Abstract
The Women-Centered Program for Women of Color, a culturally congruent sexual health intervention, was implemented in 2018 in Los Angeles County, California, according to the principles of community-based participatory research: enhancing community capacity, establishing sustainable programs, and translating research findings to community settings. Participants exhibited significantly increased knowledge of and interest in preexposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) over time, but no significant change in condom use was evident. Booster sessions are needed to maintain interest in PrEP and PEP given concerns about reproductive and sexual health. (Am J Public Health. 2023;113(S2):S110–S114. https://doi.org/10.2105/AJPH.2023.307296)
For nearly 17 years, the Center for Culture, Trauma and Mental Health Disparities at the University of California, Los Angeles, has specialized in community-based participatory approaches and trained public health professionals and clinic personnel to implement culturally congruent, evidence-based interventions. At-risk people of color are the focus of treatment programs across the United States, but few interventions are developed by women of color for women of color.
INTERVENTION AND IMPLEMENTATION
The objective of the Women-Centered Program for Women of Color (WC4WC) was to reduce sexual health risks among women of color in a low-income area of Los Angeles County, California. The program was implemented according to community-based participatory research principles in a three-year collaboration with public health organizations. The goals of community-based participatory research are to enhance community capacity by supporting equal community participation in research leading to direct benefits, establish sustainable programs that improve health behaviors and health outcomes, and accelerate the translation of research findings to communities with health disparities through the design of effective and culturally tailored interventions.1 The aims, procedures, and results of WC4WC align with these goals.
WC4WC incorporated concepts from Eban, a Yoruba word meaning fence that symbolizes good practices (e.g., self-protection and partner protection) and elimination of unhealthy ones.2,3 The intervention, which included sexual health facts provided on anatomical charts to increase condom and contraceptive use,2 involved four sessions of two hours each with eight to 10 women per group. Pretest, posttest, and one-month follow-up assessments were administered 30 days apart. Leaders of sessions with Spanish speakers were bilingual and bicultural.
Session 1: Preparing for the Journey
Participants learned the historical context of gender, race/ethnicity-based trauma, oppression, and other systemic health barriers and shared their traumatic experiences with violence and discrimination. They calculated their index of risky partners and behaviors to build resilience (e.g., bodily autonomy, sobriety, resisting coercion and violence). Homework included journaling and initiating discussions of love and harm protection with partners.
Session 2: Tools for the Journey
Participants were provided information on male and female anatomy, how to use condoms and other contraceptives,4 and preexposure prophylaxis (PrEP) and postexposure prophylaxis (PEP). They were also offered a safer sex menu, a problem-solving mnemonic (FENCE) to teach self-protection strategies, and art by women of color for empowerment. Homework focused on “talk and listen” communication techniques.2
Session 3: It Takes a Village
Women redefined their racial/ethnic status and gender status as powerful tools to build self-esteem and shared what made them proud as women of color and as WC4WC “village” members.5 Homework focused on bonding with supportive, reliable individuals and defining personal and sexual safety with partners.
Session 4: Expanding the Village
Participants played sexual health games to reinforce knowledge and received prizes. Ujima (collective work and responsibility) was applied to inform community-based villages and future goals. Women shared how they passed their knowledge on to others.
The team met monthly with community partners. With key aims established, each site took the lead in implementation with consultation and research team support.
PLACE, TIME, AND PERSONS
Three sites were located in a service planning area of South Los Angeles (SPA-6) severely affected by unintended pregnancies, HIV/AIDS, sexually transmitted infections (STIs), COVID-19, and limited health literacy and services. More than 60% of SPA-6 residents are people of color, 32% are not US citizens, 41.1% are unemployed, and 22.5% live in poverty.6 WC4WC was offered in person from September 2018 to March 20, 2020, and virtually after the COVID-19 shutdown (March 2020 to September 2021; Table 1). On-site project staff facilitated each session. All eligible, consenting women were accepted as similar programs were not available in SPA-6 (see the Appendix, available as a supplement to the online version of this article at http://www.ajph.org).
TABLE 1—
Descriptive Characteristics for the Overall Sample and by Site: Women-Centered Program for Women of Color, Los Angeles, CA, 2018–2021
| Characteristic | Overall Sample (n = 292), Mean ±SD or No. (%) | Black Women for Wellness (n = 100), Mean ±SD or No. (%) | To Help Everyone (n = 138), Mean ±SD or No. (%) | Watts Healthcare Corporation (n = 54), Mean ±SD or No. (%) | P |
| Age, y | 39.9 ±12.9 | 41.2 ±12.5 | 40.4 ±13.0 | 35.9 ±12.7 | .04 |
| Race/ethnicity | .14 | ||||
| African American | 257 (88.01) | 92 (92.00) | 116 (84.06) | 49 (90.74) | |
| Latina | 35 (11.99) | 8 (8.00) | 22 (15.94) | 5 (9.26) | |
| Incomea | .5 | ||||
| Below poverty level | 169 (58.68) | 55 (55.56) | 80 (58.39) | 34 (65.38) | |
| Above poverty level | 119 (41.32) | 44 (44.44) | 57 (41.61) | 18 (34.62) | |
| Education | .76 | ||||
| < high school | 41 (14.04) | 14 (14.00) | 21 (15.22) | 6 (11.11) | |
| High school | 251 (85.96) | 86 (86.00) | 117 (84.78) | 48 (88.89) | |
| Employment | .73 | ||||
| Unemployed | 165 (56.70) | 54 (54.55) | 78 (56.52) | 33 (61.11) | |
| Employed | 126 (43.30) | 45 (45.45) | 60 (43.48) | 21 (38.89) | |
| Currently married | 54 (18.56) | 18 (18.00) | 24 (17.52) | 12 (22.22) | .74 |
| Frequency of use of contraception other than condoms | .27 | ||||
| Always | 81 (28.72) | 25 (26.88) | 42 (30.66) | 14 (26.92) | |
| > half of the time | 15 (5.32) | 7 (7.53) | 3 (2.19) | 5 (9.62) | |
| About half the time | 13 (4.61) | 7 (7.53) | 4 (2.92) | 2 (3.85) | |
| < half of the time | 17 (6.03) | 4 (4.30) | 11 (8.03) | 2 (3.85) | |
| Never | 156 (55.32) | 50 (53.76) | 77 (56.20) | 29 (55.77) | |
| Outcomes | |||||
| Percentage of condom use in past 30 days | 0.23 ±0.41 | 0.2 ±0.39 | 0.23 ±0.41 | 0.25 ±0.41 | .001 |
| STI and HIV knowledge | 6.88 ±1.94 | 7.18 ±2.00 | 6.64 ±1.87 | 6.93 ±1.90 | .11 |
| Heard of PrEP | 113 (39.37) | 36 (37.11) | 52 (37.96) | 25 (47.17) | .43 |
| Would consider taking PrEP | 127 (45.20) | 38 (40.43) | 58 (42.96) | 31 (59.62) | .06 |
| Contraception (IUD/diaphragm) | 18 (6.16) | 6 (6.00) | 8 (5.80) | 4 (7.41) | .91 |
Note. IUD = intrauterine device; PrEP = preexposure prophylaxis; STI = sexually transmitted infection.
Income was calculated on the basis of US Census poverty thresholds by size of family and number of children.
PURPOSE
Women in SPA-6 account for 11% of new infections in Los Angeles County.7 Efforts to provide sexual health services have been thwarted by restrictive state and federal funds. Services for pregnancy and disease transmission are separated from each other.8 Biomedical HIV strategies, including PrEP and PEP, are used only marginally among women of color at risk for HIV.9 Research in medical settings has shown that women are not asked about their sexual health to the same degree as men.10 A history of racial/ethnic discrimination has sensitized women to be suspicious of studies that do not offer all services to everyone.11
EVALUATION AND ADVERSE EFFECTS
The primary outcomes were condom use over the past 30 days, contraceptive use, STI and HIV knowledge, awareness of PrEP, and consideration of taking PrEP. Calculations for condom-protected intercourse acts in the past 30 days were adapted from an evidence-based intervention.2 STI and HIV knowledge was assessed via 10 true or false statements.
Data and Statistical Analysis
Univariate and bivariate analyses were calculated for each measure and between predictors and outcomes at baseline, after program completion, and at a one-month follow-up. Using a repeated measures design with three data points, we fit mixed-effects linear models estimating fixed and random effects through SAS PROC MIXED (SAS Institute Inc, Cary, NC) for continuous outcomes (e.g., proportion of condom use) and PROC GLIMMIX (North Carolina State University, Raleigh, NC) with logit link for binary outcomes (e.g., awareness of PrEP).
Findings
Among the 379 women screened, 292 were enrolled. Attrition rates were 34.2% from pretest to posttest and 27.7% from posttest to the one-month follow-up; overall attrition was 46%. The primary reasons for dropping out were time constraints and privacy concerns. Those who dropped out after the assessment (P = .035) and at the one-month follow-up (P = .029) had significantly less education relative to the baseline sample.
The mean percentage of condom use was 23%; nearly 30% of women reported always using contraceptives other than condoms, either ongoing methods (e.g., the pill, IUD [intrauterine device], diaphragm) or one-time methods (sterilization). The mean STI and HIV knowledge score was 6.88 (of a possible 10). Almost 40% of women had heard of PrEP, and 45.2% reported that they would consider taking PrEP (Table 1).
Changes Over Time
There were significant increases from baseline to posttest with respect to HIV knowledge score (P < .001), awareness of PrEP (P < .001), and consideration of taking PrEP (P = .001). The changes from posttest to the one-month follow-up for these three outcomes trended in the right direction but did not reach statistical significance. Condom use increased from baseline to the one-month follow-up but was not statistically significant. Knowledge about STIs and HIV (P < .001), awareness of PrEP (P < .001), and consideration of taking PrEP (P = .003) increased significantly over time (Table 2). Despite the intervention, participants expressed a reluctance to take medication owing to concerns about effects on future children. Apprehension about medication toxicity may reflect uncertainty surrounding long-term HIV prevention safety.12 However, participants were more likely to consider using PrEP or PEP as the program progressed.
TABLE 2—
Changes Over Time in Outcome Variables: Women-Centered Program for Women of Color, Los Angeles, CA, 2018–2021
| Pretest, Mean ±SD or No. (%) | Posttest, Mean ±SD or No. (%) | One-Month Follow-Up, Mean ±SD or No. (%) | P | |
| STI and HIV knowledge | 6.88 ±1.93 | 8.46 ±1.72 | 8.48 ±1.59 | <.001 |
| Percentage of condom use in past 30 days | 0.23 ±0.41 | 0.31 ±0.44 | 0.25 ±0.42 | .1 |
| Heard of PrEP | 113 (39.37) | 150 (81.08) | 118 (88.72) | <.001 |
| Would take PrEP | 127 (45.2) | 110 (59.46) | 72 (54.55) | .003 |
| Contraception (IUD/diaphragm) | 18 (6.16) | 13 (6.77) | 10 (7.41) | .6 |
Note. IUD = intrauterine device; PrEP = preexposure prophylaxis; STI = sexually transmitted infection.
SUSTAINABILITY
SPA-6 community, local, and statewide health providers attended a town hall to discuss the WC4WC results. The collaboration broadened staff networks and increased referrals; sites integrated the curriculum into ongoing women’s programs, although ongoing funding was challenging. Federal, state, and private foundations are potential funding sources for sexual health intervention sustainability (e.g., hiring of permanent intervention staff).
PUBLIC HEALTH SIGNIFICANCE
Given the overrepresentation of women of color living in poverty, recent US Supreme Court rulings (e.g., Dobbs v Jackson Women’s Health) significantly restrict reproductive choices and sexual health, exacerbating a public health crisis.13 Increased information and skills that prevent unintended pregnancies and STI and HIV transmission and increase condom use need to be more easily accessible in communities of color where disease transmission is high. It is important to acknowledge women’s reluctance to engage in prevention regimens that may protect their sexual health but undermine their reproductive health. Future public health campaigns focusing on the safety and efficacy of new prevention medications should increase trust, compliance, and health care uptake among women of color.14
ACKNOWLEDGMENTS
This study was funded by the Cal Wellness Foundation (grant CA-2017-257).
We express appreciation to the Cal Wellness Foundation, including president and CEO Judi Belk and program officers Crystal Crawford and Connie Robinson; Alexandria Yip and Citlalin Lopez-Torres at To Help Everyone; Jennifer Wooten at Watts Healthcare Corporation; and Stephanie Haynes at Black Women for Wellness for recruiting, facilitating, and following participants. Also, we thank Alex Kim and Graciela Albarran for their assistance with the formatting of the article and the literature search.
Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Cal Wellness Foundation.
CONFLICTS OF INTEREST
The authors have no competing interests to declare that are relevant to the content of this article.
HUMAN PARTICIPANT PROTECTION
The study was approved by the institutional review board of the University of California, Los Angeles.
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