Sexual Health Interventions for Racial/Ethnic Minorities Using Community-Based Participatory Research: A Systematic Review

Population, Intervention, Comparison, and Outcome Process

Population, intervention, comparison, and outcome (PICO) is an evidence-based process for structuring and assessing research questions, executing the search strategy, and synthesizing the results. For the present study, the PICO was as follows: (1) Our identified population of inquiry included REMs due several REM populations having a documented history of sexual health disparities, (2) CBPR was identified as the methodological focus of the interventions, (3) assessing the comparison of intervention methods can be and was thus omitted, and (4) the outcomes of the interventions and the level of involvement of community members were assessed.

Selection of Databases

The research team selected databases based on scholarly foci, breadth, and expert recommendations. CINAHL, Medline/PubMed, and Cochrane served as the sources for publications focused in the health sciences. PsycINFO was used because it is the world’s largest behavioral science repository. Academic Search Complete was selected as it is one of the leading scholarly research databases. Last, Embase, Google Scholar, and Web of Science Core Collection were used. Along with Medline/PubMed, research suggests that these three databases can be used to access approximately 95% of available scholarly research (Bramer et al., 2017).

All the aforementioned databases, except Cochrane and Google Scholar, were searched within the newer iteration of EBSCOhost, an online search platform. The search was conducted in July 2019. The latest version of the platform is amenable to conducting simultaneous searches, eliminating the need for multiple independent database searches. EBSCOhost provides retrievable metadata on each individual database, including selected limiters, and limits duplicate results thereby reducing the number of articles needed to be read. EBSCOhost also uses proximity operators to broaden the search beyond the exact phrases entered and includes plural derivatives and word variants using truncations (e.g., Latin* = Latina/Latinas/Latino/Latinos/Latinx).

To reduce the effects of publication bias, some gray literature was examined within Google Scholar and Cochrane in December 2019. The Google Scholar search yielded more than 13,000 returns in order of relevance. As Eiseman (2012) suggested, a review of the top results failed to identify any new or appropriate studies. Cochrane, a clinical trials registry, identified 147 CBPR studies. Nine focused on sexual health but had already been identified in the EBSCOhost search.

Database Limiters

Articles were limited to those published since 2000 to account for the responses to a national call for health research with community partners and the subsequent onslaught of CBPR research (National Institute of Nursing Research, 2003). Returns were limited to intervention studies published in the United States and in English.

Identification of Search Terms

Within each database, thesaurus terms (synonyms and related concepts), including subjects and natural language (i.e., bridge between human and computer language), were mapped for the target variables. For example, thesaurus terms for CBPR included participatory action research and community action research. The results were narrowed to relevant terms by consensus and culminated with nine words/phrases for sexual health (e.g., HIV, AIDS sexually transmitted infections [STIs]) and 35 terms for race/ethnicity (e.g., race, immigrant, African Americans). These 46 words/phrases were linked with appropriate operators (i.e., “AND,” “OR”; complete syntax is available on request).

PRISMA Filtering

PRISMA is an evidence-based method for reporting and evaluating systematic reviews. In four phases, articles are identified, screened for inclusion/exclusion, full-text reviewed, and then determined eligible or ineligible in a refined screening process. Those remaining are included in a summative synthesis (Liberati et al., 2009). For the present review, when all search terms were included, 805 records were identified.

Full-Text Review and Data Extraction

After the lead team members reviewed the full-text review of the remaining 50 articles, 26 more articles were excluded that were not interventions or associated with identifiable interventions (i.e., focus groups, survey, etc.). The entire research team conducted a summative review of the two dozen remaining articles (see Figure 1 for flow diagram of inclusion/exclusion).

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Figure 1.

Flow diagram of search results.

Microsoft Excel was used to gather the extracted data (e.g., author(s), publication date). Several studies published separate methodological and outcome papers, which the authors grouped together in the database to minimize duplicate data extraction. In addition to the PICO data extrapolation, the description of “community collaboration” at each phase of the scientific research process was copied. Inclusion at each stage was coded as absent or present, and vague descriptions were rated using discussion and consensus.

Summary of Studies

A closer examination of the original 140 unduplicated studies revealed that nearly a third of the studies did not include information specifically on REMs (32.14%) or were not interventions (32.14%). The 22 studies conducted outside of the United States were beyond the scope of the present study. Less than one fifth of the identified studies met the inclusion criteria for this review (n = 24; 17.14%). The retained studies were published between 2004 and 2018. The studies were numbered to facilitate ease of referencing and are listed in brackets hereafter (see Table 1).

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Table 1.

Summary of Sexual Health Interventions Targeting Racial/Ethnic Minorities Using CBPR.

Study No.	Author(s) & year a	Name	Population	Locale type	No. of Sessions	Intervention description	CBPR level c
1	Romero et al. (2006)	Woman to Woman	Minority women engaging in risky sexual behavior	Mixed	17	HIV prevention intervention focused on traditional HIV education as well as empowerment within the context of gender, cultural, economic, and inequality.	1
2	E. M. Yancey et al. (2012)	HIV-RAAP	Heterosexual African American men and women	Urban	7	Weekly 2-hour meetings using Afrocentric and gender empowerment to teach HIV knowledge and risk reduction.	1
3	Griffith et al. (2010)	YOUR Blessed Health	African American children and young adults	Urban	—	Training for adult church/community members to educate youth on HIV awareness and knowledge and reduce HIV risk behavior.	1
4	Moya et al. (2014)	—	Mexican migrant female survivors of intimate partner violence	Urban	5	Photovoice photography for social change as it relates to intimate partner violence.	1
5	Richards & Mousseau (2012)	Sacred Beginnings Project	American Indian adolescent girls	Rural	15	Culturally specific intervention on motherhood, womanhood, relationships, and preconception health.	1
6	Berkley-Patton et al. (2010)/Berkley-Patton et al. (2016) b	Taking It to the Pews	African American adult churchgoers	Urban	1–2	Culturally and religiously developed HIV prevention program.	1
7	Sánchez et al. (2013)	Project Salud	Latinx men and women migrant workers	Rural	4	Adapted Stage-Enhanced Motivational Interviewing intervention to decrease HIV risk and increase positive health behaviors.	1
8	Dave et al. (2017)	Teach One Reach One	African American parents of adolescents	Rural	12	Intervention for adults on parental monitoring and communication about sexual health and healthy relationships with their children.	1
9	Rios-Ellis et al. (2011)	Rompe el Silencio	Latino family dyads	Urban	2	Intervention for mothers and daughters on values around sex, sexual health education, and risk reduction.	2
10	Marcus et al. (2004)	Project BRIDGE	African American adolescents	Urban	—	Long-term intervention for substance use prevention, abstinence based sexual health, and peer education with a faith component.	2
11	Tanner et al. (2018)/Tanner et al. (2016) b	weCare	Racially diverse men who have sex with men living with HIV		—	Individualized, theoretically founded social media–based intervention to reduce barriers to HIV treatment access and retention.	2
12	Juzang et al. (2017)	411 for Safe Text	African American men	Urban	36	Text message campaign with quizzes on HIV prevention.	2
13	Wilson et al. (2019)/Gousse et al. (2018) b	Barbershop talk with brothers	Heterosexual African American men	Urban	1	Modules on community responsibility and motivation to engage in health promotion, HIV education, condom education and dissemination within personal networks.	3
14	Hergenrather et al. (2013)	Hope Intervention	African American gay men living with HIV/AIDS	Urban	7	Intervention guided by social learning and hope theories focused on exploring and obtaining employment as well as self-management of HIV.	3
15	Solorio et al. (2014)/Solorio et al. (2016) b	Tu Amigo Pepe	Latino MSM	Urban	—	Social marketing campaign on HIV prevention using Spanish language radio public service announcements, a website, social media, printed materials and mobile communication.	3
16	Rios-Ellis et al. (2010)	Protege tu Familia: Hazte la Prueba	Spanish-speaking Latinx men and women	Urban	—	Interactive training on cultural values and traditions that promote healthy families and communities, communication about sexual health, and HIV risk-related information.	3
17	McKay et al. (2014)	CHAMP+	Family dyads of youth living with HIV and their caregiver	Urban	10	Family program covering topics such as impact of health and social aspects of HIV as well as parental supervision of sexual risk taking.	3
18	Madison et al. (2000)/McKay et al. (2004)/McBride et al. (2007) b	CHAMP	African American youth	Urban	12	Developmentally timed intervention that includes information on family processes, family communication, social support, parental supervision and monitoring, child assertiveness, and social problem solving related to HIV prevention.	3
19	Rhodes et al. (2011)	HoMBReS-2 (Men-2: Men Maintaining Well-being and Healthy Relationships-2)	Heterosexual immigrant Latino adult men	Rural	4	Interactive, small-group, peer-led HIV prevention program.	3
20	Rhodes et al. (2017)	HOLA	Latino immigrant sexual minority men and transgender individuals	Urban	4	Culturally relevant, theoretically grounded intervention with modules on HIV education, condom negotiation and use, influence of cultural values, and sexual health.	3
21	Aronson et al. (2013)	Brothers Leading Healthy Lives	African American male college students	—	5	Weekend retreat on masculinity, HIV education, intimate relationships, communication, and peer advocacy.	3
22	Wilkinson-Lee et al. (2018)	—	Latina women	—	3	Individual participant contacts from a trained community partner delivering a culturally based intervention focused on sexually transmitted infection and depression education.	3
23	Rink et al. (2016)	Unzip the Truth	American Indian men residing on a reservation	Rural	3	Peer-based intervention on pregnancy, HIV/STI attitudes, beliefs, and behaviors.	3
24	DeMarco & Chan (2013)	Sistah Powah	HIV-positive African American women	Urban	4	Writing intervention focused on adherence, stigma, and self-advocacy outcomes.	3

Note. CBPR = community-based participatory research; STI = sexually transmitted infection.

a

Abbreviated author list provided. ^bAdditional method or outcome paper identified. See References section for details.^cCBPR level assigned: 1 = Level 1: REM serving community agencies were the CBPR partners; 2 = Level 2: REM were involved in CBPR project, but specific role was not described; and 3 = Level 3: REM were directly involved in CBPR project and their roles are clearly described.

Objective 1: Summarizing Research on Interventions Developed Using CBPR

Objective 2: Explore Role of Target Group Members

To understand how community members, who are typically the targeted participants in intervention research, were involved as partners in these CBPR projects, we investigated their role in each study and assigned them progressively inclusive ascending levels (Levels 1–3; see Table 1). In Level 1 studies [1–8], REM-serving community agencies were the partners and not necessarily members of the target group. This distinction is commonly known as grass tops (i.e., leaders and decision makers) versus grassroots (i.e., community members) partnerships. For example, researchers in New Mexico partnered with Planned Parenthood staff to deliver an HIV prevention program with strong empowerment components in the curriculum (Romero et al., 2006). For Level 2 [9–12], REMs were involved but details of the role these target group members played were not provided or were unclear (n = 4; 16%). For example, Project BRIDGE is a faith-based/academic partnership targeting middle school African American adolescents (Marcus et al., 2004). The authors mention having a youth coalition but go on to describe the inclusion of a pastor with oversight of youth rather than specific inclusion of African American adolescents or, if present, the details of their involvement. Last, Level 3 studies [13–24] included members of the target group and clearly delineated their role (n = 12; 50%).

The role that community members played in Level 3 studies was further analyzed. Based on previous research (Jacquez et al., 2013), we created six nonmutually exclusive categories to describe target group member involvement in stages of the research process (see Table 2). These categories included (1) preliminary research design, (2) choosing/developing data collection methods or instruments, (3) recruitment, (4) facilitating the intervention, (5) data collection, and (6) data analysis/interpretation.

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Table 2.

Level of Community involvement in 12 Interventions Developed in Partnership with Target Group Members.

Intervention	Author(s) & year	Community partners and target group members	Phases of community involvement						Degree of collaboration	Key outcomes
			1	2	3	4	5	6
13 Barbershop Talk with Brothers	Wilson et al. (2019)	CBO and a board consisting of barbers, barbershop owners and managers, and one target group member	+		+	+	+		Moderate	Higher percentage of no condomless sex at 6-month follow up.
14 Hope Intervention	Hergenrather et al. (2013)	Members of the CBO serving people living with HIV/AIDS. Team of target group members, including African American gay men living with HIV/AIDS	+					+	Low	Improved HIV treatment and medication adherence. Improved ability to communicate with treatment provider.
15 Tu Amigo Pepe	Solorio et al. (2016)	CBO serving the Latino LGBT community and Latino MSM	+						Low	Increased HIV testing rates, intention, attitudes, and self-efficacy toward testing. Improved attitudes and beliefs about condom use.
16 Protege tu Familia: Hazte la Prueba	Rios-Ellis et al. (2010)	Two CBOs as well as HIV+ peer health educators from the Latino community	+	+	+	+	+		High	Increased condom use and refusal of unsafe sex. Improved HIV knowledge, intention for safer sex, and HIV testing.
17 CHAMP+	McKay et al. (2014)	Pediatric HIV primary care staff and HIV-positive youth and their adult caregivers	+					+	Low	Marginal increases in treatment knowledge and caregiver being involved in medication adherence.
18 CHAMP	McKay et al. (2004)	Parents, students, school staff, and a community mental health center staff member	+				+	+	Moderate	Increased HIV knowledge and comfort discussing sensitive topics.
19 HoMBReS-2	Rhodes et al. (2011)	Local health and Latino-serving CBOs, religious organizations, and several Latino community members	+	+	+	+	+		High	Significantly more likely to get tested for HIV and use condoms regularly.
20 HOLA	Rhodes et al. (2017)	Local health and Latino-serving CBOs and Latino MSM	+	+	+	+	+	+	High a	Consistent condom use and HIV testing.
21 Brothers Leading Healthy Lives	Aronson et al. (2013)	African American college students, university faculty and staff, and community partners involved in HIV prevention	+	+	+	+		+	High	Decreased number of sexual partners and unprotected sex, increased condom use, and increased HIV knowledge and condom use intention.
22 Intervention not named	Wilkinson-Lee et al. (2018)	CBOs, community health centers, neighborhood associations, and community volunteers	+	+	+	+	+		High	Increased STI knowledge and screening.
23 Unzip the Truth	Rink et al. (2016)	Health department staff members and tribal residents	+	+	+	+	+	+	High a	Increased sexual health knowledge and positive attitudes towards contraceptives (not significant).
24 Sistah Powah	DeMarco & Chan (2013)	Black women with HIV	+			+			Low	Increased condom use and safer sex practices.

Note. Roles of community members are as follows: 1: Design of protocol and study setup; 2: choosing/developing data collection methods or instruments; 3: recruitment; 4: facilitation of intervention; 5: data collection; and 6: data analysis and interpretation. Degree indicates that target members were included in 1 to 2 aspects of the intervention (Low), 3 to 4 (Moderate), or 5 to 6 (High). CBO = community-based organizations; LGBT = lesbian, gay, bisexual, and transgender; MSM = men who have sex with men; STI = sexually transmitted infection.

a

Indicates studies with full participation in all phases.

All 12 Level 3 studies described target group member collaboration in the preliminary design stages of the research process, including creating study protocols and choosing design strategies. Community partners were involved in development of data collection tools in half of Level 3 studies (n = 6 [16, 19–23]). Target group members were also commonly included in recruitment of participants (n = 7 [13, 16, 19–23]) and facilitating or implementing the intervention (n = 8 [13, 16, 19–24). Members of the target group were involved in data collection efforts in more than half of the studies (n = 7 [13, 16, 18–20, 22, 23]), and half of the studies reported target group member involvement in data analysis/interpretation (n = 6 [14, 17, 18, 20, 21, 23]).

Studies that reported collaboration with members of the target community in 1 to 2 aspects of the project were labeled low collaboration (n = 4; 33.3% [14, 15, 17, 24]). Those with 3 to 4 areas of collaboration were labeled medium (n = 2; 16.6% [13, 18]), and inclusion in 5 to 6 aspects are labeled high-collaboration research partnerships (n = 6; 50% [16, 19–23]). Two of these studies reported full participation of target group members. The key outcomes of these studies are also described in Table 2.

Objective 3: Potential Benefits/Outcomes of Partnering With Target Group Members

The third objective of this review was to explore the potential benefits related to engaging in CBPR with target group members. Twelve of the identified studies described target group members as research partners and clearly outlined the role these members played in several aspects of the study. While each study targeted different sexual health concerns among several REM groups, the reported outcomes are promising for reducing sexual health disparities. The studies reported significant outcomes such as decreased sexual risk taking (e.g., increased condom use), increased engagement in HIV prevention behaviors (e.g., increased medication adherence and HIV testing), attitude change (e.g., increased condom use self-efficacy or intention), and increased communication with sexual partners (e.g., discussing safer sex).

In addition to the reported outcomes related to sexual health, several studies highlighted benefits of partnering with target group members. Multiple studies attributed successful recruitment and retention to the partnership with community members (Aronson et al., 2013; DeMarco & Chan, 2013; McBride et al., 2007; Rhodes et al., 2017). Other studies highlighted that community partnership likely resulted in more culturally relevant interventions (McBride et al., 2007; Rios-Ellis et al., 2010). Wilson et al. (2019) found that target group members who participated in the partnership experienced more self-efficacy to serve as community advocates. Hergenrather et al. (2013) suggested that the cohesiveness of a 10-year partnership likely contributed to significant intervention outcomes. Rink et al. (2016) highlighted the potential limitations of using academically developed theoretical approaches to conduct research with REM communities. Results from their project suggested the utility of a more indigenous theoretical approach that was aligned with the culture of their community partners. Thus, the invaluable benefits of academic community partnerships on sexual health of REMs are evident.