Chinese Immigrant Religious Institutions and HIV Organizational Innovativeness, Social Networks and

1
Chinese Immigrant Religious Institutions and
HIVOrganizational Innovativeness,Social
Networks and Religious Worldview

• HIV Center for Clinical and Behavioral Studies
• May 22, 2008

2
Acknowledgments

• Asian Immigrant Community Institutions in NYC and
  HIV
• 2002-2006
• National Institute of Child Health and Human
  Development (R21 HD043012)
• Organizational Change toward HIV Involvement in
  Immigrant Religious Organizations
• 2007-2012
• National Institute of Child Health and Human
  Development (R01 HD054303)

3
Overview

• Overview of the Asian/Pacific Islander (API)
  population and HIV in NYC
• Why study institutions?
• Why study religious institutions?
• Evidence from previous R21 study
• Overview of new R01 study
• Research aims and study design
• Preliminary results

4
API Population

• In the US, the Asian Pacific Islander (API)
  population continues to increase rapidly.
• The API population in NYC grew by 71 between
  1990 and 2000.

5
API Population

• 999,030 APIs in NYC as of 2006.
• 45 (448,825 ) of APIs in NYC are Chinese.
• 73 of the API population in NYC is foreign-born.

http//www.aafny.org/cic/briefs/nycbrief2006.pdf
6
APIs and HIV in the US

• While HIV/AIDS prevalence among APIs in the US
  remains relatively low, there are signs of rapid
  increase.
• Between 2001 and 2004, APIs had the only
  statistically significant estimated annual
  percentage increases in HIV/AIDS diagnosis rates
  in the US.
• In the same period, NYCDOH reported that in NYC
  the number of new HIV diagnoses each year has
  declined in all racial/ethnic groups except
  Asian/Pacific Islander.

Chin JJ, Leung M, Sheth L, Rodriguez TR. Let's
Not Ignore a Growing HIV Problem for Asians and
Pacific Islanders in the U.S. (2007). Journal of
Urban Health. 84(5)642-7.
7
U.S. Males HIV/AIDS Diagnosis Rates in 2004, and
change from 2001 to 2004
Statistically significant at a .05
8
U.S. Females HIV/AIDS Diagnosis Rates in 2004,
and change from 2001 to 2004
Statistically significant at a .05
9
HIV/AIDS in the Asia/Pacific Region

• AIDS has reached epidemic proportions in parts of
  Asia, home to 60 of the worlds population.
  Globally, approximately 8.6 million Asians are
  living with HIV, including 960,000 new infections
  in 2006 alone (nearly a quarter of the new
  infections world-wide that year).

10
HIV/AIDS in China

• In China specifically, an estimated 700,000
  people were living with HIV as of the end of
  2006.
• 42 of reported cases were related to injecting
  drug use, while 44.7 were related to
  heterosexual transmission (Blanchard, 2007
  Sanderson, 2007).
• HIV in China appears to be spreading from
  isolated groups to the general population. In
  some areas, HIV prevalence already exceeds 1
  among pregnant women and those receiving
  premarital and clinical HIV testing, meeting
  UNAIDS criteria for generalized epidemic
  (UNAIDS/WHO, 2005).

Blanchard, B. China AIDS rate slows, main
transmission now sex. Reuters, 2007. Sanderson,
H. Sex now the main cause of HIV in China.
Associated Press, 2007. Ministry of Health of the
People's Republic of China, UNAIDS, World Health
Organization. 2005 Update on the HIV/AIDS
Epidemic and Response in China. Beijing National
Center for AIDS/STD Prevention and Control,
China January 24 2006.
11
HIV/AIDS and Migration

• Chinese heterosexual men, undocumented immigrants
  living in NYC, believed they were infected while
  in Southeast Asia (up to three years), waiting to
  enter the US.
• An NYC HIV subtype analysis found a group of
  Chinese immigrant men who stopped in Burma or
  Thailand for 6 to 9 months. Their HIV subtype
  was the most common heterosexually transmitted
  subtype in Thailand.

Chin JJ, Weiss L, Kang E, Abramson D, Bartlett N,
Behar E, Aidala A. (2007). Looking for a Place to
Call Home A Needs Assessment of Asians and
Pacific Islanders Living with HIV/AIDS in the New
York Eligible Metropolitan Area. New York New
York Academy of Medicine Achkar JM, Burda ST,
Konings FA, et al. Infection with HIV type 1
group M non-B subtypes in individuals living in
New York City. J Acquir Immune Defic Syndr. Jul 1
200436(3)835-844.
12
Immigrants and Institutions

• Language and cultural barriers, as well as
  discrimination, isolate API immigrants from the
  wider society.
• Immigrants rely heavily on community institutions
  for
• social support
• attaining and maintaining social status
• maintaining cultural identity
• economic linkages and employment opportunities
• social services, advice and information.

13
Predominance of Religious Institutions

• Of API immigrant community institutions,
  religious institutions are most numerous
• 42 of 316 Chinese institutions
• 47 of 213 South Asian institutions

Chin JJ, Mantell J, Weiss L, Bhagavan M, Luo X.
(2005). Chinese and South Asian Religious
Institutions and HIV Prevention in New York City.
AIDS Education and Prevention, 17(5)484-502.
14
New York City

15
New York City

16
Chinatown - Manhattan

17
Chinatown - Manhattan

18
Chinatown - Manhattan

19
Chinatown - Manhattan

20
Chinatown - Manhattan

21
Influence of Religious Institutions

• Help members make sense of their new and often
  hostile environment and negotiate their difficult
  existence in New York City.
• serves as a site for the exchange of
  information regarding jobs, housing, health
  care, and coping mechanisms for dealing with any
  of the struggles of daily life.

Guest KJ. God in Chinatown Religion and Surival
in New York's Evolving Immigrant Community. New
York New York University Press 2003.
22
Immigrant Institutions and Community Norms and
Values

• ... the arena for the construction and
  maintenance of values, beliefs, and customs of
  the immigrant community.
• ... caretakers of tradition in an alien,
  modernistic society. The moral solidarity of the
  collective becomes of vital importance.
• role as protectors of the ethnic community may
  inhibit response to certain community problems
  (such as domestic violence).

Abraham M., 2000. Speaking the unspeakable
Marital violence among South Asian immigrants in
the United States. Rutgers University Press, New
Brunswick, NJ
23
Immigrant Institutions and Community Norms and
Values

• Diverse identities and points of view in
  themselves can be seen as threatening
• A greater acceptance of heterogeneity allows for
  more porous ethnic boundaries and greater
  variation in identities within a given ethnic
  group (Sanders and Nee, 1996, p, 233).
• Greater heterogeneity makes it more difficult to
  enforce the ethnic solidarity that is crucial to
  the success of many immigrant social and economic
  structures (Light et al., 1995 Nee et al., 1994).

Chin JJ, Neilands TB, Weiss L, Mantell JE. (In
Press). Paradigm Shifters, Professionals and
Community Sentinels Immigrant Community
Institutions Roles in Shaping Places and
Implications for Stigmatized Public Health
Initiatives. Health and Place.
24
Immigrant Institutions and Community Norms and
Values

• I think for me the high level idea of going to
  the association is to keep that link to being
  from our sub-ethnic group, ... so my kids know
  what it is to be from our sub-ethnic group, and
  we make sure very specifically that they speak
  our language.
• Im creating a role model for my children so
  they see their mom grew up here but still
  maintained her ... culture and value and
  tradition and language. ... Because if parents
  dont do it, everything gets diluted as we go
  down into the generations. ...Its our job as
  people of our ancestry, as parents, to continue
  carrying that torch.

25
Immigrant Religious Institutions and HIV

• Preservation of religiously-based cultural norms
  and values may support HIV-related stigma
• I mean, in promoting HIV education we dont
  have any problem, but on certain issues we may
  say no. ... Our slogan will be no ... I mean we
  will say that sex only is allowed within the
  family structure, with a husband and wife
  otherwise its no. ... We will educate that if
  you go the other way, then you may have these
  problems and ... then your health is at risk. ...
  Yes we can discuss homosexuality and we can
  tell them that this is no as a religious
  matter. It is totally forbidden. ... That this
  is wrong.

26
Immigrant Religious Institutions and HIV

• Reluctance to address HIV in a more direct or
  productive way was compounded by lack of
  knowledge about HIV transmission
• Misinformation about modes of transmission
• Sharing a drinking glass
• Sharing soap
• Exposure to saliva
• Asked what respondent would do if a person with
  HIV moved in next door What could we do?
  (Laughter) I think its better not to be near
  this person. We would have to move, I guess. We
  couldnt ask him to move.

27
Immigrant Religious Institutions and HIV

• Some religious leaders felt that religious
  education was sufficient protection against HIV
• ... Teaching about HIV should ... go to the
  root. The problem of the root is morality. Its
  not teaching them how to avoid it, how to prevent
  it, or how to get the best doctor, where can you
  get the best medicine. Its not like that. Its
  teaching from the beginning, from the root. Its
  the morality of sex.

28
Immigrant Religious Institutions and HIV

• Organizational reputation as a results of HIV
  stigma was also a concern
• As Buddhists, we shouldnt appear in
  inappropriate occasions. Audiences will look at
  us with tainted glasses and say things like what
  kind of monks would show up here? They might
  even call us obscene monks.
• Doing such things engaging in HIV-related
  activities might pose some negative impact on
  our image. . . . We would be supportive of
  HIV-related activities under the premise that it
  wouldnt affect our image. . . . if the impact
  on our image is small, I would support it. But
  if the impact is big, then I wouldnt.

29
Immigrant Religious Institutions and HIV

• Religious imperatives to show compassion
  mitigated reluctance to get involved
• I would try to help whatever the way I can. . .
  So I would say that anybody who is sick, . . .
  it is our duty to help him.

30
The Issue

• HIV/AIDS prevalence among APIs in the US remains
  relatively low, but there are signs of rapid
  increase.
• HIV knowledge levels in API communities are low
  as a result of language and cultural barriers
• High levels of HIV-related stigma in Asian
  immigrant communities create barriers to
  effective HIV prevention and care efforts.

31
The Issue

• Religious institutions in Asian immigrant
  communities have the potential to be key partners
  in HIV prevention and care activities because of
  their central and respected role and their reach
  in Asian immigrant communities, especially with
  recent immigrants.
• But few religious institutions are involved in
  HIV-related work.
• Some may be contributing to stigmatization and
  silence around HIV.

32
The Issue

• Reluctance to be involved may be related to
• Viewing diversity of identities and views as a
  threat to the integrity of the community and
  thereby threatening the communitys very
  survival.
• Lack of knowledge about HIV.
• Concerns over institutional image and reputation.
• Reluctance to be involved may be mitigated by
  religious imperatives to show compassion, to act
  as stewards of the communitys well-being.

33
The Issue

• Views on stigma and organizational reputation are
  communicated through social interaction
• Understanding the possibilities for
  organizational change in religious institutions
  to take on the innovation that HIV involvement
  represents may be aided by an examination of
  social networks.
• This if the focus of our new study.

34
Organizational Change toward HIV Involvement in
Immigrant Religious OrganizationsNational
Institute of Child Health and Human Development
(R01 HD054303)
35
Study Aims

• 1. SOCIAL NETWORKS To determine how social
  network structures within religious organizations
  facilitate or impede organizational change.
• 2. RELIGIOUS WORLDVIEW To identify and describe
  how religiosity and religious worldview influence
  religious organizations level and type of
  involvement in HIV-related activities.
• 3. TRANSLATION OF RESEARCH INTO ACTION To
  translate study findings into strategies for
  increasing level of productive involvement in
  HIV-related activities by religious
  organizations.

36
Wider Applications

• Understanding organizational change in response
  to stigmatized public health initiatives
• for example, reproductive health, intimate
  partner violence, etc.
• Relevance for other communities in which
  community institutions are influential
• tightly-knit communities, including other
  immigrant communities and communities of color
  small towns and villages in the US and abroad.

37
Study Design

• Enumeration and telephone survey of Chinese
  religious organizations in NYC (Phase I)
• In-depth study of 21 of these organizations
  (Phase 2)

38
Religious Institution Database

• Update of religious institution database
• Listings and directories (paper and online)
• Key informants
• Walking through neighborhoods with large numbers
  of Chinese
• Walk through all census tracts with more than
  1,000 Chinese
• Walk a one-block radius around organizations
  known to exist

39
Telephone Survey

• Telephone survey of 200 religious organizations
  in database
• Characteristics of organization
• Membership size and characteristics
• Health/HIV-related activities

40
In-Depth Study of Organizations

• Selection and recruitment of 21 religious
  organizations (monetary compensation provided).
• Identification of primary contact in each
  organization.
• Enumeration of active members through short
  survey at religious service/event and
  snowballing.
• In-depth interviews with core leaders, members
  and innovators (n9 per institution total n189)
• Quantitative survey on social networks,
  religiosity and HIV knowledge and attitudes with
  active members within each institution (n40 per
  institution total n840)

41
Social Networks Data Collection

• Administer short-form survey to enumerate the
• individuals w/in each RO and collect rudimentary
• social networks info
• Short-form survey with general membership
• will identify members and create a sampling frame
  by
• 1 sampling members directly
• 2 allowing them to nominate others
• Conduct several snowball rounds if necessary to
  get better coverage of the institutions members.

42
Social Networks Data Collection

• Randomly select sample of individuals from the
• RO and administer long-form survey.
• Target n per institution 40
• Conduct long-form interview with each sampled
  individual
• Long-form survey will collect
• More extensive social network information
  (relationships among contacts)
• Religiosity, religious worldview
• Individual innovativeness perception of
  organizational innovativeness
• HIV knowledge and attitudes
• General health beliefs and attitudes

43
Social Networks Data Collection

• Steps for selecting participants for long-form
• interview
• Randomly sample from those who were named as
  contacts of those enumerated through short-form
  (75 of target N)
• Helps eliminate bias in sample of people who
  completed the survey itself (they may be more
  outgoing, social, etc.)
• Use an additional wave to try to fill relational
  holes in each organization (25 of target N)
• Prioritize selection by
• Non-redundancy of nominations (i.e.,
  individuals who are most frequently nominated who
  are not co-nominated by those already included in
  long-form sample)
• To fill the remainder of the 25 target
• Sample from those nominated by network stars
  who were not also highly nominated
• Finally, add other multiply-nominated individuals
  who have not already been interviewed

44
Data Analysis Quantitative

• Primary outcome variable
• HIV-Related Innovativeness
• Individual-Level 1) acceptability of HIV-related
  activities, 2) AIDS Attitudes scale 3)
  Individual Innovativeness scale
• Organization-level variable can be constructed
  using both quantitative and qualitative data
• Explanatory variables include social network
  characteristics, religiosity and religious
  worldview

45
In-Depth Interviews

• Sampling
• 2 religious leaders, 2 lay leaders, 3 members 2
  innovators within each institution
• Content
• Organizational basics
• Views on potential involvement in HIV-related
  activities
• Organizational change change stories

46
Data Analysis Qualitative

• Translation and transcription into English
• Identification of themes and relationships
• Development of organization-level constructs for
  use in quantitative analyses
• HIV-related and general innovativeness
• Functional role in the community
• Insularity/Openness
• Organizational structure

47
From Research to Intervention

• Final working conference with key stakeholders
• Just a beginning
• Multiple aims
• Disseminate findings
• Begin developing intervention strategies
• Create dialogue

48
From Research to Intervention

• Intervention strategies will focus on increasing
  organizations productive involvement in
  HIV-related activities.
• Strategies will follow from organizational
  typologies developed from the analysis that will
  address the following questions
• Which types of organizations are most open to
  change?
• What are the range of roles that individuals in
  organizations play in promoting or thwarting
  organizational change?
• What are the patterns of relationships between
  social network characteristics, religiosity and
  organizational innovativeness?

49
Preliminary Findings from R01 Study
50
Mapping Manhattan Chinatown
51
Chinese Religious Organizations
52
Chinese Religious Organizations
53
Chinese Religious Organizations
54
Chinese Religious Organizations
55
Chinese Religious Organizations
56
Chinese Religious Organizations
57
Chinese Religious Organizations
58
Chinese Religious Organizations
59
Chinese Religious Organizations
60
Chinese Religious Organizations
61
Chinese Religious Organizations
62
Chinese Religious Organizations
63
Chinese Religious Organizations
64
Chinese Religious Organizations
65
Institution Database

• 183 confirmed Chinese religious institutions in
  NYC
• 44 still unverified
• 59 Christian and 34 Buddhist
• Handful of other religions (7), including Taoist
  and Chinese Popular Religion

66
Manhattan Statistics
67
Queens Statistics
68
Brooklyn Statistics
69
Bronx Statistics
70
Staten Island Statistics
71
Telephone Survey Preliminary Results(n 47 2
Taoist Organizations excluded from analysis)
72
Telephone Survey Preliminary Results(n 47 2
Taoist Organizations excluded from analysis)
73
Telephone Survey Preliminary Results
HEALTH-RELATED ACTIVITIES OF ACTIVE ORGANIZATIONS
74
Telephone Survey Preliminary Results(n 47 2
Taoist Organizations excluded from analysis)
75
Telephone Survey Preliminary ResultsHIV-RELATED
ACTIVITIES OF ACTIVE ORGANIZATIONS
76
Next Steps

• Continue with telephone survey of Chinese
  immigrant religious institutions in our database
  to increase sample size.
• Complete pilot-testing and field-testing of study
  instruments for the next phase of the study.
• Recruit 7 Chinese immigrant religious
  institutions in study for first wave of data
  collection (there will be three waves over the
  course of the 5-year study for a total of 21
  organizations).

77
Study Team

• Community Partners
• Asian and Pacific Islander Coalition on HIV/AIDS
  (Yumiko Fukuda)
• Chinese American Planning Council (through Ven.
  Benkong)
• Buddhist Society of Wonderful Enlightenment (Ven.
  Zhi Kong)
• Queens Herald Church (Pastor Lai)
• Taiwanese Union Christian Church (Pastor Marianne)

• Core Research Team
• John Chin, PI
• Joanne Mantell, Co-PI
• Linda Weiss, Co-PI
• Ezer Kang, Co-Investigator
• Elana Behar, Project Dir.
• Min Ying Li, Rsrch. Assoc.
• Po-Chun Chen, Rsrch. Asst.
• Huso Yi, Post-doc Fellow

• Research Consultants
• jimi adams, RWJ Health and Society Scholars
  Program (social networks)
• Michael Botsko, New York Academy of Medicine
  (data analysis)
• Peter Kwong, Hunter College, City University of
  New York
• Todd Lewis, College of the Holy Cross (religious
  studies)
• James Moody, Duke University (social networks)
• Torsten Neilands, UC San Francisco (statistician)
• Bruce Rapkin, Memorial Sloan-Kettering Cancer
  Center (organizations)