Decolonization and antiracism: intersecting pathways to global health equity.

In this paper, as Black scholars, we address ways that interventions designed to promote equity in health can create pathways for coupling decolonization with antiracism by drawing on the intersection of the health of Africans and African Americans. To frame this intersection, we offer the Public Health Critical Race Praxis (PHCRP) and the PEN-3 Cultural Model as antiracism and decolonization tools that can jointly advance research on colonization and racism globally. We argue that racism is a global reality; PHCRP, an antiracism framework, and PEN-3, a decolonizing framework, can guide interventions to promote equity for Africans and African Americans.

Sustaining HIV Research in Resource-Limited Settings Using PLAN (People, Learning, Adapting, Nurturing): Evidence from the 4 Youth by Youth Project in Nigeria.

PURPOSE OF REVIEW: Sustaining evidence-based interventions in resource-limited settings is a perennial challenge. Despite growing research on the significance of sustainability, few frameworks describe why and how to plan for sustainability in settings limited with resources. Drawing on a synthesis of the literature on sustainability, including the Dynamic Sustainability Framework, we review lessons learned from research to date, to point out a path forward for sustaining evidence-based interventions in resource-limited settings. RECENT FINDINGS: We describe PLAN or why people learning, adapting, and nurturing the core values of an intervention can enhance its sustainability over time. PLAN is a dynamic framework that simplifies the process of planning for sustainability of evidence-based interventions throughout the lifecyle of an intervention, taking into consideration the people that matter as well as the learning, adaptation, and nurturing involved with understanding and studying the interactions between interventions/innovations, practice settings, intervention fit, and the broader ecological contexts in which implementation occurs. We use case-study data from our ongoing pragmatic HIV implementation trial, the 4 Youth by Youth project, to detail the value and implications of why people learning, adapting, and nurturing HIV interventions implemented in resource-limited settings matter. PLAN is designed to further the dialogue on ways research and practice teams can critically work to ensure the sustainability of their evidence-based interventions from the onset, particularly in settings and with populations limited with resources. It also illustrates how attention to sustainability from the beginning may foster actions necessary for sustained program → sustained benefits → sustained capacity → sustained value, but in the absence of early and active planning, none of this will occur. Ultimately, we hope to accelerate the sustainability of evidence-based HIV interventions, and making a PLAN at the bare minimum may ensure that the goals of continuing and maintaining desirable features of any evidence-based interventions can be realized.

A designathon to co-create community-driven HIV self-testing services for Nigerian youth: findings from a participatory event.

BACKGROUND: Youth are at high risk for HIV, but are often left out of designing interventions, including those focused on adolescents. We organized a designathon for Nigerian youth to develop HIV self-testing (HIVST) strategies for potential implementation in their local communities. A designathon is a problem-focused event where participants work together over a short period to create and present solutions to a judging panel. METHODS: We organized a 72-h designathon for youth (14-24 years old) in Nigeria to design strategies to increase youth HIVST uptake. Proposals included details about HIVST kit service delivery, method of distribution, promotional strategy, and youth audience. Teams pitched their proposals to a diverse seven-member judging panel who scored proposals based on desirability, feasibility, potential impact and teamwork. We examined participants' socio-demographic characteristics and summarized themes from their HIVST proposals. RESULTS: Forty-two youth on 13 teams participated in the designathon. The median team size was 3 participants (IQR: 2-4). The median age was 22.5 years (IQR: 21-24), 66.7% were male, 47.4% completed tertiary education, and 50% lived in Lagos State. Themes from proposals included HIVST integration with other health services, digital marketing and distribution approaches, and engaging students. Judges identified seven teams with exceptional HIVST proposals and five teams were supported for further training. CONCLUSIONS: The designathon provided a structured method for incorporating youth ideas into HIV service delivery. This approach could differentiate HIV services to be more youth-friendly in Nigeria and other settings.

Global Perspectives on Improving Chronic Disease Prevention and Management in Diverse Settings.

The Centers for Disease Control and Prevention (CDC) define chronic diseases as conditions that last 1 year or more and that require ongoing medical attention or limit activities of daily living, or both (1). Chronic diseases may be influenced by a combination of genetics, lifestyle and social behaviors, health care system factors, community influences, and environmental determinants of health (2). These risk factors often coexist and interact with each other. Therefore, a better understanding of determinants of chronic diseases such as tobacco use, unhealthy eating, and physical inactivity stands to benefit from effective strategies for improving primary, secondary, and tertiary disease prevention and management in diverse global settings (3). Strategies to prevent and manage chronic disease outcomes such as diabetes and cardiovascular diseases (CVDs) have global commonalities (4-7). The impact of chronic diseases is disproportionately evident in Black and Brown communities (8,9). Chronic disease prevention and management typically focus on behavioral interventions such as healthy eating, increased physical activity, and cessation of unhealthy practices such as tobacco and alcohol use (10-15). In 2020, the COVID-19 pandemic added to the fact that chronic diseases disproportionately affect low-resource communities, where many Black and Brown populations live (16,17). COVID-19 demonstrated that chronic disease disparities actually present as preexisting conditions in Black and Brown communities, who are disproportionately affected by COVID-19 outcomes. Although most of the articles in this Preventing Chronic Disease (PCD) collection were published before the pandemic, the insights they present, combined with the racial and ethnic data on the burden of COVID-19 thus far, support this reality. Many researchers and public health practitioners often consider the need to sufficiently address the relationships between chronic diseases and social, behavioral, and community factors (18). Global lessons in the prevention and management of chronic diseases, therefore, can help researchers and practitioners benefit from the shared lessons and experience derived from research and interventions conducted in different parts of the world. There are more than 7 billion people worldwide, who speak diverse languages and who have different nationalities, identities, and health systems. Yet, if we share challenges and opportunities for chronic disease prevention and management, many of the global adversities to improving health and well-being can be ameliorated, which is the purpose of this collection. The authors in this collection share lessons that represent experiences in diverse contexts across countries and regions of the world.

Structural Interventions to Reduce and Eliminate Health Disparities.

Health disparities research in the United States over the past 2 decades has yielded considerable progress and contributed to a developing evidence base for interventions that tackle disparities in health status and access to care. However, health disparity interventions have focused primarily on individual and interpersonal factors, which are often limited in their ability to yield sustained improvements. Health disparities emerge and persist through complex mechanisms that include socioeconomic, environmental, and system-level factors. To accelerate the reduction of health disparities and yield enduring health outcomes requires broader approaches that intervene upon these structural determinants. Although an increasing number of innovative programs and policies have been deployed to address structural determinants, few explicitly focused on their impact on minority health and health disparities. Rigorously evaluated, evidence-based structural interventions are needed to address multilevel structural determinants that systemically lead to and perpetuate social and health inequities. This article highlights examples of structural interventions that have yielded health benefits, discusses challenges and opportunities for accelerating improvements in minority health, and proposes recommendations to foster the development of structural interventions likely to advance health disparities research.

Commentary: Just What is Critical Race Theory and What's it Doing in a Progressive Field like Public Health?

Gloria Ladson-Billings cautiously promotes the use of Critical Race Theory (CRT) to address racism's contribution to educational disparities. Nearly a decade ago, we issued a similar call to the multidisciplinary field of public health. Public health touts its progressive roots and focus on equity, but do those efforts draw on CRT? To answer this question, we define CRT, describe its origin in the field of law, and review the ways its use has grown in the field of public health. Public health interventions and policies rely heavily on evidence; therefore, we re-introduce the semi-structured research method we developed to facilitate empirical application of CRT, ie, the Public Health Critical Race Praxis (PHCRP).

Editorial: Critical Race Theory - We Are all Others.

Over the past two years, the persistence of racism in the United States has been particularly pronounced in the policies and actions of the administration of President Donald J. Trump; however, the structure of the United States has been racialized since its inception. This supplement of Ethnicity & Disease uses Critical Race Theory (CRT) to explore several implications for public health and public health research. We intend for it to spark conversations in the classroom and among researchers on how racial phenomena operate and how we as a field can address racism.

Educated and At-Risk: How the Shortage of Available Partners Influences HIV Risk for College-Educated African-American Women.

BACKGROUND: African-Americans have the greatest gender-ratio imbalance compared to other racial groups in the United States. This has been associated with higher rates of concurrent sexual partnerships, increasing risk of HIV infection. College-educated African-American women are of particular interest as they are not often represented in studies on HIV prevention, while their dating and sexual negotiation patterns may differ from those of their lower-educated and lower-income counterparts more often the subject of study in HIV research among African-Americans. METHOD: In this qualitative study, we investigate: a) how the gender-ratio imbalance is perceived by college-educated African-American women, b) how they feel limited partner availability impacts heterosexual relationships in the African-American community, and c) the influence this has on their sexual decision making and HIV protective behaviors. RESULTS: Four major themes emerged- Limited pool of available male partners, Pressure to get married, Feelings of competition among women for male partners, and Men's negotiating power in relationships. CONCLUSIONS: Using the PEN-3 Cultural Model, we discuss how this information may be used to develop interventions for this group of women designed to address their more specific barriers to HIV risk reduction.

Exposure to air pollution and tobacco smoking and their combined effects on depression in six low- and middle-income countries.

BackgroundLittle is known about the joint mental health effects of air pollution and tobacco smoking in low- and middle-income countries.AimsTo investigate the effects of exposure to ambient fine particulate matter pollution (PM2.5) and smoking and their combined (interactive) effects on depression.MethodMultilevel logistic regression analysis of baseline data of a prospective cohort study (n = 41 785). The 3-year average concentrations of PM2.5 were estimated using US National Aeronautics and Space Administration satellite data, and depression was diagnosed using a standardised questionnaire. Three-level logistic regression models were applied to examine the associations with depression.ResultsThe odds ratio (OR) for depression was 1.09 (95% C11.01-1.17) per 10 µg/m3 increase in ambient PM2.5, and the association remained after adjusting for potential confounding factors (adjusted OR = 1.10, 95% CI 1.02-1.19). Tobacco smoking (smoking status, frequency, duration and amount) was also significantly associated with depression. There appeared to be a synergistic interaction between ambient PM2.5 and smoking on depression in the additive model, but the interaction was not statistically significant in the multiplicative model.ConclusionsOur study suggests that exposure to ambient PM2.5 may increase the risk of depression, and smoking may enhance this effect.

Using CBPR to Extend Prostate Cancer Education, Counseling, and Screening Opportunities to Urban-Dwelling African-Americans.

Community-based participatory research (CBPR) is becoming one of the dominant approaches for bringing evidence- and consensus-based cancer prevention and control practices to medically underserved communities. There are many examples of how CBPR has been useful for generating culturally specific solutions for different health issues that affect African-Americans. However, few examples exist in the literature on how the CBPR approach can be applied to address prostate cancer. This paper describes a collaborative process for linking inner-city, African-American men to free prostate cancer education, physician counseling, and screening opportunities (prostate-specific antigen (PSA) testing and digital rectal examination (DRE)). The site of this community-based participatory project was the city of Buffalo, located in Erie County, New York. The collaborative, community-academic process that is described includes the following: (1) planning and conducting a community needs assessment to contextualize local prostate cancer issues, (2) organizing town and gown event planning, and (3) manipulating aspects of the built environment to build an infrastructure within the community to address disparities in screening opportunities. This paper concludes with a description of lessons learned that can help others develop and implement similar activities in other communities.

Prevalence, determinants and systems-thinking approaches to optimal hypertension control in West Africa.

BACKGROUND: In West Africa, hypertension, once rare, has now emerged as a critical health concern and the trajectory is upward and factors are complex. The true magnitude of hypertension in some West African countries, including in-depth knowledge of underlying risk factors is not completely understood. There is also a paucity of research on adequate systems-level approaches designed to mitigate the growing burden of hypertension in the region. AIMS: In this review, we thematically synthesize available literature pertaining to the prevalence of hypertension in West Africa and discuss factors that influence its diagnosis, treatment and control. We aimed to address the social and structural determinants influencing hypertension in the sub-region including the effects of urbanization, health infrastructure and healthcare workforce. FINDINGS: The prevalence of hypertension in West Africa has increased over the past decade and is rising rapidly with an urban-rural gradient that places higher hypertension prevalence on urban settings compared to rural settings. Overall levels of awareness of one's hypertension status remain consistently low in West African. Structural and economic determinants related to conditions of poverty such as insufficient finances have a direct impact on adherence to prescribed antihypertensive medications. Urbanization contributes to the increasing incidence of hypertension in the sub-region and available evidence indicates that inadequate health infrastructure may act as a barrier to optimal hypertension control in West Africa. CONCLUSION: Given that optimal hypertension control in West Africa depends on multiple factors that go beyond simply modifying the behaviors of the individuals alone, we conclude by discussing the potential role systems-thinking approaches can play to achieve optimal control in the sub-region. In the context of recent advances in hypertension management including new therapeutic options and innovative solutions to expand health workforce so as to meet the high demand for healthcare, the success of these strategies will rely on a new understanding of the complexity of human behaviors and interactions most aptly framed from a systems-thinking perspective.

Socio-cultural factors influencing the prevention of mother-to-child transmission of HIV in Nigeria: a synthesis of the literature.

BACKGROUND: Currently, Nigeria alone accounts for 30% of the burden of mother-to-child transmission of HIV. This review explores the socio-cultural factors influencing prevention of mother-to-child transmission of HIV (PMTCT) service uptake in Nigeria. METHODS: Using the PEN-3 cultural model as a guide, we searched electronic databases and conducted a synthesis of empirical studies conducted from 2001 to 2013 that reported the perceptions people have towards PMTCT, the enablers/resources that influence PMTCT service uptake, and the role of nurturers/family or community in shaping actions and decisions towards PMTCT service uptake. RESULTS: A total of 42 articles meeting the search criteria were retained in this review. Thirty-six (36) were quantitative cross-sectional surveys; three were mixed methods, while three were qualitative studies. The findings highlight that there are perceptions, ranging from positive to negative that influence PMTCT service uptake in Nigeria. Furthermore, lack of available, accessible, acceptable, and affordable resources negatively influence decisions and actions towards PMTCT. Finally, family contexts matter with decisions and actions towards PMTCT service uptake in Nigeria particularly with disclosure and non-disclosure of sero-positive status, fertility intentions and infant feeding choices. CONCLUSION: As ambitious goals are established and unprecedented resources deployed towards the elimination of mother-to-child transmission of HIV globally by 2015, there is clearly a need to develop effective family-oriented, culture-centered community-based PMTCT programs in Nigeria so as to improve the low uptake of PMTCT services.

Framing the impact of culture on health: a systematic review of the PEN-3 cultural model and its application in public health research and interventions.

OBJECTIVE: This paper reviews available studies that applied the PEN-3 cultural model to address the impact of culture on health behaviors. METHODS: We search electronic databases and conducted a thematic analysis of empirical studies that applied the PEN-3 cultural model to address the impact of culture on health behaviors. Studies were mapped to describe their methods, target population and the health behaviors or health outcomes studied. Forty-five studies met the inclusion criteria. RESULTS: The studies reviewed used the PEN-3 model as a theoretical framework to centralize culture in the study of health behaviors and to integrate culturally relevant factors in the development of interventions. The model was also used as an analysis tool, to sift through text and data in order to separate, define and delineate emerging themes. PEN-3 model was also significant with exploring not only how cultural context shapes health beliefs and practices, but also how family systems play a critical role in enabling or nurturing positive health behaviors and health outcomes. Finally, the studies reviewed highlighted the utility of the model with examining cultural practices that are critical to positive health behaviors, unique practices that have a neutral impact on health and the negative factors that are likely to have an adverse influence on health. DISCUSSION: The limitations of model and the role for future studies are discussed relative to the importance of using PEN-3 cultural model to explore the influence of culture in promoting positive health behaviors, eliminating health disparities and designing and implementing sustainable public health interventions.

"He doesn't love me less. he loves me more": perceptions of women living with HIV/AIDS of partner support in childbearing decision-making.

Our purpose in this study was to understand the importance of male partner support in the childbearing decision-making processes of women living with HIV/AIDS (WLHA) by exploring their perceptions of support after disclosure, prepartum, and postpartum. We conducted in-depth interviews with 15 WLHA who were receiving clinical HIV care at a teaching hospital in Lagos. Results show that all male partners were consistently supportive, except the partner of the only unmarried participant. Other subthemes that emerged include the following: emotional support and reassurance; partnership and faith; and tangible support. We reveal important implications for HIV treatment and care programs.

HIV positive women's perceptions of stigma in health care settings in Western Cape, South Africa.

We explored the cultural context of HIV positive women's perceptions of stigma in health care settings in Western Cape, South Africa. We conducted seven focus groups with women living with HIV/AIDS in Gugulethu and Khayelitsha. We used deductive/inductive approaches to identify themes. Fifty-one women participated, with ages ranging from 18 to 47. Using the PEN-3 model as a guide, we detected these emergent themes: expectation of care (perceptions), care delivery protocols (enablers), and physical environment (nurturers). We recommend that the cultural context in which care is delivered to women living with HIV/AIDS be considered in efforts to reduce and eliminate HIV/AIDS-related stigma in health care settings.

Gender ratio imbalance effects on HIV risk behaviors in African American women.

Although literature suggests that African American women are no more likely to engage in risky sex than their White counterparts, they are more likely to have sex partners with higher HIV risk. Thus, it is not solely an individual's behavior that determines their risk, but also the behavior of their partner and their position within a sexual network. For this reason, it is important to consider the dynamics of heterosexual relationships in the African American community. An important area of concern regarding African American heterosexual relationships is that of partner availability. A shortage of available African American men for potential partnerships exists and is reportedly due to poorer health and higher mortality rates. Some have argued that gender-ratio imbalance may be responsible for increased HIV vulnerability for African American women. This article reviews the literature on gender ratio imbalance and HIV risk in the African American community, and presents implications and suggestions for future research and intervention.

Cultural expectations and reproductive desires: experiences of South African women living with HIV/AIDS (WLHA).

We explored factors influencing sexual and reproductive (SR) decisions related to childbearing for women living with HIV/AIDS (WLHA) in South Africa. We conducted four focus group interviews with 35 women living with HIV/AIDS. Our results show that the SR health care needs of women were not being addressed by many health care workers (HCWs). Additionally, we found that health care decisions were influenced by partners and cultural expectations of motherhood. Given the importance of motherhood, it is necessary for HCWs to address the diverse sexual needs and reproductive desires of WLHA.