Culturally Specific Health Care Model for Ensuring Health Care Use by Rural, Ethnically Diverse Families Affected by HIV/AIDS

Because of barriers such as lack of transportation, distrust of health care providers, inability to pay for medical treatment, and difficulty comprehending the serious nature of illness or disease, the health care utilization of poor rural families is relatively low. Among poor rural families, people of color additionally face cultural barriers that stand between them and health care (Darrow, 1987; Flaskerud & Rush, 1989; Navarro, 1992). The problem of low utilization of health care becomes particularly urgent when HIV is diagnosed, requiring specialized, frequent, and intensive medical care. Poor rural people of color die sooner from HIV/AIDS because they are less likely to seek the early treatment and intervention that can decrease the disease's severity and related health problems (Ellerbrock et al., 1992; Lee, 1995; Miller, Turner, & Moses, 1990; Shelov, 1994). Even when the diagnosis is made early, denial, fear, and despair work together in a "panic stage" to promote confused behaviors that become further barriers to health care (Des Jarlais, 1990; Des Jarlais, Friedman, & Sotheran, 1992; Krieger, 1988; Kubler-Ross, 1969; Sontag, 1990). Tragically, health care providers who lack knowledge and understanding of their clients' lifestyles and experiences contribute to the low utilization of health care among poor rural people of color. HIV is transmitted through individual behaviors formed within the context of ethnic culture and beliefs, and health care providers must understand and respect clients' cultural values and beliefs and develop indigenous paradigms for treatment. This article presents such a model, the culturally specific health care model (CSHCM), and illustrates how an interdisciplinary group formed to work in partnership with indigenous providers to meet a crisis. BACKGROUND During the early days of the AIDS epidemic, when the incidence was high in San Francisco and New York City, Belle Glade - a small rural town in the far southern tip of Florida - gained national attention for the high incidence of AIDS among its inhabitants. This small rural town had a cumulative AIDS incidence of 295 per 100,000 people, a rate comparable to that of San Francisco (316 per 100,000) and the borough of Manhattan in New York City (270 per 100,000). Belle Glade was the base for the migrant labor stream on Florida's eastern seaboard. Although the Glades region (including the towns of Pahokee, South Bay, Canal Point, and Belle Glade) was one of the nation's highest revenue-producing sites, its residents - migrant, foreign, and quota workers - were at a disadvantage because of their cultural diversity and underemployment. These migratory and seasonal workers harvested vegetables and sugar cane. This population is not counted by the federal census but has been identified as a group at increased risk of AIDS (Goicoechea-Balbona, 1994; Goicoechea-Balbona & Greif, 1992; Wilkinson, 1989) (Table 1). The 1980 census data indicated that the rural town's total population of 16,536 was 51.6 percent black, 29 percent white, 18.6 percent Hispanic/Latino, 0.03 percent Native American, and 0.15 percent other ethnicities. Annual incomes of families living in rental housing among Belle Glade's three major ethnic groups were as follows: white households, $17,533; Hispanic households, $12,478; and black households, $5,720. The proportion of African Americans with AIDS whose incomes were below the poverty level was high, suggesting a link between AIDS and poverty in Belle Glade and throughout Western Palm Beach County ("Acquired Immune Deficiency Syndrome," 1986; Castro et al., 1988; Goicoechea-Balbona, 1989, 1990, 1994; Goicoechea-Balbona & Greif, 1992; State of Florida, 1987; U.S. Bureau of the Census, 1981). The author's interest in this migrant rural community began in 1982. Preliminary information I gathered from informal interviews conducted from 1982 through 1986 assured me of this community's significance in the AIDS epidemic. …