Addressing Health Disparities in Marginalized Populations: A Case Study on STI Prevalence and Risk Factors in the Dominican Republic

Abstract

The Study of Prevalence of STIs among Key Populations (known by its Spanish acronym EPIC) was a cross-sectional evaluation of the frequency and risk factors for sexually transmitted infections (STIs) within six marginalized populations in the Dominican Republic (DR): pregnant adolescents; men who have sex with men; transgender women; people living with HIV; residents of bateyes (communities of Haitian decent); and female sex workers in La Romana and Santo Domingo. Additionally, the study sought to identify factors associated with STIs and HIV risk among these groups.

Introduction

EPIC was spearheaded by Clínica de Familia La Romana, in collaboration with key partners such as Columbia University, University of Texas, Instituto Dermatológico, the Children’s Global Health Fund, and BioReference Laboratories. From the time of the project’s inception, Clínica de Familia played a pivotal role in shaping its trajectory, emphasizing community and client engagement. Clínica de Familia helped conceive of, design, and implement the study, ensuring the direct involvement of the targeted communities and populations. Clínica de Familia’s team, in collaboration with community stakeholders, conducted all data collection in La Romana.

Who should benefit?

Despite ongoing efforts, the global burden of STIs remains significant, particularly in low- and middle-income countries like those in the Latin American and Caribbean region. Limited healthcare access, screening, and treatment guidelines contribute to underreporting, exacerbating the situation. The World Health Organization estimates that the region sees 38 million new cases of curable STIs annually.

The six marginalized populations in the DR included in the EPIC study—pregnant adolescents, men who have sex with men, transgender women, people living with HIV, residents of bateyes (communities of Haitian-descent), and female sex workers in La Romana and Santo Domingo—face disproportionate health burdens due to socioeconomic disparities and discrimination. The study, encompassing 1,991 participants, shed light on STI prevalence and associated risk factors within these groups, aiming to address their unmet healthcare needs.

The study took place in La Romana and Santo Domingo, two major urban centres in the DR with large catchment areas. However, the findings have broader implications for similar marginalized populations across the country, particularly those residing in low-income communities and bateyes. The study also addressed health disparities in a middle-income country context, highlighting the need for targeted interventions in resource-constrained settings.

By focusing on marginalized populations disproportionately affected by STIs and HIV, this research contributes to greater health equity by addressing the underlying social determinants that perpetuate disparities. The study provides valuable data to inform evidence-based interventions, policy initiatives, and healthcare strategies aimed at reducing inequities and improving access to STI prevention and care services for vulnerable communities. The selection of marginalized populations was based on epidemiological data indicating high STI prevalence and risk factors within these groups. Additionally, community engagement and collaboration with local stakeholders, including Clínica de Familia La Romana, ensured that the project directly addressed the needs and priorities of the target populations.

Recruitment strategies employed venue-based and structured convenience sampling to reach diverse segments of each population, ensuring representation and inclusivity in the study.

Engagement

The EPIC study prioritized community engagement from the time of its inception, recognizing the importance of involving affected populations in all stages of the research process. Community members were actively engaged in study design, implementation, and dissemination of findings, ensuring that their voices and perspectives were integrated into decision-making processes. Extensive contact occurred between the targeted community members and both research and clinical professionals throughout the project. Community stakeholders and local organizations serving marginalized populations collaborated closely with the research team to co-design recruitment strategies, develop culturally appropriate survey instruments, and implement outreach efforts. Regular feedback sessions facilitated ongoing dialogue and collaboration, fostering trust and mutual respect between community members and professionals.

Community consent and ownership were sought through transparent and inclusive processes. Prior to study initiation, community leaders and stakeholders were engaged in discussions to ensure alignment with community priorities and values. Formal consent was obtained from participating individuals, emphasizing the voluntary nature of their involvement and respect for autonomy. Additionally, community representatives had a role in decision-making regarding study protocols, ensuring that research activities were culturally sensitive and responsive to community needs.

The study made several changes based on feedback and input from the community. For example, adjustments were made to recruitment strategies to enhance accessibility and inclusivity, such as expanding outreach efforts to reach isolated batey communities and collaborating with peers to recruit female sex workers. Additionally, modifications were made to survey instruments based on community feedback to ensure clarity and relevance of questions.

Local researchers were integral to the communication of findings and outcomes to the community. Community stakeholders were actively involved in data interpretation, providing valuable insights into the meaning and implications of study results within the local context. Their contributions were acknowledged and recognized in publications, presentations, and dissemination activities, highlighting the collaborative nature of the research process and the importance of community expertise in shaping research outcomes.

Research

Insights and information obtained from community engagement significantly influenced the design and delivery of the research. Community feedback guided the development of culturally sensitive survey instruments and recruitment strategies tailored to the unique needs and preferences of marginalized populations. Additionally, input from community members informed the selection of study sites and the implementation of outreach efforts, ensuring that research activities were accessible and inclusive.

Prior to this study, limited comprehensive data existed on the prevalence of STIs among marginalized populations in the DR. This lack of data hindered the development of targeted interventions and prevention strategies tailored to the specific needs of these communities. By filling this gap in knowledge, the research provides essential evidence to support the implementation of effective public health interventions aimed at reducing STI transmission and improving health outcomes among marginalized populations.

Active involvement of community members has been integral to the research process, with individuals participating in study design, data collection, and interpretation of findings. Local researchers, healthcare professionals, and non-governmental organizations (NGOs) have played crucial roles in facilitating research activities, providing expertise, and ensuring cultural relevance and appropriateness. This collaborative approach fosters community ownership of the research process and enhances the validity and applicability of study findings within the local context.

Translating into impact

Several activities have been undertaken to ensure the utilization of research findings beyond academic channels. This includes the presentation of study results in multiple settings to policymakers, healthcare providers, and community-based organizations, in addition to representatives of the marginalized populations that participated in the study. These presentations have summarized key research findings using accessible language and provided actionable recommendations for addressing the identified health disparities. By engaging stakeholders throughout the research process, including the planning, implementation, and dissemination phases, a comprehensive understanding of the pathways to impact has been established, ensuring that research findings can be effectively translated into tangible health outcomes.

The collaborative and community-engaged approach adopted in this research could serve as a model for others seeking to address health disparities among marginalized populations. By prioritizing community involvement, fostering interdisciplinary partnerships, and leveraging existing resources and infrastructure, this approach offers a scalable and sustainable framework for advancing health equity.