Table 3.

HIV/HPV Risk and Enabling Environments of Pacific Islanders in Southern California

	Micro-environment	Macro-environment
Physical
Risk	Distance to local sexual health services and underdeveloped public transportation system Limited sexual health education resources in local schools Lack of PI providers, services in PI languagesa	Urban sprawl in Southern Californiab Migratory encounter: mixing with a general population with high HPV prevalencec Syndemic intersections of violence, HIV, and other STIs in urban areasd
Enabling	CBOs dedicated to PI communities Churches, community events and leadership High local concentration of infectious disease specialistse	Developed physical infrastructure in high-income country Current preventive modalities, advanced medical technology Geographic foci of PI immigration, concentrated communities generating social capitalf
Social
Risk	Low level of community HIV/HPV knowledge Chamorro view of individual responsibility: less community buy-in in prevention Community gossip	Limited English proficiency Otherization: homophobia, racial xenophobia Stigmatization of HIV/HPV, other STIs
Enabling	Tongan view of prevention as collective community obligationg Community understanding of parents’ critical role in prevention and willingness to engage	Developed state, market, and civil society institutions in U.S. (Social) marketing campaigns for vaccines, stigma reductionh
Economic
Risk	(Transportation to) health services unaffordable for PIs with low incomes, no health insurance Tongan community pride impeding access to needed services if free or subsidized Labor pressures on both parents limit time with children	Low PI incomes Unemployment, lack of insurance among PIsi Reductions in public health workforce due to U.S. recessionj Sluggish recovery of economy from recessionk
Enabling	Free/low cost sex education, screening, treatment Free/low cost transportation to health services Distribution of free condoms, other prevention materials	Entitlement programs –e.g., Medicaid (Medi-Cal), AIDS Drug Assistance Programl Grant funding of PI CBOs U.S. health care reform: expanded preventive services with no copay/deductiblem
Policy
Risk	Variability in school districts’ implementation of California’s sex education requirementsn Lax clinical policies regarding HPV detection, treatment at local facilitieso	National sex education policies (1996 – 2010) funding abstinence-only programsp Exclusions in CDC guidelines for HPV testing of women < 20 years old and menq Limited implementation of CDC recommendations for routine HIV testingr
Enabling	California’s sex education requirementss Language access mandates in local hospitals/clinicst Hospital/clinic and CBO-based policies governing PI health navigatorsu	National sex education policy (2010 –) requiring curricula to address increasing condom usep National HIV/AIDS Strategyv Legal protections of provider-client/patient confidentially U.S. health care reform: expanded insurance coverage for young adultsw

Note: Additional data on factors in each environment are provided in an accompanying supplementary file.

^aDang et al., 2010.

^bWolch et al., 2004.

^cCDC, 2009.

^dSinger et al., 2006; DiStefano & Cayetano, 2011; Federal Bureau of Investigation, 2009; Long Beach Police Department, personal communication, July 22, 2011.

^eInfectious Disease Association of California, 2011.

^fFukuyama, 1999.

^gToafa et al., 1999.

^hMerck & Co., 2011; Savage Love, LLC, 2011.

ⁱHHS, 2011a;

^jMorrissey, 2011.

^kU.S. Federal Reserve, 2011.

^lCalifornia Department of Public Health, 2011a,b;

^mHHS, 2011b.

ⁿPublic Schools Project, 2011.

^oDiStefano, Unpublished results.

^pHHS, 2010.

^qCDC, 2010.

^rBranson et al., 2006; Korthuis et al., 2011.

^sCalifornia Department of Education, 2011.

^tHHS, 2007.

^uNguyen et al., 2008.

^vOffice of National AIDS Policy, 2010.

^wHHS, 2011c.