Performance Improvement 1998. Syphilis in the South: A Case Study Assessment in Eight Southern Communities



This project provided a comparative case study of local-level syphilis prevention efforts in eight communities in Alabama, Mississippi, South Carolina, and Tennessee. The project focused on groups perceived to be at high risk of becoming infected with syphilis, the extent to which public health activities target such groups, and identification of factors that affect the reach of services to these groups. African Americans were found to be at greatest risk of syphilis infection. The report highlights the cultural, programmatic, and political barriers that restrict the prevention and control of syphilis and other sexually transmitted diseases (STDs) for those at greatest risk. Cultural barriers include restrictive local norms about public discussion of human sexuality, distrust of the public health system among African Americans, and a low priority of health relative to other issues of poverty in the community. The region also suffers from a shortage of providers and facilities, with inconvenient hours of operation, lack of transportation, and few trained minority staff. Women's access to services is especially limited by the need for child care and transportation, and is complicated by comorbidities (domestic violence and substance abuse). Several innovations in STD control and prevention are described. Recommendations include technical assistance to improve community prevention efforts, gender-sensitive programs that deal with the special problems of women, training/recruitment activities, and improvements in electronic data exchange.


The purpose of this study was to compare syphilis prevention efforts in southern communities during an epidemic in the Southern States between 1990 and 1992. Case studies of factors affecting the natural history, epidemiology, and management of syphilis in the South were conducted. Specific objectives included development of an improved understanding of service delivery to persons at high risk of infection with syphilis, discovery of innovative syphilis prevention and control measures planned or implemented in Southern States, and production of recommendations for improving community-level prevention strategies.


The syphilis epidemic in the South during 1990-1992 involved the reemergence of an easily diagnosed and readily treatable STD. Syphilis is a systemic disease with an initial acute stage followed by a long period of latency. Transmission occurs through lesions, normally during sexual contact. These lesions increase the likelihood that HIV transmission will occur as well. Syphilis is treated with penicillin, and it is controlled through activities that involve identification, testing, and treatment of exposed sex partners. Historically, African Americans in the South have suffered a disproportionate burden of early syphilis and congenital syphilis. During 1985-1990, rates of syphilis rose 165 percent in this population, while significantly decreasing for all other races and ethnic groups in this region. African Americans represent 90 percent of all reported cases. There is little empirical evidence to explain why syphilis rates are highest in the South and why the disease primarily affects African Americans in that region.


Case studies were conducted in eight communities in four States (Alabama, Mississippi, South Carolina, and Tennessee). Sites eligible for the study were communities in ten Southern States identified on the basis of high syphilis morbidity during 1990. Criteria for selecting States and communities included consistently high syphilis rates since 1990, or rates that show a decrease suggestive of successful control activities, and known demographic indicators of high syphilis risk (significant number of African-American residents and proportion of households with incomes below the poverty line). Selected metropolitan areas each were paired with a rural counterpart to allow urban/rural comparison of social contexts and public health activities. Background information about each community was gathered. Week-long site visits were held, with interviews of between 40 and 60 public health providers, other providers, and community representatives at each site. Open-ended interviews focused on who is perceived to be at greatest risk for syphilis transmission/

infection, what institutions are best able to reach these individuals, what barriers stand in the way of reaching at-risk individuals, and innovative ideas or activities that STD prevention programs in other locations might find useful.

Multiple interviewers were used, providing an ongoing check for validity and reliability of data collection. A descriptive case study was prepared for each study site using interview data and information from a background document review. The case studies were sent to leaders in the State and local STD programs to supply any missing information, correct misunderstandings, or add comments.


This study emphasized that a set of dynamic interactions between distinct social scenarios, institutional situations, and persons in the communities placed certain groups and individuals at greater risk for syphilis infection. Of particular importance in these communities is the overarching issue of poverty. African Americans are the demographic group in the South at greatest risk of syphilis infection. The exchange of sex for drugs, especially when related to crack cocaine use, was considered an important risk behavior. Other risk groups include homeless persons, incarcerated individuals, adolescents, and male homosexuals.

Local health departments are the only community organizations that focus directly on syphilis and STD control and prevention. Other organizations that offer STD diagnosis/treatment provide limited partner notification and contact tracing. Public health agencies tended to assign priority to disease control. Schools were a consistent source of STD prevention messages but the content of these messages was limited by local restrictions on sexually explicit material in health education curricula. Churches were effective in delivering prevention programs but faced significant barriers in any discussion that impinged on issues of human sexuality. Community-based organizations have improved the accessibility of clinical services but have done little to reduce the risk of transmission by sponsoring prevention programs.

Barriers to reaching those at greatest risk include distrust of the public health system among African Americans and a low priority of health relative to other issues of poverty in the community. A long history of mistreatment has led to a general distrust of government in many communities. In the South, prenatal and neonatal care are seen as more pressing health problems. Also, cardiovascular disease, teen pregnancy, diabetes, and cancer are given a higher priority by the African-American community. The region suffers from a shortage of health care providers and facilities, a lack of transportation, and a lack of trained minority staff. Access to services for women are particularly constrained by the need for child care and transportation, inconvenient hours of operation, and the complications caused by comorbidities, such as domestic violence and substance abuse.

Some innovative measures to improve syphilis prevention and control programs have evolved. These include training in screening and referral for agencies that are in contact with persons in high-risk situations, involvement of parents and churches in supporting school health prevention messages, and use of key local community members to serve as local experts and resources on health promotion issues (following the "natural helper" model).

Recommendations include the provision of technical assistance to State and local health departments seeking to improve community involvement in syphilis and other STD prevention efforts. The issue of distrust of the public health system among African Americans needs to be confronted directly, with open dialogue as a necessary condition for improvement. Creative adjustments are needed to overcome barriers to the utilization of clinical facilities, such as more flexible hours of operation and the provision of on-site child care services. STD prevention programs need to take into account the special problems of women. This includes the need to develop child care arrangements, new protocols for handling domestic violence, and strategies for incorporating STD services into the broader array of services offered in women's health clinics. Training in STD prevention/control and cultural competency is encouraged for workers in public health centers, corrections facilities, substance abuse treatment centers, and professional schools. Minority health staff need to be recruited. Finally, enhancements in electronic data exchange and telecommunications support for State and local public health agencies are necessary to improve contact tracing and partner notification.

Use of Results

This study provides a comprehensive overview of problems involved in the prevention and control of syphilis and other STDs in the South. This study has important implications for public health policy development and innovative intervention designs by using an approach that highlights scenarios or conditions for risk of syphilis infection, rather than focusing on the individuals who contracted the disease. The actual and perceived barriers to the use of public health services encompass a wide and complex spectrum of cultural, political, and health system factors. High rates of syphilis in a community are indicative of more than just insufficient public health budgets and point to the need for the integration of disease prevention approaches in the comprehensive planning, policy, and budgeting processes of all organizations providing services to local communities. These results indicate the need to strengthen public health infrastructure and to involve communities and community organizations in the effort to reduce the conditions that place individuals at risk. An action agenda is provided that can help strengthen STD prevention programs and make them more accessible to various at-risk population groups, especially African Americans and women in the southern States. The case studies also provide an overview of innovative ideas that can improve the availability and use of STD-related information and services.

AGENCY SPONSOR: Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention


PHONE NUMBER: (404) 639-8344

PIC ID: 6579

PERFORMER ORGANIZATION: Battelle Corporation, Arlington, VA