WELL, GOOD AFTERNOON, EVERYONE. I AM DR. JOYCE HUNTER, DEPUTY DIRECTOR OF EXTRAMURAL RESEARCH AT THE NATIONAL INSTITUTE ON MINORITY HEALTH AND HEALTH DISPARITIES, AND I'D LIKE TO WELCOME YOU TO OUR SEMINAR TODAY, WHICH COMMEMORATES NATIONAL HISPANIC HERITAGE MONTH. HISPANICS ARE THE NATION'S LARGEST MINORITY POPULATION. AT 53 MILLION, THEY MAKE UP 17 PERCENT OF THE U.S. POPULATION. BY 2050, THIS FAST-GROWING POPULATION IS ESTIMATED TO REACH NEARLY 133 MILLION, OR 30 PERCENT OF THE U.S. POPULATION. AS WE CELEBRATE THE RICH AND DIVERSE CULTURE AND CONTRIBUTIONS OF THIS VIBRANT COMMUNITY, WE ALSO RECOGNIZE THAT HISPANICS ARE IMPACTED BY HEALTH DISPARITIES SUCH AS LANGUAGE AND CULTURAL BARRIERS, LACK OF ACCESS TO PREVENTIVE CARE, AND LACK OF HEALTH INSURANCE. HISPANICS ARE SIGNIFICANTLY AFFECTED BY OBESITY, DIABETES, ASTHMA, INFANT MORTALITY, AND HIV/AIDS. THEY ARE ALSO DISPROPORTIONATELY -- THEY ALSO LIVE DISPROPORTIONATELY IN SUBSTANDARD HOUSING AND COMMUNITIES WHERE THEY ARE EXPOSED TO ENVIRONMENTAL HAZARDS. TODAY, OUR SPEAKER, DR. NILDA PERAGALLO MONTANO, WILL DISCUSS HOW CULTURALLY-TAILORED INTERVENTIONS CAN BE USED TO REDUCE HEALTH DISPARITIES AMONG HISPANICS BASED ON HER RESEARCH AT THE UNIVERSITY OF MIAMI, CENTER OF EXCELLENCE FOR HEALTH DISPARITIES RESEARCH, EL CENTRO. I'M GOING TO PAUSE FOR JUST A MINUTE TO GIVE PEOPLE A CHANCE TO GET INTO THE ROOM. LOOKS AS THOUGH THERE ARE A LOT OF SEATS UP TO MY RIGHT, TOWARDS THE TOP. I THINK IF YOU MOVE TO THE RIGHT YOU MIGHT BE ABLE TO FIND MORE SEATS. DR. PERAGALLO WILL LOOK AT THE ROLE THAT A CO-OCCURRENCE OF HIV AND OTHER SEXUALLY TRANSMITTED DISEASES, SUBSTANCE ABUSE, INTIMATE PARTNER VIOLENCE, AND MENTAL HEALTH CONDITIONS PLAY IN THE DISPROPORTIONATE BURDEN OF MORBIDITY AND MORTALITY AMONG HISPANICS AND HOW EL CENTRO IS WORKING TO ADDRESS THEM. DR. PERAGALLO IS DEAN AND PROFESSOR IN THE UNIVERSITY -- AT -- IN THE UNIVERSITY OF MIAMI SCHOOL OF NURSING AND HEALTH STUDIES. SHE IS NATIONALLY AND INTERNATIONALLY RECOGNIZED -- SHE IS A NATIONALLY AND INTERNATIONALLY RECOGNIZED NURSING SCIENTIST, SPECIALIZING IN HEALTH DISPARITIES AND CULTURALLY COMPETENT INTERVENTIONS WITH MINORITY POPULATIONS. SHE HAS DEVOTED HER RESEARCH AND ACADEMIC CAREER, WHICH SPANS MORE THAN 35 YEARS -- SHE STARTED WHEN SHE WAS FIVE -- TO IMPROVING THE HEALTH STATUS OF MINORITIES AND OTHER MEDICALLY UNDERSERVED POPULATIONS. SHE HAS A SOLID RECORD OF SUCCESSFUL, COMPETITIVE RESEARCH FUNDING, AND MOST RECENTLY, DR. PERAGALLO RECEIVED FUNDING FOR A FIVE-YEAR GRANT FROM THE NIMHD TO CONTINUE HER WORK AS DIRECTOR OF THE UNIVERSITY OF MIAMI CENTER FOR EXCELLENCE FOR HEALTH DISPARITIES RESEARCH, EL CENTRO, WHICH SHE ORIGINALLY ESTABLISHED IN 2007. HER POLICY AND LEADERSHIP ROLES INCLUDE PAST SERVICE ON THE NIMHD ADVISORY COUNCIL AND CO-CHAIRPERSON OF THE BIPARTISAN POLICY CENTER'S HEALTH PROJECTS WORKFORCE COMMITTEE. SHE IS THE PAST PRESIDENT OF THE NATIONAL ASSOCIATION OF HISPANIC NURSES AND FOUNDING CO-EDITOR OF THE HISPANIC HEALTHCARE INTERNATIONAL. IN 2012, SHE WAS APPOINTED TO BE THE NATIONAL -- SHE WAS APPOINTED TO BE -- NO, SHE WASN'T APPOINTED TO BE THE NATIONAL COMMITTEE. SHE WAS APPOINTED TO THE NATIONAL ADVISORY COMMITTEE FOR THE ROBERT WOOD JOHNSON FOUNDATION'S NURSE FACULTY SCHOLARS PROGRAM. SHE WAS ALSO CHOSEN BY HISPANICBUSINESS AS ONE OF THE 100 MOST INFLUENTIAL LEADERS IN 2012. DR. PERAGALLO HAS AUTHORED NUMEROUS PROFESSIONAL PUBLICATIONS AND IS A SOUGHT-AFTER SPEAKER IN HER FIELD. SHE IS A FELLOW IN THE AMERICAN ACADEMY OF NURSING AND A MEMBER OF SIGMA THETA TAU, THE INTERNATIONAL HONOR SOCIETY OF NURSING. PLEASE JOIN ME IN GIVING A VERY WARM WELCOME TO DR. PERAGALLO. [APPLAUSE] NILDA PERAGALLO MONTANO: THANK YOU. THANK YOU. THANK YOU VERY MUCH. I REALLY -- GOOD AFTERNOON TO EVERYONE. IT'S WONDERFUL TO SEE EVERYBODY HERE, AND ALTHOUGH I STARTED MY CAREER WHEN I WAS FIVE, I NEED GLASSES NOW TO READ. [LAUGHTER] YOU KNOW, IT'S GREAT TO BE HERE IN HISPANIC HERITAGE MONTH, AND I REALLY WANT TO THANK DR. RUFFIN, NOT ONLY FOR INVITING ME TO BE HERE TODAY, BUT ALSO FOR HIS CONTINUED SUPPORT TO OUR HEALTH DISPARITIES INITIATIVE AT UNIVERSITY OF MIAMI AND HIS NATIONAL LEADERSHIP IN THE FIGHT TO ELIMINATE HEALTH DISPARITIES. THANK YOU TO DR. HUNTER FOR SUCH A WONDERFUL INTRODUCTION. AND I'M VERY HONORED TO SPEAK ON THIS OCCASION. SO I'M GOING TO DISCUSS REDUCING DISPARITIES AMONG HISPANICS THROUGH CULTURALLY-TAILORED INTERVENTION SCIENCE, AND THE RESEARCH THAT I'M GOING TO DISCUSS, AND IT'S GOING TO BE A VARIETY OF PROJECTS, IS BEING CONDUCTED AT THE CENTER OF EXCELLENCE, LIKE JOYCE SAID, FOR HEALTH DISPARITIES RESEARCH, EL CENTRO. THAT WAS ORIGINALLY ESTABLISHED, LIKE SHE SAID, IN 2007, WITH A FIVE-YEAR NIMHD GRANT, AND WE COMPETED AGAIN IN 2012 AND WERE SUCCESSFUL TO BE FUNDED AGAIN FOR ANOTHER FIVE YEARS THROUGH 2017. SO WE JUST STARTED THE SECOND YEAR, THE SECOND GENERATION, OF EL CENTRO. SO THE STUDIES I'M FINDING, I WILL DISCUSS, TODAY WILL CONCENTRATE PREDOMINATELY ON THE FIRST FIVE YEARS. THOSE ARE THE MOST RESULTS THAT WE HAVE. WE HAVE SOME OF THE SECOND FIVE YEARS. SO, THE CURRENT EL CENTRO HEALTH CONCENTRATION, AND JUST BECAUSE THESE ARE THE AREAS THAT ARE IN THE DIFFERENT STUDIES, ARE ON HIV AND OTHER SEXUALLY TRANSMITTED INFECTIONS, SUBSTANCE ABUSE, FAMILY AND INTIMATE PARTNER VIOLENCE, AND ASSOCIATED MENTAL AND PHYSICAL HEALTH CONDITIONS. AND THE POPULATIONS THAT WE CONCENTRATED ON IN THE FIRST ITERATION WERE ONLY HISPANICS, BUT IN THIS ITERATION OF EL CENTRO WE HAVE EXPANDED THOSE POPULATIONS TO INCLUDE, BESIDES HISPANICS, ALSO BLACK, AFRICAN-AMERICAN, CARIBBEAN, AND -- INCLUDING HAITIAN, AND SEXUAL MINORITY GROUPS. AND THE THINGS -- THE APPROACHES THAT WE HAVE ARE REALLY TO LOOK AT CULTURALLY INFORMED, COMMUNITY-ENGAGED METHODS TO REALLY LOOK AT CULTURALLY RELATED FACTORS THAT IMPACT THESE MULTIPLE CONDITIONS AND TO DEVELOP, EVALUATE, AND DISSEMINATE CULTURALLY TAILORED INTERVENTIONS. WE ARE ALL, AND I THINK EVERYBODY HERE AGREES ABOUT INTERDISCIPLINARY SCIENCE -- YOU CANNOT BE BY YOURSELF OR JUST ONE DISCIPLINE. AND WHAT'S CRITICAL IS TRAINING AND MENTORING THE NEXT GENERATION OF HEALTH DISPARITIES RESEARCHERS BECAUSE THE WORK WILL NOT GET DONE WITHOUT THAT. I THINK WHAT'S IMPORTANT IS TO REALLY SHOW THE IMPACT OF HAVING SUCH A CENTER, AND IT'S REALLY AN IMPORTANT CONTRIBUTION TO SCIENCE. ONE OF THE THINGS THAT I THINK IS CRITICAL IS THE HISPANIC PARTICIPANTS THAT HAVE BEEN ENGAGED IN EL CENTRO STUDIES, TO PILOT STUDIES, TO MY STUDY, SEPA -- SEPA II, ACTUALLY -- 550 PARTICIPANTS FOR PILOT STUDIES, 495 PARTICIPANTS THROUGH A SISTER PREVENTION STUDY, THAT STUDY FROM DR. [DANIEL] SANTISTEBAN, 200 ADOLESCENTS PLUS 390 FAMILY MEMBERS, AND OTHER ASSOCIATE STUDIES, 1,213 MEMBERS FOR A TOTAL OF 2,800 HISPANIC PARTICIPANTS TO DATE. THIS IS A POPULATION THAT USUALLY DOESN'T PARTICIPATE IN STUDIES, BECAUSE MOST OF THE STUDIES WE CONDUCT ARE IN SPANISH. SO THIS IS REALLY QUITE AN IMPACT. WHAT ARE THE MAJOR BENEFITS OF HAVING STUDIES OCCUR WITHIN A CENTER OF EXCELLENCE? AND I THINK THIS IS IMPORTANT. WE ARE IN A SCHOOL OF NURSING AND HEALTH STUDIES, AND BEING IN A SCHOOL OF NURSING, WE UTILIZE MANY CLINICAL SITES. AND HERE IS SYNERGY, OF COURSE. AS MUCH AS WE ARE IN THIS CLINICAL SITE FOR THE STUDENTS TO DO CLINICAL PRACTICE, THESE PRACTICE SITES BECOME OUR RESEARCH SITES, TOO, AND THE SAME WAY, YOU KNOW, OUR PRACTITIONERS BECOME INVOLVED IN THE RESEARCH THAT WE ARE DOING. SO THIS IS VERY IMPORTANT BECAUSE WE HAVE THE COMMUNITY INVOLVED. SO OUR TRAINING EFFORTS ARE CRITICAL. STUDENTS AND YOUNG INVESTIGATORS REALLY LEARN ABOUT RESEARCH STUDIES AND THEY HAVE A CONTRIBUTION TO THESE STUDIES. IT'S NOT ONLY THEORETICAL LEARNING. THEY'RE A PART OF THESE STUDIES. THE LOCAL COMMUNITY EFFORTS -- OUR COMMUNITY PARTNERS ARE CRITICAL AND THEY PARTICIPATE IN THE RESEARCH AND FINDINGS ARE SHARED WITH THEM, WHICH CAN BE USEFUL FOR THEM BECAUSE THEY CAN APPLY FOR OTHER FUNDING FOR THEIR COMMUNITY AGENCIES, SO IT CAN REALLY BE AN ASSET TO THE COMMUNITY. AND, ALSO, THE CENTER HAS HAD QUITE A SCIENTIFIC PRODUCTIVITY, WHERE IT'S HAD IN THE PAST ITERATION 75 PEER-REVIEWED PUBLICATIONS SUPPORTED BY THE CENTER. SO IT'S NOT THAT WE'VE JUST ENGAGED THE COMMUNITY AND RUN THE CONDUCTIVE RESEARCH, BUT WE ALSO ARE PRODUCTIVE. SO IT'S REALLY IMPORTANT THAT THESE CULTURALLY TAILORED INTERVENTIONS REALLY, TRULY ENGAGE THE POPULATION THAT WE NEED TO BE INVOLVED WITH. SO, BRIEFLY, I'M GOING TO TALK TO YOU ABOUT HISPANIC HEALTH DISPARITIES. YOU ALL KNOW ABOUT THESE. AND WHAT THEY ARE IS A DISPROPORTIONATE BURDEN OF DISEASE, INJURY, AND DEATH AND DISABILITY WHEN COMPARED -- AND IN THIS CASE I'M GOING TO COMPARE TO NON-HISPANIC WHITES, BECAUSE, YOU KNOW, BLACKS AND AFRICAN-AMERICANS HAVE ALSO A HUGE DISPARITY -- BURDEN OF HEALTH DISPARITIES. AND I'M GOING TO TALK ABOUT HIV/AIDS, STIS, SUBSTANCE ABUSE, AND INTIMATE PARTNER VIOLENCE AND MENTAL HEALTH. IN HIV/AIDS, BASICALLY, YOU KNOW, YOU KNOW THE STATISTICS AND I'M NOT GOING TO REPEAT THEM TO YOU, BUT WE DO KNOW THAT HIV INFECTION AMONG HISPANICS IN '09 WAS THREE TIMES AS HIGH AS THAT OF WHITES AND THAT THE RATE OF NEW INFECTION AMONG HISPANIC MEN WAS 2.5 TIMES HIGHER THAN THAT OF WHITE MEN. SO I'M NOT GOING TO READ TO YOU EVERY SINGLE STATISTIC, BUT CERTAINLY THIS IS A DISPARITY, AND THE SAME WITH WOMEN. I WORK WITH HISPANIC WOMEN, AND THE RATE OF INFECTION IN 2009, WHICH IS THE LATEST THE CDC HAS REPORTED, WAS FOUR TIMES HIGHER THAN THAT OF WHITE WOMEN. SUBSTANCE ABUSE IS AN INTERESTING, ALSO, AREA BECAUSE ALL THE PREVALENCE RATES APPEAR TO BE APPROXIMATELY THE SAME ACROSS ETHNIC GROUPS. WHAT HAPPENS WITH SUBSTANCE ABUSE IS THAT HISPANICS BORN IN THE U.S. HAVE HIGHER RATES OF SUBSTANCE ABUSE THAN HISPANICS NOT BORN IN THE U.S., AND THAT HAS TO BE -- HAS TO DO WITH THE PROTECTIVE EFFECTS OF ACCULTURATION OF THE CULTURE, AND THAT'S AN INTERESTING AREA, AND THAT HAS TO DO WITH INTERVENTION DEVELOPMENT. ALSO, WE KNOW THAT THEY ARE LESS LIKELY TO RECEIVE THE CARE NEEDED, AND THAT WHEN THEY GET INTO CARE THAT THEY'RE LESS LIKELY -- YOU KNOW, THAT THEY GET DELAYED WHEN RECEIVING CARE. SO IT'S IMPORTANT TO HAVE THESE FACTS. ALSO, OVERALL, HISPANICS ARE LESS LIKELY TO DRINK THAN NON-HISPANIC WHITES, BUT THEY'RE MORE LIKELY TO HAVE BINGE DRINKING, FOR EXAMPLE. SO YOU MIGHT BE LOOKING FOR -- WHEN YOU ARE DOING INTERVIEWS AND COLLECTING DATA, YOU MIGHT BE ASKING MAYBE THE WRONG QUESTION WHEN YOU ARE DEALING WITH THESE POPULATIONS. SO THERE ARE THINGS TO BE CONSIDERED IN LOOKING AT THESE. WITH FAMILY AND INTIMATE PARTNER VIOLENCE, THE RATE OF IPV AMONG HISPANIC COUPLES IS GREATER THAN THAT OF WHITE COUPLES. AND, ALSO, HISPANICS, WE KNOW, ARE NOT GOING TO REPORT AS MUCH TO AUTHORITIES. AND WE KNOW WHY. YOU KNOW, THERE ARE ISSUES WITH DOCUMENTATION, WITH FEAR OF AUTHORITY AND POLICE, AND ALSO THERE IS EVIDENCE THAT HISPANIC FEMALE VICTIMS OF IPV ARE MORE LIKELY TO EXPERIENCE POOR MENTAL HEALTH OUTCOMES AND HIGHER RATES OF SUICIDAL IDEATION THAN NON-HISPANIC FEMALE VICTIMS. INTIMATE DATING VIOLENCE, WHICH IS ONE OF THE AREAS THAT ONE OF OUR RESEARCHERS STUDIES, AFFECTS 12 PERCENT OF HISPANIC YOUTH, COMPARED TO 8 PERCENT OF NON-HISPANIC WHITES. MENTAL HEALTH HAS BEEN AN ISSUE THAT HAS BEEN STUDIED FOR QUITE SOME TIME, AND WE KNOW THAT THE MENTAL HEALTH OF HISPANIC IMMIGRANTS TENDS TO GO DOWN AND GET WORSE. THE OUTCOMES GET WORSE ONCE THEY SPEND MORE TIME IN THE UNITED STATES. AND, ALSO, THEY HAVE DISPROPORTIONATE RATES OF MENTAL HEALTH CONDITIONS SUCH AS DEPRESSION AND SUBSTANCE ABUSE. ADOLESCENTS, ALSO, HAVE HIGHER LEVELS OF DEPRESSION COMPARED TO YOUTH OF OTHER ETHNIC AND RACIAL BACKGROUNDS. AND HISPANIC VICTIMS OF IPV, ALSO, ARE MORE LIKELY TO HAVE PTSD AND SUICIDAL IDEATIONS THAN NON-HISPANIC WHITE WOMEN. SO THERE IS A DISPARITY, ALSO, IN THAT AREA. WHAT'S INTERESTING IS THE STRENGTH IN SPITE OF THOSE DISPARITIES IN THE HISPANIC CULTURE, AND THAT HAS TO DO -- AND I LOVE THIS PICTURE. IF YOU SEE THAT PICTURE, THAT'S IN ONE OF THE STUDIES THAT THEY'RE DOING AT ONE OF THE SCHOOLS IN HIALEAH, WHICH IS 96 PERCENT HISPANIC. THIS IS A NINTH GRADER, AND THEY'RE HUGGING THEIR MOM. I MEAN, THIS IS UNUSUAL THAT KIDS, YOU KNOW, IN PUBLIC ARE, LIKE, YOU KNOW, CHUMMING UP THEIR MOTHERS. BUT YOU CAN SEE BEHIND HIM, THERE'S ANOTHER KID, YOU KNOW, RIGHT BY THEIR MOM, AND THIS IS A VERY TYPICAL PICTURE IN THE HISPANIC CULTURE. FAMILY RELATIONSHIPS ARE VERY IMPORTANT, BECAUSE WE HISPANICS ARE A FAMILY, RATHER THAN AN INDIVIDUAL-ORIENTED CULTURE. OUR SOCIAL PATTERN IS FAMILIES, THE MEANING OF FAMILY -- FAMILIES' INTERESTS ARE A LOT MORE IMPORTANT THAN OUR INDIVIDUAL INTERESTS. THERE'S A CERTAIN CONCEPT TO UNDERSTAND WHEN DOING CULTURALLY TAILORED WORK, BECAUSE TO ENGAGE HISPANICS AND TO DESIGN AND DEVELOP INTERVENTION THAT WORK FOR THEM, FOR US, YOU HAVE TO UNDERSTAND OUR VALUES AND LIFE; THAT THEY REVOLVE AROUND THE FAMILY UNIT. IT WON'T WORK, FOR EXAMPLE, IN OUR CASE -- I DO WORK WITH WOMEN -- TO SAY TO A WOMAN, YOU KNOW, "DO TAKE CARE OF YOURSELF BECAUSE OF YOU," BECAUSE IT DOESN'T MAKE SENSE TO HER WITHIN HER CULTURAL CONTEXT. IT'S MORE EFFECTIVE, AT LEAST IN MY EXPERIENCE, TO SAY TO HER, IF SHE'S A MOTHER, YOU KNOW, "DO THIS TO BE HERE FOR YOUR CHILD AND YOUR FAMILY," AND THAT WILL HIT A CORD AND WILL MAKE HER REACT TO WHAT, YOU KNOW, YOU WANT HER TO CHANGE. SO WE ARE NOT AN INDIVIDUALISTIC CULTURE. WE ARE NOT A "ME" CULTURE. WE ARE A COMMUNITY AND A FAMILY CULTURE, AND THAT'S IMPORTANT. THE CRITICAL -- ANOTHER FACTOR THAT ONE HAS TO CONSIDER WHEN ONE IS DEALING WITH A HISPANIC CULTURE IS THERE IS FEAR, AND SOME MEMBERS OF THE POPULATION THAT ARE IN LEGAL TRANSITION, THAT ARE UNDOCUMENTED, ARE AFRAID. THEY'RE AFRAID NOT ONLY OF LA MIGRA, OF IMMIGRATION, BUT THEY'RE ALSO AFRAID OF SIGNING ANYTHING. PEOPLE THINK THEY'RE A SCAM. YOU KNOW, THEY'RE AFRAID OF BEING SCAMMED. SO IT'S HARD TO HAVE THEM TO SIGN CONSENTS THAT ARE FIVE PAGES LONG. YOU HAVE TO EXPLAIN TO PEOPLE WHAT THEY'RE SIGNING, AND IT'S -- YOU KNOW, IT'S A TASK. SO YOU HAVE TO BE COGNIZANT OF THIS WHEN YOU'RE DOING RESEARCH WITH THESE POPULATIONS. SOCIAL SUPPORT IS CRITICAL. MANY OF THESE FAMILIES HAVE MIGRATED AND THEY HAVE LEFT FAMILY BEHIND, SO SOCIAL SUPPORT BECOMES NEW PEOPLE THAT MAY NOT BE FAMILY, BUT THEY'RE THEIR EXTENDED FAMILY, AND TO THEM IT'S LIKE THEIR OWN FAMILY. SO THIS IS IMPORTANT. SO YOU HAVE TO FIND ALSO PLACES IN WHICH THEY'LL FIND THIS SOCIAL SUPPORT THAT ARE PLACES THAT THEY FEEL COMFORTABLE TO GO TO AND THAT THEY -- YOU KNOW, THAT YOU KNOW THAT YOU WILL ENGAGE THEM THERE. RESOURCEFULNESS. PEOPLE ARE VERY RESILIENT AND RESOURCEFUL IN OUR CULTURE. I MEAN, I HAVE SEEN PEOPLE WITH VERY LIMITED FINANCIAL RESOURCES, JUST -- YET THEY FIND WAYS TO MAKE DO. FOR EXAMPLE, MANY PEOPLE -- I THINK THERE ARE SOME SEATS SOMEWHERE HERE, IF YOU WANT TO COME IN. MANY PEOPLE HAVE LEFT FAMILY BEHIND THEM AND THEY MAKE -- THEY SOMETIMES GET TOGETHER WITH FRIENDS AND HAVE THESE SAVING CLUBS TO BRING THEIR FAMILIES. AND THEY TAKE TURNS. "OKAY, THIS TIME YOU BRING YOUR FAMILY MEMBER, NEXT TIME I'LL BRING MY FAMILY MEMBER." WHICH IS VERY UNUSUAL, BUT THAT'S THE WAY THEY DO IT. THEY DO FIND INFORMAL HELP-SEEKING, YOU KNOW, AND YOU NEED TO FIND A WAY THAT WHEN YOU DO -- FOR EXAMPLE, IN MY CASE, WE DO GROUP INTERVENTION. THEY FIND THE SUPPORT AMONG EACH OTHER, AND THAT COMES BY ITSELF WITHOUT YOU EVEN HAVING THAT INTENTION TO DO THAT. SPIRITUALITY'S IMPORTANT. ALTHOUGH MANY OF THE HISPANIC POPULATION CLAIMS, INCLUDING MYSELF, TO BE CATHOLIC, ONE THING IS TO CHECK CATHOLIC, ANOTHER THING IS TO PRACTICE TO THE LETTER CATHOLIC. WE'RE NOT VERY DOGMATIC, HISPANICS, SO WE -- YOU KNOW, THERE ARE CERTAIN RULES THAT WE DON'T PRACTICE, BUT WE ARE CATHOLIC. BUT IT'S MORE OF THE SPIRITUAL SIDE, BECAUSE I THINK THE CHURCH AND THE PRIEST, OR THE MINISTER, IT'S MORE OF A COPING -- IT'S A COPING MECHANISM. YEAH, I THINK IT TAKES THE PLACE, ALSO, OF YOUR COUNSELOR OR YOUR PSYCHIATRIST, TOO. I MEAN, IN THE HISPANIC CULTURE, TO SEEK MENTAL HEALTH SERVICES IS NOT SOMETHING VERY ACCEPTABLE. YOU'D FIRST RATHER HAVE A SYMPTOM THAN SAY, "I'M DEPRESSED." I MEAN, IT'S NOT SOMETHING THAT, YOU KNOW, PEOPLE DO EASILY. THE OTHER THING IS THAT MANY OF OUR CHURCHES, UNFORTUNATELY, ARE VERY CRITICAL OF -- FOR EXAMPLE, IN OUR CASE OF PEOPLE THAT MAY BE HIV POSITIVE OR -- AND I HAD THAT EXPERIENCE IN LOOKING FOR AGENCIES TO WORK WITH WOMEN AT RISK FOR HIV. AND IT'S DIFFICULT. SO, ALTHOUGH IN OTHER CULTURES CHURCHES MAY BE THE VENUE TO DO INTERVENTIONS, MAYBE IN THE HISPANIC YOU HAVE TO FIND A VERY SPECIAL CHURCH TO REALLY BE THE VENUE FOR THAT. SO IT'S IMPORTANT FOR REVIEW PANELS, WHEN THEY LOOK AT THIS, TO UNDERSTAND THAT FAITH-BASED INTERVENTIONS MAY NOT APPLY TO ALL GROUPS, AND IT DOESN'T MEAN THAT IT'S THE SAME FOR ALL ETHNIC GROUPS OR -- SOá AND, FINALLY, THE PROTECTIVE EFFECT OF MAINTAINING HISPANIC CULTURAL PRACTICE IS CRITICAL, BECAUSE ALL OF THESE THINGS THAT I TALKED ABOUT INFLUENCE IN THAT PROTECTIVE FACTOR. AND YOU ALL KNOW ABOUT THE HISPANIC PARADOX, THAT, YOU KNOW, WOMEN HAVE GOOD BIRTH OUTCOMES IN SPITE OF SOMETIMES NOT HAVING FULL PRENATAL CARE AND THAT, YOU KNOW, LONGEVITY IS BETTER, AND SO ON. AND THAT'S PART OF THE CULTURAL -- THE PROTECTIVE FACTORS, I THINK, OF THE CULTURE. SO WE'RE GOING TO TALK A LITTLE BIT ABOUT CULTURALLY INFORMED, COMMUNITY-ENGAGED RESEARCH METHODS, AND I THINK THIS IS IMPORTANT BECAUSE YOU NEED TO THINK ABOUT CULTURALLY TAILORED METHODOLOGY. AND WHAT ARE SOME OF THE RESEARCH PARTICIPATION BARRIERS? ONE THING, LIKE IN EVERY CULTURE, IS THE MISTRUST OF RESEARCH. MANY PEOPLE THAT WE HAVE HAD AND WE HAVE HAD IN OUR STUDIES HAVE NEVER PARTICIPATED IN RESEARCH. I'VE HAD WOMEN ASK ME, SAYING, "I WANT TO BE PART OF THIS STUDY, BUT I DON'T HAVE $20 TODAY," THINKING THEY HAD TO PAY US, BECAUSE THEY HAD NEVER BEEN IN A STUDY. SO YOU HAVE TO BE PREPARED TO EXPLAIN TO PEOPLE WHAT IT MEANS TO BE IN A STUDY, AND THAT THIS IS -- YOU KNOW, TO PAY THEM, NOT FOR THEM TO PAY US. TO PAY US IS TO BE WILLING TO BE IN A STUDY AND REALLY SHARE WITH US. AND, ALSO, THAT BECAUSE OF -- AND ESPECIALLY NOW, BECAUSE OF THE ECONOMY, NOBODY IS GOING TO LOSE A DAY OF WAGE. YOU KNOW, THESE PEOPLE HAVE FRIENDS AND SOME OF THEM HAVE -- THE POPULATION WE WORK WITH, IT'S VERY VULNERABLE, VERY MARGINALIZED, SOME OF THEM, AND THEY HAVE -- YOU KNOW, ONE DAY THEY HAVE A JOB, THE NEXT DAY DON'T HAVE A JOB, SO WHATEVER THEY'RE GOING TO BE, YOU KNOW, REMUNERATED FOR THEIR PARTICIPATION HAS TO BE ENOUGH FOR THEM TO SAY, "I'M NOT GOING TO GO WORK TODAY," OR, "I'M GOING TO HAVE POOR TRANSPORTATION." BECAUSE THEY'RE POOR. THEY DON'T HAVE, YOU KNOW, FEES TO TRANSPORT THEMSELVES. LANGUAGE IS CRITICAL. THE MAJORITY OF THE PEOPLE IN OUR STUDY PREFER SPANISH. SO IF 90-SOME PERCENT, YOU KNOW, WANT THEIR QUESTIONNAIRES IN SPANISH AND PART OF THE CRITERIA TO PARTICIPATE IN YOUR STUDY, YOU KNOW, IS READ AND WRITE ENGLISH, MOST OF OUR PEOPLE WOULD BE OUT OF THOSE 2,800 I SHOWED YOU. THEY WOULD NOT BE PARTICIPANTS IN THOSE STUDIES. SO THAT'S CRITICAL. IN -- YOU KNOW, AND I NEED TO LOOK AT THESE TO SHOW YOU. THE U.M. -- OUR OWN INSTITUTION, OFFICE OF HUMAN SUBJECTS RESEARCH, CALCULATES THAT BETWEEN 15 TO 20 PERCENT OF BEHAVIORAL STUDIES CONDUCTED BY U.M. INVESTIGATORS INCLUDE NON-ENGLISH SPEAKERS, WHILE 70 PERCENT OF THE MIAMI-BASED COUNTY POPULATION SPEAK A LANGUAGE OTHER THAN ENGLISH AT HOME. SO THAT TELLS YOU SOMETHING. WHICH FRACTION OF THE POPULATION ARE WE REALLY CAPTURING AND STUDYING? SO IT'S -- THIS IS VERY IMPORTANT. THERE'S A -- THIS IS A CRITICAL DISCREPANCY, BECAUSE THE DATA WE ARE GATHERING HERE IS WHAT WE'RE USING TO DESIGN INTERVENTIONS FOR OUR TARGET HISPANIC POPULATION, AND THAT'S WHAT THEY'RE BEING, I THINK, SUCCESSFUL IN SOME OF WHAT, YOU KNOW, WE'RE DOING. WHILE THE PREDOMINANT NUMBER OF U.M. STUDIES REQUIRE THE PARTICIPATION TO BE BILINGUAL, AND SOME OF THEM ARE NOT. SO -- THE MAJORITY OF THEM ARE NOT. AND CULTURAL APPROPRIATENESS INVOLVES MORE THAN JUST A LANGUAGE, TOO. SOME OF THE CONCEPTS OF BEING INVOLVED IN RESEARCH -- LIKE, ONE OF THE IMPORTANT THINGS IS BEING ASKED THEIR OPINION. THAT'S THE REALLY DIFFICULT ONE. I'VE SEEN IT IN MY STUDIES. IT'S A DIFFICULT THING WHEN YOU ASK A WOMAN, "WHAT DO YOU THINK ABOUT THIS?" AND THEY LOOK AT YOU LIKE, "I DON'T KNOW." YOU KNOW, I SAID, "BUT IT'S YOUR OPINION." THEY HAVE NEVER BEEN ASKED THEIR OPINION. LIKERT SCALES ARE A PROBLEM, TOO. AND I HAVE A PROBLEM WITH LIKERT SCALES MYSELF. I'M NOT A -- EXCUSE ME. I'M NOT LIKE A MIDDLE PERSON THAT YOU GO A LITTLE BIT OF THIS OR A LITTLE BIT OF THAT. EITHER YOU LIKE IT OR NOT. BUT THIS GRADIENCE OF THINGS IS PROBLEMATIC, AND MANY TIMES YOU END UP IN THE EXTREMES OF THESE SCALES. SO POPULATION-WISE, THOSE ARE THINGS THAT ARE DIFFERENT. STIGMA. THE AREAS THAT WE STUDY ARE VERY SENSITIVE, AND PEOPLE, YOU KNOW, HAVE PROBLEMS ANSWERING VERY PERSONAL QUESTIONS. I DON'T THINK WE WOULD GET THE DATA WE GET IF WE WOULD USE CATI (COMPUTER-ASSISTED TELEPHONE INTERVIEWING) OR IF WE WOULD USE -- YOU KNOW, THEY WOULD HAVE TO FILL OUT QUESTIONNAIRES. SO ALL OF OUR STUDIES DO FACE-TO-FACE INTERVIEWS, AND I THINK THE QUALITY OF THE DATA WE GET IS A LOT BETTER. SO IF WE PUT ONLY FLYERS AROUND, WE WOULDN'T RECRUIT ANYBODY. THESE PEOPLE DON'T ANSWER FLYERS. OUR PARTICIPANTS, WE PARTNER WITH SOMEBODY IN THE COMMUNITY, THOSE COMMUNITY AGENCIES USUALLY ENDORSE A STUDY. WE ALSO SAY SOMETHING IN THE SPANISH RADIO. THAT'S WHAT PEOPLE LISTEN TO. WE MIGHT DO A SPOT IN THE TELEVISION, IN THE SPANISH TELEVISION THAT PEOPLE LISTEN TO, ALSO, SO THAT THEY HEAR ABOUT THE STUDIES THAT -- AND THEN PEOPLE COME, AND WHEN ONE COMES, IT STARTS ROLLING, BECAUSE ONCE A COUPLE OF PEOPLE HEAR ABOUT IT, GO THROUGH IT, THEY TELL THEIR -- SOMEBODY ELSE. COMMUNITY PARTICIPATORY RESEARCH CAN REALLY BE USED TO BRIDGE THE COMMUNITY-ACADEMIC DISCONNECTION, AND APPROACHES TO THAT IS VERY IMPORTANT. I THINK ONE OF THE THINGS -- PARTICIPANT RECRUITMENT IS CRITICAL, AND MANY TIMES WHEN WE PUT IN A PROPOSAL, SOME PEOPLE SAY -- LOOK AT THE BUDGET AND SAY, "RECRUITER? WHY DO YOU NEED A RECRUITER FOR?" IT'S CRITICAL. THIS POPULATION IS VERY MOVABLE AND TRANSIENT. THEY GO FROM PLACE TO PLACE AND YOU NEED TO FOLLOW UP. AND I THINK A RECRUITER IS THE PERSON THAT REALLY LINKS THE INDIVIDUALS, AND YOU CAN FOLLOW THEM AND NOT LOSE THEM TO THE STUDY. SO IT IS CRITICAL. AND THAT THOSE RECRUITERS BE OF THE SAME ETHNICITY OF THE POPULATION THAT YOU'RE TRYING TO RECRUIT. THAT'S ANOTHER CRITICAL POINT. THEY KNOW WHERE THEY CAN BE FOUND. IN OUR STUDY -- THE FIRST STUDY WHEN WE WERE IN CHICAGO, PEOPLE WOULD SEE US AND SAY, "YOU'RE FROM SEPA. OKAY. THE PERSON MOVED TO THAT PLACE OR THAT PLACE." AND WE WOULD HAVE A TRACKING, ALSO, THAT WE WOULD ASK THE PARTICIPANT, "IF YOU MOVED, WHO IS THE PERSON THAT ALWAYS KNOWS WHERE YOU ARE? GIVE US THAT CONTACT INFORMATION. A COUPLE OF PEOPLE THAT WE CAN REACH OUT TO THAT YOU HAVE -- THAT DON'T HAVE A PROBLEM THAT WE REACH OUT TO." SO YOU REALLY NEED SOME TRACKING. SO, KEEPING TRACK, AND ALSO WHAT'S THEIR PREFERRED WAY OF CONTACTING? IS IT TEXT MESSAGING NOW? IS IT -- BECAUSE SOMETIMES THE HUSBAND WITH WOMEN CHECK THEIR TEXT MESSAGES. JEALOUS MEN. YOU KNOW, YOU HAVE TO BE CAREFUL. IS IT -- YOU KNOW, IS IT A CARD OR THE -- YOU KNOW, IS IT PHONE? ANYTHING. WHAT TIME OF THE DAY? I MEAN, THERE ARE VARIOUS ISSUES THAT YOU HAVE TOá AND THE ASSESSORS ARE CRITICAL AS MUCH AS THE RECRUITER. AND LIKE WITH ANYTHING ELSE, YOU KNOW, IS -- YOU KNOW, PARTICIPANTS, THE CULTURE -- I MEAN, YOUR PARTICIPANTS ARE GOING TO COME AND KISS THE ASSESSOR WHEN THEY COME AND DO THEIR ASSESSMENTS. AND THEY COME VERY PERSONAL BECAUSE THAT'S CULTURAL. YOU KNOW, THAT'S THE WAY THEY SAY HELLO TO YOU. THEY COME TO AN INTERVENTION, THEY KISS YOU. THEY KISS EVERYBODY. YOU KNOW, AND THAT'S CULTURAL. THEY HAVE TO TOUCH PEOPLE. THAT'S WHO WE ARE. SO -- BUT ON THE OTHER HAND, AS GOOD AS THIS IS, YOU ALSO HAVE TO KEEP YOUR ASSESSOR VERY CLEAR ABOUT THEIR BOUNDARIES, BECAUSE YOU DON'T WANT THEM TO INTERVENE WHEN YOU ARE RUNNING A RANDOMIZED, CONTROLLED TRIAL IN WHICH YOU HAVE SEPARATE, YOU KNOW, PARTS OF THIS STUDY. THE TRANSLATION OF MEASURES IS CRITICAL BECAUSE WE SPEAK ONE SPANISH LANGUAGE, BUT YOU HAVE TERMINOLOGY THAT IS DIFFERENT. SO YOU NEED TO HAVE A WORD THAT MIGHT BE USED DIFFERENTLY BY MEXICANS THAN PUERTO RICANS THAN COLOMBIANS THAN -- YOU KNOW, AND YOU NEED TO HAVE "SLASH" -- THE WORD "SLASH," THE OTHER WORD, THAT YOU KNOW THAT IS GOING TO HAVE A DIFFERENT MEANING. AND THAT'S WHERE, WHEN WE TALK ABOUT ADAPTATION AND, YOU KNOW, DEVELOPMENT OF THE INTERVENTION, THAT THOSE PARTS ARE CRITICAL. AND WHEN YOU DO THE ANALYSIS, YOU HAVE TO TAKE INTO CONSIDERATION THE LEVEL OF ACCULTURATION. AND -- BECAUSE THAT'S GOING TO ACCOUNT FOR INTERCULTURAL VARIATION, AND IT MIGHT HAVE TO BE THAT YOU CONTROL FOR OR THAT IT'S ALSO -- IT HAS A MODERATING EFFECT, AND THAT'S -- YOU KNOW, THAT'S SOMETHING THAT YOU HAVE TO LOOK AT IN THE ANALYSIS. MEASUREMENT IS CRITICAL. YOU KNOW, SINCE NON-ENGLISH SPEAKERS ARE UNDERREPRESENTED IN RESEARCH, IT'S MANY TIMES BECAUSE YOU DON'T HAVE TRANSLATED MEASURES AVAILABLE. SO ONE OF THE THINGS THAT WE HAVE DONE IN THE CENTER IS TO KEEP A MEASUREMENTS LIBRARY AND -- INCLUDING ALL THE MEASURES THAT WE HAVE USED IN OUR STUDIES. THE LIBRARY INCLUDES A DESCRIPTION OF THE PROJECTS THAT WE USED TO TRANSLATE THE MEASURE WHEN IT WAS TRANSLATED ORIGINALLY, WHEN THERE WERE ADAPTATIONS, CITATIONS TO THE PEER-REVIEWED PUBLICATIONS THAT INCLUDE THE TRANSLATION, AND THE SUMMARY OF THE PSYCHOMETRIC FINDINGS IN THE DIFFERENT STUDIES THAT THEY WERE USED WITH THE TRANSLATED MEASURE. MANY RESEARCHERS WRITE TO US AND ASK THEM FOR THE MEASURE, AND ARE HAPPY TO SHARE. I MEAN, THIS IS NOT SOMETHING WE CAN PUT AN -- YOU KNOW, AND -- BECAUSE THEY ARE MEASURES THAT MAYBE SOMEBODY ELSE HAS, BUT WE CAN SHARE WHAT WE HAVE USED AND BE HAPPY TO. SO, EVEN WHEN TRANSLATIONS ARE AVAILABLE, WE REALLY HAVE TO GO BACK AND INVESTIGATE WHERE, YOU KNOW, THE PSYCHOMETRIC EQUIVALENTS OF THE MEASURE FOR USE FOR THE DIFFERENT POPULATION, BECAUSE IT MIGHT HAVE BEEN USED ONLY WITH MEXICANS AND NOT WITH ALL THE DIVERSITY OF HISPANICS WE HAVE IN MIAMI. MIXED METHODS ARE NEEDED TO EXAMINE EQUIVALENCY, AND, REALLY, MIXED METHODS HAVE BEEN THE WAY THAT WE HAVE DONE IN MOST OF OUR STUDIES, AND IT TRULY INFORMS WHAT WE DO WHEN WE ARE CULTURALLY TAILORING AN INTERVENTION BECAUSE EVEN MOVING AN INTERVENTION FROM -- IN MY CASE, FROM CHICAGO TO MIAMI, THE POPULATION CHANGES OF HISPANICS. THERE ARE SUBGROUPS THAT ARE DIFFERENT, AND YOU DO NEED TO DO SOME ADAPTATION AND SOME JUST REVIEW THAT YOU WILL TRANSFER. AND QUALITATIVE ANALYSIS, TOO, OF, YOU KNOW, OBVIOUS THINGS LIKE FACTOR, ITEM RESPONSE THEORY, AND ESTABLISHING [UNINTELLIGIBLE] SCORES. SO, THE NEXT PART, I'LL PROVIDE YOU SOME EXAMPLES OF THE PILOT STUDIES THAT HAVE BEEN UNDERTAKEN BY EL CENTRO, YOU KNOW, RESEARCHERS. AND THIS PARTNERSHIP FOR DOMESTIC VIOLENCE PREVENTION IS A VERY GOOD EXAMPLE OF CBPR PROJECTS THAT CREATED A PARTNERSHIP FOR THE PREVENTION OF DOMESTIC VIOLENCE. AND IT WAS THROUGH A FOCUS GROUP WITH THE DOMESTIC VIOLENCE SERVICE PROVIDERS FROM THE COUNTY AND COMMUNITY ADULTS, AND THE PREFERENCE FOR WHAT TYPE OF DOMESTIC VIOLENCE PROGRAM TO DEVELOP, TARGETING HIGHER-RISK HISPANICS IN MIAMI-DADE COUNTIES, LIKE, IN GENERAL. WHAT'S INTERESTING IS THAT THE WHOLE COMMUNITY, WHAT THEY WANTED WAS A VIOLENCE PREVENTION PROGRAM TARGETED TO TEENS. THAT'S WHAT THEY WANTED. THAT'S WHAT THE COMMUNITY WANTED. AND THEY WANTED IT IN SCHOOLS. THEY DIDN'T WANT IT -- AND THEY HAD TO BE FOR STUDENTS, FOR PARENTS, AND FOR TEACHERS. YOU KNOW, BECAUSE, THEY HAD HUGE ISSUES WITH -- AND THOSE ARE SOME OF THE PUBLICATIONS THAT CAME OUT OF THAT, AND THOSE ARE AVAILABLE, BECAUSE, YOU KNOW, THIS IS BEING TAPED. YOU KNOW, LIKE MANY OTHER STUDIES, THIS STUDY DEVELOPED INTO ANOTHER GRANT. AND THIS PARTICULAR FACULTY, AND ACTUALLY CO-INVESTIGATORS, THESE -- AND CO-DIRECTOR OF ONE OF THE COHORTS IS NOW A ROBERT WOOD JOHNSON NURSE FACULTY SCHOLAR, AND SHE WAS FUNDED TO DEVELOP THE NEXT PROJECT, WHICH IS CALLED JOVEN. [SPANISH]. TOGETHER AGAINST DATING VIOLENCE. AND THIS IS A PROJECT THAT IS GOING ON AT A SCHOOL FOR NINTH-GRADE HISPANIC STUDENTS, AND IT'S BEING CONDUCTED IN A HIGH SCHOOL WITH 96 PERCENT HISPANIC STUDENT POPULATION. HUGE HIGH SCHOOL IN HIALEAH. SO THE DATA COLLECTION IS ONGOING, AND THE PHASE 1 IS TO DEVELOP, REFINE, AND MANUALIZE THE JOVEN PROGRAM FOR YOUTH, PARENTS, AND SCHOOL PERSONNEL, AND THE PROCESS INVOLVES QUALITATIVE FOCUS GROUPS WITH STUDENTS, PARENTS, AND SCHOOLS, AND PILOT TESTS TO ASSESS DISABILITY, ACCESSIBILITY, AND PRELIMINARY EFFICACY IN PREVENTING AND REDUCING THE OCCURRENCE OF TEEN DATING VIOLENCE AND AFFECTING THEORETICALLY LINKED MECHANISMS OF CHANGE. THIS IS FUNDED BY ROBERT WOOD JOHNSON, BUT WHAT'S NICE IS YOU SEE THAT THE CENTER PROVIDED THE INITIAL BASE FOR THIS TO HAPPEN, AND HOPEFULLY FROM THIS IT WILL GO TO THE NEXT FUNDING. ANOTHER STUDY WAS PROJECT VIDA: VIOLENCE, INTIMATE RELATIONSHIPS, AND DRUG AMONG LATINOS. THIS WAS A MIXED METHOD STUDY TO -- WITH 164 PARTICIPANTS LOOKING AT COMMUNITY-DWELLING, HISPANIC HETEROSEXUAL AND MSM WITH RESPECT TO SUBSTANCE ABUSE, VIOLENCE, AND INTIMATE SEXUAL RELATIONSHIPS. DR. ELIAS VASQUEZ IS CONDUCTING A REPLICATION OF THIS VIDA PROJECT. HE'S NOW -- HE USED TO BE ON OUR FACULTY. HE'S NOW A DEAN AT THE UNIVERSITY OF TEXAS, EL PASO. AND DR. DE SANTIS, WHO IS A CO-INVESTIGATOR AT U.M,. HAS CONTINUED HIS WORK OF CONCENTRATING THE INTERSECTION BETWEEN MENTAL HEALTH AND HIV PREVENTION AND HAS RECEIVED A SUB-STUDY FUNDING ON -- UNDER THE U.M. NIAID DEVELOPMENTAL CENTER FOR AIDS RESEARCH. SO ONE PROJECT LEADS TO ANOTHER AND ANOTHER POT OF FUNDING, WHICH IS WHAT WE WANTED FROM THESE PILOT STUDIES. THOSE ARE THE PUBLICATIONS FROM THAT PARTICULAR PROJECT. THIS WAS VERY INTERESTING. THIS WAS -- THIS IS A COLLEAGUE OF MINE, A PHYSICIAN, AND IT'S ACTUALLY A CO-INVESTIGATOR, MY PROJECT, DR. JOSE CASTRO [SPELLED PHONETICALLY]. AND HE DID A STUDY ON ATTITUDES ABOUT CIRCUMCISION AND HE ENROLLED HISPANIC MEN AND WOMEN, 121, WHO WERE EXPECTING A BABY, TO ASSESS ATTITUDES AND BELIEFS SURROUNDING MALE CIRCUMCISION. AND THE DATA HAS BEEN USED FOR THE FORMULATION OF A CULTURALLY APPROPRIATE INTERVENTION TO PROMOTE CIRCUMCISION AS A PART OF AN HIV PREVENTION STRATEGY IN THE HISPANIC COMMUNITY. WHAT WAS INTERESTING IS THAT THE MOST -- YOU KNOW, AND THEY ALSO -- WERE ALSO FUNDED BY OUR CFAR HEALTH WORKERS -- FOR HEALTH WORKERS -- A PORTION OF THESE. BUT THE GREATEST RESISTANCE TO CIRCUMCISION WAS AMONG HEALTH PROVIDERS. AND THIS IS VERY IMPORTANT, BECAUSE IN THE LATINO CULTURE THERE IS SOMETHING CALLED RESPETO, AND THERE IS DISRESPECT FOR HIGHER AUTHORITY. AND THE HISPANICS LOOK AT THE PROVIDER, THE HEALTHCARE PROVIDER, AS THAT AUTHORITY. SO WHEN THEY RECOMMEND SOMETHING, IT GOES TWO WAYS. EITHER THEY TELL YOU, "YEAH, YEAH, YEAH, YEAH," AND THEY DO WHATEVER THEY WANT WHEN THEY WALK OUT THE DOOR BECAUSE THEY DIDN'T UNDERSTAND, OR THEY SAY, "YES, YES, YES," AND THEY DO WHATEVER YOU TELL THEM BECAUSE OF THE RESPECT TO THAT AUTHORITY AND NOT QUESTIONING OR NOT EVEN GOING AND, YOU KNOW, GOOGLING THE THING OR INVESTIGATING OR MAKING A DECISION. BUT BECAUSE YOU ARE THE AUTHORITY, YOU KNOW, AND YOU ARE THE PERSON GIVING THAT ADVICE, THEY TAKE IT FACE-VALUE. BUT IT'S VERY IMPORTANT WHAT WE SAY. SO WHO -- WHERE IS IT THE INTERVENTION SHOULD BE GOING TO? HEALTHCARE PROVIDERS, NOT TO THE POPULATION. THE POPULATION WOULD BE FINE, PROBABLY, IF THEY WERE BEING PROVIDED THE ADVICE. IT WAS ANOTHER INTERESTING STUDY. MARIA LOPEZ -- DR. MARIA LOPEZ WAS A PI, AND SHE DID A MIXED STUDY, TOO, BUT WHAT SHE DID FIRST WAS THE QUANTITATIVE PORTION OF THE STUDY. AND SHE LOOKED AT 74 HIV POSITIVE ADULTS TO LOOK AT ACCULTURATION, HEALTH LITERACY, LOOKING AT MEDICATION ADHERENCE PATTERNS AND HEALTHCARE UTILIZATION. WHAT SHE FOUND WHEN SHE DID THE QUANTITATIVE WAS THAT EVERYBODY AT LEAST CLAIMED THAT THEY WERE ADHERING TO THEIR MEDICATION. THEN SHE DID THE QUALITATIVE, SHE DID FOCUS GROUPS, AND THEN SOMEBODY RAISED THEIR HAND AND SAID, "NO, I DO NOT ADHERE," AND THEN ANOTHER RAISED THEIR HAND AND SAID, "NO, I DO NOT ADHERE." SO IT WAS VERY INTERESTING. AND -- WHICH, I MEAN, MAKES YOU THINK ABOUT IT. WHICH ONE SHOULD YOU DO FIRST? SHOULD YOU DO THE QUALITATIVE PORTION FIRST? WE TRY TO ALL THE TIME. IN MY EXPERIENCE, I'VE ALWAYS DONE THE QUALITATIVE PIECE FIRST, AND I'LL TELL YOU WHEN I GET TO MY STUDY ON WHY. AND -- BUT THIS IS INTERESTING BECAUSE SHE GOT ALL THOSE, "YES, I ADHERE, I ADHERE," 100 PERCENT, YOU KNOW, AND THEN IN THE QUALITATIVE SOMEBODY RAISED THEIR HAND AND THEN THEY ALL STARTED TO SAY, "NO, I REALLY DON'T TAKE MY MEDICATION ALL THE TIME." SO, INTERESTING WHAT YOU FIND OUT. AT EL CENTRO WE HAVE LOOKED AT THIS SYNDEMIC APPROACH TO LOOKING AT THIS MULTIPLE CONDITION AND COMMON PATHWAY. AND, REALLY, WE TRY TO LOOK AT CO-OCCURRING HEALTH CONDITIONS BEYOND THE CONCEPT -- AND I'M NOT GOING TO READ ALL OF THESE -- BEYOND THE CONCEPT OF COMORBIDITY, BUT REALLY LOOKING AT THIS SYNDEMIC CONCEPT AND LOOKING AT OTHER FACTORS LIKE SOCIOECONOMICS, ACCULTURATION, STRESS, AND, YOU KNOW, CULTURAL-RELATED VALUES AND PRACTICES THAT ARE REALLY IMPORTANT IN HEALTH DISPARITIES, LOOKING AT THE RISK AND PROTECTIVE FACTORS THAT REALLY IMPACT HEALTH DISPARITIES. SO THESE SYNDEMICS ARE REALLY MORE COMMON, AND PEOPLE, WHEN THEY TALK TO US, THEY REALLY TALK ABOUT THIS COMBINATION OF THINGS HAPPENING IN THEIR LIVES AND THE CLUSTERING OF THESE CONDITIONS. AND THEY DON'T SEE THEM SEPARATELY, LIKE WE TRY TO VERY CLEANLY SAY, "THIS IS ONLY HIV AND I'M GOING TO ONLY TALK TO YOU ABOUT HIV AND FORGET ABOUT THE REST OF YOUR LIFE THAT IMPACTS ON WHAT YOU'RE HAVING OR WHAT YOU'RE" -- SO IT'S DIFFERENT, THAN COMORBIDITY, LIKE I SAID. AND IT'S MORE HOLISTIC, AND I THINK THAT'S WHAT THE INTERVENTIONS WE HAVE DEVELOPED ARE. SO, THIS CAME FROM THE SAVA [SPELLED PHONETICALLY] SYNDEMIC, WAS DEVELOPED BY [DR. MERRILL] SINGER [SPELLED PHONETICALLY], THIS CONCEPT. WHAT I THINK IS NOT HERE IS THE MENTAL HEALTH COMPONENT, WHICH REALLY HAS A LINK TO ALL THESE CONDITIONS. ALL THE SUBSTANCE ABUSE YOU CAN THINK, YOU KNOW, IT'S AN ISSUE WITH MENTAL HEALTH, BUT THERE IS MORE THAN THAT. THERE'S SUPPRESSION, THERE'S OTHER THINGS. SO ONE OF OUR RESEARCHERS, ROSA GONZALEZ-GUARDA, DID THE CONCEPTUAL PAPER, LOOKING ALSO WITH SOME DATA, SOME EMPIRICAL DATA, AND LOOK AT THIS SYNDEMIC AND LOOK AT THE FOUR AREAS THAT WE STUDY. AND FOR MENTAL HEALTH, WE LOOK AT DEPRESSION. AND SHE FOUND THAT SUBSTANCE ABUSE, INTIMATE PARTNER VIOLENCE, RISK FOR HIV/AIDS, AND DEPRESSION REALLY SUPPORTED THIS SYNDEMIC MODEL. AND THIS PAPER IS PUBLISHED IN NURSING RESEARCH AND WAS PUBLISHED IN 2011. SO YOU CAN FIND THAT REFERENCE. BUT IT'S REALLY NICE IN HOW IT SHOWS HOW ALL THESE FACTORS CONNECT THAT SYNDEMIC AND HOW THEY ARE ALL LINKED, AT LEAST WITH THE DATA THAT WE HAVE IN OUR POPULATION. THERE'S ALSO SOME QUALITATIVE SUPPORT FROM THE DIFFERENT STUDIES FROM SOME OF THOSE PILOT STUDIES FOR THIS SYNDEMIC ORIENTATION. THE HISPANICS THAT WERE IN VIDA AND DIVA, THEY DON'T SEE VIOLENCE, SUBSTANCE ABUSE, RISK FOR HIV, AND MENTAL HEALTH AS A DIFFERENT PHENOMENON. IN VIDA, SUBSTANCE ABUSE, HIV, VIOLENCE, AND DEPRESSION WERE DESCRIBED BY HISPANICS AS [SPANISH] -- "BRANCHES OF ONE SAME TREE." DIVA, BEING -- THEY DESCRIBED IT AS "UPROOTED IN ONE WORLD," WHAT'S DEFINED AS A COMMON LINK. SO, LIKE, IF YOU HAVE ONE, IT ALL COMES TOGETHER. AND MANY TIMES IT DOES FOR THEM. THEY CALL IT, ALSO, [SPANISH] -- "THE CRIB" -- "THE BIRTHPLACE OF SOCIAL PROBLEMS." THINGS LIKE MACHISMO AND TRADITIONAL GENDER ROLES, AND I'M SURE YOU'VE HEARD ABOUT THAT, I DON'T HAVE TO TELL YOU, AND MACHISMO HAS A POSITIVE AND A NEGATIVE CONNOTATION. MACHISMO, THE NEGATIVE PART IS THAT MEN GET TO DO WHATEVER THEY WANT, THEY GET THE BIGGER SPACE AND, YOU KNOW, THEY ARE THE ONES THAT CONTROL EVERYTHING. BUT THE POSITIVE SIDE IS WHAT YOU SHOULD USE, ALSO, IN YOUR INTERVENTION, IS THAT THE MAN IS THE PROVIDER, AND HE'S THE -- IF HE'S THE -- REALLY THE PROVIDER AND THE CARETAKER OF THE HOME, HE SHOULD TAKE CARE OF HIMSELF SO THAT HE CAN TAKE CARE OF THE FAMILY. SO THERE IS A POSITIVE THING THAT YOU CAN ADDRESS WHEN TALKING ABOUT MACHISMO. THERE IS ALSO EDUCATION, FAMILY COHESION, YOUR CHILDHOOD EXPERIENCES, COMMUNICATION, FINANCIAL STRESS -- I MEAN, OUR -- YOU KNOW, MANY OF OUR POPULATION THAT WE STUDY ARE NOT, YOU KNOW, MIDDLE CLASS OR UPPER MIDDLE CLASS. THEY'RE -- YOU KNOW, THEY'RE VULNERABLE, THEY'RE MARGINALIZED, THEY'RE POOR, THEY HAVE RELATIONSHIP CONFLICT AND SOME INDIVIDUAL CHARACTERISTICS THAT PUT THEM AT RISK. SO HERE'S SOME EXAMPLES OF MACHISMO AND TRADITIONAL GENDER NORMS THAT THE WOMEN AND THE MEN EXPRESS. AND THE MEN SAY, "I WANT TO DRINK MY BEER TO RELAX." AND THERE, HE DRINKS HIS BEER ALL NIGHT UNTIL THE NEXT DAY -- THIS IS WHAT THEY DO USUALLY, BINGE DRINKING -- AND THE WOMAN STAYS IN THE HOUSE, TOLERATING IT BECAUSE THEY WANT TO RELAX. I USED TO HAVE ONE WOMAN THAT SAID THAT HE WENT DANCING WITH THE OTHER WOMEN WHILE SHE STAYED WITH THE KIDS. SO THE WOMEN WHO HAVE CHILDREN, MALES, RAISE POTENTIAL MACHISTA. WE ARE, EVEN THOUGH THE VICTIMS OF MEN, ALSO CREATORS OF MACHISMO, WHICH IS TRUE, SO THAT THEY GO AND BECOME AGGRESSIVE WITH OTHER WOMEN, WHO WILL BE OUR DAUGHTERS-IN-LAW. THAT'S VIOLENCE. BESIDES IN OUR COUNTRY, THE MACHISMO, AT LEAST IN MEN -- FOR EXAMPLE, "I'M A MAN AND I CAN HAVE AT LEAST 10 WOMEN, AND THOSE 10 WOMEN, I WANT THEM UNPROTECTED" -- NO CONDOMS, THAT MEANS. SO IT'S VERY TOUGH WHEN YOU HAVE THAT TYPE OF STATEMENT. SO SHE WENT BEYOND TO TEST THE SYNDEMIC MODEL THROUGH QUANTITATIVE METHODS. AND SHE TOOK THE DATA THAT WE HAVE FROM NURSING AND FROM THIS CONCEPTUAL PAPER AND LOOKED AT HISPANIC STRESS OF ALTERATION IN FAMILIES AND THIS CULTURAL FACTOR, AND THEY PREDICTED 61 PERCENT OF THE VARIANTS OF THE SYNDEMIC FACTOR, AND THAT'S IMPRESSED IN THE END, ALSO, PRACTICING ANTHROPOLOGY. AND HERE IS THE MODEL, AND I'M NOT GOING TO BORE YOU WITH, BUT YOU CAN SEE THAT HISPANIC STRESS REALLY PREDICTS A LOT OF THE SYNDEMIC FACTOR. AND IT'S REALLY -- I MEAN, THIS COMES FROM SEPARATE DATA, FROM THE DATA FROM OUR STUDY, BUT IT'S VERY INTERESTING THAT THAT PARTICULAR AREA, WHICH ARE THE CULTURAL FACTORS, IS PREDICTING SO MUCH OF THE AREAS -- THE TROUBLE AREAS. I MEAN, THE -- WHAT'S INTERESTING, TOO, IS THAT THE POSITIVE AREAS IN THE HISPANIC CULTURE, SUCH AS FAMILY SUPPORT, ACTS AS A BUFFER AGAINST HISPANIC STRESS, AND THOSE THAT HAVE LOW FAMILY SUPPORT AND HIGH -- HAVE HIGHER FAMILY STRESS. BUT, YET, THOSE WHO HAVE HIGH FAMILY SUPPORT WILL HAVE LOWER FAMILY STRESS. SO IT'S TELLING YOU THAT THAT PROTECTIVE CULTURAL FACTOR OF FAMILY SUPPORT WILL HELP IN DECREASING, YOU KNOW, THE HISPANIC STRESS, WILL HELP BUFFER. SO THOSE ARE IMPORTANT THINGS TO CONSIDER WHEN YOU'RE DEVELOPING AN INTERVENTION. SO THOSE ARE THE -- SOME OF THE PUBLICATIONS FROM THOSE THINGS I'VE BEEN TALKING TO YOU ABOUT. NOW, HOW DO WE DEVELOP, EVALUATE, AND DISSEMINATE THESE CULTURALLY TAILORED INTERVENTIONS? STANFORD JUST PUBLISHED A PAPER, VERY GOOD, IN 2010, OUTLINING FOUR CONDITIONS THAT JUSTIFY CULTURAL ADAPTATION OR TREATMENT. FINDING -- YOU KNOW, ONE OF THE FOUR CONDITIONS -- ONE IS FINDING A TREATMENT THAT'S INEFFECTIVE AT THE CLIENT ENGAGEMENT. SECONDLY, THAT IDENTIFYING A UNIQUE RACE OR RESILIENT FACTOR FOR THIS PARTICULAR GROUP AND THEN IDENTIFYING UNIQUE SYMPTOMS FOR AN OTHERWISE COMMON DISORDER FOR THIS GROUP AND DOCUMENTING FOUR OUTCOMES WITH PARTICULAR, YOU KNOW, GROUP. AND THE THINGS ABOUT THIS IS THAT, IN SOME AREAS, ESPECIALLY IN ADOLESCENT TREATMENT LITERATURE, THERE HAS BEEN, YOU KNOW, EVIDENCE OF THESE -- POOR ENGAGEMENT OF HISPANIC YOUTH INTO SERVICES -- DR. SANTISTEBAN PUBLISHED SOME EVIDENCE TO THAT. UNIQUE RISK FACTORS ASSOCIATED WITH THE ACCULTURATION PROCESS THAT CONTRIBUTE TO THE SYMPTOM -- A SYMPTOM EMERGENCE AND FAMILY BREAKDOWN. AND THERE ARE POORER OUTCOMES IN HISPANIC YOUTH THAT ARE NOT ETHNICALLY MATCHED WITH THERAPY, AND BETTER OUTCOMES FOR ADAPTED TREATMENT. SO THERE IS SOME EVIDENCE, YOU KNOW, TO DO THAT, TOO. AND WE KNOW THAT THE EBI, THE EVIDENCE BASED INTERVENTION MOVEMENT THAT HAS BEEN AROUND FOR 30 YEARS, THERE HAS BEEN AN EMPHASIS IN THIS SYSTEMATIC APPROACH TO INTERVENTION DEVELOPMENT, EFFICACY, AND EFFECTIVENESS, AND IT HAS RESULTED IN MORE ACCOUNTABILITY OF INTERVENTIONS THAT ARE USED IN PRACTICE, AN EVALUATION OF THESE AND REALLY -- YOU KNOW, THAT THESE REALLY WORK. BUT THIS BROAD BASE, YOU KNOW, EBI DO NOT INCLUDE, TYPICALLY, THE CONSIDERATION OF CULTURAL FACTORS, NOR DO THEY STUDY CULTURAL SUBGROUPS. THEY DO ANALYZE CULTURAL SUBGROUPS, BUT THAT BECOMES PROBLEMATIC BECAUSE IT'S A ONE-SIZE-FITS-ALL APPROACH, AND THAT'S NOT WHAT, AT LEAST IN THE HISPANIC CULTURE, WE'RE ABOUT. SO MAYBE WE SHOULDN'T BE ASKING WHAT TREATMENT WORKS, BUT, RATHER, WHAT TREATMENT, BY WHOM, IS MOST EFFECTIVE FOR THIS INDIVIDUAL, IN WHAT SPECIFIC PROBLEM, AND UNDER WHAT SET OF CIRCUMSTANCES. AND WE HAVE BEEN TALKING THAT WE HAVE UNIQUE VALUES, BELIEFS, BEHAVIORS, HISTORIES THAT HAVE HIGH IMPACT ON THIS EFFICACY OF INTERVENTION. AND THE OTHER PROBLEM IS THAT WE NEVER HAVE -- WE ARE ALWAYS A SUBSET OF SOMEBODY. WE ARE NEVER THE LARGE GROUP IN THE STUDY AND WE'RE NEVER LARGE ENOUGH SUBGROUPS TO REALLY MAKE -- YOU KNOW, TO REALLY BE ABLE TO ANALYZE AND SEE THE EFFECT OF THE PARTICULAR INTERVENTION. YOU SAY, "HISPANICS," AND PUT EVERYBODY THERE, AND IT'S NOT THAT EASY. I MEAN, WE HAVE QUITE A VARIATION WITHIN OUR CULTURE. I'M FROM CHILE ORIGINALLY. I'M VERY -- I DON'T THINK I'M THAT DIFFERENT NOW AFTER BEING 35 YEARS HERE, BUT VERY ACCULTURATED. BUT A CHILEAN AND A MEXICAN AND A CUBAN AND -- YOU KNOW, WE'RE VERY DIFFERENT. WE HAVE DIFFERENT, YOU KNOW, VIEWS OF THINGS, I THINK, ALTHOUGH WE HAVE A COMMON LANGUAGE. SO THEY HAVEN'T BEEN TESTED ENOUGH, AND PROBABLY NOT READY TO WIDESPREAD DISSEMINATION FOR THAT GROUP. SO THERE'S THREE LEVELS THAT [UNINTELLIGIBLE] TALKS, AND I'M NOT GOING TO GO THROUGH THESE. WHAT I'M SAYING IS THAT THERE ARE SOME THAT ARE PRODUCTS FOR THERAPIES, THEN YOU HAVE EMPIRICALLY SUPPORTED. WHAT WE DO AT EL CENTRO IS DO NEW CULTURALLY DERIVED INTERVENTIONS. THAT'S WHAT WE DEDICATE OURSELVES TO, IN A SENSE. AND ALL OF OUR INTERVENTION DEVELOPMENT IS DONE LIKE THIS. WE DO PRE-TREATMENT DEVELOPMENT STUDIES. WE DO OBSERVATIONAL STUDY, QUALITATIVE, OR QUANTITATIVE, OR MIXED, AND MOST OF OURS IS MIXED, AIMING AT INFORMING THE DEVELOPMENT OR ADAPTATION OF AN INTERVENTION. THEN WE DO A PILOT STUDY, THEN WE DO AN EFFICACY STUDY, WHICH IS USUALLY AN RCT, AND THEN WE DO AN EFFECTIVENESS STUDY, COMMUNITY-BASED RCT, TYPICALLY MORE [UNINTELLIGIBLE] SO, NOW I'M GOING TO TALK TO YOU BRIEFLY ABOUT MY STUDY. SEPA STANDS FOR [SPANISH] -- A CULTURALLY TAILORED HIV RISK-REDUCTION INTERVENTION DESIGNED FOR HISPANIC WOMEN. THIS INTERVENTION WAS DESIGNED YEARS AGO IN CHICAGO, AND IT'S IN ITS THIRD ITERATION. AND WHEN IT WAS DESIGNED, I FOLLOWED THE SAME PROCESS. I STARTED WITH A QUALITATIVE STUDY. INTERESTINGLY ENOUGH, THE FIRST STUDY WAS DONE ONLY WITH MEXICAN AND PUERTO RICAN WOMEN, AND WHEN I THOUGHT ABOUT DEVELOPING THIS INTERVENTION FOR HIV PREVENTION, THE FIRST THING I THOUGHT IS I NEED A DIFFERENT INTERVENTION FOR MEXICAN AND ANOTHER ONE FOR PUERTO RICAN. FIRST THOUGHT. WRONG. THEN I THOUGHT IT'S GOING TO BE AN HIV PREVENTION, YOU KNOW, SO IT'S HIV PREVENTION. SO I WENT TO THE COMMUNITY, HAD FOCUS GROUPS WITH THE WOMEN, HAD FOCUS GROUPS TOGETHER WITH THE MEXICAN AND THE PUERTO RICAN, AND THEN SEPARATE, TO MAKE SURE THAT THEY WANT TO BE SEPARATE OR TOGETHER. THEY SAID, "NO, WE DON'T WANT TO SEPARATE. WE FEEL WE ARE A COMMUNITY. WE WANT IT TOGETHER. WE WANT TO LEARN FROM THE MEXICAN, I WANT TO LEARN FROM THE PUERTO RICAN." SO, WRONG. SEE? ASSUMPTIONS ARE ALWAYS WRONG. SECONDLY, AT THAT TIME, AND WHICH JUST CAME FROM THE HIV TASK FORCE, THE INTERSECTION OF VIOLENCE AND HIV. I HAD -- I HAVE A WHOLE SECTION ON VIOLENCE PREVENTION, BECAUSE THE WOMEN TOLD ME WE NEED SOMETHING ON VIOLENCE. "WE WANT SOMETHING ON VIOLENCE." SO THERE'S A SECTION ON VIOLENCE, AND I'LL SHOW YOU. AND IT'S ALL BASED ON THE ISSUES -- THE CULTURAL ISSUES THAT WE HAVE ABOUT -- IN THE HISPANIC CULTURE ABOUT RELIGIOUS VALUES, TRADITIONAL, SEXUAL, GENDER ROLES, MARIANISMO, MACHISMO, AND THOSE THAT DO NOT KNOW WHAT MARIANISMO MEANS, IT'S THAT -- YOU KNOW, WANTING FOR WOMEN TO BE LIKE THE VIRGIN MARY. VIRGIN, SUBMISSIVE, YOU KNOW, AND ALL OF THAT. GOOD MOTHERS, RESPECTFUL AND OBEDIENT TO MEN, WHICH I DON'T THINK THE YOUNGER GENERATION IS GOING TO BE THE SAME, LUCKILY. BUT THAT'S EVOLVING. SO THERE'S A COMBINATION OF OVERALL EXPECTATIONS AND -- IN THAT THAT YOU HAVE TO CONSIDER. THEN YOU HAVE TO CONSIDER ALL OF THE THINGS WE HAVE TALKED ABOUT: COLLECTIVISM, SYMPATIA. SYMPATIA IS SOMETHING YOU HAVE TO -- SOME PEOPLE ARE NOT SYMPATICO, THEY'RE NOT NICE, BUT IN OUR CULTURE YOU HAVE TO VALUE DIGNITY AND RESPECT. WHEN I GO AND RUN A GROUP OR DO SOMETHING WITH THE -- BECAUSE I DO GO TO THE FIELD. I'M NOT SOMEBODY THAT SITS BEHIND A DESK. I'M NOT THE RESEARCHER, I'M NOT THE DOCTOR, I'M A WOMAN IN THE COMMUNITY, I'M A LATINO. I'M JUST LIKE THEM. FAMILISM, THAT -- LIKE WE TALKED ABOUT. RESPETO. HIGH CONTACT. THEY KISS YOU, THEY TOUCH YOU. WE'RE A TOUCHY-FEELY CULTURE. AND FLEXIBLE TIME ORIENTATION, WHICH HAS -- CAN BECOME A PROBLEM BECAUSE NOBODY'S ON TIME, ESPECIALLY IN MIAMI. BUT YOU HAVE TO ENCOURAGE TIME, SO -- TO STAY ON TIME. SO SEPA II WE DID IN MIAMI, AND ALL OF THESE ASPECTS -- AND COMMUNICATION WAS ANOTHER PART. AND I DID GO THROUGH THE SAME PROCESS WHEN WE MOVED THE INTERVENTION FROM CHICAGO TO MIAMI. WE ALSO RAN FOCUS GROUPS AND WE DID ALSO THE QUANTITATIVE INTERVIEWS TO TEST THE INSTRUMENT, AND WE RAN A SMALL PILOT BEFORE WE RAN A FULL RUN -- A FULL-FLEDGED RANDOMIZED CONTROL TRIAL. WE ENROLLED 548 WOMEN, 18 TO 50 YEARS OLD, AND WE ASSESS THEM AT THREE, SIX, AND 12 MONTHS. THE INTERVENTION HAD, I SAID, FIVE SESSIONS. NOW WE ARE INTO THREE SESSIONS, AND IT'S BASED -- IT'S THEORETICALLY BASED ON BANDURA'S SOCIAL COGNITIVE BEHAVIORAL CHANGE MODEL. AND [UNINTELLIGIBLE] PEDAGOGY OF THE OPPRESSED IN THE CONTEXT OF HOW WE DELIVER THE INTERVENTION IN THE WHO PRIMARY HEALTHCARE MODEL. THESE ARE SOME OF THE SAMPLE CHARACTERISTICS. WHAT I WANT TO SHOW YOU IS THAT THE YEARS LIVING IN THE U.S., ABOUT 10 YEARS, BOTH CONTROL AND THE DELAYED INTERVENTION IN THE INTERVENTION GROUP, THE ACCULTURATION, MOSTLY HISPANIC, MOSTLY UNEMPLOYED, A THIRD -- YOU KNOW, 30 PERCENT EMPLOYED. NINETY PERCENT BORN OUTSIDE OF THE U.S. AND ABOUT HALF -- LESS THAN HALF HAD HEALTH INSURANCE. SO ACCESS WAS ALSO AN ISSUE. THE RESULTS SHOW SIGNIFICANTLY THEY INCREASE CONDOM USE OVER TIME, AND WE FOLLOWED THEM FOR A YEAR. SO IT WAS SUCCESSFUL. WHAT WE HAD NOT PLANNED, AND IT WAS -- THE INTERVENTION WAS NOT AIMED AT THIS. THE INTERVENTION WAS AIMED AT REDUCING HIV RATES. WE REDUCED PARTNER VIOLENCE, AND THAT WAS NOT THE INTENTION OF THE INTERVENTION. SO THAT WAS VERY INTERESTING. GETTING DRUNK. THEY DO DRINK, STRESS, THE WOMEN, YOU KNOW -- IT'S AN OUTLET. COMMUNICATION WITH PARTNERS INCREASED, THEN IT STARTS TO TAPER OFF, BUT IT TELLS YOU ABOUT BOOSTERS. KNOWLEDGE INCREASES AND THEN TAPERS, TOO, BUT KNOWLEDGE DOESN'T CHANGE BEHAVIOR. SO, IN CONCLUSION, SEPA WAS EFFECTIVE IN REDUCING HIV RISK AMONG HISPANICS AND WOMEN, AND RESULTS SHOULD BE DISSEMINATED. WE NEED -- YOU NEED A STRONG REFERRAL SYSTEM, THOUGH, BECAUSE WOMEN HAVE A LOT OF PROBLEMS WHEN, YOU KNOW, DOING THIS. WE'RE IN THE SEPA III, WHICH -- WE ARE DOING THE EFFECTIVENESS IN THE COMMUNITY AND WE'RE LOOKING AT FIDELITY, FACILITATOR CHARACTERISTICS. I'M GOING TO GO FAST HERE BECAUSE I NEED TO SHOW YOU ANOTHER STUDY THAT IS VERY IMPORTANT. SO, WE'RE LOOKING AT A FIVE-YEAR STUDY AND LOOKING AT BIOLOGICAL PARAMETERS, TOO. YOU KNOW, TESTING FOR HIV, GONORRHEA, CHLAMYDIA, AND TRICHOMONIASIS, AND DOING AN RCT. WE HAVE SPIN-OFF STUDIES. WE HAD A STUDY THAT WAS DONE IN CHILE, ALSO AN RCT, AND PUBLICATIONS FROM THAT. WITH OLDER WOMEN -- WE HAVE ADAPTED SEPA FOR OLDER WOMEN, WHICH IS VERY INTERESTING. WE HAVE 68 PERCENT OF THE PARTICIPANTS LIVING WITH PARTNERS, 62 HAVING EXPERIENCED AT LEAST ONE EPISODE OF INTIMATE PARTNER VIOLENCE IN THEIR CURRENT RELATIONSHIP, 98 PERCENT DID NOT PERCEIVE THEMSELVES AT RISK FOR HIV, NONE OF THEM USE CONDOMS. THESE WOMEN GO TO A SPECIAL PLACE IN MIAMI THAT IS CALLED THE PALACE OF THE WRINKLED [SPELLED PHONETICALLY], WHICH IS WHERE THEY FIND PARTNERS YOUNGER THAN THEMSELVES, NEW IMMIGRANTS. VERY INTERESTING. I NEED TO VISIT. I NEED TO DO A FIELD VISIT TO THAT PLACE. [LAUGHTER] BUT YOU HAVE TO GO WHERE PEOPLE GO, AND, YOU KNOW, FIND OUT WHAT GOES ON, SO -- VERY -- WHO KNOWS. I'LL HAVE TO GO SEE. AND THEN THERE IS THIS ONE, THIS STUDY THAT NATALIA VEGA [SPELLED PHONETICALLY], WHO IS A PH.D. STUDENT AT -- WAS A STUDENT, NOW IS OUR POST-DOC. SHE DID -- FROM THE SEPA CONTENT, SHE DEVELOPED AN INTERNET-BASED STI AND HIV PREVENTION FOR CHILEAN YOUNG WOMEN FOR 18 TO 24. AND IT WAS REALLY GOOD. SHE DID A WEBSITE. IT WAS ALL INTERNET-BASED, AND SHE'S NOW ADAPTING THIS FOR U.S. HISPANIC YOUNG ADULT WOMEN. AND IT WAS VERY WELL-RECEIVED. IT WAS -- IT'S VERY GOOD. THIS ONE I WANT TO SHOW YOU IS DR. SANTISTEBAN'S WORK ON SUBSTANCE ABUSE AND PREVENTION TREATMENT. IT'S A CULTURALLY-INFORMED FLEXIBLE FAMILY THERAPY FOR ADOLESCENTS, IT'S CALLED CIFFTA, AND IT REALLY AIMS TO PREVENT AND TREAT ADOLESCENT SUBSTANCE ABUSE, AND IT'S BASED ON CULTURALLY INFORMED, FAMILY-BASED, AND FLEXIBLY -- WITH A BUILT-IN DECISION LOGIC FOR SYSTEMATIC IMPLEMENTATION. MINORITY FAMILIES USUALLY ENTER WITH SOME CONDITION -- I MEAN CLINICAL CONDITION: DEPRESSION, BLENDED FAMILY ISSUES, CULTURAL ISSUES, IMMIGRATION ISSUES, WHATEVER. AND SO WHAT IT IS IS THEY HAVE FAMILY THERAPY AND INDIVIDUAL THERAPY, BOTH THE ADOLESCENTS AND THE PARENTS HAVE THERAPY WITH A THERAPIST. AND THEY WOULD HAVE PSYCHO-EDUCATIONAL MODULES, AND THIS IS OUR SAMPLE OF THE MODULES, OF 20 MODULES AVAILABLE THAT THE THERAPISTS WOULD GO THROUGH WITH THEM. BUT NOW THIS HAS EVOLVED INTO CIFFTA TELE [SPELLED PHONETICALLY], AND THEY HAVE, THANKS TO NIMHD, A CHALLENGE GRANT THAT FUNDED THE DEVELOPMENT AND TESTING OF A TECHNOLOGY-ASSISTED FAMILY INTERVENTION TO ADDRESS PSYCHIATRIC AND FAMILY CONFLICT, HIGH-RISK BEHAVIORS, FOR HISPANIC AND AFRICAN AMERICAN USE, 12 TO 15. AND IT TARGETS PSYCHIATRIC AND BEHAVIOR SYMPTOMS IN THE CHILD, PARENTING PRACTICES, AND FAMILY CONFLICT COHESION. AND THE SAME THING, THE FIRST-STAGE: DEVELOPMENT, FOCUS GROUP, LAPTOP, VIDEOS THAT THEY DEVELOP WITH ALL THOSE CYCLES. AND FOLLOWING THE DEVELOPMENT PHASE, THEY DID A MEDIUM-SIZE RANDOMIZED TRIAL AND THEY WERE RANDOMLY ASSIGNED TO RECEIVE A 12-WEEK TELE CIFFTA. TWO GROUPS: IMMEDIATELY CIFFTA AND AFTER A 12 -- WITH DELAYED CIFFTA. AND THE IMMEDIATE -- THEY SAW THE TREATMENT AND MAINTENANCE OF TREATMENT, ON DELAY THEY SAW NO TREATMENT, AND TREATMENT. AND I'LL SHOW YOU, BECAUSE IT'S A BEAUTIFUL GRAPH. I TOLD THEM THAT THEY JUST DID THIS SO I COULD SHOW YOU. BUT IF YOU LOOK AT THE REVISED BEHAVIOR PROBLEM CHECKLIST, THE IMMEDIATE CIFFTA IS THE RED, AND IMMEDIATELY YOU SEE IT GOING DOWN. THEY RECEIVED TREATMENT FIRST. THE DELAYS STAY THE SAME. AS SOON AS THEY RECEIVE TREATMENT -- ON T2 YOU SEE IT COMING DOWN AND MATCHING WITH THE OTHER. YOU LOOK AT THE REVISED BEHAVIOR PROBLEM CHECKLIST, AND THESE ARE SOME OF THE OUTCOMES: SAME THING. FAMILY ENVIRONMENT SCALE, ADOLESCENT REPORT OF COHESION, LIKEWISE. FAMILY ENVIRONMENT SCALE, PARENT REPORT OF COHESION, LIKEWISE. NOW, HOW MUCH DO YOU THINK THAT THEY BENEFITED FROM PARTICIPATING IN THE PROGRAM? THE ADOLESCENTS ARE THE BLUE, THE PARENTS ARE THE RED, AND BOTH THOUGHT THEY BENEFITED. DO YOU FEEL THAT THE INFORMATION BY THE LAPTOP WAS USEFUL, OR THE MODULES, THE PSYCHO-EDUCATIONAL MODULES WERE IN THE COMPUTER? A GREAT DEAL, SOME. HOW FREQUENTLY DID YOU USE THE LAPTOP? THEY RESPONDED APPROPRIATELY, BECAUSE DAILY YOU'RE NOT GOING TO USE IT, BUT WEEKLY IS WHAT YOU EXPECT THEM TO USE IT. SO IT REALLY WAS INTERESTING. SO THE RESULT REALLY SHOWS HIGHLY PROMISING RESULTS ON BOTH CHILD AND FAMILY CHANGE TARGETS, REPORTED BY PARENTS AND ADOLESCENTS. AND, REALLY, IT'S VERY POSITIVE, BECAUSE IT ALLOWS FOR MORE USE OF MORE INNOVATIVE AND -- SO, I WON'T HAVE TO TELL YOU MORE ABOUT EL CENTRO, BUT I WANT TO SHOW YOU OUR LITTLE CASITA, BECAUSE THAT -- THOSE ARE ALL OUR CORE, AND REALLY IT IS THE STRUCTURE OF WHERE WE DO ALL OF OUR WORK, AND I THINK THAT BEING A NURSE AND BEING IN THE SCHOOL OF NURSING, I THINK THAT NURSING'S POTENTIAL TO LEAD THE REDUCTION IS TREMENDOUS. WE HAVE A VERY LOW REPRESENTATION AND DIVERSITY. WE NEED DIVERSE NURSE SCIENTISTS. AFRICAN-AMERICANS ARE ONLY 11.3 PERCENT, HISPANICS ARE 4 PERCENT. SHAMEFUL. AND ASIAN AND PACIFIC ISLANDERS, 4 PERCENT. WE'RE VASTLY UNDERREPRESENTED AMONG NURSES WITH PH.D.'S, SO WE NEED WELL-TRAINED MINORITY INVESTIGATORS. BUT INTERDISCIPLINARY TRAINING -- WE ARE AN INTERDISCIPLINARY SCHOOL. NOT ALL OF OUR FACULTY ARE NURSES, WHICH IS WONDERFUL. AND THIS IS NOT A SCIENCE THAT YOU CAN DO IN A SILO, SO THERE'S NOT ONE SINGLE DISCIPLINE THAT HAS MASTERED THIS COMPLEX SCIENCE. SO, LOOKING TOWARDS THE FUTURE, I THINK CAREER DEVELOPMENT IS CRITICAL. COMMUNITY-ENGAGED RESEARCH IS CHALLENGING AND REQUIRES A LOT OF TIME IN THE FIELD, LEADING TO ABSENCE FROM THE ACADEMIC INSTITUTION, AND INVESTIGATORS WHO ARE MEMBERS OF MINORITY GROUPS ARE OFTEN ENLISTED MANY TIMES MORE THAN NEEDED TO PARTICULAR -- TO PARTICIPATE IN ACADEMIC COMMITTEES, AND ONE HAS TO BE, YOU KNOW, VERY COGNIZANT OF THAT AND PROTECT THEIR TIME. THERE IS A NEED FOR MENTORS, FOR PEERS, FOR SENIOR RESEARCHERS, PEOPLE FROM THE SCIENTIFIC ADVISORY BOARDS TO BECOME MENTORS, AND WE NEED TO PROVIDE OPPORTUNITIES TO EMERGING RESEARCHERS. I THINK THAT WE NEED TO TRICKLE DOWN TO FUTURE GENERATIONS. YOUNG MINORITY INVESTIGATORS NEED TO BECOME FUNDED, AND, YOU KNOW, WE NEED TO FEED THAT PIPELINE. WE'RE NOT GOING TO BE HERE FOREVER. THE GOOD NEWS IS, LIKE JOYCE SAID, WITH THE GROWTH OF THE HISPANIC POPULATION THERE IS INCREASED POLITICAL CLOUT, CULTURAL INFLUENCE, RECOGNITION OF THE BENEFITS OF HISPANIC CULTURAL VALUES. BUT WE ALSO HAVE ONGOING CHALLENGES: POVERTY, EDUCATION DEFICIT, DISCRIMINATION, LANGUAGE BARRIERS, STIGMA, ACCESS TO CARE, AND UNDERREPRESENTATION OF HISPANIC HEALTHCARE PROVIDERS AND RESEARCHERS. SO, ALTHOUGH WE ACCOMPLISHED A LOT, WE DID A LOT OF WORK -- I'M VERY PROUD TO SAY, OUT OF 33 PH.D. STUDENTS, 18 MINORITY STUDENTS TRAINED IN HEALTH DISPARITY SCIENCE. WE ENGAGED AND COLLABORATED WITH MANY COMMUNITY PARTNERS, AND WE HAD A CONFERENCE THAT WAS FUNDED BY NIMHD, WHICH WE HAD 1,000 ATTENDEES FROM 40 NATIONS AT THE XIII PAN-AMERICAN NURSING RESEARCH COLLOQUIUM, FIRST TIME IN THE U.S., AND WE HAD EL CENTRO TRACK, AND THAT WAS VERY SUCCESSFUL, SOá NEXT WE HAVE -- WE JUST GOT FUNDED BY SAMHSA ON -- AND I HAVE TO READ THE TITLE, BECAUSE WE JUST GOT THE FUNDING NOTICE, AND DR. SANTISTEBAN WAS FUNDED AS A PI. IT'S SCREENING BRIEF INVENTORY AND REFERRAL TO TREATMENT: AN EVIDENCE-BASED APPROACH TO IDENTIFY SUBSTANCE ABUSE, USE, AND OTHER UNHEALTHY BEHAVIORS IN PRIMARY CARE SETTINGS AND LINKING PATIENTS TO NEEDED SERVICES. IT'S A THREE-YEAR SAMHSA GRANT FOR OVER $940,000. TO BUILD THE CONFIDENCES OF THE NEXT GENERATION OF PRIMARY CARE [UNINTELLIGIBLE] HEALTH PROFESSIONALS, PROVIDING TRAINING TO UNDERGRADUATE, MASTER'S, AND PH.D.-LEVEL NURSING, SOCIAL WORK, AND COUNSELING STUDENTS, AND TO HELP CURE TEENS. AND AS A PARTNER IN PRACTICING SCIENCE, SUCH AS OUR OWN HOSPITAL, THE UNIVERSITY OF MIAMI. AND THIS IS PART OF, ALSO, OUR COMMUNITY ENGAGEMENT AND DISSEMINATION CORE AT EL CENTRO. SO THIS IS THE TYPE OF THING THAT WE ARE INTERESTED IN DOING, THAT WHATEVER WE GET FUNDED FOR, IT GETS EXPANDED IN ANOTHER GRANT -- FROM ANOTHER. SO, THANKS TO MY EL CENTRO COLLEAGUES: VICTORIA MITRANI, MY CO-P.I. AND CORE DIRECTOR; DAN SANTISTEBAN [SPELLED PHONETICALLY], CO-INVESTIGATOR AND CORE DIRECTOR; ROSA GONZALEZ-GUARDA, CO-INVESTIGATOR AND CORE CO-DIRECTOR; AND ALSO OUR FACULTY AND CO-INVESTIGATOR, DR. CIANELLI [SPELLED PHONETICALLY], JOE DE SANTIS [SPELLED PHONETICALLY], AND NATALIA VILLEGAS [SPELLED PHONETICALLY]; AND TO ALL OF OUR PARTICIPANTS AND COMMUNITY PARTNERS, THAT WITHOUT THEM WE COULDN'T MAKE OUR WORK POSSIBLE. THANK YOU VERY MUCH. GRACIAS. JOYCE HUNTER: OKAY, WE'RE GOING TO OPEN THE FLOOR NOW FOR QUESTIONS. THERE ARE MICROPHONES ON EACH SIDE OF THE ROOM, AND DON'T BE SHY. RIGHT OVER HERE, PLEASE. RICHARD BERZON: THANK YOU VERY MUCH FOR THAT REALLY VERY THOROUGH AND COMPREHENSIVE PRESENTATION. MY NAME IS RICK BERZON. I'M A STAFF PERSON AT THE NIMHD, AND I HAD A QUESTION FOR YOU. IT'S A METHODS QUESTION, BUT SINCE YOU DO QUALITATIVE AS WELL AS QUANTITATIVE WORK, THIS SHOULD BE SOMETHING THAT YOU CAN GIVE ME YOUR THOUGHTS ON. I WAS A LITTLE BIT CONFUSED WHEN YOU TALKED ABOUT DIFFERENCES WITH RESPECT TO LIKERT RESPONSE SCALES AND DICHOTOMOUS RESPONSE SCALES. YOU SEEMED TO IMPLY THAT SOME CULTURES HAVE A PROBLEM OR AN ISSUE OR ARE UNABLE TO DEAL WITH LIKERT SCALES, AND LIKERT SCALES ARE USED QUITE OFTEN IN SOCIAL SCIENCE RESEARCH -- IN FACT, YOUR RESEARCH INDICATED THAT YOU USE THEM REGULARLY YOURSELF. BUT YOU SEEMED TO IMPLY THAT PERHAPS THERE WAS A PROBLEM WITH THEM, AND I'M WONDERING, AS A SOCIAL SCIENTIST, HOW YOU CAN AVOID USING THEM WHEN YOU DO SOCIAL SCIENCE RESEARCH AND YOU'RE TRYING TO GET INFORMATION ON PATIENT HEALTH STATUS AND BEHAVIOR AND QUALITY OF LIFE AND SO FORTH. NILDA PERAGALLO MONTANO: I THINK -- IS THIS ON? YEAH. I THINK -- YOU KNOW, AND I RECALL A GREAT ARTICLE THAT I READ MANY YEARS AGO THAT I WISH I HAD WRITTEN, BUT IN MANY OF OUR -- WHAT HAPPENED, I THINK, IN OUR CASE WITH THE LIKERT SCALES IS THAT WHEN THEY HAVE TOO MANY POINTS AND THERE IS A RANGE OF TOO MANY -- YOU KNOW, IT'S A LITTLE BIT OF THIS AND A LITTLE BIT MORE OF THAT AND -- YOU KNOW, AND IT'S VERY HARD FOR PEOPLE TO BE ANCHORED. AND WE SEE IT EVERY DAY. I MEAN, PEOPLE SAY, "BUT I LIKE IT." OKAY, BUT THEN YOU NEED TO SAY, "OKAY, YOU LIKE IT A LITTLE OR A LITTLE BIT MORE OR A LITTLE" -- YOU KNOW, ALL THOSE GRADIENTS BECOME VERY DIFFICULT. AND I'M TELLING YOU, FROM -- I MEAN, EVEN FROM A PERSONAL PERSPECTIVE, I MEAN, I THINK -- I'M NOT SAYING THAT PEOPLE ARE DUMB OR THEY CANNOT, YOU KNOW, THINK IN THOSE TERMS, BUT I THINK THERE'S SO MANY GRADIENTS IN THOSE -- IN SOME OF THOSE SCALES THAT YOU END UP WITH EXTREMES, AND YOU -- WHEN YOU DO -- YOU KNOW, AT THE END OF THE ANALYSIS, YOU KNOW, SOME OF THE STATISTICIANS SAY, YOU KNOW, THIS IS -- I MEAN, YOU DON'T HAVE ALL THE POINTS THAT -- AND IT'S VERY HARD. I MEAN, WE HAVE BEEN TO THE POINT THAT WE NEED TO DEVELOP VISUAL -- YOU KNOW, VISUAL AIDS TO BE ABLE TO ANCHOR PEOPLE AND TO SAY, "OKAY. YOU SAY YOU LIKE IT. LET'S GO BACK AND LET'S" -- I MEAN, YOU SPEND A LONG AMOUNT OF TIME, AND I -- AND EVEN SO -- I MEAN, I'VE DONE INTERVIEWS MYSELF MANY, MANY, MANY TIMES, AND IT'S -- THE MORE GRADIENT IT HAS, THE MORE POSSIBILITIES, THE DIFFICULTY -- THE MORE DIFFICULT IT BECOMES TO MAKE THOSE CHOICES. I DON'T KNOW IF YOU UNDERSTAND WHAT I'M -- IF YOU -- RICK BERZON: YEAH, I UNDERSTAND WHAT YOU'RE SAYING. MOST SCALES REALLY ONLY HAVE FOUR OR FIVE RESPONSES. IF YOU LOOK AT THE MOST -- NILDA PERAGALLO MONTANO: FIVE IS ALREADY -- RICK BERZON: THE MOST COMMONLY-USED QUESTION THAT THE U.S. GOVERNMENT USES IN ITS HEALTHCARE RESEARCH IS FROM THE RAND HEALTH INSURANCE EXPERIMENT, WHICH WAS -- TOOK PLACE 30 YEARS AGO. AND IT'S A SINGLE QUESTION, AND THERE WERE ONLY FOUR OR FIVE RESPONSES. IT'S PICKED UP BY THE SF-36, AND THE QUESTION IS, "HOW WOULD YOU RATE YOUR HEALTH?" AND THEY'RE REALLY -- THERE ARE ONLY FOUR OR FIVE RESPONSES TO THAT. AND MOST QUESTIONS THAT ARE USED IN SURVEY RESEARCH AND IN SOCIAL SCIENCE RESEARCH LIMIT THEIR RESPONSES TO APPROXIMATELY FIVE. AND THAT IS DONE FOR A -- THE REASON THERE IS TO GET THE -- A VARIABILITY IN RESPONSES FROM THE PATIENT SO THAT WHEN YOU DO THE ANALYSIS, YOU DON'T JUST HAVE A YES OR NO ANSWER SO IT GIVES YOU VARIABILITY. JOYCE HUNTER: THANK YOU, DR. BERZON. I THINK WE NEED TO MOVE TO THE NEXT QUESTION. JUDY ARROYO: IS THIS ON? I DON'T KNOW -- OKAY. JUDY ARROYO FROM THE NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOLISM. THANK YOU SO MUCH FOR YOUR PRESENTATION. I'D LIKE TO FOLLOW UP. TWO THINGS, ONE, I -- IT'S A SHAMELESS PLUG, I'M SORRY, BUT WHEN YOU TALK ABOUT YOUR MEASUREMENT LIBRARY, THAT IS A CRITICAL ISSUE. ALL RIGHT? HAVING THEM -- HAVING THE MEASURES AVAILABLE IN NON-ENGLISH LANGUAGES IS SOMETHING -- I'VE GOT A QUESTION RELATED TO THAT, BUT NIAAA HAS JUST PUT OUT -- WE'VE GOT OUT ON THE STREET RIGHT NOW A CONTRACT TO DO WHAT YOU'RE DOING, TO BASICALLY ESTABLISH A MEASUREMENT LIBRARY OF NON-ENGLISH LANGUAGES. SPANISH IS PROBABLY WHAT WE'RE GOING TO GET, BUT WE'RE GOING TO GET A LOT OF OTHER ONES, AS WELL. SO IF ANYBODY KNOWS ANYBODY THAT'S INTERESTED AND CONTRACTED TO DO THAT, WE'VE GOT IT ON THE STREET. MAYBE YOUR PEOPLE MIGHT BE. AND YOU WERE TALKING ABOUT DEPLOYMENT. IN ORDER TO MAKE IT A SMALL BUSINESS, YOU HAVE TO MONETIZE IT, AND WE FOUND THAT IF YOU ADD IN SOMETHING LIKE BUILDING AN APP TO MAKE IT ACCESSIBLE TO PEOPLE AND THEN THEY CAN BUY THE APP, IT'S A WAY TO MAKE IT SOMETHING THAT YOU CAN CONSTANTLY HAVE TO UPDATE AND THAT MAKES IT POSSIBLE FOR PEOPLE TO MAKE A LIVING OFF OF, FOR EXAMPLE. SO THE QUESTION THAT I ACTUALLY HAVE IS HOW DO YOU DO THE CULTURAL EQUIVALENCY WORK? WE HADN'T INCLUDED THAT IN THE CONTRACT. YOU KNOW, HOW DO YOU -- WHAT DO YOU MEASURE THAT YOU'RE USING TO ESTABLISH CULTURAL EQUIVALENCY? THE OTHER THINGS YOU CAN GET. THE CULTURAL EQUIVALENCY, THAT'S A HARD ONE. NILDA PERAGALLO MONTANO: YEAH. WE -- THE PART THAT -- THE WAY THAT WE DO IT IS WE TEST -- THAT'S WHY WE -- IT'S NOT -- YOU KNOW, WHEN WE TRANSFER THE INTERVENTION AND WE TRANSFER THE INSTRUMENT, LIKE WHEN WE GO FROM ONE PLACE TO ANOTHER ONE AND YOU GO FROM MEXICAN AND PUERTO RICAN POPULATION, EVEN WHEN WE DID MEXICAN AND PUERTO RICAN, WE PUT "SLASH" WHAT THE MEXICANS SAY. LET'S SAY, "MAKING OUT," OKAY? WE'RE ASKING, YOU KNOW, "HOW DO YOU MAKE OUT?" ONE CALLS IT -- I DON'T KNOW. I'M GOING TO COME UP WITH A -- ONE CALLED IT, LIKE, "SLOBBER IN YOUR FACE." SOME WEIRD TERM, I MEAN, THAT I -- THAT A MEXICAN WOULD HAVE NEVER HEARD, YOU KNOW? BUT THE PUERTO RICAN CALLS IT THAT, SO YOU HAD TO -- WHAT WE DO IS GO THROUGH THE QUESTION AND PUT "SLASH THIS OTHER ONE." SO YOU CAN SAY BOTH TERMS, YOU KNOW? AND IN SOME OF THE SCALES THAT ARE REALLY SCALES THAT HAVE BEEN ORIGINALLY TRANSLATED, YOU CAN'T CHANGE THAT. BUT, YOU KNOW, YOU CAN -- YOU -- WE TRAIN OUR INTERVIEWERS -- LIKE, THESE PEOPLE DON'T UNDERSTAND A TERM, I MEAN, WE TEST THOSE INSTRUMENTS FIRST. WE PILOT TEST THEM, AND IF THEY DON'T UNDERSTAND THE WORD, THEN WE SAY, YOU KNOW, THIS MEANS FOR SOME PEOPLE THIS OTHER WORD. I MEAN, SO YOU HAVE TO HAVE PEOPLE THAT MANAGE THE LANGUAGE TO BE ABLE TO CONDUCT THE INTERVIEW. I MEAN, YOU CAN'T HAVE, LIKE, YOU KNOW, IMPROMPTU SPANISH SPEAKERS OR -- JUDY ARROYO: NO, BUT -- SO YOU'RE TALKING ABOUT SOMEBODY MANAGING THE LANGUAGE USED IN THE INTERVIEW, BUT ARE THERE PSYCHOMETRIC TESTS OF THE CULTURAL EQUIVALENCY THAT YOU'RE USING, AS WELL? NILDA PERAGALLO MONTANO: SOME, YES. JUDY ARROYO: OKAY. MARCIA GOMEZ: YEAH, HI. DR. PERAGALLO, OUR LIVES MET TOGETHER, GOSH, ABOUT 15, 20 YEARS AGO. I'M MARCIA GOMEZ. I'M WITH NIMHD NOW. GOING FAST. [SPANISH]. THANK YOU SO MUCH. IT WAS SUCH A GREAT PRESENTATION. I HAD A QUESTION FOR YOU. I WONDER IF YOUR GROUP IS -- YOU TALKED ABOUT THE HISPANIC PARADOX, AND ESPECIALLY WITH MATERNAL CHILD HEALTH, THERE HAS BEEN SO MUCH WORK DONE AND IT'S SO DIFFERENT FOR DIFFERENT COMMUNITIES. FOR EXAMPLE, IN CALIFORNIA, AMONG THE MEXICAN POPULATION, YOU SEEM TO LOSE THAT WITHIN ONE OR TWO GENERATIONS, AND IN NEW YORK CITY, WITH DOMINICANS, IT SEEMS TO MAINTAIN THAT EVEN AFTER THREE GENERATIONS. I WONDER IF YOUR GROUP IS LOOKING INTO THAT, AND WHAT IS -- WHAT ARE SOME OF THE DIFFERENCES IN EQUALITY, AND HAVE YOU LOOKED INTO THAT PARADOX OUTSIDE OF MATERNAL CHILD HEALTH, AND ESPECIALLY AMONG MALES AND -- NILDA PERAGALLO MONTANO: WE ARE NOT LOOKING AT THAT, BUT THERE'S A HUGE STUDY GOING ON AT UNIVERSITY OF MIAMI, THAT THEY HAVE FUNDING LOOKING EXACTLY AT THAT, AT HISPANIC HEALTH, AND I'M BLOCKING HIS NAME, AND HE'S A HUGE RESEARCHER, AND HE HAS ONE OF THE LARGEST, MOST EXCITING STUDIES ALL AROUND THE COUNTRY LOOKING AT HISPANIC HEALTH, AND HE'S LOOKING AT THAT -- EXACTLY THAT. AND I CAN SEND YOU THAT, MARCIA, BECAUSE I'M LIKE A TOTAL BLOCK. I CAN SEE HIM AND I CAN -- I'M BLOCKING HIS NAME. SCHNEIDERMAN, NEIL SCHNEIDERMAN. HE HAS A BIG STUDY IN HISPANIC HEALTH, AND HE'S LOOKING ACROSS THE COUNTRY, AND WITH A HUGE SAMPLE IN MIAMI. JOYCE HUNTER: OKAY. THE YOUNG LADY AT THE TOP, WHO HAS BEEN WAITING A LONG TIME. PLEASE, GO AHEAD AND ASK HER YOUR -- FEMALE SPEAKER: OH, OKAY. THANK YOU FOR THE PRESENTATION. MY QUESTIONS ARE "YES" OR "NO." BASED ON YOUR STUDY THAT YOU PRESENTED, THEY SEEMED LIKE THEY WERE -- YOU INDICATED THAT THEY WERE THE MOST -- THE FIVE-YEARS-AGO STUDY, THAT MOST OF THEM INCLUDE PURPOSIVE SAMPLING, BECAUSE THE LAST STUDY, IT LOOKED LIKE THERE WERE 80 HISPANIC-AMERICAN WOMEN. AND, ALSO, AS FOR YOUR QUANTITATIVE STUDIES OF CONCERN, I DID HEAR YOU TALK ABOUT PSYCHOMETRICS BUT I DIDN'T HEAR A LOT ABOUT THE CONTRASTING OF RURAL AND URBAN POPULATION STUDIES, AND I WOULD THINK THERE WOULD BE UNDERLYING -- ADDITIONAL UNDERLYING SOCIOCULTURAL FACTORS WHEN YOU'RE LOOKING AT RURAL POPULATIONS. AND SO THOSE ARE MY TWO QUESTIONS. NILDA PERAGALLO MONTANO: MOSTLY ARE -- WELL, IT'S HARD TO -- IT'S URBAN IF YOU THINK OF THE PLACE THAT THEY LIVE, BUT YOU -- YOU KNOW, THERE IS A VARIABILITY AS TO HOW MANY YEARS THEY HAVE BEEN IN THE U.S., AND THEY COME FROM DIFFERENT COUNTRIES. LIKE, IN MY STUDY, THEY'RE MOSTLY URBAN, YOU KNOW, THE PARTICIPANTS OF THE STUDIES THAT I SHOWED YOU, YOU KNOW? FEMALE SPEAKER: AND THE SAMPLING? WERE THEY MOSTLY PURPOSIVE SAMPLES OR -- NILDA PERAGALLO MONTANO: THEY'RE MOSTLY COMMUNITY-BASED, AND THEY'RE CONVENIENCE SAMPLING. THEY'RE CONVENIENCE, BUT THEY'RE -- AND A LOT OF THE SAMPLING, ALSO, IS SNOWBALLING. I MEAN, THAT'S WHY I WAS SAYING, YOU KNOW, THE PEOPLE IN THE COMMUNITY HERE, AND THEY -- YOU KNOW, THAT START ROLLING, YOU KNOW, THE COMMUNITY ENGAGEMENT AND THE COMMUNITY PARTICIPATION. JOYCE HUNTER: I HAVE A QUESTION RIGHT HERE. NILDA PERAGALLO MONTANO: BUT THEN THEY GET RANDOMIZED, YOU KNOW, ONEá FEMALE SPEAKER: HI DR. MONTANO. THIS IS SCOTTIE ST. CLAIR [SPELLED PHONETICALLY]. I'M ACTUALLY WITH THE NATIONAL ASSOCIATION OF HISPANIC NURSES, THE DISTRICT OF COLUMBIA CHAPTER. JUST WANT TO CONGRATULATE YOU ON THE WONDERFUL, WONDERFUL PRESENTATION, AND, ALSO, THANK YOU SO MUCH FOR RAISING SOME OF THE RECOMMENDATIONS ABOUT THE UTILIZATION OF MORE NURSES IN THE ROLE OF RESEARCH, AS WELL, AND ALSO RAISING AWARENESS ABOUT THE LACK OF HISPANIC REPRESENTATION IN HEALTHCARE FIELDS AND RESEARCH. AND I ALSO WANTED TO SEE IF YOU CAN POSSIBLY TAKE A MOMENT TO ELABORATE ABOUT RAISING AWARENESS AMONG ALL THE COLLEAGUES HERE WHO ARE RESEARCHERS TO ACTUALLY CONSIDER THE FACT THAT WE HAVE OVER THREE MILLION NURSES IN THE COUNTRY, SO -- THAT ARE BEING VERY LITTLE UTILIZED IN RESEARCH. SO I DON'T KNOW IF YOU HAD SOME WORDS OF WISDOM TO SHARE WITH THEM. NILDA PERAGALLO MONTANO: WELL, I THINK WE HAVE A HUGE JOB AHEAD OF US IN SCHOOLS OF NURSING, AND ONE OF THE THINGS IS EXACTLY WHAT -- YOU KNOW, WE NEED TO BE DOING THE TRAINING OF THE PH.D. STUDENTS. IT'S HARD AND WE NEED TO PROVIDE FUNDING FOR THOSE PH.D. STUDENTS, WE NEED TO -- YOU KNOW, AND NIH IS PART OF THE REASON. YOU KNOW, WE NEED TO GET FUNDING FOR THOSE PH.D. STUDENTS. WE NEED THOSE F31S, F32S, YOU KNOW, TO PROVIDE THEM WITH AN OPPORTUNITY. IT'S HARD, YOU KNOW, TO RECRUIT, ALSO, NURSES, YOU KNOW, BACK TO A PH.D. SO WE HAVE DONE A LOT INTO DOING, YOU KNOW, AS MANY OTHER DISCIPLINES, GOING STRAIGHT FROM THE BSN TO THE PH.D. TRACK SO THAT PEOPLE DON'T GET OUT TO PRACTICE AND THEN THEY -- YOU KNOW, THEY DON'T COME BACK. AND, YOU KNOW, IT'S AN ISSUE BECAUSE, YOU KNOW, LIFE HAPPENS AND THEY JUST, YOU KNOW, DON'T RETURN. AND I THINK THE IOM REPORT REALLY HAS HELPED IN DOING THAT. I THINK FOR US, EL CENTRO ALSO HAS ATTRACTED ENORMOUS AMOUNTS OF STUDENTS, AND BECAUSE WE'RE IN THE AREA OF THE COUNTRY THAT WE ARE, AND BECAUSE WE'RE STUDYING THE POPULATIONS THAT WE ARE, THAT ATTRACTS A LOT OF STUDENTS, YOU KNOW, TO THE PH.D. PROGRAM, AND -- BUT WE NEED TO DO A LOT MORE. AND MANY -- YOU KNOW, I MEAN, WE ARE FORTUNATE BECAUSE WE HAVE 60 PERCENT MINORITY STUDENTS ENROLLED IN OUR SCHOOL, ALTHOUGH WE ARE A PRIVATE UNIVERSITY, WHICH IS UNUSUAL. BUT, YOU KNOW, WE'RE IN A LOCATION IN THE COUNTRY THAT THE POPULATION SURROUNDING US -- I MEAN, YOU LOOK OUT THE WINDOW AND THAT'S -- WE'RE SURROUNDED BY DIVERSITY, I MEAN, SO -- BUT WE HAVE A HUGE JOB IN NURSING, I MEAN, TO DO TO TRAIN, AND ALSO FOR STUDENTS, YOU KNOW, TO GET ENGAGED, BUT YOU HAVE TO GET PEOPLE EXCITED ABOUT RESEARCH. THEY HAVE TO GET INVOLVED, YOU KNOW, FROM UNDERGRADUATE ON. I MEAN, YOU CAN'T WAIT UNTIL YOU'RE DONE TO GET ENGAGED IN RESEARCH. AND I THINK IN EL CENTRO, THAT'S WHAT WE DO WITH THE RESEARCH TRAINING CORPS. WE'RE INVOLVING UNDERGRADUATE STUDENTS. I MEAN, I DIDN'T HAVE TIME TO GO ALL OVER THAT, BUT THAT'S WHAT WE'RE DOING. AND THEY SEND US STUDENTS FROM ALL OVER THE UNIVERSITY, INCLUDING NURSING, YOU KNOW? IN SPITE OF THEIR GRUELING SCHEDULE, WE MAKE TIME FOR THEM TO -- YOU KNOW, TO GET INVOLVED IN RESEARCH. SO I THINK THAT'S PART OF -- AND IT'S IMPORTANT. I MEAN -- AND NURSES ARE NOT ONLY THERE TO COLLECT DATA, YOU KNOW, AND TO BE -- YOU KNOW, THEY -- WE HAVE A LOT MORE TO OFFER. WE KNOW ABOUT, YOU KNOW, PATIENT CARE, WE KNOW ABOUT COMMUNITY, WE -- YOU KNOW? AND TRUST. WE'RE, YOU KNOW, THE MOST TRUSTED PROFESSION BY THE -- WHAT IS IT? THE 11TH YEAR BY THE GALLUP POLL. I MEAN, IT HAS TO BE FOR SOMETHING. AND PEOPLE TELL YOU STUFF. YOU TELL THEM YOU'RE A NURSE AND THAT REALLY HELPS. JOYCE HUNTER: WE HAVE TIME FOR ONE MORE QUESTION. OKAY. WELL, I THINK WE REALLY SHOULD GIVE DR. PERAGALLO MONTANO [INAUDIBLE] NILDA PERAGALLO MONTANO: THANK YOU.