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Evaluating the perceived impact on HIV risk behavior of a peer education program for young women; impact on the educators and selected contacts compared to case-control community women

Sonia K. González, MPH, DrPH Student, Principal Investigator

Specific Aims

Today, the HIV epidemic continues to disproportionately affect vulnerable communities, especially young people of color in urban areas (Centers for Disease Control and Prevention, 2008). The greatest prevalence of people living with HIV/AIDS (Center for the Study of Brooklyn , December 2007) in the U.S. can be found in one geographic area, Brooklyn, NY. In response, New York City has 54 teen programs with an HIV/STD/Sexuality component for youth, an estimated 11 of which are in Brooklyn and focus specifically on HIV prevention (Mack, 2010).

Since the beginning of the HIV epidemic in the U.S., health educators have counted on peer education role models to educate vulnerable populations (Campbell & MacPhail, 2002; Fongkaew, Fongkaew, & Suchaxaya, 2007; Kraft, Beeker, Stokes, & Peterson, 2000; Latkin, 1998; Ross MW & Williams ML, 2002; Suzuki & Calzo, 2004). Although a literature evaluating peer educators exists (Campbell & MacPhail, 2002; Hays, Rebchook, & Kegeles, 2003; Latkin, 1998), there is little documentation of what they do well, and long-term program effects on peer educators and those whom they reach outside of the program.

The long-term goal of this mixed-methods study is to identify or develop tools, as needed, that would improve current peer education programs throughout New York City and beyond. Dissemination tools may include texting and social networking modalities if it is found peers used these effectively and contacts report being influenced by them.

The founding of the Red Hook Initiative in 2002 and its inclusion of a peer education program offers the opportunity to look at long-range effects of peer education in a highly affected community. Specifically, this study will gather data from peer health educators (PHEs), adults who have worked with PHEs, and those served by PHEs to better understand how information about HIV is shared between and among young people of color who are participants of peer education programs. This project seeks to understand what information is conveyed and how this information is being communicated (e.g., texting, social networking sites, chatting, etc.). The project will also gather information about how, where and how often community members seek out information about HIV and other reproductive health information, and with whom peer educators are sharing educational information about HIV and other reproductive health concerns.

Using a mixed methods design, this two-year feasibility pilot project will:

▪ Measure HIV knowledge, attitudes, and risk and protective behaviors among those who graduated from 2009 to the present, adapting an existing survey for 20 PHEs and 20 comparison community members who are not peer educators, with the latter divided between community members who have been contacted educationally by PHEs (N=8) and those who have not (N=12).

▪ Assess how information about HIV prevention, condom use, and testing is shared between peer educators and community members who peers have contacted (“peer contacts” or “PCs”), if at all, through quantitative and qualitative methods.

▪ Qualitative methods will be employed to understand PCs perceptions of satisfaction, strengths and weaknesses of educational interactions between PHEs and PCs, and to explore how effective PCs think the PHEs are. If possible, sampling will be evenly distributed between male and female recipients.

Findings from this study will enlighten future directions for a larger study of peer education programs in Brooklyn or greater New York City to inform best practices and innovations as practiced by teen peer educators and to assess potential unintended positive and negative consequences of peer education through involvement of PHEs and PCs in study design.

Background and Significance

Red Hook and Its Housing Projects. Red Hook is a peninsula separated from the rest of Brooklyn and surrounded by the Gowanus Bay, Erie Basin and the Buttermilk Channel (The City of New York Community Board 6). A portion of the neighborhood recently received attention due to a brief period of gentrification (Jones, 2008; Sternbergh, November 12, 2007); however, the majority of the neighborhood is comprised of the Red Hook Houses -- New York State’s second largest public housing project (New York City Housing Authority, September 22, 2009).

Tenants in the Red Hook Houses are predominantly Black (54%) and Latino (42%). (Bloomberg, 2008). In Red Hook, 37.1% of the population are under 18 years old (vs. 19.6% in South Brooklyn) (Bloomberg, 2005). Additionally, the majority of the community faces intergenerational poverty, unemployment, and low levels of high school completion (Bloomberg, 2005; The City of New York Community Board 6). According to the 2000 census, the median household income for the Red Hook Houses is $10,372, with over half of the population in Red Hook living in poverty (Bloomberg, 2005). Less than half (44.9%) are high school graduates or higher, and only 3.4% of the population are college graduates or higher. These statistics compare unfavorably with those of a neighboring district, Carroll Gardens, where the median household income is $62,049, less than 10% of the population lives in poverty, 86.5% are high school graduates or higher and 55.5% are college graduates or higher (Bloomberg, 2005). 

HIV in Brooklyn and Red Hook African American and Latino Adolescents. From1999 through 2004, 81% of all AIDS cases in Brooklyn were among persons of color (December 2007). In fact, the HIV Infection rate in Brooklyn in 2004 was between 18.3 and 21.3 per 100,000 persons (Rosen et al., 2007, February). Given its racial/ethnic, socioeconomic and age composition, Red Hook is of particular interest regarding HIV/AIDS. Red Hook is in an area with the fourth highest number of persons living with HIV/AIDS in Brooklyn (December 2007).

HIV disproportionately impacts young people in the Red Hook community, where one-third of those diagnosed as living with HIV are 20 to 29 years old suggesting they contracted HIV as adolescents (HIV Epidemiology and Field Services Program, New York City Department of Health and Mental Hygiene, 2007). Additionally, nearly a quarter receive an HIV diagnosis concurrently with an AIDS diagnoses; the implication being that they have not sought care to manage HIV and that those living with HIV may have been putting others at risk for contracting HIV unwittingly, since treatment commonly reduces viral load and thus, transmissibility. Moreover, total HIV diagnoses are over-represented among Blacks and Latinos (72% of diagnoses are among Blacks and Latinos) (HIV Epidemiology and Field Services Program, New York City Department of Health and Mental Hygiene, 2007).

The PHEs are representative of the young people who live in the Red Hook Houses. While they receive support from the Red Hook Initiative (RHI), they continue to face the challenges of living in the Red Hook Houses including intergenerational poverty, regular exposure to violence in the community, and the emotional distress of living in NYCHA housing.

The Red Hook Initiative (RHI). The Red Hook Initiative (RHI) began in 2002 as a project of a local hospital in an effort to reduce the growing health disparities that exist in Red Hook, Brooklyn. Of the over 10,000 residents in greater Red Hook, over 80% live in the Red Hook Houses (Bloomberg, 2005). RHI continues to employ a non-traditional approach that works at the deepest level, starting from the root of the community, to address intergenerational poverty, unemployment, and low levels of high school completion.

“As I grow, my community grows. As I gain power, my community has power, because I am my community.” (personal communication, RHI staff)

Preliminary Studies

Sonia K. González, MPH, PI, Doctorate of Public Health Student has been awarded an Undergraduate University Research Fellowship (1998), a Liberal Arts Council Study Abroad Scholarship (1997), a Hispanic Women's Network of Texas Scholarship (1997)

Republic (1997) as an undergraduate at The University of Texas at Austin. As a graduate student at the Mailman School of Public Health she was awarded the Heilbrunn Department of Population and Family Health Hispanic Fellowship (2001). Most recently, she was awarded the YAI Fellowship (2010) and the Leopold Schepp Scholarship (2010) while enrolled in the CUNY School of Public Health. The current project is part of Ms. Gonzalez’s work as an NIMH fellow on a research training grant (R25).

Program Management & Recruitment

Ms. González has over a decade of program management experience. From 2005-2009, Ms. González was the Program Coordinator for the TEACH (Teens Educating About Community Health) Program, an HIV and substance abuse peer education program run out of a community court under the auspices of the Substance Abuse Mental Health Services Administration (SAMHSA). She collaborated with RHI to coordinate bi-annual HIV testing events, and joint trainings for the teens in her program and for RHI PHEs. Additionally, she formed a community advisory board for TEACH that included a representative from nearly all community based organizations within Red Hook including: the Red Hook Youth Court, the RHI, The Red Hook Youth Summer Internship, Falconworks, Inc., Center for Family Life, Red Hook Youth Baseball, Red Hook Rise, Love Heals, and The Urban Assembly School for Law and Justice. To address recruitment problems for the TEACH program, she conducted team outreach to locales where teens gather such as basketball courts. She also co-founded and was a Steering Committee member from 2005 to 2009 of the Young Women of Color HIV/AIDS Coalition. During that period she recruited and retained a cohort of 25 young women between 16 and 21 years old and with their input coordinated safer sex education parties, and an annual women’s health summit.

Evaluation Experience

Since 2005, Ms. González has held positions with TEACH, as Deputy Director for Love Heals, and as co-founder of the South Brooklyn Health Council and the Young Women of Color HIV/AIDS Coalition. Through these positions, she has developed curricula, and overseen program implementation, including SAMSHA approved evaluation and monitoring tools; additionally, she has maintained a dialogue with funders to ensure sustainability of programs.

Funding Experience

Behind the scenes, Ms. González submitted grant proposals and reports, designed programming curriculum, program evaluation, and developed and maintained community relationships with organizations such as the Family and Adolescent Experiences at SUNY Downstate University, the Family Center, Health and Education Alternatives for Teens, Love Heals, The Alison Gertz Foundation for AIDS Education, Young Peoples Project, Asian and Pacific Islander Coalition on HIV/AIDS, and the Red Hook Initiative. As Deputy Director from 2007-2009 for Love Heals, a non-profit focused on HIV prevention education throughout New York City she oversaw the general direction of programs, provided staff development, monitored and evaluated programs, and developed grant reports for funders.

Collaborations

Ms. González is uniquely qualified to conduct research in Red Hook with youth of color because of both her connections to service providers, youth, and families in Red Hook and throughout NYC, and her experiences serving hard to reach populations for over 15 years, including homeless and run away youth, GLBT throwaway youth, 14-24 year old young women and men of color in NYC. As co-chair for the Adolescent Prevention Planning Group (PPG) for the New York City Department of Hygiene and Mental Health (NYCDOHMH), she formed relationships with 51 providers from various community based organizations, hospitals, clinics, and researchers in the NYC community that included collaborations that extended far beyond HIV prevention among young women of color, a foci of her work. Through the PPG, she is connected to researchers, clinicians and other providers who serve all New Yorkers. Her networks and experience leave her well suited to oversee and carry out a research project among young women of color in Red Hook, Brooklyn, focused on HIV prevention.

Mentorship

Ms. González will receive mentorship from Drs. Lynn Roberts and Beatrice Krauss.

Selected Publications:

Roberts, L., Ross, L. Kuumba, M.B. (2005). The reproductive health and sexual rights of women of color: still building a movement. NWSA Journal, 17;1: 93-98.

Roberts, L. (1999). Creating a new framework for promoting the health of African American female (NWSA Journal Mar 1, 2005, Vol. 17, Issue 1, p93-98, 6p – add to Refworks) and

Krauss, B., O’Day, J., Godfrey, C., Rente, K., Freidin, L., Bratt, E., Minian, N., Knibb, K., Welch, C., Kaplan, R., Saxena, G., McGinniss, S., Gilroy, J., Nwakeze, P., & Curtain, S. (2006). Who wins in the status games? Violence, sexual violence and an emerging single standard among adolescent women. Annals of the New York Academy of Sciences, 1087 (November), 56-73.

Roye, C., Perlmutter, P., & Krauss, B. (2007). A brief, low-cost, theory-based intervention to promote dual method use by Black and Latina adolescents: A randomized clinical trial. Accepted in Health Education & Behavior.

Krauss, B., Godfrey, C., O’Day, J., & Freidin, E. (2006). Hugging my uncle: The impact of a parent training on children’s comfort interacting with persons with HIV. Journal of Pediatric Psychology, 31(9), 891-904.

Research Design and Methods

Overview

Using a mixed methods design, this pilot feasibility project aims to better understand how information about HIV is shared between and among young Latinos and African Americans who are participants of a peer education program, and how information about HIV is communicated and reportedly received with members of their various networks (e.g., in-and out-of-school peers, at church, with neighbors). To this end, data will be collected from peer health educators (PHEs), adults who have worked with PHEs, case-control community members who have been educated by PHEs (PCs), and community members who have not been educated by PHEs. This project will focus on a small portion of Brooklyn while future efforts will focus on greater Brooklyn or greater NYC teen peer education projects.

Recruitment and consenting of participants

The focus area of this study is an area in Brooklyn known as Red Hook. Accordingly, recruitment efforts will be concentrated in this neighborhood primarily through the Red Hook Initiative. Because the PI is well known at RHI, she will approach four staff of RHI to serve as Adult Key Informants. The primary role of AKIs will be to inform recruitment efforts and to finalize instruments. In addition, AKIs will assist with recruiting community members who have not participated in reproductive health peer education programming; these community members will be asked to complete surveys and will serve as a control group. AKIs will also be trained to reach out to participants and/or parents to explain the project. Once agreed upon, the PI will obtain written consent to participate in the project and will follow up with the participant directly if over 18 or with the parent if under 18.

Data collection procedure

All qualitative and quantitative instruments will be conducted after informed consent has been obtained from the participant, if over 18 years old or a parent/guardian if under 18 years old. Instruments will first be finalized with the input from adult key informants and finalized versions will be submitted to IRB for approval before moving forward with research.

After consent is obtained, surveys will first be administered by the PI and a research assistant (RA) after she or he has obtained the appropriate CITI IRB training certificate. Careful attention will be paid to match respondents who know the PI to have the survey instrument be administered by the RA to make respondents feel more comfortable and at ease in completing the survey. Respondents will complete surveys at RHI since the space is familiar and is conveniently located in Red Hook, where most respondents will be living. Participants will complete knowledge, attitude and behavior surveys in a private area such as in an office that will allow the respondent to reply confidentially after consent is obtained. Quantitative data will be collected from Youth Survey, AIDS Worry for Youth and a Risk Behavior Survey (samples attached).

The three groups of young people (PHEs, PCs, and community members) will be invited to come on a day to first complete the Sources of Information Survey and then participate in focus groups. After analysis of the focus groups, individual interviews will be collected. Focus groups will be facilitated by the PI and research assistant also at RHI in a larger area that has doors that close, both, to conduct focus groups in a safe space to make youth feel comfortable to share their ideas, and to provide an environment that is conducive to confidentiality. Individual interviews will be conducted only as needed to explore a possible theme more in-depth by either the PI or the RA.

Eligibility

All recruitment scripts and materials will be reviewed by the IRB to ensure the elements of informed consent are present and coercion based on prior relationships is not a factor.

Adult Key Informants (AKI) will provide context for the study. Key informants are individuals over 24 years old who have worked with PHEs for over 2 years at the Red Hook Initiative or have known teen peer educators in NYC for over 5 years from Red Hook through the Red Hook Initiative, church, school, or the Red Hook Houses (NYCHA), for example. Adult key informants (AKI) with whom Ms. González already has a relationship will inform where and when recruitment should occur. AKIs will also provide input on the appropriateness, content and flow of any instruments before they are implemented in the community.

Three groups are being recruited: 1) PHEs, 2) PCs and 3) non-PHE, non-PC community members. The inclusion and exclusion criterion and recruitment strategy for each sub-group that will be involved in this study is outlined below.

Peer Educators (PHEs) (n=20). PHE graduates eligible to participate must have completed 1 year of training on reproductive health and HIV prevention through the Red Hook Peer Education Program at the Red Hook Initiative and graduated from the program between 2009 and 2010. Of the 32 eligible PHE graduates, 20 will be randomly recruited from lists of graduates of the RHI peer education program, counterbalanced by year of graduation. They will be contacted by e-mail or phone by current staff, provided with a brief description of the project containing the elements of informed consent, and asked if they wish to participate. As well as documenting eligibility, screening will ensure that PHEs feel comfortable reporting on their activities and filling out anonymous self-report questionnaires; participants will be given the option of having instruments administered by a research assistant.

PHEs will be asked to take a survey to collect knowledge, attitude, and behavior data on HIV, and participate in a focus group about how they share information on HIV. Focus groups will be conducted with all recruited PHE or PC teens. Groups of PHEs and PCs will be conducted separately until saturation of themes is met for each group, and a final third group will contain both PHEs and PCs in order to clarify issues raised in each group–between the ages of 16 and 22 to elicit how HIV information is shared in the larger context of teens’ lives. This data will be audio taped with consent from the participant, if over 18 years old or a parent/guardian if under 18 years old.

The primary domains of inquiry for the focus groups assessing mode of communication (PHEs and PCs) include: rationale or circumstances for choice of target of communication; information sharing (type of information shared, duration of information sharing, location or mode of information sharing); networks (in school youth, out of school youth, adults and youth known from church, other social organizations); and technology (texting, social networking sites such as facebook, myspace, etc.). Pseudonyms will be used in any qualitative data that is used for reporting and dissemination.

People Contacted by PHEs (PCs) (n=8). Those educated by PHEs are community members who live in NYCHA’s Red Hook Houses or nearby neighborhoods, nominated by PHEs and AKIs as contacts. All study participants will self-identify as Black and/or Latino, and be over 16 years of age to include recently educated teens as well as adults who may be in the social networks of PHEs. The PCs will be recruited for individual interviews. The measures are described in more depth below. Participating PHEs will nominate up to 4 PCs. We recognize that PHEs are likely to nominate PCs they feel they have influenced, thus we are aware we might be getting “better practices” of PHEs.

Non-PHE/non-PC Community Members. To participate in this study, community members must have been living in Red Hook for at least 1 year or have family and/or friends they visit at least 3 times a month for the past year. Community members will comprise a comparison cohort to reveal differences between PHEs and non-PHEs/non-PCs in HIV knowledge, attitudes, and behavior and will be recruited to participate in focus groups to discuss how information around HIV is shared. Community members cannot be former or current peer educators of another HIV/teen pregnancy prevention program, PHEs, or PCs. PCs will be over 16 years of age to match the PC group for comparison in analysis.

Community members will be recruited through geographic (e.g., flyers) and snowball sampling. In addition, AKIs will recruit participants, in an attempt to recruit a separate group of teens outside of the social network of the PHEs and PCs. Community members will be screened for participation in other PHE programs or contact by other PHEs about HIV and/or reproductive health.

After informed consent is obtained, surveys will first be administered by the PI and a research assistant (RA). The RA will administer the survey to respondents who know the PI in order to make respondents feel more comfortable and at ease in completing the survey. Respondents will complete surveys at RHI since the space is familiar and conveniently located in Red Hook, where most respondents will be living. Focus groups will be facilitated by the PI and research assistant also at RHI. Individual interviews will be conducted to explore a possible theme more in-depth.

Analysis

Quantitative data collection will be driven by modifying objective measures that were used in the NIMH-funded PATH Project for inner-city preadolescents, adolescents and adults (Pequegnat et al., 2001). Data will collect HIV knowledge, attitudes, protective and risk behaviors, and sources where teens seek and obtain information on HIV.

Analysis of HIV Knowledge, Attitudes, and Behavior. Analysis of variance, adjusted for unequal N per group, will compare means for PHE, PC, and community members. Prior to analysis, candidates for covariates (e.g., differ between group and correlate with outcome measures) will be assessed. ANCOVA as opposed to ANOVA will be used if there are such covariates (e.g., age). In this pilot study, it is anticipated, that although N’s are small, there is sufficient power to detect group differences, since untutored individuals tend to have means representing 50% of items missed, while trained individuals score near 90% correct.

Analysis of Sources of Information. Descriptive statistics will indicate major sources of information for each group while significance of difference between proportions will assess if these sources vary significantly across groups. The relationship of sources to knowledge, worry, and behavior will be calculated for each group.

Analysis of Focus Groups. Digitized audiotapes will be listened to by two researchers independently. Researchers will identify themes (communication strategies, content, modalities, perceived outcome) for topic guide areas, with disagreements resolved by a third senior researcher. It is anticipated that analysis will yield hierarchies of information (e.g., type of person approached) with prototypic methods and messages. For example, different messages may be emphasized for different targets: e.g., discussion of negotiation for friends in a relationship with technological (e.g., texting) follow-up, information about the disease course for large groups. It is anticipated that some messages/modalities will be perceived as more effective by both PHEs and PCs. It is anticipated that perceived effectiveness by a PHE will influence the PHEs own risk behavior and that, in turn, will influence persistence in peer education. Any data shared from prior exchanges that are posted in public places such as on a FaceBook wall will also be analyzed for reoccurring themes by two independent researchers.

Based on findings of the quantitative and qualitative data from specific aims, directions for further study will be determined. Looking ahead, an anticipated goal of this study will be to include an ethnographic component to reveal the impact of the reach of peer education program on peer educators as well as on those they serve.

Threats to Validity

While data are being collected from different sources and findings will be triangulated, bias of self-selection into the study, self-report data and perceptions of those who are reporting retroactively are threats to the validity of these findings.

Dissemination Plan

Findings will be disseminated to other community based organizations based in Red Hook that are not focused on HIV prevention, but may be well- poised to address HIV and STI prevention. The findings of this pilot project will inform a larger study, which is hoped will lead to more innovative techniques of HIV and STI prevention programming in urban areas. Lastly, the PI will submit a peer-reviewed journal article for publication based on findings from this research.

Time Line

September – October 2010 IRB Approval at City College and Hunter College; Assemble CAB

October – December 2010 Test and finalize assessment tool, obtain IRB approval, begin participant recruitment

January – March 2011 Continue participant recruitment in Red Hook in the afternoon and evening hours and during the weekends, when young people are expected to be at RHI or in public spaces in Red Hook (such as the basketball courts and courtyards in the Red Hook Houses.)

April – July 2011 Data entry and analysis

August – September 2011 Written report & dissemination

References

Bloomberg, M. R., Mayor. (2005). In Community Board 6 (Ed.), The community district needs. New York, NY: Department of City Planning, The City of New York, Office of Management and Budget.

Bloomberg, M. R., Mayor. (2008). In Community Board 6 (Ed.), The community district needs. New York, NY: Department of City Planning, The City of New York, Office of Management and Budget.

Campbell, C., & MacPhail, C. (2002). Peer education, gender and the development of critical consciousness: Participatory HIV prevention by South African youth. Social Science & Medicine, 55(2), 331-345.

Center for the Study of Brooklyn, HIV/AIDS Initiative. (December 2007). Critical indicators.

Centers for Disease Control and Prevention. (2008). Cases of HIV infection and AIDS in urban and rural areas of the United States, 2006 Retrieved from

Fongkaew, W., Fongkaew, K., & Suchaxaya, P. (2007). Early adolescent peer leader development in HIV prevention using youth-adult partnership with schools approach. JANAC: Journal of the Association of Nurses in AIDS Care, 18(2), 60-71.

Hays, R. B., Rebchook, G. M., & Kegeles, S. M. (2003). The mpowerment project: Community-building with young gay and bisexual men to prevent HIV. American Journal of Community Psychology, 31(3), 301.

HIV Epidemiology and Field Services Program, New York City Department of Health and Mental Hygiene. (2007). New York City HIV/AIDS annual surveillance statistics. Retrieved from

Jones, C. (2008, 1/9/2008). Gentrification ebbs in NYC neighborhood USA Today,

Kraft, J. M., Beeker, C. G., Stokes, J. P., & Peterson, J. L. (2000). Finding the "community" in community-level HIV/AIDS interventions: Formative research with young African American men who have sex with men. Health Education & Behavior, 27(4), 430-441.

Latkin, C. A. (1998). Outreach in natural settings: The use of peer leaders for HIV prevention among injecting drug users' networks. Public Health Reports (1974-), 113(, Supplement 1: HIV Prevention with Drug-Using Populations: Current Status and Future Prospects), 151-159.

Mack, K. M. S. W. (2010). City research scientist focused on youth HIV prevention in the Bureau of HIV/AIDS at the New York City Department of Health and Mental Hygiene

New York City Housing Authority. (September 22, 2009). About NYCHA: Fact sheet. Retrieved October 1, 2009, from

Pequegnat, W., Bauman, L. J., Bray, J. H., Hoppe, S. K., Jemmott, L. S., Krauss, B., et al. (2001). Measures relevant to the role of families in prevention and adaptation to HIV/AIDS. AIDS and Behavior, 5(1), 1-19.

Rosen, D. B., Krauss, B. J., Murphy, J., Welch, A., Culleton, B., Kaplan, R., et al. (2007, February). Final report to lutheran HealthCare: Evaluation of “Supporting and caring for people living with HIV/AIDS": A mandatory training for lutheran HealthCare’s nonclinical staff. . Brooklyn, NY: Lutheran HealthCare.

Ross MW, & Williams ML. (2002). Effective targeted and community HIV/STD prevention programs. Journal of Sex Research, 39(1), 58-62.

Sternbergh, A. (November 12, 2007, The embers of gentrification. New York Magazine,

Suzuki, L. K., & Calzo, J. P. (2004). The search for peer advice in cyberspace: An examination of online teen bulletin boards about health and sexuality. Journal of Applied Developmental Psychology, 25(6), 685-698.

The City of New York Community Board 6. Neighborhoods: Red hook. Retrieved July 15, 2009, from

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