. Journal of transcultural nursing, Smith MP. 2005. Transnational urbanism revisited. J. Ethn. Migr. Stud. 31:235 44. Smith RC. 2006. Mexican New York: Transnational Lives of New Immigrants. Berkeley: Univ. Calif. Press. Stone, E., Gomez, E., Hotzoglou, D., & Lipnitsky, J. Y. (2005). Transnationalism as a motif in family stories. Family Process, 44(4), 381 398. Tamaki, E. (2011). Transnational Home Engagement among Latino and Asian Americans: Resources and Motivation. The International migration review, 45(1), 148-173. Viruell Fuentes, E A, & Schulz, A J. (2009). Toward a dynamic conceptualization of social ties and context: implications for understanding immigrant and Latino health. American journal of public health, 99(12), 2167-75.
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