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9 Structural Interventions
Pages 463-496

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From page 463...
... Population Overall • Health Policies • Social Policies Meso-Level Structural Interventions to Decrease Overall STI Rates and STI Inequities • Structural Interventions in the: o Health Care System o Education System o Criminal Legal System o Congregate Care Systems 463
From page 464...
... . Macro-level structural interventions target factors such as federal and state health and social policies and structural discrimination related to race and ethnicity, sexual orientation, and gender identity, among other dimensions of social inequality.
From page 465...
... STI Macro-Level Structural Interventions: • Address policies, social norms, distribution of power and resources with broad reach • Interventions target federal/state health and social policies, structural discrimination STI Meso-Level Structural Interventions: • Address community/local norms, resources, and systems with more immediate institutions in which individuals or groups are involved • Interventions target local educational, health care, and legal systems and institutions, community norms/resources, social networks FIGURE 9-1  Macro- and meso-level structural interventions.
From page 466...
... This chapter covers structural interventions that address the high rates of STIs among marginalized social groups in particular and the U.S. population in general at both the macro level -- including health and social policies addressing structural inequities -- and the meso level -- including structural interventions in health and social systems and community mobilization strategies to advance structural change.
From page 467...
... individuals -- shape STI inequities, including in the distribution of STIs across sexual orientation identity and racial and ethnic groups, respectively. It also offers insights into the types of structural interventions that might help decrease STI rates in marginalized communities.
From page 468...
... had higher odds of sexual risk behaviors, unmet HIV prevention needs, HIV testing nonuse, and sexual orientation nondisclosure compared to their counterparts in countries with low levels of structural stigma. The authors also found that MSM migrants in European countries with high levels of anti-LGBTQ+ and anti-immigrant structural stigma (as measured by national laws and policies toward LGBTQ+ populations and national attitudes toward immigrants)
From page 469...
... . While structural racism has broad population health impacts, historical and contemporary practices and patterns of pervasive discrimination toward Black, Latino/a, and Indigenous people and other individuals of color in health care and social systems both directly and indirectly shape STI outcomes in marginalized racial and ethnic groups.
From page 470...
... . Additionally, very few interventions addressing the effect of intermediary social determinants of health influenced by structural racism (e.g., housing, employment, access to health care, incarceration)
From page 471...
... . Such declarations should seek to raise public awareness and discourse about how structural racism affects population health outcomes and health inequities, including STI rates and inequities.
From page 472...
... The Medicaid expansion, subsidies for lower-income individuals to purchase individual policies, and a requirement that all employer plans offer coverage for dependent adult children up to age 26 resulted in an important structural change for those most affected by STIs, particularly young adults and low-income individuals. Another aspect of the ACA that could produce structural change are provisions that require coverage of preventive services that have been given a high rating by the United States Preventive Services Task Force and those that are recommended for children by Bright Futures and for women by the Health Resources and Services Administration (HRSA)
From page 473...
... Empirically guided research is limited on the relationship between federal and state health policies (federal and state ACA coverage and benefit provisions, state HPV vaccination policies, state sexuality education policies, and state minor STI testing consent laws) , alone and in combination, and STIs in the U.S.
From page 474...
... MESO-LEVEL STRUCTURAL INTERVENTIONS TO DECREASE OVERALL STI RATES AND STI INEQUITIES Structural Interventions in the Health Care System Several studies have examined STI-related structural interventions in health care settings (Taylor et al., 2016) and identified several clinic-based interventions that effectively promote STI screening and thus may help decrease STIs in the U.S.
From page 475...
... population overall, these clinic-based structural interventions also help mitigate STI inequities related to race, ethnicity, socioeconomic position, and sexual orientation among other social factors. Across multiple health care financing and delivery models, various stakeholders have sought innovative approaches to incentivize wellness and maintenance of health rather than solely focusing on remedying illness or providing treatment.
From page 476...
... . Challenges for prevention and treatment in these institutions are many, including financing, short stays in many jails and juvenile detention centers, lack of sexual health training among some health providers, suboptimal diagnostic capacities, and stigma that may influence policy makers to direct health resources elsewhere (NCCHC, 2020)
From page 477...
... COMMUNITY MOBILIZATION FOR STRUCTURAL CHANGE RELATED TO STIs AND HIV As described earlier in this chapter, achieving structural change related to STIs is critical to support and sustain extant and forthcoming interventions (Chutuape et al., 2014) , and community mobilization and community coalitions are an important mechanism through which to enable this change (Chutuape et al., 2010)
From page 478...
... . The majority of publications on community mobilization for structural change related to the HIV continuum of care in the United States, however, are focused on Connect to Protect (C2P)
From page 479...
... . Approaches for community mobilization for structural change around HIV include initiatives that adjust the intricate networks of services and organizations connected to the HIV continuum of care (Boyer et al., 2016)
From page 480...
... . Another community mobilization example is the HIV Prevention Community Planning effort: since 1994, the Centers for Disease Control and Prevention (CDC)
From page 481...
... . Domains, Indicators, and Structural Change Objectives There are several important components of community mobilization to lead to structural change.
From page 482...
... It took coalitions a median of 3 action steps, 12 key actors, 6 new key actors, and 7 months to complete objectives. The research indicates that structural change objectives do not necessarily take more time to complete than individual change objectives and that it is beneficial for coalitions to bundle related objectives or have multiple objectives that target the same goal for their processes (Chutuape et al., 2014; Willard et al., 2015)
From page 483...
... (2015) surveyed the coalitions' target populations, including 2,392 participants in their analysis, and found some suggested associations between an individual's exposure to structural change interventions in their community and the individual's self-reported HIV risk–related behaviors, but these were not statistically significant.
From page 484...
... Accordingly, inferences will have to be made when considering how to enable structural change for STIs. Studies that mention both HIV and STIs offer little to no discussion about how community mobilization for structural change might impact HIV risk and STI risk differently.
From page 485...
... This indicates the need for more community mobilization efforts and evaluation of those efforts around structural change for HIV and other STIs. It follows that evidence-based examples of structural interventions around HIV prevention are limited and, by extension, so are those for STIs (Willard et al., 2015)
From page 486...
... • Stigma is still a major driving factor when it comes to accessing HIV services, but stigma factors for STIs may differ. • CCAT can be effective for grounding community mobilization for structural change related to STIs.
From page 487...
... , mesolevel structural interventions in health care and social systems and institutions, and community mobilization efforts seeking structural change influence STI rates in both the U.S. population in general and marginalized U.S.
From page 488...
... should acknowledge structural racism and other forms of structural inequities as root causes of sexually transmitted infec tion (STI) outcomes and inequities and as threats to sexual health.
From page 489...
... 2005. Social context, sexual networks, and racial disparities in rates of sexually transmitted infections.
From page 490...
... 2014. Adding to the HIV prevention portfolio -- the achievement of structural changes by 13 Connect to Protect coalitions.
From page 491...
... 2012. Connect to Protect®: Utilizing community mobilization and structural change to prevent HIV infection among youth.
From page 492...
... 2013. Conceptualizing community mobilization for HIV prevention: Implications for HIV prevention programming in the African context.
From page 493...
... 2015. Hidden from health: Structural stigma, sexual orientation concealment, and HIV across 38 countries in the European MSM Internet survey.
From page 494...
... Sexually Transmitted Infections 86(Suppl 1)
From page 495...
... 2015. Targeting structural change for HIV prevention: A process and tool for community application.


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