Structural-level Interventions Research Articles

An Examination of Spatial Concentrations of Sex Exchange and Sex Exchange Norms Among Drug Users in Baltimore, Maryland

Baltimore, Maryland, consistently ranks highest nationally in rates of sexually transmitted diseases and sexually transmitted infections (STDs/STIs) and human immunodeficiency virus (HIV) infection. Prior studies have identified geographic areas where STI and HIV infection in the city is most prevalent. It is well established that sex exchange behavior is associated with HIV and STIs, yet it is not well understood how sex exchangers are spatially distributed within the high-risk areas. We sought to examine the spatial distribution of individuals who report sex exchange compared to those who do not exchange. Additionally, we examined the spatial context of perceived norms about sex exchange. Data for the study came from a baseline sample of predominately injection drug users (n = 842). Of these, 21 percent reported sex exchange in the prior ninety days. All valid baseline residential addresses of recruited participants living within Baltimore City boundaries were geocoded. The multidistance spatial cluster analysis (Ripley's K-function) was used to separately calculate the K-functions for the addresses of recruited participants reporting sex exchange versus non-sex exchange. Evidence of spatial clustering of sex exchangers was observed and norms aligned with these clusters. Of particular interest was the high density of sex exchangers in one specific housing complex of East Baltimore, which happens to be the oldest in Baltimore. These findings can inform targeted efforts for screening and testing for HIV and STIs and placement of both individual and structural-level interventions that focus on increasing access to risk reduction materials and changing norms about risk behaviors.

Commentary on Harris & Rhodes (2012): Discouraging syringe re-use by addressing drug injectors’ everyday suffering

Commentary on Harris & Rhodes (2012): Discouraging syringe re-use by addressing drug injectors’ everyday suffering

College Graduation Reduces Vulnerability to STIs/HIV among African-American Young Adult Women

African-American women are disproportionately affected by sexually transmitted infections (STIs), including HIV. The Theory of Gender and Power (TGP) posits that socioeconomic exposures, including educational attainment, place women at increased risk for STIs/HIV. This study examined the association between educational attainment and vulnerability to STIs/HIV, as well as potential TGP-driven mediators of this association, among African-American women. Baseline data were assessed from an STI/HIV prevention intervention for African-American women (n = 848) aged 18 to 29 recruited from three Kaiser Permanente Centers in Atlanta, Georgia. Data collection included a survey of demographic, psychosocial, and behavioral measures and self-collected, laboratory-confirmed vaginal swabs for STIs (trichomoniasis, chlamydia, gonorrhea, and human papillomavirus). Multiple regression analyses and multivariate mediation analyses were used to examine the association between educational attainment with a laboratory-confirmed STI and potential TGP mediators. Controlling for age and receipt of public assistance, the odds of an STI diagnosis were 73% lower among participants with a college degree or greater compared with participants who had not completed high school. There were also significant associations between educational attainment and multiple TGP mediators from the sexual division of power and the structure of cathexis. TGP constructs did not mediate the association between educational attainment and laboratory-confirmed STI. The current study suggests that graduating from college may lead to a beneficial reduction in vulnerability to STIs/HIV among African-American women. Findings from this study support expanding structural-level interventions, emphasizing both high school and college graduation, as a means of reducing vulnerability to STIs/HIV among African-American women.

Reasons for and correlates of antiretroviral treatment interruptions in a cohort of patients from public and private clinics in southern India

Understanding the prevalence and correlates of treatment interruptions (TIs) in resource-limited settings is important for improving adherence. HIV-infected adults on highly active antiretroviral therapy (HAART) in Bangalore, India, were enrolled into a prospective cohort study assessing HAART adherence. Participants underwent a structured interview assessing adherence, including occurrence of TI > 48 hours since HAART initiation, length of TI, and self-reported reasons for TI. Serum HIV viral load (VL) and CD4 was measured at 6-month intervals. Baseline data are presented in this article. For the 552 participants mean age was 37.8, 32% were female, 70% were married, 45% earned < $2/day. Eighty-four percent were on nevirapine-based antiretroviral therapy; median duration on HAART was 18 months (range: 1–175) and median CD4 count was 318 cells/µl (IQR: 195–460) at time of study enrollment. Twenty percent (n=110) reported at least one TI; of these, 33% (n=36) reported more than one TI. Median length of most recent TI was 10 days (range: 2–1095). TI was associated with a higher probability of having VL > 400 copies/ml (43% versus 12%; p<0.001). After controlling for time on HAART, TI was more likely among those who were unmarried (OR: 1.9; CI: 1.2–3.1), those treated in a private clinic setting (OR: 2.7; CI: 1.6–4.6 compared with public, and OR: 4.1; CI: 1.9–9.0 compared with public–private setting), and those on efavirenz-based therapy (OR: 2.0; CI: 1.1–3.6). The most common self-reported reason for TI was “side effects” (n=28; 25%), followed by cost of therapy (n=24; 22%). We discuss implications for both individual and structural level interventions to reduce TIs.

Community-Level Determinants of Tobacco Use Disparities in Lesbian, Gay, and Bisexual Youth

To determine whether characteristics of the social environment surrounding lesbian, gay, and bisexual (LGB) youth contribute to their rates of tobacco use after controlling for established community-level risk factors. Cross-sectional. Population-based study of youth. A total of 31,852 eleventh-grade students (1413 LGB individuals [4.44%]) in Oregon completed the Oregon Healthy Teens survey in 2006-2008. We created a composite index of the social environment in 34 Oregon counties. This measure included the proportion of same-sex couples, the presence of gay-straight alliances in schools, and school policies (nondiscrimination and antibullying) that specifically protected LGB students. Any tobacco use in the past 30 days. A more supportive social environment for LGB youth was significantly associated with reduced tobacco use (odds ratio, 0.92; 95% confidence interval, 0.90-0.94). This effect remained robust after controlling for sociodemographic variables and multiple community-level risk factors for tobacco use, including median county-level income, exposure to cigarette advertisements, exposure to teacher and peer smoking in schools, and school smoking rules. This study documents an association between an objective measure of the social environment and sexual orientation-related disparities in tobacco use. These results highlight the need for structural-level interventions that reduce smoking behaviors in LGB youth.

Residential trajectory and HIV high-risk behaviors among Montréal street youth--a reciprocal relationship.

Evidence has linked residential instability and engagement in high-risk behaviors. This paper longitudinally examines the relationship between changes in residential stability and changes in HIV risk behaviors among Montréal street youth (SY). Between April 2006 and May 2007, 419 SY (18-25years old) were recruited in a cohort study. SY (using Montréal street youth agencies services) were eligible if they had had at least one 24-hour episode of homelessness in the previous 30days. Baseline and follow-up interviews, carried out every 3months, included completion of a questionnaire (based on Life History Calendar Technique) assessing daily sleeping arrangements since the last interview, and monthly sexual and drug use behaviors. Using mixed-effects logistic regression method, we examined the association between various risk behaviors and residential stability, reached when a youth resided in any of the following settings for a whole month: own place; friends'/partner's/parent's place; any types of housing service (excluding emergency shelters). Analyses were carried out controlling for gender, age, education level, lifetime duration of homelessness, childhood sexual trauma, and lifetime mental health disorders. As of January 2009, 360 SY (79% boys) had completed at least one follow-up interview, representing 4,889months of follow-up. Residential stability was significantly associated with the following: sex exchange (adjusted odd ratio [AOR], 0.25; 95% confidence interval [CI], 0.14-0.37), drug injection (AOR, 0.55; CI, 0.33-0.76), daily alcohol consumption (AOR, 0.58; CI, 0.42-0.74), polydrug consumption (AOR, 0.61; CI, 0.50-0.73), polydrug consumption excluding marijuana (AOR, 0.55; CI, 0.45-0.65), and multiple sex partners (≥3 partners; AOR, 0.57; CI, 0.40-0.74). Our results suggest a reciprocal relationship between residential instability and HIV risk behaviors. This calls for more integrated services combining both individual and structural-level interventions to improve the health of street youth.

Efficacy of Structural-Level Condom Distribution Interventions: A Meta-Analysis of U.S. and International Studies, 1998–2007

This systematic review examines the overall efficacy of U.S. and international-based structural-level condom distribution interventions (SLCDIs) on HIV risk behaviors and STIs and identifies factors associated with intervention efficacy. A comprehensive literature search of studies published from January 1988 through September 2007 yielded 21 relevant studies. Significant intervention effects were found for the following outcomes: condom use, condom acquisition/condom carrying, delayed sexual initiation among youth, and reduced incident STIs. The stratified analyses for condom use indicated that interventions were efficacious for various groups (e.g., youth, adults, males, commercial sex workers, clinic populations, and populations in areas with high STI incidence). Interventions increasing the availability of or accessibility to condoms or including additional individual, small-group or community-level components along with condom distribution were shown to be efficacious in increasing condom use behaviors. This review suggests that SLCDIs provide an efficacious means of HIV/STI prevention.

Pathways to depression: The impact of neighborhood violent crime on inner-city residents in Baltimore, Maryland, USA

Crime and neighborhood disorder may negatively impact the health of urban residents. Neighborhoods with high levels of violent crime may also increase residents' risk of experiencing violence. Most studies supporting the assertion that neighborhood disorder impacts mental health have used residents' own ratings of their neighborhoods. The present study examines the relationships among block-group level crime, perceived neighborhood disorder, violence experienced in the neighborhood, and depression. The sample comprising the current and former drug users ( n = 786) nested in 270 block groups within Baltimore, Maryland, USA. Using path analysis, we tested the hypothesis that neighborhood violent crime has a direct impact on experiences of violence. Also, we hypothesized that neighborhood violence had a direct and indirect impact on depressive symptoms. Results support a model in which violence is associated with psychological distress through perceptions of neighborhood disorder, and through experiences of violence. We conclude that community and structural level interventions are needed to decrease neighborhood crime and improve residents' perception of their neighborhood.

Continuing Medical Education (CME) credits

Substance use is highly prevalent among transgender (trans*) females and has been associated with negative health outcomes, including HIV infection. Little is known about psychosocial risk factors that may influence the onset of substance use among trans*female youth, which can contribute to health disparities during adulthood.We conducted a secondary data analysis of a study on HIV risk and resilience among trans*female youth (N = 292). Prevalence of substance use was assessed and multivariable logistic regression models were used to examine the relationship between posttraumatic stress disorder (PTSD), psychological distress, gender-related discrimination, parental drug or alcohol problems (PDAP) and multiple substance use outcomes.Most (69%) of the trans*female youth reported recent drug use. In multivariable analyses, those with PTSD had increased odds of drug use [AOR = 1.94 (95% CI = 1.09–3.44)]. Those who experienced gender-related discrimination had increased odds of drug use [AOR = 2.28 (95% CI = 1.17–4.44)], drug use concurrent with sex [AOR = 2.35 (95% CI = 1.11–4.98)] and use of multiple drugs [AOR = 3.24 (95% CI = 1.52–6.88)]. Those with psychological distress had increased odds of using multiple heavy drugs [AOR = 2.27 (95% CI = 1.01–5.12)]. Those with PDAP had increased odds of drugs use [AOR = 2.62 (95% CI = 1.43–4.82)], drug use concurrent with sex [AOR = 2.01 (95% CI, 1.15–3.51)] and use of multiple drugs [AOR = 2.10 (95% CI = 1.22–3.62)].Substance use is highly prevalent among trans*female youth and was significantly associated with psychosocial risk factors. In order to effectively address substance use among trans*female youth, efforts must address coping related to gender-based discrimination and trauma. Furthermore, structural level interventions aiming to reduce stigma and gender-identity discrimination might also be effective.

Policy Perspectives on Public Health For Mexican Migrants in California

This analysis focuses on public policies that affect primary HIV prevention and access to HIV care for Mexican migrants residing in California. Policy or structural level interventions, as opposed to behavioral or psychologic interventions, help to shape the environment in which people live. We use a conceptual model for policy analysis in public health to understand better the challenges faced by Mexican migrants. We assess potential policy level interventions that may serve as barriers to or facilitators of primary HIV prevention and care for Mexican migrants. Among potential barriers, we discuss restrictions on public health services based on legal immigration status, limits placed on affirmative action in education, and laws limiting travel and immigration. Under potential facilitators, we discuss community and migrant health centers, language access laws, and the use of community-based groups to provide prevention and treatment outreach. We also report on the limited research evaluating the implications of these public policies and ways to organize for more responsive public policies.

Prevention interventions with persons living with HIV/AIDS: challenges, progress, and research priorities.

Prevention interventions with persons living with HIV/AIDS: challenges, progress, and research priorities.

Georgia prenatal care providers' perceptions of barriers to sexually transmitted disease screening.

Evidence suggests that sexually transmitted disease (STD) screening during pregnancy is not optimal. No published studies have systematically examined barriers that hinder routine STD screening. This study examines prenatal care providers' perceptions about barriers to routine STD screening of pregnant women. Using a conceptual framework, four a priori barrier categories were developed: provider, patient, organizational, and structural. Responses to a question on barriers to STD screening in a 1998 mail survey of Georgia prenatal care providers were qualitatively classified into one of these categories. Of the 293 providers who responded, 71% identified structural barriers, with 52% citing inadequate reimbursement. These respondents were most likely to name barriers categorized as structural, not patient, provider, or organization issues. Efforts to improve STD screening of pregnant women should include a focus on structural level interventions, such as instituting health care policies that provide adequate reimbursement for routine STD screening during pregnancy.

A Theoretical Approach to Bathhouse Environments

Summary HIV prevention guidelines have aimed primarily at the individual level, although recently the field of public health has begun to focus more on structural level interventions. This paper explores an application of Rudolf Moos' person-environment theory as one model that helps to provide an understanding of the dynamic relationship between bathhouse patrons and the environment within which they engage in sexual activities. Understanding how different dimensions of the environment affect behavior could be instrumental in revealing not just that a bathhouse intervention works, but how it works. Knowing more about how an intervention works would facilitate its application in other settings.

Joined–up Food Policy? The Trials of Governance, Public Policy and the Food System

To address the policy malfunctions of the recent past and present, UK food policy needs to link policy areas that in the past have been dealt with in a disparate manner, and to draw on a new ecological public health approach. This will need a shift within the dominant trade liberalization–national economic competitiveness paradigm that currently informs UK food policy, and the international levels of the EU and the WTO trade rules, and grants the large corporate players in the food system a favoured place at the policy–making tables. The contradictions of the food system have wrought crises that have engendered widespread institutional change at all levels of governance. Recent institutional reforms to UK food policy, such as the FSA and DEFRA, reflect a bounded approach to policy integration. Initiatives seeking a more integrated approach to food policy problems, such as the Social Exclusion Unit’s access to shops report, and the Policy Commission on the Future of Food and Farming, can end up confined to a particular policy sector framed by particular interests—a process of “policy confinement”. However, the UK can learn from the experience of Norway and Finland who have found their own routes to a more joined–up approach to public health and a sustainable food supply by, for example, introducing a national food policy council to provide integrated policy advice. Also, at the local and community levels in the UK, policy alternatives are being advanced in an ad hoc fashion by local food initiatives. More structural–level interventions at the regional and local governance levels are also needed to address the social dimensions of a sustainable food supply

Structural interventions to encourage primary HIV prevention among people living with HIV.

This analysis focuses on primary prevention for people living with HIV and the importance of actively involving HIV-infected people in developing prevention strategies. Structural-level or policy interventions--as opposed to behavioral or psychological interventions--help shape the world in which HIV-infected people live. Thus, we assess potential policy-level interventions that may serve either as a barrier to or a facilitator of primary HIV prevention from the perspective of the people living with HIV. Among potential barriers, we discuss criminalization of nondisclosure in specific sexual situations, laws limiting travel and immigration, name-based HIV reporting and mandatory partner notification. Under potential facilitators, we discuss confidentiality laws, antidiscrimination protections, expansion of HIV primary care, and primary prevention programs designed to actively involve infected people. Ultimately, whether any given policy is a 'barrier' or 'facilitator' of primary HIV prevention is an empirical question, dependent on the acceptability of an intervention to those already infected and those at risk, thus policy research evaluating the impact of structural factors on people living with HIV is encouraged.

An STD/HIV prevention intervention framework.

Historically, interventions to prevent STD/HIV transmission have been categorized by program methodology rather than defining the content and nature of the intervention. A new taxonomy is needed to help expand the scope of interventions that can be used to prevent STD and HIV transmission. The taxonomy defines two major types of interventions, individual-level and structural level. The former targets risk factors attributable to individuals. Structural interventions target conditions outside the control of the individual. Individual-level interventions focus on counseling, screening, and treatment. They include psychological and biological interventions. Structural-level interventions address accessibility of relevant consumer products (condoms, needles), physical structures (e.g. blighted and abandoned housing, lighting, design of social facilities), social structures (policies that facilitate or constrain behaviors such as supervision of youth, and enforcement of alcohol beverage laws); and media messages (messages and images in the broadcast and print media that portray high-risk behaviors as positive and without serious consequences). A new taxonomy not only clarifies the content of preventive interventions but highlights neglected strategies involving individual biological interventions and structural interventions to prevent STD/HIV transmission.