Examining the Intrapersonal, Interpersonal and Community Level Correlates of Access to Medical Care Among Women Employed by Sex Work in Southern Uganda: A cross-sectional Analysis of the Kyaterekera Study.

Women employed by sex work (WESW) experience significant gaps in accessing necessary healthcare services, leading to unmet health needs. Yet, there is a dearth of literature on the barriers to medical care access among WESW in Uganda. We used data from the Kyaterekera baseline to examine the correlates of access to medical care among WESW, defined as the ability of individuals to obtain the necessary healthcare services they require in a timely, affordable, and equitable manner. The Kyaterekera study recruited 542 WESW aged 18-58 years from Southern Uganda. We conducted a multilevel linear regression model to determine the intrapersonal (age, education level, marital status, HIV knowledge, and asset ownership), interpersonal (family cohesion and domestic violence attitudes), and community (community satisfaction, sex work stigma and distance to health facility) level correlates of access to medical care among WESW. Intrapersonal and interpersonal factors were associated with access to medical care among WESW. There was no significant association between community level factors and access to medical care. WESW with secondary education (ß = 0.928, 95% CI = 0.007, 1.849) were associated with increased access to medical care. WESW with high asset ownership (ß = -1.154, 95% CI= -1.903, -0.405), high family cohesion (ß = -0.069, 95% CI= -0.106, -0.031), and high domestic violence attitudes (ß = -0.253, 95% CI= -0.438, -0.068) were associated with decreased access to medical care. The findings emphasize the critical need for targeted family strengthening interventions to enhance family support for WESW and address domestic violence.

Demonstrating the Feasibility of an Economic Empowerment and Health Promotion Intervention among Low-Income Women Affected by HIV in New York City.

Women of color in the U.S. face systematic exclusion from the labor market, work protections, and employer-based benefits. Women's economic vulnerability increases their susceptibility to health-related issues, including HIV transmission and substance use, which are work-restricting disabilities, by constraining their capacity to effectively reduce risk. The Women's Economic Empowerment pilot examined the feasibility of a structural intervention, implemented at a neighborhood agency, combining both health promotion and economic empowerment components as a pathway to accessing an urban job market for low-income women with work-restricting disabilities, including living with HIV. Ten women clients from a partner agency in New York completed four health promotion sessions, six financial literacy sessions, and a concurrent opportunity to match savings; some also followed with up to 24 vocational rehabilitation sessions. Interviews captured self-reported data on health promotion and financial outcomes at pre-/post-intervention and 3-month follow-up. Qualitative analysis of recorded group sessions and field notes demonstrate that women express improved HVI/STI knowledge and problem-solving strategies for risk reduction, a shared optimism for the future due to group participation, enhanced social support through relationship-building, a heightened sense of empowerment regarding financial decision making, and a desire to re-engage in the labor force. Findings suggest an empowering approach to re-engage women impacted by poverty, unemployment, and disabilities, including living with HIV, into the workforce may be implemented in a community setting.

Economic Abuse and Care-seeking Practices for HIV and Financial Support Services in Women Employed by Sex Work: A Cross-Sectional Baseline Assessment of a Clinical Trial Cohort in Uganda.

Economic hardship is a driver of entry into sex work, which is associated with high HIV risk. Yet, little is known about economic abuse in women employed by sex work (WESW) and its relationship to uptake of HIV prevention and financial support services. This study used cross-sectional baseline data from a multisite, longitudinal clinical trial that tests the efficacy of adding economic empowerment to traditional HIV risk reduction education on HIV incidence in 542 WESW. Mixed effects logistic and linear regressions were used to examine associations in reported economic abuse by demographic characteristics, sexual behaviors, HIV care-seeking, and financial care-seeking. Mean age was 31.4 years. Most WESW were unmarried (74%) and had less than primary school education (64%). 48% had savings, and 72% had debt. 93% reported at least one economic abuse incident. Common incidents included being forced to ask for money (80%), having financial information kept from them (61%), and being forced to disclose how money was spent (56%). WESW also reported partners/relatives spending money needed for bills (45%), not paying bills (38%), threatening them to quit their job(s) (38%), and using physical violence when earning income (24%). Married/partnered WESW (OR = 2.68, 95% CI:1.60-4.48), those with debt (OR = 1.70, 95% CI:1.04-2.77), and those with sex-work bosses (OR = 1.90, 95% CI:1.07-3.38) had higher economic abuse. Condomless sex (ß = +4.43, p < .05) was higher among WESW experiencing economic abuse, who also had lower odds of initiating PrEP (OR = .39, 95% CI:.17-.89). WESW experiencing economic abuse were also more likely to ask for cash among relatives (OR = 2.36, 95% CI:1.13-4.94) or banks (OR = 2.12, 95% CI:1.11-4.03). The high prevalence of HIV and economic abuse in WESW underscores the importance of integrating financial empowerment in HIV risk reduction interventions for WESW, including education about economic abuse and strategies to address it. Programs focusing on violence against women should also consider economic barriers to accessing HIV prevention services.

Using the multiphase optimization strategy (MOST) framework to optimize an intervention to increase COVID-19 testing for Black and Latino/Hispanic frontline essential workers: A study protocol.

BACKGROUND: Among those at highest risk for COVID-19 exposure is the large population of frontline essential workers in occupations such food service, retail, personal care, and in-home health services, among whom Black and Latino/Hispanic persons are over-represented. For those not vaccinated and at risk for exposure to COVID-19, including frontline essential workers, regular (approximately weekly) COVID-19 testing is recommended. However, Black and Latino/Hispanic frontline essential workers in these occupations experience serious impediments to COVID-19 testing at individual/attitudinal- (e.g., lack of knowledge of guidelines), social- (e.g., social norms), and structural-levels of influence (e.g., poor access), and rates of testing for COVID-19 are insufficient. METHODS/DESIGN: The proposed community-engaged study uses the multiphase optimization strategy (MOST) framework and an efficient factorial design to test four candidate behavioral intervention components informed by an integrated conceptual model that combines critical race theory, harm reduction, and self-determination theory. They are A) motivational interview counseling, B) text messaging grounded in behavioral economics, C) peer education, and D) access to testing (via navigation to an appointment vs. a self-test kit). All participants receive health education on COVID-19. The specific aims are to: identify which components contribute meaningfully to improvement in the primary outcome, COVID-19 testing confirmed with documentary evidence, with the most effective combination of components comprising an "optimized" intervention that strategically balances effectiveness against affordability, scalability, and efficiency (Aim 1); identify mediators and moderators of the effects of components (Aim 2); and use a mixed-methods approach to explore relationships among COVID-19 testing and vaccination (Aim 3). Participants will be N = 448 Black and Latino/Hispanic frontline essential workers not tested for COVID-19 in the past six months and not fully vaccinated for COVID-19, randomly assigned to one of 16 intervention conditions, and assessed at 6- and 12-weeks post-baseline. Last, N = 50 participants will engage in qualitative in-depth interviews. DISCUSSION: This optimization trial is designed to yield an effective, affordable, and efficient behavioral intervention that can be rapidly scaled in community settings. Further, it will advance the literature on intervention approaches for social inequities such as those evident in the COVID-19 pandemic. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05139927 ; Registered on 11/29/2021. Protocol version 1.0. May 2, 2022, Version 1.0.

Recruiting and retaining service agencies and public health providers in longitudinal studies: Implications for community-engaged implementation research.

This article addresses a lack of attention in the implementation science literature regarding how to overcome recruitment and retention challenges in longitudinal studies involving large samples of service agencies and health service providers ("providers"). Herein, we provide a case-illustration of procedures that improved recruitment and retention in a longitudinal, mixed-method study-Project Interprofessional Collaboration Implementation-funded by the US National Institute of Mental Health. Project Interprofessional Collaboration Implementation included counselors, program workers, educators, and supervisors. We present a research-engagement model to overcome barriers that included developing a low-burden study, social gatherings to engage stakeholders, protocols to recruit agencies and providers, comprehensive record-keeping, research procedures as incentives to participation, a plan to retain hard-to-reach participants, and strategies for modifying incentives over time. Using our model, we retained 36 agencies over the life of the project. Between baseline (N = 379) and 12-month follow-up (N = 285), we retained 75% of the sample and between the 12- (N = 285) and 24-month follow-ups (N = 256), we retained 90%. For qualitative interviews (between baseline and 12-month follow-up and between 12- and 24-month follow-ups), we retained 100% of the sample (N = 20). We provide a summary of frequency of contacts required to initiate data collection and time required for data collection. The model responded to environmental changes in policy and priorities that would not have been achievable without the expertise of community partners. To recruit and retain large samples longitudinally, researchers must strategically engage community partners. The strategies imbedded in our model can be performed with moderate levels of effort and human resources. Creating opportunities for research partners to participate in all phases of the research cycle is recommended, which can help build research capacity for future research.

Policy Interventions Shaping HIV Prevention: Providers' Active Role in the HIV Continuum of Care.

The U.S. Centers for Disease Control and Prevention (CDC) Diffusion of Effective Behavioral Interventions project has disseminated HIV behavioral interventions (EBIs) across the United States since the 1990s. In 2011, the CDC launched the High-Impact HIV Prevention (HIP) project, providing EBIs plus high-impact services (HIV testing, primary care, and support services). Providers (nurses, social workers, educators) are unable to consistently make linkages; thus, numerous at-risk individuals are not benefitting from HIP. Research on providers' roles in the HIV Continuum of Care-linking clients to HIV testing, primary care, and support services-is lacking. This article helps fill this gap with evidence that providers exposed to EBIs, whose agencies offer EBIs, more frequently link clients to high-impact services. This is based on diffusion of innovations theory, where individuals in social networks influence one another's adoption of innovations. We hypothesize that providers are exposed to EBIs via training, reading and hearing about EBIs, and/or discussing EBIs with colleagues. We used cross-sectional data from 379 providers from 36 agencies in New York City. We used multilevel ordinal logistic regression models to test associations between provider exposure to EBIs (agency provides EBIs) and frequency of linkages to high-impact services. Providers exposed to greater numbers of EBIs more frequently link clients to HIV, hepatitis C (HEP-C), and sexually transmitted infections testing; to primary care; and to drug treatment and mental health services. Providers link clients most frequently to primary care and HIV testing and least frequently to HEP-C testing and syringe exchange. Findings suggest a dose effect, with exposure to more EBIs resulting in more linkages. Findings show a staged, evidence-based prevention approach that includes exposure to EBIs, leading to providers linking clients to high-impact services. There needs to be emphasis on inspiring providers to engage with high-impact services at the elevated levels needed to end the epidemic.

Factors That Influence Linkages to HIV Continuum of Care Services: Implications for Multi-Level Interventions.

Worldwide, the human immunodeficiency virus (HIV) continuum of care involves health promotion providers (e.g., social workers and health educators) linking patients to medical personnel who provide HIV testing, primary care, and antiretroviral treatments. Regrettably, these life-saving linkages are not always made consistently and many patients are not retained in care. To design, test and implement effective interventions, we need to first identify key factors that may improve linkage-making. To help close this gap, we used in-depth interviews with 20 providers selected from a sample of 250 participants in a mixed-method longitudinal study conducted in New York City (2012-2017) in order to examine the implementation of HIV services for at-risk populations. Following a sociomedical framework, we identified provider-, interpersonal- and environmental-level factors that influence how providers engage patients in the care continuum by linking them to HIV testing, HIV care, and other support services. These factors occurred in four domains of reference: Providers' Professional Knowledge Base; Providers' Interprofessional Collaboration; Providers' Work-Related Changes; and Best Practices in a Competitive Environment. Of particular importance, our findings show that a competitive environment and a fear of losing patients to other agencies may inhibit providers from engaging in linkage-making. Our results suggest relationships between factors within and across all four domains; we recommend interventions to modify factors in all domains for maximum effect toward improving care continuum linkage-making. Our findings may be applicable in different areas of the globe with high HIV prevalence.