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Although binational health care seeking is common among HIV-infected Latinos living near the U.S.-Mexico border, information is lacking on whether regional indicators of health access are associated with Health-Related Quality of Life (HRQL). This study examined health care seeking behaviors across 4 HRQL domains (Emotional Well-Being, Cognitive Functioning, Physical Functioning, and Pain) using linear regression. HIV-infected Latinos (n = 239) were recruited from U.S. community clinics situated near California’s border with Mexico. The Spanish-language (81%) and male (84%) dominant population had generally positive indicators of HRQL. AIDS diagnosis predicted poorer HRQL (Cognitive Functioning, Physical Functioning, and Pain), as did receipt of traditional medications/herbs in Mexico (Physical Functioning and Pain). Staying 1 or more months in Mexico in the previous year was associated with higher Cognitive Functioning and less pain. Border-related factors were inconsistently implicated in HRQL measures. Improved understanding of complementary and alternative medicine use by HIV-infected Latinos is warranted.
Among persons living with HIV infection, health-related quality of life (HRQL) indicators can be used to understand relationships between treatment and health outcomes, overall health and well-being, and survival (Bajunirwe et al., 2009; Protopopescu et al., 2007; Rao, Hahne, Cella, & Hernandez, 2007). Important studies have been published on HRQL among U.S. Latinos, who bear a disproportionate burden of HIV infection. Rao and colleagues (2007) focused on HRQL of persons living with HIV/AIDS from the continental United States and Puerto Rico and found that being male, non-Hispanic White, Spanish-speaking, having lower CD4+ T cell counts, and living with others were significantly associated with better physical health, functional health, and emotional or social well-being. Van Servellen, Chang, and Lombardi (2002) conducted a study with Latino populations living with HIV in Los Angeles County and found that neither acculturation nor socioeconomic vulnerability mediated the relationship between health status and HRQL. However, monolingual Spanish-speaking Latinos had poorer HRQL.
Use of complementary and alternative medicines (CAM) may also be associated with HRQL, although factors related to quality of life and choices surrounding CAM use in the U.S.-Mexico border region have been largely unexplored in the context of patients living with HIV. CAM utilization is common among U.S. Latinos (Lopez, 2005), and although some CAM traditions are widespread across Latino ethnicities (e.g., use of chamomile tea), many practices are deeply rooted in Mexican or other cultural practices that may be as diverse as Latino populations themselves (Hsiao et al., 2006; Rivera et al., 2005). In a study of CAM use among HIV-infected Latinos, 72% reported using Asian-related CAM (e.g., acupuncture, tai chi); 42% reported using plant-based CAM (herbs, home remedies); and 13.5% reported use of ethnomedicine/folk healing (e.g., sobadores, curanderos; Jernewall, Zea, Reisen, & Poppen, 2005). This study further revealed that ethnomedicine CAM was significantly associated with not going to medical appointments at prescribed intervals and non-adherence to Western medical regimens (Jernewall et al., 2005). Exploration of the potential role of CAM in health-related quality of life, therefore, is important and potentially significant to improve care provision and health outcomes for Latinos living with HIV.
There is a paucity of information available on correlates of HRQL for HIV-infected Latinos in the U.S.-Mexico border region. Improved understanding of factors associated with HRQL in Latino populations living with HIV is important given increasing HIV prevalence among Latinos on both sides of the California-Baja California, U.S.-Mexico border (Brouwer et al., 2006; County of San Diego Health and Human Services Agency, 2009; Iñiguez-Stevens et al., 2009; Pan American Health Organization, 2007). Regional cross-border mobility contributes to the public health and clinical relevance of understanding binational health. More than 60 million north- and south-bound yearly border crossings occur in the San Diego County and Baja California region alone (San Diego Association of Governments (SANDAG) and California Department of Transportation District 11 [SANDAG], 2006), including Latinos living with HIV who report seeking health care services on both sides of the border (Zúñiga, Brennan, Scolari, & Strathdee, 2008).
Our recent work in the San Diego and Tijuana U.S.-Mexico border region found that Latinos of Mexican-origin who made five or more round-trip border crossings in the previous year reported significantly fewer barriers to HIV care than persons who had made fewer than five crossings in the previous year (Zúñiga et al., 2008). This finding merits further research given that persons who are able to make more round-trip border crossings may also have more health care options and thus improved quality of life indicators. In our study, we hypothesized that persons who (a) reported more frequent border crossing, and (b) have accessed health care in Mexico, would report a higher quality of life. Understanding binational health care utilization and HRQL among border residents may lead to opportunities for improved clinical care of this growing population and improved coordination of care between providers on both sides of the border who serve binational patients living with HIV.
The data examined in this cross-sectional study were collected as part of a broader, multi-site demonstration project to assess access to care in HIV-infected persons in the U.S.-Mexico border region. The parent study was an observational study whose methods (e.g., data collection procedures and measures) are detailed in Zúñiga et al. (2008). Participants (≥ 18 years of age) living with HIV and receiving HIV-related services from one of four community clinics located in San Diego and Imperial Counties were recruited from July 2001-September 2004. These clinics serve a predominantly low-income population of Mexican origin. The current study was restricted to 239 persons of Mexican origin (comprising > 80% of enrolled participants) who had completed a Quality of Life survey measure as part of the parent study. Detailed information on recruitment and consenting procedures has been reported elsewhere (Zúñiga et al., 2008). This study was reviewed and approved by the Human Research Protection Program at the University of California, San Diego.
Measures used in the current study were developed by a team of researchers with expertise in U.S.-border populations (Center for Applied Social Research, 2005). The current study examined: Quality of Life, Demographics, and Lifestyle and Culture (described below).
The 22-item Quality of Life module was derived from standardized HRQL measures including HIV Patient Assessed Report of Status and Experience (HIV-PARSE) and Medical Outcomes Study-HIV (MOS-HIV; Rand Health, 2007); and the AIDS Clinical Trials Group-Short Form 21 (ACTG SF-21; Crystal, Fleishman, Hays, Bozzette, & Shapiro, 2000). The measure includes eight domains: Current Perceived Health, Role Functioning, Social Functioning, Physical Functioning, Energy-Fatigue, Pain, Cognitive Functioning, and Emotional Well-Being. Based on findings from other studies of HRQL among Latinos living with HIV, Emotional Well-Being, Cognitive Functioning, Physical Functioning, and Pain were chosen as dependent variables for our study (Mier et al., 2008; Rao et al., 2007; Van Servellen et al., 2002; ). Scoring for each domain was derived from linear transformations of Likert scale score (Center for Applied Social Research, 2005). Measures included Emotional Well-Being (3 items, Cronbach’s alpha = .81), Cognitive Functioning (3 items, Cronbach’s alpha = .82), Physical Functioning (4 items, Cronbach’s alpha = .85), and Pain (2 items, Cronbach’s alpha = .79).
The 30-item Demographics module was used to determine personal and social factors. It included questions on age, gender, sexual orientation, highest level of education completed, household size, insurance status, primary health care source, employment status, HIV/AIDS status and years since receiving the HIV diagnosis.
The 23-item Lifestyle and Culture module included additional socio-economic indicators (e.g., housing status, marital status), questions specific to the U.S.-Mexico border (e.g., ties to Mexico, round-trip border crossing frequency in the previous year, number of months living or visiting in Mexico in the previous year, health insurance in Mexico, use of a traditional healer), and language preference. Some indicator variables, such as housing status, were re-coded into new variables based on the HRQL literature. For example, current housing status was dichotomized into two groups: persons who reported living in their own house or apartment were considered to have stable housing; all others (e.g., persons who lived in someone else’s home, transitional housing, or homeless) were considered to have unstable housing (Aidala, Lee, Abramson, Messeri, & Siegler, 2007).
Outcome variables included four HRQL indicators: (a) Emotional Well-Being, (b) Cognitive Functioning, (c) Physical Functioning, and (d) Pain. Each outcome variable was scored on a scale of 0 (worst HRQL score) to 100 (best HRQL score). Independent variables were selected based on our study hypothesis (≥ 5 round-trip border crossings in the previous year) and measures of binational health care utilization (e.g., received prescription medication in Mexico) as well as indicators of HRQL derived from the literature. Univariate statistics (t-tests, ANOVA, and regression) were generated for independent variables for each of four HRQL domains. Independent variables significant at the p ≤ 0.10 level in univariate analyses were entered into a multivariate linear regression model specific to that domain. Models used for hypothesis testing were built using multiple regression through general linear models and Type III sum of squares. A manual backward elimination procedure was used to fit the best model to predict HRQL outcomes, with only variables with p ≤ 0.05 remaining in final models.
A convenience sample of 239 HIV-infected Latinos consented to participate. The study population was of Mexican origin, male (84%), Spanish-language dominant (81%), and had a mean age of 37 years (SD = 9.80). Time since HIV diagnosis was an average of 2.7 years (SD = 4) at time of study enrollment and 29% reported an AIDS diagnosis. Two thirds of participants (65%) had lived or visited in Mexico for 1 month or more in the prior year. Most participants (73%) reported having made five or more round-trip border crossings from the United States to Mexico in the previous year. About one third reported utilization of non-HIV medical care in the United States (30%) and 47% reported non-HIV medical care in Mexico. More than half (55%) reported receipt of prescription medications in Mexico in the previous year. Detailed demographic and regional characteristics are provided in Table 1. Univariate associations across HRQL domains are presented in Table 2. Our primary study hypothesis, number of round-trip border crossings (≥ 5 vs. < 5) in previous year, was not significantly associated with any of the four HRQL outcomes at the univariate level.
Mean HRQL indicators for Emotional Well-Being, Cognitive Functioning, Physical Functioning and Pain were in the second highest quartile range towards better health, between 58 and 70 (score range 0–100). These scores reflected that, at the time of the survey, participants reported generally good levels of quality of life across the four indicators.
Mean Emotional Well-Being score was 57.9 (SD = 23.2), indicating that on average, participants reported occasionally feeling anxious, blue, and unhappy in the previous 4 weeks. The final model for Emotional Well-Being explained 18% of the variation in the Emotional Well-Being score. Adjusting for all other variables in the model, being male and married, younger age, having at least a high school education, and having stable housing were associated with better Emotional Well-Being. Predictors of worse Emotional Well-Being (e.g., frequently or always felt anxious, blue, and unhappy) included persons who were raised exclusively in the United States and had received non-HIV medical care in the United States in the previous year.
The average score for Cognitive Functioning was 69.4 (SD = 25.2), indicating that on average, participants reported that sometimes in the previous 4 weeks they were unable to remember, focus, and solve problems. The final model for Cognitive Functioning explained 18% of the variation in the Cognitive Functioning score. Male gender, younger age, stable housing, and persons who had spent at least 1 month living or visiting in Mexico in the previous year were associated with better Cognitive Functioning. Predictors of worse Cognitive Functioning (e.g., frequently or always unable to remember, focus, and solve problems) included having an AIDS diagnosis.
On average, respondents reported good ability to be active or perform activities of daily living (ADL) as indicated by the mean Physical Functioning score (M = 67.1, SD = 31.1). The final model for Physical Functioning explained 27% of the variation in the Physical Functioning score. Higher Physical Functioning was associated with at least a high school education and reported wages/salary. Persons with an AIDS diagnosis and those who had received traditional medications or herbs in Mexico in the previous year had significantly worse Physical Functioning.
The mean Pain score for participants was 63.7 (SD = 29.0), indicating that slight pain somewhat interfered with normal work activities in the previous 4 weeks. The final model for Pain explained 19% of the variation in physical pain. Multivariate analysis revealed that persons who had stable housing, reported wages/salary, and who had spent at least 1 month in Mexico in the previous year reported experiencing less pain. Bodily pain interfered more frequently with normal activities for persons who had an AIDS diagnosis, had received non-HIV medical care in the United States or Mexico, and had received traditional medications or herbs in Mexico.
This study advances our understanding of HRQL in a population of HIV-infected Latinos who reported considerable time spent in Mexico and who engaged in binational health care seeking behavior. We observed that mean scores of Emotional Well-Being, Cognitive Functioning, Physical Functioning, and Pain for our sample of Mexican-origin Latinos are consistently in the range of generally good health (e.g., good ability to be active or to perform ADL).
Although border crossing was not associated with HRQL, our analyses indicated a more complex picture of how border-related life experiences may be related to HRQL indicators. We observed, for example, that persons who lived or visited 1 month or more in Mexico in the previous year reported better cognitive functioning and less pain, and that receiving traditional medications or herbs in Mexico indicated poorer HRQL as measured by Physical Functioning and Pain. The implications of these findings for improved HIV clinical nursing care for HIV-infected Latino patients in a U.S.-Mexico border context are further discussed below.
Our first hypothesis that frequent border crossings would be associated with higher HRQL score was not supported by the data. Lack of significance may indicate that border crossing alone is not a sufficient proxy of access to care in Mexico because, among other considerations, it does not indicate the nature or amount of time the person spent in Mexico, nor the ability or disposition to access medical services while in Mexico. Future studies should explore reasons for extended visits or stays in Mexico. This information may improve coordination of HIV and other clinical care delivery between U.S. and Mexican providers.
Our hypothesis that HIV-infected Latinos in San Diego who reported accessing health care in Mexico in the previous year would have higher HRQL indicators was also not supported by the data. On the contrary, participants accessing non-HIV medical care in Mexico reported worse Pain; those who received traditional medications or herbs in Mexico reported worse Pain and Physical Functioning. It is likely that patients who seek care outside of routine HIV clinical care, regardless of country, may be sicker and thus have lower HRQL. Our findings appear to be in contrast with those of Wallace, Mendez-Luck, and Castañeda (2009), who found that among Mexican immigrants in California, poor self-reported health reduced the odds of obtaining medical care or prescription drugs in Mexico. Our findings suggest that future work in this area should include qualitative research to assess type of care or medication sought, where services were accessed, and reasons for accessing care in Mexico. Additionally, understanding how complementary and alternative medicine (CAM) use in this population may be related to HRQL and other health outcomes would be important given the potential for certain types of herbal therapies to interfere with antiretroviral efficacy and uptake (Jernewall et al., 2005), and that use of CAM may be associated with HIV care utilization behavior (Turner et al., 2000). CAM use among binational populations living with HIV is an understudied area and merits further research.
No consistent pattern of predictors of HRQL emerged across the four domains; however, some of our findings were consistent across HRQL studies. For example, older age, female gender, lower educational attainment, not being married/no partner, and not living in one’s own home have been previously related to lower HRQL (Bajunirwe et al., 2009; Mier et al., 2008; Protopopescu et al., 2007; Rao et al., 2007). Similarly, Protopopescu and colleagues (2007) found that higher educational attainment and comfortable housing conditions were associated with better mental and physical HRQL. Among existing studies with Latino populations living with HIV, Rao et al. (2007) found that men had better HRQL than women, which was consistent with our study’s findings. Rao et al.’s (2007) study also found that participants who were Spanish speakers, who had lower CD4+ T cell counts and who lived with others had better HRQL indicators.
Age and gender were not independent predictors of Physical Functioning and Pain in our study. In a study of 317 HIV-infected persons in San Francisco, Aouizerat and colleagues (2010) also found no gender or age differences in predictors of pain. Across studies, the variations in findings are likely influenced by issues such as differences in how the constructs were measured, general illness, or level of well-being of a given study population, and factors that may not be measured but that influence how the individual feels about her/his health.
There are important limitations in the current study, most notably the cross-sectional nature of the data. This limits our understanding of causality or directionality of influence on HRQL outcomes. For example, we are unable to determine whether low Emotional Well-Being predicted utilization of health services or whether persons who accessed traditional medications in Mexico had lower HRQL prior to going to Mexico to access this care. Additionally, we lacked the ability to discern more detailed inference of stable/unstable housing due to limited response options; for example, we do not know if persons who reported not living in their own home/apartment lived with family or friends in a stable arrangement. In this case, we may have inadvertently overestimated the number of individuals with unstable housing.
A further limitation in our study was the attempt to oversimplify a complex health condition and a dynamic environment of care access and delivery in the U.S.-Mexico border region. There are many other factors that may influence health care behavior that we did not examine. For instance, loss of employment may have influenced binational care seeking and this should be explored further in future studies. As well, familiarity with life in Mexico and the United States may not be associated with improved health care access for persons who are undocumented in the United States or for HIV-infected persons who are deported. To this effect, Brouwer and colleagues (2009) found that injection drug users in Mexico who had been deported from the United States were less likely to have received treatment for drug abuse, recent medical care, or HIV testing than persons who had not been deported.
It is likely that the limited number of indicators available for Physical Functioning and Pain proved insufficient to gauge such complex constructs. As well, greater depth in measurement of Emotional Well-Being would include an assessment of symptoms of depression among study participants, as measured in a recent pain study by Aouizerat and colleagues (2010), who found that increased pain was associated with lower immune status (CD4+ T cell count), race, and sleep disturbance. Improved measures of clinical health indicators in this population will lead to better understanding of the whole health of patients living with HIV in the U.S.-Mexico border region, as persons living with HIV have poorer HRQL when compared with the general population, and the degree of illness and co-morbid conditions have been shown to impact quality of life among HIV-infected patients (Rajagopalan, Laitinen, & Dietz, 2008).
Because HIV care providers in the border region serve a large number of binational Latino patients with familial and socio-economic ties in Mexico (Zúñiga, Blanco, Martinez, Strathdee, & Gifford, 2007; Zúñiga et al., 2008), it can be anticipated that U.S. Latino patients will continue to interact with health care services on both sides of the border. From a methodological standpoint, our study underscored the need for improved conceptualization and measurement of binational care seeking behavior among U.S.-Mexico border residents. Researchers working in the field of border health have made important contributions to understanding the health of populations living in the border region; however, the scope of research with binational populations tends to be largely focused on the United States. The potential for a health care continuum in Mexico and the United States among border residents is infrequently contextualized with the nature and duration of cross-border activity. As such, border health-seeking behavior has been largely focused on purchase and importation of prescription drugs from Mexico (de Guzman et al., 2007). A notable exception to earlier research was work conducted by Bastida, Brown, and Pagán (2008) who contextualized disparities among U.S. border residents by considering the changing environment of health care access and delivery in the U.S.-Mexico border region. Future research that addresses the dynamic nature of binational residency and mobility will strengthen our understanding of health care consumer choices as a critical piece of understanding health care utilization and outcomes, including HRQL.
This work would not have been possible without the trust and support of the persons living with HIV and the clinicians and staff who dedicate their work to serving this population. We gratefully acknowledge the critical role of our community clinic partners: Clinicas de Salud del Pueblo, Family Health Centers of San Diego, San Ysidro Health Center, and Vista Community Clinic.
This study was part of a 5-year border HIV/AIDS demonstration project funded in 2000 by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), HIV/AIDS Bureau, Ryan White Care Act Special Projects of National Significance Program. This project was also partially supported by the National Institutes of Mental Health (Grant Numbers K01 MH072353; R21MH084266); National Center for Complementary and Alternative Medicine (Grant Number 1R21AT004676), and National Center of Minority Health and Health Disparities, National Institutes of Health (P60 MD00220). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA or the National Institutes of Health. The authors gratefully acknowledge Alisa Olshefsky for her role in overseeing successful implementation and completion of the project, and Terry Whitaker, Director of Program Development (San Ysidro Health Center), for his vision and leadership throughout the development and implementation of this project.
Disclosure Statement read and approved by all authors: The authors report no real or perceived vested interests that relate to this article (including relationships with pharmaceutical companies, biomedical device manufacturers, grantors, or other entities whose products or services are related to topics covered in this manuscript) that could be construed as a conflict of interest.
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María Luisa Zúñiga, Associate Professor, Division of Global Public Health, Department of Medicine, Division of Child Development and Community Health, Department of Pediatrics, University of California San Diego, La Jolla, CA.
Estela Blanco, Research Associate, Division of Child Development and Community Health Department of Pediatrics, University of California, San Diego, La Jolla, CA.
Jesse J. Brennan, Senior Statistician, Division of Child Development and Community Health, Department of Pediatrics, University of California, San Diego, La Jolla, CA.
Rosana Scolari, Director of Program Integration, San Ysidro Health Center, San Diego, CA.
Irina V. Artamonova, Statistician, Division of Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, CA.
Steffanie A. Strathdee, Harold Simon Professor, Associate Dean of Global Health Sciences, Chief, Division of Global Public Health, University of California San Diego School of Medicine, Institute of the Americas, La Jolla, CA.