Project for inner-city women shows benefits
Project for inner-city women shows benefits
Program uses popular opinion leaders’
The theory is a lot like a high school social behavior model: Get the most popular people to change to a certain behavior, and the rest will follow.
That’s how a recently published intervention project aimed at reducing HIV risk behaviors among inner-city women was designed. The project was based on the selection of popular "opinion leaders," who would undergo training and then lead the community intervention projects.
It worked. The women targeted in the intervention program increased their use of condoms. The proportion of women receiving the intervention who had unprotected intercourse within the past two months declined from 50% to 37.6%, while the women in the control group showed no significant change.1 Also, at baseline, the average percentage of acts of intercourse in which condoms were used within the past two months was 30.2% among women in the intervention group and 33.9% in the comparison group. At the 12-month follow-up, the comparison group’s condom use had increased insignificantly to 36.3%, and the intervention group’s use had increased to 47.2%.1
Targeting leaders
The project was based on a community-level intervention that was used earlier to target men in gay bars. "We had considered a bar a community and had done a model at finding popular people and doing interventions to change social norms through them," says Kathleen J. Sikkema, PhD, associate professor in psychiatry at the Yale University School of Medicine in New Haven, CT.
"As that study concluded and the epidemic was affecting women more and more in its second decade, we wanted to find out how to modify this approach with gay men and implement it with women," Sikkema says. "It was a theoretical adaptation of something we had done before."
Researchers decided to target 18 housing developments in urban areas, primarily inner-city locations. They selected second-tier cities for HIV infection, including Milwaukee; Roanoke, VA; Cleveland; Rochester, NY; and Seattle/Tacoma. Nine of the 18 housing developments were treated with the prevention intervention program, and the other nine were part of a control group. "Even though these were more like neighborhoods, as opposed to communities, we decided that in a sense, these housing developments were communities," Sikkema says. "They’re not nearly as connected as men in gay bars, and the women didn’t perceive themselves as a community, but the physical structure of a housing development allowed us from a research perspective to evaluate it."
Investigators offered the intervention to all women in the targeted developments, which were chosen because they were populated primarily by single women of childbearing age.
Here’s how the program worked:
• Select popular leaders. Researchers surveyed the women living in the housing developments, aiming for an 80% response rate to ensure there was a good representation of the entire community. The actual response rate was 82%. Through the initial surveys, the women answered questions about who was popular and credible and who they liked in their communities. Those most frequently named were asked to be opinion leaders.
"Our model indicates that 10% to 15% of any community are popular opinion leaders, and on average, it was about 12%," Sikkema says.
• Train the leaders. The women selected to be opinion leaders were made part of a women’s health council in their communities. The first thing they did was say they didn’t like the term "opinion leaders" and instead preferred "peer leaders." Peer leaders attended focus groups to give investigators input on how to make the intervention work in their communities. Through the focus groups, researchers learned that the women did not always have the motivation or behavioral skills to negotiate condom use with partners, so skills training workshops were held.
"These helped the women reduce their own risk or communicate with family members or neighbors about HIV risk reduction," Sikkema says.
The peer leaders were told that in their roles as leaders, they would mobilize the community around HIV prevention.
• Have leaders recruit others to attend workshops. There was a four-session series of workshops. Each woman was paid $15 to attend the series; each was paid to conduct surveys and received $10 per month for her participation in attending meetings, plus $5 for child care. Each council was given a $500 budget to pay for intervention projects.
• Start community intervention projects. The projects were held over a nine-month period, divided into quarters. Each council decided which activities to hold and how to spend their budgets, which created immediate buy-in of the programs.
Some of the projects included dropping gift packs door-to-door and talking with women about HIV prevention. Others were musical events with AIDS prevention messages, family carnivals with educational contests, and potluck dinners with HIV-positive women. "Then, every three months there would be a large social event that brought in everyone from the community," Sikkema says. "There also would be two smaller events, such as the door-to-door intervention."
A group that wanted to include teens in the intervention project held a teen night of HIV prevention. Other projects included a health fair with HIV prevention booths and booths on fire safety and mammography.
Community events
In one city, the health council convinced community politicians to become involved with the health fair. They blocked off neighborhood streets for a cookout, helping attract crowds. A big tent contained information about HIV and other health issues, and women with HIV spoke in group discussions about what it was like living with the disease. In some booths, proper condom use was demonstrated on an anatomical model, and women were able to practice how to use them correctly. Then, free condoms were handed out. "The community was invited to the health fair, and parents could bring in their adolescents and talk about HIV with their children," Sikkema says.
The projects were well-attended and appeared to get the message across. "We gave guidelines and a small budget to the women, and they decided what they wanted to do in their neighborhoods," she says. "We really tried to make it something that the women felt was owned by them."
As the women in the health councils began to plan the activities, they generated a great deal of energy, and soon groups of women were mobilized around the idea of HIV prevention, she adds.
Reference
1. Sikkema KJ; Kelly JA; Winett RA, et al. Outcomes of a randomized community-level HIV prevention intervention for women living in 18 low-income housing developments. Am J Public Health January 2000; 90:57-63.
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