Learning from a community action plan to promote safe sexual practices.
COMMUNITY-BASED PARTICIPATORY ACTION
The project described in this article represents a nontraditional form of community-based participatory research (CBPR).Although the funding, formal planning, and evaluation characteristic of traditional CBPR projects were not present at the outset of our project, the work patterns and accomplishments mirror successful CBPR projects. CBPR, sometimes called "participatory action research" or simply "action research," is a perspective often used to integrate education and social action to improve health and decrease health disparities (Wallerstein & Duran, 2006). Action research is different from basic research in which findings are sought to provide explanations that can be generalized to a broad range of contexts. In comparison, action research uses the collective wisdom and insight of the local community to formulate strategies that enhance the well-being of local community members (Stringer & Genat, 2004). Similar to basic research, action research usually takes place in a systematic manner following a scientific process. The phases of action research involve forming and maintaining partnerships; assessing the community; defining the issue; documenting and evaluating the partnership process; obtaining feedback; and interpreting, disseminating, and applying the results (Israel, Eng, Schultz, & Parker, 2005). The phases of our community action project followed this format.
Israel et al. (2005) identified several principles of action research. The ones most applicable to our project are as follows: building on strengths and resources within the community; facilitating a collaborative, equitable partnership in all phases of the project; using an empowering and power-sharing process while respecting social inequities; fostering co-learning and capacity building among partners; integrating and achieving a balance between knowledge generation and intervention that is beneficial for all partners; focusing on relevant local public
health problems and the larger contexts in which these exist and affect the determinants of health; promoting systems development involving the entire community and all partners; disseminating results to all partners and involving them in the dissemination of results; and involving a long-term process with commitment to sustainability (Israel et al., 2005).
Call to Action
In 2001, Surgeon General David Satcher issued a Call to Action to Promote Sexual Health and Responsible Sexual Behavior (U.S. Department of Health and Human Services, Public Health Service [HHS, PHS], 2001).This Call to Action, developed by a team of experts across the nation, was based on Healthy People 2010 health indicators promoting responsible sexual health (HHS, PHS, 2000). The Call to Action was issued because of the United States' alarming rates of sexually transmitted diseases (STDs), including HIV/AIDS; unintended pregnancy; abortion; sexual dysfunction; and sexual violence (HHS, PHS, 2001). Although these problems have the potential for lifelong consequences for all, there are serious disparities among the populations most affected: ethnic minority groups, people with different sexual orientations, people with disabilities, and adolescents (HHS, PHS, 2001). One purpose of the Call to Action was to generate meaningful discussion, not only among policymakers and health care providers, but also among all people within communities. A specific appeal was made to, and for, those living with HIV/AIDS. Another purpose of the call was to provide the best available science-based information to the nation, along with an appeal for those with different views to come together for dialogue to find solutions to the problems faced by the nation (HHS, PHS, 2001). This Call to Action by the surgeon general was considered a call for action by concerned St. Lucie County leaders.
St. Lucie County, "Almost Paradise"
St. Lucie County, with tropical weather and a lush landscape, is a rapidly growing area on the east coast of south Florida. Unfortunately, the rates of STDs and teenage pregnancy are higher in St. Lucie County than in many other counties in the state. In 2005, St. Lucie County ranked fourth in Florida for the number of STDs with concomitant HIV infections (2.3 percent) (Department of Health, 2006). In 2000, only three Florida counties had higher teen age birthrates than did St. Lucie County (National Campaign to Prevent Teen Pregnancy, 2003), and these rates have changed little since then.
Evidence-based practice (EBP), the conscientious use of current best evidence in making decisions about health care (Melnyk & Fineout-Overholt, 2005), is the ideal to guide action for change in health-related professions such as social work. EBP is a problem-solving approach that integrates the most relevant research evidence with the expertise of leaders and the preferences and values of those involved (Melnyk & Fineout-Overholt, 2005). Unfortunately, a large gap often exists between knowing the best evidence from large-scale research studies and effectively implementing this evidence into practice within communities (Miller & Shinn, 2005).Action research generally uses established evidence as a basis for action, as well as the expertise of professionals and the knowledge and experience of the people or communities they serve (Stringer & Genat, 2004).
In the Beginning
Keys to the success of an effective community action project are the supporting strengths and resources within the community. A major strength in St. Lucie County is the Shared Service Network Executive Roundtable (ERT), a group of 24 chief executive policymakers; elected officials; and leaders from funding agencies, state and local government entities, and nonprofit organizations. The mission of the ERT is "to accomplish system change that results in improved outcomes for youths in local schools and in the community" (HIV Group, 2005). The ERT meets to share resources, collaborate, and problem-solve to remove community barriers that face youths and families (HIV Group, 2005). In February 2005, the ERT recognized that the HIV/AIDS rate was a community challenge needing focused attention. The impetus for a community action project was initiated at this key meeting.
An initial step in a community action project is the gathering of a working leadership group. Concerned members of the ERT became the nucleus of the group and invited members of the academic community to become involved. In traditional action research, this step typically occurs in the opposite order.
Because HIV/AIDS is a social and public health issue, key members of the working group included community social workers, community health educators, and CHD leaders. Following the ERT initiation of dialogue, some key members held a grassroots meeting in April 2005 to create strategies to address the high STD and HIV/AIDS rates. During the same month, other concerned individuals partnered to develop a community action group specifically to address the high teenage birthrate within the county. The work of these groups began simultaneously, and some key players were involved in both groups. These individuals became members of the working group and provided the driving force for action. Among these leaders were several social workers whose professional roles included addressing the needs of community members infected with HIV and the community as a whole related to the STD/HIV crisis.
Due to the efforts of this grassroots group, the Board of County Commissioners (BCC) (2005) proclaimed the month of April 2005 "Sexually Transmitted Disease Awareness Month." The proclamation was based on the belief that a healthy and productive community is necessary to promote and protect the safety of all citizens and that unhealthy lifestyles could erode the community (BCC, 2005). The proclamation was also based on the knowledge that STIs cross all geographic and socioeconomic boundaries and are preventable and that lack of treatment can cause the spread of infections and long-term negative health outcomes. Recognizing that, in 2004, 103 women in the county had STIs during their pregnancies, 3 percent of all infants were born to women with diagnosed STIs during their pregnancies, and the AIDS case rate was second highest in the state, the proclamation was made to support educational activities designed to empower all residents and visitors to make educated and informed decisions about behaviors that affect their health (BCC, 2005).The BCC further encouraged all residents and visitors to set goals to improve their personal health and wellness by avoiding behaviors that could increase their risks of infection by becoming informed about STDs, including methods of prevention, signs and symptoms, available treatments, and services within the community.
Reaching the Most Vulnerable
To reach the most vulnerable and uninformed at-risk populations, the group realized that strategies for change must include school-age students. St. Lucie County, like many other Florida counties, provides abstinence-only education to students based on an interpretation of Florida Statute 1003.46 ("Health Education," 2005) requiring schools to "teach abstinence from sexual activity outside of marriage as the expected standard for all school-age students while teaching the benefits of monogamous heterosexual marriage." The statute also states that
each district school board may provide instruction in AIDS education as a specific area of health education. Such instruction may include, but is not limited to, the known modes of transmission, signs and symptoms, risk factors associated with AIDS, and means used to control the spread of AIDS. (Florida Statute 1003.46)
The specific content taught in any subject is determined by local school district policy; state statute does not prohibit any district from providing comprehensive human sexuality instruction.
Because only minimal information about safe sexual practices to prevent STDs and pregnancy is currently provided via the school curriculum, the need for more information for students who choose to be sexually active seemed evident. As a result, in June 2005 members of the newly formed working group gave presentations to school district executives and school district principals emphasizing the need for more informative education about HIV/ AIDS prevention in the school curriculum. With a positive, though cautious, response from school officials at this meeting, the group felt encouraged to move forward.
Teenage Pregnancy Prevention Group
As noted earlier, the teenage pregnancy prevention group began concurrently with the development of the HIV/AIDS group and involved many of the same members. A call went out, asking for participation by all groups and individuals involved with or providing services to the youths of the community and particularly those interested in teenage pregnancy prevention. A wide variety of individuals representing a broad range of teenage pregnancy views participated, including members from local youth development programs, religious groups, abstinence-only groups, Planned Parenthood, the CHD, Healthy Start, and other groups. Key members in this group were social workers, whose professional roles included improving the health and status of adolescents who are indigent, incarcerated, or at increased risk for STIs/HIV/AIDS and teenage pregnancy. This group chose the name TIPPS:Teen Impact for Pregnancy Prevention and Services.
With similar concerns for the youths of the community, the HIV/AIDS group and TIPPS work in concert with each other. Although the primary focus of each group differs, the underlying concerns for safe and appropriate sexual activity for all, particularly the youths of the community, are the same. Perhaps because of the more pressing issue of HIV/AIDS, the HIV/AIDS group provided the leadership for community action. Also, because pregnancy is a normal, appropriate developmental stage under healthy circumstances, the need for prevention is temporary and intermittent, whereas HIV/AIDS/STD prevention is a life-long need. Teenage pregnancy prevention was clearly a moral issue for some participants, whereas the need for HIV/AIDS prevention was undisputed. As a result, the focus of the action plan ultimately became HIV/AIDS prevention.
DEFINING THE ISSUE
Key members of the HIV/AIDS working group presented their concerns to the ERT in October 2005, emphasizing the need for greater HIV prevention within the county. In response, the ERT chose HIV prevention as a major project, with the goal of implementing the best HIV prevention programs possible within the county (ERT, 2005). The ERT appointed an HIV/AIDS Subcommittee to tackle this task, giving an official name to the previously formed working group.
Recommendations from the ERT that helped define the work of the HIV/AIDS Subcommittee were as follows: encourage community agencies to integrate a prevention message curriculum into their programs, coordinate community outreach that would include public forums to educate the public on the problem of HIV within the community, identify a best practice curriculum in the schools, and create a forum to educate parents on HIV and how to prevent it (ERT, 2005). On the basis of these recommendations, the subcommittee developed strategies to reach out to the educational system, parents, the faith community, the business community, and other organizations within the community.
As indicated in the Call to Action by the surgeon general, common ground must be found among people with widely differing views (HHS, PHS, 2001). Since the members of the HIV/AIDS Sub committee held widely differing points of view, an important step in finding common ground was agreement on a disease prevention message that could be used in all the work within the community. After much discussion, the group agreed on the following: "Our unbiased approach to sexual health emphasizes the benefits of abstinence and includes factual information about sexual behavior including intercourse, contraception and disease prevention methods" (HIV/AIDS Subcommittee, 2006).
Incorporating the Public School System
As indicated in the Call to Action, school-based sexuality education can be a controversial issue (HHS, PHS, 2001). Although parents should be the primary source of sexuality information for their children, public school education is a mechanism to ensure that all U.S. youths are provided basic knowledge of sexuality, presented in an equitable fashion (HHS, PHS, 2001). Although some individuals and community agencies and institutions prefer abstinence-only educational programs, programs emphasizing abstinence and also providing information about condoms and contraceptives (abstinence-plus) have been shown to be more effective in changing adolescent behaviors (Santelli et al., 2006). To date, no evidence exists that abstinence-plus programs hasten sexual debut (first intercourse) or increase the frequency of sexual activity or number of partners (Kirby, Lepore, & Ryan, 2005), and because nearly half of all high school students (grades 9 to 12) are sexually active nationwide (Eaton et al., 2006), our working group believed that this broader approach should be considered. Making changes of this controversial nature requires broad community consensus and a clear plan of action. As a result, an HIV/AIDS curriculum task force was formed.
Achieving a balance between knowledge generation and intervention that is beneficial for all requires an understanding of attitudes within the community. The HIV/AIDS Subcommittee realized that it needed to know the views of community members on their preferred type of sex education to be presented in public schools. The subcommittee decided to conduct a survey to gather this information. Seeking an extant survey tool, the subcommittee identified a sex education survey that had been developed by National Public Radio (NPR), the Henry J. Kaiser Family Foundation, and Harvard University's Kennedy School of Government (Sex Education in America, 2004).This NPR survey was conducted in 2003 via nationwide telephone surveys with the general public and school principals. The general public survey was conducted among a random nationally representative sample of 1,759 adults, including an oversampling of 1,001 parents of middle and high school students. Statistical results were weighted to be representative of the national population. The margin of sampling error for the survey was 3 percent for total respondents and 4.7 percent for parents (Sex Education in America, 2004).
The NPR survey consisted of 52 questions, many with multiple queries, plus 16 demographic questions. Due to more specific concerns, and the cost involved, the HIV/AIDS Subcommittee used only the section of this tool that specifically addressed sex education in public schools. This resulted in 22 questions, used verbatim in the St. Lucie County survey. Two additional questions taken from Zogby International's (2004) Survey on Parental Opinions of Character- or Relationship-Based Abstinence Education vs. Comprehensive (or Abstinence-first, Then Condoms) Sex Education were added due to concerns of some members of the subcommittee. Seven demographic questions were added as well.
The next obstacles were finding experienced researchers to conduct the survey and funding to cover the cost. A contract was arranged with researchers from the Public Opinion Research Laboratory of the University of North Florida to conduct the St. Lucie County survey. Funding, approximately $20,000, came from the combined efforts of local organizations represented by members of the HIV/ AIDS committee. Preparing the survey, negotiating the contract, and gathering funding took several months.
Research assistants made multiple telephone calls to community members until over 1,000 surveys were completed, with a strong representation of parents (1,005 general population and 402 parents). Community residents were chosen by random-digit dialing from all zip code areas in the county. Each number chosen was tried a minimum of six times. This number, which included an oversampling of 402 parents with children attending local schools, was required to achieve a 95 percent confidence level (Sex Education Survey, 2006). The margin of error for the general population sample was 3.1 percent and for the parent oversample was 4.9 percent. Efforts were made to reach individuals from all parts of the county, including those who were Spanish speaking. In the general population, 73.7 percent described themselves as white, 11.4 percent as black or African American, and 12.3 percent as Hispanic or Latino. In the parent sample, 64.7 percent identified as white, 17.2 percent as black or African American, and 19.2 percent as Hispanic or Latino. Data were collected over a three-week period in September and October 2006 during interviews that lasted an average of 8.2 minutes (Sex Education Survey, 2006).
Key findings from the survey were similar to findings from the NPR survey (Sex Education in America, 2004). A large majority, over 90 percent of St. Lucie County respondents (NPR = 90 percent), believed that teaching sex education in the schools was either very important or somewhat important, and this number was greater among parents (91.1 percent for general population compared with 93.5 percent for parents) (Sex Education Survey, 2006). In the general population, 47.8 percent (NPR = 46 percent) believed that teaching abstinence in conjunction with giving information about condoms and other contraceptives was preferable to abstinence alone; 55.5 percent (NPR = 54 percent) felt this way in the parent group. In the general population 34.4 percent (NPR = 36 percent), and in the parent group 28.8 percent (NPR = 30%), believed that abstinence was not the most important thing; sex education should focus on teaching teenagers how to make responsible decisions about sex. Only 13.4 percent (NPR = 15 percent) of the general population and 11.9 percent (NPR = 16 percent) of parents believed that abstinence-only education was preferable. The majority of respondents believed that teaching students how to use and where to get birth control and other methods to prevent pregnancy (87.7 percent; NPR = 87 percent) and how to use a condom (82.5 percent; NPR = 83 percent) and providing them with information about masturbation (71 percent; NPR = 77 percent), abortion (78.8 percent; NPR = 85 percent), and homosexuality (75.8 percent; NPR = 73 percent) was appropriate (Sex Education in America, 2004; Sex Education Survey, 2006). A majority of the respondents (75 percent; NPR = 77 percent) believed that giving teenagers information about contraception would result in safer sex practices now or in the future. These findings indicated that community members were ready for a change in HIV prevention strategies within the public school system. These results were shared with the ERT in November 2006 and then sent to the community in various media formats.
Silence Is Death
To further emphasize the need for preventive action in the county, Silence is Death: The Crisis of HIV/ AIDS in Florida's Black Communities was published by the Bureau of HIV/AIDS of the Florida Department of Health in 2006. Striking statistics about the residents of St. Lucie County were presented in this publication. This county had the highest HIV rate among black residents in Florida in 2005, with one out of 35 testing positive. The need for preventive action within the county was clear.
OBTAINING FEEDBACK AND INTERPRETING AND APPLYING RESULTS
Educating Students The task of the HIV/AIDS curriculum task force to identify a best practice curriculum in the schools was clear and reinforced by the survey results. Educating the youths of St. Lucie County was recognized as a shared responsibility involving not only parents, but also the community and the public school system. Key members of the HIV/AIDS Subcommittee as well as principals from local middle and high schools were invited to participate in the task force.
The HIV/AIDS curriculum task force members felt that implementing a more comprehensive sex education curriculum in the schools could reduce identified risk factors and increase protective factors in students, build developmental assets, strengthen existing community programs and interventions, and supplement current science and health curricula. An informal presentation was made to all members of the curriculum task force explaining the concept and benefits of using effective (evidence-based) curricula to teach students about HIV/AIDS prevention. Members of the task force agreed that the recommended curriculum should be scientifically proven to be effective in changing sexual behavior. As a result, the criterion for selection was a curriculum identified by the Centers for Disease Control and Prevention (CDC) as effective and on the preferred list of the Florida Board of Education.
To determine the most appropriate curriculum for St. Lucie County, samples of all programs recommended by the CDC (N = 6) were examined by members of the HIV/AIDS curriculum task force, including school principals. After reviewing all of the available curricula, two were chosen by the task force as appropriate for implementation in the public schools and acceptable to parents in the somewhat conservative county. These two curricula were submitted to educators for further evaluation. To facilitate the health teachers' review, the task force developed a checklist incorporating learning objectives of effective curricula recommended by the Florida Department of Education, the CDC, and ETR Associates, a research organization that has studied HIV prevention and sex education in schools for over 20 years (Kirby, Laris, & Rolleri, 2006). Reaching consensus within the taskforce to create the review form took several months of work to accomplish.
As recommended by school principals on the task force, health educators were chosen from each of the county high schools to evaluate the recommended curricula using the newly developed review form. Following an introduction explaining the curricula selection process and use of the review form, the health teachers reviewed all of the materials for each of the curricula during a teacher workday. This group unanimously chose the program Get RealAboutAIDS (2006) to be used for high school students in St. Lucie County. Their recommendation was then given to the ERT for approval.
The work of the HIV/AIDS Subcommittee, and particularly the curriculum task force, was not without challenges. Sex education in public schools is a sensitive issue. Several people in the group and in the community were opposed to any change from current abstinence-only strategies in the county. Some individuals who strongly opposed these changes held community meetings and press conferences and circulated petitions to assert their stand for the continuation of abstinence-only education. These tactics served to emphasize several key points. Using the most appropriate, acceptable terminology is essential. Making a curriculum change is needed to teach students about their health, not sex. Therefore, the phrase "sex education" was replaced by the terminology "comprehensive health education. "Also, more members of the faith-based community representing a broader range of perspectives were needed to present a more balanced perspective. Finally, knowledge of community views about comprehensive health education in the schools (determined through the survey) was essential.
The recommendation to incorporate the program Get Real about AIDS into the public school health curriculum was made to the St. Lucie County School Board. To allow for ample community input, copies of the curriculum were made available for review in the school board office, online, and on the school district Web site. Several public forums were held to allow community members to voice their opinions to school board members. After three months of community review and sometimes contentious discussion, the St. Lucie County School Board voted 4 to 1 to incorporate Get RealAboutAIDS into the health curriculum in all middle and high schools in the county beginning in 2008.
Reaching the Broader Community
In addition to reaching students in the school system, we needed to reach the broader St. Lucie County community, including those in the faith communities. Recognizing the available resources within the community, the group deemed that the best means of communicating HIV/AIDS information was through a DVD. A former TV broadcaster, now working for a supportive county commissioner and ERT member, took the lead on this project. With assistance from a production center at a local community college, the DVD was developed. Participants, scripts, graphics, and designs were all identified, developed, and reviewed by the group. The speakers in the DVD included leaders from the faith-based community (both black and white), individuals who were living with HIV (black, Hispanic, and white; male and female), and concerned community leaders. The outcome was an easily accessible, professionally prepared, concise DVD to be used as a communication tool within the county. The DVD was reproduced, and approximately 1,000 copies (700 in English, 200 translated into Spanish, and 100 translated into Creole) were distributed to interested people in the community. These DVDs are used to reach out to St. Lucie County community members to educate them about the need for HIV testing and prevention. The production and distribution of these DVDs addressed the second recommendation of the ERT--that is, to coordinate community outreach that would include public forums to educate the public on the problem of HIV in the community.
The HIV/AIDS Subcommittee has worked hard to address a significant health problem in St. Lucie County by using a community action plan. Although the subcommittee has achieved some success, the members recognize that their job is not complete. The next action phase recognized by the group is peer-to-peer education. Although large-scale efforts are essential, one-on-one contacts promoting health and disease prevention are necessary as well.
INTERPRETING AND DISSEMINATING RESULTS
As other communities grapple with similar social problems, acknowledging some of the more successful aspects of this project could be helpful. Lessons from this example include the following:
* This project was born and thrived because community members were motivated to find ways to make needed changes in their community.
* Empowerment for the process was provided by an organized group of respected leaders within the community, including social workers in key roles such as task force facilitators and group leaders.
* Membership in the HIV/AIDS Subcommittee was fluid, being open and not limited in number. Special efforts were made to include all interested people, especially key individuals with strong voices in minority communities, the educational system, and faith-based communities.
* Development of and agreement of the HIV/ AIDS Subcommittee members on a prevention message to be used throughout the community provided a stronger more unified voice.
* Development and implementation of specific tangible strategies helped accomplish goals outlined by the ERT.
* Formation of smaller working groups led by key members of the subcommittee that were granted autonomy, although with accountability expected, helped accomplish the outlined goals in an efficient manner.
* An independent, professional countywide survey assessing attitudes about sex education within the public school system was necessary to bring about change.
* Strategies developed by using available resources resulted in more community involvement and conserved limited resources.
* Adopting terminology (using "health education" rather than "sex education") that was accurate and acceptable to the broad community was essential.
* Monthly reporting to the ERT helped maintain the momentum for the project.
* Viewing obstacles and disagreements within the community as impetuses for revising strategies prevented the obstacles from becoming roadblocks.
One purpose of community action projects is to provide new knowledge that will enable social workers to resolve significant problems in community settings (Stringer & Genat, 2004). Through action plans, participants use their understanding of the problems they face to formulate actions directed toward resolving the problems (Stringer & Genat, 20(14). Communities have rich sources of knowledge and skills and are dynamic places within which prevention programs will ultimately need to be established and encouraged to grow (Miller & Shinn, 2005). Because of their broad roles within communities, social workers are in ideal positions to lead communities to promote needed change. The community action project in St. Lucie County provides a fine example.
Original manuscript received June 6, 2007
Final manuscript received August 19, 2008
Accepted November 3, 2008
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Josie A. Weiss, PhD, FNP-BC, FAANP, is associate professor, Christine E. Lynn College of Nursing, Florida Atlantic University, 500 NW California Boulevard, Port St. Lucie, FL 34974; e-mail: jweiss email@example.com. Kathy Dwonch-Schoen, MA, RN, former director of programs, Kids Connected by Design, resides in Fort Pierce, FL. Elissa M. Howard-Barr, PhD, CHES, is associate professor of public health, Community Health, University of North Florida, Jacksonville, FL. Michael P. Panella, MEd, AASECT, is senior community educator, Planned Parenthood, West Palm Beach, FL
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|Author:||Weiss, Josie A.; Dwonch-Schoen, Kathy; Howard-Barr, Elissa M.; Panella, Michael P.|
|Date:||Jan 1, 2010|
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