Abstract
Intimate partner violence (IPV), HIV, and substance use are serious intersecting public health issues. This paper aims to describe the Social Intervention Group (SIG)'s syndemic-focused interventions for women that address the co-occurrence of IPV, HIV, and substance use, referred to as the SAVA syndemic. We reviewed SIG intervention studies from 2000 to 2020 that evaluated the effectiveness of syndemic-focused interventions which addressed two or more outcomes related to reducing IPV, HIV, and substance use among different populations of women who use drugs. This review identified five interventions that co-targeted SAVA outcomes. Of the five interventions, four showed a significant reduction in risks for two or more outcomes related to IPV, substance use, and HIV. The significant effects of SIG's interventions on IPV, substance use, and HIV outcomes among different populations of women demonstrate the potential of using syndemic theory and methods in guiding effective SAVA-focused interventions.
Keywords
The Intersecting Epidemics of Intimate Partner Violence, HIV, and Substance Use Among Women
Accumulating research over the past three decades has documented that intimate partner violence (IPV), HIV, and substance use are highly concentrated and significantly associated among marginalized women globally. Prevalence rates of IPV in the past year range from 20% to 57% in the United States, and have been found to be two to five times higher among populations of women who use drugs (WUDs), compared to general populations of women (Gilbert et al., 2012; Gilbert et al., 2015). Studies conducted across a range of international settings suggest that WUDs experience levels of IPV and other forms of gender-based violence (GBV) between 5 and 24 times higher than national surveillance estimates of IPV/GBV among general populations of women (Stoicescu et al., 2020). Longitudinal research, including studies conducted by the SIG investigative team, has found significant bi-directional associations between IPV and drug and alcohol use among different populations of women (El-Bassel et al., 2005a; Gilbert et al., 2012). These associations are complex, varying by type of drug, type of IPV, and whether or not the perpetrator was also using drugs and alcohol.
Similarly, longitudinal studies, including SIG studies, have documented multiple bi-directional associations between different types of IPV and HIV/STI risks, as well as poor HIV treatment outcomes among women who use drugs or alcohol (El-Bassel et al., 2005b; Gilbert et al., 2015). Mixed methods research, including SIG studies, has elucidated multiple biopsychosocial mechanisms and processes linking IPV, HIV, and substance use (El-Bassel et al., 2000; El-Bassel et al., 2005a; Gilbert et al., 2001, 2012). Taken together, this research underscores the critical need for multi-level multi-component interventions to address these intertwined issues among WUD.
Applying Syndemic Theory to Designing Integrated Interventions That Address IPV, HIV, and Substance Use
Over 25 years ago Merrill Singer developed syndemic theory based on his ethnographic work with people who use drugs in low-income urban communities in Hartford, Connecticut. Syndemic theory aimed to advance a conceptual framework for understanding how substance use, violence, and AIDS (SAVA) tend to concentrate and interact synergistically in disadvantaged groups to produce adverse health consequences (Hatcher et al., 2015; Meyer et al., 2011). Syndemic theory posits that the clustering and complex interactions among two or more psychosocial and health problems occur in specific temporal and geographical contexts that increase the likelihood of one epidemic contributing to another. The SAVA syndemic is reinforced by poverty, stigma, incarceration, lack of access to care, and a host of other social determinants of health (Singer, 1996). Drug use, violence, and HIV interact bi-directionally through biological, behavioral, and structural pathways that may be countered with multi-level protective factors. Syndemic theory has guided the design of several multi-component and multi-level interventions that target complex interacting social determinants of health with the intersecting issues of IPV, HIV, and substance use.
Syndemic theory has been applied to investigate the clustering and synergistic interactions among communicable and non-communicable diseases among a wide range of populations and contexts using a range of qualitative and quantitative methods that have benefited from rich interdisciplinary contributions from across scholarly disciplines, including anthropology, epidemiology, medical, and social sciences (Hossain et al., 2021). Such methods include: qualitative and mixed-methods assessments to explore underlying structural contexts; community-based participatory research (CBPR) to ensure contextual and cultural relevance; and epidemiology and biomedical evidence to identify mechanisms that link SAVA. Tsai and Burns systematically reviewed quantitative literature on syndemics and showed that most quantitative studies used a summative approach (i.e., a count variable or a sum score corresponding to the total number of biopsychosocial problems) (2015), which indicates the co-occurrence of psychosocial issues but does not provide insights on their syndemic synergy or mutual causality (Tsai et al., 2017). More recently, accumulating empirical studies have employed complex statistical models and measures of interaction and synergism to assess the disease interaction concept central to the theory of syndemics (Chakrapani et al., 2019; Singer et al., 2020). This more recent literature has identified different types of syndemic relationships that have implications for designing interventions: (1) clustered psychosocial or health issues that co-occur independently; (2) serial or sequential interactions among psychosocial or health issues; (3) mutually causal psychosocial or health issues that synergistically interact in an additive manner resulting in more deleterious health outcomes; and (4) shared social determinants of health that negatively impact two or more health issues (Singer et al., 2020).
The Role of Social Determinants of Health in Driving the SAVA Syndemic
Over the past decade, research has established the role of numerous social determinants of health in driving the SAVA syndemic (El-Bassel et al., 2022), including racial segregation (Poteat et al., 2020), drug criminalization (DeBeck et al., 2017), sex work criminalization (El-Bassel et al., 2022), social marginalization (Brennan et al., 2012), and police violence (Gilbert, Marotta et al., 2021). This research has elucidated how social determinants of health play a significant role in contributing to the disproportionate burden of SAVA epidemics among subgroups of women who often have intersecting minority or marginalized identities based on race/ethnicity, sexuality, non-cisgender identity, class, and ability status (El-Bassel et al., 2022). Findings and conclusions from these studies support the need for culturally tailored approaches for subgroups of women; as well as the need for robust engagement of consumer representatives who are members of key affected populations at all stages of intervention design, implementation, and evaluation.
SAVA Syndemic Focused Interventions for Women
Understanding the precise nature of the interaction and mechanisms linking psychosocial and health issues and how they are influenced by social determinants of health and larger social forces is key to identifying core multi-level intervention strategies which may best counter these mechanisms at individual and population levels (Singer et al., 2017; Tsai & Burns, 2015). By targeting concentrated health disadvantage and its related mechanisms simultaneously, syndemic-focused interventions aim to achieve greater reductions in disease and comorbidities than would be feasible if psychosocial challenges were addressed individually.
Over the past decade, multi-level integrated interventions, including individual, group, and community-level interventions have shown promise in addressing the biological, behavioral, and structural mechanisms that drive the SAVA syndemic among WUD (El-Bassel & Strathdee, 2015; Gilbert, Raj, et al., 2015; Stoicescu et al., 2020). Existing literature on SAVA-focused interventions among women is dominated by narrative and scoping reviews employing heterogeneous review methodologies (Gilbert, Raj, et al., 2015; Mason & O’Rinn, 2014; Meyer et al., 2011; Mitchell et al., 2016). A global systematic review of SAVA syndemic-focused interventions identified 23 interventions that co-target two or more psychosocial syndemics (e.g., HIV, GBV, substance use, or mental health mechanisms) among WUD (Stoicescu et al., 2021).
Recent systematic reviews (El-Bassel et al., 2022; Stoicescu et al., 2020) have identified core mediators or components of SAVA syndemic interventions that have largely focused on individual-level factors, including: (1) behavioral skills-building guided by social cognitive theory (Bandura, 1994) to reduce risks for IPV, HIV, and substance use; (2) screening, brief intervention, and referral to treatment tools (SBIRT) for IPV and substance use; (3) increasing social support and coping self-regulatory skills; and (4) service care coordination to address SAVA issues and broader social determinants of health that are driving the syndemic. A few more recent SAVA syndemic interventions have focused on upstream community-level or structural factors, such as targeting long-term changes in gender norms and legislation, promoting community norms of zero tolerance against GBV/IPV, and system-level changes to integrate IPV SBIRT models in HIV services and substance use treatment (El-Bassel et al., 2022; Stoicescu et al., 2020).
Aims of Review on SIG's SAVA Syndemic Interventions
The literature on data-driven methods for selecting core components that are most likely to synergistically reduce co-occurring risks for IPV, substance use, and HIV remains sparse. The intervention science on how to develop and test the effectiveness of implementing SAVA syndemic-focused interventions with appropriate research designs that can identify optimal syndemic components also remains limited. Over the past 15 years, SIG has designed and tested a range of SAVA syndemic-focused interventions for different populations of WUD. These include: the Relapse Prevention and Relationship Safety Intervention (RPRS) (Gilbert et al., 2006); Women on the Road to Health (WORTH), an integrated group-based HIV and IPV prevention intervention for women in the criminal-legal system (El-Bassel et al., 2014; Gilbert et al., 2016); Empowering African American Women on the Road to Health, an Afrocentric integrated HIV and IPV prevention intervention for Black/African-American women in the criminal-legal system (E-WORTH) (Gilbert, Goddard-Eckrich, et al., 2021); Women Initiating New Goals of Safety (WINGS) (Gilbert, Shaw, et al., 2015); and Wings of Hope (Gilbert et al., 2017). To address gaps in the existing literature on designing and testing SAVA syndemic interventions for women, this review (1) describes the mixed methods we employed to design these SAVA syndemic-focused interventions; (2) identifies syndemic core components of these interventions and measures; (3) describes SAVA outcomes of these interventions; (4) presents lessons learned and gaps in methods of designing and testing data-driven SAVA syndemic focused interventions; and (5) discusses future directions for advancing syndemic intervention science and implications for social work practice.
Method
Overview
We conducted a review of all studies conducted by SIG investigators from 2000 to 2021 that evaluated SAVA syndemic-focused interventions for WUD with two or more SAVA outcomes that were published in peer-reviewed publications. This review yielded five intervention studies (Table 1). In this section, we describe the steps of intervention planning and piloting that we employed to develop and evaluate the interventions.
SIG SAVA Syndemic Interventions That Address Intimate Partner Violence, Substance Use, and HIV Outcomes Among Women Who Use Drugs.
Mixed Methods to Identify SAVA Syndemic Mechanisms That Informed Intervention Components
Over the past 25 years, SIG has conducted mixed methods research to identify bi-directional and complex interactions among different types of IPV, substance use, and HIV risk behaviors, as well as to identify social determinants of health that may be driving the SAVA syndemic among different populations of women. This mixed methods research has guided the design of RPRS, WORTH, E-WORTH, WINGS, and Wings of Hope interventions. The theories guiding these five syndemic-focused interventions, core components, sample size and setting, intervention study design, and outcomes are described in Table 1.
We conducted longitudinal survey research that identified multiple bi-directional associations linking the experience of different types of IPV to the use of different types of drugs and hazardous drinking among different populations of women (Gilbert et al., 2012; El-Bassel et al., 2005a). Our longitudinal research has documented multiple bi-directional relationships linking IPV to HIV risks among women (El-Bassel et al., 2005b), including engaging in condomless sex, having multiple sexual partners, having sex under the influence of drugs or alcohol, injecting drugs, and reporting higher rates of STIs (Gilbert, Raj, et al., 2015).
SIG's qualitative research using focus groups and in-depth interviews (El-Bassel et al., 2000; Gilbert et al., 2000, 2001) has elucidated multiple syndemic biopsychosocial mechanisms linking different types of IPV to substance use, including (1) use of drugs and alcohol to cope with or recover from relationship conflict and all types of partner abuse; (2) partners physically fighting women for a greater share of drugs; (3) partners preventing women from accessing drug treatment; (4) partners threatening to report women to child welfare; and (5) partners' verbal/emotional abuse focusing on how women's drug use makes them “second class” intimate partners or “loose” women. Similarly, qualitative research conducted by the SIG investigative team identified multiple biopsychosocial mechanisms linking IPV to HIV/STIs among WUD (El-Bassel et al., 2000; Gilbert et al., 2000), including (1) women being coerced by their partners to sell sex for money or drugs; (2) partners drugging and raping women while they are incapacitated or asleep; (3) partners preventing women from accessing HIV care continuum services; (4) partners preventing women from seeking HIV care continuum services or taking HIV medications; (5) partners threatening to disclose women's HIV status to family, friends, employers; and (6) partners verbally/emotionally abusing women in relation to their HIV status.
Abundant research, including several studies conducted by SIG investigators, has also established multiple associations between injection and non-injection use of different drugs and alcohol, elevated sexual and drug-related risk behaviors, and increased likelihood of poor HIV treatment outcomes (Gilbert, Raj, et al., 2015; Stoicescu et al., 2020). These associations also vary by mode and drug use severity and whether or not partners are also using drugs.
Focus Groups With Women With Lived Experience of SAVA
For the RPRS, WINGS, and WORTH interventions, we conducted a series of focus groups with 6–10 women from diverse backgrounds who met study eligibility criteria. The aim of the focus groups was to gain insights into the contextual relevance of the SAVA intervention core components and content delivered by facilitators in a group or individual sessions; as well as the narration, characters, and content of individual skill-building exercises of the digital self-paced tools. We also elicited feedback on the quality and accessibility of specific services that address broader social determinants of health issues and other SAVA syndemic issues for the service-linkage component.
Core Components of SIG's Syndemic-Focused Interventions
This mixed methods research informed the content of the core IPV/SBIRT components that have been integrated into RPRS, WORTH, E-WORTH, WINGS, and Wings of Hope. Components include: (1) psychoeducation interactive component to raise awareness of the multiple bi-directional ways that different types of drug use and drug-related activities are linked to experiences of different types of IPV; (2) screening for different types of drug-related IPV (e.g., being coerced by partners into exchanging sex for money to buy drugs, being prevented by partners from accessing drug treatment); (3) safety planning that is geared to address drug-related types of IPV (e.g., sexual safety planning when women or their partners are under the influence of drugs); (4) social support enhancement strategies that focus on identifying and strengthening ties with network members who can provide emotional support, advice, and instrumental support to help women cope with IPV and avoid harmful substance use; (5) identification and prioritization of service needs that focus on enabling women to identify the most important services that will best address the syndemic SAVA and related social determinants of health; and (6) self-care and service goal setting that focus on enabling women to identify and create a plan for self-care strategies that will promote self-regulation and coping strategies that will most effectively address relationship conflict and substance use. For this last component, we reviewed peer-reviewed literature and consulted with consumer representatives from key affected populations to identify self-care strategies (e.g., spirituality, social support networks, help-seeking behavior, mindfulness strategies, and resilience) that would be feasible and can be culturally tailored.
The service care coordination component of RPRS, WINGS, and WORTH interventions was informed by systematic reviews of the literature to identify the social determinants of health that exacerbate risks of IPV and substance use, which include: homelessness or housing instability, food insecurity, extreme poverty, unemployment or underemployment, criminal-legal involvement, and stigma/discrimination preventing access to IPV and substance use services.
The selection of specific services for the care coordination component was also informed by recommendations from focus groups with members of affected populations as well as from community advisory boards (CABs). This feedback ensured that the service providers selected have the expertise, cultural competence, and commitment to work with women who are using drugs and experiencing IPV.
In addition to the IPV/SBIRT core components, RPRS, WORTH, and E-WORTH included core social-cognitive behavioral skills building activities that focused on safer sex negotiation and communication skills. These skills-building activities were introduced and modeled by facilitators and then rehearsed and practiced in role plays with group members.
Community Engagement Approaches to Localize SAVA Intervention Content
CBPR practices are central to developing effective, sustainable, and community-owned interventions (El-Bassel et al., 2021; Karris et al., 2020). This is especially true for marginalized communities where the SAVA syndemic is highly concentrated and who have historically been subject to health inequities due to racism, homophobia, transphobia, classism, and other forms of oppression. For the WINGS and WORTH interventions, we formed CABs of key stakeholders that played a pivotal role in refining intervention content and overseeing intervention implementation and evaluation. CABs were comprised of women who met the eligibility criteria of the study population (people with lived experience/affected communities), service providers (e.g., IPV services, drug treatment, harm reduction, and HIV care services), criminal-legal representatives (e.g., probation and alternative-to-incarceration programs, parole), city department of health and social service representatives, and community leaders and advocates focused on SAVA issues. The CABs for WINGS and WORTH interventions played a pivotal role in ensuring that the language and content of the intervention components would resonate with the diverse and minoritized members of the study target population (e.g., women who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual [LGBTQIA]; women with disabilities, women who are homeless, women who engage in sex work). In addition, the CAB members were instrumental in identifying and recruiting a network of service providers that were most competent and best equipped to address the SAVA issues and social determinants of health needs of the population. The CABs also focused on tailoring the design and delivery of the interventions so that they would fit best within the real-world organizational settings of the criminal-legal system, harm reduction programs, drug treatment programs, and other low threshold social work service settings for which WINGS and WORTH interventions are designed. The CABs also reviewed and provided feedback on all intervention materials, assessments, recruitment strategies, materials, evaluation methods, and consent forms to improve language and contextual relevance, and identify potential ethical concerns. In addition, the CAB for Wings of Hope in Kyrgyzstan has played a major role in sustaining and expanding the intervention in a country-wide network of harm reduction, domestic violence, and drug treatment programs over the past 10 years.
Addressing Ethical Issues in SAVA Intervention Research With Women Who Use Drugs
All stages of SAVA intervention research with WUDs—from formulating research questions to dissemination—should be guided by research and social justice ethical principles (i.e., autonomy, beneficence and non-maleficence, justice, common good, inclusion and social participation, informed consent—particularly for vulnerable people, and health equity and proportionality). A goodness-of-fit ethical framework that conceptualizes participant respect and protections between the specific research context and unique characteristics of the participant population (Fisher, 2015) has guided the operationalization of core ethical principles in practice. Examples include: ensuring recruitment and data collection procedures that avoid exacerbating stigma by community or providers against participants, or unintentional disclosure of illicit and/or stigmatized behaviors and identities; identifying participant risks and specific local contexts in which these risks can play out, and wherever possible fitting research benefits to participant needs; weighing confidentiality/privacy concerns and other risks and benefits to participants in deciding the optimal modality of delivering a syndemic intervention (e.g., digital mHealth intervention tools vs. in-person group or individual); ensuring health equity by monitoring rates of enrollment and retention by race/ethnicity, sexuality, sex assigned at birth, ability status, etc.; designing respectful consent procedures that are culturally tailored and consider participants’ familiarity with their research rights; and ensuring fair compensation for research participation. Special attention to identifying and addressing risks to participants’ privacy and confidentiality with respect to disclosing IPV/GBV and substance use is of paramount importance given the real dangers that if perpetrators find out about such disclosures they may retaliate with more violence. The pros and cons of disclosing IPV/GBV among WUDs to the police or other criminal-legal authorities for the purpose of seeking protection need to be carefully weighed and done in a way that does not exacerbate harm given the potential negative consequences that might ensue (e.g., women being arrested for drug use and reported to child welfare authorities). An optimal goodness-of-fit on these issues depends on robust community engagement and a co-learning approach with key stakeholders and affected populations grounded in a core harm reduction principle of “Nothing for us without us!” (Jürgens, 2005).
Piloting Interventions With Members of Study Population
After refining the intervention content with feedback from the focus groups and the CAB, we then piloted the full versions of the RPRS, WINGS, and WORTH interventions with a group of 6 to 8 women who met study eligibility criteria. During the pilot, the full content of each session is delivered. After each session, a debrief session with participants is conducted to elicit detailed feedback and recommendations to improve the content, sequencing, and delivery of the intervention components.
Selection of Intervention Study Designs and Core Components
As shown in Table 1, we have employed a range of intervention designs including randomized control efficacy and effectiveness trials, as well as pre-post trial designs to evaluate the RPRS and different adaptations of WINGS (Gilbert, Raj, et al., 2015; Gilbert, Shaw, et al., 2015) and WORTH (Gilbert et al., 2016, 2021; El-Bassel et al., 2014). For RCTs evaluating these interventions, control conditions have varied from attentional control interventions that matched dosage and type of modality, such as the four-session wellness promotion intervention, to standard-of-care interventions for the primary outcome(s) that are available in real-world settings (e.g., HIV counseling and testing that was used as a control condition for the E-WORTH intervention trial). Other control conditions were selected to assess the comparative effectiveness of digital health versions of WORTH and WINGS against traditional facilitator delivery of the same interventions. The purpose of these comparison conditions was to test whether digital health or computerized self-paced versions of delivering WORTH and WINGS interventions were equally effective to traditional facilitator delivery modalities.
Social cognitive theory (Bandura, 1994) guided all of our syndemic interventions. Several interventions (i.e., RPRS, WORTH, and E-WORTH) also integrated empowerment theory (Zimmerman, 2000). Syndemic theory served as an overarching framework to inform the selection and application of core components from social cognitive and empowerment theories that were hypothesized to address syndemic mechanisms and reduce SAVA risks and social determinants of health drivers of these risks.
Core components of all interventions included: (1) SBIRT models to identify and address IPV; (2) enhancing social support, safety planning, and self-regulatory skills to strengthen coping to address SAVA-related issues; and (3) service care coordination to address the broader social determinants of health factors that drive SAVA, such as homelessness, food insecurity, and unemployment in order to allow women to prioritize and address their service needs. E-WORTH also addresses social determinants of health related to structural racism as a core component, including how the war on drugs disproportionately impacts Black communities. This includes experiences of provider stigma and discrimination experienced by Black women involved in the criminal-legal system, medical racism and historical reasons for medical mistrust (e.g., Tuskegee trial and Henrietta Lacks), and historical trauma, from slavery to Jim Crow and ongoing police violence against Black/African-Americans. At the same time, E-WORTH draws on the unique sources of resilience, spirituality, and coping in the Black/African-American communities as a core component (Johnson et al., 2018). RPRS, WORTH, and E-WORTH include social cognitive behavioral skills that may be unilaterally applied to increase intentions, self-efficacy, and ability to negotiate safer sex, refuse unsafe drug use, and avoid risky situations that increase exposure to partner violence.
Selection of Primary and Secondary SAVA Outcomes
The primary and secondary SAVA outcomes for these intervention studies varied depending on the extent to which the integrated intervention content and core components focused on IPV, substance use, and/or HIV risk reduction.
Results
SAVA Outcomes of RPRS, WINGS, and WORTH Interventions
IPV Outcomes
RPRS, WINGS of Hope, and WORTH interventions all showed a significant reduction of IPV over different time frames ranging from 3 to 12 months, varying by type and severity of IPV (Table 1). In addition, both the computerized and case manager versions of WINGS showed significant gains in IPV self-efficacy and linkage to IPV services over the follow-up period. The moderate to strong effect sizes on IPV outcomes suggest that these outcomes are not only statistically significant, but clinically meaningful (Table 1).
HIV Risk Outcomes
Both WORTH and E-WORTH showed significant reductions in the primary behavioral outcome—the number of condomless sex acts over the 12-month follow-up period. In addition, E-WORTH participants experienced a 54% reduction in biologically confirmed STIs (primary outcome) from baseline to the 12-month follow-up, compared to the control participants. To consider these findings in context, the intervention effect on reducing STI incidence found in this study is larger than the average effect reported in a meta-analysis of 17 HIV/STI interventions conducted among Black women that observed 19% reduced odds of STI incidence among intervention participants relative to comparison participants (Crepaz et al., 2007).
Compared to control participants, RPRS participants were also significantly more likely to reduce engaging in sex when they were under the influence of drugs or alcohol as both an HIV risk reduction behavior and a sexual IPV risk reduction behavior. However, there were no significant reductions in the number of condomless sex acts as a secondary HIV behavioral outcome. In addition, WINGS of Hope that included an HIV counseling, testing, and referral component showed effective uptake of completing HIV testing and counseling and linkage to HIV treatment among women attending harm reduction programs.
Substance Use Outcomes
WINGS and WINGS of Hope showed significant reductions in the number of days of illicit drug use over a three-month time period.
Two or More SAVA Outcomes
RPRS, WINGS, WINGS of Hope, and WORTH showed significant improvement in two or more SAVA outcomes. Secondary outcome analyses for additional IPV and substance use outcomes of E-WORTH are in progress.
Discussion and Applications to Practice
The significant effects of SIG's syndemic-focused interventions on one or more SAVA outcomes among different populations of WUDs demonstrate the promise for using syndemic theory and methods in guiding the design and content of effective, integrated interventions. Four out of five of these interventions had a significant effect on at least two SAVA outcomes. WINGS as a single-component, brief, IPV prevention intervention had effects on multiple SAVA outcomes of reducing drug use, as well as increasing linkage to IPV services. In other multi-component interventions like WORTH, adding an IPV/SBIRT tool to a behavioral HIV prevention intervention resulted in reducing both HIV risks and IPV over the 12-month follow up. This review highlights the utility of integrating SBIRT models to address SAVA syndemic issues. It also demonstrates how syndemic-focused interventions may be used in conjunction with social cognitive and other theories to inform the selection, sequencing, and dosage of core components that are likely to have an optimal impact on SAVA outcomes, taking into consideration the real-world budgetary, resource, and staffing constraints of agency settings.
The mixed methods, community engagement approaches, and use of focus groups and pilot intervention methods that we employed to design the syndemic content of RPRS, WINGS, WINGS of Hope, WORTH, and E-WORTH, and tailor them to the unique needs and strengths of different populations of marginalized women, are feasible and replicable. Robust community engagement of key stakeholders and affected populations of women has been instrumental to the design, cultural tailoring, and successful adaptation and implementation of these interventions for different subgroups of WUDs. The adoption and sustainability of WINGS in a range of multiple low-resource settings in several countries are also largely due to the engagement of core community stakeholders, and leadership by consumer representatives.
Moreover, these syndemic intervention planning methods are grounded in core principles of social ecological theories central to social work practice that recognize the clustering and interacting social and health issues like SAVA are driven by multi-level risk factors and social determinants of health. These SAVA risks may be effectively countered by identifying the optimal combination of multi-level protective factors (e.g., social support, coping self-regulatory skills, SAVA-related self-efficacy, increasing access to SAVA-related services, and social determinants of health drivers), which are most likely to result in one or more improved SAVA outcomes. Syndemic theory-driven approaches to intervention design also recognize that the way in which SAVA syndemics evolve and play out among different populations of women is highly dependent on local context, space, and time, and thus require a high degree of cultural and contextual tailoring and community engagement (Mendenhall et al., 2022). For example, although WORTH and E-WORTH employed very similar core components and intervention strategies, the content was tailored to the different populations of women in community supervision programs (CSPs) in the United States. The WORTH intervention addressed social determinants of health drivers of the SAVA syndemic that disproportionately affect women in CSPs, such as housing instability, food insecurity, unemployment, and lack of access to SAVA services. The E-WORTH adaptation of WORTH for Black women in CSPs in New York City focused on addressing the role of anti-Black racism, historical trauma, stigma, medical racism and mistrust, and racialized drug laws and policing that Black women in CSPs experience, as well as harnessing the unique resiliency, strengths, and coping strategies that Black women have gained in dealing with historical trauma and racism. It is worth noting that all of these interventions were developed and tested in relatively high resource settings in the United States that will need robust adaptation for implementation in lower resource settings outside the United States. WINGS of Hope, an adaptation of WINGS, is the only one of the five interventions that has been tested in a low-resource setting in Kyrgyzstan. WINGS has been adapted and tested and is currently being implemented in a wide range of settings in Kyrgyzstan, Ukraine, India, and Kazakhstan.
The findings of this review have several limitations. Intervention study samples are relatively small and not generalizable to other populations. The lack of longer-term follow-ups does not allow us to ascertain whether the positive changes we observed with SAVA outcomes were sustained over time. The lack of biomarker outcomes for drug use in all studies, and STIs in some studies, is another limitation. Future research on SAVA interventions should include larger representative samples, with longer-term follow-ups, and biological indicators for substance use and HIV/STIs.
Moreover, there are limitations in our syndemic intervention methods and analytic approaches that may be addressed in future research on SAVA interventions. Although we used mixed methods research to inform intervention content, we did not employ more recent methods of identifying precise biopsychosocial mechanisms and types of interactions that have been recommended by Tsai (2018), Singer et al., (2020), and Chakrapani et al., (2019). Identifying more precise types of SAVA interactions along with social determinants of health drivers of SAVA risks will improve the content and focus of syndemic interventions. Without further mediation analyses, it is difficult to identify what type, dosage, and combination of the SAVA core components were needed to achieve the SAVA outcomes of these five intervention studies. Such mediation analyses conducted using path analyses or structural equation modeling will advance a better understanding of how core components may be optimally combined and integrated to synergistically address SAVA outcomes in resource-constrained settings, as other researchers have suggested (van den Berg et al., 2017). The intervention designs and selection of control groups that were used in these five intervention studies were not optimal for identifying the syndemic effects of these SAVA-focused interventions. More rigorous intervention designs would have compared the effects of multiple SAVA component interventions to a single SAVA component in a standard RCT, such as an IPV/SBIRT intervention + HIV prevention intervention compared to the same HIV prevention intervention.
Syndemic intervention science could benefit from more cross-disciplinary methods of public health, biology, sociology, anthropology, epidemiology, and social work to advance data-driven approaches to identifying core components of multi-level syndemic-focused interventions that may best address SAVA risks with greater precision and efficiency. Syndemic researchers have recommended employing agent-based models or counterfactual models that may employ mathematical modelling to simulate the effects of multi-level or multi-component interventions on reducing SAVA risks, as well as on social determinants of health drivers of SAVA (Stone et al., 2022; Tsai, 2018). Geospatial analyses and social network analyses of where and how SAVA risks and social determinants of health drivers are concentrated in marginalized communities and in social network nodes can further help focus the contours of SAVA interventions (Tsai, 2018).
A challenge inherent in intervening on multiple, interacting social and health problems—also embedded in meso and macro determinants of psychosocial and health issues—is that there are unlimited combinations and levels of factors that interact non-linearly. At the least, this leads to heterogeneity among the study populations, and more to the point, is likely to lead to heterogeneity in treatment response. Adaptive interventions or dynamic treatment regimens—in which the treatment varies as a function of how the participant is responding as the intervention unfolds—hold great promise for overcoming this challenge and delivering more effective syndemic interventions (Murphy et al., 2007). Future research on syndemic interventions may benefit from experimental designs tailored for adaptive approaches, for example, sequential multiple assignment randomized trials.
It is important to note that WINGS, Wings of Hope, and E-WORTH were all implemented by practitioners in real-world settings of harm reduction programs and CSPs, suggesting the feasibility and effectiveness of implementing such syndemic-focused interventions in a range of resource-constrained settings. Another strength of these interventions for direct practice is their grounding in motivational interviewing principles which enables practitioners to let the participants drive the pace and type of syndemic changes they want to make to improve their safety and well-being. Participants are encouraged to decide what SAVA-related risks are most important for them to address first, and to select the services, resources, and social support that may best address these risks, as well as social determinants of health that may be driving these risks. The multiple modality options for delivering these interventions, which include traditional facilitator-driven individual and group-based approaches—which may be combined with self-paced digital MHealth tools—allow for diverse practitioners, and peers with limited clinical training, to implement these interventions.
Moving forward, there remains a critical need for implementation research that can help identify multi-level structural and organizational barriers and facilitators to delivering these evidence-based SAVA syndemic-focused interventions, such as level and type of staff training, organizational resources, leadership commitment, level of community engagement, and network of services needed to address SAVA risks and social determinants of health drivers. Implementation science frameworks that integrate a health equity lens (Baumann & Cabassa, 2020; Woodward et al., 2019) are especially needed to evaluate how well SAVA interventions are reaching, engaging, and retaining different subgroups of women globally who have been systematically excluded as a result of their minoritized identities by race/ethnicity, gender, sexual orientation, ability, and other statuses.
Syndemic theory-driven approaches have the potential to advance data-driven social work practice that can more effectively address SAVA and co-occurring health and psychosocial issues among WUD and other underserved populations of women. This review of SIG's first generation of SAVA-focused interventions for WUD suggests that the mixed method approaches employed to design the syndemic content of these interventions were effective in improving multiple SAVA outcomes. Recent SAVA syndemic research has identified gaps and additional methodological approaches for designing and evaluating syndemic interventions that more precisely target SAVA risks and social determinants of health drivers among different populations of women. However, these data-driven syndemic intervention research strategies do not replace the importance of relying on best social work direct practices of conducting ecological assessments to disentangle the most salient SAVA risks and social determinants of health drivers from the participant/clients’ perspective; as well as to select, implement, and evaluate evidence-based intervention strategies or service linkage strategies that may best address their SAVA risks.
The intersecting and mutually reinforcing nature of the SAVA syndemic requires multi-level, integrated care, and trauma-informed practice (Karris et al., 2020). Healthcare or community-based settings where women most impacted by SAVA conditions feel comfortable (e.g., harm reduction programs, community-based primary care centers) present favorable environments for integration of SAVA health services. Implementation research on SAVA syndemic-focused interventions is needed to inform how best to scale up the delivery of these interventions in a range of agency settings. All five SIG syndemic-focused interventions resulted in improving SAVA outcomes among different populations of women, consistent with outcomes found in other SAVA syndemic-focused interventions (Gilbert, Raj, et al., 2015; Stoicescu et al., 2020).
The SAVA syndemic is unlikely to be fully addressed by adding downstream individual SBIRT components for substance use, IPV, or integrated behavioral interventions targeting individual SAVA behavioral risks. There remains a critical need for upstream approaches (e.g., structural interventions) that can effectively tackle root social determinants of health drivers of the SAVA syndemic at a population level, such as policies that promote racial, gender, and income equity, housing stability, and/or food security. Social work can play a pivotal role in mobilizing key stakeholders in communities to not only form a network of services and resources that can make a collective impact on the SAVA syndemic in marginalized communities, but also to advocate for policies and resources that may address broader social determinants of health driving the SAVA syndemic.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
