Journal of Urban Health

, Volume 83, Issue 1, pp 59–72 | Cite as

Structural Interventions: Concepts, Challenges and Opportunities for Research

  • K. M. Blankenship
  • S. R. Friedman
  • S. Dworkin
  • J. E. Mantell
HIV Perspectives After 25 Years

Abstract

Structural interventions refer to public health interventions that promote health by altering the structural context within which health is produced and reproduced. They draw on concepts from multiple disciplines, including public health, psychiatry, and psychology, in which attention to interventions is common, and sociology and political economy, where structure is a familiar, if contested, concept. This has meant that even as discussions of structural interventions bring together researchers from various fields, they can get stalled in debates over definitions. In this paper, we seek to move these discussions forward by highlighting a number of critical issues raised by structural interventions, and the subsequent implications of these for research.

Keywords

HIV prevention Structural interventions 

References

  1. 1.
    Friedman S, McKnight K. What is the Role of Structural Interventions in HIV Prevention? San Francisco, CA: University of San Francisco; Jan 2003. Report No. 46E.Google Scholar
  2. 2.
    Horgen KB, Brownell KD. Comparison of price change and health message interventions in promoting healthy food choices. Health Psychol. 2002;21(5):505–512.CrossRefPubMedGoogle Scholar
  3. 3.
    Galea S, Vlahov D. Social determinants and the health of drug users: socioeconomic status, homelessness, and incarceration. Public Health Rep. Vol 117. Association of Schools of Allied Health Professionals; 2002:S135.Google Scholar
  4. 4.
    Holtgrave DR, Crosby RA. Social determinants of tuberculosis case rates in the United States. Am J Prev Med. 2004;26:159.CrossRefPubMedGoogle Scholar
  5. 5.
    Karpati A, Galea S, Awebuch T, Levins R. Variability and vulnerability at the ecological level: implications for understanding the social determinants of health. Am J Public Health. Vol 92. American Public Health Association; 2002:1768.Google Scholar
  6. 6.
    Rhodes T, Singer M, Bourgois P, Friedman SR, Strathdee SA. The social structural production of HIV risk among drug users. Soc Sci Med 2005;61(5):1026–1044.CrossRefPubMedGoogle Scholar
  7. 7.
    Rhodes T, Mikhailova L, Sarang A, et al. Situational factors influencing drug injecting, risk reduction and syringe exchange in Togliatti City, Russian Federation: a qualitative study of micro risk environment. Soc Sci Med. 2003;57(1):39–54.CrossRefPubMedGoogle Scholar
  8. 8.
    Rhodes T, Stimson GV, Crofts N, Ball A, Dehne K, Khodakevich L. Drug injecting, rapid HIV spread, and the ‘risk environment’: implications for assessment and response. AIDS. 1999;13(Suppl A):S259–S269.PubMedGoogle Scholar
  9. 9.
    Friedman SR, O'Reilly K. Sociocultural interventions at the community level. AIDS. 1997;11(Suppl A):S201–S208.PubMedGoogle Scholar
  10. 10.
    Friedman SR, Des Jarlais DC, Ward TP. Social models for changing health-relevant behavior. In: DiClemente RJ, Peterson JL, eds. Preventing AIDS: Theories and Methods of Behavioral Interventions. New York: Plenum; 1994:95–116.Google Scholar
  11. 11.
    Friedman S, Wypijewska C. Social science intervention models for reducing HIV transmission. Assessing the Social and Behavioral Science Base for HIV/AIDS Prevention and Intervention: Workshop Summary: Background Papers. Washington, D.C.: National Academy; 1995:53–74.Google Scholar
  12. 12.
    Friedman SR, Neaigus A, Jose B, Curtis R, Ward TP, Des Jarlais DC. Social models for altering health-relevant behaviors. SIDA: Publ Soc Esp Interdiscip SIDA. March 1995;6(3):153–158.Google Scholar
  13. 13.
    Friedman S, Reid G. The need for dialectical models as shown in the response to the HIV/AIDS epidemic. Int J Sociol Soc Policy. 2002;22177(4–6):177–201.CrossRefGoogle Scholar
  14. 14.
    Hankins CA, Friedman SR, Zafar T, Strathdee SA. Transmission and prevention of HIV and STD in war settings: implications for current and future armed conflicts. Paper presented at: American Sociological Association; August 16–19, 2002; Chicago, IL.Google Scholar
  15. 15.
    Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No:80–94.PubMedCrossRefGoogle Scholar
  16. 16.
    Phelan J, Link B, Diez-Roux A, Kawachi I, Levin B. “Fundamental causes” of social inequalities in mortality: a test of the theory. J Health Soc Behav. Sep 2004;45(3):265–285.CrossRefGoogle Scholar
  17. 17.
    Des Jarlais DC. Structural interventions to reduce HIV transmission among injecting drug users. AIDS. Jun 2000;14(Suppl 1):S41–S46.CrossRefGoogle Scholar
  18. 18.
    Fullilove R, Green L, Fullilove M. The Family to Family program: a structural intervention with implications for the prevention of HIV/AIDS and other community1 epidemics. AIDS. 2000;14(Suppl 1):S63–S67.CrossRefPubMedGoogle Scholar
  19. 19.
    Heimer R, Bray S, Burris S, Khoshnood K, Blankenship KM. Structural interventions to improve opiate maintenance. Int J Drug Policy. 2002;13:103.CrossRefGoogle Scholar
  20. 20.
    Rotheram-Borus MJ. Expanding the range of interventions to reduce HIV among adolescents. AIDS. Jun 2000;14(Suppl 1):S33–S40.CrossRefGoogle Scholar
  21. 21.
    Sumartojo E, Doll L, Holtgrave D, Gayle H, Merson M. Enriching the mix: incorporating structural factors into HIV prevention. AIDS. Jun 2000;14(Suppl 1):S1–S2.CrossRefGoogle Scholar
  22. 22.
    Blankenship KM, Koester S. Criminal law, policing policy, and HIV risk in female street sex workers and injection drug users. J Law Med Ethics. 2002;30(4):548–559.PubMedCrossRefGoogle Scholar
  23. 23.
    Burris S, Blankenship KM, Donoghoe M, et al. Addressing the “risk environment” for injection drug users: the mysterious case of the missing cop. Milbank Q. 2004;82(1):125–156.CrossRefPubMedGoogle Scholar
  24. 24.
    Cohen DA, Scribner R. An STD/HIV prevention intervention framework. AIDS Patient Care STDs. Vol 14. Mary Ann Liebert, Inc.; 2000:37–45.Google Scholar
  25. 25.
    Lane SD, Rubinstein RA, Keefe RH, et al. Structural violence and racial disparity in HIV transmission. J Health Care Poor Underserved. Aug 2004;15(3):319–335.CrossRefGoogle Scholar
  26. 26.
    Bluthenthal RN, Lorvick J, Kral AH, Erringer EA, Kahn J. Collateral damage in the drug war: HIV risk behaviors among injection drug users. Int J Drug Policy. Feb 1 1999;10(1):25–38.CrossRefGoogle Scholar
  27. 27.
    Parker RG, Easton D, Klein CH. Structural barriers and facilitators in HIV prevention: a review of international research. AIDS. 2000;14(Suppl 1):S22–S32.CrossRefPubMedGoogle Scholar
  28. 28.
    Blankenship KM, Bray SJ, Merson MH. Structural interventions in public health. AIDS. Jun 2000;14(Suppl 1):S11–S21.CrossRefGoogle Scholar
  29. 29.
    Sumartojo E. Structural factors in HIV prevention: concepts, examples, and implications for research. AIDS. 2000;14(Suppl 1):S3–S10.CrossRefPubMedGoogle Scholar
  30. 30.
    Friedman SR, Curtis JB, Neaigus A, Jose B, Des Jarlais DC. Social Networks, Drug Injectors' Lives, and HIV/AIDS. New York: Kluwer; 1999.Google Scholar
  31. 31.
    Cohen J. HIV/AIDS in India. Sonagachi sex workers stymie HIV. Science. Apr 23 2004;304(5670):506.CrossRefGoogle Scholar
  32. 32.
    Jana S, Bandyopadhyay N, Saha A, Kanti Dutta M. Creating an enabling environment: lessons learnt from the Sonagachi Project, India. Res Sex Work. 1999;2:22–24.Google Scholar
  33. 33.
    Jana S, Basu I, Rotheram-Borus M, Newman P. The Sonagachi Project: a sustainable community intervention program. AIDS Educ Prev. Oct 2004;16(5):405–414.CrossRefGoogle Scholar
  34. 34.
    Jenkins C. Female Sex Worker HIV Prevention Projects: Lessons Learnt from Papua New Guinea, India and Bangladesh. Geneva, Switzerland: UNAIDS; 2000.Google Scholar
  35. 35.
    Scribner R, Cohen D, Farley T. A geographic relation between alcohol availability and gonorrhea rates. Sex Transm Dis. Nov 1998;25(10):544–548.Google Scholar
  36. 36.
    Blankenship KM, Smoyer A, Bray SJ, Mattocks K. Black-white disparities in HIV/AIDS: the role of drug policy and the corrections system. J Health Care Poor Underserved. 2005;in press.Google Scholar
  37. 37.
    Buning E. Effects of Amsterdam needle and syringe exchange. Int J Addict. Dec 1991;26(12):1303–1311.Google Scholar
  38. 38.
    Celentano DD, Nelson KE, Lyles CM, et al. Decreasing incidence of HIV and sexually transmitted diseases in young Thai men: evidence for success of the HIV/AIDS control and prevention program. AIDS. Mar 26 1998;12(5):F29–F36.CrossRefGoogle Scholar
  39. 39.
    Phoolcharoen W. HIV/AIDS prevention in Thailand: success and challenges [see comment]. Science. Jun 19 1998;280(5371):1873–1874.CrossRefGoogle Scholar
  40. 40.
    Punpanich W, Ungchusak K, Detels R. Thailand's response to the HIV epidemic: yesterday, today, and tomorrow. AIDS Educ Prev. Jun 2004;16(3 Suppl A):119–136.CrossRefGoogle Scholar
  41. 41.
    Evaluation of the 100% Condom Programme in Thailand. Corp Author(s): Joint United Nations Programme on HIV/AIDS. Geneva, Switzerland: UNAIDS in collaboration with AIDS Division Ministry of Public Health Thailand; 2000.Google Scholar
  42. 42.
    Kanchanachitra C. Reducing Girls' Vulnerability to HIV/AIDS: The Thai Approach. Geneva, Switzerland: UNAIDS; 1999.Google Scholar
  43. 43.
    Friedman SR, Maslow C, Bolyard M, Sandoval M, Mateu-Gelabert P, Neaigus A. Urging others to be healthy: “intravention” by injection drug users as a community prevention goal. AIDS Educ Prev. Jun 2004;16(3):250–263.CrossRefGoogle Scholar
  44. 44.
    Basu I, Jana S, Rotheram-Borus MJ, et al. HIV prevention among sex workers in India. J Acquir Immune Defic Syndr. 2004;36:845–852.PubMedCrossRefGoogle Scholar
  45. 45.
    Jana S, Bandyopadhyay N, Dutta LK, Saha A. A tale of two cities: shifting the paradigm of anti-trafficking programmes. Gender Dev. Vol 10. Carfax Publishing Company; 2002:69–79.Google Scholar
  46. 46.
    Claiming citizenship. The Royal Tropical Institute (KIT). Available at: http://www.kit.nl/gcg/html/claiming_citizenship__projects.asp. Accessed May 26, 2005.
  47. 47.
    Avahan: India AIDS Initiative. Available at: http://www.gatesfoundation.org/GlobalHealth/HIVAIDSTB/HIVAIDS/IndiaAIDSInitiative/default.htm. Accessed May 24, 2005.
  48. 48.
    Askew I, Berer M. The contribution of sexual and reproductive health services to the fight against HIV/AIDS: a review. Reprod Health Matters. Nov 2003;11(22):51–73.CrossRefGoogle Scholar
  49. 49.
    Population Council Horizons Program. Empowering communities to respond to HIC/AIDS. Ndola demonstration project on maternal and child health: operations research final report. The Population Council. Available at: http://www.popcouncil.org/pdfs/horizons/ndolafnl.pdf. Accessed May 25, 2005.
  50. 50.
    Médecin San Frontieres Malawi. Antiretroviral Therapy in Primary Health Care: Experience of the Chiradzulu Programme in Malawi Case Study. Geneva: World Health Organization; 2004.Google Scholar
  51. 51.
    Mekonnen Y, Bradley S, Malkin M, Hardee K. Country Analysis of Family Planning and HIV/AIDS: Ethiopia. October: USAID Policy Project; October 2004.Google Scholar
  52. 52.
    Shelton J, Peterson E. The imperative for family planning in ART therapy in Africa. Lancet. Nov 27–Dec 3 2004;364(9449):1916–1918.CrossRefGoogle Scholar
  53. 53.
    Strauss SM, Astone JM, Des Jarlais DC, Hagan H. Integrating hepatitis C services into existing HIV services: the experiences of a sample of U.S. Drug treatment units. AIDS Patient Care STDs. 2005/02// 2005;19(2):78–88.CrossRefGoogle Scholar
  54. 54.
    Kresina T, Bruce R, Cargill V, Cheever L. Integrating care for Hepatitis C Virus (HCV) and primary care for HIV for injection drug users coinfected with HIV and HCV. Clin Infect Dis. 2005;41(Suppl 1):S83–S88.CrossRefPubMedGoogle Scholar
  55. 55.
    Ickovics J, Kershaw T, Westdahl C, et al. Group prenatal care and preterm birth weight: results from a matched cohort study at public clinics. Obstet Gynecol. Nov 2003;102(5 Pt 1):1051–1057.CrossRefGoogle Scholar
  56. 56.
    Ickovics J. Sustainable Prevention: Integrating HIV/STI Prevention with Prenatal Care for At-Risk Young Women. Paper presented at: AIDS Science Day, 2005; New Haven, CT.Google Scholar
  57. 57.
    O'Reilly KR, Dehne KL, Snow R. Should management of sexually transmitted infections be integrated into family planning services: Evidence and challenges. Reprod Health Matters. 1999/11 1999;7(14):49–59.CrossRefGoogle Scholar
  58. 58.
    SB 1291: An Act Implementing the Recommendations of the Red Ribbon Commission on the Improvement of HIV/AIDS Prevention and Care in Connecticut. Public Health Committee, trans. January ed; 2005.Google Scholar
  59. 59.
    Libit E. Senate Votes to Overturn Devastating Global Gag Rule Repudiates Bush Administration's Global War on Women. Planned Parenthood. Available at: http://www.plannedparenthood.org/pp2/portal/files/portal/media/pressreleases/pr-050405-gag.xml. Accessed May 26, 2005.
  60. 60.
    Ideology and AIDS. New York Times. February 26, 2005;A:14.Google Scholar
  61. 61.
    Deadly Ignorance. The Washington Post. February 27, 2005;B:6.Google Scholar
  62. 62.
    Losing tolerance with zero tolerance. Lancet. Feb 19 2005;365(9460):629–630.Google Scholar
  63. 63.
    A Misguided Anti-Vice Pledge. Los Angeles Times. March 20, 2005;M:4.Google Scholar
  64. 64.
    Bluthenthal RN, Malik MR, Grau LE, Singer M, Marshall P, Heimer R. Sterile syringe access conditions and variations in HIV risk among drug injectors in three cities. Addiction. Vol. 99. Blackwell; 2004:1136–1146.Google Scholar
  65. 65.
    Kaplan EH, Heimer R. HIV incidence among New Haven needle exchange participants: updated estimates from syringe... J Acquir Immune Defic Syndr Human Retrovirol. 1995;10:175.CrossRefGoogle Scholar
  66. 66.
    Kaplan EH, Khoshnood K, Heimer R. A decline in HIV infected needles returned to New Haven's needle exchange program: client shift or needle exchange. Am J Public Health. Vol 84. American Public Health Association; 1994:1991.Google Scholar
  67. 67.
    Heimer R, Kaplan EH. Needle exchange decreases the prevalence of HIV-1 proviral DNA in returned syringes in New Haven. Am J Med. Vol 95. Excerpta Medica Publishing Group; 1993:214.Google Scholar
  68. 68.
    Jacobson J. Restrictive, U.S. Policies Undermine Anti-AIDS Efforts. Mandatory ‘Anti-Prostitution Pledge’ Threatens Lives of Sex Workers and Trafficking Victims. Center for Health and Gender Equity. Available at: http://www.genderhealth.org/PressRelease.php. Accessed May 25, 2005.
  69. 69.
    Hallman KK. Socioeconomic disadvantage and unsafe sexual behaviors among young women and men in South Africa. Population Council [Book; Internet Resource]. Available at: http://www.popcouncil.org/publications/wp/prd/190.html.
  70. 70.
    Greig F, Koopman C. Multilevel analysis of women's empowerment and HIV prevention: quantitative survey results from a preliminary study in Botswana. AIDS Behav. Jun 2003;7(2):195–208.CrossRefGoogle Scholar
  71. 71.
    Mahmud S. Actually how empowering is microcredit. Dev Change. 2003;34:577–605.CrossRefGoogle Scholar
  72. 72.
    Holvoet N. Impact of microfinance programs on children's education: do the gender of the borrower and delivery model matter? J Microfinance. 2004;6:27–49.Google Scholar
  73. 73.
    Larance LY. Building social capital from the center: a village-level investigation of Bangladesh's Grameen Bank. Grameen Trust Working Paper; 1998.Google Scholar
  74. 74.
    Nyanzi B, Nyanzi S, Wolff B, Whitworth J. Money, men and markets: economic and sexual empowerment of market women in southwestern Uganda. Culture, Health Sex. Vol. 7. Taylor and Francis Ltd; 2005:13–26.Google Scholar
  75. 75.
    Hashemi SM, Schuler SR. Rural credit programs and women's empowerment in Bangladesh. World Dev. 1996;24:635.CrossRefGoogle Scholar
  76. 76.
    Grown C, Gupta GR, Kes A. UN Millennium Project. Task Force on education and gender equality. Taking Action: Achieving Gender Equality and Empowering Women. London; Sterling, Va.: Earthscan; 2005.Google Scholar
  77. 77.
    Center for Global Development, International Center for Research on Women, U.N. Development Project. Missing the mark: girls’ education and the way forward. Available at: http://www.cgdev.org/docs/girlsedtrans1.pdf. Accessed March 22, 2005.
  78. 78.
    Mayoux L. Microfinance and women's empowerment: rethinking ‘best practice’. Dev Bull. 2001;57:76–80.Google Scholar
  79. 79.
    Des Jarlais D, McKnight C, Milliken J. Public funding of US syringe exchange programs. J Urban Health Mar 2004;81(1):118–121.Google Scholar
  80. 80.
    Tempalski B, Friedman SR, Des Jarlais DC, McKnight C, Keem M, Friedman R. What predicts which metropolitan areas in the USA have syringe exchanges? Int J Drug Policy. 2003/12 2003;14(5–6):417–424.CrossRefGoogle Scholar
  81. 81.
    Tempalski B. The Uneven Geography of Syringe Exchange Programs in the United States: Need, Politics and Place [Doctoral dissertation]. Seattle: Department of Geography, University of Washington; 2005.Google Scholar

Copyright information

© The New York Academy of Medicine 2006

Authors and Affiliations

  • K. M. Blankenship
    • 1
  • S. R. Friedman
  • S. Dworkin
  • J. E. Mantell
  1. 1.Center for Interdisciplinary Research on AIDSYale University USA

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