Integrating Qualitative and Quantitative Methods in the Study of Bilingual Code Switching

©2002 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.

MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016

SUBSTANCE USE & MISUSE

Vol. 38, No. 1, pp. 1–24, 2003

Integrating Qualitative and Quantitative

Methods: Comparing HIV-Related Risk

Behaviors Among Puerto Rican Drug Users

in Puerto Rico and New York

S. Deren, Ph.D.,1,* D. Oliver-Velez,1 A. Finlinson, Ph.D.,2

R. Robles, Ed.D.,2 J. Andia, Ph.D.,1 H. M. Colon, Ph.D.,2

S.-Y. Kang, Ph.D.,1 and M. Shedlin, Ph.D.1

1National Development and Research Institutes, Inc.,New York, New York, USA

2Universidad Central Del Caribe, Centro de Estudiosen Adiccion, Bayamon, Puerto Rico

ABSTRACT

A dual site project was conducted to assess determinants of injectionand sex-related risk behaviors among Puerto Rican drug users. Theproject focused on injection drug users and crack smokers, and was

conducted in East Harlem, NY and Bayamon, PR in 1996–2000.

*Correspondence: Sherry Deren, Ph.D., National Development and Research

Institutes, Inc., Center for Drug Use and HIV Research, 71 West 23rd St., 8thFloor, New York, NY 10010, USA; E-mail: [email protected].

1

DOI: 10.1081/JA-120016563 1082-6084 (Print); 1532-2491 (Online)

Copyright & 2003 by Marcel Dekker, Inc. www.dekker.com

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Qualitative methods included ethnographic mapping, focus groups,in-depth interviews, and observations. A survey component (East

Harlem, n¼ 800; Bayamon, n¼ 400) was also conducted. Proceduresto ensure integration of methodologies and comparability of datawere developed. This paper describes the qualitative and survey

methods used, and presents the comparative HIV risk behaviors.The integration of the two methodologies served multiple functions:each component identified issues to be addressed in the other,enhanced cross-site comparability of data, and assisted in interpreta-

tion of findings. The survey data showed high levels of risk behaviorsin both communities, with significantly higher levels of risk reportedin Bayamon. Conducting studies of similar ethnic groups in different

communities provides opportunities to examine diverse sources ofinfluence on risk behaviors. The integration of qualitative and quan-titative methods can enhance comparability and understanding of

findings, particularly when there are differences in behaviors betweencommunities.

Key Words: Qualitative and quantitative methods; Puerto Ricandrug users; Injection drug users (IDUs); Crack users.

INTRODUCTION

Hispanics have been disproportionately affected by the HIV/AIDSepidemic in the United States since early in the epidemic (1). TheHispanic community in the United States accounts for 9% of the popula-tion, but 19% of the cumulative AIDS cases through December 1999 (2).Puerto Rican drug users have been identified as a group at especially highrisk for HIV transmission (3,4). Injection drug use has been identified asthe primary risk behavior among Puerto Ricans (5–7). In addition,geographical differences as well as mobility of drug users must also beconsidered in examining risk behaviors among Puerto Ricans (8).

The largest concentration of Puerto Ricans outside of the island is inthe northeast, especially in the New York City area (9). Travel betweenthe island and New York is common, and has been identified as impor-tant to consider in understanding and developing health care-relatedinterventions (10). Studies on injection drug users (IDUs) in both loca-tions have indicated high HIV seroprevalence rates in both communities,approximately 40–50%(11) during the late 1980s and early 1990s.Furthermore, differences in injection-related risk behaviors (e.g., injec-tion frequency, sharing injection paraphernalia) and sex risk behaviors

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have been reported among Puerto Rican injectors and crack smokers inPuerto Rico compared to those in New York in the late 1980s and early1990s (11,12). Seroprevalence rates among crack users of approximately15% have been reported in both communities (13).

A dual site project, utilizing both qualitative and quantitative meth-ods, was undertaken in New York and Puerto Rico to help understandthe differences in risk behaviors between the two sites. This project,Alliance for Research in El Barrio and Bayamon (ARIBBA), provideda unique opportunity to study the same ethnic group in two socioculturalcontexts. The anticipation of substantial differences in environmental aswell as sociocultural influences led to the use of qualitative and quanti-tative methodologies. Despite a growing recognition of the advantages ofconducting integrated qualitative and quantitative research (14), and theavailability of some models of how this has been successfully accom-plished (15,16), this integration has been infrequently reported in theliterature. The primary goal of this paper is to provide a description ofthe qualitative and quantitative multiple methods used in the ARIBBAstudy, with examples of how they enhanced comparability of findings aswell as how the methods were integrated. In addition, for illustrativepurposes, a summary comparison of characteristics of respondentsrecruited for the survey in the two locations, including sociodemographiccharacteristics and injection and sex risk behaviors, is provided.

METHODS

Description of Locations

The project was conducted in East Harlem, New York andBayamon, Puerto Rico from 1996–2000. Teams of experienced research-ers, who had previously conducted HIV-related research in these com-munities, were established in the two sites. East Harlem (also known as ElBarrio and Spanish Harlem), a densely populated area in the northeast-ern area of Manhattan, has about 110,000 residents and covers approxi-mately three square miles. It has one of the highest total cumulativeAIDS rates in New York City, with 4594/100,000 (17). The municipalityof Bayamon, located southwest of San Juan (and part of the San Juanmetropolitan area), contains approximately 220,000 people, and iscomposed of 45 square miles of sprawling, primarily urban environments.Puerto Rico has the fourth highest AIDS incidence rates among statesand possessions (2).

HIV Risk-Related Behavior Comparison 3

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Qualitative Component

Each site had an ethnographic team, consisting of a senior ethnogra-pher and an outreach worker/ethnographic assistant. These individualswere familiar with their communities, having engaged in HIV- and drug-related research in their respective communities formore than 10 years, andthe outreach/ethnographic assistants were indigenous community mem-bers. An ethnographic consultant met with the ethnographers on bothteams, and helped coordinate efforts across sites, e.g., in facilitating jointdevelopment of all data collection guides, includingmapping, focus group,observation, and interview guides. While the intensive qualitative datacollection was focused during the first year of the study, some qualitativecomponents (including follow-up interviews and observations to notechange in the community) were conducted throughout the study period.

Mapping the Research Sites

Efforts to become familiar with the entire geographical areas initiallydesignated for the study were initiated early in the project. One focus ofthe ethnographic mapping was the development of recruitment and studysites, which would encompass a variety of drug-using areas, and be fea-sible for recruitment. This effort, conducted by car and then in detail onfoot, resulted in identifying specific sectors within each community forrecruitment (18), including a smaller, more manageable geographicalarea for recruitment in Bayamon. In addition to identifying the researcharea boundaries, mapping guides, developed jointly by the ethnographicteams, also helped identify locations of drug selling and buying, needleexchange programs, and other venues for future observations and surveyrecruitment. Mapping also initiated the process of identifying environ-mental differences and similarities between the two locations. Althoughdetailed mapping information was conducted only during the first year ofthe four-year project, since the mapping teams included members of theoutreach staff recruiting research participants, notes were maintained onany changes in the community that occurred throughout the study period.

Focus Groups

Five focus groups were conducted at both sites with specific sub-groups that could inform the research questions (crack-using women,

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male IDUs, gay (MSM) drug users, recovering drug users) and withoutreach personnel who were in direct contact with the target popula-tions. Approximately 7–10 individuals were recruited by the ethno-graphic field staff to participate in each focus group, and they werepaid $20 for their time. As part of the informed consent, participantsin the focus groups, as in the other qualitative components, were toldabout the study and that their participation would be helpful in enhanc-ing the study understanding of HIV risk in the two communities. Thesefocus groups helped identify cross-cultural differences and provideda first look at the ‘‘emic’’ perspective (concepts and categoriesthat are relevant to the culture under analysis) (19). All focus groupswere taped, and transcriptions were reviewed for accuracy by thequalitative team.

Field Observations

Direct observations of field locations were conducted in drug-buyingand selling areas, indoor and outdoor injection locations, and of serviceproviders (NEPs, drug programs, and AIDS outreach groups). Thesedirect observations provided an ‘‘etic’’ perspective (analytical researchers’view)(19) of the target population in their environment rather than in aresearch setting. Field notes were collected by all members of the ethno-graphic team and were entered into the infobases for analysis (seequalitative data analysis below).

Qualitative Interviewing

In-depth interviewing was conducted with two different populations:Targeted ethnographic interviews (TEIs) were conducted (10 in

Puerto Rico/11 in New York) using open-ended interview guides explor-ing the emic perspective of the subjects’ drug use; sexual history; child-hood; migration patterns; health care; social, familial, and drug-usenetworks; as well as their feelings about and knowledge of HIV/AIDS.Male and female IDUs and crack smokers were recruited in each locationby outreach personnel. These interviews were conducted during the firstyear of the study (baseline TEls), and follow-up TEIs were conductedapproximately one year later (to understand changes that occurred in theinterim that impacted on risk behaviors). Baseline TEIs often required


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two sessions to complete and follow-up TEIs were completed in onesession (all interviews required approximately 1.5 h). Participants werepaid $20 per interview for their time.

Key informant interviews were conducted with community leaders,service providers, and community persons involved in HIV/AIDS anddrug treatment, care or law enforcement (nine in each location) toenhance knowledge about the environmental and historical variablesimpacting the study population.

Qualitative Data Analysis

The focus group and interview transcripts and field notes wereanalyzed using Folio Views 4.0 (Folio Corporation, Provo, UT). Thissoftware program permits the creation of ‘‘infobases’’ which are notlanguage-specific, so they allow access to data in Spanish, English,and street jargon. All of the transcripts from both locations were usedto build one qualitative database, shared by the ethnographers fromboth sites. Folio search engines eliminated the need for extensivecoding and provided instant access through its advanced query functionto all references in the transcripts in both English and Spanish and‘‘Spanglish’’ (street Spanish). Multiple infobases were constructedaccording to the particular analysis needed, e.g., separate infobases offocus group data, interviews, and open-ended survey data responseswere constructed, and a master infobase of all data, including fieldnotes, focus groups, and TEIs from both sites was made available toboth teams of researchers. Ethnographic analysis was conducted usingannotated infobases, which could be e-mailed between the ethnographersand updated as data collection proceeded. Analysis of the infobases wasconducted thematically using keywords extracted from the interviewguides, survey instruments, and texts, and permitted within-site as wellas cross-site comparisons.

Survey Component

A survey was conducted of 1200 Puerto Rican IDUs and cracksmokers, consisting of 800 in New York and 400 in Puerto Rico.Locations for recruitment were developed based on the qualitative map-ping. Recruitment of subjects for the survey occurred between January1998 and August 1999.

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Recruitment of Survey Participants

Each of the two communities was divided into recruitment sectors(three in Bayamon and five in East Harlem) based on ethnographic map-ping(18) to ensure that recruitment occurred from a range of drug ‘‘cop-ping’’ and using locations. Sectors for daily recruitment were randomlyselected within each site, and recruitment was undertaken by a male/female outreach team in East Harlem, and, alternately, by male andfemale recruiters in Bayamon (budget limitations precluded a two-member team in Bayamon). Outreach staff were indigenous communitymembers who had been engaged in prior HIV and drug-related researchin these communities. Criteria for recruitment included: (a) aged 18 orover; (b) self-report as Puerto Rican; (c) injected drugs or smoked crackwithin the prior 30 days, and recent use of heroin or cocaine (verificationof recent [prior 48 h] drug use by urinalysis, for either heroin or cocainemetabolytes, was required [using Roche ONTRAK]). After recruitmentin the community, subjects were brought to the field site in each location,where recent drug use was verified and an informed consent obtained.The computer-assisted baseline interview was then conducted (averageduration approximately 1.5 h) by trained interviewers. Subjects werepaid $15 for the baseline interview.

Interviewing

The interview included sections on a wide variety of possible influ-ences on risk behaviors, including items to assess characteristics relatingto demographics, psychological (e.g., depression), social (e.g., networks),health-related (e.g., HIV status), cultural (e.g., migration) and environ-mental (e.g., NEP availability) variables. Detailed information on currentdrug use, as well as drug use and drug user treatment histories, werecollected. In addition, participants were asked about risk behaviors forthe prior 30 days. Subjects were also informed that they would be con-tacted for a six-month follow-up interview. A total of 1200 baseline inter-views were conducted, 800 in New York City and 400 in Puerto Rico.After the interview, subjects received HIV pretest counseling and wereoffered HIV testing (using ORASURE, Epitope Inc., Beaverton, OR).Subjects who were tested were given an appointment approximatelyone week later to return for HIV test results and to receive posttestcounseling.


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Ensuring Comparability of Findings

Issues arising in multisite research, which had to be addressed becausethey could interfere with ensuring comparability of findings, were identi-fied at the outset of the project and included: (a) need to standardizemeaning of terms, or identify different terms with comparable meanings,especially those related to risk and protection behaviors; (b) importance ofassessingmacro-level environmental differences (e.g., availability of NEPs,drug user treatment programs, and other resources for risk reduction);(c) ensuring comparability of survey data collection methods (18,20).

Multiple methods were used to ensure comparability of proceduresfor data collection and comparability of findings, including extensivequalitative research at the start-up phase to inform all instruments,joint development of instruments, and cross-site visits.

Qualitative Research at Start-Up

The ethnographic mapping undertaken during the first few monthsof the project was conducted to begin gaining familiarity with distinctivefeatures of the sites as well as identify areas for subject recruitment (18).For example, staff visited shooting galleries in both locations, and learnedthat there were differences in the locations (indoor, outdoor), size, andmaterials (for risk reduction) found at shooting galleries in each location.This provided the context to help understand the different levels of riskbehaviors that may be likely for those who reported using shootinggalleries in the survey data.

All elements of the qualitative component also helped identify con-tent areas and specific terminology to be used in the survey instrument.The latter was particularly important since the instrument was to bedeveloped in Spanish and English, and the Spanish version, developedprimarily for use in Puerto Rico, required some changes in terminologyto convey the same meaning in ‘‘Spanglish’’ for the New York partici-pants who preferred being interviewed in Spanish.

Joint Development of Instruments

All qualitative instrument guides and the survey instrument werejointly developed. To ensure comparability of the qualitative information,guides were developed for all components, including mapping, observa-

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tions, TEls, and key informant interviews. The joint development ofinstruments required several steps, including (a) discussions among allstaff regarding general content areas and identification of specific instru-ments; (b) more detailed discussions among those developing the specificinstrument (e.g., ethnographers for the qualitative data collection guides,survey research staff for the survey component); (c) development of draftinstruments; (d) piloting in each site; and (e) subsequent discussion andfinalization of instruments. Once instruments were developed, trainingof local staff was required. Standardization of data collection in terms ofhow instruments were used or administered involved cross-site visits.

Cross-Site Visits

Cross-site visits by all staff, including interviewers, outreach workers,ethnographers, and project managers, were critical to enhancing datacomparability. Interviewers ‘‘sat-in’’ on each other’s interviews (withthe subjects’ consent). This permitted the identification of differences inhow questions were asked, and discrepancies were resolved. Visits byoutreach workers, who were part of the ethnographic teams at bothsites, enhanced understanding of differences in contextual conditions,as well as developed standardization of the use of observation guides.Visits by the project management (one per year at each site) were used fordiscussion of management and methodological issues, to ensure compa-rability of data collection procedures (e.g., subject recruitment methods),and to provide the opportunity to become familiar with local conditions.In addition, these two-day planning meetings allowed the ethnographicand survey teams from both locations to discuss emerging issues, find-ings, and any modifications in project methods or content areas. Cross-site visits by ethnographers (one per year at each site) were more exten-sive, averaging three to four days at each site, and involved conductingjoint observations of the research sites. This was deemed as particularlycritical, since some important differences might be identified only whenmaking comparisons with the other location.

Interactions Between Qualitative and Survey Components

A unique aspect of this project was that the qualitative and surveycomponents were conducted in a bidirectional and parallel fashionthroughout all phases. At the outset, qualitative research provided a


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context for interpreting findings from the survey; subsequently, surveyresearch findings were used to corroborate phenomena identified throughqualitative methods. In many studies, qualitative and quantitativeresearch paradigms are seen as focused on inductive methods (for dis-covery) and deductive methods (for validation), respectively (21,22). Anunusual aspect of the ARIBBA project was that both methods operatedparallel to each other throughout the project, and each identified findingsor unusual issues to examine in the other method, for corroboration.Hence, both methods provided both discovery and validation for theother. As noted by Donovan et al. (23), quantitative research on HIV-related risk behaviors is difficult to turn into useful interventions withoutqualitative research, which is helpful in understanding the individuals,their social context, and the meaning they ascribe to their behaviors.

Input from the results of the qualitative component helped identifyspecific topic areas as well as language to utilize. For example, the qua-litative team noted that based on their observations and interviews, druginjectors may engage in higher-risk injection practices during the firstinjection episode of each day; this led to the development of detailedquestionnaire items regarding the most recent day during which the sub-ject injected, to obtain information regarding the difference in risk beha-vior between the first injection episode and subsequent injection episodesthat occurred on that day. In addition, subsequent to the initiation ofinterviewing, the ethnographic teams identified the widespread practice of‘‘caballos,’’ the pooling of money to buy drugs, and its association withdrug sharing as a potential source of riskier injection behavior. As aresult, a section with additional questions regarding details of the mostrecent injection day, including questions regarding pooling of money anddrug sharing, was added to the follow-up interview.

Focus groups and survey interviews pointed to a reduction in ‘‘shoot-ing gallery’’ use in New York City; however, in the focus groups and thequalitative interviews it became clear that it was important to clarify theparticular terminology used to describe these types of multiperson injec-tion locations. While shooting galleries, per se, were reported to havedeclined, other venues for multiperson injection, which were locationswhere risky behavior potentially could occur, were identified in the qua-litative component, e.g., single room occupancy hotels (SROs) inNew York City. For example, the following was collected in a focusgroup of male IDUs:

Years ago they use to have shooting galleries. Now theydon’t have that because they got this needle exchange. . . .

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No galleries that I know of. There may be some, but veryfew. . .. I think it’s better now with the needle exchange, itmore safety for everybody now.

(Lou)

The following data emerged in a focus group of outreach workers:‘‘You don’t find too many indoor galleries anymore’’ (Lydia).

‘‘I do volunteer work on needle exchange, and I service three hotelsdown 110th, 111th, and 94th Street these are SROs and those are shoot-ing galleries, even though they’re SROs they’re like MAJOR shootinggalleries now’’ (Mikki).

These data accomplished two things: (a) they corroborated surveydata in New York City indicating declines in shooting gallery use, andindicated that this was in part related to needle exchange use; and (b) theyresulted in the development of a specific definition of the types of beha-vior to describe when we asked about any ‘‘shooting gallery’’ use, e.g.,‘‘a place regularly used by people to inject, where injection paraphernaliaare provided and there is some payment (either in money or drugs) for theuse of the place.’’

Observations in New York identified the existence of Puerto Ricanswho had recently come to the New York area from Puerto Rico, resided inshelters, and were seen practicing risky injection at outdoor sites. This ledto examination of the category of ‘‘newcomers’’ in the survey data, andcomparisons of their risk behaviors with otherNewYork participants (24).

Findings from the qualitative component also helped guide analyses.For example, two of the participants in follow-up ethnographic inter-views in New York had entered methadone treatment since their baselineinterview. Reports of improvements in areas related to HIV risksincluded becoming domiciled and more regularly taking HIV medication.This report led to conducting analyses regarding enrollment in metha-done treatment and the examination of a wide variety of behaviors fromthe survey data (25). In addition, the importance of easy access toservices, which emerged in the qualitative interviews, led to additionalquestions and analyses of data based on proximity of services. Qualitativedata on the importance of proximity of services can be illustrated by thefollowing quote from Juanito, an injector who was interviewed inNew York and who had spent most of his drug-using life in a smalltown in Puerto Rico with no access to methadone treatment:

If, if they would put a, a methadone maintenance programin Loiza and a needle exchange program I think it would


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help a lot. I really think so. You know what ‘cause, mm, themethadone management program they got in Puerto Rico isin Rio Piedras, it’s called Desca. Now imagine a dope fiend,you know, that’s just, you know, he’s broke all day causehe’s, he, got to depend on going to a spot and trying to pitchsomething (sell drugs), you know, so he could get his kick.Now imagine you trying to get five dollars to get in a guaguapublica (public jitney bus) to go all the way to Rio Piedrasto get medicated to come back to Loiza. Come on man, forthat, I just take the five dollars and do a bag and that’s it,you know. So, if they do put a methadone maintenanceprogram in the pueblo in Loiza then I see a lot of addictsgoing to it.

(Juanito)

There were also instances where data from the quantitative com-ponent were explained by qualitative findings. For example, analysesof survey data on sex-related risk behaviors (see Table 3) led to afinding that female drug users in Puerto Rico seemed to have greateraccess to condoms than males. Ethnographic observations in PuertoRico helped explain this difference by noting that despite the limi-tations in free distribution of condoms, when they are distributed,they are often targeted for female sex workers. Another examplerelates to the findings of the significant differences in residentialstatus between the two locations (see Table 1). The survey datafound that many more of the participants recruited in Puerto Ricowere likely to live with their parents, and that residing either withparents or being homeless was found to be related to higher injec-tion-related risk behaviors (e.g., using shooting galleries and sharinginjection paraphernalia). The ethnographic interviews and obser-vations provided a more complete understanding of why theseparticular residential statuses were related to higher risks (e.g.,no access to private room in which to inject, increased comfortand safety for those who have their own residence in which touse drugs) (26).

As noted above, it is particularly important to include qualitativemethods in dual- or multisite studies, when large differences in riskbehaviors are likely to emerge, and a wide range of explanatory factorsmay be necessary to help understand these differences. Below is a briefsummary of some of the findings from the survey instrument, includingdemographics and risk behaviors.

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Descriptions of the Survey Samples and Risk Behaviors

Approximately three-quarters of the ARIBBA survey participants inboth locations were male, and the New York sample was significantlyolder (38 years old vs. 33, p<0.001) (see Table 1). More than half (52%)

Table 1. Selected socio-demographic characteristics of Puerto Rican injectors

and crack smokers in New York City and Puerto Rico.

NYC(n¼ 800)

PR(n¼ 400)

Significancelevela

DemographicsGender (male) 73% 79% <0.05Age (mean) 38 33 <0.001

Birthplace <0.001New York 45% 11%Puerto Rico 52 86Other 3 3

Education <0.05<High school 62% 54%High school or above 38 46

Marital status <0.05Single 46% 49%Married or common law 26 19

Separated/divorced/widowed 28 32Residential status <0.001Parent’s house 13% 43%

Own house 31 15Other’s house 25 19Temporary housing 10 3

Ever in jail/prison (total) 87% 74% <0.001

Income (prior 30 days) <0.001<$500 37% 39%$500–$999 38 26

>$999 25 35Recruitment groups <0.001Injection drug user (IDU) 39% 53%

Crack user 30 22Both IDU and crack user 31 25

aChi square tests were used for categorical data; t-tests were used for

continuous data.


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of the New York sample was born in Puerto Rico; of those recruited inPuerto Rico, the great majority (86%) were born there. A significantdifference was also found in education level, with more of those recruitedin Puerto Rico having a high school diploma or higher (46% comparedwith 38%, p<0.05). Residential status at recruitment was significantlydifferent, with close to half (43%) of the Puerto Rican sample living intheir parent’s home, compared with 13% in New York (p<0.00l).Jail/prison experience was reported by 87% of the New York group,compared with 74% in Puerto Rico (p<0.00l), and twice as many‘‘New Yorkers’’ reported having been in jail or prison in both locations.

As noted in the Methods section, recruitment was based on currentdrug use, IDU or crack, and overall, a higher percent recruited in PuertoRico were IDUs (78% vs. 70%, p<0.00l). The data on injection-relatedrisk behaviors (see Table 2) indicate significant differences on eachvariable (p<0.00l) with the direction of greater risk in all cases foundin the sample recruited in Puerto Rico.

Table 2. Injection-related risk and protective behaviors for Puerto Rican IDUsin New York City and Puerto Rico (prior 30 days).

NYC(n¼ 561)

PR(n¼ 312)

Significancelevela,b

Times injected 76 183 <0.001Number of days injected 19 27 <0.001Used indoor or outdoor shooting gallery 23% 79% <0.001

Shared other’s needles/syringes 7% 20% <0.001Shared needles/syringes w/others 8% 31% <0.001Shared other’s cotton 18% 36% <0.001

Shared your cotton w/others 24% 54% <0.001Shared other’s cookers 7% 34% <0.001Shared your cookers w/others 10% 52% <0.001Shared other’s rinse water 9% 23% <0.001

Shared your rinse water w/others 10% 33% <0.001Any sharing of paraphernalia w/others 28% 70% <0.001Any sharing of other’s paraphernalia 23% 53% <0.001

Any sharing, either direction 34% 74% <0.001

aChi square tests were used for categorical data; t-tests were used forcontinuous data.bAll comparisons remained statistically significant, at p<0.001 after controllingfor sex and age in multivariate analyses.

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Frequency of injection was 183 times (in the prior 30 days) in PuertoRico, compared with 76 in New York. Use of ‘‘shooting galleries’’ wassignificantly higher in Puerto Rico (79% vs. 23%), as was the percentsharing others’ needles (20% vs. 7%) or sharing their needles with others(31% vs. 8%). Sharing of any drug paraphernalia, in both directions, washigher in Puerto Rico, e.g., sharing others’ cookers was reported by 34%vs. 7%. Any sharing of any paraphernalia, in either direction, wasreported by almost three-quarters of the sample in Puerto Rico (74%)compared with about one-third (34%) of the New York-recruitedsample. After controlling for gender and age in multivariate analyses,all these differences between sites were still statistically significant.

Sex-related risk behaviors were analyzed separately for IDUs(including those who also reported recent crack use) and crack users(with no injection drug use reported [see Table 3]). For IDUs, a higherproportion in New York subjects engaged in sex, however, higher risks,in terms of the percent of unprotected sex (76% vs. 49%) and thenumber of unprotected sex acts (13 vs. 7) were reported amongPuerto Rican male IDUs. Among the IDU women, a higher percentin Puerto Rico reported having paid partners (78% vs. 32%), and thepercent of unprotected sex was lower in Puerto Rico as compared withNew York (29% vs. 47%, respectively). Similarly, among crack users, ahigher percent of females in Puerto Rico reported having paid partners,although a smaller percent reported unprotected sex. After controllingfor gender and age in multivariate analyses, almost all these differencesbetween sites were still statistically significant (with the exception ofpercent of unprotected sex among IDU females and percent with paidpartners among male crack users).

CONCLUSIONS

The integration of qualitative and quantitative methodologies, andthe bidirectional communication, both across sites and across methodo-logical approaches, enhanced the study in multiple ways. This integrationwas essential for the development of comparative data collection instru-ments as well as for understanding the different environmental contextswithin which the participants lived and risk behaviors occurred.

The comparison of risk behaviors among injection drug users inNew York and Puerto Rico indicates continued higher levels ofinjection and sex-related risk behavior in Puerto Rico. Further analysesof these data sets are underway, and the use of both survey data and


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Table 3. Sex-related risk behaviors for Puerto Rican IDUs and crack smokers in

New York City and Puerto Rico by risk group (prior 30 days).

NYC PR

Significance

levela,b,c

IDU (including IDU who

also used crack)

(n¼ 561) (n¼ 312)

Engaged in sex (%)b 58% 45% <0.001

Total number sex partners (mean)

Among males 2 2 ns

Among females 10 29 ns

% with paid partners

(who traded sex for money or drugs)

Among males 8 10 ns

Among females 32 78 <0.001

% unprotected vaginal/anal sex

Among males 49 76 <0.001

Among females 47 29 0.05

Number unprotected sex acts



Crack (n¼ 239) (n¼ 88)

Engaged in sex (%)b 70 76 ns

Total number of partners

Among males 2 12 ns

Among females 8 34 ns (<0.06)

% with paid partners


Among females 28 62 0.001

% unprotected vaginal/anal sex

Among males 50 55 ns


Number unprotected sex acts

Among males 6 16 ns


aChi square tests were used for categorical data; t-tests were used for continuous

data.bData for variable ‘‘engaged in sex’’ are based on the entire sample in that druguse subgroup; data for all other items are based only on those engaging in sex in

prior 30 days.cAll significant comparisons remained statistically significant, at the same levels,after controlling for ages, except: (1) IDU, % unprotected vaginal/anal sex, forfemales (p changed from 0.05 to <0.06) and (2) crack, % with paid partners, for

males, went from 0.05 to ns and (3) for females, changed from 0.001 to 0.01.

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qualitative data to help identify sources of risk and potential interven-tions has been initiated. These analyses have begun to help our under-standing of injection-related risks, which thus far have been found to berelated to differences in residential status (26), needle exchange use (27),availability of methadone treatment (25), and activities associated withthe purchasing and sharing of drugs (28). Contributing factors regard-ing sex-related risks include differences in cultural norms (29), types ofmaterials available at NEPs (30), and residential status (26). The con-sistent finding of greater risk in Puerto Rico indicates that issues in theenvironment and local factors, e.g., in terms of the availability ofmechanisms to reduce risk, will continue to be factors which must beassessed as influences. Qualitative information about environmental dif-ferences is essential to enhancing understanding of the environmentalfactors that operate to influence risk as well as the conditions underwhich these factors may or may not have an impact. Multivariatemodels are needed to understand the relative importance of influenceson risk behaviors, and efforts to build these models are currentlyunderway.

The findings from the ARIBBA project demonstrate the importanceof studying similar ethnic groups in different communities. Dual sitestudies provide the opportunity to examine diverse sources of influenceon risk behaviors, including individual, cultural, and environmentalfactors. The development of recommendations for interventionswill draw from our understanding of both the survey data and thequalitative findings.

ACKNOWLEDGMENTS

This research was funded by the National Institute on Drug Abuse,Grant No. DA1O425. The authors also acknowledge Mark Beardsley,Ph.D., and Theresa Perlis, Ph.D., for their contribution to earlierversions of this manuscript.

REFERENCES

1. National Commission on AIDS. The challenge of HIV/AIDS inCommunities of Color. Rockville, MD, 1992.

2. Centers for Disease Control. HIV/AIDS Surveillance Report. 1999;11:2.


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3. Klevens RM, Diaz T, Fleming PL, Mays MA, Frey R. Trends inAIDS among Hispanics in the United States, 1991–1996. Am JPublic Health 1999; 89:1104–1106.

4. Montoya ID, Bell DC, Richard AJ, Carlson JW, Trevino RA.Estimated HIV risk among Hispanics in a national sample of drugusers. JAIDS 1999; 21(1):21–50.

5. Diaz T, Buehler JW, Castro KG, Ward JW. AIDS trends amongHispanics in the United States. Am J Public Health 1993; 83:504–509.

6. Puerto Rico Department of Health. HIV/AIDS surveillance report,June: San Juan, Puerto Rico: Puerto Rico Department of Health,Central Office for AIDS Issues. June 1999.

7. Selik RM, Castro KG, Pappaioanou M, Buehler JW. Birthplace andthe risk of AIDS among Hispanics in the United States. Am J PublicHealth 1989; 79:836–839.

8. Colon HM. The travel patterns of Puerto Rican drug injectors:implications for the transmission and prevention of the HIV/AIDS. In: Menendez BS, ed. The HIV/AIDS Epidemic in aCommuting Population: Puerto Ricans in New York City andPuerto Rico. Proceedings from The Conference. Bronx, NY:Lehman College, Nov 12–13, 1992:33–42.

9. Singer M, Jia Z. AIDS and Puerto Rican injection drug users in theUnited States. In: Brown BS, Beschner GM, eds. Handbook onRisk of AIDS: Injection Drug Users and Sexual Partners.Westport, CT: Greenwood Press, 1993:227–255.

10. Menendez BS, ed. The HIV/AIDS epidemic in a commuting popu-lation: Puerto Ricans in New York City and Puerto Rico.Proceedings from The Conference. Bronx, NY: Lehman College,Nov 12–13, 1992.

11. Robles RR, Colon HM, Matos TD, Reyes JC, Marrero CA, LopezCM. Risk factors and HIV infection among three different culturalgroups of injection drug users. In: Brown BS, Beschner GM, eds.Handbook on Risk of AIDS: Injection Drug Users and SexualPartners. Westport, CT: Greenwood Press, 1993:256–274.

12. Colon HM, Robles RR, Marrero CA, Freeman D. Frequency ofdrug injection in Puerto Rico and among Puerto Rican injectiondrug users compared to other ethnic groups and geographicalregion. Presented at the American Public Health AssociationMeeting Washington, DC, October, 1994.

13. Kral AH, Bluthenthal RN, Booth RE, Watters JK. HIV sero-prevalence among street-recruited injection drug and crack cocaine

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users in 16 US municipalities. Am J Public Health 1998; 88(1):108–113.

14. Society for Applied Anthropology. Section 5–51: Integratingqualitative and quantitative methods: challenges and futureprospects in drug and AIDS research. Presented at the Society forApplied Anthropology Annual Meeting, Tucson, AZ, April, 1999,

15. Carlson RG, Siegal HA, Wang J, Falck RS. Attitudes toward needle‘‘sharing’’ among injection drug users: combining qualitative andquantitative research methods. Human Organization 1996; 55(3):361–369.

16. Lambert EY, Ashery RS, Needle RH, eds. Qualitative methods indrug abuse andHIV research.NIDAResearchMonograph 1995:157.

17. New York City Department of Health/Office of AIDS Surveillance.AIDS surveillance update, Third Quarter. New York: Author,November, 1999.

18. Oliver-Velez D, Finlinson HA, Deren S, Robles RR, Shedlin M,Andıa JF, Colon HM. Mapping the air bridge locations: The appli-cation of ethnographic mapping techniques to dual-site study ofHIV risk behavior determinants in East Harlem, New York andBayamon, Puerto Rico. Human Organization 2002; 61(3): 262–276.

19. Harris M. The Rise of Anthropological Theory. New York:Harper & Row, 1968.

20. Deren S, Robles RR, Beardsley M, Andia J, Colon HM, Oliver-Velez D, Finlinson HA. Issues in studying high-risk populations indiverse locations: Puerto Ricans in New York and Puerto Rico.Presented at the 12th International Conference on AIDS, Geneva,Switzerland, July, 1998.

21. Steckler A, McLeroy KR, Goodman RM, Bird ST, McCormick L.Toward integrating qualitative and quantitative methods: an intro-duction. Health Educ Q 1992; 19(1):1–8.

22. Sullivan ML. Integrating qualitative and quantitative methods inthe study of developmental psychopathology in context.Development and Psychopathology 1998; 10(2):377–393.

23. Donovan C, Mearns C, McEwan R, Sugden N. A review of theHIV-related sexual behaviour of gay men and men who have sexwith men. AIDS Care 1994; 6(5):605–617.

24. Deren S, Kang S-Y, Colon HM, Andıa JF, Robles RR, Oliver-VelezD, Finlinson HA. Migration and HIV risk behaviors: Puerto Ricandrug injectors in New York City and Puerto Rico. AmericanJournal of Public Health, in press.


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25. Oliver-Velez D, Beardsley M, Deren S, Robles RR, Finlinson HA,Andia J, Colon HM. The impact of methadone treatment on HIVrisk behaviors among Puerto Rican IDUs in East Harlem, Presentedat the American Public Health Association Annual MeetingChicago, IL,NewYork andBayamon, PuertoRico,November, 1999.

26. Andia J, Deren S, Kang S-Y, Robles RR, Colon HM, Oliver-VelezD, Finlinson HA, Beardsley M, Friedman SR. Residential statusand HIV risk behaviors among Puerto Rican drug injectors inNew York and Puerto Rico. Am J Drug Alcohol Abuse 2001;27(4):719–735.

27. Finlinson HA, Oliver-Velez D, Deren S, Robles RR, Colon HM,Beardsley M, Andia J, Lopez MS. Syringe acquisition and use byPuerto Rican drug injectors in New York and Puerto Rico: compar-isons based on quantitative and qualitative methods. AIDS andBehavior 2000; 4(4):341–351.

28. Colon HM, Finlinson HA, Robles RR, Deren S, Andia J, KangS-Y, Oliver-Velez D. Joint drug purchases and drug preparationrisk behaviors among injection drug users. AIDS and Behavior2001; 5(1):85–96.

29. Oliver-Velez D, Finlinson HA, Deren S, Robles RR, Beardsley M,Shedlin M, Andia J, Colon HM. Differences in sexual risk behaviorsbetween Puerto Rican drug users in East Harlem. Presented at theSociety for Applied Anthropology Annual Meeting Tucson, NewYork and Bayamon, Puerto Rico, AZ, April, 1999.

30. Finlinson HA, Colon HM, Robles RR, Deren S, Soto Lopez M,Munoz A. Access to sterile syringes by injection drug users in PuertoRico. Human Organization 1999; 58(2):201–211.

RESUMEN

El proyecto se condujo en dos sitios para determinar las conductas deriesgo relacionadas con inyeccion y sexo entre usuarios de droga deorigen Puertorriqueno. El proyecto se enfoco en usuarios de drogainyectables y fumadores de crack (un derivado de la cocaına) y se condujoen el Este de Harlem, NY y Bayamon, PR en 1986–2000. Los metodoscualitativos, incluyeron cartografıa etnografica, grupos del foco, entre-vista personales a fundo y observaciones. Entrevistas en forma deencuesta (Este de Harlem, n¼ 800; Bayamon, n¼ 400) fueron tambienrealizadas. Procedimientos para asegurar que la integracion demetodologıas y compatibilidad de datos fueron desarrolladas. Este

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papel describe los metodos cualitativos y de encuesta que fueron usados ypresenta las conductas relativas del riesgo al VIH. La integracion de lasdos metodologıas sirvio multiples funciones: cada componente identificaasuntos para ser analizados por el otro componente, elevo la compatibi-lidad de datos en ambos sitios, y ayudo en la interpretacion de los hal-lazgos. Los datos de la encuesta mostraron niveles altos de conductas deriesgo en ambas comunidades, con niveles significativamente mas altosdel riesgo en Bayamon. Conducir estudios con grupos etnicos semejantesen comunidades diferentes proporciona oportunidades para examinar lasdiversas fuentes que influyen en las conductas de riesgo. La integracionde metodos cualitativos y cuantitativos puede aumentar la compatibili-dad y comprension de hallazgos, particularmente cuando hay diferenciasen conductas entre las comunidades.

RESUME

Un projet dans 2 sites a ete conduit pour evaluer les causes determi-nantes d’injection et de comportements de nature sexuelle de hautrisque parmi des utilisateurs de drogue Porto Ricains. Le projet a misl’emphase sur des utilisateurs de drogue d’injection et des fumeurs decrack, et a ete conduit dans East Harlem (New York) et a Bayamon(Porto Rico) entre 1996–2000. Les methodes qualitatives comprennenttrace ethnographique, groupes de discussion, entrevues personnellesdetaillees et observations. Une enquete fut egalement conduite(Harlem, n¼ 800; Bayamon, n¼ 400). Des procedures pour assurerl’integration des methodes et al comparabilite des donnees ont ete devel-oppees. Cet article decrit les methodes qualitatives et d’enquetes utiliseeset presente des donnees comparatives sur les comportement a hautrisque pour the SIDA. L’integration des deux methodes a rempli desfonctions multiples: chacune a identifie des questions a adresser dansl’autre, mise en valeur la comparabilite des donnees entre les 2 sites etfacilitite l’interpretation des resultats. Les donnees quantitatives indi-quent de hauts niveaux de comportement de risque dans les deux com-munautes, avec des niveaux sensiblement plus eleves a Bayamon. Laconduite d’etudes de groupes ethniques similaires dans communautesdifferentes donne la possibilite d’examiner des sources diversesd’influence sur des comportements de risque. L’integration de methodesqualitatives et quantitatives peut mettre en valeur la comparabilite etl’interpretation des resultats, en particulier quand il y a des differencesde comportement entre les communautes.


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THE AUTHORS

Sherry Deren, Ph.D., is Director ofthe Center for Drug Use and HIVResearch (CDUHR) and the Institutefor AIDS Research at NationalDevelopment and Research Institutes,Inc. (NDRI). Her current researchinterests include expanding the uses ofoutreach methodologies, developingHIV/AIDS-related interventions fordrug injectors and crack smokers, andenhancing the dissemination ofresearch findings and their utilizationby service providers.

Denise Oliver-Velez is the SeniorResearch Associate/Ethnographer forthe New York ARIBBA team. She hasconducted research on AIDS and drugabuse for more than ten years. Hercurrent interests include genealogy,social stratification, and rose growing.

Ann Finlinson, Ph.D., is an anthro-pologist who has worked for morethan 12 years at the Center forAddiction Studies, School ofMedicine, Universidad Central delCaribe in Bayamon, Puerto Rico. Sheis a member of a research team con-ducting studies on a wide range oftopics related to drug abuse andHIV/AIDS on the island of PuertoRico. Dr. Finlinson’s published articlesfocus on syringe acquisition and use

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among Puerto Rican IDUs, the evaluation of needle exchange programsin Puerto Rico, and vaginal microbicide acceptability among drug-involved women in Puerto Rico.

Rafaela Robles, Ed.D., is a seniorscientist and professor of theUniversidad Central del Caribe,School of Medicine. She is also theDirector of the Center for AddictionStudies and the Puerto Rico and U.S.Virgin Islands Addiction TechnologyTransfer Center. She has been conduct-ing research on the HIV and drugaddiction field in Puerto Rico formore than 12 years.

Jonny Andia, Ph.D., is the projectdirector of a NIDA study examiningdeterminants of HIV risk behaviorson Puerto Rican drug users in NewYork and Puerto Rico. He is also anadjunct assistant professor ofSociology at the John Jay College ofCriminal Justice of the CityUniversity of New York. He is authorand co-author of several articles focus-ing on substance use.


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Hector M. Colon, Ph.D., has beenconducting research on HIV and druguse in Puerto Rico for more than tenyears. His interests span many topicsrelated to drug use, including a focuson frequency of injection and HIVrisk behaviors.

Sung Yeon Kang, Ph.D., has beeninvolved in a wide variety of projectsfunded by the National Institute onDrug Abuse (NIDA). These pro-jects have focused on drug abuse andrelated problems, such as criminalinvolvement, psychological status,HIV/AIDS, and other public healthissues. Her numerous publishedarticles include topics on criminalbehaviors of drug abusers, evaluationof treatment, validity of self-reporteddrug use, HIV/AIDS risk behaviors,and drug use patterns among youth.

Michele Shedlin, Ph.D., is a medicalanthropologist with extensive researchand intervention experience in LatinAmerica and the United States. Shehas designed and implemented beha-vioral research at the community,regional, and national levels, toinform and evaluate prevention andcare programs. Her recent publicationsreport results of research on sociocul-tural factors affecting HIV risk in ElSalvador, Nicaragua, the DominicanRepublic, and Latino immigrantgroups in the United States.

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Integrating Qualitative and Quantitative Methods in the Study of Bilingual Code Switching

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