Strategic Approach: Implement evidence based Universal Precautions for Preventive Behavioral Health and Wellness.

1. Community Peer Review (CPR)
Universal Precautions for Preventive Behavioral Health
R.E.S.I.L.I.E.N.C.E. to HIV/ SA and Stress
Tarik Smith, MA
Director of Community Engagement and Outreach
Center for AIDS Health Disparities Research
School of Medicine
Meharry Medical College
“Healthy People Make Healthy Choices”

2. What is Community Peer Review?
“The peer review process is integral to scholarly research. It is a
process of subjecting research methods and findings to the scrutiny of
others who are experts in the same field.”*
“Peer-review is a critical part of the functioning of the scientific
community, of quality control, and the self corrective nature of
science”.**
Community Peer Review utilizes leaders and members of the
surrounding community, especially communities of color, as experts in
assessing and in supporting culturally competent preventive health
interventions.
*California State University. 2007. Chancellor’s Doctoral Incentive Program. The Definition and Purpose of Peer Review.
http://teachingcommons.cdl.edu/cdip/facultyresearch/Definitionandpurposeofpeerreview.html
**Steven, S. 2008. The Importance and limitations of peer review. Science Based Medicine. https://sciencebasedmedicine.org/the-importance-and-
limitations-of-peer-review

3. Community Engagement Goals and
Objectives
• Our community engagement objectives
support the Healthy People 2020 national
goals of: reducing new HIV infections;
increasing access to care and improving health
outcomes for people who have HIV; reducing
HIV related disparities and health inequities;
and achieving a coordinated response to the
HIV epidemic.

4. Educational Philosophy
• Educational Philosophy: Identify community
leaders and stakeholders, train the trainer and
make it peer to peer.
• Mission: To develop sustainable initiatives that
increase community protective factors and
decrease risky behavior in the AA community
• Strategic Approach: Implement evidence
based Universal Precautions for Preventive
Behavioral Health and Wellness.

5. R.E.S.I.L.I.E.N.C.E. to HIV/ SA and
Stress
• Resilient individuals demonstrate a narrow
and conservative band of responsiveness to
stress. There have been numerous studies
which show that performance is enhanced
when there is optimal sympathetic nervous
system activation, meaning low levels of
baseline epinephrine, with “robust” increases
in epinephrine and norepinephrine in
response to challenges, followed by relatively
rapid return to baseline levels.

6. The Psychobiology of Stress
• Southwick, Ozbay, Charney and McEwen
(2008) described the psychobiology of stress
and the process of adapting to it. They
identified a set of “primitive but effective
means to improve the odds of survival. The
classic fight-or-flight response involves
activation of immune function, energy
mobilization, and memory enhancement to
recognize and avoid similar dangers in the
future.”

7. The Neurochemistry of Resilience to
Stress
• Southwick et al. (2008) also discussed the neurochemistry of
resilience to stress. They related resilience to allostasis, which is the
process of achieving physiological stability by adjusting critical
parameters of stability (such as pH values, oxygen tension and body
temperature) so that these values remain within the narrow range
required for survival. They proposed that resilience can be
conceived as the ability to minimize the allostatic load imposed on
the body during a stressful event. In this model, the resilient
individual is able to switch on mediators of allostasis (e.g., cortisol
and adrenalin) when the immediate stressor is encountered and
then to switch off these mediators when the threat or danger has
ended (p. 93).
Southwick, S.M., Ozbay, F., Charney, D, & McEwen, B.S. (2008). Adaptation to stress and psychobiological mechanisms of
resilience. In B.J. Lukey & V. Tepe (Eds.), Biobehavioral resilience to stress (pp. 91- 115). Boca Raton, Fl: CRC Press.

8. Resilience to HIV/SA and Stress
• R Reframe the Problem and find Reasons for Hope.
• E Empathy: A Culturally informed understanding of how the individual or family has arrived at
a perilous point that threatens his or his family’s emotional or physical health.
• S Stress Tolerance: A Set of techniques to reduce the somatic or physical response to stress.
These include: Breathing exercises, relaxation techniques and exercise routines.
• I Identify Prevalence and Risks of the Problem in the population being served: Review
current scientific knowledge. Example: Prevalence of high risk sexual behavior in youth; Prevalence
of depression and mental illness in college students.
• L Limit the Effect of Automatic Thoughts: The trainee learns to identify automatic thoughts
and limit his or her immediate response to them. This is a set of cognitive skills based on the Ellis
ABC model (Activating Event - Behavior - Consequence model).
• I Identify Protective Factors: A culturally informed exercise to identify historical, family
influences and resources in the community being served that mitigate against developing a
behavior related illness. Example: Strongly held religious beliefs can mitigate against suicidal
thinking…
• E Emotional Rating and Mindfulness: This process teaches how to rate and monitor one’s
emotional reaction to real or perceived threats.
• N Normalize the problem: This involves the skills of: “decatastrophizing” and removing the
powerful emotional impact of a problem, when this is possible.
• C Challenge and “Change Talk”: Embrace the challenge of meeting a difficult problem (rather
than giving in). Conceptualize the problem. Use Cognitive dissonance skills to arrive at new
solutions to the problem. Identify and reinforce key phrases that indicate the individual is
motivated to change.
• E Evaluate your concept of the problem and your proposed solution. Experiment with the
solution and re-evaluate your plan.

9. African American HIV Health
Disparities
• “The CDC estimates that African Americans
represent more than one-third (40 percent
or 498,400 persons) of all people living with
HIV and represent almost half (45 percent in
2015) of all persons with newly diagnosed
infection. Black, gay and bisexual men are
the most affected, followed by heterosexual
women.
• Black men accounted for almost one-third
(33 percent) of all HIV diagnoses in 2015.
• The rate of HIV diagnoses for black men was
nearly eight times as high as the rate among
white men, and more than twice that of
Hispanic men. Among black men, most new
diagnoses occur among men who have sex
with men (MSM).”*
• Black women accounted for 11 percent of all
HIV diagnoses in 2015 and the majority (61
percent) of diagnoses among women overall.
• The HIV diagnosis rate for black women
remains 16 times as high as that of white
women, and almost five times that of
Hispanic women.
• If current rates persist, CDC projects that
approximately one in 20 black men, one in
48 black women, and one in two black gay
and bisexual men will receive a diagnosis of
HIV during their lifetimes. *
*https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/cdc-hiv-aa-508.pdf

10. HIV/STD Risk Prevention: Behavioral Health Interventions
The CAHDR’s Office of Community Engagement
supports recognized methods to reduce HIV risk,*
including but not limited to:
• Interactive, client centered prevention counseling to
persons at risk
• Increased condom use
• Abstinence and Reduction of Number of Sex
Partners*
• CDC HIV Risk and Prevention. http://www.cdc.gov/hiv/risk.

11. Train-the-Trainer: POL
• Popular Opinion Leader (POL) is an intervention
designed to effectively implement HIV/AIDS Risk
reduction strategies by using peer educators who
are trained in the science of HIV Risk reduction as
an effective means of communicating essential
information. The POL intervention is based on
social diffusion theory, which asserts that
behavioral change in a population can be started
and then diffused to others if it is supported,
adopted and endorsed by a sufficient number of
opinion leaders within the population.

12. Why POL?
• Popular Opinion Leader is an established DEBI (Diffusion of
Evidence Based Interventions) for HIV/AIDS risk reduction.
In this model, trusted community leaders reach out to
others in their community to share information on specific
HIV risk reduction practices (CDC, 2010). The outreach is
done in popular social settings. During peer to peer
interactions involving personal statements, misperceptions
about the disease are corrected and strategies for risk
reduction are shared. Peer educators are trained in
communication skills and factual information about disease
transmission. In this model, peer educators focus on
specific behavioral change, e.g., assertiveness, improved
sexual decision making, and negotiating skills.

13. LOGIC MODEL: Prevention of HIV/HV/SA in Minority
Youth
GOALS Target Behaviors /Conditions Intervening Variables Interventions Outcomes
Reduce HIV/HV/SA
Risky Behaviors
Increase
Knowledge, Skills and
Attitudes for
Prevention
Increase Resilience to
HIV/SA Stress
Unplanned and casual sex/ multiple
sex partners;
Lack of knowledge about
HIV/HV transmission
Universal Preventive
Behavioral Health Literacy
Precautions for HIV/HV/ SA
Education- via web based and
multi –media
Increased and sustained
knowledge of HIV /HV
transmission and negative
effects of drug/alcohol
abuse
Decreased frequency of
unplanned sex and fewer
sexual partners
Increased condom use
Increased HIV Testing and
referral for treatment/ and
Increased number of
Young adults know their
HIV status
Decreased reported use of
alcohol and drugs
Increased Self Efficacy and
Increased Resilience to
social stressors that
influence drug use and
sexual practices
Condoms not routinely acquired and
used; HIV testing not routine
Cultural factors among AA
Youth may influence
ability to negotiate for safe
sex, monogamy, abstinence.
Culturally appropriate
HIV/HV/Prevention
Interventions
Excessive Alcohol use and
Use of Illegal Drugs
Mis-perception that binge
drinking and drug use is
“normal” for college age
youth.; Alcohol and drugs
increase HIV risk
Popular Opinion Leader
Minority youth experience social stress
and environmental stresses that can
reduce ability to protect against risky
sexual behaviors and drugs/alcohol use
Minority youth may lack
problem solving skills and
emotional resilience to
resist environmental stressors
and reject drugs/alcohol/
Resilience Training:
Cognitive Behavioral Skills
to manage social stressors
and reduce HIV/SA stress

14. Outreach Education: Web-based
Service Delivery
• The Social Vaccine (SoVac) Lab is an interactive
translational research center that functions as a virtual
conduit for community connections and
complimentary resources. The SoVac Lab was
established in the CAHDR to implement and study
projects that apply novel approaches to the prevention
of disorders which have a behavioral or psychological
component. The SoVac Lab was developed to provide
effective delivery systems, quality content and tracking
mechanisms for culturally competent web-based
services that address the disproportionate health
disparities in the African American community.

15. Social Vaccine Lab: Interactive Support
Network
• In the SoVac Lab’s interactive support network, students
communicate culturally competent prevention messaging and
strategies, archive relevant resources, model prosocial behavior and
livestream prosocial interactions with the target population in real
time. The implementation and widespread use of Universal
Precautions for Preventive Behavioral Health & Wellness is
expected to reduce the prevalence of risky behavior in the African
American student community. Using a medical model, this work can
be understood as disseminating a “social vaccine” designed to
“inoculate” the target population from the social pressures
associated with the transmission of HIV. The web based interactive
infrastructure supported by this initiative will extend access to
thousands of young people and create the potential for “herd
immunity.”

16. Universal Precautions for Preventive
Behavioral Health Literacy
• Universal Precautions for Preventive
Behavioral Health Literacy is a body of
knowledge, skills and behaviors that help to
prevent behavior related illnesses such as:
HIV/AIDS; Substance Abuse Disorders; and
Stress Related Disorders. Diabetes,
Hypertension and Heart Disease are also
known to be influenced by behavior such as
overeating and lack of exercise.

17. • Universal precautions refers to a set of
procedures, such as hand washing and
disinfecting with bleach to prevent the spread
of infection, that are commonly used and
promoted to prevent illness.
What are Universal Precautions?

18. Why Health Literacy?
According to the Centers for Disease Control,
“…health literacy [is] the degree to which an individual has the capacity to
obtain, communicate, process, and understand basic health information and
services to make appropriate health decisions.”*
Persons with limited health literacy are more likely to:
• skip preventive services;
• enter the health care system when they are sicker;
• have more hospitalizations;
• be less able to manage chronic conditions and
• report that their health is poor.**
*CDC. Health Literacy. https://www.cdc.gov/healthliteracy/learn
** U.S. Department of Health and Human Services. Quick Guide to Health Literacy.
https://health.gov/communication/literacy/quickguide/factsliteracy.htm

19. Health Literacy Toolkit
• The US Department of Health and Human
Services (2010) has developed a National
Action Plan to Improve Health Literacy, and
the Agency for Healthcare Research and
Quality (https://ahrq.gov) has developed a
Health Literacy Universal Precautions Toolkit.

20. Communities of Color Have Disproportionately High Burden of
Mental Health and Substance Use Disorders
• Racial and ethnic minorities currently make up
about a third of the population of the nation and
are expected to become a majority by 2050.
• Communities of color tend to experience greater
burden of mental and substance use disorders
often due to poorer access to care; inappropriate
care; and higher social, environmental, and
economic risk factors.*
*SAMHSA. https://www.samhsa.gov/specific-populations/racial-ethnic-minority

21. HIV/AIDS in African American Communities and Youth:
Health Disparities
• “Youth aged 13 to 24 accounted for more than 1
in 5 new HIV diagnoses in 2014. 81% of diagnoses
were among youth aged 20 to 24.**
• Among youth ages 18 to 24 living with HIV, 44%
did not know they had HIV.**
(Note African Americans were 14.2% of population in 2014,
according to the NSDUH)
• Center for Behavioral Health Statistics and Quality.*National Survey on Drug Use and Health (NSDUH)
https://nsduhweb.rti.org/
** CDC: https://www.cdc.gov/hiv/group/age/youth/index.html

22. Drugs and Alcohol and HIV
• The rate of illegal drug use in the last month among African
Americans ages 12 and up, in 2014 ,was 12.4%, compared to
the national average of 10.2%. (National Survey on Drug Use
and Health*.
• “Drug abuse and addiction have been linked with HIV/AIDS
since the beginning of the epidemic. The link has to do with
heightened risk- both of contracting and transmitting HIV and
of worsening its consequences.” Drug abuse treatment fosters
the goals of HIV prevention and reducing transmission.**
*National Survey on Drug Use and Health (NSDUH). https://nsduhweb.rti.org/
**National Institute on Drug Abuse. 2012, DrugFacts: HIV/AIDS and DrugAbuse.

23. Community Protective Factors
Protective Factors for Adolescent Risk Behaviors and Substance Use
• Affiliation with friends who model
conventional behavior and adoption of
conventional norms about substance
use/positive peer support….
• Good coping styles, including empathy,
problem solving, internal locus of control….
• Intolerance of attitudes toward deviance….
• Moral beliefs and values….
• Optimism and positive orientation toward
health….
• Perception of risk of substance use….
• Perception of strong anti-drug attitudes and
behavior among peers…
• Perception of strong social controls or
sanctions against transgressions….
• Positive relations with adults
• Religious beliefs& practices…
• Social competence skills, e.g., social
interaction skills and values….”
• Access to support services….
• Community/cultural norms against violence
and substance use….
• Community networking….
• Healthy leisure activities….
• Strong bonds with pro-social institutions
such as religious organizations or other
community groups….
• Strong cultural identity and ethnic pride….
European Monitoring Center for Drugs and Drug Addiction, 2004*

24. Acknowledgements
• My Mother, Jean Wheeler-Smith, MD and my
daughter Kayah
• My teachers, mentors, students and colleagues
• President James E.K. Hildreth, PhD., MD & the
Meharry family
– Kim, Ciara & Jade in HR
– Young Brother Nate at the Valet
– Miss Winston in security dispatch, Sgt. Heirs & Officer
Karen in the LRC…
Thank you for your service!

25. References
• AHRQ. Agency for Health Care Research & Quality. 2016. Universal Precautions for Health Literacy Toolkit.
https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html
• California State University. 2007. Chancellor’s Doctoral Incentive Program. The Definition and Purpose of Peer Review.
http://teachingcommons.cdl.edu/cdip/facultyresearch/Definitionandpurposeofpeerreview.html.
• CDC. Centers for Disease Control and Prevention. 2016. Health Literacy. https://www.cdc.gov/healthliteracy/learn.
• CDC. 2017. CDC Fact Sheet. HIV among African Americans. https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/cdc-hiv-aa-
508.pdf.
• CDC. 2016. HIV Among Youth. https://www.cdc.gov/hiv/pdf/group/age/youth/cdc-hiv-youth.pdf.
• CDC. 2015. HIV Risk and Prevention. https://www.cdc.gov/hiv/risk/index.html.
• Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results
from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from
http://www.samhsa.gov/data.
• European Monitoring Center for Drugs and Drug Addiction (2004). Analysis of risk and protective factors. Retrieved from
http://ww.emcdda.europa.eu/attachements.cfm.
• NIDA. National Institute on Drug Abuse. 2012. Drug Facts: HIV/AIDS and Drug Abuse: Intertwined Epidemics.
https://www.drugabuse.gov/publications/drugfacts/hivaids-drug-abuse-intertwined-epidemics.
• SAMHSA. 2016. Specific Populations. Racial and Ethnic Minority Populations. African Americans. https://www.samhsa.gov/specific-
populations/racial-ethnic-minority
• SAMHSA. Key Facts from the National Survey on Drug Use and Health (NSDUH).
https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf.
• Southwick, S.M., Ozbay, F., Charney, D, & McEwen, B.S. (2008). Adaptation to stress and psychobiological mechanisms of resilience. In
B.J. Lukey & V. Tepe (Eds.), Biobehavioral resilience to stress (pp. 91- 115). Boca Raton, Fl: CRC Press.
• Steven, S. 2008. The Importance and limitations of peer review. Science Based Medicine. https://sciencebasedmedicine.org/the-
importance-and-limitations-of-peer-review.
• U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to
Improve Health Literacy. Washington, D.C. https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-
toolkit/index.html.
• U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Quick Guide to Health Literacy.
https://health.gov/communication/literacy/quickguide/factsliteracy.html.