Minoritized racial, ethnic, sexual, and gender communities and populations face profound health disparities and their engagement in research remains low. In a randomized controlled trial, our community-based participatory research partnership tested the efficacy of ChiCAS, an HIV prevention intervention designed to increase pre-exposure prophylaxis use among Spanish-speaking transgender Latinas. Of 161 eligible Spanish-speaking transgender Latinas screened, we enrolled 144, achieving an 89% participation rate, and retained 94% at 6-month follow-up. Given these participation and retention rates, we sought to identify strategies used for engaging transgender Latinas in the trial. We abstracted and analysed data from archived trial and meeting notes, reports, and facilitated discussions with partners and steering committee members. A nominal group process was used to identify, refine, and interpret engagement strategies; 17 strategies emerged. Strategies included building trust through our community-based participatory research partnership; fostering relationships with HIV, lesbian, gay, bisexual, transgender, and queer, and Latine organizations; and leveraging peer networks. Additional strategies such as ensuring members of the research team reflected the community, providing logistical support (e.g. flexible scheduling and transportation), and giving cash tokens of appreciation were also identified. These strategies can be adapted to enhance engagement, including participation and retention, of other minoritized populations in research.
The impact of COVID-19 on specific populations, including gay, bisexual, and other men who have sex with men (GBMSM), varies based on a range of factors such as access to health care, underlying health behaviors and conditions, and social determinants of health. Our community-based participatory research partnership sought to better understand perspectives about and experiences with the COVID-19 pandemic, COVID-19 vaccination, and related health care among GBMSM. We collected, analyzed, and interpreted qualitative in-depth interview data from a diverse sample of GBMSM (N = 30) in North Carolina, USA. Using purposive sampling, we recruited native English (n = 15) and Spanish (n = 15) speakers and persons with HIV (n = 13) and persons without HIV (n = 17). We analyzed interview data using constant comparison, an approach to grounded theory. Participant mean was 33.4 (SD = 8.5) years. Sixteen themes emerged that were categorized into five domains: trust/mistrust of politicians, healthcare professionals, and the US government (n = 4 themes); engagement in COVID-19 prevention strategies (n = 2 themes); attitudes towards COVID-19 vaccination (n = 3 themes); access to and use of health care (n = 4 themes); and impact of COVID-19 on social determinants of health and mental health (n = 3 themes). This research increases our understanding of the COVID-19 pandemic among particularly minoritized and underserved communities: racially and ethnically diverse, English- and Spanish-speaking GBMSM with and without HIV in the US South. By addressing the unique needs and concerns of these communities, we can promote more equitable public health responses; enhance preventive healthcare delivery; improve preparedness for subsequent outbreaks (e.g., mpox), epidemics, and pandemics; and be better equipped to support delivery and uptake of potential future preventive HIV vaccines among communities impacted by health disparities.
Background Latine populations in the United States continue to be disproportionately affected by COVID-19 with high rates of infection and mortality. Our community-based participatory research partnership examined factors associated with COVID-19 testing and vaccination within a particularly hidden, underserved, and vulnerable population: Spanish-speaking Latines. Methods In 2023, native Spanish-speaking Latine interviewers conducted phone-based structured individual assessments with 180 Spanish-speaking, predominantly immigrant Latines across North Carolina. We used univariate and multivariable logistic regression analyses to examine associations between participant characteristics and COVID-19 testing and vaccination. Results Participant mean age was 41.7 (SD = 13), and 77.2% of the sample reported being cisgender women. Most participants reported immigrating from Latin American countries (89.9%), being uninsured (66.1%), and lacking US immigration documentation (51.1%). While most reported ever being COVID-19 tested (83.3%) and ever being vaccinated against COVID-19 (84.4%), only 24% were up to date with vaccination. Nearly half of the sample reported one or more barriers to COVID-19 testing, and over one-quarter reported one or more barriers to COVID-19 vaccination. Higher educational attainment was significantly associated with ever being tested (P = .031). Fewer concerns about the vaccine, including fewer worries about side effects and having more confidence in vaccine effectiveness and safety, was associated with ever being vaccinated (P < .001). Conclusions Spanish-speaking Latines face barriers to getting tested and vaccinated against COVID-19. Although ever testing and ever vaccination rates were high, being up to date with recommended vaccinations was low. Educational attainment and concerns about the vaccine were associated with COVID-19 testing and vaccination, respectively. Our findings suggest the need for culturally congruent strategies to address the challenges facing Spanish-speaking Latines in the United States.
Black/African American transgender (trans) women experience disproportionately high rates of HIV, yet few evidence-based interventions are designed specifically for them. This study outlines the development of the Sisters United intervention through the adaptation of ChiCAS, an evidence-based intervention for trans Latinas. Sisters United promotes use of pre-exposure prophylaxis (PrEP), condoms, and medically supervised gender-affirming hormone therapy (GAHT) among Black/African American trans women. Integrating community-based participatory research and implementation science, our systematic process included multiple steps conducted in partnership with a steering committee of Black/African American trans women, other community representatives, scientists, practitioners, and consultants. We held focus groups and obtained iterative feedback about intervention objectives, messaging, and activities, including new activities focused on medical mistrust and the use of injectable PrEP, to guide the adaptation. Key intervention components developed through this process include an implementation manual, facilitator's guides for in-person and virtual delivery, video segments, and an e-learning course to support effective implementation. Like the original ChiCAS intervention, Sisters United is designed to be delivered in two sessions, with a focus on raising awareness about HIV and GAHT, building condom use skills, and overcoming barriers to health care. This intervention fills a critical gap by offering a scalable solution to promote HIV health equity among Black/African American trans women. Moreover, our systematic process can serve as a guide for others developing, refining, or adapting interventions to meet the needs of a new community or population and/or infuse updated information and innovations into an existing intervention.
Guatemalan gay, bisexual, and other men who have sex with men (GBMSM) and transgender women experience profound HIV disparities, with prevalence rates far exceeding those of the general population. Limited access to and suboptimal use of HIV prevention and treatment services hinder progress towards the Joint United Nations Programme on HIV and AIDS goal to end the epidemic by 2030. Our binational community-based participatory research partnership developed a blueprint of twelve recommendations to reduce HIV disparities in Guatemala. Recommendations include enhancing HIV surveillance, increasing research, combatting stigma, bolstering provider training, addressing social determinants of health, improving sexual health literacy and mental health services, and partnering with LGBTQ+ communities. The blueprint aims to advance HIV prevention and treatment among populations most affected by the epidemic in Guatemala and may serve as a model for other countries to respond to the urgent need for approaches to end the HIV epidemic globally.
Our community-based participatory research partnership developed and tested the bilingual Appalachian Access Project, a peer navigation and mHealth intervention designed to promote HIV, sexually transmitted infection, hepatitis C virus, and mpox prevention and care among gay, bisexual, queer, and other men who have sex with men and transgender and nonbinary persons in Appalachia and to support medically supervised gender-affirming hormone therapy (GAHT) access among those desiring it. Although the intervention did not achieve its intended behavioral outcomes (e.g., increased use of HIV testing, preexposure prophylaxis [PrEP], HIV care, and GAHT), we identified ten critical lessons for future intervention research, including needs for: increased contact between study team members and peer navigators, more streamlined health outcome priorities, minimum intervention dose requirements for peer navigators, formal group activities, smaller catchment areas, and provider and organizational capacity-building interventions. Deeper understanding of intervention implementation can strengthen future efforts to reduce health disparities in Appalachia.
We tested the Appalachian Access Project, a bilingual, HIV status-neutral, social network, peer navigation, and mHealth intervention aimed at increasing use of HIV, STI, hepatitis C virus, and mpox prevention and care services among gay, bisexual, queer, and other men who have sex with men (GBQMSM) and transgender and nonbinary persons in Appalachia. The intervention also aimed to support use of medically supervised gender-affirming hormone therapy among participants desiring such care. Trial participants were recruited and randomized by social network to the intervention (n = 7 networks including 56 individuals) or delayed-intervention waitlist control group (n = 7 networks including 57 individuals). At follow-up, relative to control participants, intervention participants reported slight, but nonsignificant, increases in an HIV status-neutral service-use outcome, PrEP use, and HIV testing; and significant increases in HIV and STI knowledge. This intervention provides a foundation for future initiatives to reduce disparities in rural Appalachia; further research with larger sample sizes is warranted.
Background The impact of COVID-19 on specific populations, including gay, bisexual, and other men who have sex with men (GBMSM), varies based on a range of factors such as underlying health conditions, access to health care, and other social determinants of health. Our community-based participatory research partnership sought to better understand perceptions about the COVID-19 pandemic, COVID-19 vaccination, and related health care among GBMSM. Methods We collected, analyzed, and interpreted qualitative in-depth interview data from a diverse sample of GBMSM (N = 30). Using purposive sampling, we recruited native English (n = 15) and Spanish (n = 15) speakers and persons with HIV (n = 13) and persons without HIV (n = 17). We analyzed interview data using constant comparison, an approach to grounded theory. Results Mean age of participants was 33.4 (SD = 8.5). Seventeen themes emerged that were categorized into five domains: trust/mistrust of healthcare professionals, politicians, and the US government (n = 5 themes); engagement in COVID-19 prevention strategies (n = 2 themes); attitudes towards COVID-19 vaccination (n = 3 themes); access to and use of health care (n = 4 themes); and impact of COVID-19 on social determinants of health (n = 3 themes). Conclusions This research increases our understanding of the COVID-19 pandemic among particularly minoritized and underserved communities: racially/ethnically diverse, English- and Spanish-speaking GBMSM with and without HIV. By addressing the unique needs and concerns of these communities and populations, we can foster more equitable health responses, enhancing both preventive healthcare delivery and preparedness for potential future outbreaks (e.g., monkeypox), epidemics, and pandemics.
BACKGROUND:Gay, bisexual, queer, and other men who have sex with men (GBQMSM) and transgender persons in Appalachia are at an increased risk for HIV, sexually transmitted infections (STIs), hepatitis C virus (HCV), mpox (formerly known as monkeypox) and are less likely to use prevention and care services. OBJECTIVES:Our community-based participatory research partnership sought to develop an intervention to increase use of HIV, STI, HCV, and mpox prevention and care services among diverse GBQMSM and transgender and nonbinary persons living in rural Appalachia. METHODS:We used ENGAGED for CHANGE, a novel community-engaged participatory intervention development process, to integrate two evidence-based strategies-community-based peer navigation and mHealth-into a multi-cultural intervention. RESULTS:The developed Appalachian Access Project intervention contains five modules to train GBQMSM and transgender and nonbinary persons to serve as peer navigators (known as "community health leaders") within their social networks. The modules are designed to increase awareness of HIV, STIs, HCV, and mpox and their prevention and care; provide guidance on how to promote use of services, including pre-exposure prophylaxis, syringe services, and medically supervised gender-affirming hormone therapy; improve understanding of social determinants of health; and increase ability to effectively communicate and apply social support strategies in person and through mHealth social media. CONCLUSIONS:The Appalachian Access Project intervention builds on the strong, preexisting social networks of GBQMSM and transgender and nonbinary persons. It is designed to meet the needs and priorities of underserved and minoritized communities in rural Appalachia through community-based peer navigation and mHealth.
INTRODUCTION:Improving the delivery of existing evidence-based interventions to prevent and diagnose HIV is key to Ending the HIV Epidemic in the United States. Structural barriers in the access and delivery of related health services require municipal or state-level policy changes; however, suboptimal implementation can be addressed directly through interventions designed to improve the reach, effectiveness, adoption or maintenance of available interventions. Our objective was to estimate the cost-effectiveness and potential epidemiological impact of six real-world implementation interventions designed to address these barriers and increase the scale of delivery of interventions for HIV testing and pre-exposure prophylaxis (PrEP) in three US metropolitan areas. METHODS:We used a dynamic HIV transmission model calibrated to replicate HIV microepidemics in Atlanta, Los Angeles (LA) and Miami. We identified six implementation interventions designed to improve HIV testing uptake ("Academic detailing for HIV testing," "CyBER/testing," "All About Me") and PrEP uptake/persistence ("Project SLIP," "PrEPmate," "PrEP patient navigation"). Our comparator scenario reflected a scale-up of interventions with no additional efforts to mitigate implementation and structural barriers. We accounted for potential heterogeneity in population-level effectiveness across jurisdictions. We sustained implementation interventions over a 10-year period and evaluated HIV acquisitions averted, costs, quality-adjusted life years and incremental cost-effectiveness ratios over a 20-year time horizon (2023-2042). RESULTS:Across jurisdictions, implementation interventions to improve the scale of HIV testing were most cost-effective in Atlanta and LA (CyBER/testing cost-saving and All About Me cost-effective), while interventions for PrEP were most cost-effective in Miami (two of three were cost-saving). We estimated that the most impactful HIV testing intervention, CyBER/testing, was projected to avert 111 (95% credible interval: 110-111), 230 (228-233) and 101 (101-103) acquisitions over 20 years in Atlanta, LA and Miami, respectively. The most impactful implementation intervention to improve PrEP engagement, PrEPmate, averted an estimated 936 (929-943), 860 (853-867) and 2152 (2127-2178) acquisitions over 20 years, in Atlanta, LA and Miami, respectively. CONCLUSIONS:Our results highlight the potential impact of interventions to enhance the implementation of existing evidence-based interventions for the prevention and diagnosis of HIV.
Background Latine communities in the United States have been disproportionately affected by COVID-19. It is critical to gain a better understanding of the sociocultural determinants that challenge and facilitate COVID-19 testing, vaccination, and booster uptake within these vulnerable communities to inform culturally congruent strategies and interventions. Methods In summer 2022, our community-based participatory research partnership conducted 30 key informant interviews and 7 focus groups with 64 Spanish-speaking Latine participants in North Carolina. Interviewees consisted of representatives from health and service organizations, most of whom were engaged with direct service to Spanish speakers. Interviews were conducted in either English or Spanish, depending on the preference of the participant; all focus groups were conducted in Spanish. Interviews and focus groups were conducted in person or by videoconference. Results Twenty themes emerged that we organize into four domains: general perceptions about COVID-19; barriers to COVID-19 testing, vaccination, and booster uptake; facilitators to COVID-19 testing, vaccination, and booster uptake; and recommendations to promote testing, vaccination, and booster uptake. Discussion Results underscore important sociocultural determinants of ongoing COVID-19 testing, vaccination, and booster uptake to consider in developing interventions for Spanish-speaking Latines in the United States. Based on this formative work, our partnership developed Nuestra Comunidad Saludable (Our Healthy Community). We are implementing the intervention to test whether trained peer navigators can increase COVID-19 testing, vaccination, and booster uptake among Spanish-speaking Latines through blending in-person interactions and mHealth (mobile health) strategies using social media.
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.
Objectives. To evaluate Chicas Creando Acceso a la Salud (Girls Creating Access to Health; ChiCAS), a Spanish-language, small-group intervention designed to increase preexposure prophylaxis (PrEP) use, consistent condom use, and medically supervised gender-affirming hormone therapy use among Spanish-speaking transgender Latinas who have sex with men. Methods. Participants were 144 HIV-negative Spanish-speaking transgender Latinas, aged 18 to 59 years, living in North and South Carolina. From July 2019 to July 2021, we screened, recruited, and randomized them to the 2-session ChiCAS intervention or the delayed-intervention waitlist control. Participants completed assessments at baseline and 6-month follow-up. Follow-up retention was 94.4%. Results. At follow-up, relative to control participants, ChiCAS participants reported increased PrEP use (adjusted odds ratio [AOR] = 4.64; 95% confidence interval [CI] = 1.57, 13.7; P < .006). However, ChiCAS participants did not report increased use of condoms or medically supervised gender-affirming hormone therapy. ChiCAS participants reported increases in knowledge of HIV (P < .001), sexually transmitted infections (P < .001), and gender-affirming hormone therapy (P = .01); PrEP awareness (P < .001), knowledge (P < .001), and readiness (P < .001); condom use skills (P < .001); and community attachment (P < .001). Conclusions. The ChiCAS intervention was efficacious in increasing PrEP use among Spanish-speaking, transgender Latinas in this trial. (Am J Public Health. 2024;114(1):68–78. https://doi.org/10.2105/AJPH.2023.307444 )
Background Southeast Asian refugee communities are frequently underserved by social and medical systems and experience profound health and health care inequities. The purpose of this study was to detail the health needs, priorities, and health care utilization of the Karenni, a Southeast Asian refugee community, in Forsyth County, North Carolina. Methods A mixed-mode survey (i.e., online and in-person) was distributed in Kayah, Burmese, and English to Karenni adults in Forsyth County. Quantitative and qualitative questions focused on community health needs, health and public health service utilization, and social determinants of health. Results 101 Karenni adults completed the survey, with a total of 91 participants completing the quantitative portion (N = 91). Utilization of health care and public health services was low and impacted by individual- and contextual-level barriers, such as limited English proficiency and social determinants of health (e.g., lower levels of education and employment compared to state and national averages). Mental health, chronic pain, and health care access were highlighted as prominent community concerns while theh plaw theh jie (togetherness) and community organizations were described as community strengths. Limitations Data were collected using convenience sampling, and limited knowledge from the Karenni community regarding research served as a barrier to recruitment. Some sensitive questions (e.g., income) also experienced higher levels of missingness. Conclusion This assessment highlights the need to increase engagement with and lower barriers to care for the Karenni community in Forsyth County, North Carolina. To produce culturally congruent and acceptable care, public health and health care systems should partner with the community to identify and address community needs and priorities, harness assets, and mitigate health and health care inequities.
Background: Sexually transmitted infections (STIs) and HIV disproportionately affect young people; gay, bisexual, queer, and other men who have sex with men (GBQMSM); transgender women; and persons of color. Our community-based participatory research partnership developed and implemented Impact Triad, a bilingual multilevel intervention harnessing peer navigation and mHealth to increase STI/HIV preventive behaviors and address 4 community-prioritized social determinants of health-education, employment, social support, and discrimination-among young African American/Black and Latine GBQMSM and transgender women. Methods: Fifteen community-based peer navigators were trained to work within their social networks for 12 months. Each navigator engaged 5 social network members who completed baseline and immediate post-intervention assessments (retention rate, 97.3%). Regression modeling was used to assess changes in outcomes between baseline and follow-up. Results: Among 74 enrolled social network members, the average age was 27.8 years; 61% identified as African American/Black, 31% as Latine, and 8% as multiracial/multiethnic. The majority self-identified as cisgender men and 8% as transgender women; 78% identified as gay. About half reported monthly income below $1000.Compared with baseline, at follow-up, social network members increased: STI screening (P = 0.001), HIV testing (P = 0.001), condom use (P = 0.03), and preexposure prophylaxis use (P = 0.02). Knowledge of preexposure prophylaxis (P < 0.0001) and of community-based educational (P = 0.047), job-training (P = 0.002), and job-finding resources (P = 0.02) also increased. Social support increased (P < 0.0001) and perceived discrimination decreased (P < 0.01). Conclusions. Pilot findings suggest that Impact Triad is promising in increasing STI/HIV protective behaviors and addressing social determinants of health among young GBQMSM and transgender women of color; further testing is warranted.
There is a dearth of HIV prevention behavioral interventions for transgender Latinas, despite this population's HIV risk. ChiCAS (Chicas Creando Acceso a la Salud) is an intervention to increase PrEP, condom, and gender-affirming hormone therapy (GAHT) use among transgender Latinas. To inform future work, semistructured interviews were conducted postintervention with 28 ChiCAS participants. Thematic analysis with inductive coding was used. Six themes emerged: (1) health-related priorities include sexual health and avoiding discrimination; (2) safe and collaborative community is of high importance; (3) interactive education with time for sharing stories and discussion was valued; (4) PrEP uptake was facilitated through awareness and health care navigation; (5) accessing GAHT depends on cost, clinic location, and individual goals; (6) ChiCAS could be improved with more PrEP/GAHT details and social connection. Interventions with goals similar to those of ChiCAS should prioritize building community, PrEP and GAHT education tailored to participants’ needs, and emphasize health care options available locally.
Research demonstrates that stigma and resilience influence transgender peoples' healthcare use. Less is known about transgender Latinas in the U.S. South who face multilevel barriers to healthcare access. We used baseline data from the ChiCAS intervention study. Using logistic regression, we examined how stigma (perceived discrimination related to gender identity, race/ethnicity, sexual behavior and perceived documentation status and internalized transphobia), and resilience (ethnic group pride and social support) are associated with two healthcare outcomes (use of routine medical care and medically supervised gender-affirming hormones). We also explored barriers to accessing both types of care. After removing 13 participants with missing data, our sample size was 131 transgender Latinas in the U.S. South. Most participants (74.8%, n = 98) received routine medical care in the past year and 57.3% (n = 75) had ever received medically supervised gender-affirming hormones. Reports of discrimination were highest for gender identity and documentation status. Race/ethnicity-based discrimination was positively associated with accessing routine medical care in the past year (OR = 1.94, p = 0.048). Having more social support was positively associated with care (routine care: OR = 3.48, p = 0.002 and gender-affirming hormones: OR = 2.33, p = 0.003). The most commonly reported barriers to accessing both types of care included cost, insurance, and not knowing where to go. Findings highlight the importance of social support for healthcare use among transgender Latinas. Social support may be especially important when considering the unique experiences of discrimination faced by transgender Latinas in the U.S. South.
Intersectionality is a critical yet understudied and often misused concept in health behavior research.To address this, the American Academy of Health Behavior organized its 2023 annual scientific conference held on March 12-15 th , 2023 around issues of intersectionality conceptualization, measurement, and methods (San Francisco, California).The conference, titled "The science of identities: Measurement &The science of identities: Measurement & methods for translational health behavior research methods for translational health behavior research," brought together a diverse group of nearly 170 health behavior researchers from across the United States to highlight current research and challenges facing intersectionality.The conference included two invited keynotes and eight symposium presentations.Here, we highlight some of the research presented and key themes that emerged across presentations.
