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The core role of providing coaching and social support includes four sub-roles: providing individual support and coaching; motivating and encouraging people to obtain care and other services; supporting self-management of disease prevention and management of health conditions (including chronic disease); and planning and/or leading support groups. In this chapter, two teams describe the role of community health workers (CHWs) in providing coaching and social support in New York City, New York, and Chicago, Illinois. The first team explores the work of Cure Violence (CV) Credible Messengers, CHWs, to implement a neighborhood-based, public health approach to gun violence reduction. The history, trends, and disparities in community gun violence across New York City are highlighted to illustrate the landscape in which CV CHWs work. This section also describes a shift in how local government agencies work to prevent gun violence, largely in response to the work done by these CHWs. The second team shares the stories of a team of CHWs who work at Sinai Urban Health Institute (SUHI), serving some of the poorest and most disadvantaged neighborhoods in Chicago. By providing social support and utilizing effective coaching techniques, this team of CHWs moves their clients toward the ultimate goal of “thriving in health,” a key component of SUHI’s mission. The stories and lessons contained herein will support others interested in more effectively utilizing CHWs in providing social support and coaching.

Disclosure of HIV status to potential and current sex partners by HIV-positive people (HIVPP) is a complex issue that has received a significant amount of attention. Research has found that disclosure depends upon the evaluation by HIVPP of potential benefits and risks, especially of the risks stemming from the profound social stigma of HIV and AIDS. Drawing on concepts from Goffman's classic stigma theory and Anderson's more recently developed cultural-identity theory of drug abuse, we analyzed data from in-depth, post-intervention qualitative interviews with 116 heterosexually active, HIV-positive injection drug users enrolled in a randomized trial of a behavioral intervention to prevent HIV transmission. We explored how disclosure experiences lead to "identity impacts" defined as: (1) identity challenges (i.e. interactions that challenge an individual's self-concept as a "normal" or non-deviant individual); and (2) identity transformations (i.e. processes whereby an individual comes to embrace a new identity and reject behaviors and values of an old one, resulting in the conscious adoption of a social and/or public identity as an HIV-positive individual). Participants engaged in several strategies to manage the identity impacts associated with disclosure. Implications of these findings for research and prevention programming are discussed.

In 2006, more than 56,000 new HIV infections occurred in the United States1. Women comprised 27% of new HIV diagnoses, with 80% of these attributed to high-risk heterosexual contact2. Black and Latino women had the highest incidence of infection attributed to heterosexual transmission2. Although early in the epidemic injection drug use emerged as a risk factor for women, the role of non-injection drug use in heterosexual HIV risk among women is increasingly important. Non-injection drug use, including crack cocaine and inhaled heroin and cocaine, has been associated with higher HIV prevalence and sexual risk behaviors, such as unprotected sex, increased number of partners and exchange of sex for drugs and money3–5. A preventive HIV vaccine is one biomedical prevention strategy being developed and tested among populations at risk. While significant challenges exist in the search for a safe and effective HIV vaccine6, an important part of the discovery process is testing in humans for safety and immunogenicity, as well as for efficacy. To measure vaccine efficacy, trials of HIV vaccines must be conducted among participants who are at high risk for acquiring HIV. At the same time, it is ethically imperative that efficacy trials also include HIV risk reduction counseling to help reduce risk behaviors and behavioral disinhibition, i.e., increases in risk behavior based on assumption of receiving vaccine rather than placebo or misplaced assumptions about any protective effect of the vaccine being studied7;8. However, there is no general agreement on the type of behavioral risk reduction counseling that could be effective in conjunction with an HIV vaccine efficacy trial9. Most behavioral HIV risk reduction interventions shown to be effective in reducing sexual risk among at-risk women have been group-based and multi-session10;11. These intervention characteristics may make integration into vaccine trials challenging as, ideally, HIV risk reduction counseling within the context of a vaccine trial (with study visits that are often long due to the extent of study procedures) would be a series of brief, one-on-one intervention sessions designed to be delivered concurrently with a vaccine schedule. Effective behavioral interventions for populations, including non-injection drug using women, that can be delivered within the context of a vaccine trial have yet to be tested. Another important issue for HIV vaccine efficacy trials is ensuring that participants are knowledgeable about HIV vaccines and trial conduct so that they may make informed choices about participating. In addition to concepts related to any research participation (e.g., purpose of trial, what is expected, risks and benefits, alternatives to trial participation, ability to withdraw)12, there are several concepts important to the conduct of vaccine efficacy trials, such as placebo, blinding, randomization, vaccine-induced seropositivity, the potential for social harms and the possibility of adverse events13–15. Previous studies indicate that women who were non-injection drug users had the lowest levels of knowledge about HIV vaccine trial concepts compared to other at-risk populations, such as men who have sex with men (MSM) and injection drug users15;16. With ongoing education, vaccine knowledge among the women who were non-injection drug users increased, but was still below the knowledge levels of MSM16. A limited number of studies have been conducted to examine education about HIV vaccine trials in the context of the informed consent process17–20. New modalities for vaccine education and the informed consent process are particularly relevant for conducting vaccine trials with participants characterized by poverty, low education and unfamiliarity with the research process21. The UNITY Study was a two-arm randomized trial to determine the efficacy of enhanced HIV risk reduction and vaccine trial education interventions to 1) reduce the occurrence of unprotected vaginal sex acts; and 2) increase HIV vaccine trial knowledge among HIV-negative, high-risk non-injection drug using women. This paper presents the trial design, baseline characteristics of participants, and primary study outcomes of the UNITY Study.

Data on adolescents' views regarding the female condom are limited. We conducted seven single-gender focus groups with 47 New York City boys and girls aged 15-20 years (72% African American; 43% ever on public assistance; 72% sexually active; 25% had either been pregnant or fathered a pregnancy). Conceptual mapping was performed by participants to reveal the characteristics of protective methods deemed important to them. During analysis we specifically evaluated how the female condom was mapped. Girls consistently organized methods by, and thus were concerned about, contraceptive effectiveness, side effects, and availability (over the counter vs. provider controlled). Participants tended to classify the female condom with the male condom rather than as "female controlled." Maps varied among boys but contraceptive effectiveness was an important theme. Boys, but not girls, consistently and variously articulated an awareness of sexual pleasure when discussing this topic. Emphasizing the female condom's contraceptive effectiveness, lack of side effects, and availability may be important when counseling adolescents.

Objectives: Few studies of hepatitis B virus (HBV) infection and hepatitis B vaccination have focused on women, and specifically, women who are at high risk. This study was designed to assess the extent of HBV infection and vaccination, level of knowledge about hepatitis B, motivators and barriers to accepting vaccination and uptake of hepatitis B vaccine. Design: From March 2005 to June 2006, 402 HIV-negative noninjection drug-using women at sexual risk were recruited, interviewed, and tested for markers of HBV infection. Results: Based on serologic testing, 16.7% were previously vaccinated against HBV, 31.1% were previously infected and 52.2% were still susceptible to HBV. Knowledge of HBV infection, transmission, and prevention was low with a mean of 6.1 of 12 knowledge items correctly identified as true or false; a substantial percent of women were not sure of the correct answer. Of the women still susceptible, 69.0% started the hepatitis B vaccine series after counseling given through the study. Conclusion: This study illustrates that there continues to be gaps in current strategies for administering hepatitis B vaccine among female populations at sexual risk. Interventions are needed for this population to increase awareness and knowledge of hepatitis B, its transmission, impact on health and the availability of a safe and effective vaccine, supplemented by community programs for adult vaccination.

Problem: Despite several studies demonstrating the benefits of community–academic partnerships, their value to academic health centers (AHCs) is often viewed with skepticism by some in the academic community. Purpose: This paper examines the roles of community organizations and the mechanisms by which they can enhance the AHC missions of education, research, and patient care. Key Points: As lay educators, community organizations can contribute to medical education by exposing students to diverse cultural perspectives. As community advocates, they can facilitate the research process by helping to frame culturally relevant research questions, by ensuring that research survey instruments are culturally and linguistically appropriate, and that research findings are disseminated to community stakeholders. As lay health workers, they can facilitate health care delivery by providing a link to hard-to-reach populations through their outreach and referral initiatives. Conclusion: Forming partnerships between community organizations and AHCs can support the missions of AHCs and simultaneously develop and strengthen community capacity.

Statement of purpose While New York City (NYC) is one of the safest big cities in the US, cycles of violence persist in some NYC neighborhoods. Where the violence is most concentrated, the NYC Department of Health and Mental Hygiene (DOHMH) oversees implementation of ‘Cure Violence’ (CV), an evidence-based, nationally recognised public health approach to violence prevention, at six sites with planned expansion to 11 more. Methods/Approach The CV model reduces shootings/killings by promoting behaviour change among high risk youth and changing social norms that reinforce violence. “Credible messengers” identify and mediate conflicts before they escalate and direct high-risk program participants towards needed support services, and to engage community members to support non-violence. With stakeholder partnerships, NYC DOHMH enhances the model increasing access to ‘wraparound’ services, implementing anti-violence services in hospitals, and providing staff development. For example, coaching on Motivational interviewing (MI) techniques empower staff to better engage with participants and promote referrals. DOHMH provides TA by coordinating and training, monitoring program performance, engaging in feedback, facilitating sharing best practices, and troubleshooting. Results Program implementation data were analysed for one year (from July 1, 2013 to June 30, 2014) at six CV programs. CV programs served 202 high-risk participants. They conducted 588 mediations (267 in hospitals), and led 92 community events engaging 14,649 residents. Each CV program went at least 70 days with no shootings in their service catchment area. One went more than a year (367 days) with no shootings (from7/21/2012 to 7/23/2013). 41 CV program staff received MI training over 8 intensive sessions. Conclusions Under DOHMH direction, CV programs are unifying program practices and testing program enhancements. Technical assistance is producing signs of strong service delivery and foreshadows an efficient launch of 11 new programs. Significance and contribution to the field DOHMH’s adaptation of a proven public health model in high-violence communities: 1) advances the public discourse on violence as a health concern; 2) expands the inventory of solutions to the problem; and 3) informs replication in other NYC communities and beyond.

In order to address the social, physical and economic determinants of urban health, researchers, public health practitioners, and community members have turned to more comprehensive and participatory approaches to research and interventions. One such approach, community-based participatory research (CBPR) in public health, has received considerable attention over the past decade, and numerous publications have described theoretical underpinnings, values, principles and practice. Issues related to the long-term sustainability of partnerships and activities have received limited attention. The purpose of this article is to examine the experiences and lessons learned from three Urban Research Centers (URCs) in Detroit, New York City, and Seattle, which were initially established in 1995 with core support from the Centers for Disease Control and Prevention (CDC). The experience of these Centers after core funding ceased in 2003 provides a case study to identify the challenges and facilitating factors for sustaining partnerships. We examine three broad dimensions of CBPR partnerships that we consider important for sustainability: (1) sustaining relationships and commitments among the partners involved; (2) sustaining the knowledge, capacity and values generated from the partnership; and (3) sustaining funding, staff, programs, policy changes and the partnership itself. We discuss the challenges faced by the URCs in sustaining these dimensions and the strategies used to overcome these challenges. Based on these experiences, we offer recommendations for: strategies that partnerships may find useful in sustaining their CBPR efforts; ways in which a Center mechanism can be useful for promoting sustainability; and considerations for funders of CBPR to increase sustainability.

Each year about 100,000 people return to New York City communities from municipal jails. Although about four-fifths report drug or alcohol problems, few have received any formal drug treatment while in jail. Researchers and practitioners have identified a number of policies related to corrections, income, housing, and drug treatment that may be harmful to the successful reintegration of people leaving jail. In order to explore the challenges to successful community reentry, six focus groups and one in-depth interview were conducted with 37 men and women who had been released from jail or prison in the last 12 months. Participants were asked to describe their experiences prior to and immediately following release from jail. Findings suggest that many people leaving jail are not prepared for release and, upon release, face a myriad of obstacles to becoming healthy, productive members of their communities. We discuss the implications of these findings for programs and policies that promote community reintegration of individuals returning from correctional facilities.