Project DiSH – Dietary and Sexual Health: an HIV risk-reduction intervention for African American men who have sex with men
Although the disproportionate burden of HIV/AIDS among African American MSM is stark and alarming, few interventions have been developed exclusively for African American MSM whose social community involves a complex intersection of economics, ethnicity, family ties, community values, and personal aspirations, all of which impact on their intimate partnerships and sexual behavior. To meet this need, acollaboration has been formed between two divisions of The New York Academy of Medicine – CUES and the Division of Health Policy – and the New York Blood Center. With funding from the CDC, we will develop a novel intervention that weaves proven cognitive-behavioral sexual risk-reduction information and skills building modules into cooking and meal sharing activities to engage participants in creating supportive caring communities of friends that value health, self-worth, self-identification as MSM, and social integration. This is a novel ecological approach to HIV risk-reduction in that the intervention re-engineers the social environment and models interpersonal socialization that can be replicated by participants within their own social contexts. Why cooking and meal sharing? Food is a metaphor for health and support. Preparing and sharing food is a powerful way to demonstrate support and caring for oneself and others. Food provides a way to bring participants together in a context where the focus is on nourishment and health and building relationships that do not necessarily involve sex, in contrast to parks, or the bar and club scene where alcohol and drug use and an emphasis on casual and anonymous sex dominate. Under CDC funding, we will recruit 300 men, randomize them into a two-arm study, and follow up for three months. Groups of 8-12 men will meet for six 2-hour sessions during which they will prepare quick, delicious, healthful low-cost entrées, smoothies and desserts using electric skillets, toaster ovens and immersion blenders – inexpensive food preparation tools that make healthful meals possible in almost any residential situation. The culturally appropriate recipes are designed for small budgets, with menus appropriate for family, friends or romance. We are currently developing the experimental intervention, with component testing and piloting to follow. The research trial is scheduled to begin in summer of 2008.
Preventing HIV Acquisition among Heterosexually Active African-American Men
African-Americans are disproportionately affected by HIV/AIDS, particularly heterosexually acquired HIV. A number of HIV prevention interventions for heterosexual women exist, but there are fewer for heterosexual men, and none specifically for heterosexual African-American men. To fill this gap, the CDC funded three sites across the United States to conduct significant formative research and to develop a prevention intervention for these men. Together with the New York Blood Center, CUES investigators are conducting qualitative research to better understand the prevention needs of African-American men who are at roisk fro heterosexual acquisition of HIV. The data collected will lead directly to the development and testing of an innovative HIV prevention intervention. It is anticipated that approximately 100 men will participate in the formative research and that another 50 men will participate in a pilot study of the intervention developed.
Asthma Surveillance and Education in Preschool Settings
This research project was funded in April 2004 by the National Heart, Lung and Blood Institute of the NIH. It is a continuation of our research to improve asthma care for children in Head Start and subsidized preschool programs in disadvantaged communities heavily impacted by asthma. The current project stems from our long collaborative partnership in East Harlem with Union Settlement Association, the largest provider of preschool childcare services in East Harlem. We have additionally partnered with preschool childcare agencies in the Bronx and the Lower East Side. The intervention that’s at the heart of this project builds on lessons learned in earlier studies and utilizes procedures and materials that were effective in improving the proportion of children identified with probable asthma and receiving appropriate medical management. There are three components to the intervention: surveillance, monitoring and education. A surveillance procedure is in place at all 3 sites to identify children with probable asthma during the routine process of enrollment/re-enrollment, and to require parents/guardians of all children identified as having probable asthma to get a written Asthma Action Plan from their doctor. The "HealthTrak” monitoring system that ensures staff compliance with administering the surveillance procedure and parental compliance with the Asthma Action Plan policy is in place in two of the sites. And at one site, our asthma coach is delivering one-to-one education to parents using a series of educational modules designed for families who haven’t bought into the idea that asthma is a disease that can be controlled with inhaled corticosteroids. To build interest and enthusiasm for this intervention at the three sites, we present group educational workshops on asthma for enrolled families and site staff. Our work has had some impact on public health practices. Building on the success of the pilot work that led to this study, the New York City Department of Health and Mental Hygiene has funded a pilot dissemination of the surveillance and monitoring procedures to over 200 subsidized preschool and Head Start centers in East Harlem, the South Bronx, Central Brooklyn, and Queens, reaching over 20,000 children. The surveillance instrument that we developed has been incorporated onto page 1 of the medical form that the Department of Health and Mental Hygiene requires physicians to fill out for children enrolling in preschool. Work is ongoing on manuscripts and academic conference submissions. We are also developing programs for elementary school level children and parents.
Changes in Homicide and Drug Overdose in New York City
Through a collaboration with investigators at Cornell University and with the New York City Office of the Chief Medical Examiner, we are exploring trends in homicide and fatal drug overdoses in New York City (NYC )between 1990-2006. The aims of the study are: (1) to determine the incidence, temporal trends, and correlates of homicide, accidental drug overdoses and other fatal accidents with a focus on identifying the emerging role of newer drugs such as ecstasy and oxycodone; (2) to determine neighborhood-level determinants of homicide (e.g., drug use, policing, concentrated disadvantages) and to assess how they are related to changes in the frequency of homicide over time and place; (3) to determine the association between individual drug use, age of decedents, neighborhood factors (e.g., economic disadvantage, level of illicit drug use), and the risk of becoming a homicide case using fatal accidents as controls; and (4) to determine neighborhood-level determinants of drug overdose and to assess how these are related to changes in fatal drug overdose over time and place. Early results show significant declines in homicide and that drug overdose deaths now exceed homicides in NYC; results have been shared with the NYC Department of Health and Mental Hygiene to develop overdose prevention interventions such as naloxone administration and distribution programs. Analyses are underway to identify factors that may explain the dramatic and continuing drop in homicides in NYC over the past 15 years; whether and to what extent this can be attributed to changes in demographics, improvement in medical care for those admitted for injuries, changes in policing (“quality of life” arrests), changes in illicit drug use (e.g., crack) are the subject of active inquiry.
Collaborative Injection Drug Users Study (CIDUS) II: Mortality
Between 1997 and 1999, injection drug users were enrolled to take part in the second Collaborative Injection Drug Users Study (CIDUS-II), a prospective cohort study funded by the Centers for Disease Control and Prevention (CDC). This multi-site study was conducted at six sites in five U.S. cities: Baltimore, Chicago, Los Angeles, New Orleans and New York City (where recruitment was conducted in two distinct neighborhoods– Lower East Side of Manhattan and Harlem). The purpose of the study was to examine the risk for HIV and other blood borne pathogens among young and/or recently initiated injection drug users.
The mortality study aimed to quantify the risk of mortality among this group of recently initiated injection drug users, to compare their risk to their peers in the general population, and to distinguish characteristics that were associated with premature death. Death was ascertained through the National Death Index through the end of 2002. Causes of death were determined by National Death Index-Plus and as a check of the NDI plus, supplemental death certificate and medical record review by the study’s endpoints committee. Analyses for this study are nearing completion with manuscripts due out in 2008.
Evaluation of a Parenting and Domestic Violence Curriculum for At-Risk Parents
Working in collaboration with Connect, Inc., a community-based non-profit dedicated to building communities’ capacity to respond to domestic violence and child abuse, this project is designed to evaluate the acceptability and feasibility of a parenting skills curriculum aimed at parents who are in on-going domestic violence situations. Growing research and practice evidence indicates that intimate partner violence and child abuse often co-occur in families; despite recent improvements in both policies and procedures, abusers often still live with their families, putting both women and children at risk. In addition, there are situations where, for a variety of reasons, women do not want their abusive partners to leave the family and therefore do not access legal protections. These realities catalyzed the creation of a parenting skills curriculum for parents who are experiencing or have experienced intimate partner violence and are also deemed to be at-risk for child abuse and/or neglect. Through a grant from the Department of Health and Human Services, researchers from CUES are working to evaluate the implementation of the training curriculum in four busy child abuse and neglect preventive agencies throughout New York City. In 2006, we completed the curriculum development process and the evaluation and the curriculum is currently being used in the Connect Clinical Training Institute.
Pharmacists as the Link to Community Services (Pharm Link) – Harlem Community-based Participatory Research Evaluation Project
This community based participatory research (CBPR) study will evaluate the impact of the Expanded Syringe Access Program (ESAP) in Harlem pharmacies to reduce substance abuse-related health and social risks among injection drug users (IDUs) participating in ESAP, a program that allows the purchase of syringes at pharmacies without a prescription. Pharmacists participating in ESAP have become a first point of contact for IDUs and could feasibly help connect their IDU patients/customers with services focusing on drug treatment, primary care, mental health services, and benefits/entitlement services. Using pharmacies to link IDUs to medical/social services was the logical next step in addressing the multitude of consequences faced by those burdened and at risk of HIV and progressive drug-involvement. To enhance and help sustain the relationship between IDUs and pharmacy staff, this study will connect pharmacies to community-based organizations so that pharmacy staff will have the necessary tools and support to provide these extended services. Thus, the study aims are to (1) evaluate the extent to which community-involved pharmacies are more likely than standard ESAP-pharmacies to achieve the following outcomes in IDUs: (a) increased positive attitudes toward pharmacists as public health providers; (b) increased access/use of medical/social service referrals; (c) decreased substance use; (d) increased safe injection practices; and (2) in pharmacists: (a) increased positive attitudes toward ESAP/IDUs; (b) increased contacts with CBOs; (c) increased ability to maintain and/or increase syringe customers; (d) increased IDU customers with whom a positive rapport has been established; and determine if these outcomes sustain overtime. This project has the potential to create a stronger public health role for pharmacies, improve the lives of IDUs, and potentially reduce substance abuse — all lending to enhanced support of non-prescription syringe sales among NY State legislators. This study has been funded by the Robert Wood Johnson Foundation, 2007-2009.
Pharmacists as The Link to Community Services (PharmLink/HIV) - : HIV Counseling and Testing Feasibility Study
The goal of this research project is to pilot test the feasibility of using ESAP-registered pharmacists as “linkages” to HIV counseling and testing. To achieve the specific aims of this study, the evaluation design will involve measurement of IDUs and pharmacy personnel. Twelve ESAP-registered pharmacies in Harlem, who have expressed interest in participating in a research study that helps link IDU-syringe customers to HIV testing services will be randomly selected. Ten pharmacies will undergo training to provide HIV testing referrals to local testing sites and two pharmacies will undergo training in on-site HIV testing referral. We will compare and contrast IDU syringe customers who patronize the PharmLink/HIV pharmacies with respect to uptake of HIV testing referrals and on-site HIV testing. Demographics, drug and sexual behaviors, perceptions and attitudes towards HIV testing, prior HIV testing, and prior HIV positive diagnosis will be compared by those who utilize HIV testing referrals and/or services and those who do not. Additionally, we will examine the impact of HIV testing referral and on-site HIV testing on pharmacy staff with regards to customer base, business flow and attitudes and perceptions of HIV testing services linked to syringe sales. This study has been funded by the Centers for Disease Control, 2007-2011.
Pharmacists as The Link to Community Services (Pharm Link): Community Intervention Trial
As the independent evaluator of ESAP since 2001 (a NY state public health program allowing non-prescription syringe sales in pharmacies), we found that a large number of pharmacies enrolled in ESAP, early uptake of syringe purchases were made by IDUs, and no potential adverse effects (e.g. increased drug-related arrests, drug use, needle stick injuries, etc) were observed. However, there were racial disparities in pharmacy access. The Harlem Community & Academic Partnership (HCAP) board actively generated and implemented a community mobilization campaign involving IDUs, pharmacists and community residents for NYC, 2001-2003. By targeting both the individual and the social environment, our intervention increased pharmacy use among IDUs from 13% to 32% in Harlem, with significant increases among black IDUs. While the outcomes in this multilevel intervention were positive, room for improvement still existed. The purpose of this newly funded community-based intervention trial is to evaluate the effect of "enhanced" pharmacy services on the following outcomes among IDUs : 1) increased repeated use of pharmacies for syringes, 2) increased safe syringe disposal practices, 3) increased frequency of HIV testing and use of other primary care services, 4) increased utilization of drug abuse treatment, and 5) increased health insurance coverage. Additionally, we will test the intervention effect among pharmacy staff with respect to attitudes towards IDUs and syringe sales services, and pharmacy customer base. Specifically we will assess the following outcomes (1) increased support of ESAP; (2) increased support of enhanced pharmacy services for drug users; (3) increased new IDU customers / frequency of existing customers; and (4) increased prescription customer base. This study will target pharmacies across the four boroughs (Manhattan, Bronx, Queens and Brooklyn) to enroll 110 pharmacies that will be randomized to three arms: (1) provision of expanded services in combination with syringe sales, referral of IDUs for a structured survey, and pharmacy staff survey; (2) standard syringe sales only, referral of IDUs for a structured survey, and pharmacy staff survey; and (3) standard syringe sales and pharmacy staff survey only. This study has been funded by the National Institute on Drug Abuse, 2007-2012.
HCAP: Harlem Community Academic Partnership
The Harlem Community & Academic Partnership (HCAP) is committed to identifying social determinants of health and implementing community-based interventions to improve the health and well being of urban residents using a community-based participatory research approach. The geographical communities of focus are East and Central Harlem, areas where a substantial proportion of the residents are poor people of color. The HCAP is comprised of community based organizations, partners from academia, the health department, and from CUES. The Board has developed an interim conceptual model for social determinants of health, which it then uses to review community-identified health problems and structure interventions to address social determinants. In the past year, HCAP activities have included the following: (1) a pilot intervention aimed at increasing physical activity among overweight women in Harlem, (2) a policy review paper on prisoner reentry into communities, and (3) ongoing supervision of our ongoing National Institutes of Health funded research interventions aimed at developing an intervention in East Harlem to increase the use of Expanded Syringe Access Legislation in New York City and for developing a rapid vaccination program for hard-to-reach populations in East and Central Harlem.
IMPACT: Inner-City Mental Health Study Predicting HIV/AIDS, Club and Other Drug Transitions
IMPACT is a series of multi-level studies aimed at determining the association between features of the urban environment and three negative health outcomes: (1) club and other drug use, (2) HIV and other blood-borne pathogens, and (3) post-traumatic stress disorder (PTSD). Surprisingly little systematic research has explored the relation between features of the individual’s environment, her/his risk behavior, and disease morbidity (i.e. PTSD, HIV, and substance use) while controlling for relevant individual-level covariates. These studies will examine the independent and interactive effect of key features of the urban social environment (residential segregation, income distribution, neighborhood disadvantage) and of the urban physical environment (population density, public transportation, the built environment) as they relate to PTSD, sexual and drug use risk factors for HIV infection, HIV prevalence, and club drug use. We have published two methodological papers from this study. The first focused on the selection of neighborhoods. In research combining census or other publicly available data with surveys of residents and/or street-level observations, questions regarding neighborhood definition take on added significance. Neighborhoods must be identified and delineated in such a way as to optimize quality and availability of data from each of these sources. IMPACT (Inner-City Mental Health Study Predicting HIV/AIDS, Club and Other Drug Transitions), a multilevel study examining associations among features of the urban environment and mental health, drug use, and sexual behavior, utilized a multistep neighborhood definition process including development of census block group maps, review of land use and census tract data, and field visits and observation in each of the targeted communities. Field observations were guided by a preidentified list of environmental features focused on the potential for recruitment (e.g., pedestrian volume), characteristics commonly used to define neighborhood boundaries (e.g., obstructions to pedestrian traffic, changes in land use), and characteristics that have been associated in the literature with health behaviors and health outcomes (such as housing type and maintenance and use of open spaces). This process, implemented in February through July 2005, proved feasible and offered the opportunity to identify neighborhoods appropriate to study objectives and to collect descriptive information that can be used as a context for understanding study results.
The second methodologic paper provided the background and rationale for the sample selection. Studies seeking to identify neighborhood level determinants of drug use, particularly among marginalized urban populations need to overcome significant challenges, particularly in the area of sampling and recruitment. One key issue is defining functional neighborhoods which are relevant to local residents. Another arises from the need to sample a representative, or even a diverse, population when studying marginalized groups such as illicit drug users. These are common problems which raise particular challenges when both need to be addressed in the same study. For example, many sampling approaches for neighborhood-level studies have included some form of random sample of households, but this may systematically overlook marginalized populations. On the other hand, the sampling approaches commonly used in studies of hidden populations such as chain referral, snow ball and more recently, respondent driven sampling, typically expand beyond a geographic “neighborhood.” We describe the organization and rationale for the IMPACT Studies as a case illustration on how such issues may be addressed.
Updates on each of the three components of the study are detailed below.
B-VIVA: Venue Intensive Vaccines for Adults, Hepatitis B
The prevalence of hepatitis B among injection drug users (IDUs) is high, but vaccination coverage in this group remains low. Screening for exposure to hepatitis B virus prior to vaccination is generally recommended for adults in high risk groups, where the prevalence of hepatitis B is greater than 17% to 40%. In high risk populations such as injection drug users (IDUs), the prevalence of hepatitis B virus exposure is reported to be between 20% and 80%. This implies that IDUs should undergo prevaccination screening prior to being offered hepatitis B vaccination in most cases.
Prevaccination screening is recommended solely based on economic factors; hepatitis B vaccine is safe and there is no harm in administering it even if a person has completed the vaccination series or has been exposed to hepatitis B in the past. Whether to screen or not depends on the cost of screening tests, the cost of the hepatitis B vaccination series and their administration, and the seroprevalence; generally, other costs such as staff time invested in follow-up efforts have not been included in these analyses.
The purpose of this study is to evaluate and compare the acceptability of the first dose of HBV vaccine and completion of the vaccination series among IMPACT study participants in two settings: a community-based storefront and a mobile van. The study proposed is a natural experiment based on available resources to provide vaccines during the participants’ first visit to the storefront or mobile van. Due to limited resources, a clinician will not be available to administer HBV vaccines at the storefront and the van everyday. Thus will we examine vaccine uptake among those offered HBV vaccine on their first study visit versus tose who are referred to the next vaccination day.
Club Drugs Use and HIV Risks among Minorities in NYC
As one of the IMPACT studies, the purpose of this cross-sectional study is to determine the prevalence, correlates, and sequelae of club drug use among an economically disadvantaged, racial/ethnically diverse population of substance users in New York City (NYC) in order to provide information on the associations between use of club drugs and high risk sexual behavior in this population. Club drug use [a collective term for ecstasy (MDMA), GHB, ketamine, LSD, methamphetamines, PCP, and flunitrazepam] is increasing in NYC based on data from indicator surveillance, the medical examiner, and hospital reports. In this study we will enroll more than 2,000 substance users using systematic recruitment techniques in 36 disadvantaged neighborhoods within four boroughs of NYC. Eligible and consenting participants will undergo a structured interview and specimen collection. The study will address three aims: (1) to estimate the prevalence of club drugs (separately and combined) among persons who report injection and non-injection drug use, and to report personal characteristics (e.g. demographics, other illicit drug use), place (e.g., by neighborhood) and time (e.g., time trends within a multi-year sampling scheme) factors associated with club drug use; (2) to identify and compare the predisposing factors (e.g., availability, opportunity, family and peer influences, neighborhood characteristics) and specific circumstances of initiation and subsequent purchases of club drugs and to compare these factors for club drug use separately whether or not participants use inhaled or injectable forms of heroin, cocaine alone or together; and (3) to identify and compare sexual risk behaviors (e.g., types and frequency) associated with club drugs (separately and in combination) at three time frames (first use, last use, last six months), after accounting for such other factors as illicit drug use characteristics. This study will add new information about club drug use in urban settings and among minorities and the extent to which it may impact transmission of infectious diseases.
HIV and the Urban Environment
As one of the IMPACT Studies, this multi-level study aims to determine the association between features of the urban environment and sexual and drug use risk factors for HIV infection among injection drug users (IDUs) and men who have sex with men (MSM). Recent evidence about the growing role of sex risk behavior in the transmission of HIV, even among habitual drug using populations, suggests that more comprehensive studies of the determinants of both sex and drug risks are important. While earlier studies have differentiated sexual risk by types of sex practices and precautionary behaviors, recently, a more nuanced typology of sexual relationships has been proposed for study. We propose to assess this typology in IDUs and MSM, followed by an analysis of the independent and interactive effect of features of the urban physical environment (e.g., population density, public transportation, housing quality) and of the social environment (e.g., violence, policing, racial/ethnic segregation, income distribution, neighborhood disadvantage) as they relate to sexual partner dynamics, sexual and drug use risk factors for HIV infection, and to HIV and STD prevalence. To address the study aims, we will recruit more than 2,000 individuals from 36 New York City neighborhoods using multi-stage sampling over a four year period to allow for temporal trend analysis. Features of the urban environment will be assessed using publicly available archival information. Hierarchical multivariate modeling will be used to determine the relations between features of the urban environment and individual risk behavior. Mathematical modeling, based on information theory, will examine the associations between changing features of the city and current behavior. Identification of the key features of the urban environment that shape risk behavior can guide structural intervention, increase the efficiency of individual-level behavioral intervention, and identify features of urban neighborhoods that could suggest population vulnerability to rapid transmission of HIV.
PTSD and HIV Risk Behavior among Drug Users
This three-year study will investigate the role of trauma exposure in HIV risk behavior and is one of the IMPACT studies. While the link between the drug use and HIV/AIDS epidemics is well known, there is an emerging body of evidence suggesting that violence and other types of trauma exposure are integrally connected to these two public health problems. The central purpose of this recently funded study is to document these associations and to investigate the role that trauma exposure plays in injection drug use and HIV/AIDS risk behavior. We believe that a clearer understanding of the associations among the three epidemics is a key to crafting an effective public health response. Such knowledge may allow us to improve the treatment of victimized or traumatized individuals, to design more effective HIV risk prevention programs, to better target drug prevention programs, and to guide the development of more effective drug treatment programs. Perhaps most significantly, understanding the interrelations among these public health problems may point us toward policies and programs that can break the cycle of violence, drug use and disease in those disadvantaged communities that have been most affected by all three epidemics. This research will be conducted on samples of intravenous drug user (IDUs; N = 200), non-intravenous drug users (NIUs; N = 200), and non-users of illicit drugs (NUs; N = 200) sampled from communities in Harlem and the Bronx that are known to experience high levels of drug use and HIV risk behavior. This study is a collaboration between NYAM and the RAND Institute in Santa Monica, CA.
ISUH: International Society for Urban Health
ISUH: International Society for Urban Health The International Society for Urban Health (ISUH) was started by CUES as a forum to encourage collaboration between researchers and practitioners interested in urban health. ISUH is an association of researchers, scholars, and professionals from various disciplines and areas of the world who study the health effects of urban environments and urbanization. Enrollment is currently at roughly 250 members. The goals of ISUH are to encourage research, interventions, and program evaluations that lead to healthier cities in the twenty-first century. The principal aims of the society are to: (1) facilitate the exchange of perspectives, research methods; and data on the study of diseases in urban areas; (2) study the effects of urbanization on health; and (3) evaluate and help develop programs that lessen urban health risks and promote the well-being of people living in urban areas. More information is available at the ISUH web-site www.isuh.org.
The primary activity of ISUH is the International Conference on Urban Health, held in a different global city each year. In October, 2008, the Seventh International Conference on Urban Health was held in Vancouver, BC, bringing over 500 people from over 25 countries together to discuss different issues relevant to urban health. The keynote speaker was Dr. Jo Ivey Boufford, president of the Academy, and plenary speakers included Anthony Zwi, PhD, Julio Montaner, PhD, Trudy Harpham, and others. In 2009, the 8th International Conference on Urban Health will be held in Nairobi, Kenya and includes a number of new events, including a Community Voices Forum and an Urban Health Champions Forum. Please visit www.icuh2009.org for more details.
Project MIX: a group intervention to reduce sexual risk of HIV associated with drug and alcohol use among African American, Latino and white men who have sex with men
This CDC-funded project, awarded to four cities (NYC, Chicago, San Francisco, and Los Angeles) is a multi-session group-level intervention targeted to gay and bisexual men who use non-injection drugs and/or alcohol and engage in unprotected sex. The target sample included a mix of 1/3 African American men, 1/3 Latino men and 1/3 white men, and included both HIV+ and HIV- serostatus. CUES is collaborating with the New York Blood Center on this project. All intervention activities have been completed to compare the experimental intervention arm with an active control condition. The baseline and follow-up data are being analyzed. The CDC appended to this study a third arm – a non-attention control condition – to provide additional comparisons of outcomes. When the final interviews are completed of participants in this third arm, all data will be analyzed and reports prepared for publication. Analyses are being coordinated through the CDC.
Rapid Vaccination of Hard-to-Reach Population: Project VIVA
This is a quasi-experimental project involving a multilevel community participatory intervention that is designed to rapidly immunize hard-to-reach (HTR) populations in disadvantaged minority communities; this project was started at the end of 2004. Low vaccination coverage among minorities and persons living in and near poverty is a persistent problem that is particularly acute among HTR populations (e.g. injection drug users, elderly shut-ins). Immunization rates are affected by multiple factors including demographics, attitudes about vaccination, health norms, barriers to access, and immunization delivery methods. Efforts to successfully vaccinate HTR populations must address these factors. A community-based program with rapid vaccination can serve as an initial model for emergency preparedness vaccination plans in the event of an influenza pandemic and for future efforts to widely introduce HIV vaccination in disadvantaged urban communities. This project has been conducted by a community-public health partnership in eight disadvantaged neighborhoods within Harlem and the South Bronx in three phases. In Phase 1, we implemented a brief survey assessment of residents in designated neighborhoods to identify current key barriers to immunization faced by the target HTR populations in these neighborhoods. Also, using several estimation methods, we determined the size of the target populations in the study neighborhoods to establish vaccine needed and to estimate denominators for vaccination rates. In Phase 2, we implemented two waves of a multilevel community intervention trials (developed with input from the survey and community partners). In the first wave, four randomly selected neighborhoods received the intervention (i.e., community education, community-organization engagement, and door-to-door influenza vaccination program for eligible groups, etc). In the four control communities, target populations were invited to come for vaccination at specified locations as part of usual public health efforts. Although the nationwide flu vaccine shortage made it challenging to provide vaccination to the hard-to-reach populations of interest during wave 1, we offered an alternative vaccintation (pneumococcal vaccine) to maximize the benefit of the extensive infrastructure that had been developed vacacine delivery until we could secure a small supply of the influenza vaccination. In the second vaccination wave, using a crossover design, after updating and revising the approach based on experience from Wave 1, we implemented the intervention in the four control communities over two weeks, to test the feasibility of rapid vaccination of these populations. We are currently engaged in Phase 3 of this project, where we are identifying the promising elements of the program and developing materials to allow generalizability and dissemination to other urban areas and to other vaccines (e.g., HIV, HBV, etc). This includes the development of a Project VIVA website, carrying out another round of local presentations, outreach and follow-up mailings to community agencies, networks, and organizations to disseminate our results, and convening an influenza expert advisory group meeting at The New York Academy of Medicine in September, 2006. The expert group (which included national and international influenza and vaccine experts, federal, state and local public health officials, and community leaders) is in the process of developing recommendations based on the information and discussion that arose from this study and related projects. Work is ongoing on manuscripts and academic conference submissions. Materials from the project are available at www.projectviva.org. We currently have submitted proposals to scale up the project to all of Harlem and Central Brooklyn, communities traditionally with low rates of influenza immunization.
Sequelae of the September 11thTerrorist Attacks in New York City
The September 11th terrorist attacks were the single largest human-made disaster in the United States. Nearly 3,000 people in NYC died as a result of the attacks, more than 100,000 jobs have been lost and billions of dollars in damage have been incurred. Early CUES work demonstrated the substantial mental health burden in NYC as a result of the attacks. CUES developed cross-sectional and longitudinal research projects investigating the psychological sequelae of the September 11th attacks on residents of New York City. We are currently in the process of following-up a cohort of more than 2,500 NYC metropolitan area residents 3 years after the disaster. The survey assessed rates of new onset posttraumatic stress disorder, depression, and other mental health outcomes, and identified subgroups with the highest rates, to target interventions. Data from our cross-sectional surveys and from this cohort have been provided to the New York City Department of Housing and the State Health Department of Mental Health to provide information for program planning. We continue to serve on the New York State Mental Health Consortium formed after September 11th. To date, we have published over 50 papers addressing issues surrounding the World Trade Center attacks, and this work is being extended to look at factors other than the attacks that are associated with mental health in city residents.
The Social Ecology of Intimate Partner Violence against Women
This line of research encompasses two studies designed to further our understanding of what neighborhood factors are related to the distribution of intimate partner violence against women. Intimate partner violence against women is a major public health and social problem. Both the public health and safety system are working to reduce the prevalence of such violence. Developing primary and secondary prevention programs at the neighborhood level has been identified as an important way to do this. However, our understanding of what neighborhood factors are associated with intimate partner violence against women is limited. Thus, we designed two studies to explore how the “informal social control” of intimate partner violence against women works at the individual and neighborhood levels. The first study uses data from the “NYSES” and the “Changes in Homicide and drug Overdose” studies to examine what neighborhood factors, such as social cohesion and related social capital factors, predicted self-reported likelihood of intervening in an intimate partner violence situation. The results will provide an improved understanding of how the social environment influences an important form of social control of partner violence. The second study uses a qualitative method, concept mapping, to understand what neighborhood residents believe affect their likelihood of intervening in or offering assistance to women who experience partner violence. Both studies were funded in 2006 by NIDA via a five-year Career Development Award to Victoria Frye, DrPH, a research investigator at CUES.
Social Ties Associated with Risk for Transition into Injection Drug Use (START Study)
In collaboration with the Department of Epidemiology at Columbia University, Mailman School of Public Health, we have set forth to investigate the effect of high-risk social networks on transition into injection drug use, early high-risk behaviors following transition, and subsequent HIV and HCV infection among young adult drug users in South Bronx, East/Central Harlem,, Brooklyn, Queens, and the lower East Side of Manhattan neighborhoods of New York City (NYC). Since transmission of HIV/HCV occurs within the first 2-3 years of injection drug use, identifying factors associated with the start of an injection career is important so that early prevention and intervention strategies can be designed. Given the persistent racial disparities in HIV disease, race ethnicity will also be examined in relation to one’s social network and other social circumstances that predispose an individual to injection drug use. Typically, white drug users initiate injection drug using more often and at a younger age, while black drug users carry the burden of HIV. Therefore this study aims to understand the effect ones’ social network has on the start of injecting illicit drugs and the role that one’s race/ethnicity plays in this increase in severity of drug use. Additionally this study will determine the social characteristics associated with (1) adolescent transition into injection drug use, and (2) early post-transition drug-related socio-behavioral events among new IDUs using a four-year historical review. Finally, we will prospectively determine the incidence of transition into injection drug use, and the social network/support risk factors that predict transition into injection among non-IDUs. Participants will be recruited from selected high drug activity neighborhoods in NYC through use of ethnographic mapping and respondent-driven sampling. This study is funded by the National Institute on Drug Abuse, 2005-2010.
UNITY: HIV Vaccine Efficacy Trials in Non-injecting Drug-using Women
Low income women of color who reside in HIV epi-centers such as New York City are the fastest growing sector of the population at risk for HIV. However, women have been under-represented in studies testing potential HIV vaccine. We need to increase representation of women in HIV vaccine trials and learn how to more effectively teach high risk women “vaccine concepts” to improve their willingness to take part in such trials. Further, since no potential HIV vaccine is expected to be 100% effective, it is also necessary to find brief, yet powerful ways to motivate vaccine trial participants to minimize risky behavior that may put them at risk for HIV. In this study CUES is collaborating with the New York Blood Center to develop and test a series of brief, individually-based counseling sessions to improve understanding of vaccine trial concepts and sexual risk reduction within a population of women at high risk for HIV. In 2005, piloting was completed of the control and experimental interventions, and the trial was begun. The intervention has been delivered to the entire target sample, and follow-up interviews are underway. One paper on focus group findings is in progress, and further publications are expected in 2007 after final interviews are completed.
Heroin Cessation: A Case-Control Study
As a chronic relapsing condition, drug use is a major risk factor for HIV infection and lower access to HIV medications. An extensive literature on drug treatment entry, relapse and retention has been reported suggesting individual to neighborhood barriers to cessation and triggers to relapse, but recent data on spontaneous recovery and sustained cessation are sparse. Identifying factors associated with sustained cessation can contribute meaningfully to HIV prevention and treatment. The purpose of this case-control study is to characterize the individual and neighborhood-level determinants of initial and sustained cessation of heroin use among persons who report a history of chronic heroin use within economically disadvantaged, predominantly racial/ethnic minority neighborhoods in New York City (NYC). Groundbreaking studies in the 1960’s and 70’s provided mostly descriptive data on the natural history of drug abuse with samples drawn from drug abuse treatment and the criminal justice system. Considerable literature has continued to be devoted to short term cessation and relapse primarily as related to drug abuse treatment and incarceration although some dated information describes spontaneous recovery. Data are sparse on the prognostic indicators and course of sustained heroin cessation, particularly in street-recruited samples. Likewise, while cessation makes sense in terms of parenteral HIV prevention, heroin dulls libido, and little is known about levels of sexual risk following heroin cessation short or long term. Recruitment in field settings has advantages over that done in treatment of criminal justice settings (e.g., getting a broader cross section), and our group has experience in field methods and analyses related to drug use epidemiology including short term cessation. Our proposed work can be advanced with newer methods that have been developed to consider determinants simultaneously at multiple levels, including the potential influence of individual-level factors and neighborhood context on heroin cessation. Thus, this proposal seeks to isolate potentially modifiable factors to assist the overall goal of sustained abstinence if not risk reduction. Key to this proposal is our recognition of cessation as not only an outcome, but also a possible exposure associated with sexual risk behavior.
Methods for evaluating the physical and social environment of urban neighborhoods
The purpose of this study is to design and evaluate a comprehensive, systematic approach to characterizing urban neighborhoods through direct observation of neighborhood characteristics. Public health researchers and practitioners have begun to refocus on the context in which as individual lives as an important determinant of health. Neighborhood characteristics are typically measured through participant self-report, observation (often via video), or secondary databases like the US Census. Major limitations of these approaches include the inability to monitor changes over time, costs and significant staff. This has limited their inclusion in more than a few studies and resulted in neighborhoods being evaluated at a single point during a study. Yet, during a multi-year study, the urban neighborhood context may significantly change as a result of seasonality, gentrification, immigration, etc. We propose to evaluate and revise a brief scale, already developed by the research team, aimed at measuring the social, physical and resource environment of urban neighborhoods through direct observation and examine the reliability and validity of the scale. To achieve these aims, we will be working within a larger multi-level parent study aimed at examining the associations between features of the urban environment and mental health, drug use, and HIV risk in 36 NYC neighborhoods that have already been ethnographically defined. We will first define an additional 15 neighborhoods in affluent and/or predominantly white neighborhoods in New York City, as our current sampling frame is overrepresented by neighborhoods with a high prevalence of economic deprivation and minorities. Next, we will use our neighborhood evaluation scale and neighborhood mapping to measure the urban environment. Each of the 51 target neighborhoods will be rated by two independent observers twice a year for 2 years, providing 4 iterations for data collection, analysis and scale revision. In year 2, we will also administer the scale in 50 randomly selected Detroit neighborhoods to evaluate the scale’s performance in another urban setting and assess the generalizability.
Facilitators and barriers to HPV vaccine acceptance and uptake among minority women in economically disadvantaged communities
The purpose of this study is to examine knowledge, attitudes and beliefs towards HPV vaccine and patterns of health care seeking in the era of HPV vaccine among African American and Hispanic women who are either eligible for Gardasil® and/or the mothers/legal guardians of girls and young women eligible for HPV vaccine in economically disadvantaged communities. Human papillomavirus (HPV) infection is the primary etiologic agent for cervical neoplasia worldwide. Substantial racial/ethnic differences exist for cervical cancer; incidence and mortality rates are higher in African American and Hispanic than White women. Current recommendations include routine vaccination for women ages 11-12 and catch-up vaccination for women aged 13-26, with girls as young as 9 being eligible for vaccination. HPV vaccine presents an interesting challenge for delivery because it is a vaccine for a sexually transmitted disease that is aimed at children and may need parental consent in some settings. Racial/ethnic and socioeconomic disparities have been documented for other childhood vaccines and there is potential for similar disparities to develop as HPV vaccine comes into widespread use. The work proposed will be important in providing information for designing interventions aimed at preventing or reducing disparities in HPV vaccine access and uptake which may then contribute to reducing or eliminating disparities in cervical cancer diagnosis, treatment and survival. Thus, this proposal seeks to identify and understand potential barriers and facilitators of HPV vaccine access and uptake among African American and Hispanic women and their children in economically disadvantaged neighborhoods.
The ALIVE Study
The ALIVE study is a longitudinal study of HIV and other infections in a cohort of injection drug users in Baltimore Maryland that has recently completed its 20th year of semiannual follow-up. While data collection continues, analyses are ongoing on factors associated with risk factors for infection, factors associated with rate of progression to disease, effectiveness of HIV treatment, genetic susceptibility and resistance, risks of mortality and effectiveness of HIV prevention efforts. CUES has been involved in these analyses.
HIV Prevention Trial Network (HPTN)
The HIV Prevention Trial Network (HPTN) is a major NIAID sponsored project to conduct large scale HIV prevention trials in international and domestic sites. Dr. Vlahov is on the Executive Committee of the study and part of the team that has successfully renewed the leadership core.
New York City Alliance against Sexual Assault (NYCASA)
Victoria Frye, DrPH, has been an active member of the New York City Alliance against Sexual Assault's research advisory board in 2006. She is currently working with them on a proposal to design a primary prevention program to discourage male peer support for sexual violence among young men.
New York City Asthma Partnership (NYCAP)
CUES researcher serves on the Steering Committee of the New York City Asthma Partnership (NYCAP), which is the umbrella group for all asthma coalitions in New York. One of NYCAP's responsibilities is to oversee the New York City Department of Health and Mental Hygiene's Day Care Asthma Program which disseminates the surveillance and monitoring system that CUES researcher developed with NIH funding.
PTSD pos-Katrina
On August 29, 2005, Hurricane Katrina made landfall resulting in widespread flooding and damage to New Orleans and the Gulf Coast. Researchers at the Tulane University School of Public Health and Tropical Medicine are investigating potential mental health sequelae among a New Orleans work force. CUES researchers worked with their colleagues at Tulane to examine post traumatic stress disorder (PTSD) and perceived stress in this population. The prevalence of PTSD symptoms was 19.2%. Correlates of PTSD symptoms in a multivariate-adjusted regression model included female sex, non-black race, knowing someone who died in the storm, not having property insurance, having had a longer evacuation, a much longer work commute compared to before Hurricane Katrina, and currently living in a newly purchased or rented house or in a temporary trailer. Despite universal health coverage and the benefits of an employee assistance program for all employees, only 28.5% of those with PTSD symptoms had talked to a health professional about the events of Hurricane Katrina or issues encountered since the storm. In terms of perceived stress, 24.1% stated they felt that they were "fairly often" or "very often" unable to control the important things in their life and 21.4% considered that their difficulties were "fairly often" or "very often" piling up so high that they could not overcome them. Also, 6.1% reported that they "almost never" or "never" felt confident about their ability to handle their personal problems and 15.2% indicated that things were "almost never" or "never" going their way. Higher stress scale scores, indicating more stress, were present for women, and for participants with lower income, displaced longer than 3 months, who were more afraid of losing their life during hurricane Katrina and its immediate aftermath, and who knew someone that died during the storm. Additionally, participants who were living in a relative of friend's house or in a temporary trailer at the time of the survey had higher stress scores compared to their counterparts who had returned to live in their pre-hurricane residence. There was a direct association between higher stress scores and symptoms of post-traumatic stress disorder. A significant burden of perceived stress and PTSD symptoms was present 6 months following Hurricane Katrina among a large group of adults who had returned to work in New Orleans.
Women's Interagency Health Study (WIHS)
The Women's Interagency Health Study (WIHS) is a multi-centered observational epidemiology study of HIV infection in women that started in 1994. CUES was funded to conduct analyses on the impact of illicit drug use and drug abuse treatment on progression of HIV infection and treatment effectiveness. Analyses and manuscripts are underway for 2007 and 2008.
New York City Neighborhood and Mental Health in the Elderly Study (NYCNAMES)
There is mounting evidence that where you live may be a powerful influence on many aspects of your health. This may be particularly true for older adults who are likely to spend more time in their neighborhood of residence, and may be more vulnerable to neighborhood features such as high crime rates or lack of disabled access. While many surveys have shown higher rates of depression in disadvantaged areas, there has been surprisingly little longitudinal research into the relationship between neighborhood characteristics and mental health. This is important since the previous survey findings may simply reflect a tendency for depressed individuals to become disadvantaged, or to live in disadvantaged neighborhoods. If the influence of neighborhood on risk of depression could be confirmed and the neighborhood characteristics that influence depression better defined, this would provide the opportunity for structural interventions to reduce the risk of depression, regardless of an individual’s socio-economic status. The New York City Neighborhood and Mental Health in the Elderly Study (NYCNAMES) is a longitudinal study funded by the City of New York that has been designed to identify features in the urban environment that influence the risk of an older person developing symptoms of depression. 808 older residents of all Boroughs of New York City were interviewed in 2005 and 2007 and asked about a range of health issues including symptoms of depression and physical activity. Early findings suggest that where an older person lives does, indeed, influence their risk of depression. Living in an affluent area appeared to protect against depression, regardless of an individual’s income, and living in an area with high “walkability” also had a positive effect. Analysis of NYCNAMES continues with the researchers looking to identify other neighborhood characteristics that may influence the risk of depression, levels of physical activity and obesity.
Age Friendly Cities New York
In conjunction with the Division of Policy, CUES is working to provide a blueprint for making New York City “a city for all ages”. This document will guide city agencies as they assess their current and potential capacity for increasing the age friendliness of NYC. CUES is working with partners at the Built Environment and Health Project at Columbia University to build a geospatial database of environmental factors relevant to older people and map these in a form that will be useful for Agencies and policy makers. This project will be completed in June 2008.
Knowledge Network on Urban Settings
At the 2004 World Health Assembly, WHO Director-General Dr LEE Jong-wook called for the formation of the Commission on Social Determinants of Health. Operating for three years from March 2005, the Commission is charged with recommending interventions and policies to improve health and narrow health inequalities through action on social determinants. The Commission on Social Determinants of Health (CSDH) supports countries and global health partners to address the social factors leading to ill health and inequities. It draws the attention of society to the social determinants of health that are known to be among the worst causes of poor health and inequalities between and within countries. The determinants include unemployment, unsafe workplaces, urban slums, globalization and lack of access to health systems. The CSDH established knowledge networks to synthesize knowledge to inform the Commission of opportunities to improve action on social determinants of health (SDH) by fostering the leadership, policy, action and advocacy needed to create change.
Researchers at CUES were a part of the Synergy Circle of the Knowledge Network on Urban Settings (KNUS). The focus of the KNUS was on urbanization, particularly broad policy interventions related to "healthy urbanization", and closely examined slum upgrading as an entry point among other possible interventions. The upstream determinants of healthy urbanization will include: stimulation of job creation, land tenure and land use policy, transportation, sustainable urban development, social protection, settlement policies and strategies, community empowerment, vulnerability reduction and better security among others. CUES contributed two working papers to the KNUS and contributed to the final report of the KNUS to the CSDH. The work of the KNUS culminated in a special issue of the Journal of Urban Health.
Development of a Short Course on Urban Health Equity
Working with the WHO’s Center for Health Development in Kobe, Japan (WKC), researchers from CUES developed a short course on urban health equity as a part of the WKC’s Health Urbanization Project. Through its project on "Healthy Urbanization: Optimizing the impact of social determinants of health on exposed populations in urban settings", WKC hopes to contribute to the generation of new knowledge and stimulate action to confront the issue of health inequity in urban settings in both developing and developed countries. The overall goal of the project is to promote health equity in cities, particularly among exposed populations through actions in areas that relate to the project objectives. To achieve these goals, Healthy Urbanization Field Research Sites have been established in Bangalore, India; Kobe, Japan; San Joaquin, a municipality of Santiago, Chile; Ariana, Tunisia and Suzhou, China (see report of meeting held here with Healthy Urbanization Field Research Site mayors).
In June 2007, WKC staff visited Suzhou, traveling with WHO country office staff of China, the WKC country advisor, and a CUES investigator. The outcomes of a scoping paper developed by Fudan University, Shanghai, which focused on two vulnerable groups: migrant populations and the elderly, were presented to and supported by Suzhou. The municipality decided to focus on the issue of ageing while endorsing Suzhou University as the training institute to deliver the short course in the local language. In November 2007, CUES staff again went to China with colleagues from the WHO to conduct a “training of the trainers” and further adapt the short course to the local context.
The short course, which is designed to teach stakeholders about the issue of urban health equity and train them in interventions, is being piloted in Suzhou, China.
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