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Partner in Health

Nidhi Khosla says cooperation can combat HIV/AIDS infections

By Anita Neal Harrison

Encountering commercial sex workers for the first time, Nidhi Khosla says, shook her up quite a bit. "I knew the stereotypes we see in the media are not what people are really like, but to actually see women who could be your mother or your aunt or your neighbor — I mean they looked just like anybody else."

Khosla met the women while working for Hindustan Latex Limited in her native India about 15 years ago. Her job was to prepare grant proposals aimed at social marketing of contraceptives and other health care products. Sexual health was a taboo topic then, but Khosla did not hesitate to go to work for a condom manufacturer.

“I wanted to follow my own path,” says Khosla, who left a highly respected position in banking to pursue a graduate degree in not-for-profit management. She later turned down a prestigious internship with UNAIDS in Geneva to accept an internship with a World Health Organization project in Bangladesh. “I think working at the grassroots is important.”

Now an assistant professor of health sciences, Khosla still has a passion for grassroots public-health. Among her more recent community-based projects was a study, published in Social Science and Medicine, that explored collaboration among agencies serving people living with HIV in Baltimore, a city severely affected by the virus. The research used two distinct approaches — social network theory and relational coordination theory — to investigate how much and how well agencies collaborated.

Khosla says social network theory was an obvious choice. It holds that actors, in this case, HIV agencies, establish connections among themselves to + p r o f i l e access resources. Khosla used it to analyze who was interacting with whom, something the agencies themselves have trouble discerning.

“Agencies know their own patterns of interactions, but they don’t know how the system as a whole looks,” Khosla says. “Using social network analysis, we can see what the map looks like. We can see which agencies are more heavily connected, so if we want to target agencies for dissemination of information, we can see which ones to target.”

Relational coordination, on the other hand, aims at examining the “how well,” or the effectiveness, of coordination efforts using assessment measures such as “frequency of communication” and “mutual respect.”

To Khosla’s knowledge, no previous research had combined the social network and relational coordination theories. “That was a key innovation,” she says. “We could figure out what is strong and what is weak in the collaboration. Is timeliness of coordination strong? Is frequency low?”

Khosla’s interest in assessing collaborative efforts against HIV/AIDS arose during her graduate school days at the Johns Hopkins Bloomberg School of Public Health. There she learned the number of HIV agencies in Baltimore, where the school is located, numbered more than 60.

“I said to my advisor, ‘I don’t understand why the situation in Baltimore is so bad when we have so many resources,’” she says. Back in India she had worked on effective social marketing campaigns in places that did not even have electricity. “We had skits and plays in local fairs to attract people to the products, and we commissioned wall paintings on houses and other large buildings."

She learned then, she says, that social structures make people vulnerable to HIV. She’s seen that’s also true in the U.S. “A lot of programs traditionally have taken the safe route of just focusing on information provision: You tell people how to protect themselves from HIV and everything will be fine. But that’s not how things work. Our behavior, our goals are shaped by the social environment in which we live, so if we do not address the social factors that predispose people to HIV risk, then we are not going to stop the epidemic.”

During her data collection in Baltimore, Khosla interviewed agencies’ staffs. “What does collaboration mean to you?” she asked. “What are examples of good and bad interactions? How can your agency do better?” Their answers helped Khosla identify six areas that could lead to service improvement, findings she published in the journal AIDS Care earlier this year.

Asking, not telling, goes back to another lesson Khosla learned in India, one that makes her singularly well-suited to helping public-health professionals better connect with those they strive to serve.

“A lot of us get into this work thinking we want to help, to share our expertise,” she says, “and we forget how much expertise already exists within the community. So to go in with humility, to know the people you want to help have solutions, is very important.”

Nidhi Khosla

Nidhi Khosla

Photo by Shane Epping

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