Using community-based participatory research (CBPR) to develop a community-level HIV prevention intervention for Latinas: a local response to a global challenge

Introduction and BackgroundThe arsenal of interventions to reduce the disproportionate rates of HIV and sexually transmitted disease (STD) infection among Latinos in the United States lags behind what is available for other populations. The purpose of this project was to develop an intervention that builds on existing community strengths to promote sexual health among immigrant Latinas.MethodsOur community-based participatory research (CBPR) partnership engaged in a multistep intervention development process. The steps were to (1) increase Latina participation in the existing partnership, (2) establish an intervention team, (3) review the existing sexual health literature, (4) explore health-related needs and priorities of Latinas, (5) narrow priorities based on what is important and changeable, (6) blend health behavior theory with Latinas’ lived experiences, (7) design an intervention conceptual model, (8) develop training modules and (9) resource materials, and (10) pretest and (11) revise the intervention.ResultsThe MuJEReS intervention contains five modules to train Latinas to serve as lay health advisors (LHAs) known as “Comadres.” These modules synthesize locally collected data with other local and national data, blend health behavior theory with the lived experiences of immigrant Latinas, and harness a powerful existing community asset, namely, the informal social support Latinas provide one another.ConclusionThis promising intervention is designed to meet the sexual health priorities of Latinas. It extends beyond HIV and STDs and frames disease prevention within a sexual health promotion framework. It builds on the strong, preexisting social networks of Latinas and the preexisting, culturally congruent roles of LHAs.     

Counseled women's perspectives on their interactions with lay health advisors: a feasibility study.

Although the use of lay health advisors (LHAs) has become a popular intervention in public health promotion projects, few programs have conducted evaluations demonstrating program impact by interviewing people actually counseled by LHAs. This study used semistructured, in-person interviews with 29 older, black women to elicit their perceptions of their interactions with the North Carolina Breast Cancer Screening Program's LHAs, and the ways in which these interactions affected their mammography attitudes and behavior. Interview data indicate that a majority of the respondents felt that LHAs had helped them in some way; most said that talking to advisors made them think more positively about mammograms and/or consider getting one. LHAs influenced the women they counseled because the women knew the advisors well, felt comfortable talking to advisors about private issues, considered advisors to be credible sources of information about mammography and because advisors offered women support with respect to their mammography behavior. These results elucidate some of the mechanisms through which LHAs affect the attitudes and behavior of individuals in their social networks.     

A lay health advisor program to promote community capacity and change among change agents

The Charlotte REACH 2010 project focuses on cardiovascular disease and diabetes among African Americans in a geographically defined community. The goal of the project is to create changes in individual behaviors, community capacity, change agents, and systemic policies and actions that will result in the reduction of health disparities related to cardiovascular disease and diabetes. The project consists of three main components: lay health advisors as change agents, targeted interventions (exercise, nutrition, smoking cessation, primary care), and environmental and systemic interventions. The purpose of this article is to describe the lay health advisor intervention using qualitative methodologies that were developed to document changes in community capacity and change among change agents. Lay health advisors report that they have internalized their role as a community advocate and have made positive changes in their own personal health behavior. Their understanding of the underlying causes of poor health has expanded to include social and institutional factors and they have begun to shift their emphasis toward advocacy for social and institutional change.     

Things ain't what they ought to be: social forces underlying racial disparities in rates of sexually transmitted diseases in a rural North Carolina county.

Social forces shaping a region can also affect behaviors that facilitate the transmission of sexually transmitted diseases (STDs), including HIV. We sought to understand the social forces underlying high rates of infection, particularly among blacks, in a rural county of North Carolina in which 40% of the county is black. In the context of ongoing research on STDs we collected information from archival data on the county since the 1940s and interviewed local residents knowledgeable about the county's history. We present local data in the context of national economic and demographic trends. Successive changes in the national economy and farming policies disproportionately affected black farmers. A rural ghetto formed when poor blacks left their farms to seek work in the central town of the county. Segregationist housing policies and race-based differentials in employment opportunities exacerbated the concentration of poverty. Migration to northern industrial cities, predominantly by skilled black men, decreased the social capital of the community and lowered the ratio of men to women. Poverty, income disparity, social capital and the ratio of men to women can all affect the behaviors that facilitate transmission of STDs. Knowledge of social forces and their effects is critical for designing and evaluating interventions to prevent STDs and to decrease extreme racial disparities in rates of disease.     

Local Public Health Systems and the Incidence of Sexually Transmitted Diseases

Objectives. We examined the associations of local public health system organization and local health department resources with county-level sexually transmitted disease (STD) incidence rates in large US health jurisdictions.Methods. We linked annual county STD incidence data (2005–2008) to local health department director responses (n = 211) to the 2006 wave of the National Longitudinal Study of Local Public Health Systems, the 2005 national Local Health Department Profile Survey, and the Area Resource File. We used nested mixed effects regression models to assess the relative contribution of local public health system organization, local health department financial and resource factors, and sociodemographic factors known to be associated with STD incidence to county-level (n = 307) STD incidence.Results. Jurisdictions with local governing boards had significantly lower county-level STD incidence. Local public health systems with comprehensive services where local health departments shoulder much of the effort had higher county-level STD rates than did conventional systems.Conclusions. More integration of system partners in local public health system activities, through governance and interorganizational arrangements, may reduce the incidence and burden of STDs.US annual sexually transmitted disease (STD) incidence rates have not declined despite the identification of effective surveillance and prevention methods.1–5 For example, after decreasing annually since 1999, gonorrhea infection rates among adolescents increased 2% from 2004 to 2005, from 421.9 to 431.8 per 100 000, and then increased 6% again from 2005 to 2006, from 431.8 to 458.8 per 100 000.6,7 Untreated STDs can have serious long-term health effects, such as cervical cancer, infertility, and pregnancy complications.8 STDs are among the largest Black–White racial disparities in health,9 which are heavily influenced by social determinants (i.e., area-level sociodemographic factors).9–12It is a widely accepted view that local health departments and their system partners play a critical role in controlling the spread of STDs.13–15 Local health departments differ dramatically in size, organizational structure, and available resources, and these factors can influence the reach and effectiveness of local STD prevention strategies. Previous studies indicate that larger local health departments, better resourced local health departments (as measured by expenditures per capita), and jurisdictions with local boards of health with policymaking authority more consistently provide a diverse set of essential public health functions,16–19 including diagnosing and preventing health problems and informing and educating the public about health issues. Moreover, recent evidence indicates that increases in STD prevention funding are associated with reductions in gonorrhea20 and syphilis21 incidence rates. This suggests that resources available to local health departments and their system partners can affect the “reach” of STD prevention programs.The contribution of community partner organizations to performing essential public health functions18 may also influence the reach and effectiveness of STD prevention and treatment programs. For example, low integration of local health departments with their local system partners, including physician organizations, community health centers, and faith-based organizations, can impinge on the effectiveness of local STD prevention and treatment efforts.15 Given that rescreening previously infected individuals is increasingly viewed as central to controlling the spread of STDs,22 local health departments that have low integration with their health care delivery system partners might face more difficulties curtailing the spread of STDs. It may be difficult for local health departments that have limited integration with system partners to communicate surveillance data and to generate action to combat emerging health epidemics.Little research, however, has assessed organizational and market determinants of local public health system effectiveness using population health indicators.17–19 Although several studies have assessed the relationship of county-level sociodemographic factors and STD rates,23,24 to our knowledge, no study has ever assessed the relationship of local public health system organization and STD incidence rates. Consequently, the extent to which the scope of local health department services and their integration with their local health system partners is associated with STD incidence rates remains unclear. Using responses to the National Association of County and City Health Officials (NACCHO) 2005 National Profile of Local Health Departments in the United States (NACCHO Profile) and county-level data from the Area Resource File, we examined the extent to which local health department financing per capita, the existence of a local governing board of health, and integration among key system partners are associated with county-level incidence rates of gonorrhea and chlamydia.Consistent with previous research examining public health spending and medical care expenditures,25 we hypothesized that local health departments with greater total expenditures per capita have lower STD incidence rates when controlling for county-level sociodemographic and other local health department characteristics. Local boards of health are increasingly considered central to improving community-based linkages and setting priorities for jurisdictions. Accordingly, we hypothesized that county-level STD rates would be lower in jurisdictions where local boards of health have governance responsibility than in those having no local board of health. The integration of local health departments with local public health system partners can influence the dissemination of preventive health care information and epidemiologic data to target interventions. We hypothesized that local health departments with a higher integration with system partners, as measured by the recent typology of local public health systems,26,27 have lower STD incidence rates, controlling for other factors. Finally, we examined the role of social determinants of STD incidence relative to measurable local public health system factors.     

Adolescents and Sexually Transmitted Diseases

Sexually transmitted diseases (STDs) are a serious health problem for adolescents, occurring in an estimated one-quarter of sexually active teen-agers. Many of the health problems--including STDs--result from specific risk-taking behaviors. Determinants of STD risks among adolescents include behavioral, psychological, social, biological, institutional factors. Education is an important component in STD control in adolescents. The goal of education is to increase adolescent self-efficiency in practicing STD prevention and risk-reduction. A comprehensive approach including quality, theory-based education, accessible and effective health clinics, and improved social and economic conditions has the most promise of controlling STDs in adolescents.     

The social ecology of syphilis.

Factors affecting the transmission of syphilis can be categorized into those acting at the level of individuals (e.g., number of sex partners) and others at the level of the sociophysical environment (e.g., availability of treatment services for curable infections). In a prior study, we identified several sociophysical factors correlated with the ten-year mean syphilis rate in a regression analysis of United States counties. In the present study we used qualitative methods to investigate additional aspects of some factors in the regression, as well as to identify entirely new factors. Twelve counties with populations less than 100,000 and ten-year mean syphilis rates that were greater or less than expected by the regression model were selected for a three to five day visit. The case study protocol included observations, unstructured interviews with care providers and county residents, and a standardized questionnaire completed by state and local sexually transmitted disease control personnel pertaining to characteristics and practices of the local health department. Comparisons of the field notes and questionnaires revealed patterns of factors of the sociophysical environment that potentially affect county syphilis rates. These included access to the health department STD clinic, race relations, employment opportunities for minorities, interagency coordination, STD outreach activities, the social acceptability of discussing STDs, and intercommunity dynamics. In addition we noted the disproportionate influence of particular individuals on these factors. Some of the factors identified are readily quantifiable and could enhance the predictive power of multivariable models of county syphilis rates. The hypotheses generated by this study may also lead to a better measurement and understanding of potentially important environmental determinants of community syphilis rates, and the development of new or enhanced prevention strategies.     

"Condoms are reliable but I am not": A qualitative analysis of AIDS-related beliefs and attitudes of young heterosexual adults in Budapest, Hungary, and St. Petersburg, Russia

HIV and STD prevention is an essential component of public health initiatives in countries throughout Central and Eastern Europe. Liberalization in sexual values, declining age at first sex, higher levels of sexual activity, and inconsistent condom use have been well-documented among young people in the region following the political, economic, and cultural transitions after the end of the state socialism era. Less well-understood are the reasons for high-risk sexual behavior and psychosocial factors that must be addressed in the development of effective HIV/STD prevention programs. This study recruited members of 12 high-risk social networks of young adult men and women (n= 66 participants) in two cities, St. Petersburg, Russia, and Budapest, Hungary. In-depth focus groups were conducted with all members of each network, and qualitatively analyzed to examine factors surrounding high-risk sexual behavior. Main themes that emerged were that STDs are less known and less feared than AIDS, HIV risk factors were relatively well known among young adults in both countries but vulnerability is perceived differently, pregnancy prevention is a more immediate concern than protection from HIV or STDs, condom use declines quickly following first sex with a new partner, reintroducing condom use in a relationship is very difficult, and young adults report many barriers to condom use including those related to alcohol or other substance use. HIV/STD prevention programs are needed that extend beyond risk education alone and that also address critical psychological, social, and relationship factors related to sexual risk behavior.     

Developing socio-spatial knowledge networks: a qualitative methodology for chronic disease prevention

Chronic disease is a significant and costly social problem. The burden is even more pronounced in communities with high rates of a particular chronic disease. Assessment of health belief systems and the local geographies of health beliefs can assist community health planners to create cost-effective strategic intervention programs where populations are at high risk for chronic diseases. In this paper, we elaborate the concept of socio-spatial knowledge networks (SSKNs) and demonstrate that SSKNs can be useful in informing the design of health care prevention strategies. In our project, we demonstrate how to identify key socio-spatial information for intervention strategies which will prevent or delay the onset of a particular chronic disease, Type 2 diabetes. Our qualitative framework allows us to determine which sites might be best characterized as socio-spatial knowledge network nodes for sharing diabetes information and which sites might be less suited to such exchange. Our strategy explores cross-cultural similarities, differences, and overlap in a multi-ethnic rural North Carolina context through simple techniques such as mapping social networks and sites in which people share their knowledge and beliefs about diabetes. This geographical analysis allows us to examine exactly where health knowledge coincides with other social support, and where such resources may be improved in a particular community. Knowing precisely what people in a community understand about a chronic disease and its treatment or prevention and knowing where people go to share that information helps to (1) identify strategic locations within a community for future interventions and, (2) evaluate the effectiveness of existing interventions. The geographical approach presented here is one that can serve other communities and health practitioners who hope to improve chronic disease management in diverse local environments.     

External collaboration and performance: North Carolina local public health departments, 1996

OBJECTIVES: This study examined the extent to which local public health departments in North Carolina collaborated with other groups and organizations, the health problems on which they worked together, and the effect of external collaboration on health departments' performance on core public health functions. METHODS: The author mailed a questionnaire asking about interactions with city and county government agencies, boards of health, schools, nonprofits, physicians/private clinics, community health centers/migrant clinics, community members, citizens' groups, state and federal agencies, and universities to all of the directors of local public health departments in North Carolina. Sixty-four directors returned the questionnaire, for a response rate of 74.4%. RESULTS: Local public health departments most frequently interacted with boards of health, state agencies, community members, schools, city and county government agencies, and nonprofit agencies. Large majorities reported productive relationships with boards of health, state agencies, city and county government agencies, schools, nonprofit agencies, and hospitals. Greater frequency of interaction with several types of partners was associated with better performance. CONCLUSIONS: While questions exist about whether performance on core functions improves the community's health status, the results suggest that it is important for local public health departments to continue to build relationships with other organizations in the community.     

Where do people go for treatment of sexually transmitted diseases?

CONTEXT: Major public health resources are devoted to the prevention of sexually transmitted diseases (STDs) through public STD clinics. However, little is known about where people actually receive treatment for STDs. METHODS: As part of the National Health and Social Life Survey, household interviews were performed from February to September 1992 with 3,432 persons aged 18-59. Weighted population estimates and multinomial response methods were used to describe the prevalence of self-reported STDs and patterns of treatment utilization by persons who ever had a bacterial or viral STD. RESULTS: An estimated two million STDs were self-reported in the previous year, and 22 million 18-59-year-olds self-reported lifetime STDs. Bacterial STDs (gonorrhea, chlamydia, nongonococcal urethritis, pelvic inflammatory disease and syphilis) were more common than viral STDs (genital herpes, genital warts, hepatitis and HIV). Genital warts were the most commonly reported STD in the past year, while gonorrhea was the most common ever-reported STD. Almost half of all respondents who had ever had an STD had gone to a private practice for treatment (49%); in comparison, only 5% of respondents had sought treatment at an STD clinic. Respondents with a bacterial STD were seven times more likely to report going to an STD clinic than were respondents with a viral STD--except for chlamydia, which was more likely to be treated at family planning clinics. Men were significantly more likely than women to go to an STD clinic. Young, poor or black respondents were all more likely to use a family planning clinic for STD treatment than older, relatively wealthy or white respondents. Age, sexual history and geographic location did not predict particular types of treatment-seeking. CONCLUSIONS: The health care utilization patterns for STD treatment in the United States are complex. Specific disease diagnosis, gender, race and income status all affect where people will seek treatment. These factors need to be taken into account when STD prevention strategies are being developed.     

Sexually transmitted diseases: meeting the 1990 objectives--a challenge for the 1980s

Sexually transmitted diseases (STDs) represent a major public health problem in the country, cause patients enormous suffering, and cost the nation billions of dollars annually. Demographic, sociological, and behavioral changes in our society during the past decade are important contributors to the growing complexity and scope of the STD problem. Several agencies in the Public Health Service are engaged in the Federal effort against STDs. The Centers for Disease Control, as the lead agency, assists State and local health departments in their STD control efforts. In fiscal year 1981, federally supported syphilis and gonorrhea control efforts--based on prevention of an estimated 209,400 new cases--saved the taxpayers approximately $150 million. To meet the 1990 objectives, both the public and private medical sectors must recognize the STD problem of the 1980s. Without the support of the professional community and involvement of the private sector, the incidence of STDs will continue to increase at alarming proportions during this decade. The opportunity for promoting health, preventing human suffering, and reducing costs to society is great. Making the best of this opportunity is our challenge during this decade.     

Traditional women's associations as channels for HIV / AIDS / STD prevention

Women of the Laobe ethnic group and the Dimba, a traditional women's association, provide advice about sexuality and reproductive health in southern Senegal. Research was initiated in October 1992 by the Cheikh Anta Diop University to determine whether these women could also help in HIV/AIDS and STD prevention activities. The study investigated men's and women's knowledge, attitudes, beliefs, and practices (KABP) related to sexuality and HIV/AIDS/STDs in the community of Kolda; practices potentially increasing women's risk of HIV/STD infection; and possibilities for integrating HIV/STD prevention messages into the interactions which take place between the Laobe and Dimba groups and the Kolda community. The KABP study was a questionnaire administered to 250 men and 250 women of reproductive age representing five ethnic groups residing in Kolda. 11 men and 14 women older than age 40 participated in in-depth sexual life history interviews. The survey and interviews indicate that people in Kolda do not generally see a link between sexual relations and STD transmission. Instead, STDs are attributed to behaviors such as urinating, walking barefoot on the urine of an already-infected person, encountering a "bad wind", and being cursed. Women may be at increased risk of HIV infection through practices designed to enhance sexual pleasure, including the insertion of organic and mineral product into the vagina, and the cutting of bumps and warts in and around the vagina. Sexual practices, knowledge, prevention through the Laobe and Dimba, and outcome and follow-up are discussed.     

Informal Occupational Safety Information Exchange Among Latino Migrant and Seasonal Farmworkers

ABSTRACT

Latino farmworkers in North Carolina are a hard-to-reach population that faces diverse occupational health risks, including pesticide exposure. Health and safety education efforts often employ lay health advisor or promotor(a) de salud models in which farmworker community members are trained to provide health education. As a frequently tight-knit and isolated group, farmworkers may be well suited to serve as resident lay health advisors. This paper presents data collected from a nonrandom sample of Latino farmworkers living in North Carolina regarding the natural level of occupational safety information exchange among Latino farmworkers, specifically pesticide safety information. The data affirm that farmworkers informally exchange occupational safety information with one another, with the level of exchange increasing during the agricultural season. Consequently, if trained, the data suggest that farmworkers might be situated to provide in situ occupational health and safety education to their peers. This remains to be systematically tested and evaluated.     

Social trust, firearm prevalence, and homicide

PURPOSE: Past research suggests that Americans arm themselves when they do not trust one another. We reexamine the relationship between social trust and firearm prevalence with improved data and methods. We also control for conditions, including area homicide rates, that other research showed to be related to both social trust and firearm prevalence. METHODS: We use structural equation models to assess reciprocal effects of social trust, firearm prevalence, and homicide rates for a nationally representative sample of counties and county clusters (n = 99). RESULTS: We found no direct relationship between social trust and firearm prevalence. Social trust is related to firearm prevalence indirectly through its influence on homicide rates. Areas with low levels of social trust have high homicide rates, which, in turn, increase firearm prevalence. CONCLUSIONS: Americans arm themselves in response to high levels of firearm violence. Because greater social trust is related to lower homicide rates, public health researchers should be concerned with the community conditions that promote social trust.     

Health policies for controlling AIDS and STDs in developing countries

In developing countries the control and prevention of SexuallyTransmitted Diseases (STDs) and the ensuing complications hasreceived renewed attention since the emergence of the latestsexually transmitted disease, AIDS. Prevention via behaviouralchange has become more important than ever because of the currentlack of therapy or vaccination for HIV infections. Considerationsabout STD and AIDS control programmes are discussed, and theoption employed by the European Community to combine STD andAIDS control, is discussed. The strategies used for STD and AIDS control are health promotionand adequate management of patients with STDs. It is arguedthat health promotion should be targeted, and take into considerationpriority activities and groups; that condom promotion shouldbe an integral part of health promotion rather than being anautonomous activity; and that promotion of health seeking behaviouris an important part of the strategy. Adequate management of patients with STDs is effective for AIDSprevention because some STDs are associated with an increasedrisk of HIV transmission, but also because people coming spontaneouslyto a clinic can be considered a self-referred group, at an increasedrisk from HIV infection. The methodology used to implement thosestrategies is discussed, on three levels: the programming andmanagement level; the expertise unit; and implementation atperipheral levels. Experiences, obstacles and technical problemsencountered by the AIDS Task Force of the European Communityare enumerated.     

Beyond the knowledge deficit: recent research into lay and expert attitudes to food risks

The paper reviews psychological and social scientific research on lay attitudes to food risks. Many experts (scientists, food producers and public health advisors) regard public unease about food risks as excessive. This expert-lay discrepancy is often attributed to a 'knowledge deficit' among lay people. However, much research in psychology and sociology suggests that lay risk assessments are complex, situationally sensitive expressions of personal value systems. The paper is organised around four themes: risk perception, the communication of risk, lay handling of risk, and public trust in institutions and experts. It suggests that an interdisciplinary, contextualised and psychologically sound approach to the study of risk is needed.     

Sexual behaviour and sexually transmitted diseases among young men in Zambia

Sexually transmitted diseases (STDs) are an increasing public health problem in Zambia. About 200 000 cases of STDs are treated annually in the formal health sector. Young people are the most affected by STDs. High-risk sexual behaviour has been identified as the major risk factor for STDs among young people. We conducted interviews and focus group discussions with a purposely selected sample of 126 young men aged between 16 and 26 in Chiawa, rural Zambia. The aim of the interviews and focus group discussions was to explore views about sexual practices and attitudes towards STD. Fifty-eight (59%) young men reported having had pre-marital or extra-marital sexual partners during the past year. The maximum number was five partners for six individuals. Forty-two (43%) had pre-marital or extra-marital sexual partners at the time of the interviews. Focus group discussions revealed that perceptions of manhood encouraged multiple sexual relationships. Twenty-two (23%) reported having suffered from an STD in the past. Seventy-nine (81%) said they were likely to inform their sexual partners if they had an STD. Although condoms were believed to give protection against STDs by the majority (94%), only 6% said they always used condoms. The data suggest that condoms were perceived to affect male potency. These results show that STDs, multiple sexual relationships and unprotected sex are common among the young men of Chiawa. Perceptions that emphasize manhood are widespread and these may negatively affect efforts for positive behavioural change. Health messages that target the young men should take into account the local perceptions and values that seem to sustain risky sexual behaviour.