From individuals to complex systems: exploring the sexual networks of men who have sex with men in three cities of Karnataka, India.

INTRODUCTION: Research on the HIV vulnerability of men who have sex with men (MSM) in India has tended to focus on aggregates of individual risk behaviours. However, such an approach often overlooks the complexities in the sexual networks that ultimately underpin patterns of spread. This paper analyses a set of sexual contact network (SCN) snapshots in relation to ethnographic findings to reorientate individual-level explanations of risk behaviour in terms of more complex systems. METHODS: Fifteen community researchers conducted a 2-month ethnographic study in three cities in Karnataka to generate descriptions of the risk environments inhabited by MSM. SCNs were reconstructed by two methods. First, initial participants, defined as nodes of various sexual networks, were purposively sampled. In each site, six nodes brought in three sexual partners separately as participants. In all sites, 72 participants completed 431 surveys for their 7-day sexual partners. Second, each site determined four groups representing various sexual networks, each group containing four individuals. In all sites, 48 participants completed 334 surveys for their regular sexual partner. RESULTS: Considerable differences were observed between sites for practically all included behavioural variables. On their own, these characteristics yielded contradictory interpretations with respect to understanding contrasts in HIV prevalence at each site. However, viewing these variables in relation to SCNs and ethnographic data produced non-linear interpretations of HIV vulnerability which suggested importance to local interventions. CONCLUSION: SCN data may be used with existing data on risk behaviour and the structural determinants of vulnerability to re-tailor more tightly focused interventions.

The Baltimore Community-Based Organizations Neighborhood Network: Enhancing Capacity Together (CONNECT) Cluster RCT.

INTRODUCTION: This cluster RCT aimed to reduce healthcare utilization and increase the referral of patients between an academic health center and local community-based organizations (CBOs) that address social determinants of health. STUDY DESIGN: Cluster RCT. SETTINGS/PARTICIPANTS: Twenty-two CBOs located in Baltimore, Maryland, were randomly assigned to the intervention or control group, and 5,255 patients were allocated to the intervention or control group based on whether they lived closer to an intervention or control CBO. Data were collected in 2014-2016; the analysis was conducted in 2016. INTERVENTION: A multicomponent intervention included an online tool to help refer clients to community resources, meet-and-greet sessions between CBO staff and healthcare staff, and research assistants. MAIN OUTCOME MEASURES: The primary outcomes were patient emergency department visits and days spent in the hospital. Additional outcomes for CBO clients included knowledge of other CBOs, number of referrals to CBOs by the healthcare system, and number of referrals to healthcare system by CBOs. Outcomes for CBO staff included the number of referrals made to and received from the healthcare system and the number of referrals made to and received from other CBOs. RESULTS: There was no significant effect of the intervention on healthcare utilization outcomes, CBO client outcomes, or CBO staff outcomes. Ancillary analyses demonstrated a 2.9% increase in referrals by inpatient staff to intervention CBOs (p=0.051) and a 6.6% increase in referrals by outpatient staff to intervention CBOs between baseline and follow-up (p=0.027). Outpatient staff reported a significant reduction in barriers related to the lack of information about CBO services (-18.3%, p=0.004) and an increase in confidence in community resources (+14.4%, p=0.023) from baseline to follow-up. CONCLUSIONS: The intervention did not improve healthcare utilization outcomes but was associated with increased healthcare staff knowledge of, and confidence in, local CBOs. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT02222909.

Baltimore CONNECT: A Randomized Trial to Build Partnership Between Community Organizations and a Local Health System.

BACKGROUND: Community-based organizations (CBOs) are key partners in supporting care, but health systems and CBOs operate in silos. Baltimore Community-based Organizations Neighborhood Network: Enhancing Capacity Together (CONNECT) was a randomized, controlled trial based on the core tenets of the World Health Organization's (WHO) African Partnerships for Patient Safety Community Engagement (ACE) approach. OBJECTIVES: We describe a research protocol and lessons learned from a partnership between Johns Hopkins Health System and 11 CBOs. METHODS: Baltimore CONNECT involved 22 CBOs in East Baltimore randomized to a co-developed intervention bundle versus control. Data were from review of notes and minutes from meetings, and discussions with each CBO on value added by intervention elements and on impact of the project. LESSONS LEARNED: It is feasible to engage and maintain a network of CBOs linked with a local health system. CONCLUSIONS: The WHO ACE approach supported development and sustainment of a network of organizations linking health care and social services across East Baltimore.

How Co-Developed Are Community and Academic Partnerships?

BACKGROUND: The world-renowned resources of Johns Hopkins Hospital (JHH) in Baltimore, Maryland, stand in marked contrast with the surrounding impoverished neighborhoods. Community-based organizations (CBOs) are critical frontline responders to residents' needs. Baltimore CONNECT, an academic-community partnership, co-developed an intervention to strengthen connections between CBOs and between CBOs and the health care system. OBJECTIVES: To understand how members of an academic- community partnership define the act of "co-development" and share perceptions of barriers, facilitators, and ways to measure it. METHODS: We conducted semistructured interviews with 15 community partners, academic partners, and external stakeholders. RESULTS: Partners conceptualized co-development as a fluid and evolving process that is the outcome of shared decision making. This exploration revealed nuances within partnership dynamics, including motivations for participation, underlying incentives, partnership equality, balance of power, and trust and relation building. CONCLUSIONS: We present insights that can be used by academic researchers and community leaders looking to co-develop interventions to improve health in urban communities domestically and internationally.JHH in Baltimore, Maryland, is one of the most highly regarded hospitals in the United States. However, its institutional resources stand in marked contrast with those available to the impoverished neighborhoods that surround it. Many have called for JHH to play a greater role in the surrounding community, where it serves as a leading source of health care.

Behaviours of overweight and obese women during pregnancy who achieve and exceed recommended gestational weight gain.

BACKGROUND: Excessive gestational weight gain (GWG) is associated with increased risk of pregnancy-related complications, postpartum weight retention, and long-term obesity. Little is known about the behavioural habits of pregnant women who achieve and exceed recommended GWG. METHOD: In 2011, qualitative interviews were conducted in Pennsylvania with postpartum women who were overweight or obese prior to pregnancy to ascertain their behaviours and attitudes regarding dietary habits, physical activity, and self-monitoring during pregnancy. Thematic analysis identified the habits of women who achieved and exceeded recommended GWG guidelines. RESULTS: Of the 29 women interviewed, 11 had appropriate GWG and 18 had excessive GWG. Women achieving appropriate GWG reported modest increases in caloric intake if at all, with deliberate meal and snack planning, while women with excessive GWG described "eating-for-two." Nearly all women with excessive GWG reported exercising less during pregnancy (or remaining sedentary), while women with appropriate GWG largely increased or maintained pre-pregnancy physical activity levels. About half of the sample reported self-monitoring weight gain during pregnancy, but women achieving recommended GWG tied their weight monitoring with GWG goals consistent with recommended guidelines. CONCLUSIONS: Women who achieved appropriate GWG reported deliberate dietary habits and physical activity planning, with appropriate GWG goals during pregnancy. Women exceeding recommended GWG described "eating-for-two," were sedentary, and either had no goals for GWG or intended to gain more weight than recommended.

"What my doctor didn't tell me": examining health care provider advice to overweight and obese pregnant women on gestational weight gain and physical activity.

BACKGROUND: Appropriate gestational weight gain (GWG) is vital, as excessive GWG is strongly associated with postpartum weight retention and long-term obesity. How health care providers counsel overweight and obese pregnant women on appropriate GWG and physical activity remains largely unexplored. METHODS: We conducted semistructured interviews with overweight and obese women after the birth of their first child to ascertain their experiences with GWG. A grounded theory approach was used to identify themes on provider advice received about GWG and physical activity during pregnancy. RESULTS: Twenty-four women were included in the analysis. Three themes emerged in discussions regarding provider advice on GWG: 1) Women were advised to gain too much weight or given no recommendation for GWG at all, 2) providers were perceived as being unconcerned about excessive GWG, and 3) women desire and value GWG advice from their providers. On the topic of provider advice on exercise in pregnancy, three themes were identified: 1) Women received limited or no advice on appropriate physical activity during pregnancy, 2) women were advised to be cautious and limit exercise during pregnancy, and 3) women perceived that provider knowledge on appropriate exercise intensity and frequency in pregnancy was limited. CONCLUSIONS: This study suggests that provider advice on GWG and exercise is insufficient and often inappropriate, and thus unlikely to positively influence how overweight and obese women shape goals and expectations in regard to GWG and exercise behaviors. Interventions to help pregnant women attain healthy GWG and adequate physical activity are needed.

Primary care physicians' perceptions of barriers to preventive reproductive health care in rural communities.

CONTEXT: Women residing in rural areas are less likely than urban women to receive preventive reproductive health care, but reasons for this disparity remain largely unexplored. METHODS: In 2010, semistructured interviews were conducted with 19 rural primary care physicians in central Pennsylvania regarding their experiences in two domains of preventive reproductive health-contraceptive care and preconception care. Major themes were identified using a modified grounded theory approach. RESULTS: Physicians perceived that they had a greater role in providing contraceptive care than did nonrural physicians and that contraceptives were widely accessible to patients in their communities; however, the scope of contraceptive services they provided varied widely. Participants were aware of the importance of optimal health prior to pregnancy, but most did not routinely initiate preconception counseling. Physicians perceived rural community norms of unintended pregnancies, large families, and indifference toward career and educational goals for young women as the biggest barriers to both contraceptive and preconception care, as these attitudes resulted in a lack of patient interest in family planning. Lack of time and resources were identified as additional barriers to providing preconception care. CONCLUSIONS: Rural women's low use of contraceptive and preconception care services may reflect that preventive reproductive health care is not a priority in rural communities, rather than that it is inaccessible. Efforts to motivate rural women to engage in reproductive life planning, including more proactive counseling by providers, merit examination as ways to improve use of services.

Sex in the city: privacy-making practices, spatialized intimacies and the environmental risks of men-who-have-sex-with-men in South India.

Employing community-based approaches, the spatialization of sexual risk among men-who-have-sex-with-men (MSM) at local cruising spots was explored in South India. To move beyond individualistic and structural deterministic understandings of sexual risk the study examined how erotic associations and networks formed and dissolved as social actors connect to each other through their material world (which includes other bodies). Crowding was important for safely establishing intimacy in public but also created contexts of discrimination and violence, particularly for feminine-acting males. Risk itineraries drawn by MSM anticipated fluctuating levels of risk, enabling them to avoid dangerous situations. Although sexual typologies connected gender nonconforming males to HIV prevention networks, they reinforce the exclusion of men who did not identify with sexual minority identities. Future work must therefore address the HIV prevention needs of men whose identities cannot be readily separated from "the general population".