Community empowerment paradigm drift and the primary prevention of HIV/AIDS

Advancing the science of community-level interventions

Community interventions are complex social processes that need to move beyond single interventions and outcomes at individual levels of short-term change. A scientific paradigm is emerging that supports collaborative, multilevel, culturally situated community interventions aimed at creating sustainable community-level impact. This paradigm is rooted in a deep history of ecological and collaborative thinking across public health, psychology, anthropology, and other fields of social science. The new paradigm makes a number of primary assertions that affect conceptualization of health issues, intervention design, and intervention evaluation. To elaborate the paradigm and advance the science of community intervention, we offer suggestions for promoting a scientific agenda, developing collaborations among professionals and communities, and examining the culture of science.

Promoting critical consciousness and social mobilization in HIV/AIDS programmes: lessons and curricular tools from a South African intervention

The development of critical consciousness is seen as a key stage in communities increasing levels of dialogue about priority problems and effecting structural change for health. However, relatively little research identifies concrete methods for programmes to build critical consciousness. We examined how a South African structural intervention used critical consciousness as a tool for prevention of intimate partner violence and HIV infection. We collected qualitative data in the form of in-depth interviews with managers, trainers, and participants of the Intervention with Microfinance for AIDS and Gender Equity intervention (IMAGE) in rural South Africa. The data were analysed through a coding structure developed in QSR NVivo. We draw practical lessons from IMAGE to guide other HIV programmes aiming to promoting critical consciousness and social mobilization. This research suggests that specific curricular tools can work towards critical consciousness and that mobilization efforts in future programmes can be strengthened by including individual and collective efforts by participants.

Critical health literacy: a review and critical analysis

Though there has been a considerable expansion of interest in the health literacy concept worldwide, there has also been criticism that this concept has been poorly defined, that it stretches the idea of "literacy" to an indefensible extent and more specifically, that it adds little to the existing concerns and intervention approaches of the better established discipline of health promotion. This paper takes as a starting point the expanded model of health literacy advanced by Nutbeam (2000) and addresses these concerns by interrogating the concept of "critical health literacy" in order to draw conclusions about its utility for advancing the health of individuals and communities. The constituent domains of critical health literacy are identified; namely information appraisal, understanding the social determinants of health, and collective action, and as far as possible each are clearly delineated, with links to related concepts made explicit. The paper concludes that an appreciation of work undertaken in a range of different disciplines, such as media studies, medical sociology, and evidence-based medicine can enhance our understanding of the critical health literacy construct and help us understand its usefulness as a social asset which helps individuals towards a critical engagement with health information. There is some evidence that aspects of critical health literacy have indeed been found to be a resource for better health outcomes, but more research is needed in this area, both to develop quantitative and qualitative approaches to evaluating health literacy skills, and to offer convincing evidence that investment in programmes designed to enhance critical health literacy are worthwhile.

Inverse probability weighting in sexually transmitted infection/human immunodeficiency virus prevention research: methods for evaluating social and community interventions

BACKGROUND

Intervention effects estimated from nonrandomized intervention studies are plagued by biases, yet social or structural intervention studies are rarely randomized. There are underutilized statistical methods available to mitigate biases due to self-selection, missing data, and confounding in longitudinal, observational data permitting estimation of causal effects. We demonstrate the use of Inverse Probability Weighting (IPW) to evaluate the effect of participating in a combined clinical and social sexually transmitted infection/human immunodeficiency virus prevention intervention on reduction of incident chlamydia and gonorrhea infections among sex workers in Brazil.

METHODS

We demonstrate the step-by-step use of IPW, including presentation of the theoretical background, data set up, model selection for weighting, application of weights, estimation of effects using varied modeling procedures, and discussion of assumptions for use of IPW.

RESULTS

A total of 420 sex workers contributed 840 data points on incident chlamydia and gonorrhea infection. Participators were compared with nonparticipators following application of inverse probability weights to correct for differences in covariate patterns between exposure groups and between those who remained in the intervention and those who were lost-to-follow-up. Estimators using 4 model selection procedures provided estimates of intervention effect between odds ratio 0.43 (95% CI, 0.22- 0.85) and 0.53 (95% CI, 0.26 -1.1).

CONCLUSIONS

After correcting for selection bias, loss-to-follow-up, and confounding, our analysis suggests a protective effect of participating in the intervention. Evaluations of behavioral, social, and multilevel interventions to prevent sexually transmitted infection can benefit by introduction of weighting methods such as IPW.

Cultura e empowerment: promoção à saúde e prevenção da Aids entre prostitutas no Rio de Janeiro

Neste artigo, discutimos as dificuldades encontradas na realização de projetos de promoção à saúde entre grupos marginalizados, a partir de questionários e grupos de discussão realizados no trabalho de prevenção da aids entre prostitutas, no Mangue, no Rio de Janeiro (RJ), em 1989, passando pelas histórias de vida das prostitutas da Praça São João, em Niterói (RJ), e pelo movimento de prostitutas do Rio de Janeiro, durante a década de noventa. Na análise dos dados, observamos que, apesar de a saúde pública ver as prostitutas como um "grupo", estas raramente se viam dessa forma. Ou seja, enquanto a meta das agências de promoção à saúde e do movimento de prostitutas era a de construir uma comunidade de prostitutas que pudesse se organizar, lutando por seus direitos e cidadania, a maioria das prostitutas estudadas tinham uma representação negativa da sua atividade e, consequentemente, criavam narrativas que negavam o seu pertencimento ao grupo das prostitutas. Diante desse impasse, fica evidente a necessidade de se pensar o processo de empowerment e de organização comunitária, sempre levando em conta o contexto cultural do grupo em que se quer promover a saúde.

Tracking the rise of the "expert patient" in evolving paradigms of HIV care

In the context of rolling out antiretroviral treatment programmes in resource-constrained settings, "expert patients" are hailed as an important step towards greater involvement of people living with HIV (PLHIV) in HIV care, and in addressing the human resources crisis. The rise of the "expert patient" in HIV care partly echoes the move towards greater patient agency and self-management that informs health services delivery in industrialised countries. However, the "expert patient" also represents a particular moment in the trajectory of PLHIVs' quest for greater access to treatment and health care. In this paper, we examine the unique evolution and 'instrumentalisation' of PLHIV in public health in relation to shifts in the epidemiology, interventions and socio-political response related to HIV since the 1980s. Synthesised broadly as "risk-based", "empowerment", "structural" and "activist" approaches, four key paradigms are identified that attribute different levels of citizenship for PLHIV, that is the motivation, agency and responsibility to act not only on their own interests, but also on behalf of collective interests in HIV prevention and care. We problematise the concept of the patient-citizen by drawing attention to the context-specificity of such notions as patient identity, capacity and rights as well as the structural realities of access to treatment, and broader engagement with the health system. We conclude by offering some thoughts on the applicability of 'expert patient' approaches across a broad range of settings.

Power and empowerment: fostering effective collaboration in meeting the needs of orphans and vulnerable children

In sub-Saharan Africa, HIV/AIDS has resulted in a rapidly growing population of orphans and vulnerable children (OVC). These OVC have strained the traditional safety net provided by extended families to its breaking point. Increasingly, community-based initiatives are emerging to fill the gap. However, relatively little is known about these efforts and their effectiveness. This article looks at one such initiative in rural Tanzania, and explores the relationship between local communities that seek to empower themselves to address the needs of their OVC and external organisations that have the resources and power to help them. This case study describes the successful effort of a community to build a Centre housing its orphans, and the subsequent closure of that Centre despite its evident success, because of a conflict between internal and external interests. This case study is used as the basis of a broader discussion on how those with power, and communities seeking empowerment, are complexly intertwined.

The impact of social environments on the effectiveness of youth HIV prevention: A South African case study

Few would disagree that 'social context' shapes the effectiveness of HIV-prevention programmes. However much work remains to be done in developing systematic conceptualisations of HIV/AIDS-relevant aspects of social environments in vulnerable communities. This paper contributes to this challenge through a case study (44 interviews, 11 focus groups with 55 people and fieldworker diaries) of the impact of social context on a participatory peer education programme involving young people in a peri-urban community in South Africa. Three interacting dimensions of context undermine the likelihood of effective HIV-prevention. Symbolic context includes stigma, the pathologisation of youth sexuality (especially that of girls) and negative images of young people. Organisational/network context includes patchy networking amongst NGOs, health, welfare and education representatives and local community leaders and groups. This is exacerbated by different understandings of the causes of HIV/AIDS and how to manage it. These challenges are exacerbated in a material-political context of poverty, unemployment and crime, coupled with the exclusion of young people from local and national decision-making and politics. HIV-prevention initiatives seeking to promote health-supporting social environments should work closely with social development programmes to promote young peoples' social and political participation, increase opportunities for their economic empowerment, challenge negative social representations of youth, and fight for greater recognition of their sexuality and their right to protect their sexual health.

Views of young, rural African Americans of the role of community social institutions in HIV prevention

BACKGROUND

We explored rural African American youths' perceptions about the role of community social institutions in addressing HIV.

METHODS

We conducted four focus groups with African Americans aged 16 to 24 years in two rural counties in North Carolina. Groups were stratified by gender and risk status. We used a grounded theory approach to content analysis.

RESULTS

Participants identified four social institutions as primary providers of HIV-related health promotion efforts: faith organizations, schools, politicians, and health agencies. They reported perceiving a lack of involvement in HIV prevention by faith-based organizations, constraints of abstinence-based sex education policies, politicians' lack of interest in addressing broader HIV determinants, and inadequacies in health agency services, and viewed all of these as being counter-productive to HIV prevention efforts.

CONCLUSIONS

Youth have important insights about local social institutions that should be considered when designing HIV prevention interventions that partner with local organizations.

Mobilising a disadvantaged community for a cardiovascular intervention: designing PRORIVA in Yogyakarta, Indonesia

INTRODUCTION

Cardiovascular disease (CVD) is a burden for developing countries, yet few CVD intervention studies have been conducted in developing countries such as Indonesia. This paper outlines the process of designing a community intervention programme to reduce CVD risk factors, and discusses experiences with regard to design issues for a small-scale intervention.

DESIGN PROCESS

THE DESIGN PROCESS FOR THE PRESENT COMMUNITY INTERVENTION CONSISTED OF SIX STAGES: (1) a baseline risk factor survey, (2) design of a small-scale intervention by using both baseline survey and qualitative data, (3) implementation of the small-scale intervention, (4) evaluation of the small-scale intervention and design of a broader CVD intervention in the Yogyakarta municipality, (5) implementation of the broader intervention and (6) evaluation of the broader CVD intervention. According to the baseline survey, 60% of the men were smokers, more than 30% of the population had insufficient fruit and vegetable intake and more than 30% of the population were physically inactive, this is why a small-scale population intervention approach was chosen, guided both by the findings in the quantitative and the qualitative study.

EXPERIENCES

A quasi-experimental study was designed with a control group and pre- and post-testing. In the small-scale intervention, two sub-districts were selected and randomly assigned as intervention and control areas. Within them, six intervention settings (two sub-villages, two schools and two workplaces) and three control settings (a sub-village, a school and a workplace) were selected. Health promotion activities targeting the whole community were implemented in the intervention area. During the evaluation, more activities were performed in the low socioeconomic status sub-village and at the civil workplace.

Challenges, strategies, and lessons learned from a participatory community intervention study to promote female condoms among rural sex workers in Southern China

China faces a rapidly emerging HIV epidemic and nationwide resurgence of sexually transmitted infections associated with a growing sex industry. Community empowerment and capacity building through community-based participatory research partnerships show promise for developing, testing, and refining multilevel interventions suited to the local context that are effective and appropriate to address these concerns. However, such efforts are fraught with challenges, both for community collaborators and for researchers. We have built an international team of scientists from Beijing and the United States and collaborating health policy makers, health educators, and care providers from Hainan and Guangxi Province Centers for Disease Prevention and Control and the local counties and towns where we are conducting our study. This team is in the process of testing a community-wide, multilevel intervention to promote female condoms and other HIV prevention within sex-work establishments. This article presents lessons learned from our experiences in the first two study sites of this intervention trial.

YOUR Blessed Health: a faith-based CBPR approach to addressing HIV/AIDS among African Americans

Despite substantial federal, state, and local efforts to reduce the transmission of HIV/AIDS, African Americans experience higher rates of infection than any other ethnic or racial group in the United States. It is imperative to develop culturally and ecologically sensitive interventions to meet the sexual health needs of this population. Capitalizing on the assets, resources, and strengths of faith-based organizations, YOUR Blessed Health (YBH) is a community-based participatory research project developed to increase HIV/AIDS awareness and reduce HIV-related stigma among the African American faith community in Flint, Michigan. This article describes the historical context and development of YBH, discusses the results of the pilot study, and illustrates how YBH grew into a community mobilization effort led by faith leaders and their congregations to address HIV/AIDS. YBH highlights the importance of developing and testing intervention models that originate from community-based organizations to address complex and sensitive health issues among marginalized populations.

Social-environmental factors and protective sexual behavior among sex workers: the Encontros intervention in Brazil

OBJECTIVES

We sought to determine the association of social-environmental factors with condom use and sexually transmitted infections (STIs) among 420 sex workers participating in an STI/HIV prevention study in Corumbá, Brazil, to inform future intervention efforts.

METHODS

Participants provided urine samples for polymerase chain reaction testing of chlamydia and gonorrhea and responded to multi-item scales addressing perceived social cohesion, participation in networks, and access to and management of resources. We conducted multivariate log-linear and negative binomial regression analyses of these data.

RESULTS

Increased social cohesion was inversely associated with number of unprotected sex acts in the preceding week among women (adjusted incidence rate ratio [IRR] = 0.80; P < .01), and there was a marginal association among men (adjusted IRR = 0.41; P = .08). Women's increased participation in social networks was associated with a decrease in frequency of unprotected sex acts (adjusted IRR = 0.83; P = .04), as was men's access to and management of social and material resources (IRR = 0.15; P = .01). Social-environmental factors were not associated with STIs.

CONCLUSIONS

The social context within which populations negotiate sexual behaviors is associated with condom use. Future efforts to prevent STI/HIV should incorporate strategies to modify the social environment.

Suicide prevention as a community development process: understanding circumpolar youth suicide prevention through community level outcomes

OBJECTIVES

Community-based models have become increasingly prominent in prevention, and have special relevance for suicide prevention in circumpolar Indigenous communities. It follows that outcomes from circumpolar suicide prevention programs might be more completely understood at the community level. We present here a methodology for analysis at this level. This paper seeks to understand a cultural prevention program for rural Yup'ik youth in Alaska targeting suicide and co-occurring alcohol abuse as a community development process through changes at the community level.

STUDY DESIGN

Quasi-experimental design with assessment at pre- and post-intervention or at 4 time points. The community development process for this project began in October 2004. The first program baseline assessment began in November 2006, prior to prevention activities with youth and parents, and the post-intervention assessment concluded in March 2008.

METHODS

Five key informants pre- and post-intervention completed a community readiness assessment, which is a structured procedure assessing a community's awareness of suicide as an issue and its, organizational readiness for prevention programming. Forty-three adult caregivers or sponsors of youth in the prevention program completed an assessment of behaviours that contributed to community protective factors from youth suicide and alcohol abuse at 4 time points before, during and after the intervention. The 54 youth who participated in the prevention program completed an assessment of community protective factors, also at 4 time points before, during and after the intervention. The community protective factors from suicide that were assessed included safety, enforcement of alcohol prohibitions, role models, support and opportunities for youth.

RESULTS

Community readiness for the prevention efforts increased to new developmental stages of readiness post-intervention, and a trend in the data suggested community protective factors increased in the amount of protective behaviours performed by adults (slope estimate = 0.0162, 95% CI--0.0028-0.0351, d=.55) and in the perceptions of youth (slope estimate=0.0148, 95% CI--0.0004-0.0291, d=.45), in a dose response relationship to the number of prevention program sessions attended by adults and youth.

CONCLUSIONS

Using data from a feasibility study, this paper demonstrates the feasibility and potential utility of methodological approaches that use community-level variables beyond individual level outcomes in circumpolar suicide prevention research.

Frustrated Potential, False Promise or Complicated Possibilities? Empowerment and Participation Amongst Female Health Volunteers in South Africa

We present a longitudinal case study of lay women's participation in a project seeking to facilitate home-based care of people dying of AIDS in a rural community in South Africa, drawing on four sets of interviews conducted with volunteers over a five-year period. We link participation in the project to three dimensions of women's agency: their knowledge and skills, their confidence; and their personal experiences of efficacy. We show that whilst the experience of participation enhanced each of these dimensions of volunteers’ agency at various stages of the project, the empowerment that did take place appeared to be limited to women's project-related roles, rather than generalising to other areas of their lives beyond the project. The project had limited impact on women's ability to negotiate condom use with husbands, to assert themselves in relation to male project leaders and to become more involved in wider community decision-making and leadership. We discuss three possible interpretations of our findings: (i) that greater empowerment might have occurred had the project run for a longer time period; (ii) that whilst such projects play a vital role in providing services, the more general ‘empowerment via participation’ agenda is a false promise in highly marginalised communities; or (iii) that whilst generalised positive impacts of such projects on volunteers are hard to track, such projects do open up glimpses of increased agency for many women. These might have positive but unpredictable results in ways that defy formulation in linear conceptualisations of social transformation and development, understood in terms of clearly observable and measurable inputs and outputs.

A descriptive study of empowerment and sexual decision making in HIV-positive African-American women

Empowerment, defined as economic opportunity that lessens dependence, is a unique concept that may affect a woman's sexual decision making. In this analysis taken from a larger statewide study, 91 HIV-positive African-American women were administered a survey to assess factors of empowerment in association with sexual choices. Age, incarceration history, and alcohol use were associated with bartering with sex. Incarceration history and alcohol use were associated with having unprotected sex with someone of unknown serostatus.

Multilevel community-based culturally situated interventions and community impact: an ecological perspective

The purpose of this paper is to apply an ecological perspective to the conduct of multilevel community-based culturally-situated interventions. After a discussion of the emerging consensus about the value of approaching such interventions ecologically, the paper outlines a series of questions stimulated by an ecological perspective that can guide further theory development in conducting multilevel interventions. These questions all derive from the importance of assessing the local community ecology where the intervention occurs. The paper concludes with a series of topics which, taken together, provide a roadmap for further conceptual development of multilevel interventions as vehicles for long-range community impact.

Evaluation of STD/HIV/AIDS peer-education and danger: a local perspective

An evaluation of peer-education projects with sex workers, men who have sex with men and marginalized adolescents, was introduced in a remote region of Brazil. The context of varied limits of predictability made it difficult to conduct inquiry. To go beyond available epidemiological surveys and questionnaires on sexual behavior, a self-evaluation aimed at increasing pragmatic knowledge about prevention in a challenging socio-political context. During five-months, a participatory-action research explored participant observation; individual and collective exchanges with users, peer-educators, coordinators, administrators, politicians and regional health professionals. Collective understanding of peer-education in prostitution zones underlines the reality of unforeseen social repercussions and confluence/divergence of multiple actors' perspectives. It identifies meaningful dimensions at a community-level, such as the collective history and dangerous working conditions. Nurses face complex struggles and negotiations over multiple actors in their practice. This study suggests that nurses have a role to play in the conceptualization of participatory evaluation. It also underlines the threats to their physical and social safety, which they might share with peer-educators.

"You've gotta know the community": minority women make recommendations about community-focused health research

OBJECTIVES

To determine what ethnic and racial minority women recommend as the best approaches to participatory health research in their communities. To achieve this goal, this study focused on HIV prevention research.

METHODS

In 2003, Seven African American and seven Latina women (ages 33 to 52), all members of an HIV Prevention Collaborative Board, participated in individual interviews, lasting about 90 minutes each. Participants discussed their involvement in participatory research, and made recommendations as to how health researchers might better engage their communities. Data were coded independently by two coders following standard procedure for content analysis.

RESULTS

Women's voices and expertise can help guide health-related research. This study shows that: (1) participatory HIV prevention research should be founded on trust and commitment, leading to social support; (2) research partners ought to come from diverse backgrounds and be knowledgeable about the community and willing to work on common objectives; and (3) collaborative partnerships ought to portray an image of strength and cohesion, and a clear articulation of the mission around a research project.

IMPLICATIONS

To develop meaningful health research, researchers need to establish long-term ongoing relationships with community collaborators, including minority women from diverse backgrounds. Researchers ought to take a holistic approach working with communities, and ought to consider their research interests vis-a-vis the community's needs.

The 6-step model for community empowerment: revisited in public housing communities for low-income senior citizens

The 6-step community empowerment model was replicated in communities with different geographical, racial, and age backgrounds from the original application. Resident groups of Blue Ribbon Health Panels (BRHPs) in federally funded senior housing in Pennsylvania followed the 6 steps to identify community health issues, to develop strategies to address priority issues, and to implement the strategies in collaboration with partner agencies. The 6-step model served as an operationalization strategy of community empowerment by facilitating quick accomplishments of communities' desired outcomes, legitimizing and motivating BRHP efforts. Community capacities to actively participate and collaborate influenced the model's progress in this replication study, as did partner agencies' capacities to adhere to the community-based participatory and collaborative orientation of the project. Community capacity development and partnership facilitation would be important for a community empowerment project, as well as consistent and clear communication among everyone involved in the process.

Preventing Mother-to-Child HIV Transmission Among South African Adolescents

Although prevention of mother-to-child HIV transmission (PMTCT) programs are predicated on maternal behavior change, little is known about sociocultural factors affecting maternal—child care practices in this arena. The authors used narrative methods (key informant workshops, questionnaires, focus groups, and case study analysis) to explore how sociocultural context shapes adolescent mothers' ability to adhere to programmatic recommendations in rural and urban South Africa. The study aims were to understand the extent to which mothers' decisions are borne out in PMTCT-related practices and to identify contextual elements that affect the link between individual resolutions and action. The results revealed rural adolescents as less likely than urbanites to successfully implement most PMTCT-related practices. HIV stigma, family decision making, and cultural norms surrounding infant feeding hampered mothers' efforts to implement practices that would decrease the risk for infant infection. Barriers to behavior change were analyzed along four domains: history, culture, gender, and power. Methodological aspects and programmatic implications are discussed.

Promoting child and adolescent mental health in the context of the HIV/AIDS pandemic with a focus on sub-Saharan Africa

BACKGROUND

The pandemic of HIV/AIDS is actually a composite of many regional and national-level epidemics. The progress made in many parts of the developed and developing world is tempered by the continued devastating consequences of HIV infection in sub-Saharan Africa (SSA). This review focuses on the ways in which children and adolescents are impacted by the epidemic, giving particular attention to their mental health.

METHODS

A health promotion framework is adopted to guide analysis. Three issues are covered: prevention of HIV infection, care and treatment of children infected with HIV, and care of children whose caregivers are ill or have died of AIDS. Existing reviews and literature search engines were used to review the scientific literature, focusing on the past five years.

RESULTS

Preventive interventions continue to manifest limited benefits in behavioral changes. More complex causal models and improved behavioral measures are needed. In the African context, the time has come to view pediatric AIDS as a chronic disease in which the mental health of caregivers and children influences important aspects of disease prevention and management. Increasingly sophisticated studies support earlier findings that social and psychological functioning, educational achievement and economic well-being of children who lose parents to AIDS are worse than that of other children.

CONCLUSIONS

Important changes are taking place in SSA in increased access to HIV testing and antiretroviral therapies. To be effective in promoting mental health of children and adolescents, interventions require a more fundamental understanding of how to build HIV competence at personal and community levels. A key recommendation calls for the design and execution of population-based studies that include both multilevel and longitudinal features. Such rigorous conceptual and empirical investigations that assess the capacities of children are required to mobilize children, families and communities in comprehensive actions plans for prevention, treatment and care in response to the enduring HIV/AIDS pandemic.

Application of Empowerment Scale to patients with schizophrenia: Japanese experience

Rogers et al. invented the Empowerment Scale, and conducted a factor analysis, which found five factors: self-esteem, power, activism, righteous anger and optimism. Hata et al. translated this scale into Japanese and named it Empowerment Scale-J. They found that the score of the righteous anger factor does not have a significant correlation with the overall score of the Empowerment Score-J. With the aim of clarifying the characteristics of the Empowerment Scale-J, the purpose of the present study was to assess the levels of empowerment in 72 Japanese patients with chronic schizophrenia using the scale, and examine the relationship between the results of the scale and the results of the following two batteries: Social Adjustment Scale II (SAS II), and Expanded Attributional Style Questionnaire (EASQ; a questionnaire to assess some aspects of attitude toward negative circumstances). Four results were obtained as follows. No significant correlation was found between the score of righteous anger factor and overall score. No significant correlation was found between the Empowerment Scale-J score and the degree of social adjustment. Significant correlations were found between some subscales of Empowerment Scale-J and the degree of social adjustments: self-esteem and optimism, but inverse correlations were obtained between the power factor and the righteous anger factor and the degree of social adjustment. Results for the EASQ showed that subjects with a higher righteous anger score have a tendency opposite to that of subjects with higher social adjustment. On the basis of these results it is suggested that behavior related to the righteous anger among Japanese persons with schizophrenia may have some negative influence on their social adaptation and that in applying Empowerment scale-J attention should be paid to the significance of the righteous anger factor.

Space: the new frontier in HIV prevention for young men who have sex with men

Young men who have sex with men (MSM) in urban areas of the United States continue to be vulnerable to HIV infection. Qualitative data collected with participants in a community level HIV intervention in West Hollywood and Orange County, California, suggest that space -- both actual physical space and the concept of having space -- should be an integral part of an HIV prevention intervention for young MSM. Having such spaces appears to contribute to youth sense of empowerment and efficacy and foster community building, all important components of an effective HIV prevention. Data were drawn from a qualitative research sample of 73. Through narratives, young men describe specific characteristics of the space necessary for effective HIV intervention, including mentoring and supportive staff, tolerant and like-minded peers, information exchange, opportunities for strengthening self-esteem, and a sense of collaborative community invested in social change.

Woman to Woman: Coming Together for Positive Change--using empowerment and popular education to prevent HIV in women

HIV risk is the product of social, cultural, economic, and interpersonal forces that create sex-role definitions and expectations that can lead to gender inequalities in health. Woman to Woman: Coming Together for Positive Change is an HIV/AIDS prevention intervention that takes into account that choices and actions may be constrained by poverty, gender roles, and cultural norms. This project educates and empowers, promotes women's perspectives, reaches women "where they are," and encourages women to speak of their experience. The following study presents the evaluation of the effectiveness of an empowerment based participatory HIV prevention program over a 3-year period, implemented in both rural and urban settings in New Mexico, targeting over 300 women at-risk of HIV/AIDS. In addition, the practicalities of conducting participatory process and outcome evaluation with a small nonprofit with minimal budget will be discussed.

Women who fall by the roadside: gender, sexual risk and alcohol in rural Uganda

AIMS

To investigate community perceptions about the different relationship between alcohol consumption and sexual risk-taking for men and women in a high HIV prevalence African setting.

DESIGN AND SETTING

Participatory learning and action (PLA) activities were conducted in five rural villages in south-western Uganda in 2002. For each village, discussions and visualization activities over the course of 5 days explored local concepts of fun, drinking alcohol and HIV-related behavioural risks. Twelve focus group discussions (FGDs) investigated emerging themes. Analysis is based on visual outputs, observation notes and focus group transcripts.

PARTICIPANTS

Attendance at sex-segregated PLA sessions was open to all village residents. FGDs were purposively sampled from drinkers and general population groups.

FINDINGS

For men, drinking is conducted invariably outside the home, usually at night in bars, emphasizing independence, masculinity and freedom from domestic responsibilities. For women, drinking outside male supervision challenges feminine ideals of domesticity and signifies potential sexual vulnerability. Accepting drinks from men was viewed as signifying assent to sex and refusal could justify men resorting to sexual coercion. Even though drinking is seen to promote sexual risk, HIV prevention campaigns were considered unwelcome in bars. Communities preferred seminars involving drinkers and non-drinkers alike.

CONCLUSIONS

Public drinking in this community serves as a marker for men willing to exercise privileges of independence (sexual and otherwise) and women willing to defy gender norms (and risk the sexual consequences). The social and symbolic context of drinking suggests why effective HIV prevention around alcohol should not be limited to drinking environments alone.

The evaluation of the JEWEL project: an innovative economic enhancement and HIV prevention intervention study targeting drug using women involved in prostitution

The JEWEL (Jewellery Education for Women Empowering Their Lives) pilot study examined the efficacy of an economic empowerment and HIV prevention intervention targeting illicit drug-using women (n=50) who were involved in prostitution in Baltimore, Maryland. The intervention was comprised of six 2-hour sessions that taught HIV prevention risk reduction and the making, marketing and selling of jewellery. Bivariate comparisons examined behaviour change pre- and 3-months post-intervention. The intervention's effect on the change in the number of sex trade partners from baseline to follow-up was explored with multiple linear regression. Participants were 62.0% African American, 5.0% were currently employed, and the median age was 39 years old (Inter Quartile Range [IQR]: 34-45). Women attended an average of six (IQR: 4.5-6.0) sessions. The women sold over $7,000 worth of jewellery in eleven sales. In comparing self-reported risk behaviours pre and 3-month post intervention participation, we found significant reductions in: receiving drugs or money for sex (100% versus 71.0%, p<0.0005); the median number of sex trade partners per month (9 versus 3, p=0.02); daily drug use (76.0% vs. 55.0%, p=0.003); the amount of money spent on drugs daily (US$52.57 versus US$46.71, p = 0.01); and daily crack use (27.3% versus 13.1.0%, p = 0.014). In the presence of other variables in a multivariate linear model, income from the jewelry sale was associated with a reduction in the number of sex trade partners at follow-up. The pilot indicated effectiveness of a novel, HIV prevention, economic enhancement intervention upon HIV sexual risk behaviours and drug utilization patterns.

Latino recruitment and retention strategies: community-based HIV prevention

Latinos are disproportionately affected by HIV/AIDS. The need for community-based AIDS prevention programs that are culture specific is well recognized. Lay Health Advisor (LHA) interventions are a culturally appropriate way to provide information about HIV/AIDS to community members. LHA programs use natural helpers in the community to disseminate information through their social networks. Natural helpers are community members who informally provide support to their neighbors and to whom others naturally turn for advice. This paper reports the recruitment and retention experiences of a Lay Health Advisor Program: Protegiendo Nuestra Familia (Protecting Our Family) for prevention of HIV/AIDS among Latinos in North Carolina.

Reframing research on sexual behavior and HIV

This review of recent studies examines the conceptual and methodological tools that are used to understand sexual behavior and HIV. Whereas surveys have provided reliable indicators of behavior, their validity is uncertain, their correlation with biological indicators tenuous, and the explanations they offer limited. Microlevel research has called into question the rationalizing, medically informed, and risk-averse frameworks used in the public health literature on HIV and behavior, but its impact has been limited. Thus, surveys and qualitative research have proceeded along two separate tracks, and this separation has hampered our understanding of sexual behavior. A small but growing number of studies, however, provide examples of less-compartmentalized research that avoids oversimplification. They show that expanding the models that drive research in this area is possible, and that efforts to combine disciplinary perspectives result in deeper understandings of knowledge, risk perceptions, attitudes, and behavioral change.

Notification of positive HIV test results in Haiti: can we better intervene at this critical crossroads in the life of HIV-infected patients in a resource-poor country?

The current study was conducted in Port au Prince, Haiti, to determine if information collected at HIV notification during voluntary counseling and testing (VCT) can predict patients' future adherence with risk reduction counseling and medical referral. Case histories describe HIV-infected patients with signs of depression during counseling who do not return for medical care, and women afraid of economic ruin and domestic violence who do not notify their sexual partners. Quantitative predictors of seeking medical care include: denial at the announcement of HIV test results (odds ratio [OR] 0.3, 95% confidence interval [CI] 0.1-0.6), belief that HIV can be transmitted by magic (OR 0.6, 95% CI 0.3-0.9), and having symptoms at the time of HIV testing (OR 1.9, 95% CI 1.6-2.3). Predictors of refusal to notify sexual partner of HIV status include: being poor (OR 1.8, 95% CI 1.1-2.5), female (OR 2.1, 95% CI 1.7-2.5), and belief that HIV can be transmitted by magic (OR 2.3, 95% CI 1.9-2.6) In conclusion, information collected during HIV counseling and testing can predict patients' future adherence with counseling and medical referral. Counselors can use information such as signs of severe depression, economic hardship, and denial of HIV disease to identify patients at risk for nonadherence and to provide them with specialized counseling and care.

The Sonagachi Project: a sustainable community intervention program

High rates of HIV infection among sex workers in India indicate the importance of understanding the process of establishing a sustainable community intervention program. The Sonagachi Project, based in Calcutta, India, has been associated with lower HIV rates among sex workers as compared to other urban centers in India. The program defined HIV as an occupational health problem and included multifaceted, multilevel interventions addressing community (having a high-status advocate; addressing environmental barriers and resources), group (changing social relationships), and individual factors (improving skills and competencies related to HIV prevention and treatment). The Sonagachi Project's core concepts and strategies evolved as community needs were expressed and defined. In particular, the program was not initially conceptualized as a community empowerment project but emerged over time, allowing for project sustainability. Project components appear to be replicable across settings within India and worldwide.

Protection and participation: an interactive programme introducing the female condom to migrant sex workers in Cambodia

The female condom has received much attention for its potential to empower users in negotiating safer sex. Studies demonstrate that the process used to introduce the method can influence subsequent use rates, resulting in calls for comprehensive documentation of introduction activities. This paper details an intervention study introducing the female condom to Vietnamese sex workers in Cambodia. Part of a wider community mobilization approach to reducing HIV/AIDS transmission, the intervention emphasized informed debate, group skills building and collective support. Research methods included both quantitative and qualitative data collection to evaluate the introduction's effect on sex workers' negotiation skills and social support networks. The findings show that approximately 16% of sex workers tried the female condom. Ever-use was significantly associated with participation in intervention workshops, and with indicators of both individual and community empowerment. Sex workers who incorporated the female condom into their work were also more likely to feel a sense of community identity. Introduced through an appropriate process, the female condom can serve as an 'entry point' to building community capacity. It can support sex workers in achieving protected sex and developing cooperative relationships, even in severely restrictive settings.

Collaboration and social inquiry: multiple meanings of a construct and its role in creating useful and valid knowledge

The concept of collaboration in community research and intervention, although not new, has grown tremendously in importance in the past 20 years. Yet, it is both a contested concept in terms of its intent and a still evolving idea in terms of its meaning and implications. The purpose of this monograph is to begin to "unpack" the collaboration construct in terms of its many meanings, rationales, goals, models, dynamics, and accomplishments. Although models of collaboration are often well articulated there is "partial paradigm acquisition" (E. J. Trickett, 1984) in terms of understanding their behavioral and ethical implications. There is more theology than conclusion. The promise of collaboration, although considerable, is still in need of multiple and varied empirical examples of how collaboration contributes to both the process and goals of community research and intervention, however defined. The monograph closes with a brief overview of what we have learned from reviewing this literature, an articulation of the kinds of questions that need to be addressed, and a series of recommendations for how to increase our understanding of the collaboration construct in community research and intervention.

Community group participation:

The lifetime risk of acquiring HIV infection in many rural as well as urban areas of southern Africa is currently as high as two-in-three. For women, much of this risk still accrues rapidly at young ages despite high levels of knowledge about HIV/AIDS. Thus, programmes that are more participatory and address underlying structural and community-level factors appear to be essential. We use cross-sectional data from a large-scale, population-based survey in rural eastern Zimbabwe to describe the relationships between membership of different forms of community group and young women's chances of avoiding HIV. Our results show that participation in local community groups is often positively associated with successful avoidance of HIV, which, in turn, is positively associated with psychosocial determinants of safer behaviour. However, whether or not these relationships hold depends on a range of factors that include how well the group functions, the purpose of the group, and the education level of the individual participant. We identify factors that may influence the social capital value of community groups in relation to HIV prevention at the individual, group, and community levels. Young women with secondary education participate disproportionately in well-functioning community groups and are more likely to avoid HIV when they do participate. Longitudinal studies are needed: (i) to establish whether community group membership supports the development of safer lifestyles or merely has greater appeal to individuals already predisposed towards such lifestyles, and (ii) to pinpoint directions of causality between hypothesised mediating factors. In-depth research is needed on the specific qualities of community groups that enhance their contribution to HIV control. However, our findings suggest that promotion of and organisational development and training among community groups could well be an effective HIV control strategy.

Addressing the "risk environment" for injection drug users: the mysterious case of the missing cop

Ecological models of the determinants of health and the consequent importance of structural interventions have been widely accepted, but using these models in research and practice has been challenging. Examining the role of criminal law enforcement in the "risk environment" of injection drug users (IDUs) provides an opportunity to apply structural thinking to the health problems associated with drug use. This article reviews international evidence that laws and law enforcement practices influence IDU risk. It argues that more research is needed at four levels--laws; management of law enforcement agencies; knowledge, attitudes, beliefs, and practices of frontline officers; and attitudes and experiences of IDUs--and that such research can be the basis of interventions within law enforcement to enhance IDU health.

'It was like my little acorn, and it's going to grow into a big tree': a qualitative study of a community support project

Government initiatives aimed at reducing health inequalities and combating poverty amongst families increasingly take an area-based approach, and seek to involve local families in building community capacity. Sure Start is one such initiative, and was set up to develop services for pre-school children and their families, and improve child health and well-being. Based on a local evaluation of a Sure Start programme, the present paper describes the development of a community support project aimed at engaging local people in supporting the parents and carers of young children. This paper draws on qualitative data to explore stakeholders' experiences of the project. These are then described from two main perspectives: the personal and the wider community. It also explores the organisational conditions necessary to encourage lay involvement in such initiatives. The paper concludes that policies aimed at involving local people in delivering services to families need to take account of long-standing structural problems in disadvantaged communities if they are not to be perpetuated.

Addressing urban health in Detroit, New York City, and Seattle through community-based participatory research partnerships

OBJECTIVE

This study describes key activities integral to the development of 3 community-based participatory research (CBPR) partnerships.

METHODS

We compared findings from individual case studies conducted at 3 urban research centers (URCs) to identify crosscutting adaptations of a CBPR approach in the first 4 years of the partnerships' development.

RESULTS

Activities critical in partnership development include sharing decision-making, defining principles of collaboration, establishing research priorities, and securing funding. Intermediate outcomes were sustained CBPR partnerships, trust within the partnerships, public health research programs, and increased capacity to conduct CBPR. Challenges included the time needed for meaningful collaboration, concerns regarding sustainable funding, and issues related to institutional racism.

CONCLUSIONS

The URC experiences suggest that CBPR can be successfully implemented in diverse settings.

The impact of utilizing HIV-positive speakers in AIDS education

A longitudinal matched control study was conducted to evaluate the effects on young people (n = 1,280) of talks by HIV-positive speakers who disclose their personal perspective of living with HIV. Focus-group discussions with students (n = 117) were used to elucidate the impact. Meeting HIV-positive people decreased fear and prejudice, reinforced messages about protective behavior and increased the belief that HIV is preventable. Improved attitudes after talks by females remained significant over 3 months. Speakers changed perceptions, broke down stereotypes, and made students realize that anybody is vulnerable to infection. The speaker provided an anonymous, nonjudgmental person to whom young people could easily relate. They opened the doorway to discussions about AIDS. AIDS interventions must focus on recruiting, supporting and training young articulate HIV-positive people, particularly females, to deliver sex education to in- and out-of-school youths. HIV-positive speakers have an essential role to play in AIDS prevention and must be utilized appropriately.

Ethnic identities, social capital and health inequalities: factors shaping African-Caribbean participation in local community networks in the UK

This paper examines the impact of ethnic identity on the likelihood of peoples' participation in local community networks, in the context of recent policy emphasis on the participation of marginalised communities in such networks as a means of reducing health inequalities. Conceptually, the paper is located against the background of debates about possible links between health and social capital--defined in terms of grassroots participation in local community networks--and an interest in the way in which social exclusion impacts on social capital. The paper draws on lengthy semi-structured, open-ended interviews with 25 African-Caribbean residents of a deprived multi-ethnic area of a south England town. While African-Caribbean identity played a central role in peoples' participation in inter-personal networks, this inter-personal solidarity did not serve to unite people at the local community level beyond particular face-to-face networks. Levels of participation in voluntary organisations and community activist networks were low. Informants regarded this lack of African-Caribbean unity within the local community as a problem, saying that it placed African-Caribbean people at a distinct disadvantage--furthering their social exclusion through limiting their access to various local community resources. The paper examines the way in which the construction of ethnic identities--within a context of institutionalised racism at both the material and symbolic levels--makes it unlikely that people will view local community organisations or networks as representative of their interests or needs, or be motivated to participate in them. Our findings highlight the limitations of policies which simply call for increased community participation by socially excluded groups, in the absence of specific measures to address the obstacles that stand in the way of such participation.

Peer education, gender and the development of critical consciousness: participatory HIV prevention by South African youth

Despite the growing popularity of participatory peer education as an HIV-prevention strategy worldwide, our understandings of the processes underlying its impact on sexual norms are still in their infancy. Starting from the assumption that gender inequalities play a key role in driving the epidemic amongst young people, we outline a framework for conceptualizing the processes underlying successful peer education. We draw on the inter-locking concepts of social identity, empowerment (with particular emphasis on Freire's account of critical consciousness) and social capital. Thereafter we provide a critical case study of a school-based peer education programme in a South African township school, drawing on a longitudinal case study of the programme, and interviews and focus groups with young people in the township. Our research highlights a number of features of the programme itself, as well as the broader context within which it was implemented, which are likely to undermine'the development of the critical thinking and empowerment which we argue are key preconditions for programme success. In relation to the programme itself, these include peer educators' preference for didactic methods and biomedical frameworks, unequal gender dynamics amongst the peer educators, the highly regulated and teacher-driven nature of the school environment and negative learner attitudes to the programme. In relation to the broader context of the programme, we point to factors such as limited opportunities for communication about sex outside of the peer educational setting, poor adult role models of sexual relationships, poverty and unemployment, low levels of social capital and poor community facilities. We discuss the implications of our findings for the design of peer educational activities, and point to a number of broader social and community development initiatives that would maximize the likelihood of programme success.

Exploring the community response to a randomized controlled HIV/AIDS intervention trial in rural Uganda

Investigators need, both for ethical and methodological reasons, to consider the acceptability of their intervention to the study population. We explored the response to a community-based randomized controlled trial (RCT) of an HIV/AIDS behavioral change intervention in rural Uganda. The views of field-workers, trial community, nongovernment organization representatives, and religious leaders were explored via focus groups (13) and interviews (45). The results suggest that the components of the intervention valued by the community are not necessarily those prioritised by trial implementers. Specifically, prevention activities appear to be valued less than material assistance. Furthermore, universal acceptance of the trial is probably unattainable. For these reasons, sensitive mobilization, respect for community members and their appointed leaders, and ongoing communication is essential. We suggest that evaluations of process be regarded as essential to the conduct of community-based RCTs and highlight the need for appropriate evaluation indicators to facilitate this.

Is social capital a useful conceptual tool for exploring community level influences on HIV infection? An exploratory case study from South Africa

This paper reports on an exploratory study investigating links between sexual health and social capital in a South African mining community. In this study, social capital is defined in terms of people's membership of voluntary community organizations (e.g. church, residents' associations, youth groups). Using biomedical and social survey data from a stratified random sample of 1,211 Carletonville residents, we tested the hypothesis that organizational members were less likely to have HIV. Multivariate analysis of variance sought to identify significant associations between nine organizational memberships and HIV infection, as well as three risk factors for infection (casual partners, condom use with casual partners and alcohol consumption). Analysis yielded a range of significant results, but findings varied across age and gender, and were not all in the hypothesized direction. For example, young men and young women who belonged to sports clubs were less likely to be HIV-positive, and young women who belonged to sports clubs were more likely to use condoms with casual partners than non-members. Amongst members of stokvels (voluntary savings clubs accompanied by social festivities), however, young men were more likely to be HIV-positive, women of all ages were more likely to have a casual partner, and both young men and young women were more likely to drink alcohol than non-members. While our exploratory study has produced sufficient evidence to justify the need for further research in this area, it also highlights that the interface between HIV infection and social capital is a complex area that defies easy generalization.

What is community? An evidence-based definition for participatory public health

Increased emphasis on community collaboration indicates the need for consensus regarding the definition of community within public health. This study examined whether members of diverse US communities described community in similar ways. To identify strategies to support community collaboration in HIV vaccine trials, qualitative interviews were conducted with 25 African Americans in Durham, NC; 26 gay men in San Francisco, Calif; 25 injection drug users in Philadelphia, Pa; and 42 HIV vaccine researchers across the United States. Verbatim responses to the question "What does the word community mean to you?" were analyzed. Cluster analysis was used to identify similarities in the way community was described. A common definition of community emerged as a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings. The participants differed in the emphasis they placed on particular elements of the definition. Community was defined similarly but experienced differently by people with diverse backgrounds. These results parallel similar social science findings and confirm the viability of a common definition for participatory public health.