Friends, Lovers, Educators
Tapping into social networks to spread the word about sexual health
"I think one of my girlfriends gave me a sexually transmitted disease," a man named Vernon confides to his friend. The two are seated at a playground watching their children. His friend suggests he see a doctor. But Vernon doesn't have a doctor and doesn't have health insurance. Next she suggests a local health clinic that offers free testing for sexually transmitted diseases (STDs). Vernon hesitates. Everybody there would know his business. His friend continues to talk to him, telling him that she's concerned about his health and that she'll go with him to the clinic. "OK," Vernon finally says. "If you'll go with me, I'll go."
This conversation is not a scene from real life but a role-playing exercise that is part of a Bloomberg School study called CHAT. As the scene ends, "Vernon" returns to her real-life self, a middle-aged woman in an orange sundress. And the "playground" morphs back into a basement room plastered with posters on topics like "HIV 101." On a long table covered with stacks of pamphlets about condom use and STD prevention sits a glass jar full of condoms.
The two women and three others in the room are completing the last session of a peer mentor training program aimed at reducing the spread of HIV and other STDs in Baltimore. The women are all in their 40s. Some are mothers and at least one is a grandmother. None holds a PhD or master's degree in public health, nor has anyone worked in the STD prevention field. But all five are intimately aware of the problem of AIDS in Baltimore, where 14,000 people are infected with HIV. That's because they see devastating effects of AIDS every day in their communities, where the disease has claimed friends, sickened neighbors and destroyed families. In fact, these women themselves face a high risk of contracting HIV.
For the past month, they have gathered in this room with Bloomberg School research assistants Tiffany Walker-Hill and Kathy Dolan to learn about STDs and sexual health and to practice communication skills that will help them discuss these sensitive topics with friends, lovers, neighbors and acquaintances—the web of personal connections known as a social network. If the intervention works as investigators hope it will, this information will then diffuse through the women's social networks and perhaps beyond. The goal: to convince people in this broad network, as well as the women themselves, to change behaviors that put them at risk of STDs.
These sessions take place at the Bloomberg School's Lighthouse project. The community-based research center, housed in a brick row house a few blocks away from the School, sponsors studies focused on preventing disease among the inner-city poor. Like CHAT, several of the Lighthouse's studies are testing the concept of using the social networks of high-risk groups to help reduce HIV risk behavior.
Until now, researchers have generally overlooked this approach to HIV prevention, says Carl Latkin, PhD, professor of Health, Behavior and Society and principal investigator for Lighthouse studies. People who were at high risk for HIV could not be part of the solution. Or so the thinking went.
Latkin saw things differently.
The idea for using peer outreach first occurred to him as a postdoc, when he would accompany city health workers as they handed out condoms and bleach and talked to injection drug users about protecting themselves from HIV. Latkin often heard drug users say, "Hey, I'm going to tell my friend about this."
Perhaps, he mused, drug users themselves could disseminate the same information—and even more efficiently since they already had contacts in the drug-using community.
Eventually, Latkin and his colleagues launched SHIELD (Self-Help In Eliminating Life-Threatening Diseases). The NIDA-sponsored study involved 250 illicit drug users from Baltimore whom researchers randomly divided into two groups. Those in the experimental group completed a 10-part training session to become peer health educators. These volunteers learned about reducing HIV risk and participated in exercises and role-playing activities to gain skill at talking to others about risk reduction. A group facilitator also accompanied the volunteers while they did outreach on the street and later offered feedback on those conversations.
Control group participants also met for 10 sessions and received basic information about HIV prevention but did not receive training in peer outreach.
The SHIELD study built upon several theories in social psychology, starting with social identity theory. "If your team wins, you feel very strongly allied to that group," says Latkin. Thus, a volunteer might be encouraged to participate in a group if he sees that his "team" is helping protect his community from HIV. Latkin also applied the theory of cognitive consistency—people generally want their actions to match their words. Thus, talking to friends and neighbors about using condoms or washing their drug paraphernalia in bleach might motivate the peer health educator to adopt those same risk reduction strategies himself.
Indeed, interviews conducted six months after the training program and three years later showed a decline in risky behavior in the experimental group. Compared to the control group, the peer health educators reported having fewer casual sex partners and using condoms more frequently during casual sex. They also reported less needle sharing and other injection drug behaviors that raise the risk of HIV. Researchers also interviewed members of the peer health educators' social network. An initial analysis suggests that those network members—the recipients of the outreach—had taken steps to reduce their HIV risk behavior. (The study was not large enough to determine its effects on HIV transmission.)
The results supported the study's underlying theories, says Latkin. But they also yielded an unexpected finding: a decline in drug use among the peer health educators. Compared to the control group, these volunteers were almost three times as likely to say they had cut down on their injection drug use. Though that result was surprising, says Latkin, it makes sense. Many injection drug users want to stop injecting drugs, says Latkin. "This program provided them with an opportunity to work on that."
Like SHIELD, the CHAT study uses a peer education model. But here the volunteers are women at risk for HIV. (The study's risk criteria include having recently been diagnosed with an STD; or having a sex partner who is HIV positive, who injects drugs or smokes crack.) While CHAT researchers will not have their first results for more than a year, Latkin is hopeful the study will have the same success as SHIELD. "We've re-garded many impoverished urban residents as unable to fulfill a narrow set of social roles, and hence discarded them to the societal dunghill," he says. "These individuals have many talents and abilities that are untapped. Certainly one social role they can fulfill is that of peer health educator."
What's clear so far is that CHAT volunteers like the program.
Back in the Lighthouse basement meeting room, Dolan and Walker-Hill hold a short graduation ceremony for the group completing their peer mentor training. They hand out certificates and give each woman a chance to share her thoughts about the training.
Society has overlooked the abilities of impoverished urban residents. "These individuals have many talents and abilities that are untapped. Certainly one social role they can fulfill is that of peer health educator," says Carl Latkin.
Says one: "I'll tell you one thing. In 29 years of being sexually active, I've never used a condom. And now I wouldn't have sex without one." Another says she is looking for a paying job or volunteer work where she will be able to continue to promote HIV prevention.
However, the best part of the training, say the women, has been learning skills that help them talk about STDs and sex without arguing, shouting or preaching. A poster on one wall reads:
Choose the Right Time and Place
Hear what the person is saying (avoid assumptions)
Ask questions (to evaluate the situation)
Talk with respect (acknowledge the positive)
But Dolan and Walker-Hill know that even with this set of skills, the women are likely to encounter embarrassment or fear in people when they raise topics like sex or condoms or HIV. So they are sending each peer mentor on her way with a shiny pink "goody bag" full of conversation starters: condoms (male and female versions), lubricants and literature on how to use a condom.
As Walker-Hill gives the women their bags, Dolan cuts slices of a pink and white cake and hands them out—a small celebration for the work that she hopes these women are just beginning.