Chapter 3.0 Case Study Summaries

We prepared case studies for the four pairs of study sites: Hinds and Humphreys counties, Mississippi (Liebow et al. 1996a); Montgomery and Lowndes counties, Alabama (Mitchell et al. 1996); Richland and Orangeburg counties, South Carolina (Liebow et al. 1996b); and Shelby County, Tennessee, and Tunica County, Mississippi (Fish et al. 1996). For full case studies see Appendix D.

Highlights of the case study findings are summarized below, with summary tables appended to the end of this chapter. Each of the case study pairs is introduced by individual community profiles, followed by a section on key assessment issues in the study communities, including at-risk populations, institutions available to reach those populations, and any barriers identified. Each case study summary concludes with a discussion of community action issues. The complete case studies are included as Appendix D.

3.1 Hinds and Humphreys Counties, Mississippi

The pilot study was conducted in two Mississippi communities: Hinds County (Jackson) was the urban site, and Humphreys County was the rural site. See map in Figure 3.1

3.1.1 Community Profiles

Hinds County (Jackson) - Urban

Geography and demographics. Home to Jackson, Mississippi's capital and largest city, Hinds County had a population of 254,606 in 1990. The city of Jackson's population was 196,637. Over the past decade the population of Jackson's central city has been shrinking while the rest of the Jackson Metropolitan Area (including most of Hinds and Madison counties) grew by more than 9 percent (US Bureau of the Census 1994a).

Hinds County was 51 percent African American and 48 percent white in 1990, with small groups of Hispanics, Asians and Pacific Islanders, and American Indians. The city of Jackson was about 56 percent African American and 44 percent white during this same period. Between 1980 and 1990, Hinds County grew by 1.4 percent; however, this trend reflected a 10.6 percent decrease in the white population and a 14.4 percent increase in the non-white population. At the same time, there was a 63.2 percent increase in the white population in neighboring Madison County, reflecting "white flight" from the city.

Economic characteristics. The median household income in Hinds County was $24,676 in 1990, with 16.7 percent of families below the poverty level (US Bureau of the Census 1994a). When the county's median family income of $30,125 is separated by race, the result is $41,636 for white families and $18,316 for African-American families (Howell et al. 1995:138). The median household income in the city of Jackson was $23,270 in 1990, with almost 23 percent of the population falling below the poverty level (US Bureau of the Census 1994a).

Social characteristics. Jackson is reported to have some of the worst inner-city housing conditions in the entire country, with up to 10 percent of the housing in some sections of the city substandard or abandoned. Because of its location, Jackson is a distribution center for illegal drugs being transported from the Gulf of Mexico to urban centers in the north. The crack cocaine epidemic in the mid-1980s has spawned other social and public health problems, including drug-related crime, prostitution, and sex-for-drug exchanges.

Syphilis morbidity. Early syphilis morbidity is declining in Hinds County from a 1991 high of 102.3 cases per 100,000 to less than 50 per 100,00 by 1995.

Public STD services. The Mississippi State Department of Health (MSDH) operates several clinics in the Jackson Metropolitan Area, including an HIV/STD clinic (Ellis Avenue Clinic) that was opened in July 1995. Disease Investigators in Jackson operate out of the Ellis Avenue Clinic. The HIV and STD divisions of the Health Department were combined on April 1, 1995, with four branches: Education and Prevention, Care and Services, Field Operations, and Surveillance.

Health care. Residents of Jackson can seek health care in the University Medical Center, the Veterans Affairs (VA) Medical Center, and at nine other local hospitals. There are also clinics throughout the Jackson Metropolitan Area operated by the Jackson/Hinds Comprehensive Health Center (JHCHC), available to low-income patients on a sliding fee scale. The JHCHC clinics are utilized primarily by low-income African Americans for general care, WIC, Medicaid screenings, family planning, physicals, and dentistry.

Humphreys County - Rural

Geography and demographics. Located in the heart of the Mississippi Delta, Humphreys County had a population of 12,134 in 1990 (US Bureau of the Census 1994a), much of it concentrated in the county seat of Belzoni and other small towns such as Isola and Louise.

The population of Humphreys County was about 68 percent African American and 32 percent white in 1990. From 1980 to 1990, Humphreys County had a population decrease of 12.9 percent, including a 22.4 percent decrease in the white population and a 10.1 percent decrease in the non-white population (Howell et al. 1995:18). Between 1940 and 1990, the county population decreased by 53.8 percent, largely due to the mechanization of cotton production.

Economic characteristics. The economy of Humphreys County is based almost solely on cotton and catfish production, leaving very few other employment options for residents. The unemployment rate in Humpheys County in 1988 was 15.5 percent. When separated for race, the unemployment rate was 2.8 percent for whites and 25.7 percent for non-whites (Campbell et al. 1992:136).

The median household income in Humphreys County was $12,696 in 1990, with 38.3 percent of families living below the poverty level (US Bureau of the Census 1994a). When the median family income of $15,269 is separated for race, the median family income for whites was $27,083, while for African Americans it was $9,350 (Howell et al. 1995:138). Of the Humphreys County residents living below the poverty level, 91 percent are African American (Mason 1992).

Social characteristics. Educational achievement in Humphreys County is well below state and national averages. As of 1990, the number of persons over 25 years of age who had a high school diploma or equivalency was only 1,336 (Howell et al. 1995:126). Unmarried females head 33 percent of all households in the county. Crime, gangs, and drug use are reported throughout the county, with a great deal of movement occurring between Mississippi and such northern cities as Chicago and Detroit.

Syphilis morbidity. In Humphrey's county, syphilis prevalence rates increased over the period 1991 through 1994 to a peak of 302 cases per 100,000. The 1995 rate dropped to 207.1 cases per 100,000.

Public STD services. The town of Isola has a clinic run by a registered nurse that offers medical screenings, lab work, patient exams, STD testing, and treatment of common problems such as hypertension and diabetes. The small town of Louise has a clinic opened by Humphreys County Hospital in September 1995 to provide for people without transportation and to discourage unnecessary use of the emergency room at the hospital in Belzoni. The clinic is staffed by a nurse and a doctor who is an attending physician at the hospital. The Health Department Clinic in Belzoni is used for prenatal and postnatal care, family planning, WIC, and STD testing and treatment. The public health clinic in Belzoni falls under the administrative control of Public Health District III, based in neighboring Greenwood, Mississippi. There are nine Disease Intervention Specialists (DIS) in District III, one of whom is responsible for Humphreys County.

Health care. In Humphreys County, health care is available in three of the small towns: Belzoni, Isola, and Louise. In Belzoni health care facilities include two family practice clinics run by private physicians, the Humphreys County Hospital, and the local Health Department Clinic. The private physicians are well utilized, while the hospital is avoided by most residents except in emergencies.

3.1.2 Key Assessment Issues in Hinds and Humphrey Counties

Who is considered to be at greatest risk for syphilis?

Reported cases of early syphilis in both urban and rural Mississippi settings almost exclusively involve low-income African Americans. Public health agency respondents suspect reporting bias, however, since white residents tend to turn to private physicians who treat them but provide diagnoses of a more general nature. Other risk factors are discussed below, first in the urban, then in the rural site.

Hinds County (urban). Risk factors discussed by interviewees included:

• Substance abuse. In the metropolitan Jackson area, public health officials single out the use of crack cocaine, and the attendant sex-for-drugs exchanges, as an important risk factor for syphilis infection.
• Prostitution. A distinction is made between those who trade sex for crack and prostitutes,- commercial sex workers who are said to take better care of their health - e.g., are more regularly tested for STDs - because their ability to charge adequately for their services depends on it.
• Age. Those treated in the urban setting for syphilis infection are usually in their mid-20s to late 30s, slightly older than those treated for gonorrhea and chlamydia. Due to the connection with crack use, with a user population that includes teenagers and younger adults, public health officials note that the average age of those treated for syphilis has decreased.
• Gender. Approximately equal numbers of males and females are treated for syphilis infection in Jackson.
• Sexual orientation. A general consensus emerged that many African-American men engage in sex with other men without self-identifying as gay or bisexual; these individuals are seen as particularly difficult to reach with risk-reduction and health promotion messages.
• HIV and other STDs. Those at greatest risk for becoming infected with syphilis are not seen as overlapping significantly with those at greatest risk for HIV infection, although DIS staff feel that the same risky sexual behavior that leads to syphilis will eventually put people at risk for HIV.

Humphreys County (rural). In Humphreys County, use of crack cocaine and patterns of sexual relationships among teenagers are mentioned as important risk factors.

• Substance abuse. In Humphreys County, use of crack cocaine is cited as an important risk factor. The county is connected with a major drug distribution route based in Greenville, and gang activity from Chicago is evident even in the county's small towns.
• Age. Young people are becoming sexually active at a very young age, and many are dropping out of school before they reach the grade levels where sexuality and STDs are introduced into the health education curriculum. The absence of employment and recreational opportunities for youth in the rural area are also said to lead to risky teenage sexual activity

What institutions are thought to be most likely to reach those at greatest risk?

Schools, religious institutions, the Health Department, and community-based organizations were mentioned by respondents as the institutions in their communities most likely to reach those at greatest risk for contracting syphilis, although neither the schools nor the religious institutions are heavily engaged at present.

• Schools. Because of resistance by administrators, schools in both the urban and rural areas lack programs to address sexually transmitted disease, although they do invite in outside organizations to conduct health fairs, workshops, and presentations addressing health issues. Respondents felt that health promotion messages relating to STDs and teen pregnancy should be provided earlier and more intensively than is currently the case.

• Religious institutions. Although churches were identified as important community institutions in a position to reach most area residents in both urban and rural areas, it is the exception and not the general rule that a local minister has sought to incorporate health education and issues of human sexuality into his/her church's community service or educational programs.

• Health Department. In the metropolitan area and to a lesser extent in the rural, institutions are in place that could be mobilized to reach those at risk, at least to provide services such as primary health care, health education, risk reduction, substance abuse treatment, domestic violence intervention, and other prevention services. The District Health Department is viewed as the only institution with a broad enough reach in the area to bring these institutions, as well as churches and public schools, under the auspices of health education.

• Community-based organizations. Youth service organizations like Operation Shoestring, the Children's Home Society, and Boys and Girls Clubs are involved in age-appropriate health education activities that include discussions of sexuality and sexual health. The American Red Cross Chapter has been a source of HIV prevention training.

What are the barriers to reaching those at greatest risk?

Several barriers were identified that must be overcome to reach those at greatest risk of syphilis infection more effectively and to prevent others from increasing their risk of infection.

Local norms about public discourse on sexuality and sexual health. Local norms tend to be conservative in both the religious and the secular domains in Mississippi:

• Religious domain. Local churches are dominant institutions whose resistance to public discussion of sexuality issues has been coupled with an unwillingness to acknowledge a disparity between official church teachings and some congregants' sexual behaviors.

• Secular domain. The churches' resistance is reinforced in the secular arena and has translated to banning broadcasts of popular network television shows, screening out candidates for elected office whose views are less resistant, and restricting the content of public school health education curricula.

Barriers to access and utilization. Some of the barriers to reaching those at greatest risk of syphilis infection involve limited access to and utilization of STD clinics.

• Staffing. Barriers include a shortage of physicians and agency regulations restricting the services other health care professionals can provide.

• Transportation and hours. Transportation is a major barrier to access, especially in rural areas, as are hours that do not accommodate patient work schedules.

• Closing of a satellite clinic. One health department clinic, near an area known for the crack cocaine trade and sex-for-drugs exchanges, is being closed due to safety concerns of the staff. This creates a barrier to access for persons at high risk of syphilis infection.

• Cost. Even $10 clinic fees and $35 testing fees (chlamydia testing, for example) may seem high to some patients, especially teenagers and those living in poverty. Fee waivers and deferments must be negotiated, which discourages some from clinic use.

• Awareness of services. Fully 75 percent of teens surveyed by the Mississippi Department of Education in 1993 did not know how to access health services, including physical exams, family planning, and STD testing.

• Restrictions on programmatic funding. Patients must often schedule multiple appointments at different clinics for various types of services.

• Mistrust of the public health system. Perceived lack of confidentiality at the Health Department represents a barrier to some, as does the perception that the Department is a primarily white institution. Negative staff attitudes or behavior toward those presenting with STDs may also play a role, as may the Tuskegee legacy.

Adequacy of public health staff recruitment and training. Barriers related to staffing included:

• Clinic staff attitudes. Clinic staff attitudes and the waiting-room environment discourage some from seeking testing and treatment.

• Insensitive intake procedures. The "glass window" syndrome - referring to the typical waiting-room setup where patients must announce their names to a receptionist in a raised voice through a glass window and then are subsequently called out by name when they can be seen - does not preserve patient confidentiality.

• Lack of adherence to clinic procedures. Nurses do not always follow standing orders for syphilis treatment, and not all female nurses feel comfortable conducting urogenital tract exams with male patients.

3.1.3 Community Action

In Jackson, our brief site visit leaves us with an uneven impression about the effectiveness of neighborhood organizing. A small cadre of energetic, resourceful, and dedicated activists maintains an informal institutional alliance that covers many important bases. However, coping with inner-city poverty dissipates energy and distracts from neighborhood organizing. For many of the city's neediest areas, no "neighborhood" exists to link with counterparts and divert public investment resources towards efforts through which they could make a significant difference.

Small towns in Humphreys County are widely dispersed in a large agricultural area, making county-wide coalitions difficult to create and sustain. We encountered one example of local-level organizing in Isola, where a community planning group has been formed by local leaders to address the needs of the residents. The group has been collaborating with the District III Health Officer, members of Mississippi State Department of Health, and a representative of the Community Health Advisory Network from Jackson. The group is exploring ways to purchase two adjoining properties in Isola to build a community center. The community center would be used to house GED and job training, recreation, exercise, day care, as well as health education programs. The members of the community group are looking for ways to involve Country Skillet, a local employer, in their efforts to build and operate the community center and are investigating the possibility of receiving rural empowerment community grant funds.

3.2 Montgomery and Lowndes Counties, Alabama

The two Alabama sites were Montgomery County (urban) and Lowndes County (rural). See map in Figure 3.2

3.2.1 Community Profiles

Montgomery County - Urban

Geography and demographics. Located in central Alabama on the Alabama River, Montgomery County is home to the city of Montgomery, Alabama's state capital. In 1990, Montgomery County had a population of 214,996, and the city of Montgomery's population was 187,106 (US Bureau of the Census 1994a). Downtown and west Montgomery are predominantly poor areas; new middle class suburbs are developing in east Montgomery.

Montgomery County was approximately 57 percent white and 42 percent African American in 1990; the city of Montgomery was 53 percent white and 46 percent African American. Census data also show small pockets of Asians and Pacific Islanders and other ethnic groups, and fewer than 1 percent are of Hispanic origin (US Bureau of the Census 1994a).

Economic characteristics. The economic base of Montgomery is well diversified, with manufacturing, trade, and several military installations. The State of Alabama is the area's largest employer, with 19,000 workers, and an additional 9,000 are employed at Maxwell Air Force Base. The median household income in Montgomery County was $26,551 in 1990, with 14 percent of families in the county living below the poverty level. Of those, 38.8 percent are female-headed households (US Bureau of the Census 1994a). The median household income in the city of Montgomery was $26,311 in 1990.

Social characteristics. Gang activity was mentioned as a problem in Montgomery - including local sets of gangs from as far afield as Los Angeles - as was illegal drugs (notably crack cocaine). The State of Alabama has no authority to insist on the incorporation of sexual health into school curricula. Control over sexual education is instead vested in the local school boards, which tend to resist discussion of sex in the classroom. Schools and churches are divided largely along racial lines. Few organized recreational activities are available for area youth.

Syphilis morbidity. Early syphilis morbidity declined sharply in Montgomery County between 1990 and 1992, with prevalence rates reduced from a 1991 high of 182.6 per 100,000 population to less than 60 per 100,000 by the next year. The rate has continued to decline over the period 1992-1995, but at a much less dramatic pace.

Public STD services. Alabama is divided into Public Health Areas (PHAs) to facilitate coordination, supervision, and development of public health services. In terms of STD epidemiology and follow-up, Montgomery County is part of a PHA that includes five other counties. In July 1995, the Health Department STD clinic, known as the Specialty Clinic, moved from a stand-alone location in the central city into the Montgomery County Health Department building.

Health care. Montgomery has four major hospitals, in addition to a VA Hospital. Due to the absence of any public hospitals in the city, a rotating "ER (Emergency Room) of the Day" arrangement was instituted in the late 1980s to spread the cost of treating those who lack primary care and to balance distribution of uncompensated walk-ins. Three hospitals alternate as ER of the Day. Announcements for ER of the Day are made daily on the radio, and ambulance services are aware of which hospital to bring patients to on any given day.

Montgomery AIDS Outreach (MAO) is a community-based organization that operates a clinic at its offices near Jackson Hospital five days and four nights a week, offers services at the Montgomery County Health Department twice a month, and has opened several rural health clinics around the region.

Lowndes County - Rural

Geography and demographics. Located about 30 minutes to the west of Montgomery, Lowndes is one of nine counties in the western part of the "Black Belt," named for its rich black cotton-growing soil. Hayneville, with a population of about 400 people, is the county seat and closest town to Montgomery. Other towns in Lowndes County include Whitehall (pop. 1,000) in the northwest part of the county and Fort Deposit (pop. 1,600) in the southern part of the county. To the west of Hayneville is a small town called Mosses, which is 100 percent African American and is the site of a large government housing project.

Although Lowndes County's population decreased by about 5 percent between 1980 and 1990, nearby Montgomery's recent growth is spilling over, and Lowndes County has grown modestly since 1990. The 1990 population of Lowndes County was 12,658, with 76 percent African American, 23.5 percent white, and the rest mainly Hispanic (US Bureau of the Census 1994a). Underreporting in the last census may have underestimated the county's African-American population.

Economic characteristics. Many people in the labor force in Lowndes County seek work outside the county, in Montgomery, Selma, or Greenville. General Electric opened a plant in Lowndes County, but most local residents could not meet the skill requirements, and jobs at the plant have gone mainly to those with advanced degrees. GE received tax breaks from the county and operates its own health center and day care for its employees, so there has not been much economic benefit to the county. Other forms of employment in the county include some manufacturing, agriculture, and construction.

The median household income for Lowndes County was $15,584 in 1990, with 31.7 percent of all households and 58.6 percent of female-headed households falling below the poverty level (US Bureau of the Census 1994a). Close to 30 percent of Lowndes County residents live in mobile homes.

Social characteristics. The small rural towns in the county offer little in the way of community services. Transportation was reported as a significant problem for residents. Organized recreational activities for teens are limited, and adolescent sexual activity is extremely high, with teen pregnancy a significant problem. Drugs, gangs, and other urban problems have been introduced by youth living in the north but sent home to live with grandparents when they "get in trouble." Law enforcement resources are insufficient to control drug trafficking.

Syphilis morbidity. In Lowndes County, early syphilis prevalence rates have declined sharply over the period 1992-1995. After a 1991 peak of 165.4 cases per 100,000 population, the 1995 rate has dropped to 16 per 100,000.

Public STD services. Lowndes County is one of the six counties, along with Montgomery, that comprise Public Health Area 12 for STD services. The local Health Department clinic is located in Hayneville. One Disease Investigator based in Montgomery is responsible for syphilis and other STDs in Lowndes and two other rural counties.

Health care. The West Alabama Health Services (WAHS) Center in Hayneville is a federally funded community health center and offers full medical services including primary care, physicals for Headstart and school athletes, Medicaid screenings, WIC, immunizations, elderly adult day care, and dental services all on a sliding fee scale. To improve access in the county, WAHS has established one school-based health center in Fort Deposit and plans to start another one in Whitehall. The school-based health center is funded by the Kellogg Foundation through the School of Nursing at Auburn University-Montgomery. The WAHS Center is the most utilized facility for health care in Lowndes County, especially by the African-American population.

Also located in Hayneville is the Four Rivers Health Clinic, which is operated by the Four Rivers Hospital from Selma. The Four Rivers Health Clinic is staffed by a nurse practitioner, and a physician from the hospital in Selma comes in one day a week. There is also one private physician in Lowndes County, located in Fort Deposit.

3.2.2 Key Assessment Issues in Montgomery and Lowndes Counties

Who is considered to be at greatest risk for syphilis?

Montgomery County (urban). Most respondents in Montgomery thought that drug users, teenagers, and African Americans in low-income areas are at the highest risk of contracting syphilis.

• Drug use. The majority of urban respondents perceived drug use, especially the exchange of sex for crack cocaine, as a major risk factor.

• Prostitution. Professional prostitutes, in contrast with crack users trading sex for drugs, were not thought to be at high risk for syphilis because it makes good business sense for them to remain disease free.

• Age. Perceptions of age-related risk depended on how fine a distinction respondents draw between syphilis and other STDs. For those who did not distinguish syphilis from gonorrhea and chlamydia, teenagers were considered to be at risk because of their high level of sexual activity. A lack of recreational activities and an outlook of invincibility were said to contribute to unprotected sexual activity among teens. For respondents who do make the distinction between syphilis and other STDs, teens were thought to be more likely to contract gonorrhea, with syphilis infections usually seen among people in their mid-20s to late 30s

Lowndes County (rural). As a whole, respondents in Lowndes County did not place as much emphasis on syphilis as on other STDs like gonorrhea and chlamydia. Respondents were also much less likely to distinguish syphilis from other STDs. For this reason, teenage sexuality was often given as much emphasis as drug usage when discussing risk. For those who made the distinction, gonorrhea and chlamydia were thought to be more of a problem with teens, while syphilis is seen more in people in their 20s and 30s.

• Age. The high rates of STDs in teens is due to their reported high level of sexual activity. In a survey conducted in the county, teens reported that they have had 25 to 250 sexual partners. It is common for girls of 14 or 15 years of age to have multiple sexual partners and to date men in their mid- to late 20s. As a result, teenage pregnancy is a problem in the county; almost 20 percent of all births are to mothers under age 20.

• Race. Every person with whom we spoke said that African Americans were at higher risk for syphilis than whites, but this is not surprising since African Americans make up close to 80 percent of the population in the county.

• Substance abuse and prostitution. Exchanging sex for crack cocaine is reported to be extensive in the county, although this has not been reflected in cases reported by public health officials. Commercial prostitution is said not to exist in rural Lowndes County; however, some local women reportedly have a series of short-term "boyfriends" from whom they receive gifts, money, drugs, or other favors.

What institutions are thought to be most likely to reach those at greatest risk?

In Montgomery, and to a lesser extent in Lowndes County, institutions are in place that could potentially be mobilized to reach those thought to be at greatest risk.

• Schools. In both the urban and rural areas, the majority of respondents felt that the schools are the best institution through which to deliver prevention messages to youth of all ages. Suggested messengers include the Department of Education HIV coordinators, School nurses, Public Health Representatives, and special outside speakers.

• Religious institutions. In previous years, churches have strongly opposed STD/HIV prevention messages. There has been less resistance in the past two years, attributable in large part to the work of a minister at the University of Alabama-Birmingham. This minister started an AIDS Care Team, and now other churches are becoming involved as well.

• Health care providers. More could be done to mobilize providers. For example, physicians specializing in obstetrics and gynecology would lend credibility - establishing that syphilis and other STDs are truly a major health concern - and could influence other physicians in the Alabama Medical Association. The Health Department could do more to deliver prevention messages in the community. Also recommended were intensified collaborative efforts between the Health Department and local hospitals, drug treatment facilities, and community-based organizations.

• Community health centers (CHCs). Statewide, Alabama has 17 CHCs with 52 outreach centers set up to treat indigent residents. These CHCs have good access to the at-risk populations in both urban and rural areas and are said to be better utilized and trusted by African-American and other minority communities than the Health Department.

• Housing authority. In both the urban and rural areas, the Housing Authority is an institution with good access to young single mothers and other residents of the government housing projects. Because of the lack of transportation for these residents, programs offered in the housing projects could reach at-risk individuals not reached by other efforts.

What are the barriers to reaching those at greatest risk?

Several barriers to reaching those at greatest risk for syphilis were identified in Montgomery and Lowndes counties.

Local norms about public discourse on sexuality and sexual health. Barriers related to local norms included:

• Denial about extent of teen and extra-marital sexual activity. In spite of high rates of STD and pregnancy among teens, most parents believe their children are not involved in any sexual activity and so do not need information about reducing their risk of pregnancy or sexually transmitted infection.

• Prominence of the abstinence message. State law prohibits mention in the schools of any sexual option other than abstinence. Also, many parents fear that if course materials even mention anything but abstinence, they will be promoting sexual activity among youth.

• Conservative religious norms. Most churches are not open to messages about protected sex and disease prevention unless they are delivered solely within the context of abstinence. Issues involving sexuality and sexual health are considered moral issues (not public health issues) that should be dealt with in the family context, rather than in the public sector.

• Secular conservatism. Reluctance to discuss issues of sexuality can also be seen in the secular arena. Although television was identified as an effective medium through which to reach teens, the conservative nature of the community prohibits mention of condoms on television.

Barriers to access and utilization of services. Barriers to access and utilization were also mentioned:

• Mistrust. Perceived breaches of confidentiality and a feeling by patients that they are not treated humanely by Health Department staff represent barriers to service utilization. Public health nurses feel so over-worked and under-appreciated that they may become cynical, judgmental, and punitive. Fear of being seen at the clinic is an additional barrier to many patients, especially in rural areas or for those visiting dedicated clinics where only STDs are treated.

• Programmatic funding issues. Funding restrictions can be a barrier to service. For example, if a pregnant woman goes to the Health Department's maternity clinic and is diagnosed with an STD, she will be sent to the Specialty Clinic for STD treatment. The Specialty Clinic cannot treat that woman, however, because she is pregnant, so the patient is sometimes sent to an emergency room for treatment.

• Emphasis on the medical model with little attention to prevention. The "medical model" involves diagnosis, treatment, contact tracing, and surveillance, without significant attention paid to primary prevention efforts such as outreach or education. Since new administrative staff have taken over in the STD Division of the Health Department, this is beginning to change in Alabama, with the introduction of education efforts by Public Health Representatives.

• Excessive amount of paperwork. Public Health Representatives told us they spend about 15 percent of their time each day just doing paperwork and must wait each day for their turn to use the single computer available. This time that could more productively be spent in the field.

• Resource availability. Success in controlling STDs leads to decreased funding because funding mirrors STD rates. STD staff are never able to get ahead of the game and focus their efforts on preventing future cases of syphilis and other STDs.

3.2.3 Community Action

We saw little evidence for community activities directed specifically to STD prevention and control, although there were a number of community organizations delivering more general health education programs. For example, the School of Nursing at Auburn University-Montgomery is using innovative approaches to health education such as designing an anatomically correct model to show how to use contraceptives. They are also opening and operating school-based clinics in Lowndes County through a program sponsored by the Kellogg Foundation.

However, people in these communities spoke of possible community strategies for prevention and control. Respondents working in public health suggested funding full-time street outreach workers to reinforce prevention messages, provide community service, and educate on what health services are available and how to access them.

Community-wide health education was a common theme among respondents. Many respondents suggested educational training courses to provide parents, teachers, and community leaders with appropriate information and ideas on how to present it to youth.

Another idea for increasing knowledge about STDs (currently being implemented for other diseases) is to educate core members of communities to serve as local experts and resources on health issues such as STDs. This decentralized approach, where community leaders become the messengers, is known as the "natural helper" model and is said to be especially effective in rural minority communities, where trust of the messenger is very important.

3.3 Richland and Orangeburg Counties, South Carolina

In South Carolina, Richland County (Columbia) was the urban site and Orangeburg County was the rural site. See map in Figure 3.3.

3.3.1 Community Profiles

Richland County (Columbia) - Urban

Geography and demographics. Located in the center of South Carolina, Richland County contains the city of Columbia, the state capital. Between 1980 and 1990, the white population of Richland County decreased slightly, while the African-American population increased by 15 percent. The population of Richland County was 285,720 in 1990, while the city of Columbia had a population of 98,052 (US Bureau of the Census 1994a).

Economic characteristics. The median household income in Richland County was $28,848 in 1990, with 10.1 percent of families falling below the poverty level. When broken down by race, only 7 percent of white residents live in households below the poverty level, while 30 percent of the African-American households were below the poverty level (US Bureau of the Census 1994a).

Although centrally located in the state, Columbia is less of a commercial and industrial center than are the Charleston and Greenville/Spartanburg areas. Employment in Columbia is concentrated in government, trade, and the service sector. The University of South Carolina is a large area employer along with the Fort Jackson US Army base.

Social characteristics. Although Columbia has not escaped the crack cocaine epidemic, the two larger metropolitan areas (Charleston and Greenville/Spartanburg) have been affected more profoundly and persistently.

Syphilis morbidity. Early syphilis morbidity has remained relatively stable in Richland County between 1991 and 1995, with prevalence rates varying between 61.2 per 100,000 population and 49.3 per 100,000.

Public STD services. The Public Health Department in Richland County falls within the four-county Palmetto District. The Public Health Department operates several clinics in the District, including STD clinics at its offices in Columbia and in Lexington County. The South Carolina Department of Corrections operates a large complex in neighboring Lexington County that includes reception and evaluation facilities for men and women, where medical screening and, when necessary, treatment is provided to all inmates upon sentencing and entry into the state prison system.

Health care. A source of health care for low-income residents is Richland Primary Health Care, a not-for-profit care provider with two clinics in Richland County. Planned Parenthood also operates a clinic in Columbia with full reproductive health services, including STD testing. The federal Department of Veterans Affairs operates a medical center near Fort Jackson on the eastern edge of Columbia, and emergency room care is available from two private hospitals.

Orangeburg County - Rural

Geography and demographics. Located between Columbia and Charleston, the city of Orangeburg is the county seat and also, with its 13,739 residents, the largest population center in Orangeburg County, which had a population of 84,803 in 1990 (US Bureau of the Census 1994a). The population of Orangeburg County is about 58 percent African American and 41 percent white, with the black portion of the population increasing slightly (from 56 percent) since the 1980 census.

Economic characteristics. Employment in Orangeburg County is dominated by manufacturing (farm and automotive equipment, chemicals, and clothing), government, and education (South Carolina State University and several private colleges). Median household income in 1990 was $20,216 in Orangeburg County. About 10 percent of the county's white residents belong to households with incomes below the poverty level, while more than 36 percent of the black households were below the poverty level (US Bureau of the Census 1994a).

Social characteristics. Drugs are regarded as a serious problem in Orangeburg, with the governor calling in the National Guard in 1994 to tear down several crack houses.

Syphilis morbidity. Syphilis prevalence rates in Orangeburg County have declined sharply over the period 1992-1995. After a 1992 peak of 147.4 cases per 100,000 population, the 1995 rate has dropped to 16.5 per 100,000.

Public STD services. The Health Department in Orangeburg is the headquarters of the Edisto District Health Department. In addition to the main clinic in the city of Orangeburg, there are three satellite clinics throughout the county. South Carolina State University has the Brooks Health Center on campus, which offers services for family planning, health screenings, pregnancy testing, physicals, and STD testing. The high school has had a school-based health center since November 1995 that offers physical exams, immunizations, family planning, counseling, health education, and free pregnancy testing among other services. The school district does not allow the student health center to distribute condoms.

Health care. In Orangeburg County, the Family Health Center (FHC) is the main source of primary health care. It is a federally funded facility that operates on a sliding fee scale. The FHC is a large facility with departments for adult medicine, pediatric medicine, ob/gyn, urgent care, and dentistry. In addition to its main location in the city of Orangeburg, the Family Health Center also operates seven satellite clinics throughout the county. One mobile unit staffed by a physician or nurse practitioner is available for Orangeburg, Calhoun, and Bamberg counties. There is also a Regional Medical Center based in the city of Orangeburg that was formerly a small private hospital but is now a 286-bed acute care facility servicing a six-county area.

3.3.2 Key Assessment Issues

Who is considered to be at greatest risk for syphilis?

Richland County (urban). The risk factors for syphilis identified in Richland County are:

• Substance abuse. Public health staff reported that drug users, especially those who exchange sex for crack cocaine, are at high risk for syphilis.

• Age and gender. Community activists said that young adults, especially women in their early 30s, may be engaged in a series of relationships involving unprotected sex, and therefore are more likely to be exposed to STDs like syphilis.

• Homeless and indigent. Those providing services to homeless and indigent residents in Columbia said that these individuals, especially women who may circulate with their children among several temporary living situations to keep off the streets and out of shelters, may be at risk for syphilis.

• Corrections facility inmates. Corrections facility staff told us that male inmates may become infected through sex with other inmates and then infect their long-term partners on the outside upon release or during conjugal visits.

• Sexual orientation. Men having sex with men are also at risk, especially those having anonymous sex at highway rest stops.

• Race and socioeconomic status. As in other urban sites, reported cases of early syphilis were almost exclusively among low-income African Americans. However, some public health agency staff and community activists feel that these morbidity statistics reflect reporting bias. White residents can turn to private physicians and may receive treatment without reportable diagnosis.

Orangeburg County (rural). Risk factors for syphilis identified in Orangeburg County include:

• Race and socioeconomic status. Low-income African Americans are seen as having a greater risk of syphilis infection than their white counterparts, but syphilis is also showing up among residents in higher socioeconomic strata.

• Age. Health and social service providers spoke of the early ages at which teens initiate sexual activity and about their unprotected sex with multiple partners. However, teenagers are more likely to become infected with gonorrhea, chlamydia, or trichomoniasis, while those infected with syphilis are generally older.

• Substance abuse. The connection between crack cocaine use and syphilis is not as strong as it has been in recent years. However, the relatively small number of those treated for repeat syphilis infections are often crack users.

What institutions are thought to be most likely to reach those at greatest risk?

In a January 1996 Draft of the South Carolina Health Services Long Range Plan: 1996-2000, HIV/AIDS/STD prevention is listed among the highest priority programs for the Governor's 1996-97 budget, outranked only by family planning and tuberculosis control programs. In both the Columbia metropolitan area and rural Orangeburg County, institutions are in place that could be mobilized to reach those thought to be at greatest risk. Below we discuss relevant institutions in first the urban and then the rural site.

Richland County/Palmetto District - Urban

• Health Department. Within the Health Department, DIS staff activities are organized to facilitate cooperative action with other institutions. For example, one staff member works with the military base and several housing projects. Another works with prison facilities.

• Move to integrated services. To become more responsive to patient needs, Health Department officials are examining ways to integrate clinical services and to establish alternative sites in conjunction with drug treatment and public housing facilities. While funding is available to support additional training for primary care assistants, special attention may be needed for staff who have not previously dealt with STD patients on a regular basis.

• Drug treatment centers. The Syphilis in the South program has sought an agreement to have screening operations established in at least one drug treatment center (Lexington-Richland Alcohol and Drug Abuse Council, or LRADAC) and is also pursuing similar agreements in state and local correctional facilities.

• Religious institutions. A few churches in Columbia have begun to use organized activities to focus on health promotion. When these activities focus on sexuality issues, it is usually HIV prevention and not syphilis that provides the main emphasis.

• Correctional facilities. The State Corrections Department operates central Reception and Evaluation facilities for men and women near Columbia. The Department of Health and Environmental Control already works closely with the State Corrections Department; one DIS staff member's assignment includes the state corrections facilities, and his work focuses both on contact tracing for the Reception and Evaluation centers and pre-release counseling for inmates who are about to complete their sentences. STD screening at the county jail facilities is planned as part of the Syphilis in the South program.

• Community-based organizations. CBOs in Columbia have put health education in places where people gather informally and where the talk is about relationships: hair salons, barber shops, night clubs, liquor stores. While the principal focus of these efforts has been to reduce the risk of HIV infection, they have targeted audiences primarily including adolescents, college students, and adult women; the main risk reduction messages apply more generally to preventing all STDs.

• SC Minority AIDS Council. The SC Minority AIDS Council is a broad-based collaboration involving representatives from 35 different area organizations spanning health care, social service, educational, housing, and criminal justice domains. The Council's main focus is HIV prevention and services to persons with HIV/AIDS.

Orangeburg County/Edisto District - Rural

• Health department and other health care providers. Improved access to services in outlying areas is being pursued by establishing a network of satellite Health Department clinics. Services at the local hospitals are considered inadequate for community needs, but the Family Health Center and the Health Department are doing a good job of filling the gap.

• Religious institutions. Abstinence is the central message in church-based discussions of sexuality involving adolescents.

• Community-based organizations. Orangeburg-Calhoun-Allendale-Bamberg (OCAB) Community Action Agency is a CBO involved in general health promotion activities, although syphilis is not as high a priority as Head Start, teen pregnancy prevention, maternal and child welfare, and HIV prevention.

What are the barriers to reaching those at greatest risk?

Several barriers were identified in the South Carolina sites that would prevent reaching those at greatest risk of syphilis infection.

Local norms about public discourse on sexuality and sexual health. Public discussion in South Carolina about human sexuality is subject to the same pressures as in the other study sites. Conservative norms dominate both the religious and the secular arenas.

Local priorities. Barriers relative to local priorities include:

• Prominence of HIV/AIDS. STD prevention is identified as a high priority statewide, but syphilis is given less specific attention than HIV/AIDS. Furthermore, from the perspective of the Health Department's DIS staff, labor-intensive tracing of HIV contacts leaves little time for tracing syphilis contacts.

• Prominence of other health care issues. In Orangeburg County, STD prevention and treatment takes a back seat to other health care needs seen as more pressing health problems within the African-American community. Competing priorities include prenatal care, teen pregnancy, and chronic diseases.

• Missed infections. In Richland County, the STD clinic deals with resource limitations by setting treatment guidelines based on symptoms or a patient's history. Clinic nursing staff feel that some unspecified number of infections are missed because the patients are asymptomatic when they come to the clinic, or because their histories are incomplete or inaccurate.

Barriers to access and utilization. Barriers to access and utilization include:

• Transportation. Inaccessibility of STD services is a problem in areas where public transportation service is poor or altogether absent. Health Department officials must balance tradeoffs between the cost efficiencies of centralized facilities and the improved accessibility afforded by a more decentralized approach.

• Inadequate staffing. Limited staff resources sometimes result in STD clinic patients being asked to return on another day. DIS staff cutbacks, for example, have resulted in reduced outreach efforts.

• Mistrust of public STD clinics. Use of the STD Clinic by African-American clients may be lowered because of mistrust and past experience, a factor compounded when Health Department staff treat patients insensitively.

• Restrictions by private providers on number of Medicaid patients seen. This may mean that low-income patients may have few treatment alternatives to use of the public clinic.

Adequacy of public health staff recruitment and training. Barriers related to staffing include:

• Competition with the private sector. The public health care sector has a difficult time competing for trained staff in South Carolina because better pay and working conditions are often available in the private sector.

• Lack of racial diversity among staff. STD clinic staff may not have the racial mix needed to accommodate African-American clients. In the Palmetto District, we were told that the nursing staff is 99 percent white and includes only one male nurse. African-American staff say they receive many more requests than they can honor from black females who say they would prefer to talk to someone more like themselves. However, in rural Orangeburg County, we were told that clients may prefer dealing with staff of a different race who they are less likely to see in a social setting.

Programmatic funding restrictions. Informal and formal collaborations in both Richland and Orangeburg counties join organizations and agencies from health care, educational, church, housing, and criminal justice/law enforcement domains. While syphilis has not been an explicit focus of these activities, HIV/AIDS and teen pregnancy prevention have been. Yet funding sources often place limits on how funds can be spent in the interests of increasing accountability and avoiding duplication of services. Such limits may result in organizations unable to find common ground, with their different staffing patterns (levels and areas of expertise), different geographic service areas, different boards or advisory panels, and different administrative structures.

3.4 Shelby County, Tennessee and Tunica County, Mississippi

In this pair, the urban site was Shelby County (Memphis), Tennessee, and the rural site was Tunica County, Mississippi. See map in Figure 3.4.

3.4.1 Community Profiles

Shelby County (Memphis), Tennessee - Urban

Geography and demographics. Shelby County, home to the city of Memphis, is in the southwestern corner of Tennessee, bordered by the Mississippi River to the west and the Mississippi state border to the south. Shelby County had a population of 826,330 in 1990; Memphis had a population of 610,337 (US Bureau of the Census 1994a). The city's population decreased by about 35,000 between 1980 and 1990, while suburban portions of the metropolitan area outside the city increased by almost 100,000.

In Shelby County, whites make up 55 percent of the population, and African Americans are 43 percent. In the city of Memphis these numbers are reversed, with African Americans making up 55 percent and whites 44 percent. Asians and Pacific Islanders constitute almost 1 percent and Hispanics another 1 percent (US Bureau of the Census 1994a).

Economic characteristics. Memphis is central to the southern region of the country as an active transportation and distribution hub. The Federal Express Corporation has its central operations based in Memphis and is the area's largest employer with 23,000 workers. Other large employers include educational institutions and area hospitals. Median household income in Memphis was $22,674 in 1990; however, this is not evenly distributed. About 35 percent of the African-American households have median incomes below the poverty level, compared with only 7 percent of the white households (US Bureau of the Census 1994a).

Social characteristics. According to local residents, the social situation in downtown Memphis has improved in the past 10 to 15 years, with reduced crime, increased public and private investment, and redevelopment efforts that have made the downtown area safe for tourism and recreation. In other areas of the city, however, there are problems with gangs, violence, and prostitution. Throughout Memphis, lower-, middle-, and upper-income neighborhoods are interspersed, and public housing projects are distributed throughout the city. Neighborhoods with public housing projects include Orange Mound, Hurt Village, Little Chicago, Lemoyne Gardens, Foot Homes, Getwell Gardens, and Dixie Homes.

One area in particular, the Binghampton neighborhood, has problems with prostitution and hourly motels. Other areas of high poverty include Court Street near Cleveland and Jefferson, the intersection of Lamar and Winchester, and the area around Graceland. One small housing project, Getwell Gardens, is known by locals as the crack center of Memphis.

Approximately 107,000 students are enrolled in the Memphis City Schools, of which 88 percent are African American. The majority of white children attend either the County schools or private schools throughout the city, many of which are church-based schools.

Syphilis morbidity. Early syphilis morbidity has declined steadily in Shelby County between 1991 and 1995, with prevalence rates reduced from a 1991 high of 158.8 per 100,000 population to less than 60 per 100,000 by 1995.

Public STD services. The Memphis/Shelby County Health Department operates as one administrative unit under the Tennessee STD/HIV program. The Health Department STD clinic is located in the city center, with all STD and HIV services offered in the same location. The Health Department also operates five satellite clinics in low-income areas throughout Memphis. The Memphis/Shelby County Health Department is the principal organization working with syphilis in Memphis and Shelby County. The Infectious Disease Division of the Memphis/Shelby County Health Department has 18 DIS staff who rotate through three teams: surveillance team, field team, and jail team.

Health care. In addition to the Health Department, Memphis has five major hospitals. There is one public hospital in Memphis, and this is the facility most accessed by low-income patients. The working poor in Memphis can access health services at the Church Health Center (CHC), which is funded by individual donations from over 150 church congregations in the Memphis area. Tenncare, the statewide program designed to replace Medicaid and other health entitlement programs, has improved access to health services for some. But a lack of public education about how the program works has led to some confusion among enrollees and may keep some program participants from seeking health care.

Tunica County, Mississippi - Rural

Geography and demographics. Tunica County, Mississippi, is located 35 miles south of Memphis along the Mississippi River. Tunica County had 8,146 residents in 1990, about 2,000 of whom lived in the town of Tunica. The town of Tunica is the only incorporated municipality in the county. The total population of the county decreased by 15 percent between 1980 and 1990. The white population decreased by nearly 30 percent during this time, while the non-white population decreased by nearly 13 percent. Seventy five percent of the county population was African American in 1990 and 24 percent were white (US Bureau of the Census 1994a).

Economic characteristics. Until recently, Tunica County's economic base has been agricultural. Since 1992, 12 gambling casinos have opened up at the north end of the county; however, four of these are no longer in operation. The casinos that have closed were those located closest to the town of Tunica. Most of the casino development is now under way several miles outside of town, more easily accessible to Memphis. The casinos have provided almost 10,000 jobs and substantial tax revenues, and county AFDC and food stamp recipients have been reduced by nearly one-third since their opening. In 1990, the median household income in Tunica County was $10,965, and 50.5 percent of all families were below the poverty line (US Bureau of the Census 1994a). However, these conditions have improved somewhat since the casinos opened.

Social characteristics. Educational institutions in Tunica are completely divided by race, with the public school population more than 90 percent African American. Until recently, the public school was at risk of losing accreditation because of low standardized test scores. Tunica schools are now on probationary status.

Syphilis morbidity. In Tunica County, syphilis prevalence rates have varied widely over the period 1990-1995. After a 1991 peak of 444.7 cases per 100,000 population, the rate dropped to as low as 25 per 100,000 in 1993, and then rose back up to 285 per 100,000 the following year. The 1995 rates had dropped to about 79 per 100,000 population.

Public STD services. Tunica County is one of nine counties in Mississippi Public Health District 1, with the District office located in Batesville. The Tunica County Health Department is the primary organization responsible for STDs such as syphilis. The DIS for the county works with the Aaron E. Henry clinic and the Methodist Family Medical Center on testing, treating, and contact tracing/partner notification efforts.

Health care. Other health care facilities in Tunica include a satellite clinic of the Aaron E. Henry Community Health Center (AEH) and the Methodist Family Medical Center. The AEH clinic is a federally qualified health center offering general medical care, physicals, obstetrics, WIC, diabetes and geriatric care, all on a sliding fee scale. AEH opened a school-based clinic in Tunica in 1991, staffed by a nurse practitioner and an LPN. A pediatrician goes to the AEH clinic and the school-based clinic once a week. AEH also has health educators who serve Tunica, Quitman, and Coahoma counties. The Methodist Family Medical Center in the town of Tunica also does follow-up for the Health Department for hypertension, hepatitis, TB, skin infections, baby formulas, and upper respiratory problems.

Tunica residents do a lot of "shopping" for health care, meaning that they will go to the facility with the shortest wait, resulting in a lack of continuation of care. A community member said that African Americans will usually go to AEH or Methodist for care, while whites go to Memphis.

3.4.2 Key Assessment Issues

Who is considered to be at greatest risk for syphilis?

Shelby County (Memphis) Health Department statistics for the county show syphilis primarily affects African Americans between the ages of 20 and 29 living in high-poverty areas.

• Socioeconomic status. Poverty is reported to be a risk factor in Memphis, with syphilis cases mapped by public health officials tracking closely to the distribution of high-poverty areas and government housing projects in the city.

• Gender. Men and women are equally affected by syphilis, but women were said to be more likely to be tested than males because they are more engaged in the health care system.

• Substance abuse. Most respondents in Memphis thought that the exchange of sex for crack cocaine is a significant risk factor for syphilis, although a small handful of people did not agree.

• Prostitution. Commercial sex workers were said to be more likely to protect themselves and take care of their health than were crack addicts exchanging sex for drugs.

Tunica County African Americans between the ages of 15 and 30 are considered to be at the greatest risk for syphilis in Tunica County. A lack of recreation except for the casinos outside of town, along with drug and alcohol use, are thought to contribute to the prevalence of syphilis and other STDs in Tunica.

• Substance abuse. Crack cocaine use and the attendant sex-for-drugs exchanges are cited as a major syphilis risk factor.

• Prostitution. Prostitution as an industry does not exist in Tunica, even with the presence of the casinos.

• Age. Teenagers are considered at high risk because of their levels of unprotected sexual activity, often with multiple partners.

• Socioeconomic status. Although poverty is a risk factor for syphilis, recent casino development has led to an improvement in economic conditions and, according to DIS staff, has attributed to the recent decline in syphilis morbidity.

What institutions are thought to be most likely to reach those at greatest risk?

In Memphis and Tunica County, poverty is a major barrier to effective institutional responses to syphilis and other STDs. Below we discuss local institutions first in the urban, then in the rural site.

Shelby County (Memphis) - Urban

• Health Department. Traditional infection control methods are used to control syphilis and other STDs. Health Department staff and other respondents feel that targeted outreach, neighborhood screenings, and other less traditional methods that are currently not emphasized are potentially effective ways of reaching those at greatest risk.

• Schools. The Memphis City Schools are also thought to have the potential to reach the populations at greatest risk. A lifetime wellness curriculum is currently in place, but sex education continues to be controversial due to opposition from conservative groups. A number of those we interviewed emphasized the need for more proactive sex education and prevention programs in the school system.

• Religious institutions. Churches may be the single most powerful and influential set of institutions in Memphis. Public health agencies and community-based organizations have attempted to involve churches in STD/HIV prevention activities with varying degrees of success. Suggested means to involve churches further in STD prevention through broad-based community services included teen peer counseling services, training for lay health workers, services for the homeless, residential centers for substance abuse treatment, and financial support for prescription drugs.

• Community-based organizations. A number of community-based organizations are implementing programs that address the immediate health needs of at-risk communities, while also focusing on broader issues such as education and economic development. Such programs often sponsor activities targeted to specific needs of a clearly defined population. However, long-term sustainability of community development efforts is a concern.

Tunica County - Rural

Tunica County is a small, rural community with few formally instituted ways to reach those at greatest risk for syphilis. Health care facilities are the institutions most actively engaged in outreach activities; complementary efforts from other institutions do not appear to be forthcoming.

• Schools. Local providers felt that health education and STD education in Tunica schools is very limited, leaving substantial room for improvement in delivering effective prevention messages to children. The State of Mississippi has adopted a comprehensive health education curriculum, but it is not mandatory. Aaron E. Henry Community Health Services Center provides health education classes to students at the Rosa Forte School, but health educators are not permitted to use anatomical models to demonstrate condoms.

• Community-based organizations. A few organizations in Tunica address the immediate health care needs of the community, and even fewer are addressing the broader issues associated with poverty. Youth Opportunities Unlimited (YOU) works with children and teens outside of the school system by teaching abstinence and safe sex.

• Religious institutions. Churches were identified as a powerful mediating structure in the community. AEH health educators, DIS staff, and YOU staff all mentioned that they have tried to work with churches, but no formal relationship has been established.

What are the barriers to reaching those at greatest risk?

We discuss barriers to reaching those at greatest risk for syphilis, first in the urban, then in the rural site.

Shelby County (Memphis) - Urban

Local norms about public discourse on sexuality and sexual health. Many of those we interviewed identified community norms regarding sexuality, STDs, and HIV/AIDS as one of the major barriers to effective prevention programs. Respondents told us that communities are in denial about adolescent sexual activities, STDs in general, and HIV. Comprehensive sex education, including age-appropriate discussions of reproductive anatomy and physiology, is not taught in the schools. Several representatives from community-based organizations said that they specifically avoid developing school programs because of the bureaucracy and controversy. Few churches address STD or HIV prevention, and those that do focus exclusively on moral dimensions without addressing public health issues.

Local priorities. Barriers relating to local priorities included:

• Emphasis of treatment over prevention. Syphilis treatment and control are given relatively high priority by the Memphis/Shelby County Health Department. However, the focus is on surveillance and contact tracing, while prevention and education receive less emphasis.

• Bureaucratic restrictions on employee hours. Strict enforcement of the federal Fair Labor Standards Act has resulted in tight controls over the number of hours worked by non-exempt staff, including DIS. DIS staff feel that it would be more effective for them to work some evenings and weekends to locate difficult contacts and extend their prevention education activities, but flex-time schedules are difficult to approve under current restrictions.

• Lack of a unified message. While the Health Department focuses on syphilis as a distinct public health problem, other Memphis organizations address syphilis prevention within the context of HIV prevention or pregnancy prevention. Respondents felt prevention messages would be more effective were they not to separate out syphilis, but rather to address modifying behaviors that place individuals at risk for HIV and STDs.

Barriers to access and utilization. Barriers relating to access and utilization included:

• Medicaid managed care. Tenncare - the statewide program providing health care to the uninsured - was cited by most respondents as the foremost barrier to access and utilization of health care. The plan is confusing to patients and providers alike. Also, many providers only accept some of the insurance plans available under Tenncare and do not accept others. A result of the confusion about plans and providers is that substantial numbers of people are not seeking treatment for disease symptoms.

• Clinic location and fees. The location of the Health Department STD clinic presents a barrier to effective testing and treatment of syphilis, and the clinic fee may deter patients with limited financial resources. Several public health agency staff and representatives from community-based organizations felt it would be more effective to have testing and treatment facilities in easily accessible satellite clinics, rather than the centralized structure currently employed.

• Transportation issues. Access to the STD clinic is limited by local parking problems. Some respondents felt that public transportation was a problem, while others thought the bus system was accessible and convenient. Bus fares may deter poor patients.

• Appointment system. Several years ago the STD clinic converted to an appointment system, and this has reduced some waiting room congestion. Walk-in patients are still accepted, but the nurses attempt to limit potential walk-ins by doing "triage" with those patients who call before coming to the clinic. When patients referred to the clinic by the DIS arrive in the waiting room, they are supposed to be seen immediately. However, these referral patients do not necessarily tell the nurse they have been referred by the DIS and may be forced to wait.

• Testing issues. DIS staff expressed concern about patients who had a reactive test at another site and were then referred to the Health Department for treatment. The Health Department staff is required to retest the patient. If the blood is non-reactive, the patient is not treated and is sent home.

Tunica County - Rural

Local norms about discourse on sexuality and sexual health. Many of those interviewed commented on "promiscuity" among young people in Tunica, but adolescents are difficult to reach with prevention messages. People feel that STD prevention is important, but very difficult to discuss openly in a conservative community.

Concerns about confidentiality may prevent people from seeking treatment for STDs at the Health Department. Because Tunica is a small rural town, people are embarrassed to go for STD services because clinic staff may be neighbors, friends, or relatives. Also, because the health department clinic only sees patients for WIC or STD services, men do not want to be seen entering the facility. Many people in the community are said to believe that the Health Department keeps and distributes a list of STD patients. DIS staff have spent a great deal of time convincing people that no list exists and that all services are confidential. Possible public embarrassment prevents some people from getting treated for STDs.

Local priorities. Priorities rated higher by the community than STD prevention were:

• Poverty. In Tunica County, 50 percent of households live below the poverty level. For many people, the difficulties one faces in keeping a roof over one's head place health issues as a lower priority.

• Teen pregnancy and substance abuse. Respondents were most concerned about high teen pregnancy rates and drug use among young people. The teen pregnancy rate has dropped over the last few years, but it is still one of the highest in the United States.

Barriers to access and utilization. AEH and the Methodist Clinic are the only two primary health care facilities serving the community, and clinic hours are limited. In addition, many people lack transportation and are unable to reach health care providers for treatment. Although AEH and Catholic Charities in Clarksdale provide free van services to as many people as resources will permit, transportation remains problematic for many residents.

Adequacy of public health staff recruitment and training. Barriers related to staffing included:

• Physician retention. Physician retention is an ongoing problem for health care facilities in Tunica. For example, 16 doctors have worked at AEH between 1993 and 1996. In general, doctors in the Mississippi Delta region are characterized as overworked and underpaid, and it is difficult to attract providers who will stay for any substantial time period.

• Support staff issues. The Health Department nurses have standing orders to treat patients diagnosed with syphilis. However, some nurses have reported feeling uncomfortable giving bicillin without a doctor present. This has improved with the statewide effort to train nurses in syphilis treatment.

3.4.3 Community Action

In Memphis, a number of community-based organizations are implementing programs that address the immediate health needs of at-risk communities, while also focusing on broader issues such as education and economic development. Three particularly successful programs were identified for us - Project Success in Hurt Village, Project Vision in Binghampton Neighborhood, and ECHO (Empowering Choice Healthy Opportunities) in Lemoyne Gardens administered by the West Tennessee Health Education Center. Each of these programs has targeted activities to specific needs of a clearly defined population. We were told that many other poor neighborhoods are in need of similar programs. One representative of a community-based organization suggested that community development in Memphis is motivated by which housing project is the "flavor of the year." With this year-to-year approach to project definition, long-term sustainiability of community development efforts is a concern.

Only a few organizations in rural Tunica County are involved in health care and social service, and these organizations appear to have little direct involvement in community development and coalition-building. AEH has established the Family Preservation and Family Support program, which provides tutoring and mentoring to children. The program is co-sponsored with local churches and meets in participants' homes to discuss family and community issues. The organizations actively involved in STD prevention and treatment - such as the Health Department, AEH, and the Methodist Clinic - occasionally collaborate on an informal basis.

The community is sharply divided along racial lines. Little interaction is reported between black and white residents. Blacks and whites go to separate schools, churches, and doctors. This profound racial division poses a barrier to organizing efforts that seek to take full advantage of all the local resources available in the community.