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      Leveraging social capital: multilevel stigma, associated HIV vulnerabilities, and social resilience strategies among transgender women in Lima, Peru

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          Introduction: In Peru, transgender women (TW) experience unique vulnerabilities for HIV infection due to factors that limit access to, and quality of, HIV prevention, treatment and care services. Yet, despite recent advances in understanding factors associated with HIV vulnerability among TW globally, limited scholarship has examined how Peruvian TW cope with this reality and how existing community-level resilience strategies are enacted despite pervasive social and economic exclusion facing the community. Addressing this need, our study applies the understanding of social capital as a social determinant of health and examines its relationship to HIV vulnerabilities to TW in Peru.

          Methods: Using qualitative methodology to provide an in-depth portrait, we assessed (1) intersections between social marginalization, social capital and HIV vulnerabilities; and (2) community-level resilience strategies employed by TW to buffer against social marginalization and to link to needed HIV-related services in Peru. Between January and February 2015, 48 TW participated (mean age = 29, range = 18–44) in this study that included focus group discussions and demographic surveys. Analyses were guided by an immersion crystallization approach and all coding was conducted using Dedoose Version 6.1.18.

          Results: Themes associated with HIV vulnerability included experiences of multilevel stigma and limited occupational opportunities that placed TW at risk for, and limited their engagement with, existing HIV services. Emergent resiliency-based strategies included peer-to-peer and intergenerational knowledge sharing, supportive clinical services (e.g. group-based clinic attendance) and emotional support through social cohesion (i.e. feeling part of a community).

          Conclusion: This study highlights the importance of TW communities as support structures that create and deploy social resiliency-based strategies aimed at deterring and mitigating the impact of social vulnerabilities to discrimination, marginalization and HIV risk for individual TW in Peru. Public health strategies seeking to provide HIV prevention, treatment and care for this population will benefit from recognizing existing social capital within TW communities and incorporating its strengths within HIV prevention interventions. At the intersection of HIV vulnerabilities and collective agency, dimensions of bridging and bonding social capital emerged as resiliency strategies used by TW to access needed healthcare services in Peru. Fostering TW solidarity and peer support are key components to ensure acceptability and sustainability of HIV prevention and promotion efforts.

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          Most cited references 38

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          Social capital, income inequality, and mortality.

          Recent studies have demonstrated that income inequality is related to mortality rates. It was hypothesized, in this study, that income inequality is related to reduction in social cohesion and that disinvestment in social capital is in turn associated with increased mortality. In this cross-sectional ecologic study based on data from 39 states, social capital was measured by weighted responses to two items from the General Social Survey: per capita density of membership in voluntary groups in each state and level of social trust, as gauged by the proportion of residents in each state who believed that people could be trusted. Age-standardized total and cause-specific mortality rates in 1990 were obtained for each state. Income inequality was strongly correlated with both per capita group membership (r = -.46) and lack of social trust (r = .76). In turn, both social trust and group membership were associated with total mortality, as well as rates of death from coronary heart disease, malignant neoplasms, and infant mortality. These data support the notion that income inequality leads to increased mortality via disinvestment in social capital.
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            Poor people, poor places, and poor health: the mediating role of social networks and social capital.

             V Cattell (2001)
            This paper explores the dynamics between poverty and exclusion; neighbourhood, and health and well being by considering the role of social networks and social capital in the social processes involved. It is based on qualitative research taking two deprived areas as exemplary case studies, and involving depth interviews with residents. Neighbourhood influences on networks and social capital were explored, network typologies developed reflecting structural and cultural aspects of individual's networks, and pathways implicated in health effects considered. The complexity of social capital is addressed. The role of three factors in influencing social networks and social capital are demonstrated: neighbourhood characteristics and perceptions; poverty and social exclusion, and social consciousness. Perceptions of inequality could be a source of social capital as well as demoralisation. Different network structures-dense and weak, homogeneous and heterogeneous- were involved in the creation of social capital and had implications for well being. Coping, enjoyment of life and hope are identified as benefits. Although participation in organisations was confirmed as beneficial, it is suggested that today's heterogeneous neighbourhoods also require regenerated local work opportunities to develop bridging ties necessary for the genesis of inclusive social capital and better health. Despite the capacity of social capital to buffer its harsher effects, the concept is not wholly adequate for explaining the deleterious effects of poverty on health and well being.
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              Social capital and self-rated health: a contextual analysis.

              Social capital consists of features of social organization--such as trust between citizens, norms of reciprocity, and group membership--that facilitate collective action. This article reports a contextual analysis of social capital and individual self-rated health, with adjustment for individual household income, health behaviors, and other covariates. Self-rated health ("Is your overall health excellent, very good, good, fair, or poor?") was assessed among 167,259 individuals residing in 39 US states, sampled by the Behavioral Risk Factor Surveillance System. Social capital indicators, aggregated to the state level, were obtained from the General Social Surveys. Individual-level factors (e.g., low income, low education, smoking) were strongly associated with self-rated poor health. However, even after adjustment for these proximal variables, a contextual effect of low social capital on risk of self-rated poor health was found. For example, the odds ratio for fair or poor health associated with living in areas with the lowest levels of social trust was 1.41 (95% confidence interval = 1.33, 1.50) compared with living in high-trust states. These results extend previous findings on the health advantages stemming from social capital.

                Author and article information

                J Int AIDS Soc
                J Int AIDS Soc
                Journal of the International AIDS Society
                Taylor & Francis
                27 February 2017
                : 20
                : 1
                [ a ]Department of Sociomedical Sciences, Columbia University Mailman School of Public Health , New York, NY, USA
                [ b ]The Fenway Institute, Fenway Health , Boston, MA, USA
                [ c ]Division of General Pediatrics, Boston Children’s Hospital/Harvard Medical School , Boston, MA, USA
                [ d ]Department of Epidemiology, Harvard T.H. Chan School of Public Health , Boston, MA, USA
                [ e ]Universidad Peruana Cayetano Heredia , Lima, Peru
                [ f ]Epicentro , Lima, Peru
                [ g ]Asociación Civil Impacta Salud y Educación , Lima, Peru
                [ h ]Department of Global Health, University of Washington , Seattle, WA, USA
                [ i ]Centro de Investigaciones Tecnologicas, Biomedicas y Medioambientales , Lima, Peru
                [ j ]Department of Medicine, Division of Infectious Diseases, University of California Los Angeles , Los Angeles, CA, USA
                [ k ]The Institute for Community Health Promotion, Brown University School of Public Health , Providence, RI, USA
                Author notes
                [ § ] Corresponding author: Amaya G. Perez-Brumer, Department of Sociomedical Sciences, Columbia University Mailman School of Public Health , 722 West 168th St. NY, NY 10032. ( agp2133@ 123456cumc.columbia.edu )
                © 2017 Perez-Brumer AG et al;

                licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 Unported (CC BY 3.0) License ( http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 1, Tables: 2, References: 43, Pages: 9
                Funded by: National Institute of Child Health and Human Development T32 10.13039/100000071
                Award ID: T32HD049339
                Funded by: amfAR, The Foundation for AIDS Research 10.13039/100001117
                Award ID: 109071-57-HGMM
                This work was supported by amfAR, The Foundation for AIDS Research, Grant Number: 109071-57-HGMM (PI: Javier R. Lama). APB is supported by a National Institute of Child Health and Human Development T32 grant (T32HD049339; PI: Nathanson).
                Research Article


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