Katharine E. Stewart - US grants

DESCRIPTION (provided by applicant): The incidence of HIV infection is increasing among heterosexual women of childbearing age in the United States. Advances in the treatment of HIV have resulted in longer lifespans for those with the virus, as well as reductions in the incidence of vertical transmission. Women living with HIV report that their greatest source of stress is combining their role as mother with the medical and psychological demands of coping with a chronic, life-threatening condition. Social isolation, depression, and a lack of confidence in parenting skills are common, and significantly affect women?s quality of life. Despite this evolution in the epidemic, interventions to assist HIV+ mothers with the demands of the combined parent and patient roles are rare. Such interventions are urgently needed by this highly burdened yet underserved population. The primary objective of the proposed 5-year project is to conduct a randomized clinical trial to evaluate the efficacy of a 6-week, theory-based, behavioral intervention to enhance positive parenting skills among HIV+ mothers. We will recruit 240 participants from among women receiving services at the UAB 1917 Clinic, the Children?s Hospital Family Clinic, AIDS Alabama, or AIDS in Minorities. Participants will be randomized either to an attention control condition or to a theory-based skills training condition that systematically addresses specific psychosocial issues associated with parenting as an HIV+ mother. The primary outcome measure to evaluate parenting outcomes will be use of positive parenting behaviors, measured by the Parent Practices Scale. The secondary outcome measures will be physical and mental maternal health status, measured by the MOS-HIV, and children?s behavior, measured by the CBCL. Additional measures collected will include parenting self-efficacy, overall parenting stress, children?s reports of parental behaviors, and behavioral observations of parent-child interactions. Depressive symptoms, hopelessness, household composition, child temperament and serostatus, and parents? social support will also be assessed to examine theoretical assumptions regarding the relationships between these constructs and parenting. Outcome measures will be collected at baseline and at weeks 6, 18, and 30. This application brings together a strong group of investigators with a history of individual and collaborative research relevant to the conduct of the proposed study examining the behavioral and social issues faced by HIV-affected families.

DESCRIPTION (provided by applicant): HIV and other sexually transmitted infection (STI) rates continue to rise disproportionately among African-Americans, and particularly dramatically among rural populations. Stimulant use, especially cocaine use, among rural African-Americans is also increasing, and is related to multiple risk behaviors for HIV/STI, including sex with multiple partners, exchanging sex for drugs and other commodities, and inconsistent condom use. Despite these documented risk patterns, and the increasing disparities in HIV/STI incidence, few theory-based interventions have been specifically designed and tested for rural African-American populations with high-risk behavioral patterns. The primary aims of this project are to adapt an existing risk reduction program to the needs of rural African-American cocaine users, to test the adapted intervention's efficacy via a behavioral clinical trial, and to answer outstanding questions regarding intraclass correlation and sampling methodologies in the sexual risk reduction literature. The project team will conduct a longitudinal intervention study with stratified group randomization, so that participants receive the sexual risk intervention or an active control intervention condition in groups. Each intervention condition is equivalent in terms of contact time and in terms of number and type of contacts (each participant receives two group sessions, two individual sessions, two community-building sessions, and two follow-up "booster" sessions over four months). Respondent-driven sampling will be used to recruit and enroll 280 participants across two rural, predominantly African-American counties in the Arkansas Delta region to one of the two intervention conditions. The primary outcome variables will include condom use skills, sexual negotiation skills, and self-reported risk behaviors. Additional measures, including self-efficacy for decreased sexual risk, perceived peer norms for sexual risk, perceived benefits and barriers of sexual risk reduction, social support and social trust, mental health status, partner violence, and substance use, will also be collected to assess their theory-based mediating and moderating influences on the sexual risk skills and behaviors. Assessments will be conducted prior to the intervention, immediately post-intervention, and at 6- and 12-month follow-ups. This project brings together a strong, experienced investigative team which has an established, trusting relationship with the community that will be involved in the study. PUBLIC HEALTH RELEVANCE The project not only will provide critically-needed information about the efficacy of tailored behavioral interventions among rural African-Americans at high risk for HIV/STIs, but also will allow the study team to investigate important methodological questions about the use of respondent- driven sampling approaches in rural settings and about intraclass correlation coefficients for sexual risk measures in tight-knit rural communities. This research can thus make important contributions that address racial disparities in HIV/STIs, provide approaches for slowing the rapid growth of the epidemics in rural areas, and inform methodological innovations of importance to sexual risk reduction science.

One important mechanism for achieving the goal of eliminating minority health disparities (MHD) is to increase the number of faculty, especially under-represented minority (URM) faculty, in public health, medicine, and related sciences who are trained and are participating in MHD-related research. Both the Institute of Medicine and the Sullivan Commission, in their reports on the importance of diversity within the health and public health workforce, emphasize that talented URM students with interests in health sciences should be identified as undergraduates, encouraged to pursue advanced study, and supported during these early phases of their development as research scientists. Because of of its emphasis on MHD and community-based public health, and given the significant racial and ethnic health disparities that exist in Arkansas, the UAMS College of Public Health has as a primary goal to maintain an over-representation (relative to the State census) of African-American students in graduate degree programs. Unfortunately, many undergraduate students, including URM students, are unaware of public health sciences as a career option, suggesting the need to inform them of public health career opportunities. To our knowledge, no other accredited school of public health has developed BA/MPH combined degree programs with multiple historically Black colleges or universities (HBCUs) throughout their region specifically to enhance involvement of URM students in public health graduate study, tracking them into research careers. The Education/Training Core of the proposed NCMHDA therefore has as its aims to work closely with all three HBCUs in Arkansas to: (1) implement BA/MPH collaborative degree programs and enroll multiple students into the programs annually;(2) provide support and peer mentoring systems for URM students enrolled in the BA/MPH programs and throughout the COPH to increase their academic success and support their readiness for related doctoral programs, and (3) increase COPH recruitment activities within partner HBCUs, not only for the BA/MPH program but also for all available degree programs, especially doctoral programs. The Education Core includes representatives from the COPH, the Arkansas Minority Health Commission, and each HBCU, and will engage in ongoing process and outcome evaluation, monitoring specific objectives under each specific aim.

Efforts to understand and overcome health disparities are compromised by the underrepresentation of minorities in relevant areas of research.¿ Factors affecting minority participation include a history of discrimination, lack of trust, power differences, limited access to healthcare and research opportunities, participant burden, and lack of perceived relevance.Underrepresentation greatly diminishes the relevance of research findings in at risk populations bearing a disproportionate burden of disease and premature mortality. A growing body of evidence indicates that minority research participation can be increased by intentional structural support of community engagement (CE) such as establishing community advisory boards (CABs), involving minority investigators, and hiring community health workers. Key elements of CE include: cultivating long-term community-university partnerships that extend beyond the funding periods of individual research projects; eliciting community input to identify interests and priorities; and integrating community perspectives in methodologically rigorous research reflecting the complementary strengths of community and university partners.