A culturally tailored intervention for a particularly vulnerable group of Black women has reduced the odds of testing positive for a sexually transmitted infection (STI) and increased condom use in vaginal or anal intercourse, the authors of a recent study found.1

The five-session, group-based intervention, called Empowering African American Women on the Road to Health (E-WORTH), was created in 2015. More than 350 Black women were recruited from community supervision programs for the study. Participants had a history of drug use, but were in drug treatment. They also were on probation, parole, or in an alternative-to-incarceration program in New York City. They had risk factors for HIV or STIs, and/or they were HIV positive. The women were randomized to receive E-WORTH or an HIV testing control condition.1

“The intervention was designed by Black women for Black women,” says Louisa Gilbert, PhD, associate professor and co-director of the Social Intervention Group, the Global Health Research Center of Central Asia, and CHOSEN (Columbia Center for Healing of Opioid and Other Substance Use Disorders — Intervention Development and Implementation) at Columbia University School of Social Work in New York City.

For example, a group of Black women who helped design E-WORTH tweaked the characters created for various scenarios and examples in the group sessions. The women would say that a particular scenario or verbal exchange was not realistic, and the content then was changed, Gilbert says.

“We used words that were in their everyday language, in terms of the way we’d introduced activities,” she adds. “These examples in scenarios and vignettes would resonate with them.”

The intervention featured trained counselors or case managers, who also were Black women, to deliver both E-WORTH and the control condition. Women who received the E-WORTH intervention had 54% lower odds of a positive STI test in the 12-month follow-up when compared with the control group. Their rates of sex without condoms dropped 38%.

The four 90-minute group sessions were designed to gain trust and engagement among the target population. For instance, they featured scenarios with Black women characters, whose narratives were designed by Black women who helped create the program.

“They gave motivational pieces on how to stay safe and addressed sexual communication and negotiation skills,” Gilbert explains. “It addresses how to stay safe in certain sexual situations, and also in social support enhancement in reducing risks and identifying needs.”

Part of the cultural aspect of the intervention involved talking with women about the effect of race on their circumstances, including laws and policing that landed these women under community supervision in the first place. “It’s the new Jim Crow system, and we acknowledged that their partners are in and out of prison because of the same radicalized drug laws,” she explains. “There are huge disparities in legal reaction to drugs.”

E-WORTH raised awareness of systemic racism and what Black women face. It also suggested they needed to band together to protect themselves from STIs and HIV, she adds.

The sessions included 45 minutes of computerized activities and time for social support enhancement and group interactions. This included discussions about drug treatment, sexual health, and how intimate partner violence can affect reproductive health decisions.

“Often, women in abusive relationships have trouble negotiating safer sex,” Gilbert says. “As a group, they talk about the challenges they’re having, what their goals are for the following week, and how they will achieve them.”

These group sessions promoted bonding and provided support, she notes.

Because so much of healthcare and research participation has moved to electronic versions over the past year, Gilbert says E-WORTH also could be adapted to a virtual intervention. “Half of the intervention was computerized self-paced modules, and there is potential for a virtual group, as well.”

An essential feature is how it is culturally tailored for its audience. “It’s consistent with other culturally tailored interventions for African Americans,” she explains. “Those interventions tend to do better than non-culturally tailored interventions.”

One of the factors that makes this population particularly challenging for a health-related intervention is the propensity for medical distrust. “African American mortality rates and STI rates are higher [than other groups],” Gilbert says. “We have to openly acknowledge the medical distrust and huge racial disparities in terms of reproductive health and outcomes.”

For instance, Black women are two to three times more likely to die from pregnancy-related causes than are white women, according to data from the Centers for Disease Control and Prevention.2

E-WORTH, while designed for at-risk Black women, could be tailored to other populations such as Latinas and adolescents. “It primarily targeted women in community supervision, their life experiences, and challenges of reproductive health and negotiating safer sex, which could be universally applied to a lot of women,” Gilbert says. “There is broader applicability, and there are options to tweak it to whatever population you’ll deliver it to.” Culturally tailored interventions work in whichever population is being served, she adds.

Disseminating the intervention is the next step. “Now that we know it works, we’re looking at how we can scale it up in different settings,” Gilbert says. “I’d like to see it used in family planning, in addition to community supervision settings to reach African American women at risk.”

REFERENCES

  1. Gilbert L, Goddard-Eckrich D, Chang M, et al. Effectiveness of a culturally tailored HIV and sexually transmitted infection prevention intervention for Black women in community supervision programs: A randomized clinical trial. JAMA Network Open 2021;4:e215226.
  2. Centers for Disease Control and Prevention. Racial and ethnic disparities continue in pregnancy-related deaths. Sept. 5, 2019.