Social context of sexual relationships among rural African Americans.

BACKGROUND: Reasons for the strikingly increased rates of HIV and other sexually transmitted infections (STIs) among African Americans in the rural Southeastern United States remain unclear. Investigators have devoted little attention to the potential influence of the social and economic context on sexual behaviors. GOAL: To examine the potential influence of these contextual factors on behaviors that promote the transmission of STIs. STUDY DESIGN: Focus group interviews in which African Americans from rural North Carolina discussed life in their communities and contextual factors affecting sexual behavior. RESULTS: Respondents reported pervasive economic and racial oppression, lack of community recreation, boredom, and resultant substance abuse. Many perceived a shortage of black men because of their higher mortality and incarceration rates compared with whites, and believed this male shortage to be partly responsible for the concurrent sexual partnerships that they perceived as widespread among unmarried persons. CONCLUSION: Contextual features including racism, discrimination, limited employment opportunity, and resultant economic and social inequity may promote sexual patterns that transmit STIs.

Black-white inequalities in mortality and life expectancy, 1933-1999: implications for healthy people 2010.

OBJECTIVES: Optimistic predictions for the Healthy People 2010 goals of eliminating racial/ethnic disparities in health have been made based on absolute improvements in life expectancy and mortality. This study sought to determine whether there is evidence of relative improvement (a more valid measure of inequality) in life expectancy and mortality, and whether such improvement, if demonstrated, predicts future success in eliminating disparities. METHODS: Historical data from the National Center for Health Statistics and the Census Bureau were used to predict future trends in relative mortality and life expectancy, employing an Autoregressive Integrated Moving Average (ARIMA) model. Excess mortality and time lags in mortality and life expectancy for blacks relative to whites were also estimated. RESULTS: Based on data for 1945 to 1999, forecasts for relative black:white age-adjusted, all-cause mortality and white:black life expectancy at birth showed trends toward increasing disparities. From 1979, when the Healthy People initiative began, to 1998, the black:white ratio of age-adjusted, gender-specific mortality increased for all but one of nine causes of death that accounted for 83.4% of all US mortality in 1998. From 1980 to 1998, average numbers of excess deaths per day among American blacks relative to whites increased by 20%. American blacks experienced 4.3 to 4.5 million premature deaths relative to whites in 1940-1999. CONCLUSIONS: The rationale that underlies the optimistic Healthy People 2010 forecasts, that future success can be built on a foundation of past success, is not supported when relative measures of inequality are used. There has been no sustained decrease in black-white inequalities in age-adjusted mortality or life expectancy at birth at the national level since 1945. Without fundamental changes, most probably related to the ways medical and public health practitioners are trained, evaluated, and compensated for prevention-related activities, as well as further research on translating the findings of prevention studies into clinical practice, it is likely that simply reducing disparities in access to care and/or medical treatment will be insufficient. Millions of premature deaths will continue to occur among African Americans.

The Family to Family program: a structural intervention with implications for the prevention of HIV/AIDS and other community epidemics.

OBJECTIVES: To describe a case study of a community-based intervention located in the Harlem community of New York City, one of the oldest African-American communities in the United States. Although not specifically designed to prevent HIV infection, the program, 'Family to Family', exemplifies a 'structural intervention' that was created to strengthen family functioning and to strengthen the bonds that connect families to each other. By fostering strong relationships within and between families in a community with high rates of violence, drug abuse, and HIV infection, the program seeks to improve the quality of neighborhood life and influence the social determinants of individual risk behavior. SOCIAL CAPITAL: Family to Family was created specifically to develop the 'social capital' that is available to children and families in the Harlem community. Social capital refers to resources that result from social relationships, and that enhance an individual's or a group's ability to function and achieve a given set of goals and objectives. In addition to fostering closer relationships between children and their parents, this program also works to help participating families develop closer relationships with other participating families and with Columbia University student and faculty volunteers. Finally, Family to Family is sustained through the efforts of volunteers; it receives no grant support and is entirely self-supporting. CONCLUSIONS: Family to Family has the potential to change the social dynamics that promote HIV risk behavior in communities such as Harlem. Should it prove successful in improving the relationships between families and children, and in increasing the social capital available to all of its participants, it may become an important asset to public health prevention specialists concerned about preventing the spread of HIV.

Building momentum: an ethnographic study of inner-city redevelopment.

OBJECTIVES: One factor contributing to the decay of inner-city areas, and to consequent excess mortality, is the massive loss of housing. This report studied the effects of a redevelopment project on social functioning in an inner-city community. METHODS: This ethnographic study included the following elements: a longitudinal study of 10 families living in renovated housing, repeated observations and photographing of the street scene, focus groups, and informal interviews with area residents. The project was located in the Bradhurst section of Harlem in New York City and was focused on a redevelopment effort sponsored by local congregations. RESULTS: Those who were able to move into newly renovated housing found that their living conditions were greatly improved. Neighborhood revitalization lagged behind the rehabilitation of individual apartment houses. This uneven redevelopment was a visual and sensory reminder of "what had been." Residents missed the warmth and social support that existed in Harlem before its decline. CONCLUSIONS: Rebuilding damaged housing contributes greatly to the well-being of inner-city residents. The current pace and scope of rebuilding are insufficient to restore lost vitality.

Risk factors for excess mortality in Harlem. Findings from the Harlem Household Survey.

INTRODUCTION: In 1980, age-adjusted mortality rates in Central Harlem were the highest among New York City's 30 health districts. This population-based study was designed to describe the self-reported frequency of selected health conditions, behavioral risk factors, preventive health practices, and drug use in the Harlem community. METHODS: From 1992 to 1994, in-person interviews were conducted among 695 adults aged 18 to 65 years who were randomly selected from dwelling-unit enumeration lists for the Central Harlem health district. Descriptive statistics were computed for men and women separately, and compared to other population-based surveys. RESULTS: Self-reported medical insurance coverage in Harlem was unexpectedly high (74% of men, 86% of women) as was lifetime use of preventive health practices, e.g., blood cholesterol screening (58% of men, 70% of women). However, lifetime rates of substance use, e.g. crack cocaine (14%) and self-reported history of traumatic events, e.g., witnessing someone seriously injured or violently killed (49% of men, 21% of women) were also high in Harlem, especially in comparison to other populations. CONCLUSIONS: This study has identified important patterns of similarities and differences in risk behaviors between Harlem and other populations. Potential solutions to the health problems of Harlem may lie in the creation of strategies that operate at the community, municipal, and regional level, as well as at the level of individual behavior and risk-taking.

Stories of spiritual awakening. The nature of spirituality in recovery.

Substance abuse has had a devastating impact on the lives of millions. As substance use and abuse continues to ravage communities, researchers remain in the dark about what works to ensure successful recovery from addiction. In searching for the answers, researchers have often overlooked the role of religious and spiritual practices and beliefs in preventing use and relapse. The study reported here describes the process of spiritual awakenings experienced by some persons in recovery during their quest for sobriety. The data suggests that persons in recovery often undergo life altering transformations as a result of embracing a power higher than one's self, that is, a Higher Power. The result is often an intense spiritual journey that leads to sustained abstinence. Given how widespread substance abuse is, research on the nature, implications, and limitations of a spiritual approach to addiction might offer new options for treatment.

Injury and anomie: effects of violence on an inner-city community.

OBJECTIVES: Widespread violence affects individuals but also alters group life. This study was designed to examine the effects of violence on an inner-city community. METHODS: A qualitative study was undertaken that included field observations and semistructured interviews. The study took place in Washington Heights, a New York City neighborhood with a high rate of violence, largely secondary to the drug trade. RESULTS: The 100 people interviewed differed widely in their definitions of violence and in their likelihood of having experienced violent acts in the course of daily life. High, medium, and low violence microenvironments were identified; risk of exposure to violence, but not individual definitions of violence, differed by location. Violence in all parts of the neighborhood inhibited social interactions, but the intensity of this effect differed by microenvironment. CONCLUSIONS: In Washington Heights, violence has injured individuals and fractured social relationships, leading to the state of social disarray referred to as "anomie." The public health response to the violence epidemic should address anomie through community organizing efforts.

Chaos, criticality, and public health.

Self-organized criticality offers more than a descriptive model or a doomsday forecast. We have tried to suggest that it is a paradigm for understanding the interconnections between apparently complex processes. At best, it suggests a method for finding the pressure points that can be used to bring unstable systems of public health services into greater levels of stability. The model enjoins us to understand that our goal is not to achieve equilibrium--that perfect match between the demand for health services and its delivery--but rather stability (or, more precisely, metastability). As is true of the sandpile, our systems of public health are constantly evolving. If we are correct, then the mechanism driving this ostensibly complex pattern of change and growth reflects the existence of simpler and, hopefully, more manageable processes. By monitoring these processes, it may be increasingly possible to adapt to change and even manage it effectively.

Determination of sleep and wakefulness with the actigraph data analysis software (ADAS).

Current evidence has shown that, overall, actigraphy is an excellent tool for unobtrusive documentation of sleep/wake activity in normal individuals. However, a number of methodological issues remain to be resolved to warrant its use in clinical research. In this paper, we report the results of a study aimed at the development of a new scoring software that can accurately identify sleep and wakefulness. Using total sleep time as an index of comparison, the software was optimized on a calibration sample and prospectively tested on a validation sample. A strong correlation coefficient (r = 0.93, p < 0.008), with an average discrepancy value of 10 minutes, was observed for the calibration sample. The application of the optimal software to the validation sample revealed an even higher correlation coefficient (r = 0.97, p < 0.0001), with an average discrepancy value of 12 minutes.

Will AIDS be contained within U.S. minority urban populations?

Recent empirical research, and a simple stochastic modeling exercise, suggest that affluent suburban communities are at increased risk for the diffusion of HIV from present inner city epicenters, while the 'core group' construct of sexually transmitted disease theory suggests, somewhat counter-intuitively, that the hypercongregated and strongly self-interacting nature of affluent heterosexual elites in the U.S. places them at significant and increasing risk as well. In turn, a growing body of work strongly associates high HIV prevalence in minority urban populations with the processes of coupled physical and social disintegration which have produced the now-common and politically-generated 'hollowed out' pattern of U.S. cities. We conclude that a return to the principles of the Great Reform Movement, which first brought public health and public order to U.S. urban areas, is a necessary, but at present largely unrecognized, component to any successful national program to control AIDS in the United States, and particularly to stem the diffusion of HIV into heterosexual populations outside present diseases epicenters.

Prevalence and correlates of AIDS-risk behaviors among urban minority high school students.

BACKGROUND: To guide the development of an AIDS prevention program for urban minority high school students, the authors investigated the prevalence of AIDS-risk behaviors, and the relative explanatory power of demographic, contextual, and cognitive correlates of these behaviors, among black and Hispanic students in three New York City public high schools. METHODS: A survey was administered to a randomly selected sample of classrooms in the 9th through 12th grades of three public academic high schools in a New York City borough. Survey participants (n = 926) were 59% black and 34% Hispanic; the mean age was 16.4 (sd 1.4) years. RESULTS: Two-thirds of students reported having had sexual intercourse. Of the more than one-half of students who reported past-year intercourse, three-quarters had never or had inconsistently used condoms, one-third had multiple intercourse partners, one-tenth had a sexually transmitted disease, and one-twentieth had intercourse with a high-risk partner. Demographic (i.e., age, race/ethnicity) and contextual (i.e., academic failure, substance use, adverse life circumstances, cues to prevention) factors were most strongly associated with involvement in AIDS-risk behaviors; in contrast, cognitive factors (i.e., knowledge and beliefs about AIDS and AIDS-preventive actions) had little explanatory power. CONCLUSIONS: Addressing demographic and contextual risk factors for involvement in AIDS-related behaviors may prove to be a more powerful AIDS-prevention strategy among adolescents than simply teaching facts about AIDS and fostering prevention-related beliefs.

Acupuncture heroin detoxification: a single-blind clinical trial.

The increasing prevalence of HIV infection among injection drug users mandates the development of innovative treatments. While extensive clinical experience suggests that acupuncture detoxification is both safe and acceptable to those in withdrawal, little research has been conducted to assess its efficacy as a treatment modality. In this first controlled study of acupuncture heroin detoxification, 100 addicted persons were randomly assigned, in a single-blind design, to the standard auricular acupuncture treatment used for addiction or to a "sham" treatment that used points that were geographically close to the standard points. Attrition was high for both groups, but subjects assigned to the standard treatment attended the acupuncture clinic more days and stayed in treatment longer than those assigned to the sham condition. Additionally, attendance varied inversely with self-reports of frequency of drug use, suggesting that those with lighter habits found the treatment modality more helpful. Limitations of the study are discussed.

Crack cocaine use and high-risk behaviors among sexually active black adolescents.

The recent spread of crack cocaine use among inner-city teenagers has been accompanied by dramatic increases in juvenile delinquency and sexually transmitted diseases (STDs) among teenagers. This study examined the prevalence of five factors which promote STDs, including human immunodeficiency virus (HIV), among a sample of sexually active black adolescent crack users and non-users from the San Francisco Bay Area. Significant differences were observed between these groups with respect to history of engaging in sexual intercourse under the influence of drugs or alcohol, exchanging sexual favors for drugs or money, condom use in the most recent sexual encounter, and having five or more sexual partners in the last year. Approximately 63% of all respondents reported engaging in at least one of these risk behaviors. In multiple logistic regression analysis, reporting one or more of these STD/HIV risk behaviors was significantly associated with crack use and having one or more relatives who used drugs. Intervention efforts need to address both individual and environmental risk factors in order to reduce teens' risk for STDs, including HIV.

PIP: Researchers combined data from two surveys conducted in the summer of 1988 to examine the association between sexually transmitted diseases (STD) risk behaviors and crack cocaine use among sexually active, black teenagers. All of the subjects lived in an inner city neighborhood in the San Francisco Bay Area in California. The Centers for Disease Control had earlier found a large increase in gonorrhea among black teenagers in San Francisco. Crack users were more likely the nonusers to have sexual intercourse under the influence of drugs or alcohol (43% vs. 11% for boys and 46% vs. 14% for girls; p .001), to take part in sexual acts placing them at risk for STD in exchange for money or drugs (29% vs. 4% for boys and 25% vs. 0 for girls; p .001), and to have more sexual partners in the last year (11.1 vs. 5.3 partners for boys; p .01 and 4.5 vs. 2.5 partners for girls; insignificant). Female nonusers were more likely to have used a condom during last sexual intercourse than were female crack users (39% vs. 18%; p .01). For both groups of boys, condom use during the last sexual act was at the same low rate (about 25%). Approximately 63% of all adolescents admitted to having at least one sexual risk behavior. Crack cocaine use and having at least one relative who used drugs were the greatest predictors of STD risk behavior (odds ratios, 2.2 and 1.97; p .001 and .01, respectively). An urban anthropology study in the same neighborhoods showed that the teenagers lived in an area conducive to high-risk behaviors including drug use common among friends and relatives, more than one sexual partner/year, high prevalence of STDs, and low condom use. The findings from these studies indicated that public health workers planning to implement interventions to prevent or reduce the risk of teenage drug use and/or HIV infection must consider both individual and environmental influences.

Risk for AIDS in multiethnic neighborhoods in San Francisco, California. The population-based AMEN Study.

To examine the actual and potential spread of human immunodeficiency virus (HIV) from an acquired immunodeficiency syndrome (AIDS) epicenter to surrounding neighborhoods, we studied the prevalence of the viral infection and AIDS risk behaviors from 1988 to 1989 in a representative sample of unmarried whites, African Americans, and Hispanics living in San Francisco. We surveyed 1,770 single men and women aged 20 to 44 years (a 64% response rate) in a random household sample drawn from 3 neighborhoods of varying geographic and cultural proximity to the Castro District where the San Francisco epidemic began. Of 1,369 with blood tests, 69 (5%) had HIV antibodies; all but 5 of these reported either homosexual activity (32% HIV-positive; 95% confidence interval [CI] = 23%, 41%), injection drug use (5% HIV-positive; CI = 1%, 14%), or both (59% HIV-positive; CI 42%, 74%). Homosexual activity was more common among white men than among African-American or Hispanic men, but the proportion of those infected was similar in the 3 races. Both the prevalence of homosexually active men and the proportion infected were much lower in the 2 more outlying neighborhoods. Risk behaviors in the past year for acquiring HIV heterosexually--sex with an HIV-infected person or homosexually active man or injection drug user, unprotected sexual intercourse with more than 4 partners, and (as a proxy) having a sexually transmitted disease--were assessed in 1,573 neighborhood residents who were themselves neither homosexually active men nor injection drug users. The prevalence of reporting at least 1 of these risk behaviors was 12% overall, and race-gender estimates ranged from 5% among Hispanic women to 21% among white women. We conclude that in San Francisco, infection with HIV is rare among people who are neither homosexually active nor injection drug users, but the potential for the use spread of infection is substantial, as 12% of this group reported important risk behaviors for acquiring the virus heterosexually.

Crack cocaine and the exchange of sex for money or drugs. Risk factors for gonorrhea among black adolescents in San Francisco.

In contrast to rates for the United States as a whole, the incidence rate of gonorrhea increased 11% in San Francisco between 1986 and 1988, with substantial increases observed among black adolescents. Reports by health department personnel and police suggested that crack cocaine use, specifically the exchange of sex for drugs, contributed to this increase. To test this hypothesis, the authors conducted a case-control study from August 1988 to October 1988 that compared 68 prospectively identified adolescent gonorrhea patients with 136 neighborhood control patients. Thirty-two percent of the female gonorrhea patients had received money or drugs in exchange for sex, while none of the control patients reported having done so (P = 0.0001). Most of the female patients (89%) who had received money or drugs in exchange for sex had used crack. Crack use was less common among female patients who denied receiving money or drugs in exchange for sex (11%) and among control patients (6%). Crack use and providing money or drugs in exchange for sex were not risk factors for gonorrhea among the male patients, but were reported frequently by both gonorrhea patients and control patients. Not living with parents was a risk factor for male patients (odds ratio 4.9, 95% confidence limit 1.4 to 19.5). For all patients, a history of a sexually transmitted disease appeared to be an independent risk factor for gonorrhea. The conclusion is made that crack-related exchange of sex for money or drugs is a risk factor for gonorrhea among black adolescent girls in San Francisco.(ABSTRACT TRUNCATED AT 250 WORDS)