Adaptation and implementation of HoMBReS: a community-level, evidence-based HIV behavioral intervention for heterosexual Latino men in the midwestern United States

Community-Based Participatory Research to Promote Health Equity Among Sexual and Gender Minorities in the US South: Research Laureate Address

Sexual and gender minorities (SGM), including lesbian, gay, bisexual, transgender, and queer (LGBTQ+), communities, continue to face profound health disparities in the United States and globally. Although the terms SGM and LGBTQ+ are used as umbrella terms, the populations they describe are highly diverse. Currently, SGM persons are increasingly open and visible in the United States and many other parts of the world, and a modest body of knowledge on the health and well-being of some SGM subgroups currently exists. However, significant gaps exist in the emerging knowledge base, and there remains a profound need to promote health equity and reduce disparities. I am committed to advancing health behavior research to promote health equity and reduce disparities using community-based participatory research (CBPR) approaches. In this paper, based on the address I gave at the Scientific Meeting of the American Academy of Health Behavior (AAHB) on April 14, 2024, I describe what inspires me, a few things I have learned so far, and my future directions as I continue to partner with SGM communities to address health equity and reduce health disparities.

Characteristics of Sexual Health Programs for Migrants, Refugees, and Asylum Seekers: A Scoping Review

BACKGROUND

Social, cultural, and structural determinants of health for migrants, refugees, and asylum seekers can contribute towards poorer sexual health outcomes. People from migrant, refugee, and asylum seeker backgrounds usually use less mainstream sexual healthcare services and have lower levels of sexual health literacy compared with the destination countries' general population. However, there is little collated knowledge about sexual health programs that have been implemented to improve sexual health among these groups. This study aimed to describe the characteristics of programs for improving sexual health among migrants, refugees, and asylum seekers.

METHODS

This study was a scoping review in which Scopus and PubMed were searched for peer-reviewed articles published in English since 2010 from countries similar to and including Australia such as New Zealand, the United States of America, Canada, the United Kingdom, and European Union countries). The final search of databases was performed on 26 June 2023, and resultant studies were inputted into Endnote and Covidence systematic review software to remove duplicates before screening. The study utilised a qualitative approach using inductive thematic analysis of the content of the studies to extract and categorise the characteristics of the program.

RESULTS

A total of 3044 articles were screened and 20 were included for data extraction. The included studies were conducted in six countries (the United States of America, Australia, France, Italy, Denmark, and Belgium). The key characteristics of sexual health programs identified included consumer consultation and engagement, cultural appropriateness, language support, peer education, self-directed learning, group learning, financial support, and outreach services. the programs had a combination of these characteristics to ensure that they can improve target population engagement with educational materials and decrease barriers to accessing sexual healthcare.

CONCLUSION

Consideration of migrants, refugees, and asylum seekers' culture, language, socioeconomic characteristics, and access to information and services in the design of the sexual health programs may improve sexual health outcomes among these groups. However, further research is needed to assess the importance and implementation feasibility of the identified characteristics for sexual health programs in specific context.

Family-based Interventions of Preventing Substance Use Among Immigrant Youth: A Scoping Review

Introduction

Immigrant youth face heightened risks of substance use due to the stress associated with immigration and acculturation. While parental intervention can have a preventative impact on substance use, parents need to be well-informed about substance use and effective interventions that can prevent substance use among immigrant youth. Such interventions ought to be culturally sensitive, family-based, and targeted at the specific substances that are prevalent in a given context. Identifying and curating interventions that can empower parents in addressing substance use can help mitigate the risks that immigrant youth may face.

Methods

This scoping review aimed to identify the types, characteristics, and effectiveness of family-based substance use intervention programs. Based on Arksay and O'Malley's guidelines, interventions included in the review must have met the following criteria: (a) was a family-based intervention aiming to prevent substance use; (b) targeted immigrant teens aged 12 to 17 years old; (c) was published in English; (d) originated from Australia, Canada, New Zealand, or the United States. The pinch table was used to synthesize included articles, after which studies were compared and categorized, and cross-cutting categories were identified.

Results

After screening 4551 searched literature, 13 studies that utilized family-based interventions were included in the review. All interventions were face-to-face programs, and most interventions involved parents and youth as participants. Eco-developmental theory and active learning strategies were used by multiple interventions. Given immigrant families were target stakeholders, both deep structure and surface structure cultural adaptations were utilized. Interventions increased parents' knowledge and skills regarding substance use prevention and delayed substance use initiation among youth.

Conclusion

From the review, it was evident that parents are an essential element in any program aiming to prevent or reduce children's substance use. Besides information about substance use prevention, the curriculum also involves parenting and communication skills for parents to understand the protective effects of family. Effective family-based interventions for immigrant youth require attention to parenting and immigration stress, while also considering cultural adaptation. Future directions and limitations are also discussed.

Development and refinement of a corner-based injury prevention programme for Latino day labourers

Objective

Latino day labourers (LDLs) in the USA are at increased risk for non-fatal and fatal occupational injuries, which are compounded by stressors that include wage theft, job insecurity and discrimination. This paper describes the development and refinement of Vales+Tú (You are Worthy of More), an injury prevention programme currently being evaluated as part of a cluster randomised trial in which health promotion is taken directly to the 'corners' (e.g. street corners, home improvement store parking lots, and public parks) where workers gather to seek employment.

Design

Vales+Tú comprises two corner-based intervention approaches, group problem-solving (small group discussions) and brief motivational interviewing (one-on-one dialogue), that aim to activate LDL agency to control their safety and that of their peers.

Setting

Corners in Houston, Texas, where LDLs seek employment.

Method

Intervention Mapping informed the refinement of Vales+Tú for the current trial. We provide a narrative review of the development process based on needs assessment and formative development activities (surveys, focus group discussions and pilot tests).

Results

In addition to documenting the need for LDL injury prevention, with 20.2%-41.6% of Houston-based LDLs surveyed between 2013-2014 and 2019 reporting a severe work-related injury in the past year, we describe key facets of the Vales+Tú corner-based intervention approaches - including their theoretical basis and LDL-centred activities, as well as enhancements made informed by formative evaluation.

Conclusion

The community-engaged development process of Vales+Tú resulted in two practical intervention approaches that can be adopted by worker centres and other organisations to promote LDL worker safety.

Improving sexually transmitted infection screening, testing, and treatment among people with HIV: A mixed method needs assessment to inform a multi-site, multi-level intervention and evaluation plan

Bacterial sexually transmitted infections (STIs) continue to be a worsening public health concern in the United States (US). Though the national incidence of HIV infection has decreased over recent years, that of chlamydia, gonorrhea, and syphilis have not. Despite national recommendations on prevention, screening, and treatment of these STIs, these practices have not been standardized. Nine Health Resources and Services Administration Ryan White HIV/AIDS Program funded clinics across 3 US jurisdictions (Florida, Louisiana, and Washington, DC), were selected as clinical demonstration sites to be evaluated in this mixed method needs assessment to inform a multi-site, multi-level intervention to evaluate evidence-based interventions to improve STI screening and testing of bacterial STIs among people with or at risk for HIV. These 3 US jurisdictions were selected due to having higher than national average incidence rates of HIV and bacterial STIs. Descriptive statistics and deductive analysis were used to assess quantitative and qualitative needs assessment data. Results indicate the following needs across participating sites: inconsistent and irregular comprehensive sexual behavior history taking within and among sites, limited routine bacterial STI testing (once/year and if symptomatic) not in accordance with CDC recommendations, limited extragenital site gonorrhea/chlamydia testing, limited annual training on STI-related topics including LGBTQ health and adolescent/young adult sexual health, and limited efforts for making high-STI incidence individuals feel welcome in the clinic (primarily LGBTQ individuals and adolescents/young adults). These findings were used to identify interventions to be used to increase routine screenings and testing for bacterial STIs.

Adapting evidence-informed population health interventions for new contexts: a scoping review of current practice

BACKGROUND

Implementing evidence-informed population health interventions in new contexts often requires adaptations. While the need to adapt interventions to better fit new contexts is recognised, uncertainties remain regarding why and when to adapt (or not), and how to assess the benefits (or not) of adaptation. The ADAPT Study aims to develop comprehensive guidance on adaptation. This scoping review informs guidance development by mapping and exploring how adaptation has been undertaken in practice, in public health and health services research.

METHODS

We searched seven databases from January 2000 and October 2018 to identify eligible studies for this scoping review and a related systematic review of adaptation guidance. We mapped the studies of adaptation by coding data from all eligible studies describing the methods, contexts, and interventions considered for adaptation. From this map, we selected a sample of studies for in-depth examination. Two reviewers extracted data independently into seven categories: description, key concepts, types, rationale, processes, evaluation methods, evaluation justification, and accounts of failures and successes.

RESULTS

We retrieved 6694 unique records. From 429 records screened at full text, we identified 298 eligible studies for mapping and selected 28 studies for in-depth examination. The majority of studies in our map focused on micro- (i.e., individual-) level interventions (84%), related to transferring an intervention to a new population group within the same country (62%) and did not report using guidance (73%). Studies covered a range of topic areas, including health behaviour (24%), mental health (19%), sexual health (16%), and parenting and family-centred interventions (15%). Our in-depth analysis showed that adaptation is seen to save costs and time relative to developing a new intervention, and to enhance contextual relevance and cultural compatibility. It commonly follows a structured process and involves stakeholders to help with decisions on what to adapt, when, and how.

CONCLUSIONS

Adaptation has been undertaken on a range of health topics and largely in line with existing guidance. Significant gaps relate to adaptation of macro- (e.g., national-) level interventions, consideration of programme theories, mechanisms and contexts (i.e., a functional view of interventions), nuances around stakeholder involvement, and evaluation of the adapted interventions. Registration Open Science Framework, 2019, osf.io/udzma.

Promoting Pre-exposure Prophylaxis to Prevent HIV Infections Among Sexual and Gender Minority Hispanics/Latinxs

Sexual and gender minority Hispanics/Latinxs (henceforth: Latinxs) continue to be disproportionately impacted by HIV/AIDS in the U.S. Pre-exposure prophylaxis (PrEP) is a biomedical prevention approach which holds significant promise for at risk and vulnerable populations. We discuss barriers and facilitators to uptake of PrEP among sexual and gender minority Latinxs living in the U.S. through an ecosocial lens that takes into account structural, community, and individual contexts. The impact of immigration status on PrEP uptake emerges as a major and recurrent theme that must be understood and addressed by HIV prevention programs aiming to promote an inclusive strategy for sexual and gender minority Latinxs living in the U.S.

Long-term consequences of early sexual initiation on young adult health: A causal inference approach

Although early sexual initiation has been linked to negative outcomes, it is unknown whether these effects are causal. In this study, we use propensity score methods to estimate the causal effect of early sexual initiation on young adult sexual risk behaviors and health outcomes using data from the National Longitudinal Study of Adolescent to Adult Health. We found that early sexual initiation predicted having 2 or more partners (for both males and females) and having a sexually transmitted infection in the past year (females only) but did not predict depressive symptoms in the past week (for either gender). These results underscore the importance of continued programmatic efforts to delay age of sexual initiation, particularly for females.

Adaptation of a Couple-Based HIV/STI Prevention Intervention for Latino Men Who Have Sex With Men in New York City

Predominantly Spanish-speaking Latino men who have sex with men (MSM) and their same-sex partners continue to be at high risk for HIV and STIs. Behavioral research has identified how relationship dynamics for male couples are associated with sexual risk behavior. Connect 'n Unite (CNU), an evidence-based HIV/STI prevention intervention originally created for Black MSM and their same-sex partners, was adapted for predominantly Spanish-speaking Latino MSM and their same-sex partners on the assumption that its key elements would be translatable while its efficacy would be retained. A systematic adaptation process utilizing qualitative methods was used, including intervention adaptation sessions with 20 predominantly Spanish-speaking Latino gay couples and 10 health service providers. The process included five steps: (1) engaging community stakeholders, (2) capturing the lived experiences of Latino gay couples, (3) identifying intervention priorities, (4) integrating the original intervention's social cognitive theory into a relationship-oriented, ecological framework for Latino gay couples, and (5) adapting intervention activities and materials. The adapted intervention, which we called Latinos en Pareja or Latinos in a Relationship, incorporates elements that effective HIV prevention interventions share, including: a solid theoretical foundation; emphasis on increasing risk reduction norms, sexual communication skills and social support for protection; and guidance on how to utilize available, culturally and linguistically appropriate services. The systematic adaptation approach used for a couples-based HIV prevention intervention also can be employed by other researchers and community stakeholders to adapt evidence-based interventions that promote wellness, linkage to care, and disease prevention for populations not originally targeted.

Integration of Social, Cultural, and Biomedical Strategies into an Existing Couple-Based Behavioral HIV/STI Prevention Intervention: Voices of Latino Male Couples

INTRODUCTION

Successful HIV prevention and treatment requires evidence-based approaches that combine biomedical strategies with behavioral interventions that are socially and culturally appropriate for the population or community being prioritized. Although there has been a push for a combination approach, how best to integrate different strategies into existing behavioral HIV prevention interventions remains unclear. The need to develop effective combination approaches is of particular importance for men who have sex with men (MSM), who face a disproportionately high risk of HIV acquisition.

MATERIALS AND METHODS

We collaborated with Latino male couples and providers to adapt Connect 'n Unite, an evidence-based intervention for Black male couples, for Latino male couples. We conducted a series of three focus groups, each with two cohorts of couples, and one focus group with providers. A purposive stratified sample of 20 couples (N = 40, divided into two cohorts) and 10 providers provided insights into how to adapt and integrate social, cultural, and biomedical approaches in a couples-based HIV/AIDS behavioral intervention.

RESULTS

The majority (N = 37) of the couple participants had no prior knowledge of the following new biomedical strategies: non-occupational post-exposure prophylaxis (nPEP); pre-exposure prophylaxis (PrEP); and HIV self-testing kits. After they were introduced to these biomedical interventions, all participants expressed a need for information and empowerment through knowledge and awareness of these interventions. In particular, participants suggested that we provide PrEP and HIV self-testing kits by the middle or end of the intervention. Providers suggested a need to address behavioral, social and structural issues, such as language barriers; and the promotion of client-centered approaches to increase access to, adaptation of, and adherence to biomedical strategies. Corroborating what couple participants suggested, providers agreed that biomedical strategies should be offered after providing information about these tools. Regarding culturally sensitive and responsive approaches, participants identified stigma and discrimination associated with HIV and sexual identity as barriers to care, language barriers and documentation status as further barriers to care, the couple-based approach as ideal to health promotion, and the need to include family topics in the intervention.

DISCUSSION

We successfully adapted an evidence-based behavioral HIV prevention intervention for Latino male couples. The adapted intervention, called Conectando Latinos en Pareja, integrates social, cultural, behavioral and biomedical strategies to address the HIV epidemic among Latino MSM. The study highlights the promise regarding the feasibility of implementing a combination approach to HIV prevention in this population.

The HoMBReS and HoMBReS Por un Cambio Interventions to Reduce HIV Disparities Among Immigrant Hispanic/Latino Men

Hispanics/Latinos in the United States are affected disproportionately by human immunodeficiency virus (HIV) infection, acquired immunodeficiency syndrome (AIDS), and other sexually transmitted diseases (STDs); however, few effective evidence-based prevention interventions for this population exist. This report describes the Hombres Manteniendo Bienestar y Relaciones Saludables (Men Maintaining Wellbeing and Healthy Relationships) (HoMBReS) intervention, which was developed by a community-based, participatory research partnership in North Carolina and initially implemented during 2005-2009. HoMBReS is an example of an effective intervention that uses lay health advisors (known as Navegantes [navigators]) in the context of existing social networks (i.e., recreational soccer teams) to promote consistent condom use and HIV and STD testing among Hispanic/Latino men. In 2012, HoMBReS was classified as a best-evidence community-level HIV prevention intervention (CDC. Compendium of evidence-based behavioral interventions and best practices for HIV prevention. Atlanta, GA: US Department of Health and Human Services, CDC; 2015). The intervention has been implemented elsewhere, enhanced, and further evaluated in longitudinal intervention and implementation studies. HoMBReS has been adapted for other populations, including men who have sex with men and transgender persons. Additional evaluation has found that Navegantes continue in their roles as health advisors, opinion leaders, and community advocates after study support ends. Hispanic/Latino men's social networks can be leveraged to promote sexual health within the community by decreasing HIV risk behaviors among Hispanics/Latinos in the United States.

Community coalition-driven interventions to reduce health disparities among racial and ethnic minority populations

BACKGROUND

Racial and ethnic disparities in health status are pervasive at all stages of the life cycle. One approach to reducing health disparities involves mobilizing community coalitions that include representatives of target populations to plan and implement interventions for community level change. A systematic examination of coalition-led interventions is needed to inform decision making about the use of community coalition models.

OBJECTIVES

To assess effects of community coalition-driven interventions in improving health status or reducing health disparities among racial and ethnic minority populations.

SEARCH METHODS

We searched MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, Social Science Citation Index, Dissertation Abstracts, System for Information on Grey Literature in Europe (SIGLE) (from January 1990 through September 30, 2013), and Global Health Library (from January 1990 through March 31, 2014).

SELECTION CRITERIA

Cluster-randomized controlled trials, randomized controlled trials, quasi-experimental designs, controlled before-after studies, interrupted time series studies, and prospective controlled cohort studies. Only studies of community coalitions with at least one racial or ethnic minority group representing the target population and at least two community public or private organizations are included. Major outcomes of interest are direct measures of health status, as well as lifestyle factors when evidence indicates that these have an effect on the direct measures performed.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias for each study.

MAIN RESULTS

Fifty-eight community coalition-driven intervention studies were included. No study was considered to be at low risk of bias. Behavioral change outcomes and health status change outcomes were analyzed separately. Outcomes are grouped by intervention type. Pooled effects across intervention types are not presented because the diverse community coalition-led intervention studies did not examine the same constructs or relationships, and they used dissimilar methodological designs. Broad-scale community system level change strategies led to little or no difference in measures of health behavior or health status (very low-certainty evidence). Broad health and social care system level strategies leds to small beneficial changes in measures of health behavior or health status in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions led to beneficial changes in health behavior measures of moderate magnitude in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions may lead to beneficial changes in health status measures in large samples of community residents; however, results were not consistent across studies (low-certainty evidence). Group-based health education led by professional staff resulted in moderate improvement in measures of health behavior (very low-certainty evidence) or health status (low-certainty evidence). Adverse outcomes of community coalition-led interventions were not reported.

AUTHORS' CONCLUSIONS

Coalition-led interventions are characterized by connection of multi-sectoral networks of health and human service providers with ethnic and racial minority communities. These interventions benefit a diverse range of individual health outcomes and behaviors, as well as health and social care delivery systems. Evidence in this review shows that interventions led by community coalitions may connect health and human service providers with ethnic and racial minority communities in ways that benefit individual health outcomes and behaviors, as well as care delivery systems. However, because information on characteristics of the coalitions themselves is insufficient, evidence does not provide an explanation for the underlying mechanisms of beneficial effects. Thus, a definitive answer as to whether a coalition-led intervention adds extra value to the types of community engagement intervention strategies described in this review remains unattainable.

Anticipated and actual reactions to receiving HIV positive results through self-testing among gay and bisexual men

We explored anticipated and actual reactions to receiving HIV positive results through self-testing with a diverse group of 84 gay and bisexual men in New York City. Grounded Theory was used to investigate these reactions in a two-phase study, one hypothetical, followed by a practical phase in which self-tests were distributed and used. Three major themes emerged when participants were asked about their anticipated reactions to an HIV positive self-test result: managing emotional distress, obtaining HIV medical care, and postponing sexual activity. When participants were asked about their anticipated reactions to a partner's HIV positive self-test result, five themes emerged: provide emotional support; refrain from engaging in sex with casual partner; avoid high-risk sexual activity with both main and casual partners; seek medical services; and obtain a confirmatory test result. Although none of the participants tested positive, seven of their partners did. Participants provided emotional support and linked their partners to support services. The availability of HIV self-testing kits offers potential opportunities to tackle HIV infection among individuals with high-risk practices.