Shayna D. Cunningham

Attitudes about sexual disclosure and perceptions of stigma and shame.

Objectives: To determine the association between stigma and shame about having a sexually transmitted disease and adolescents’ past STD related care seeking; between stigma, shame, and perceptions about disclosure of sexual behaviours to a doctor or nurse; and whether the association of stigma, shame, and care seeking was moderated by perceptions about disclosure. Methods: A household sample of 142 sexually active African-American youths, 13–19 years old, was questioned about STD related stigma (alpha = 0.89), STD related shame (alpha = 0.90), and perceptions about disclosure of sexual behaviours to a doctor or nurse (alpha = 0.81). Results: Among females, stigma was associated with increased anticipation of negative reactions to disclosure of sexual behaviours to a doctor or nurse (odds ratio (OR) = 0.319; 95% confidence interval (CI) =0.12 to 0.85) while shame was not. Stigma was also independently associated with STD related care seeking in the past year (OR = 0.296; 95% CI = 0.09 to 0.94) while shame was not. There was no association between stigma and shame with perceptions about disclosure or past care seeking in males. Perceived outcomes of disclosing sexual behaviours did not moderate the association of stigma, shame, and past STD related care seeking. Conclusions: Stigma about STDs may influence how female adolescents perceive reactions to disclosure of their sexual behaviour to healthcare providers. It may also be an important factor in their decision seek to STD related care. Perceptions about disclosure of sexual behaviour to a doctor or nurse do not change the relation of stigma or shame to past STD related care seeking.

Use of geographic information systems for planning HIV prevention interventions for high-risk youths

Geographic information system (GIS) analysis is an emerging tool for public health intervention planning. Connect to Protect, a researcher-community collaboration working in 15 cities to reduce HIV infection among youths, developed GIS databases of local health, crime, and demographic data to evaluate the geographic epidemiology of sexually transmitted infections and HIV risk among adolescents. We describe the process and problems of data acquisition, analysis, and mapping in the development of structural interventions, demonstrating how program planners can use this technology to inform and improve planning decisions. The Connect to Protect projects experience suggests strategies for incorporating public data and GIS technology into the next generation of public health interventions.

How to Adapt Effective Programs for Use in New Contexts

A wide variety of underused effective HIV prevention programs exist. This article describes sources for obtaining such effective programs and issues to consider in selecting an existing effective program for use with one’s priority population. It also discusses seven steps involved in adapting an effective program to meet the needs of a new context while preserving core components (what made, or is believed to have made, the intervention effective in the first place) and best practices (characteristics common to effective programs). Although the examples presented are from the HIV prevention field, the seven-step framework is applicable to the adaptation of effective programs in other health promotion and disease prevention arenas.

The Role of Structure Versus Individual Agency in Churches’ Responses to HIV/AIDS: A Case Study of Baltimore City Churches

This paper examines the activities of churches in Baltimore, Maryland, concerning the issues of sexuality, whether they potentially stigmatize persons with or at risk for HIV/AIDS, and to what extent individual agency versus institutional forces influence churches in this regard. In-depth interviews were conducted with 20 leaders from 16 churches and analyzed using a grounded theory methodology. Although many churches were involved in HIV/AIDS-related activities, the content of such initiatives was sometimes limited due to organizational constraints. Church leaders varied, however, in the extent to which they responded in accordance with or resisted these constraints, highlighting the importance of individual agency influencing churches’ responses to HIV/AIDS.

Cluster Randomized Controlled Trial of Group Prenatal Care: Perinatal Outcomes Among Adolescents in New York City Health Centers

OBJECTIVES We compared an evidence-based model of group prenatal care to traditional individual prenatal care on birth, neonatal, and reproductive health outcomes. METHODS We performed a multisite cluster randomized controlled trial in 14 health centers in New York City (2008-2012). We analyzed 1148 pregnant women aged 14 to 21 years, at less than 24 weeks of gestation, and not at high obstetrical risk. We assessed outcomes via medical records and surveys. RESULTS In intention-to-treat analyses, women at intervention sites were significantly less likely to have infants small for gestational age (< 10th percentile; 11.0% vs 15.8%; odds ratio = 0.66; 95% confidence interval = 0.44, 0.99). In as-treated analyses, women with more group visits had better outcomes, including small for gestational age, gestational age, birth weight, days in neonatal intensive care unit, rapid repeat pregnancy, condom use, and unprotected sex (P = .030 to < .001). There were no associated risks. CONCLUSIONS CenteringPregnancy Plus group prenatal care resulted in more favorable birth, neonatal, and reproductive outcomes. Successful translation of clinical innovations to enhance care, improve outcomes, and reduce cost requires strategies that facilitate patient adherence and support organizational change.

Realities of replication: implementation of evidence-based interventions for HIV prevention in real-world settings

BackgroundTo have public health impact, evidence-based interventions (EBIs) must be implemented appropriately at meaningful scale. The Center for Disease Control and Prevention’s Replicating Effective Programs and Diffusion of Effective Behavioral Interventions programs disseminate select EBIs by providing program materials and training health providers on their appropriate use and implementation. Sociometrics’ HIV/AIDS Prevention Program Archive (HAPPA) and Program Archive for Sexuality, Health, and Adolescents (PASHA) are likewise the largest EBI collections targeting sexual risk behaviors in the private sector. This study examined the extent to which organizations that obtain EBIs from HAPPA and PASHA implement, adapt and evaluate them and factors associated with program implementation.MethodsSurvey data were collected from 123 organizations that acquired, and had been in possession for a minimum of six months, at least one EBI from HAPPA or PASHA between January 2009 and June 2011. Data regarding program characteristics and date of acquisition were obtained from Sociometrics’ sales and marketing databases. Logistic regression was used to assess barriers to program implementation.ResultsAmong organizations that obtained an EBI from Sociometrics intending to implement it, 53% had implemented the program at least once or were in the process of implementing the program for the first time; another 22% were preparing for implementation. Over the three-year time period assessed, over 11,381 individuals participated in these interventions. Almost two-thirds (65%) of implementers made changes to the original program. Common adaptations included: editing content to be more current and of local relevance (81%); adding, deleting or modifying incentives for participation (50%); changing the location in which the program takes place (44%); and/or changing the number, length and/or frequency of program sessions (42%). In total, 80% of implementers monitored program delivery. Participant outcomes were tracked by 78%; 28% of which used evaluation designs that included a control or comparison group. Lack of adequate resources was significantly associated with decreased likelihood of program implementation (odds ratio = 0.180, p <0.05).ConclusionsFindings provide greater understanding of implementation processes, barriers and facilitators that may be used to develop strategies to increase the appropriate use of EBIs.

An HIV prevention protocol reviewed at 15 national sites: how do ethics committees protect communities?

To learn whether ethics committees reviewing community-based participatory research concentrate on the protection of communities, in addition to individual participants, data from 15 sites were analyzed. Eighty-two ethics committee concerns related to consent (35%), protocol procedures (49%), data collection (17%), and HIPAA (6%) were identified. Concerns generally involved individual level subject issues; only 17% were related to community issues. To improve community-level protections in research, the authors recommend that both ethics committee members and research staff receive education concerning protection and respect for communities, that a community member group be established to advise researchers throughout the planning and implementation of community-level studies and that local ethics committee boards include members with community-level experience.

Phase-specific network differences associated with the syphilis epidemic in Baltimore city, 1996-2000.

Objectives: The objective of this study was to determine whether the syphilis epidemic in Baltimore City during the mid-1990s was associated with changes in sexual networks. Methods: Data on index cases of syphilis and their partners were collected from 1996 to 2000 and entered into CDC STD*MIS software. Unique pairs of dyads were used to create networks using SAS Interactive Matrix Language. PAJEK and UCINET were used to analyze the largest component from all years (1996–2000), during the epidemic (1997–1998), and after the epidemic (1999—2000). Results: Between 1996 and 2000, there were 3343 components containing 18,709 nodes. The 2 largest components were comprised of 1103 nodes and 125 nodes, respectively. From the period during the epidemic to after the epidemic, the average distance among reachable pairs, network centralization, number of n-cliques (n = 2, size = 3), and number of k-plexes (k = 2, n = 3) declined, whereas the block densities increased. Conclusions: Important differences exist between the sexual networks during and after the syphilis epidemic.

Exploring Group Composition among Young, Urban Women of Color in Prenatal Care: Implications for Satisfaction, Engagement, and Group Attendance.

PURPOSE Group models of prenatal care continue to grow in popularity. However, little is known about how group composition (similarity or diversity between members of groups) relates to care-related outcomes. The current investigation aimed to explore associations between prenatal care group composition with patient satisfaction, engagement, and group attendance among young, urban women of color. METHODS Data were drawn from two studies conducted in New Haven and Atlanta (2001-2004; n = 557) and New York City (2008-2011; n = 375) designed to evaluate group prenatal care among young, urban women of color. Women aged 14 to 25 were assigned to group prenatal care and completed surveys during their second and third trimesters of pregnancy. Group attendance was recorded. Data were merged and analyzed guided by the Group Actor-Partner Interdependence Model using multilevel regression. Analyses explored composition in terms of age, race, ethnicity, and language. MAIN FINDINGS Women in groups with others more diverse in age reported greater patient engagement and, in turn, attended more group sessions, b(se) = -0.01(0.01); p = .04. CONCLUSION The composition of prenatal care groups seems to be associated with young womens engagement in care, ultimately relating to the number of group prenatal care sessions they attend. Creating groups diverse in age may be particularly beneficial for young, urban women of color, who have unique pregnancy needs and experiences. Future research is needed to test the generalizability of these exploratory findings.

Psychosocial factors influencing the disclosure of sexually transmissible infection diagnoses among female adolescents

BACKGROUND Individuals diagnosed with a sexually transmissible infection (STI) often face psychosocial concerns through which they must navigate to arrive at disclosure decisions. The objective of this study was to qualitatively explore the decision-making process for disclosure of STI diagnoses to sex partners among adolescent females in Baltimore City, MD. METHODS Semi-structured interviews were conducted with 21 African American adolescent females who tested positive for chlamydia and/or gonorrhoea in the previous 3 months. Three individuals also provided audio diaries in which they tape recorded a daily journal discussing their lives and experiences with STIs. RESULTS Female adolescents often do not notify all potentially infected sex partners or tell sex partners all of the STIs to which they may have been exposed. Although participants recognised the importance of informing their sex partner(s) of their STI diagnosis, there were other competing psychosocial factors that influenced their decisions to disclose, such as perceptions of the social consequences of having an STI including fear of stigmatisation and loss of relationship. Such concerns appear to vary by disease and partner type as well as previous STI experience. CONCLUSIONS To increase disclosure of STI diagnoses, clinic counselling strategies to encourage partner notification should seek to engage patients in a dialogue regarding their fears related to their diagnoses, how this might affect their relationships with different types of partners and the individual and social meanings their specific STI diagnosis(es) might hold.