<%BANNER%>

Stigma and Tuberculosis Contact Investigation

Permanent Link: http://ufdc.ufl.edu/UFE0022168/00001

Material Information

Title: Stigma and Tuberculosis Contact Investigation A Perspective on a Mexican Community in Central Florida
Physical Description: 1 online resource (85 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: born, contact, culture, foreign, investigation, mexicans, stigma, tuberculosis
Latin American Studies -- Dissertations, Academic -- UF
Genre: Latin American Studies thesis, M.A.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Generally speaking, tuberculosis (TB) control programs in the United States have successfully achieved their goals; however, the poor decrease of TB incidence among foreign-born population has prevented tuberculosis control programs from achieving their ultimate goal of 'TB elimination.' TB in the USA affects primarily foreign-born and within that group, Mexicans are the principal ethnicity represented. An integral component of TB control is timely identification of cases through contact investigation (CI) and subsequent treatment, if required. Unpublished data from the Bureau of Tuberculosis and Refugee Health of the Florida Department of Health suggest that in Florida, Mexicans tend to identify fewer contacts during TB contact investigation than the average patient. Specific factors influencing CI are not well characterized, although stigma has been mentioned. It is imperative to determine how stigma influences CI involving those cultures most affected by TB given that stigma is a cultural construct. The purpose of this study was to determine if the stigma related to TB influences the effectiveness of tuberculosis contact investigation among Mexicans living in Central Florida. A nonexperimental cross-sectional survey research design using mixed methods, where quantitative data served as the primary source was utilized. Components of several existing instruments to measure stigma were modify for use in this study. The community selected for the study was a small church-based community from Hillsborough County in Florida. Forty two surveys and four face-to-face interviews were conducted. Data were analyzed using descriptive statistics and linear regression in SPSS. The majority of the participants were young adult females, with low levels of education and low socioeconomic status. Although most participants reported that they have lived in the United States more than 5 years, they show low English proficiency and limited interaction with people from other than their own country. The majority of participants do not have a legal immigration status. The analysis of the results showed no statistically significant weak relationships between the dependent and the independent variables. These results contrast with what was hypothesized. The sampling design and some characteristics of the population, such as being a member of a church-based community, may have influenced these results. Stigma seems to be a more intricate construct than what has been portrayed in the literature. Additional research is needed to untangle the complexity of TB related stigma in multicultural environments.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (M.A.)--University of Florida, 2008.
Local: Adviser: Burns, Allan F.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022168:00001

Permanent Link: http://ufdc.ufl.edu/UFE0022168/00001

Material Information

Title: Stigma and Tuberculosis Contact Investigation A Perspective on a Mexican Community in Central Florida
Physical Description: 1 online resource (85 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: born, contact, culture, foreign, investigation, mexicans, stigma, tuberculosis
Latin American Studies -- Dissertations, Academic -- UF
Genre: Latin American Studies thesis, M.A.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Generally speaking, tuberculosis (TB) control programs in the United States have successfully achieved their goals; however, the poor decrease of TB incidence among foreign-born population has prevented tuberculosis control programs from achieving their ultimate goal of 'TB elimination.' TB in the USA affects primarily foreign-born and within that group, Mexicans are the principal ethnicity represented. An integral component of TB control is timely identification of cases through contact investigation (CI) and subsequent treatment, if required. Unpublished data from the Bureau of Tuberculosis and Refugee Health of the Florida Department of Health suggest that in Florida, Mexicans tend to identify fewer contacts during TB contact investigation than the average patient. Specific factors influencing CI are not well characterized, although stigma has been mentioned. It is imperative to determine how stigma influences CI involving those cultures most affected by TB given that stigma is a cultural construct. The purpose of this study was to determine if the stigma related to TB influences the effectiveness of tuberculosis contact investigation among Mexicans living in Central Florida. A nonexperimental cross-sectional survey research design using mixed methods, where quantitative data served as the primary source was utilized. Components of several existing instruments to measure stigma were modify for use in this study. The community selected for the study was a small church-based community from Hillsborough County in Florida. Forty two surveys and four face-to-face interviews were conducted. Data were analyzed using descriptive statistics and linear regression in SPSS. The majority of the participants were young adult females, with low levels of education and low socioeconomic status. Although most participants reported that they have lived in the United States more than 5 years, they show low English proficiency and limited interaction with people from other than their own country. The majority of participants do not have a legal immigration status. The analysis of the results showed no statistically significant weak relationships between the dependent and the independent variables. These results contrast with what was hypothesized. The sampling design and some characteristics of the population, such as being a member of a church-based community, may have influenced these results. Stigma seems to be a more intricate construct than what has been portrayed in the literature. Additional research is needed to untangle the complexity of TB related stigma in multicultural environments.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (M.A.)--University of Florida, 2008.
Local: Adviser: Burns, Allan F.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022168:00001


This item has the following downloads:


Full Text

PAGE 1

1 STIGMA AND TUBERCULOSIS CONTACT INVESTIGATION: A PERSPECTIVE ON A MEXICAN COMMUNITY IN CENTRAL FLORIDA By PAULA CATALINA A. HAMSHO-DIAZ A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS UNIVERSITY OF FLORIDA 2008

PAGE 2

2 2008 Paula Catalina A. Hamsho-Diaz

PAGE 3

3 To my husband, and my sons, Sebastian, Sergio, Sebastian Jr. and Ricky

PAGE 4

4 ACKNOWLEDGMENTS First, I would like to thank all m embers of my committee, Dr. Allan Burns for his support and guidance as the chairman, Dr. Willie Baber for working with me and for his valuable assistance with making it possible for me to finish this program successfully. I would also like to express my deep a ppreciation to Dr. Mich ael Lauzardo for his contribution as a member of my committee but especially for believing in me and supporting my dreams since the beginning of th is journey; without his support none of this would have been possible. I would also like to express my special gratitude to all my workmates and friends from the SNTC for continually reminding me that my work was appreciated. I would also thank all my professors from the Latin American Center, the Anthropology Department and the College of Pu blic Health at the University of Florida for contributing to my professional development. Furthermore, I thank all people that gran ted me access to the community to conduct this study and I want to acknowledge the In terdisciplinary Field Research Grant for providing funding for it. I also thank my friends that supported me and make this journey easier for me. Most importantly, I would lik e to thank my family. Thanks go to my husband and sons for all their patience, support and enc ouragement throughout this process. I could not have asked for a better family. I thank them for sharing their wife and mother during this time and supporting my professional developm ent. Like most thi ngs, this success is only meaningful because of them.

PAGE 5

5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 LIST OF FIGURES.........................................................................................................................8 LIST OF ABBREVIATIONS.......................................................................................................... 9 CHAPTER 1 INTRODUCTION..................................................................................................................12 Problem Statement.............................................................................................................. ....12 Research Question and Purpose of the Study......................................................................... 14 2 LITERATURE REVIEW OF TU BERCULOSIS AND STIGMA ........................................ 16 Introduction................................................................................................................... ..........16 Tuberculosis Overview...........................................................................................................16 Scope of TB: Epidemiology................................................................................................... 18 Contact Investigation.......................................................................................................... ....19 Stigma Background................................................................................................................21 Summary.................................................................................................................................30 3 METHODOLOGY................................................................................................................. 32 Introduction................................................................................................................... ..........32 Research Design.....................................................................................................................32 Purpose............................................................................................................................32 Hypotheses......................................................................................................................33 Hypothesis #1........................................................................................................... 33 Hypothesis #2........................................................................................................... 33 Hypothesis #3........................................................................................................... 34 Community......................................................................................................................36 Sampling..........................................................................................................................38 Sample Size.....................................................................................................................39 Instruments.................................................................................................................... ..39 Data Collection................................................................................................................42 Data Analysis...................................................................................................................43 Variables..........................................................................................................................43 Demographic variables............................................................................................. 44 Reliability.................................................................................................................45 Contact investigation comfort (d ependent variable) CIC index............................... 46

PAGE 6

6 Perception of stigma related with tuberculosis (independent variable) TB stigma index.................................................................................................... 46 Immigrant experience (independe nt variable) MG index........................................ 46 General knowledge about tubercul osis (independent variable) TB knowledge index...................................................................................................46 4 RESULTS...............................................................................................................................48 Overview of the Chapter.........................................................................................................48 Community Demographics.....................................................................................................48 Descriptive Statistics......................................................................................................... .....50 Linear Regression.............................................................................................................. .....53 Qualitative Results............................................................................................................ ......54 5 DISCUSSIONS AND CONCLUSIONS ................................................................................ 65 Introduction................................................................................................................... ..........65 Statement of the Problem....................................................................................................... .65 Review of the Methodology...................................................................................................67 Interpretation of Results.........................................................................................................68 Conclusions.............................................................................................................................72 Implications................................................................................................................... .........74 Recommendations................................................................................................................ ...76 LIST OF REFERENCES...............................................................................................................79 BIOGRAPHICAL SKETCH.........................................................................................................84

PAGE 7

7 LIST OF TABLES Table page 3-1 Cronbachs Alpha coefficients........................................................................................... 47 4-1 Demographics............................................................................................................... .....57 4-2 The importance of tuberculosis to participants.................................................................. 57 4-3 The relationship of tuberculosis to sterotypes................................................................... 58 4-4 Tuberculosis knowledge in the community....................................................................... 58 4-5 Immigration experience..................................................................................................... 58 4-6 Level of comfort in the c ontact investigation interview.................................................... 59 4-7 Stigma related with TB regressed on the likelihood of TB of been equal to any other problem. .............................................................................................................59 4-8 Level of comfort during contact inves tigation regressed on th e level of stigma related with TB, the level of stigma re lated with the migration experience and the level of knowledge about TB.......................................................................................59

PAGE 8

8 LIST OF FIGURES Figure page 2-1 Contact investigation. concentric circle approach............................................................. 31 3-1 Map of Hillsborough County............................................................................................. 47 4-1 Years of United States residency....................................................................................... 60 4-2 English proficiency........................................................................................................ ....60 4-3 Time spend with other pe ople from county of origin. ....................................................... 61 4-4 Visa status................................................................................................................ ........61 4-5 Tuberculosis and perceived stigma.................................................................................... 62 4-6 Likelihood of disclosing tuberculosis status...................................................................... 62 4-7 Distribution of frequencies acr oss CI comfort index values.............................................. 63 4-8 Perceived negative migration experience.......................................................................... 63 4-9 Percived TB stigma......................................................................................................... ...64 4-10 Distribution of frequencies acr oss TB knowledge index values........................................ 64 5-1 Cultural model for tuberculosis stigma. Biocultural interaction........................................ 77 5-2 Cultural model for tuberculosis stigma. No biocultural interaction.. ............................... 78

PAGE 9

9 LIST OF ABBREVIATIONS AIDS Acquired Im mune Deficiency Syndrome CB Cultural Brokers CDC Centers for Disease Control and Prevention CI Contact Investigation HIV Human Immunodeficiency Virus LTBI Latent Tuberculosis Infection MDR-TB Multi Drug Resistant Tuberculosis TB Tuberculosis WHO World Health Organization XDR-TB Extremely Drug Resistant Tuberculosis

PAGE 10

10 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Arts STIGMA AND TUBERCULOSIS CONTACT INVESTIGATION: A PERSPECTIVE ON A MEXICAN COMMUNITY IN CENTRAL FLORIDA By Paula Catalina A. Hamsho-Diaz May 2008 Chair: Allan F. Burns Major: Latin American Studies Generally speaking, tuberculosis (TB) cont rol programs in the United States have successfully achieved their goa ls; however, the poor decrease of TB incidence among foreign-born population has preven ted tuberculosis control pr ograms from achieving their ultimate goal of TB elimination. TB in the USA affects primarily foreign-born and within that group, Mexicans are the princi pal ethnicity represented. An integral component of TB control is timely identific ation of cases through contact investigation (CI) and subsequent treatment, if required. Unpublished data from the Bureau of Tuberculosis and Refugee Health of the Flor ida Department of Hea lth suggest that in Florida, Mexicans tend to identify fewer cont acts during TB contact investigation than the average patient. Specific factors influe ncing CI are not well characterized, although stigma has been mentioned. It is imperative to determine how stigma influences CI involving those cultures most a ffected by TB given that stig ma is a cultural construct. The purpose of this study was to determine if the stigma related to TB influences the effectiveness of tuberculosis contact investigation among Mexicans living in Central Florida. A nonexperimental cross-sectional survey research design using mixed methods, where quantitative data served as the primary source was utilized. Components of several

PAGE 11

11 existing instruments to measure stigma were modify for use in this study. The community selected for the study was a small church-b ased community from Hillsborough County in Florida. Forty two surveys and four face-to -face interviews were conducted. Data were analyzed using descriptive statis tics and linear regression in SPSS. The majority of the participants were young adult females, with low levels of education and low socioeconomic status. Alt hough most participants reported that they have lived in the United States more than 5 years, they show low English proficiency and limited interaction with people from other than their own country. The majority of participants do not have a legal immigration status. The analysis of the results showed no st atistically significant weak relationships between the dependent and the independent vari ables. These results contrast with what was hypothesized. The sampling design and some characteristics of the population, such as being a member of a church-based comm unity, may have influenced these results. Stigma seems to be a more intricate constr uct than what has b een portrayed in the literature. Additional research is needed to untangle the complexity of TB related stigma in multicultural environments.

PAGE 12

12 CHAPTER 1 INTRODUCTION National secu rity in the United States is curren tly considered a top priority on the countrys agenda. Immigration, both documented and undocum ented, plays a key role in the security of the nation. One of the contexts within which immi grants are considered to be a challenge for the nations security is within the public health s ector. Tuberculosis (TB) is a good example of a disease considered a public health threat and because it is intimately linked with the foreign-born it has also been associated with immigration issues and national security. Surveillance data has shown a significant disparity of TB inciden ce among US-born and foreign-born. While over all TB incidence rates are decreasing fa st, those of foreign-born origin s are going slower. There is a need to explore and understand what the obstacles are for the reduction of TB in the foreign-born to alleviate the effect that th is group has on the overall effectiv eness of TB control programs. Problem Statement Tuberculosis is a communicable disease cau sed by bacteria, and although it has had an effective treatment for more than 6 0 years, ap proximately 2 million people around the world still die because of it. In the United States TB is also a problem. Although TB incidence in the United States is under control, some minorities groups are still being affected. For example, in 2005, foreign-born individuals represented more than half of the total cases in the United States and Mexicans alone accounted for 23% of this group (Centers for Disease Control and Prevention [CDC], 2006). The foreign-born population in the United States has maintained, as a group, almost the same incidence rate of TB during the past deca des. Meanwhile, all other groups within the United States have successfully contributed to the overall decrease of TB incidence (CDC, 2007). The fact that the forei gn-born are not responding in the sa me way that the other groups

PAGE 13

13 are, suggests that this populat ion may not be appropriately reached by current approaches of tuberculosis control programs. Numerous studies have been completed over the last few decades regarding health and migration. Specific studies in TB have been conducted to better understand cultural differences and how to reach the foreign-born population. Special emphasis has been placed in understanding cultural differences to better deliver health care to this population. Stigma is one of the cultural constructs studied by researchers. However, st igma is a concept broadly used in research without a precise definition. A litera ture review conducted by Van Brakel (2006) reviewed the work done to measure health relate d stigma and found that TB studies investigating stigma used mainly qualitative methods and are minimal when compared to studies on other diseases. Although stigma in relationship to TB has not been completely understood and described, the difficulty in controlling TB among foreign-born persons has been linked to it. Most of these studies associate stigma and TB w ith effects related to the search for medical care and adherence to treatment. However, little ha s been done to study the effects of stigma on the outcomes of contact investigation. Contact investigation of patient s with active tuberculosis is an important component in tuberculosis control programs in the United States. When a person is diagnosed with active TB disease, apart from r eceiving medical care, these patients are asked to participate in a contact investiga tion process. The contact investigation process aims to identify persons that could be at risk of being infected with the Mycobacterium and offer testing and appropriate treatment if they are infected. Foreign-born populations repres ent a challenge to public health in the United States, and within them, Mexicans represent th e largest single group. It is nece ssary to conduct research that helps to better understand these populations in or der to control TB in the United States. The

PAGE 14

14 studies must be specific to the Mexican populatio n and target specific cu ltural char acteristics within the group. Florida is among the top ten st ates with high incidence rates of TB. Within Florida, Hillsborough County ranks in the top four counties ac cording to TB rates. Inside this group of four counties, Hillsborough has the second highest percentage of foreign-born TB incidence. (Bureau of TB and Refugee Health [BTBRH], 2007). Unpublished data from the Florida Department of Health, Bureau of Tuberculosis and Refugee Health suggest that in Florida, Mexicans tend to identify fewer contacts during TB contact investigation than the average patient. Th is characteristic deserves to be explored as it may be one factor contributing to the slow d ecline in TB incidence among this population. A low detection of possible cont acts could be keeping TB in cidence rates high due to the ineffective detection of TB inf ection among contacts. Failing to detect these cases may allow the infection to develop to active TB disease and further TB spread. However, little is known about the factors that might influence contact investig ation and even less is known about TB contact investigation among Mexican-born populations in the United States. Research Question and Purpose of the Study The purpose of this study is to determine if s tigm a related with tuberculosis and immigrant experience influences the effec tiveness of tuberculosis cont act investigation among a small community of Mexicans living in Hillsborough C ounty, Florida. This is nonexperimental research study using a cross sectional survey design. The study used mixed methods where quantitative data served as the pr imary source of data. Qualitative data were used as a secondary source to provide context and to better understand the community. After this Introduction, the sec ond chapter will review the con ceptual framework related to the study. Rather than attempt to present a co mprehensive discussion about tuberculosis and

PAGE 15

15 stigma, I chose to review more indepth topics related to stigma and tuberculosis that were relevant for this research. Chapter 3 pres ents detail about the research design and the methodology used in the study. This chapter incl udes descriptions of the community, sampling, sample size as well as all methodology used to co llect data and for the analysis of the data. Chapter 4 presents the results of the study including demographic description, descriptive statistics, statistical analysis and interpretation of the results. Also this chapter provides the finding from the interviews conduc ted in this study. Chapter 5 provides the discussion and conclusions.

PAGE 16

16 CHAPTER 2 LITERATURE REVIEW OF TU BERCULOSIS AND STIGMA Introductio n Tuberculosis (TB) is one of th e oldest infectious diseases affecting and killing humans in the world and is taking new strength during The Third Epide miological Transition (Barrett, Kuzawa, McDade, & Armelagos, 1998). The Third Epidemiological Tran sition corresponds to the current phenomenon of emerging infection di seases characterized by three major trends: unprecedented number of new diseases, increased incidence and prevalence of old infectious diseases, and a rapid rate increasing of a ne w generation of antimicrobial-resistant strains (Barrett et al., 1998). The fast growth of new strains of microorganisms resistant to drugs is faster than the development of new drugs to co mbat them. This situat ion is pushing the public health infrastructure to its limits leading them to not have the ability to control these infections. This is what is being called The Post Anti-Microbial Era (Cohen, 1992). Tuberculosis is now recognized as a reemerging infecti on disease threatening global publ ic health in this period of history. This chapter reviews the literature to provide background information related to tuberculosis, including active TB disease and latent TB infecti on (LTBI). An overview of the scope of TB is presented with the epidemiology of TB in the world, in United States and among the foreign-born within the United States. Contact investigation is described and stigma is reviewed. Tuberculosis Overview Tuberculosis, caused by the Mycobacterium tuberculosis complex is usually spread from person to person when diseased p eople cough, ta lk, sing, or sneeze, and airborne infectious particles are dispersed and inhale d by other people. Most individuals who become infected do

PAGE 17

17 not develop the disease because their body's immune system keeps the infection under control. However, if the person is infected, the infection can persist for years in the body, perhaps for life, waiting patiently for the best moment to attack. Latent TB infection (LTBI) is when a person has the Mycobacterium tuberculosis in the body but the bodys immune sy stem is keeping the bacilli under control. Infected persons remain at risk fo r developing the disease at any time in their life, especially if for any reason their immune system becomes impaired. Although the disease usually affects the lung, it can occur at virtually any site in the body. After the introduction of anti -TB medication in the late 1940s, there was hope that tuberculosis would soon be eradi cated. There was a steady decreas e in the incidence of TB in the United States from 1953 through 1984. Howe ver, from 1985 through 1992 the number of reported TB cases increased by 20% in spite of th e public health system in the United States. The are several reasons for this tuberculosis explosion; the increase in HIV/AIDS infection, increased immigration, and the weaknesses of the tuberculosis programs due to a false feeling of safety TB control. New efforts were made to control TB infection and even though the disease is now considered once again under control, surveillan ce data have shown that tuberculosis in the United States disproportionately affects some racial/ethnic minor ities, especially foreign-born populations (CDC, 2007a). Also new strains of Mycobacterium tuberculosis are now challenging the United States and the world; this new bacteria has shown greater resistance and persistence in doing damage to humans. Tube rculosis can now be found in forms that are resistant to TB medication, such as Multi Dr ug Resistant TB (MDR-TB) and Extremely Drug Resistant TB (XDR-TB). This new global emerge ncy has reversed years of progress in public health because these new strains have higher mortality rates, higher infectious periods and a higher treatment cost. What is really unfortunate is that MDRTB and XDR-TB did not occur in

PAGE 18

18 a natural way, it was produced as the result of inadequate treatments, non-adherence and poor tuberculosis control management allowing the Mycobacterium to evolve. Scope of TB: Epidemiology Currently, one third of the worlds population ca rries the organism that leads to active TB disease (W orld Health Organization [WHO], 2007). Among these two billion people, approximately 9 million people will develop the disease worldwide every year and almost 2 million will die because of it (CDC 2007b). Every second someone in the world is infected with TB (WHO, 2007). The most affected areas remain in the poorest areas of the developing world. Countries in Sub-Saharan Africa are the most affected, where TB still takes a great toll on its population. But other regions in the world are also affected; As ia, Europe and Latin American are suffering from this communicable disease. Al so, drug resistant TB is widespread and affects individuals all over the world. The World Health Organization (W HO) estimates that there are nearly half a million new cases of MDR-TB, about 5% of the total nine million new TB cases worldwide each year (WHO, 2008). There are so me hot spots of MDR-TB and XDR-TB and these are mostly in the poor and middle income countries of the world. Despite all effort made around the World, TB re mains a global public health problem. In the developed world, TB incide nce is lower but it remains a concern. The United States incidence rate of TB in 2006 was 4.6 cases per 100,000 habitants (CDC 2007a). Although the incidence has successfully declin e after the alarming breakout in the 80s, fifty states annually report new cases (CDC, 2007a) and MDR-TB and XDR-TB are reported as well. However, much like between countries, within the United States tuberculosis disproportionably affects the poor. Surveillance data has shown that the incidence of TB in th e United States is greater among some minority groups, especially the foreign-born. The proportion of total cases occurring in foreign-born persons has been increasing sinc e 1993. In 2006, 57% of TB cases occurred in

PAGE 19

19 foreign-born persons (CDC, 2007a). During the last two decades, the incidence has been declining, but for the foreign-born population the d ecline in incidence has been at a slower rate. The foreign-born population from the region of Latin America and the Caribbean represent a major proportion of foreign-born TB cases in the United States (C DC, 2006); of the 7,799 TB cases reported among foreign-born persons in 2006, 45% occurred among persons born in the Americas region, and for this group, Mexicans are the largest single group (CDC, 2007a). The factors that may contribute to this disp arity are complex. Some anthropologists argue that the failure to control inf ectious disease is related to th e lack of knowledge about health education and related behaviors (Manderson, 1998). Others ar gue that the reason for TB disparity relate to poverty, une qual opportunity, structural viol ence and the lack of access to adequate biomedical services (Farmer, 1999, 2003). However, regardless of this tension, it is imperative to conduct research that untangle the complexity of this dilemma and enlighten the path that will lead to the successful intervention that will achieve the ultimate goal, reduction and eventual elimination of TB in this population. Contact Investigation An im portant part in the fight to stop the dissemination of TB, regardless of the rates of disparity, is the timely detection of cases and proper treatment. Fo r this purpose it is necessary to identify those individuals that co uld be at risk of infection due to proximity to active TB cases. Contact investigation of patient s with active tuberculosis is an important component in tuberculosis control programs in the United States (CDC, 2005a). When a person is diagnosed with active TB disease, apart from receiving medical care, these patients are asked to participate in a contact investigation proce ss. The contact investigation process aims to identify those persons that could be at risk of being infected with the Mycobacterium and offer them testing and appropriate treatment if th ey are infected (CDC, 2005b).

PAGE 20

20 The goal of a contact investigation is to id entify approximately 10 c ontacts per active TB case. A study found that close contacts of an active TB case were 100 times more likely to be diagnosed with TB than the general populations (as cited in CDC, 2005b). This high prevalence among contacts is what urges the co ntact investigation of all new ac tive TB cases. The ultimate goal of identifying contacts is to diagnose LTB I and active TB cases, to provide treatment for LTBI or active TB among contacts and ultimately to stop further TB spread by prevention and early detection of active TB cases. Contact investigation helps to identify those persons that spent time with the patient in optimal conditions for tuberculosis transmission dur ing the period that the patient was considered infectious. Factors that play a role in the deci sion of initiating a contact investigation are disease related: characteristics (a) clinical, (b) radiological, and (c) of laboratory; or related with the host: (a) presence of behaviors that in creases aerosolization of respirat ory secretions, (b ) age, and (c) HIV status. Once the decision of initiating a cont act investigation is made, it is necessary to collect as much information as possible regarding the patient, including disease characteristics, time of early symptoms, and all information about contacts as well as the physical characteristics of exposure locations. Identification of contact s follows a concentric circle analysis (CDC, 1999). In this approach (fig.2.1), th e original TB patient (the inde x case) is at the center. The circle is divided into three concentric rings to represent the levels of risk: close contact (high risk) and other than close contact (middle risk and low risk). The circle is also divided in segments that represent the three types of envi ronment where the contact may have taken place: home, work and leisure environment. The first step of a contact investigation is to identify close contacts (first circle) of the Index case in their home, their work and in thos e places where they spen t their leisure time.

PAGE 21

21 Using the results obtained in this first step and th e evidence of transmission in the first circle, the decision is made whether it is necessary to ex pand the investigation to the other than close contacts. The best way to identify contac ts is to understand the patient social networks through the contact investigation interview. With this interview, health care providers may identify persons with whom the patient has spent time as well as the details of this cont act regarding frequency, duration, and proximity (Shrestha-Kuwahara, Wilce, DeLuca, & Taylor, 2003). This interview is expected to provide adequate info rmation that leads to the identific ation of those that could be at risk, thereby allowing health professionals to diag nose, treat patients, and contain the spread of TB. Low results in contact investigation could be related to multiple factors, some of them connected to the health system and other factor s related to the community or to individuals. Barriers for the identifica tion of contacts could be related to economic factors, social factors or cultural factors, among individuals as well as in the health institutions. Some of these factors may include interviewer skills, interviewer understanding of the pa tients social setting, and the patients ability and willingness to share informa tion (Reichler et al., 2002). Factors that may influence the identification of contacts are no t well characterized, however. Shrestha-Kuwahara et al. (2003) completed a study that described TB patients perceptions of the contact investigation interview, and the researchers identified potential factors associated with identifying contacts. Stigma, language barrie rs, cultural insensitivity, and mistrust may all contribute to the outcomes of contact inve stigation (Shrestha-Ku wahara et al., 2003). Stigma Background Mycobacterium tuberculosis was first described on March 24, 1882 by a German physician nam ed Robert Koch (Hass & Hass, 1996). At that time the Mycobacterium was known as the

PAGE 22

22 tubercle bacillus. Apart from the great medical achievement that this discovery represented, the description of the bacillus changed the way peopl e saw tuberculosis. Although previous to the discovery of the bacillus, others had introduced the idea of the germ theory regarding the cause of TB it was until the discovery of the bacillu s that the argument regarding the cause of tuberculosis finally ended (Hass & Hass, 1996). It was after knowing the real cause of TB that tuberculosis started to be st rongly viewed as an undesirable disease (Dubos, 1996). There were now good reasons to fear the presen ce of people with tuberculosis and people with tuberculosis started not only to confront their own debility an d possible death but also th ey have to deal with isolation and the anger of an intolerant phobic society (Ott, 1996) It was at the end of 1800s and the beginning of 1900s when in United States th e popular image of tuberc ulosis started to be associated with poverty and people of non Angl o-Saxon ethnicity (Ott, 1996). There is a misconception by the general public regarding undesirable charac teristics of high risk groups due to the manner in which this information is communicated to them by the medical field (Ott, 1996). Epidemiological and other health related fields use of risk factors based on social characteristics tends to support soci al differences as threat. These social differences associated with the risk groups can become identifiable by the public and they are then held as scientific truth leading individuals to reject those that have these characteristics. Currently in United States, most of the risk fa ctors associated with TB are socially based such as addictions, homelessness, history of incarceration and forei gn-born status (CDC, 2000), conditions that are also strongly related to undesirable behaviors. In addition, the foreign-born may also experience the negative effects of anti-immigration at titudes. Although these risk factors have scientific bases a ssociated to the characteristics th at facilitate TB spread, the information is not accurately transferred to the general public

PAGE 23

23 This unique social aspect of t uberculosis awakened the interest of researchers regarding the stigma associated with the disease. At the end of the 90s research interest in the implication of stigma in tuberculosis control started to emerge. Although the number of studies conducted relating stigma and TB is not close to the number found in studi es relating stigma to other diseases such as AIDS and mental health, currently it appears to have its niche in the world of TB academia and the studies about stigma associated with TB and its imp lication in TB control increase each year. However, regardless of the number of studies conducted with an emphasis on stigma, stigma is a concept broadly used in research without a precise definition. The word stigma is repeatedly used in medical research but not well understood. Si nce Goffmans book (1963), numerous scholars from different disciplines have conducted resear ch on stigma but because it is a vague concept and it operates at different levels, the idea of stigma is used in different ways. As a sociologist, Goffman studied stigma as a pr operty related to normative behaviors in society that generate stigmatized identities in individual s. In medicine, Goffmans conceptualization of stigma is commonly applied to individuals in spite of Goffmans gr oup-level reference for stigma. This discrepancy in the level of applic ation of Goffmans theory may lead to erroneous conclusions. A more comprehensive model of culture is required in order to resolve this individual versus group discrepancy noted in medical research linked to stig ma. Prior to the influence of Ward Goodenough (1981 [1967]), and other social scie ntists interested in relating culture to both individuals and to groups, cultu re was limited to normative and behavioral terms. This is reflected in Goffmans early work on stigma. The contribution of Goodenough, and others, was to define culture in ideational terms (values and beliefs), and to develop models of culture based

PAGE 24

24 upon language. Like language, cultur e is learned by individuals. This approach shifted the study of culture from groups to an emphasis on individu als, and learned behavior. This shift was controversial because a behavioral definition of culture can lead to observable behaviors and patterns in groups, whereas culture defined in id eational terms cannot be directly measured. However, an ideational model of culture, such as the one proposed by Goodenough, contributes to a better understanding of how the perception of stigma in i ndividuals would re late to their interactions with each others. Goodenoughs model of culture includes culture as it relates to groups and culture as it relates to individuals. This allows for the articulation of culture at both levels, so that we may perceive stigma as a process. The culture of a group may be seen subjectively as the system of values and beliefs a person attributes to a set of other persons (Goodenough, 1981). However this subjectivity is any individua ls operating culture, the particular set of values and beliefs that she uses to interpret the behavior of others or to guide her own beha vior on a given occasion (Goodenough, 1981). Thus, the differences between groups are relative in Goodenoughs model and dependent upon interaction. This view of culture contrasts with culture defined in normative terms, as implied in Goffmans definition of stigma. Goodenoughs model allows us to understand stigma as a process involving individuals and groups. Goffmans (1963) work, Goodenoughs (1981) m odel, and Link & Phelans (2001) work together provide the bases to better understand stigma. According to Goffman(1963, chap. 1), stigma is an attribute possessed by a person (mark) that is deeply discred iting causing her to be viewed as less than fully human because of it. Goffman makes strong em phasis in stigma as a relationship between the mark and the group-related stereotype ascr ibed to that mark. But he does not explain the process of how stigma deve lops or how it is maintained. Relating

PAGE 25

25 tuberculosis to stigma is challenging because the definition proposed by Goffman assumes a visible mark, or physical difference that TB as a disease does not have. TB could be linked to visible attributes like the cough and disease consumption, as we ll as other attributes rooted in socioeconomic differences perceive d as a proxy for the disease. What makes stigma interesting and complicated, according to Link and Phelan, is that stigma is not only the attribute (label) but the consequent set of characte ristics linked to that attribut e (stereotype) and the following responses to the stereo type (status loss and discrimination). Link and Phelan assume a given stigma and then look at process; this can be associated with Ward Goodenoughs model of culture. Conceptualizing Stigma (Link & Phelan, 2001) provides a good concept of stigma to work with in relationship to TB. The authors st ate that: stigma exists when all its components converge (Link & Phelan, 2001, p. 367). They r ecognize five components of stigma: (a) the first one is the action of people distinguishing and labeling differences; (b) the second corresponds to the action of linking labels to negativ e stereotype, (c) the thir d refers to the action of placing distinct categories to make a line between us and them, (d) the fourth is related to the resulting status loss and disc rimination, and (e) the fifth refers to the indispensable presence of power for stigma to exist. Based upon Link and Phelans work, stigma may be present even if a visible label is not present. According to this definition of stigma, the label Tuberculosis people will be described using all five components. The first component of stigma is the action of people learning and labeling differences; this will be what Goffman (1963) refers to as the attribute or mark. This action may also apply to differences learned and labeled, but not directly visible, and they will only be meaningful in the context of time and culture modeled by Ward Goodenough (1981). For this component to be

PAGE 26

26 applicable to tuberculosis, first, one should expe ct that people will perceive tuberculosis as a difference in a specific period of time and in a cu ltural context, and that this difference would rise above all other attrib utes, including those that ar e visible or those that are not visible. As a result, tuberculosis has had differe nt meanings attached to it. We can find tuberculosis hidden all over scientific and fiction liter ature with its various names now known as conditions probably caused by tuberculin bacilli (D ubos, 1996). There are enough novels dramas, plays and stories in fiction literature that suggest that there was a time when TB was seen as a melancholic tragedy that affects all. During the XIX Century, protagonists of famous theatrical plays suffered from tuberculosis and famous people died because of it. Because many famous people suffered and died from tuberculosis it was al so thought to be a symbol of intelligence (Dubos, 1996). After the introduction of better sanita tion systems and public health infrastructure, tuberculosis incidence started to decline. The differen ces between who was affected and who was not became clear. Tuberculosis started to take different meanings, and probably because of the decrease in incidence of the disease, the romanticism surrounding it disappeared. The germ theory of disease produced further changes in att itude toward tuberculosis both in popular view and in the literature. Now, after having been both a symbol of the hero and of beauty, TB as an infectious disease became contag ious and unclean, making affected people seem undesirable and untouchable (Dubos, 1996). Thus, as Dubos notes, differences are meaningful only in the context of a specific time and culture; difference will only be under stood and classified in the cont ext of what is important and socially accepted. There is a social norm that will dictate what differences should be important and what should be ignored. It is not well known how culturally cr eated categories arise and how they are maintained, but they will only matter in the cultures in which they are embedded. In this

PAGE 27

27 sense, I suggest that tuberculosis in the Unite d States is a difference considered important enough to be raised to a category of label, though th e invisibility of the TB label is tied to other labels that are visible. This association follows from the literature; for example, surveillance data in the United States indi cates that tuberculosis is mo re common among person born outside its borders, and these same people are affected by it the most. Places outside the borders of the United States are diverse and each one is unique. If stigma emerges, in part, as a difference that is defined in some way by the culture; then, stigma may emerge in the context of cultural differences in which the critical difference is a di sease, unseen. But, is it possible to explain how the differences named tuberculosis people affect the host culture compared to persons representing another culture, a nd more affected by the disease? The second component of stigma corresponds to the action of linking the differences, reflecting different cultures, to a category of labels that b ecome negative attributes or stereotypes. These linkages between labels and stereotypes also will be defined by specific periods of time and in relationship to a given cu lture. The host society defines what labels correspond to which attributes. Attributes become so deeply imprinted in the minds of people that they became unaware of them (Link & Ph elan, 2001); similar to how individuals acquire linguistic competence (Goodenough, 1981). The literature on tuberculosis suggests differe nt beliefs and attitudes in many different cultures, but this literature does not apply a m odel of culture that would describe stigma. Instead, there is an emphasis of stigma simply as involving some type of cultural difference. For example; in a cultural feasibility study with th e objective of identifying factors that may shape the behaviors toward screening and treatment in Haitians community from South Florida (Coreil, Lauzardo, & Heurtelou, 2004), the researchers found that stigma and fear of isolation were

PAGE 28

28 important factors. Another study, conducted in Ca li, Colombia, explored the correlation of the beliefs about TB mechanism of tr ansmission and the attitudinal aspe ct of TB stigma, finding that contagiousness and severity perception are the ma in predictors of prejudice (Jaramillo, 1999). A study conducted to describe the so cio-cultural aspects of tuberculosis (TB) among Mexicans in the United States (Joseph, Waldman, Rawls, W ilce, & Shrestha-Kuwahara, 2007) found results suggesting that the Mexican-born persons are no t homogenous in their pe rceptions toward TB, including stigma and that the level of stig ma changes depending on the TB status and TB educational exposure. In this study they found that participants anticipate greater stigma than the stigma actually experienced by persons with active TB. Among those with TB disease, perceived stigma did not preven t disclosure of status. A different study was conducted to describe socio-economic consequences of tuberc ulosis in Vietnam with special reference to gender differentials concerning social stig ma and isolation (Long, Johansson, Diwan, & Winkvist, 2001). It was found that male patie nts often worried a bout economic-related problems, while female patients worried about social consequences of the di sease. According to their results they conc lude that stigma might play a grater role among females than males because of their greater focus on social consequences Numerous studies conducted in different cultu ral contexts suggest that culture is an important component of stigma related to TB, a nd that it will define its characteristics and implications. These various studies indicate th at the label tuberculosis people will have different meanings and linkages to different stereotypes according to the culture in question. The most common stereotype mentioned in the literatur e regarding tuberculosis is the belief that people with TB are poor and dirt y people with bad habits (Joh ansson et al., 1996; Kelly, 1999;

PAGE 29

29 Macq, Solis, Martinez, Martiny, & Dujardin, 20 05; Westaway, 1989). Al so, tuberculosis is strongly attached to foreign-born status (Porter & Kessler, 1995). The third component in the work of Link and Ph elan (2001) relates dire ctly to the process of stigma in which a line is drawn between them and us, the tuberculosis people and us. This level of culture is bette r described by Goodenough (1981), who states that culture may be understood as a taxonomic hierarchy of what he calls public cultures or subcultures. These subcultures are based upon the classification of groups according to degrees of similarity and differences in their respective public cultures. A groups public culture is defined as an individuals perception of values and beliefs that a groups member s expect one another to use as their operating culture in dealing with others (Goodenough, 1981). This level of culture allows us to describe how stigma emerges in the interactions of public cultures. The forth component of stigma, according to Link and Phelan (2001), is related to the resulting status loss and discri mination. However, the hierarchy implied in the discrimination and loss of status requires description. In Goodenoughs model (1981), the notion of hierarchy or a distinction between them and us, arises in the interactions of individuals and requires some understanding of previous experiences of individuals representing different groups. The label of tuberculosis people of the American host group is linked to the stereotype immigrant status, and this stereotype tri ggers the behavioral responses th at are discriminatory, and that reinforce the label. This proce ss would reflect inter-cu ltural interaction, but hierarchies of public cultures also operate intra-culturally. While this process is difficult to observe, the outcomes are linked to tuberculosis studies wher e researchers have found that patients are afraid of losing their job and various other forms of discrimination.

PAGE 30

30 The fifth component of stigma, according to Link and Phelan, is related to the imperative necessity of a relation of power in hierarch ies of public culture (Goodenough, 1981). In saying this, it is necessary that the people who are stig matizing others have a higher social or cultural status of power over those who are being stigma tized, and are able to enforce the stigma over those suffering from it. Tuberculosis is a di sease of minorities, povert y, and the foreign-born. This situation of unequal power places the host public culture in a powered position against those affected. Summary Stigma exists according to the beliefs and values learned in a given cu ltural context. It develops in the minds of peopl e as a process triggered by the linkages to stereotypes and the consequent behavioral response to persons likely to carry TB. The relationships between those who stigmatize and those who are stigmatized are reinforced by unequal power relations embedded in a hierarchy of public cultures. The label tuberculosis people links negati ve characteristics such as poverty, poor hygiene, and other bad habits to people from a different country, usually a poor country with a different culture. This perception triggers behavioral responses that reject others and place social distance between them and us, and those w ho suffer the disease risk being rejected by friends and family, isolated from society and to have unequal opportunities in a powerless situation. Although stigma in relationship to tuberculosis is not well understood and is not well described, the difficulty in controlling TB among foreign-born persons has been linked to stigma. Stigma in patients with tuberculosis has b een frequently mentioned emphasizing cultural differences, according to the society in questi on (Castillo, 2001; Coreil et al., 2004; Hudelson, 1996; Jaramillo, 1999; Joseph et al., 2001; Macq et al., 2005; Menegoni, 1996; Poss, 1998).

PAGE 31

31 Most of these studies relate stigma and TB w ith its effects on medical care and adherence to treatment. However, little has been done to study the effects of stig ma on the outcomes of contact investigation. A study conducted on foreign-born TB patients perceptions of the contact investigation interview (Shrestha-Kuwahara et al., 2003), identified stigma as a chief factor affecting the contact investigation outcome. This study also identified the impact of language barriers, cultural insensitivity, and mistrust on the effectivenes s of contact investigation. The elements mentioned above could be associated w ith the status of foreign-born status that is somehow tied to the label of tuberculosis people. Therefore, it is important to explore this relationship. Figure 2-1. Contact investigation. Con centric circle approach. (CDC, 1999)

PAGE 32

32 CHAPTER 3 METHODOLOGY Introduction The previous chapter reviews the literature on stigma, tuberc ulosis, tuberculosis contact investigation, and stigma in tuberculosis. This ch apter aims to describe the procedures used in this study. The objectives and the description of the research design will be discussed at the beginning of the chapter followed by the res earch questions which guided the study. The selection of the community of study, the criteria for selecting the partic ipants within the community, sample size and all in struments needed in this rese arch will be described followed by a brief description of the process of the data collection. The chapter en ds with a description of all the variables included in the study and the description of data analyses used. This study does not attempt to explore the rela tionship between patients and doctors or any other relationship between patients and the heal th care providers. This study aims to understand the presence of stigma embedded in the society. Research Design Purpose The purpose of this study was to determine if stigm a related with TB and the immigrant experience affects the likeli hood of identifying contacts durin g the tuberculosis contact investigation. The study focused on Mexican migrants living in central Florida. This study is a nonexperimental research usi ng a cross-sectional survey design. The study used mixed methods where quantitative data served as primary source of data. Qualitative data was used as secondary source to provide cont ext and to better understand the community. The surveys and interview guides were designed and conducted by the researcher. All instruments were developed originally in English and translated into Spanish for its application.

PAGE 33

33 A panel of experts composed of faculty members fr om the University of Florida in the areas of Anthropology, Medical Anthropolog y, and Biomedicine reviewed the instruments used in this study. The protocol of this study was submitted to the Institutional Review Board of the University of Florida and approved prior to data collection. The survey s and interviews were conducted in Spanish. The hypotheses are on the classical format to fac ilitate the definition of all variables in the statistical analysis condu cted in this research, acknowledging all the limitations of statistical analyses in the understanding the processes of social stigma (Goffma n, 1963; Link & Phelan, 2001). The following hypotheses are a simplification of stigma as a process; simplification is required for the purpose of measurement. Fo r example, the hypotheses below do not address directly the foreign-born vers us host culture proce ss of stigma formation. The following hypotheses assume the existence of the perception of stigma. Hypotheses Hypothesis #1 Ho: There is no association betw een the perceived level of stig ma related to tuberculosis and the likelihood of identifying contacts during a TB contact investigation Ha: The higher the perceived level of stigma related with TB the lower the likelihood of identifying contacts during a TB contact investigation Hypothesis #2 Ho: There is no association between the im migrant experience and the likelihood of identifying contacts during a TB contact investigation Ha: The higher the level of negative immigrant experien ce the lower the likelihood of identifying contacts during a TB contact investigation

PAGE 34

34 Hypothesis #3 Ho: There is no association between the leve l of knowledge about TB and the likelihood of identifying contacts during a TB contact investigation Ha: The lower the level of knowledge about TB the lower the like lihood of identifying contacts during a TB c ontact investigation Having been born in Mexico gave me the a dvantage of being a native Spanish speaker. The Spanish speaking ability and knowledge of Mexican culture facilitated access to the community. However, these advantages did not prevent me from some unanticipated challenges while carrying out this study My experience working in the Southeastern National Tuberculosis Center (SNTC) for more than two years also brought some advantages th at facilitated the selecti on of a research site. While working at the SNTC, I learned the importa nce of tuberculosis in Florida, especially among the foreign-born. By 2006, Florida ranked acco rding to rate in se venth place nationwide and 45% of its cases were among foreign-born an d within them, 18% were from Mexico (CDC, 2007). In Florida, the four firs t counties ranked according to TB rate are, Dade County, Orange County, Duval County, and Hillsbo rough County occupying the 1st, 2nd, 3rd, and 4th place, respectively (Bureau of TB and Refugee Health, 2007a). Within these four counties, Hillsborough is the second with more TB cases among foreignborn, surpassed only by Miami Dade. (Bureau of TB and Refugee Health, 2007b, 2007c, 2007d, 2007e). In Hillsborough County in 2006, 46% of TB cases were in the foreign-born population. I selected Hillsborough County for my study because it is one of the counties with more problems of TB among the foreign-born. In a ddition, the study required access to a small community mostly of Mexican-born people with long-term residenc y in the United States. In Hillsborough these types of communities are more pr evalent compared to other parts of Florida.

PAGE 35

35 To test my hypotheses I needed to develop constructs that allow me to measur e the effect of the variables. Because this research did not use TB patients to test these hypotheses, I chose to measure the low contact identification during the TB contact investigation with the level of comfort participants have in re sponding to the questions health care providers usually ask during the contact investigation interview. The rationa le for this decision was that TB patients during the contact investigation are asked several questi ons regarding their priv ate lives in order to identify the patients network and to identify the likelihood of TB spread. However, the patients may feel uncomfortable answeri ng these questions assuming perceived stigma is present. The level of comfort participants have regarding this questionnaire may affect the likelihood of TB patients answering questions about their private li fe, affecting in turn the level of information health care providers receive a nd the likelihood that he althcare providers would be able to identify those contacts that may be at risk. Due to the fact that this research did not use TB patients to measure TB stigma, a scale of hypothetical questions regarding how a person woul d feel if they had TB was constructed. Therefore, this scale is intended to understand TB stigma as a perception in the general community, regardless of the presence or absenc e of TB disease. Measuring the perceived stigma in the general population and not in TB patients could provide valuable information regarding the perception of stigma present in th e general community. This information may be valuable to understand the perceptio n of stigma present in patient s before they are confronted with the diagnosis of TB. Regarding immigrant experience a few questi ons regarding their own experience of perceived discrimination against them because of th eir condition as migrants as well as attitudes and beliefs toward their own c ondition as immigrants were included in the survey instrument.

PAGE 36

36 When the first five participants were survey ed, it was clear that Spanish-speaking ability was not enough. The educational le vel and the particular characteristics of the community made communication difficult. The Likert scales were partic ularly difficult for them to understand; it seems that they had some confusion with intervals in their responses. After the pre-test of the survey questions, so me modifications were made to the survey questions. New strategies were also designed to better administer questions based on the Likert scales. At this moment I realiz e that there were validity issues with the instrument, particularly in relationship to the use of the Likert scales. I stopped the data collection at that point and went back to review the instruments. I developed further strategies that helped me to better explain what was expected from the participants in res ponse to these scales. I modified the language, rephrased the scale labels to use simple words lik e more or less, a big no or a big yes to differentiate between the levels of agreement or disagreement with the statements presented in the survey, the big no or yes st rategy. Another aspect consider ed after this first survey day was that the level of literacy in this community required reading the survey to them. Community Note: the name of the small town the three siblings and the church Perpetuo Socorro where the study took place are not the real names. To protect identities and maintain confidentiality, all names are fictitious. For the purpose of this research it was necessary to identify a community and culture composed of Mexicans in Hillsborough County, a county known to have high incidence of TB among Mexicans. A key informant assisted me in selecting the community. The Community selected is part of a church located in Hillsbor ough County in the state of Florida. The sampled population was participants in P erpetuo Socorro church activities, persons originally from Mexico, and persons older than 18 years. The study took place in two areas of this County, one

PAGE 37

37 was in Ruskin. Florida and the other one was a small community located nearby that for this study will be identify as the three siblings. In Ruskin, Florida, the da ta collection took place in the local Community Health Center and in t he three siblings the study took place in the Perpetuo Socorro Church. Information regarding specific demographics about Mexican-born population is difficult to find due to the mobility of the population and other sensitive immigration issues that prevent accurate collection of demographic data. However, some information may be found that help to picture the community where this study took place. The 2000 Census reported a population of 998,948 for Hillsborough County, with 17.99% reporting a Hispanic or Latino race. The Census of 2000 reported for Ruskin, Florida a populatio n of 8,321 with a 36.73% of residents reporting Hispanic or Latino race. The three siblings has a population of 3,095 with a 73% self reported Hispanic or Latino ethnicity. From the 73% of the Hispanics living in the area, 66% are originally from Mexico. A Dissertation presented to the graduate school of the University of Florida (Unterberger, 2005) portray the poor living conditions, the strong ties in the community and the vivid Mexican culture in the area. In her pape r she describes how the community develops to be a town mostly composes by Mexican. At the middle of the 20th Century, The three siblings population was about 50% African American. Afte r a series of freezes that destr oyed the harvests, the main way of living for the area, African Am erican locals started to move out of the area looking for better opportunities. Meanwhile Mexican immigrants began to arrive and started to overtake the town. The population grew from 1979 to 1990 from 15 00 to almost 3000 mostly due to Mexican immigrants (Maio, Mohlman, & Capanna, 1998). Unte rberg also describe the festivals and other activities that resemble a small town in Mexico.

PAGE 38

38 Sampling A snowball strategy (Bernard, 2006) was used to identify the community and the persons who served as cultural brokers. Contacts from within the SNTC assisted me in identifying the correct venues that guided me to the best comm unity. Numerous calls and informal interviews with stakeholders took place until the appropriate community was found. Two weeks were spent selecting the most suitable community in the county and the best way to access it. After several attempts, I was directed to the Coordinator of Migran t Outreach at the Local Community Health Center in Ruskin, Florida, duri ng the summer of 2007. Together we identified a community with the characteristics I needed and that the Coordi nator also knew well. The community selected was a church-based community named Perpetuo Soco rro. After this initial planning, a meeting with the coordinator at the church, where th e study was going to be conducted, took place and arrangements were made to collect data during regular social church activities. The coordinator of migrant outreach also introduced me to woman in charge of events in the Church, and together we planed how best to reach the larger community. From key informants I obtained qualitative information about tuberculosis and contact investigation. Two key informants were cultural brokers, bicultural persons with extensive knowledge about health care delivery in the community selected for this study. One informant was familiar with health care issues of Mexican-born persons but did not identify as a co mmunity member, and the other key informant was knowledgeable about health care issues and also identified as a member of the community selected. The Perpetuo Socorro church has weekly or ganized events. Hispanic people participate and receive different types of information, guid ance and education, and faith meetings. They also receive help with different aspects of ad ministrative paperwork, such as for Medicaid and Medicare. During these activities participants also receive donation of food and other donations

PAGE 39

39 and free services. After participating in differe nt activities with them, people started to feel comfortable with my presence. At that point I interviewed two community members regarding their personal opinion, feelings and fears about TB, other health issues, and their migration status. Attending Church activitie s gave me the opportunity to meet the people, and over time this interaction helped me to define the community. For the quantitative part of this study, the sampling technique used was convenience sampling. Only persons participating in the ch urch activities older than 18 years old were subject to the study, and the sel ection of the sample was only limited by the proximity of the subject in the moment the survey was being applied and their willingness to participate. Sample Size The sample size was calculated according to the needed ratio of cases to independent variables in multiple regressions. According to Ta bachnick & Fidell (1989), this ratio has to be substantial for the study to have meaning. The au thors state that a bare minimum requirement is to have at least 5 times more cases than inde pendent variables. Participants were verbally invited to participate; the informed consent was read and signed before the application of the instrument. A total of 42 surveys were collect ed in a period of two weeks at the end of the summer 2007. Instruments The focus of this study was to determine wh ether the perception of stigma related to tuberculosis and the immigrant experience were possible causes of low contact identification during the tuberculosis contact investigation. The study used mi xed methods where quantitative data served as the primary source of data. Qual itative data was used as the secondary source to provide context and to better understand the commun ity. Quantitative data were collected with surveys and qualitative data w ith face-to-face interviews and informal conversations during

PAGE 40

40 church activities and other social functions. Et hnographic interviews of key informants were also conducted. The survey: The survey consisted of 53 questions divided in five sections: (a) general knowledge on TB, (b) stigma related to TB, (c) immigrant experience, (d) comfort during contact investigation interview, and (e) demographics. The first section was designed to collect im portant information reflecting participants understanding on tuberculosis. Th is section contained 15 questi ons, labeled TB Knowledge. In this section participants were asked to dete rmine whether the statement presented is true or false. To develop this section, different survey s and structured interview guides previously used by other researchers were modified (CDC 1994-1995; Shrestha-Kuwahara & Joseph, 2002). The first three questions explored what the par ticipants understood regarding the importance of TB and who is affected by TB. The following que stions, four to fifteen, provided information regarding the participants understanding about TBs transmission and treatment. The second section of the survey was designed to collect data about s tigma in relationship to tuberculosis. This section captured the par ticipants perceptions of stigma using hypothetical questions. This section was named TB stigma. These questions were designed to use Likert scales to measure the level of agreement participan ts have with the statements presented to them. This section contained nine questions. To develo p this section different surveys and structured interview guides previously used by other researchers were modified in to Likert scale type questions (CDC, 1994-1995; Shrest ha-Kuwahara & Joseph, 2002-2004). The third section of the survey was designed to collect data about immigrant experience. This section explores particip ants perceptions on their particular experiences regarding migratory status in the United States. These ques tions were designed to function as Likert scales

PAGE 41

41 measuring the level of agreement participants have with the statement presented in the survey. This section had six questions, and it was develo ped based on other general stigma measurement instruments (King et al., 2007). The fourth section of the survey focused on th e participants level of comfort disclosing personal information to health care providers. This section was designed to measure the participants level of comfort using a Likert scale where participants were asked to hypothetically express their leve l of comfort providing personal information to healthcare professionals. This section had 12 questions and it was designed using general information, guidelines, and instructions to conduct a tuberculosis contact investigation interview (CDC, 1999, 2005a; Wolman, Bhavaraju, Napolitano, & Kantor, n.d.). The fifth section of the survey collected demographic data from participants. Ten questions were included here, regarding age, gender, socioeconomic status, education, acculturation, immigration status and household characteristics The interview: Two different intervie w guides were used in this study. One was designed to collect data from cu ltural brokers and the second was designed to collect data from community members. Cultural brokers: An ethnographic interview was used to establish the key informants beliefs and knowledge about TB, and insights on their perceptions rega rding the communitys health care concerns and barriers to migrants. This interview also included an activity where the interviewer pretended to be an immigrant asking for help and guidance regarding health issues and the interviewee played the role of a guide for the community. Cultural brokers (CB): The term cultural broker is used to refer to those pe ople that serve as links between the mainstream culture and the subcultures (Gentemann & Whiteh ead, 1983). These people are at some degree

PAGE 42

42 acculturated in both cultures, facilitating human communication and interaction among persons from both cultures. CBs were included to facili tate the interaction between the researcher and the community and to corroborate th e validity of the instruments. Community members: using informal interviews, community members were asked questions regarding TB and the im portance of TB contact investig ation. They were allowed to talk freely about these, and other, topics they recognized as impor tant in relation to health and health services, as well as their migrant status. Data Collection The survey: Data collection took place during th e summer of 2007 in the Perpetuo Socorro church, during the church community or ganized activities. All data collection was conducted in Spanish. Community members were in formed by their leader about my presence in the church, my intentions there, and verbally invited the community to participate in the research. After this announcement to all community members, I personally approached each potential participant to e xplain in detail the purpose of my vis it. Then, I invited them again to participate in the survey. The informed consent was read to those who chose to participate, and they were asked to sign it before starting the surv ey. I read the questions to all participants, and used the strategies previously planned to better e xplain the Likert scales a nd to give participants a consistent idea of the meaning of their level of agreement and co mfort to these scales, the big yes or no strategy. The interviews: Participants were invited to participat e in the research and they read and signed the informed consent. The interviews were audio recorded to facilitate the analysis of the information obtained.

PAGE 43

43 The interviews collected with the cultural brokers took pl ace one in the church and a second interview took place in the Local Community Health Center at Ruskin, Fl. Cultural brokers were recognized by community members as persons with the tool s necessary to better navigate the health system. The interview guide was followed but informants were allowed to expand upon any of their comments. The interviews collected with the comm unity members took place in the church. Community members were individually interviewed in nonformal settings. Data Analysis The data obtained from the 42 surveys were an alyzed using SPSS. Descriptive statistic analysis, cross tabulations, and simple linear regr ession analysis were th e procedures used to analyze the survey data. Some sections of survey are designed as Likert scales, Likert scales are often used to gather information in different disciplines relate d to attitudes, beliefs, emotions, and values to access constructs that are not directly measurab le (Babbie, 2004; Selltiz, Wrightsman, & Cook, 1976). Although, Likert scales are or dinal scales, they can be used to construct indexes to be use in statistical analysis. Likert sc ales are normally used as interval scales in social sciences. To follow this practice, it is required the use of a s cale with at least 5 point s, because scales with fewer than 5 points violate assumptions of nor mality (Garson, 1998). Disc ussing the effects of departure form intervalness on parametric statis tics, Jaccard and Wan (1996, p.4) state that For many statistical tests, rather seve re departures do not seem to affect Type I and Type II errors dramatically. Variables The survey used in the study included five s ectio ns, each one related to the variables of interest. All questions were pre-coded and participants chose the best response to the questions.

PAGE 44

44 The sections regarding TB stigma, immigrant experience and the level of comfort during the contact investigation interview were designed as likert scales. The section of TB knowledge involved yes or no questions, and demographics section provided options from which to choose the most appropriate response. Demographic variables Socio-economic status (SES): To assess the socio-economic status, the survey included a question with a pre-coded respond with three op tions to chose from, Low, medium or high SES. Gender: The survey included a question asking th e gender of the participants-responses were pre-coded as Female or Male. Education: A question was included in the survey for participants to self report their highest level of school complete d. Pre-coded responses included: Elementary school, Middle school, High school, and Universi ty. There was included a No Applicable response for those who have not completed any education. Age: The survey included a pre-coded question w ith four different options for age group. Participants were asked to choose between these age groups: 18-30, 31-40, 41-50, and more that 50 years old Acculturation: To assess acculturation three survey items were included. Length of residency in the United States with four pre-code d responses options: less than 1 year, between 1 and 5 years, between 5 to 10 years and more than 10 years. Self reported English proficiency and time spent with people from their own Country completed the acculturation section. Migration status : One survey item was included with a specific question regarding their migration status. Because of the sensitivity of this question the answers were only reported as documented or undocumented migration status.

PAGE 45

45 Household: The survey included two items regarding the household composition. One was about their marital status and the sec ond was about the current household composition specifically currently, with whom they live. Reliability With the intent to quantify constructs that are no t directly meas urable I developed a multiple-item Likert scale. When using Likert-typ e scales it is imperative to calculate and report Cronbachs alpha coefficient for internal c onsistency reliability (Gliem & Gliem, 2003). Cronbachs alpha is a test of reliability t echnique that provides a unique estimate of the reliability for a given test, and provides a number between 0 and 1. The closer Cronbachs alpha coefficient is to 1.0 the greater the internal cons istency of the items in the scale. George & Mallery suggest a rule of thumb on how to interpret this number as follows > .9 should be considered Excellent > .8 Good, > .7 Accepta ble, > .6 Questionable, > .5 Poor and < .5 Unacceptable (as cited in Gliem & Gliem, 2003, p. 87). The reliability of each construct in the study is shown in table 3.1. From the set of nine questions on the section of TB stigma, three questions were used for the TB stigma construct. The Cronbachs Al pha coefficient obtained was .862. This construct has a good reliability according to the rule of thum b to interpret Cronbachs Alpha coefficient. This construct was called TB Stigma Index. From the set of six questions in the secti on about immigrant experi ence, four questions were used for the MG construct. The Cronbach s Alpha coefficient obtained was .762. This construct has an acceptable reliability Cronbachs Alpha coefficient according to the rule of thumb. This construct was called MG Index.

PAGE 46

46 For the 12 questions of the section in contact investigation comfort, the Cronbachs Alpha coefficient obtained was .935. This construct has an excellent reliability Cronbachs Alpha coefficient according to the rule of th umb. This construct was called CIC Index. Contact investigation comfort (dependent variable) CIC index To construct this index, an average of all twelve values was obtained to make one total value for the CIC Index. The maximum value for this index is five and the minimum value is one; were five corresponds to very comf ortable and one to very uncomfortable. Perception of stigma related with tuberculo sis (independent variabl e) TB stigma index To construct the index only three items from th e section were used; an average of all three values was obtained to make one total value for the TB stigma Index. The maximum value for this index is five and the minimum value is one; were five corresponds to high levels of perception of stigma and one to the lowest. Immigrant experience (independent variable) MG index Only four items were included in the construct. To construc t the MG Ind ex, an average of all four values was obtained to make one total value for the MG Index. The maximum value for this index is five and the minimum value is one; were five corresponds to high levels and one to the lowest. General knowledge about tuberculosis (i ndepe ndent variable) TB knowledge index The first section provided information regarding the overall TB knowledge the participants have. This section contains 15 questions long yes or no answers. Each correct answer received a value of one and zero for wrong answers. To c onstruct the TB Knowledge Index, all the values obtained were totaled to make one single value. The maximum value with all correct answers is 15; the minimum value with all incorrect answers is zero.

PAGE 47

47 Table 3-1. Cronbachs Alpha Coefficients. Construct Cronbach's Alpha N of Items TB stigma .862 3 MG .762 4 CI .935 12 Ruskin, Fl Ruskin, Fl Figure 3-1. Map of Hillsborough County (Univers ity of South Florida, 2001): The red box shows the area the study took place.

PAGE 48

48 CHAPTER 4 RESULTS Overview of the Chapter In the previous chapter th e research design and m ethods of the study, including the variables, the instruments, data collection tec hniques, and analyses, were described. In this chapter the results of th e study are reviewed. The first step in this chapter is to describe demographic findings of this research. Specifics regarding each of the items included regarding demographic data will be describe according to the results obtained using descriptive statistic analysis with SPSS. After reviewing the demographics of the community this chapter continue with the description of the dependent and indepe ndent variables used. Th e first part included a description of the items included in the survey, followed by a description of the constructs used in the analysis. The third part of the chapter refe rs to the statistical analysis used to test the hypothesis. A brief summary of the major findings fr om the interviews is described at the end of this chapter. Community Demographics The sample consisted of 42 members of the Per petuo Socorro church that participated in the activities organized by the church during A ugust 2007. From all church members invited to participate in my study, only 3 of them chos e not to do it. Table 4.1 summarizes the demographics of the participants. The church members that chose to particip ate in the study were predominantly female (62%). It is important to not e that the members that chose not to participate were in the 2 females and 1 male. The sample only included co mmunity members older than 18 years old. In general the sample was composed mostly from young adults, 46% of a ll participants were between the age of 18 and 30 year s old, and 76% of a ll participants report ed belonging to an

PAGE 49

49 age group younger than 40 years; 17% of the pa rticipants were olde r than 50 years old. Participants were asked to identify their soci o-economic status (SES) (high, middle, or low); 69% of the participants responded to have a low SES and 31% to have a middle SES. Regarding education, the survey asked participan ts to place themselves in the category to which they belong according to the level of scho ol they have completed. People that did not complete any school level were placed in th e N/A category (7.1%). 42.9 % of all participant responded that they had completed elementary school, 28% completed middle school, 14% high school, and 3 participants (7.1%) responded that they had some uni versity educati on (Table 4.1). To profile the acculturation among community members, two questions were included in the survey regarding the number of years each respondent has been in the United States, and their English proficiency. Almost half of the participants (4 8%) reported having 10 years or more of residency in the United States residency, 19% a have lived here between 5 and 10 years, 24% between 1 and 5 years, and 10% less than a year (fig 4.1). Regarding English proficiency, 26% of the participants do not to speak English at all, 57% speak a little English, and 10% speak some English. Only 7% of all participants said they are proficient sp eaking English (Fig 4.2). To better understand the commun ity, a question regarding the amount of time they spend with other people from their coun try of origin, and a question re garding immigration status were included in the survey. Participants responded that they are more likely to spend time people from their home country; 23.8% of all particip ants responded they sp end all the time, 47.6% responded to spend most of the time, 26.2% re sponded that some time, and only 2.4% responded that they never spend time with people from their own country (Fig 4.3). For the question about whether they have a VISA or not to be in the United States, 42% of the participants do have a VISA and 62% of all participants do not (Fig 4.4).

PAGE 50

50 Participants were asked about the composition of their households. 83.3% of all participants live with their fa mily, 4.8% live with friends, 7.1% live with coworkers, and 4.8% live alone. 47.6% were married, 28.6 %single, 4 .8% divorced, and 9.5% widowed; the remaining participants placed themselves in the category of other. Descriptive Statistics Participants were asked to respond to que stions regarding the importance of the tuberculosis. Table 4-2 shows the results of these questions 61.9% of participants responded that they totally agree that TB would be as important as any other of their problems and 21.4% responded th at they agreed with this statement. 83.3% either agreed or totally agreed with this statem ent. However, when asked if this problem is important for people coming to the United States 42.9% totally agreed and 2.4% agreed, and the sum of this percentage do not represent the majority (45.3%). Participants were asked to res pond to questions about tuberculos is as a disease, whether TB affects only poor people and do they think tu berculosis is a diseas e of the past. 78.6% answered that they do not think Tb only a ffects poor people, and 71.4% did not think TB affected people in the past (table 4.3). Knowledge about TB: The survey asked part icipants about their knowledge of TB to understand how much they know about TB. Table 44 is the percentage of people that answer correctly regarding different topics about TB. The majority of respondents knew the correct re sponses. With respect to TB transmission, if people were presented with a true statement, then they were more likely to respond correctly; if they were presented with in correct statements, then their re sponses where less accurate. 73.2% of participants knew that TB is spread through the air and 90% knew that it is transmitted person to person. With respect to prevention and trea tment, people knew that TB can be prevented

PAGE 51

51 (83.3%) that TB have an availabl e treatment (78.6%) and that is necessary to take a treatment to get better (93% in average) Perceived TB stigma: These questions may reflect stigma as perceived by members of this community. Hypothetical questions were asked regarding how participants would feel if they had TB. More than 60% of all pa rticipants were more inclined to totally agree with the statement that they would feel badly about themselves if th ey have TB (fig 4-5). However, in general, more than 80% of participants responded totally agree or agree that they would tell others their TB condition. No considerable difference is observable regarding to whom they would disclose their TB status (fig 4.6) Table 4-5 shows the results of the survey section on immigrant experience. Number of responses, the possible values and the mean and standard deviations, are reported. In general, participants are not afraid to go to a clinic due to their migration status. Also, participants have not experience discrimination in h ealthcare settings or discriminated by employers. However, in questions regarding their feelings the averages are slightly higher compared to the questions regarding their own experience w ith discrimination. The highest average corresponds to their perception that opportu nities are lacking. Regarding the level of comfort, participants were asked to respond to the level of comfort they would feel in the presence of a health care worker if they were asked personal questions about their private lives. Tabl e 4-6 shows the means and the sta ndard deviation of each of the 12 questions. The maximum value is 5, this corre sponds to the highest le vel of comfort, and 1 refers to the lowest. The means of all questions are higher than 3, reflecting that most participants feel comfortable. However, some sl ight differences are observa ble. Participants are

PAGE 52

52 less comfortable responding to questions about thei r sexual partners and about the places where they spend the night, followed by income and guests in the home. CIC index: The histogram in Figure 4-7 shows the frequency distribution for each one of the possible values of Contact I nvestigation Comfort index). 42 cases were included. The mean of the sample was 3.60 with a standard devia tion of .76. We can obs erve also that the distribution is close to normal. It is interesting to note that almost 60% of the respondents are located above 3.5 in this CIC and 100% is above 2. These results could reflect higher levels of comfort different from what it was e xpected to find in this population. Perceived TB stigma index: A perceived stigma related to TB index was created with the mean of the values from 3 questions. This index was called TB stigma. The chart in Figure 4-9 shows two categories for stigma (Low and Hi gh). 42 cases were included. The mean of the sample was 1.62 with a standard deviation of 1.06. It is interesting to note th at the majority of the respondents are located below 2.5 in this index su ggesting that the perceived level of stigma related to TB in this specific community was lower than expected. Immigrant experience index: An index was created with th e average of 4 items from the questions regarding migration experience. This index was cal led MG. The chart in Figure 48 shows two categories for MG (Low and High) values of MG index. 42 cases were included. The mean of the sample was 2.01 with a standard de viation of 1.08. It is interesting to note that the majority of the respondents are located below 2.5 in this in dex suggesting that the negative immigrant experience in this specific community was lower than expected.

PAGE 53

53 TB knowledge index: An index was created with the sum of the 15 questions regarding TB knowledge. This index was called TB Knowle dge. The histogram in Figure 4-10 shows the frequency distribution for each one of the possi ble values of TB Know ledge index. 42 cases were included. The mean of the sample was 11.18 with a standard devi ation of 2.043. We can observe also that the distribution is proximal to normal distributed. Linear Regression Although this study is a nonexperime ntal research and its sample is not a sim ple random sample, the data obtained with the surv ey was analyzed with linear regression. Perceived TB stigma index was regressed on th e the likelihood of TB of been equal to any other problem and the results are shown on Table 4-7. The results indicate the more different in importance related with all their probl ems participant think TB is, the more perceived stigma related to TB they would have (B .440 a nd R-squered.241). The results are statistically significant (p-value 0.001) To test the null hypothesis #1There is no associ ation between the percei ve level of stigma related to tuberculos is and the likelihood of identifyi ng contacts during a TB contact investigation, CI Comfort Index was regresse s by the independent variables perceived TB stigma using SPSS. Table 4-8 shows the results. 42 cases were included. Results show a very weak negative relationship represented by a B coefficient of -.095 and a R squared of .018, with a p-value .399. To test the null hypothesis #2 There is no a ssociation between the immigrant experience and the likelihood of identifying contacts during a TB contact investigation, CI Comfort Index was regresses by the independent variables rela ted to immigrant experience using SPSS. The results are on Table 4-8. 42 cases were included. Results show a very weak negative relationship

PAGE 54

54 (B coefficient -.048 and R squared of .005). The re sult of this analysis were not statistically significant (p-value .668) To test the null hypothesis #3 There is no association between the level of knowledge about TB and the likelihood of identifying cont acts during a TB contact Investigation, CI Comfort Index was regresses by the independent variables TB knowledge using SPSS. The results are on Table 4-8. 42 cases were included. Results show a weak positive relationship (B coefficient .078 and R squared of .209). Results we re not statistically si gnificant (p-value .184). Although the results show the expected relations hip to reject the nul l hypothesis, none of the results shows strong ev idence to conclude that these rela tionships are not due to chance. Qualitative Results Cultural brokers (CB): The term cultural broker is us ed to refer to those people that serve as link s between the mainstream culture and the subcultures (Gentemann & Whitehead, 1983). This people are at some degree accultur ated in both cultures, facilitating human communication and interaction among persons from both cultures. In this study, CBs were included to facilitate the inter action between the researcher and the community as well as to serve as a proof to the instruments. Two kind of CB were included: A CB that id entify itself as a community member and a CB that does not identify itself as a community member. The cultural broker who identifies himself as a community member stated that he did not have knowledge about TB other than he has been tested and was negative. He also c onsidered that in this community TB was not something people talk about or even think about: In the community you never hear about TB. The participant and cultural br oker who did not identify hims elf as a community member had general knowledge about TB but he stated also that TB is not a problem in the community: I do not think that TB is something that is in th eir minds, unless someone cl ose to them has it.

PAGE 55

55 This cultural broker did not think TB was prev alent in the community: TB is contagious; I imagine that if someone has TB we would all know it. Both cultural brokers think that migrants in the community share information regarding health services as well as other services where they can receive health care. La comunicacion entre ellos es tremenda (Communication among them is huge). If someone has a problem, their friends or neighbors will provide with guidance to where they can go. The CB who identifies himself as a community member states that he feels that people in the area are very sensitive to th e migrants. They feel OK when they approach to any agency to receive help. The people who provide services to them are very caring with the migrants. They feel welcome. Also, the sharing of inform ation among community members provides them with a sense of security regarding immigrati on issues. They know how migration agencies work. The MIGRA is not looking for them in health care facilities, howeve r, the CB that do not identify himself as a community member said that even if they kind of know, they will want to make sure that they are safe. I asked the CB about the barriers that this community experience s in health care facilities. But this concern, according to the CB, is the least of this communitys problems. Instead, their major concerns involve money, transportation, language barriers. They will place their health in a less important level compared to these other need s: They need to survive, and do what they are here to do, work and get money. Their health is less important. Unless their health status unable them to work, they will not look for help, they need to work if they have TB I am positive that they will receive health services until it is very advance. At the Church, they all fell safe. They know th at we have contact wi th several agencies where that can receive help. If someone has a problem, they know we will help them and that we

PAGE 56

56 will refer them to this other agencies to receive what they need. Among them, they spread the word; they are very communicative with the new ones. They share the information they have with others. According to these findings, it seems to me that the community is not concerned about TB, even if they do think sometimes about TB; they have more important things to be worry about placing any health related issues to less impor tant levels. Also, the community is very supportive. They are taking care of themselves sharing all the information they have to facilitate anything among them. Community members: Community members agree that they will not withhold valuable information from health care professionals because they fell responsible for the health of others. One of them had received LTBI treatment and stat ed: I did not have any bad feeling against the person who made me infecte d, on the contrary, I kind of ar e grateful that this person protected my health I do not th ink people should reje ct the ones that have TB and say their names to health care professionals,. They are protecting their health. The other participants had neve r had contact with TB but his stamens were similar to the previous one If I have TB I will make sure th at health care professiona ls know who my contacts are, I dont care if they fell upset, with time th ey will understand but I will not feel OK if I put someone at risk. According to these qualitative findings, it seem s for me that the comm unity is very loyal and that they will care more about the well be ing of their own community than anything else. The community recognized that they may be subjects to rejection but they are not afraid of it because they are positive that people with time will understand and the satisfaction of doing the right thing to protect th em is more valuable.

PAGE 57

57 Table 4-1. Demographics Demographics % Gender Male 38 Female 62 Age 18 to 30 45.2 30 to 40 31 40 to 50 7.1 More than 50 16.7 SES Low 69 Middle 31 Education N/A 7.1 Elementary 42.9 Middle school 28.6 High school 14.3 University 7.1 Table 4-2. The importance of tuberculosis to participants TB would be a problem as important as any other of my problems % Totally agree 61.9 Agree 21.4 Neither agree nor disagree 2.4 Disagree 9.5 Totally disagree 4.8 TB is a big problem for people coming to the USA % Totally agree 42.9 Agree 2.4 Neither agree nor disagree 16.7 Disagree 14.3 Totally disagree 23.8

PAGE 58

58 Table 4-3. The relationship of tuberculosis to stereotypes N YES % NO % Only affect poor people 42 21.4 78.6 Only affected people in the past 42 28.6 71.4 Table 4-4. Tuberculosis knowledge in the community TB transmission n Correct % Incorrect % Through the air41 73.2 26.8 With food and water42 40.5 59.5 Sexual relations42 42.9 57.1 Congenital41 46.3 53.7 Bug bites41 53.7 46.3 Person to person42 90.5 9.5 Cure and prevention Can be prevented42 83.3 16.7 Have treatment available42 78.6 21.4 Need treatment to get better42 93 7 Table 4-5. Immigration experience N Totally disagree Totally agree Mean Std. Dev Feel afraid to go to the clinic 42 1 5 1.62 1.306 Had been discriminated by healthcare workers 42 1 5 1.76 1.246 Had been discriminated by employer 42 1 5 1.95 1.361 I feel alone 42 1 5 2.10 1.527 I would have better opp ortunities if I was a non migrant 42 1 5 3.74 1.531 People had made me feel ashamed of my self 42 1 5 2.24 1.511

PAGE 59

59 Table 4-6. Level of comfort in th e contact investigation interview. N Mean Std. Deviation Home 42 3.57 1.129 People I live with 42 3.79 .842 Income 42 3.50 1.065 Work place 40 3.73 1.012 Occupation 40 3.73 1.012 Transportation 42 3.88 .739 Where do you spend leisure time 42 3.62 1.168 With ho do you spend leisure time 42 3.57 1.016 friends 42 3.74 .939 Sexual partners 40 3.23 1.143 Guest at home 42 3.52 .890 Places where they spend the night 42 3.38 .987 Table 4-7. Stigma related with TB regressed on th e likelihood of TB of b een equal to any other problem. The level of stigma related with TB regresse d on the importance attrib uted to tuberculosis. N B R R-square Sig. TB would be a problem as important as any other of my problems 42 .440 .491 .241 .001 Table 4-8. Level of comfort during contact investigati on regressed on the leve l of stigma related with TB, the level of stigma related with the migration experience and the level of knowledge about TB. Level of Comfort during contact In vestigation regressed on the leve l of stigma related with TB, the level of stigma related with the migration experience and the level of Knowledge about TB. N B R R-square Sig. TB stigma 42 -.095 .134 .018 .399 MG experience 42 -.048 ..068 .005 .668 TB Knowledge 42 .078 .209 .044 .184

PAGE 60

60 Figure 4-1. Years of Un ited States residency Figure 4-2. English proficiency

PAGE 61

61 Figure 4-3. Time spend with othe r people from county of origin. Figure 4-4. Visa status

PAGE 62

62 Figure 4-5. Tuberculosis and perceived stigma. (If I have TB it will make me feel bad about myself) Figure 4-6. Likelihood of disclosi ng tuberculosis status. (If I have TB I would tell to my friends, the people I live with, my coworkers?)

PAGE 63

63 Figure 4-7. Distribution of frequencies across CI comfort index values. Figure 4-8. Perceived nega tive migration experience.

PAGE 64

64 Figure 4-9. Perceived TB stigma. Figure 4-10. Distribution of frequenc ies across TB knowledge index values

PAGE 65

65 CHAPTER 5 DISCUSSIONS AND CONCLUSIONS The previous chapters review ed the lite rature regardi ng tuberculosis, TB contact investigation and stigma. The methodology used in this study was described and the results were presented. Chapter five starts with a synops is of each stage of the study, followed by the discussion of results and conclusions drawn from them. The chapter ends with the implications concerning this study and the recommendations for future research. Introduction Generally speaking, tub erculosis control programs in the United States have successfully achieved their goals; however, the slow d ecrease of TB incidence among foreign-born population has prevented tuberculos is control programs to achieve their ultimate goal of TB elimination. The success of these programs de pends on the development of interventions to reach this population. The development of thes e interventions relies on the knowledge that researches could gain referent to specific cultural characteristic s as well as specific implications of these characteristics for TB cont rol for the specific culture. Stigma related with tuberculosis is one of this culture characteristics mentioned in the literature but in need of more research. Statement of the Problem The foreign-born population in the United States has ma intained, as a group, almost the same incidence rate of tuberculosis (TB) during the past decade s. Meanwhile, all other groups within the United States have successfully cont ributed to an overall decrease in these rates (CDC, 2007). The fact that this group is not responding in the same way than others are, suggests that this population may not be appr opriately reached by current approaches for tuberculosis control programs.

PAGE 66

66 Florida is among the top ten stat es with highest incidence rate s of TB. Within Florida, Hillsborough ranks among the top four counties in highest rates of TB. Inside these four counties, Hillsborough has the second highest per centage of foreign-born TB incidence (Bureau of TB and Refugee Health, 2007) Unpublished data from the Bureau of Tuberculosis and Refugee Health of the Florida Department of He alth, suggest that in Florida Mexicans tend to identify fewer contacts during TB contact inve stigation than the average patient. Contact investigation is an inquiry in th e patients network with the pur pose to identify those that could be infected due to proximity with the active TB case. The poor identification of contacts is a characteristic that deserves to be explored as it may be one factor contri buting to the slow decline in TB incidence among this population. A low detection of contacts is likely to reduce the effectiveness of programs aimed to reduce TB incidence rates. Failing to detect these cases in a timely manner may allow the infection to develop into active TB disease promoting further TB spread. However, little is know n about the factors that might in fluence contact investigation and even less is known about TB contact investig ation among Mexican-born populations in the United States. It is needed to determine if stigma is a po ssible cause in low cont act identification during contact investigation. The purpose of this study was to determine if stigma related with TB and immigrant experience affect the likelihood of id entifying contacts during tuberculosis contact investigation in a small Mexican-born communi ty in Hillsborough County in Florida. To investigate this, three hypotheses were included in this study Hypothesis #1: Ha: The higher the perceived level of stigma related with TB the lower the likelihood of identifying contacts during a TB contact investigation

PAGE 67

67 Hypothesis #2: Ha: The higher the level of negative immigrant experience the lower the likelihood of identifying contacts dur ing a TB contact investigation Hypothesis #3: Ha: The lower the level of knowledge about TB the lo wer the likelihood of identifying contacts during a TB contact investigation Review of the Methodology This is a cross-sectional none xperime ntal research. Mixed methods were used throughout the study; quantitative and qualitative data were treated as primary and secondary sources of data, respectively. Qualitative data were us ed by the researcher to better unde rstand the community during the stage of in terpretation of results, and to provide context where it was required during the discussion of the results. The community selected for the study wa s a small church-based community from Hillsborough County in Florida. The snowball sampling strategy (Bernard, 2006) was used to identify the community and the persons who served as cultural brokers. Quantitative data were collected through structured questionnaires. Qual itative data were collect ed through face to face interviews and informal conversations during ch urch activities and othe r social functions; ethnographic interviews of key informants were also conducted. The surveys and interviews guides were designed and conducted by the res earcher. All instrume nts were developed originally in English and translated into Spanis h for its use. A panel of experts integrated by faculty members of the University of Flor ida in the areas of Anthropology, Medical Anthropology, and Biomedicine review ed all data collection instrume nts. The protocol of this study was submitted to the Institutional Review Boar d of the University of Florida and approved prior to data collection. All activities related to collection of data took place in Spanish. The questionnaire contained 53 items distributed in five sections: (a) general knowledge on TB, (b) stigma related to TB, (c) immigrant expe rience, (d) comfort duri ng contact investigation

PAGE 68

68 interview, and (e) demographics. Many of the questions in each sec tion were adapted from similar studies, and are consistent with the instruments commonly used to investigate stigma associated with TB, (Robin Shrestha-Kuwahar a & Joseph, 2002), and contact investigation interview (CDC, 1999, 2005a; Wolman et al., n.d.). Some other questions were developed by the researcher based on theory. A total of 42 participants we re surveyed. The data obtained from these 42 questionnaires were analyzed using SPSS. Descriptive statis tics and simple linear regression were the procedures used to analyze the data. Four inde xes were created, one for the dependent variable (CIC index), and three for independent variab les (TB stigma index, TB Knowledge Index, and MG index). CIC measures comfor t during contact investigation interview, TB stigma measures the perceived stigma related to TB, TB Knowledge measures th e level of knowledge about TB, and MG measures the negative immigrant experien ce. The reliability and validity of each index was tested using Cronbachs Alpha. Interpretation of Results In this study, conducted in Hillsbo rough County in the state of Florida, the participants were mostly young adult females, with low levels of education and low socioeconomic status as compared to the general US population, all members of the Perpetuo Socorro Church. Although most participants reported having long time (more than 5 years) of residence in the United States, they show low English proficiency and limited interaction with people other than from their own country. The majority of partic ipants do not have a legal immigration status. In the CIC Index, almost 60% of the respondents were located above 3.5, where 5 corresponded to the highest level of comfort when being asked by health care professional questions about their personal lives. In the TB stigma Index, th e majority of the respondents (80%) were located below 2.5, where five was the maximum value corresponding to the higher

PAGE 69

69 perception of stigma related to TB. In the TB Knowledge Index, the mean of the sample was 11.18 with a standard deviation of 2.04. The ma ximum value was 15 for the highest level of knowledge about TB, suggesting that the TB knowl edge in this specific community was higher than expected. Finally, in the MG Index, the ma jority of the respondents are located below 3, where five correspond to the worst immigrati on experience suggesting that the negative immigrant experience in this specific community was lower than expected. To test the three hypotheses, the indexes fo r TB stigma, migration experience, and TB knowledge were treated as independent variable s for the Hypotheses 1, 2, and 3, respectively. These indexes were individually regressed against the dependent variable represented by the CIC index. For Hypothesis 1, linear regressi on analysis showed a very we ak negative relationship (Rsquare .018; B -.095); this result was also not sign ificant (p-value=.399). Therefore, it is not possible to conclude that the hi gher the level of perceived stigma related with TB the lower the level of comfort as previously suspected. For Hypothesis 2, linear regression analysis showed also a very weak negative re lationship (R-square .005; B -.048); this result was also not significant (p-value .668). Theref ore, it is not possible to conclude that the higher the level perceived negative immigrant experi ence the lower the level of comf ort as previously suspected. Finally, for Hypothesis 3, linear regression analysis showed a very weak positive relationship (Rsquare .044; B .078); this result was also not sign ificant (p-value .184). Therefore, it is not possible to conclude that the lower the level of knowledge abou t TB the lower the likelihood of identifying contacts during a TB contact Investigation as previously suspected. The results show that in all three cases, the relationship represented by the slope (B) corresponds to the expected findi ngs based on literature. It is possible to observe that the

PAGE 70

70 perceived TB stigma is negatively affecting comf ort during the contact in vestigation interview, which is consistent with previous research that suggested that as TB stigma increases, the level of comfort during the co ntact investigation interview dimini shes (Shrestha-Kuwahara et al., 2003); however this study used qualitative methods only. The non significant p-values of these results could be result of the small sample size used in the study. The relationships observed in these results may be stronger if a larger sample was used. Stigma may not be common enough to be detected in a small sample. The fact that this is a church-based community may have also affected the results. This community receives information related to healt h, and other issues, thro ugh the church. This may promote an increased level of comfort in the interaction with health care professionals. The factor Church Community may be associated with the attenuation of stressors due to religions promotion of social support, a sense of belonging and convivial fellowship (Levin, 1994). This increased sense of belonging and fellowship could enhance the willingne ss to protect their community against any threat, in cluding health threat. One na tural way of pr otecting their community would be to provide ac curate and complete information to health staff in order to prevent further dissemination of a disease. Co mmunity is important, and people would sacrifice their own interests to protect it. The literature suggests that st igma may influence the likeli hood of identifying contacts, however, it is also mentioned that language barriers and cultural insensibility play a role in the process (Shrestha-Kuwahara et al ., 2003). It is possibl e that health care pr oviders serving this community are specialized in the care of immigrant clients; theref ore they are culturally sensitive and Spanish speakers. These characteristics may bring in turn trust, a factor identified as positively affecting the identif ication of contacts (Shres tha-Kuwahara et al., 2003).

PAGE 71

71 When asked to respond whether they agreed or not to the statement that If I had TB it would be as important as any other of my probl ems, the majority of the participants either agreed or totally agreed. The part icipants did not seem to consider TB as something different that any other problem common in their lives. It is important to consider that according to the literature (Link & Phelan, 2001), the society needs to identify a differen ce as important and give it a spec ial category that elevates this difference to a category of label. The results to this question may suggest that participants in the study do not place tuberculosis in a special place and probably the label tuberculosis people do not apply to them. Also, linkage from the la bel tuberculosis people to negative stereotypes may be absent. These results could reflect that in their understandings and in their culture, TB does not have a special place in their lives or th e difference named tuberculosis people is not as special as we imagined. For these participants, tuberculosis may not be different enough from having the flu, or another common disease, that it deserves a label, and most likely will not detonate the chain reaction to negative stereo types and subsequent behavioral respond. Also, when asked if they agreed or not with the statement that TB is a disease of poor people the majority answered that they did not agree, suggesting that th ere is not a perceived association between poverty and th e label of tuberculosis people. These results suggest that even if a label were formulated, poverty, the mo st common stereotype mentioned in the literature linked to tuberculosis (Kelly, 1999 ; Macq et al., 2005), is more like ly not to be present in this community, at this particular time and cultural context. The fact that members of this community spe nd most of the time with people of their own country of origin reflects isol ation from American culture. This factor could protect the

PAGE 72

72 community from perceiving stigma in the way Am ericans do due to the lack of bicultural interaction. When the TB stigma index was regressed ag ainst the answers to the question concerning the relative importance of TB in the lives of the participants, the result was consistent with what was anticipated. Those participants that perc eived TB to be very different in importance compared to any other problem common in their lives also ranked higher on stigma related to TB. This finding is consistent with what the literature on stigma suggests regarding that the difference needs to be important enough to be raise to the category of a label (Goffman, 1963, Link & Phelan, 2001). The qualitative findings suggest that in the co mmunity participants were more concerned about protecting their co mmunity than of the possibility of being isolated for being sick. According to these qualitative findings, it seems th at the community is very loyal and that they will care more about the well being of their own co mmunity than anything else. The participants recognized that they may be subjected to rejecti on but they are not afraid of it because they are confident that over time people will understand, a nd they consider the satisfaction of doing the right thing to protect them more valuable. Also, from the cultural brokers answers was possible to understand that the community is not conc erned about TB, even if they do think sometimes about TB, they have more important things to be worry about; this situa tion makes them to place any health related issues to less important levels. Also, the comm unity is very supportive. They are taking care of themselves sharing all the info rmation they have to facilitate anything among them. Conclusions From the results of this study it can be concl uded that the m embers of the community have high level of knowledge on TB, have low level of stigma related with TB, and in general, they

PAGE 73

73 have a positive migrant experiences. These resu lts also support the th eory on stigma that describes the necessity of identifying a difference to be important for stigma to be present. The results also show that this community does not relate TB with poverty co ntrasting to what is speculated in the literature referent to stigma associated with TB. It can also be concluded that the slopes of the lines with a larger sample may show a stronger association than the observed in this study. That is that as stigma increases the comfort during the interview may d ecrease originating fewer shares of contacts There are findings in this study that suggest that the commun ity is very concerned about their own and that TB as well as other health rela ted issues do not play an important role in their daily life and that their main con cern is to use the time wisely to be able to fulfill their basic economical necessities. Stigma in association to tuberculosis has b een studied from different points of view. Although the presence of stigma on TB has not been studied as much as other diseases such as AIDS it did have its boom during the last decade. Although in academia stigma related to TB is not that common, in the day to day TB clinic ac tivities the term is us ed with relative high frequency. However, the understanding of the word stigma may be different from the clinic to the academic theory. The loose use of the concept may be reflected in research. It is common to find the use of stigma in the lite rature with lack of definition. There are several issues regarding this topic. One is the consta nt use of the word stigma to explain undesirable behaviors from the patients in day to day clinic activities. This use of the word stigma in TB clinic may confound the real pr esence of stigma and the real effect of stigma related to the disease in TB control.

PAGE 74

74 Other aspects may be the discrepancies in th e understanding and in the beliefs that each group may have regarding tuberculosis. These di screpancies may be present between countries, social class or any other asp ect that could modify the group experience and/or the individual experience with the disease. Regarding the identification of contacts it is also possible that many other aspects could be influencing the number of contact identified by a Mexican-born patient. Apart from other cultural, social or language barrie rs, other more simple causes may be present. Perhaps, they do have fewer contacts because they liv e socially isolated. It is also possible that they do not really know the people with whom they work becau se of the high mobility. Although cultural differences may play a huge role in the control of TB, many other reasons may explain this lower identification of contacts of the Mexican-born gr oup compared with other groups in America and not all of those necessarily need to be link to complex cultural differences as it is speculated Implications When I decided to conduct this study, I decided to measure the behavioral response to establish the presence of perceived stigm a; questions regarding status loss and discrimination were included in the instrument. Figure 5.1 repr esents a conceptual model of the process of stigma proposed by Link and Phelan (2001), with the incorporation of c oncepts from the model of culture proposed by Goodenough (1981) and assuming a biocultural interaction as part of the process. According with Link and Phelan, stigma exists when its five components converge: (a) the difference label; (b) the link of the labe ls to stereotypes; (c) the status loss and discrimination; (d) the line between them and us; and (e) the relation ship of power. They propose that this process will be meaningful only in the context of a culture. Culture became important in the sense that the culture of a gr oup will allow a persons operating culture (learned beliefs and values) including the importance attri buted to a difference (label) and the stereotypes

PAGE 75

75 linked to that label. In a bi ocultural interaction among two di fferent cultures of a group both cultures incorporate part of their values and belie fs into the process of learning, resulting in the formation of a single set of values and beliefs for this particular group. This single set of values and beliefs would allow the members of the grou p to share equally the labels and stereotypes associated with it, and therefore, the subsequent behavioral responses. We could define this common group as the Mexican American culture. If these conditions are met the process of stigma could go until the end (behavioral responses) in the shared path. For stigma to exist a relationship of power among both groups inte rvening in the proce ss is also needed. The problem with the conceptual model pr esented in Figure 5.1 is its reliance on the assumption of the existence of a meaningful in teraction between both cultures in the group due to geographical reasons, the Mexican-American cu lture. It did not take into account the possibility of a lack of inte raction among both groups in the processes of learning belief and values. In this study, it was observed that the mi grant members of this community are isolated from the mainstream American culture. This ha s allowed them to maintain a set of values and beliefs very similar to what they originally ha d and, most likely, behavior al responses consistent with it. Figure 5.2 represents how the concep tual model should look wh en a poor interaction between groups is present. In this case, each group has a separate set of beliefs and values which allows for the existence of different labels a nd resulting stereotypes, as well as behavioral responses and other processes. It is important to note that there may be some kind of interaction, because the community is not clos ed to the larger society, which may result in some overlapping of their paths. This means that persons living in the same geographical area may socially interact but may not share culture.

PAGE 76

76 If there were no interactions among both gr oup cultures, each one will follow their own path and characteristics of the process would be independent one from the other. In that case we have to expect that each group will have the elemen ts to initiate the process of stigma and to maintain it. We will also expect that the labels and their asso ciated stereotypes would probably differ from one to the other. Also we would expect that the behavi oral response would not necessarily be the same. If we take in considerati on all these possible scenarios, we can easily understand how difficult it could be to measure stigma especial ly when more than one culture of a group is involved. Recommendations Tuberculosis in the foreign-born population needs to be addressed. Studies that provide direction to the people in charge of the development of interven tion program s in this population are needed. However, stigma rela ted with tuberculosis needs to be clarified. It is necessary to develop models of TB related stigma that allo ws untangling this complex cultural construct. Assumptions regarding the topic need to be put away and a new generation of research explaining stigma, its specific characteristics as well as its implications in the control of TB, need to emerge. Medical anthropologist have the responsibil ity to help the health sector in the understanding of cultural features that make difficult the delivery of health care as well as the control of infectious diseases. If an understanding of stigma is going to occur it needs to be in collaboration with this discipline. This study provi des a model in its first stages that need to be worked out. Socioeconomic and political issues need to be included in the study of stigma. Especially in immigrant populations that hold a story of socio politico and economic disadvantages.

PAGE 77

77 Critical medical anthropologist with their unique theories to expl ain health related disparities supported by Latin-American scholars using socio politic and economic theories may reach to a better explanation in this topic. The understanding of stigma in relation with t uberculosis and it effect in the control of tuberculosis in foreign-born population need to be addressed in a multidisciplinary approach. culture of a group Americans culture of a group Mexicans Persons operating culture Learned beliefs and valueslabel Behavioral responseStatus loss and discrimination Persons operating culture Learned beliefs and values Stereotypes themand us Relationship of power Hierarchy of public culture Cultural Model for Tuberculosis Stigma culture of a group Americans culture of a group Mexicans Persons operating culture Learned beliefs and valueslabel Behavioral responseStatus loss and discrimination Persons operating culture Learned beliefs and values Stereotypes themand us Relationship of power Hierarchy of public culture culture of a group Americans culture of a group Mexicans Persons operating culture Learned beliefs and valueslabel Behavioral responseStatus loss and discrimination Persons operating culture Learned beliefs and values Stereotypes themand us Relationship of power Hierarchy of public culture Cultural Model for Tuberculosis Stigma Figure 5-1. Cultural model for tubercul osis stigma. Biocultural interaction.

PAGE 78

78 Behavioral response themand us culture of a group Mexicans Persons operating culture Learned beliefs and values label culture of a group Americans Persons operating culture Learned beliefs and values labelRelation of power Hierarchy of public culture Persons operating culture Stereotypes Behavioral response Persons operating culture Stereotypes themand us Cultural Model for Tuberculosis Stigma Behavioral response themand us culture of a group Mexicans Persons operating culture Learned beliefs and values label culture of a group Americans Persons operating culture Learned beliefs and values labelRelation of power Hierarchy of public culture Persons operating culture Stereotypes Behavioral response Persons operating culture Stereotypes themand us Behavioral response themand us culture of a group Mexicans Persons operating culture Learned beliefs and values label culture of a group Americans Persons operating culture Learned beliefs and values labelRelation of power Hierarchy of public culture Persons operating culture Stereotypes Behavioral response Persons operating culture Stereotypes themand us Cultural Model for Tuberculosis Stigma Figure 5-2. Cultural model for tuberculos is stigma. No biocultural interaction.

PAGE 79

79 LIST OF REFERENCES Babbie, E. R. (2004). The practice of social research (10th ed.). Belmont, CA: Thomson/Wadsworth. Barrett, R., Kuzawa, C. W., McDade, T., & Arme lagos, G. J. (1998). Emerging and re-emerging infectious diseases: the th ird epidemiologic transition. Annual Review of Anthropology, 27(1), 247-271. Bernard, H. R. (2006). Research methods in anthropology: qualitative and quantitative approaches (4 ed.). Lanham, MD: AltaMira Press. Bureau of TB and Refugee Health. (2007a). 2006 Florida TB incidence rates Florida Health Department. Bureau of TB and Refugee Health. (2007b). 2006 Tuberculosis Fact Sheet, Duval County Available from: URL: http://www.doh.state.fl.us/Disease_ctrl/tb /WorldTBDay/2006/Factsh eets/Fact_SheetDuval06pdf45kb.pdf Bureau of TB and Refugee Health. (2007c). 2006 Tuberculosis Fact Sh eet, Hillsborough County. Available from: URL: http://www.doh.state.fl.us/Disease_ctrl/tb /WorldTBDay/2006/Factsh eets/Fact_SheetHillsborough06pdf45kb.pdf Bureau of TB and Refugee Health. (2007d). 2006 Tuberculosis Fact Sheet, Miami-Dade County. Available from: URL: http://www.doh.state.fl.us/Disease_ctrl/tb /WorldTBDay/2006/Factsh eets/Fact_SheetDade06pdf45kb.pdf Bureau of TB and Refugee Health. (2007e). 2006 Tuberculosis Fact Sheet, Orange County Available from: URL: http://www.doh.state.fl.us/Disease_ctrl/tb /WorldTBDay/2006/Factsh eets/Fact_SheetOrange06pdf45kb.pdf Castillo, M. A. (2001). Tendencias y determinantes estructurales de la migracin internacional en Centroamrica. In L. Rosero Bixby (Ed.), Poblacin del Istmo 2000: familia, migracin, violencia y medio ambiente. San Jos, CR: Centro Centroamericano de la Poblacin de la Universidad de Costa Rica. Centers for Disease Control and Prevention. (1 994-1995). National Health Interview Survey Supplement. Available from: URL: http://www.cdc.gov/nchs/nhis.htm Centers for Disease Control and Prevention. (1 999). Module 6: Contact Investigation for Tuberculosis. In Self-Study Modules on Tuberculosis. Atlanta, GA: U.S. Departme nt of Health and Human Services

PAGE 80

80 Centers for Disease Contro l and Prevention. (2000). Core curriculum on tuberculosis. What the Clinician Should Know (4th ed.). Atlanta, GA: U.S. Department of Health and Human Services Centers for Disease Control a nd Prevention. (2005a). Guidelin es for the Investigation of Contacts of Persons with Infectious Tuberc ulosis: Recommendations from the National Tuberculosis Controllers Association and CDC and Gu idelines for using the QuantiFERON-TB Gold test for detecting Mycobacterium tuberculosis infection, United States. MMWR, 54 (RR-15). Centers for Disease Control and Prevention. (2 005b). Controlling tuberculosis in the United States: recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR, 54(RR-12). Centers for Disease Contro l and Prevention. (2006). Reported Tuberculosis in the United States, 2005. Atlanta, GA: U.S.: Department of Health and Human Services, CDC. Centers for Disease Contro l and Prevention. (2007a). Reported Tuberculosis in the United States, 2006. Atlanta, GA: U.S. Department of Health and Human Services, CDC. Centers for Disease Control and Prevention. (2007b). TB Elimination: Now is the Time! 2007. Available from: URL: http://www.cdc.gov/TB/pubs/ nowisthetime/default.htm Cohen, M. L. (1992). Epidem iology of drug resist ance: implications for a post--antimicrobial era. Science, 257 (5073), 1050-1055. Coreil, J., Lauzardo, M., & Heurtelou, M. (2004). Cu ltural feasibility assessment of tuberculosis prevention among persons of Haitian origin in South Florida. Journal of Immigrant Health, 6(2), 63-69. Dubos, R., & Dubos, J. (1996). The white plague. tuberculosis, man, and society (3rd ed.). New Brunswick, New Jersey: Rutgers University Press. Farmer, P. (1999). Infections and inequalitie s: the modern plagues. Berkeley: University of California Press. Farmer, P. (2003). Pathologies of power: health, hum an rights, and the new war on the poor. Berkeley: University of California Press. Garson, G. D. (1998). Data levels and measurement. Available from: URL: http://www2.chass.ncsu.edu/garson/PA765/datalevl.htm Gentemann, K. M., & Whitehead, T. L. (1983) The cultural broker concept in bicultural education. The Journal of Negro Education, 52 (2), 118-129.

PAGE 81

81 George, D., & Mallery, P. (2003). SPSS for Windows step by step: A simple guide and reference. 11.0 update (4th ed.). Bost on: Allyn & Bacon. Gliem, J. A., & Gliem, R. R. (2003, October). Calculating, Interpreting, and Reporting Cronbach's Alpha Reliability Coeffi cient for Likert-Type Scales. Paper presented at the 2003 Midwest Research to Practice Conferen ce in Adult, Conti nuing and Community Education, Columbus, OH. Goffman, E. (1963). Stigma: notes on the manage ment of spoiled identity Englewood Cliff, N.J.: Prentice-Hall, Inc. Goodenough, W. H. (1971). Cultu re, language, and society. Addison-Wesley Modular Publications, 7, 1-48. Goodenough, W. H. (1981). Culture, language, and society. Menlo Park, CA: Benjamin/Cummings Pub. Co. Hass, F., & Hass, A. S. (1996). The origins of Mycobacterium tuberculos is and the notion of its contagiousness. In W. N. Rom & S. Garay (Eds.), Tuberculosis (pp. 3-19). Boston, Mass: Little, Brown and company. Hillsborough County Planning Commission. (2005). Hillsborough evaluation and appraisal report. Available from: URL: http://www.theplanningcommissi on.org/hillsborough/hillsboroughear Hudelson, P. (1996). Gender differentials in tuberc ulosis: the role of socio-economic and cultural factors. Tubercle and Lung Disease, 77 (5), 391-400. Jaccard, J., & W an, C. K. (1996). LISREL approaches to interaction effects in multiple regression. Thousand Oaks, CA: Sage Publications. Jaramillo, E. (1999). Tuberculosis and stigma: predictors of prejudice against people with tuberculosis. Journal of Health Psychology, 4 (1), 71-79. Johansson, E., Diwan, V. K., Huong, N. D., & Ahlb erg, B. M. (1996). Staff and patient attitudes to tuberculosis and complianc e with treatment: an explorat ory study in a district in Vietnam. Tubercle and Lung Disease, 77 (2), 178-183. Joseph, H. A., Waldman, K., Rawls, C., Wilce, M., & Shrestha-Kuwahara, R. (2007). TB perspectives among a sample of Mexicans in the United States: results from an ethnographic study. Journal of Immigrant and Minority Health 10(2), 177-185. Kelly, P. (1999). Isolation and stigma: the experience of patients with active tuberculosis. Journal of Community Health Nursing, 16 (4), 233-241.

PAGE 82

82 King, M., Dinos, S., Shaw, J., Watson, R., Stevens, S., Passetti, F., et al. (2007). The stigma scale: development of a standardized measure of the stigma of mental illness. The British Journal of Psychiatry, 190(3), 248-254. Levin, J. S. (1994). Religion and health: is there an association, is it valid, and is it causal? Social Science & Medicine, 38 (11), 1475-1482. Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27 (1), 363-385. Long, N. H., Johansson, E., Diwan, V. K., & Winkvist, A. (2001). Fear and social isolation as consequences of tuberculosis in Vietnam: a gender analysis. Health Policy, 58 (1), 69-81. Macq, J., Solis, A., Martinez, G., Martiny, P., & Dujardin, B. (2005). An exploration of the social stigma of tuberculosis in five "municipios" of Ni caragua to reflect on local interventions. Health Policy, 74 (2), 205-217. Maio, T., Mohlman, G., & Capanna, D. (1998). Hillsborough County Historic Resources Survey Report Tampa, FL: Hillsborough County Planning and Growth Management. Manderson, L. (1998). Applying medical anthropol ogy in the control of infectious disease. Tropical Medicine and International Health, 3 (12), 1020-1027. Menegoni, L. (1996). Conceptions of tuberculosis and therapeutic choices in highland Chiapas, Mexico. Medical Anthropology Quarterly, 10 (3), 381-401. Ott, K. (1996). Fevered lives: tuberculosis in American culture since 1870 Cambridge, Mass.: Harvard University Press. Porter, J., & Kessler, C. (1995). T uberculosis in refugees: a negl ected dimension of the global epidemic of tuberculosis. Transactions of the Royal Society of Tropical Medicine and Hygiene, 89 (3), 241-242. Poss, J. E. (1998). The meanings of tuberculosis for Mexican migrant farmworkers in the United States. Social Science & Medicine, 47 (2), 195-202. Reichler, M. R., Reves, R., Bur, S., Thomps on, V., Mangura, B. T., Ford, J., et al. (2002). Evaluation of investigations conducted to detect and prevent transmissi on of tuberculosis. JAMA, 287 (8), 991-995. Selltiz, C., Wrightsman, L. S., & Cook, S. W. (1976). Research methods in social relations. New York: Holt, Rinehart and Winston. Shrestha-Kuwahara, R., & Joseph, H. (2002). Perceptions of tuberculosis (TB) among foreignborn persons: an ethnographic study. CDCsponsored project. Available from: URL: http://www.findtbresources.org/script s/index.cfm?F useAction=Behavioral

PAGE 83

83 Shrestha-Kuwahara, R., Wilce, M., DeLuca, N., & Taylor, Z. (2003). Factors associated with identifying tuberculosis contacts. International Journal of Tu berculosis Lung Disease, 7(3), 510-516. Tabachnick, B. G., & Fidell, L. S. (1989). Using multivariate statistics (2nd ed.). New York, NY: Harper & Row, Publishers, Inc. University of South Florida. (2001). Hillsborough community atlas: interactive mapping. Available from: URL: http://maps.communityatlas.usf.edu/h illsborough community/index.asp?id=12057&level= cnty Unterberger, A. G. (2005). The Guanajuato-Florida connection: a binational study on health status and the United Stat es-Mexican migration. University of Florida, Gainesville, FL. Van Brakel, W. (2006). Measuring health -related stigma-A literature review. Psychology, Health & Medicine, 11(3), 307-334. Westaway, M. S. (1989). Knowledge, belie fs and feelings about tuberculosis. Health Education Research, 4(2), 205-211. World Health Organization. (2007). Tuberculosis. Fact sheets Available from: URL: http://www.wpro.who.int/media_ centre/fact_sheets/fs_20060829.htm World Health Organization. (2008). World health organization repor ts highest rates of drugresistant tuberculosis to date. TB news. Available from: URL: http://www.who.int/tb/features_archive /drsreport_launch_26f eb08/en/index.html Wol man, M., Bhavaraju, R., Napolitano, E., & Kantor, D. (2000). Performance guidelines for contact investigation: the TB interview. Newark, NJ. New Jersey Medical School Global Tuberculosis Institute.

PAGE 84

84 BIOGRAPHICAL SKETCH Paula C. Hamsho-Diaz was born in Veracruz, Mexico, on June 1st, 1972. She obtained a professional medical degree from the Universidad Veracruzana in 2001. Before moving to Gainesville, Florida, she worked at an NGO dedicat ed to assisting HIV/AI DS patients and at the Universidad Veracruzana. Paula has been a Grad uate Research Assistance at the South Eastern National Tuberculosis Center (SNTC) providing critical support in activities involving Puerto Rico and other Spanish speaking initiatives and as sisting the SNTC in the translation of various CDC and other materials. She also contributed to the development of the new international initiative at the SNTC. She star ted the Master of Arts degree in Latin American studies at the University of Florida in 2006. Her program wa s concentrated in an thropology with special emphasis on medical anthropology; she also comple ted a Public Health Certificate during this period. After graduation, she will continue working at the SNTC.