Masculinity, medical mistrust, and preventive health services delays among community-dwelling African-American men

The Health and Sociocultural Correlates of AIDS Genocidal Beliefs and Medical Mistrust Among African American MSM

This study examined social and health-related correlates of AIDS conspiracy theories among 464 African American men who have sex with men (MSM). Exploratory factor analysis revealed two subscales within the AIDS conspiracy beliefs scale: medical mistrust and AIDS genocidal beliefs. Multiple regression analyses revealed medical mistrust and AIDS genocidal beliefs were both associated negative condom use attitudes and higher levels of internalized homonegativity. Medical mistrust was also associated with lower knowledge of HIV risk reduction strategies. Finally, we conducted bivariate regressions to examine the subsample of participants who reported being HIV-positive and currently taking HIV antiretroviral therapy (ART) to test associations between sexual behavior and HIV treatment and AIDS conspiracy theories. Among this subsample, medical mistrust was associated with having a detectable viral load and not disclosing HIV-status to all partners in the previous 3 months. Collectively, these findings have implications for HIV prevention and treatment for African American MSM.

Too Important to Ignore: Leveraging Digital Technology to Improve Chronic Illness Management Among Black Men

Health disparities associated with chronic illness experiences of black men demonstrate widespread, systematic failures to meet an urgent need. Well-established social and behavioral determinants that have led to health disparities among black men include racism, discrimination, and stress. While advocacy work that includes community-engagement and tailoring health promotion strategies have shown local impact, evidence shows the gaps are increasing. We suspect that failure to reduce current disparities may be due to conventional public health interventions and programs; therefore, we submit that innovative interventions, ones that embrace digital technologies and their ability to harness naturally occurring social networks within groups, like black men, have particular importance and deserve attention. This commentary characterizes the current literature on chronic illness among black men as well as health interventions that use digital technology, to build a case for expanding research in this area to reduce the overwhelming burden of chronic illness among black men.

"Like finding a unicorn": Healthcare preferences among lesbian, gay, and bisexual people in the United States

Lesbian, gay, and bisexual (LGB) peoples' healthcare preferences are often developed in response to social and institutional factors that can ultimately deter them from care. Prior qualitative explorations of LGB healthcare preferences have been limited in their ability to identify and compare patterns across age cohort, gender, and race/ethnicity. The current study examines qualitative data from 186 modified Life Story Interviews with three age cohorts of LGB people from New York City, NY, San Francisco, CA, Tucson, AZ, and Austin, TX to understand the factors influencing LGB people's healthcare preferences. Data are analyzed using a directed content analysis approach. Five key themes emerged regarding influences on healthcare preferences: Stigma, provider expertise, identity, service type, and access. Findings suggest that healthcare preferences among LGB people are both complex and closely linked to social changes over time. Healthcare preferences among LGB people are both complex and closely linked to social changes over time.

Perspectives of Fear as a Barrier to Self-Management in Non-Hispanic Black Men With Type 2 Diabetes

BACKGROUND

Self-managing type 2 diabetes (T2D) is critical but often challenging for non-Hispanic Black (NHB) men. Fears may contribute to poor self-management; however, the evidence is sparse. The purpose of this study is to examine the relationship between fear and diabetes self-management in NHB men from the southern United States.

METHODS

Nineteen NHB men with T2D were recruited from barbershops and churches. Interviews were conducted using a semistructured interview guide. Transcripts were analyzed using a phenomenological approach and focused on identifying common themes describing the perceptions of fear as a barrier to self-managing T2D in the study participants.

RESULTS

More than 68% of the sample was >55 years of age, where 42% reported an annual income of ≥$100,000, 74% were married, and 26% had a college degree. Fifty-three percent expressed fear with diabetes management, while 47% reported no fears with diabetes management. Direct fears associated with self-management included the use of needles and syringes for self-monitoring and medication adherence, respectively. Indirect fears were associated with the development of adverse complications resulting in poor mental and physical quality of life. No fears were reported secondary to diabetes knowledge, perceived control, and social support.

CONCLUSIONS

In this sample of NHB men, fear was perceived by many as a direct barrier to self-management and an indirect barrier to optimal quality of life. These findings suggest the need to address the fears of NHB men when guiding treatment and developing research interventions to improve self-management skills.

Power of Peer Support to Change Health Behavior to Reduce Risks for Heart Disease and Stroke for African American Men in a Faith-Based Community

INTRODUCTION

Peer support has powerful potential to improve outcomes in a program of health behavior change; yet, how peer support is perceived by participants, its role, and how it contributes to intervention efficacy is not known, especially among African Americans. The purpose of this study was to identify the subjectively perceived experience and potential contributions of peer support to the outcomes of a peer group behavioral intervention designed to change health behavior to reduce risks for heart disease and stroke in African American men in a faith-based community.

METHODS

A peer support group intervention was implemented to increase health knowledge and to improve health behaviors in line with the American Heart Association's Life Simple 7 domains (get active, control cholesterol, eat better, manage blood pressure, lose weight, reduce blood sugar, and stop smoking). Fourteen peer group sessions and eight follow-up interviews with program participants were recorded, transcribed, and analyzed.

RESULTS

Seven key themes emerged, including (1) enhancing access to health behavior information and resources, (2) practicing and applying problem-solving skills with group feedback and support, (3) discussing health behavior challenges and barriers, (4) sharing health behavior changes, (5) sharing perceived health outcome improvements and benefits, (6) feelings of belonging and being cared for, and (7) addressing health of family and community.

CONCLUSION

Qualitative findings revealed a positive perception of peer support and greater understanding of potential reasons why it may be an effective strategy for African American men.

Public Mistrust of the U.S. Health Care System's Profit Motives: Mixed-Methods Results from a Randomized Controlled Trial

BACKGROUND

Decision makers are increasingly tasked with reducing health care costs, but the public may be mistrustful of these efforts. Public deliberation helps gather input on these types of issues by convening a group of diverse individuals to learn about and discuss values-based dilemmas.

OBJECTIVE

To explore public perceptions of health care costs and how they intersect with medical mistrust.

DESIGN AND PARTICIPANTS

This mixed-methods study analyzed data from a randomized controlled trial including four public deliberation groups (n = 96) and a control group (n = 348) comprising English-speaking adults aged 18 years and older. Data were collected in 2012 in four U.S. regions.

APPROACH

We used data from four survey items to compare attitude shifts about costs among participants in deliberation groups to participants in the control group. We qualitatively analyzed deliberation transcripts to identify themes related to attitude shifts and to provide context for quantitative results about attitude shifts.

KEY RESULTS

Deliberation participants were significantly more likely than control group participants to agree that doctors and patients should consider cost when making treatment decisions (β = 0.59; p < 0.01) and that people should consider the effect on group premiums when making treatment decisions (β = 0.48; p < 0.01). Qualitatively, participants mistrusted the health care system's profit motives (e.g., that systems prioritize making money over patient needs); however, after grappling with patient/doctor autonomy and learning about and examining their own views related to costs during the process of deliberation, they largely concluded that payers have the right to set some boundaries to curb costs.

CONCLUSIONS

Individuals who are informed about costs may be receptive to boundaries that reduce societal health care costs, despite their mistrust of the health care system's profit motives, especially if decision makers communicate their rationale in a transparent manner. Future work should aim to develop transparent policies and practices that earn public trust.

Stoic beliefs and health: development and preliminary validation of the Pathak-Wieten Stoicism Ideology Scale

INTRODUCTION

We developed and validated a new parsimonious scale to measure stoic beliefs. Key domains of stoicism are imperviousness to strong emotions, indifference to death, taciturnity and self-sufficiency. In the context of illness and disease, a personal ideology of stoicism may create an internal resistance to objective needs, which can lead to negative consequences. Stoicism has been linked to help-seeking delays, inadequate pain treatment, caregiver strain and suicide after economic stress.

METHODS

During 2013-2014, 390 adults aged 18+ years completed a brief anonymous paper questionnaire containing the preliminary 24-item Pathak-Wieten Stoicism Ideology Scale (PW-SIS). Confirmatory factor analysis (CFA) was used to test an a priori multidomain theoretical model. Content validity and response distributions were examined. Sociodemographic predictors of strong endorsement of stoicism were explored with logistic regression.

RESULTS

The final PW-SIS contains four conceptual domains and 12 items. CFA showed very good model fit: root mean square error of approximation (RMSEA)=0.05 (95% CI 0.04 to 0.07), goodness-of-fit index=0.96 and Tucker-Lewis Index=0.93. Cronbach's alpha was 0.78 and ranged from 0.64 to 0.71 for the subscales. Content validity analysis showed a statistically significant trend, with respondents who reported trying to be a stoic 'all of the time' having the highest PW-SIS scores. Men were over two times as likely as women to fall into the top quartile of responses (OR=2.30, 95% CI 1.44 to 3.68, P<0.001). ORs showing stronger endorsement of stoicism by Hispanics, Blacks and biracial persons were not statistically significant.

DISCUSSION

The PW-SIS is a valid and theoretically coherent scale which is brief and practical for integration into a wide range of health behaviour and outcomes research studies.

Racial Discrimination in Health Care Is Associated with Worse Glycemic Control among Black Men but Not Black Women with Type 2 Diabetes

BACKGROUND

A growing body of research suggests that racial discrimination may affect the health of Black men and Black women differently.

AIMS

This study examined Black patients with diabetes mellitus (DM) in order to test gender differences in (1) levels of perceived racial discrimination in health care and (2) how perceived discrimination relates to glycemic control.

METHODS

A total of 163 Black patients with type 2 DM (78 women and 85 men) provided data on demographics (age and gender), socioeconomic status, perceived racial discrimination in health care, self-rated health, and hemoglobin A1c (HbA1c). Data were analyzed using linear regression.

RESULTS

Black men reported more racial discrimination in health care than Black women. Although racial discrimination in health care was not significantly associated with HbA1c in the pooled sample (b = 0.20, 95% CI = -0.41 -0.80), gender-stratified analysis indicated an association between perceived discrimination and higher HbA1c levels for Black men (b = 0.86, 95% confidence intervals (CI) = 0.01-1.73) but not Black women (b = -0.31, 95% CI = -1.17 to -0.54).

CONCLUSION

Perceived racial discrimination in diabetes care may be more salient for glycemic control of Black men than Black women. Scholars and clinicians should take gender into account when considering the impacts of race-related discrimination experiences on health outcomes. Policies should reduce racial discrimination in the health care.

Black-White Differences in Incident Fatal, Nonfatal, and Total Coronary Heart Disease

BACKGROUND

Blacks have higher coronary heart disease (CHD) mortality compared with whites. However, a previous study suggests that nonfatal CHD risk may be lower for black versus white men.

METHODS

We compared fatal and nonfatal CHD incidence and CHD case-fatality among blacks and whites in the Atherosclerosis Risk in Communities study (ARIC), the Cardiovascular Health Study (CHS), and the Reasons for Geographic and Racial Differences in Stroke study (REGARDS) by sex. Participants 45 to 64 years of age in ARIC (men=6479, women=8488) and REGARDS (men=5296, women=7822), and ≥65 years of age in CHS (men=1836, women=2790) and REGARDS (men=3381, women=4112), all without a history of CHD, were analyzed. Fatal and nonfatal CHD incidence was assessed from baseline (ARIC=1987-1989, CHS=1989-1990, REGARDS=2003-2007) through up to 11 years of follow-up.

RESULTS

Age-adjusted hazard ratios comparing black versus white men 45 to 64 years of age in ARIC and REGARDS were 2.09 (95% confidence interval, 1.42-3.06) and 2.11 (1.32-3.38), respectively, for fatal CHD, and 0.82 (0.64-1.05) and 0.94 (0.69-1.28), respectively, for nonfatal CHD. After adjustment for social determinants of health and cardiovascular risk factors, hazard ratios in ARIC and REGARDS were 1.19 (95% confidence interval, 0.74-1.92) and 1.09 (0.62-1.93), respectively, for fatal CHD, and 0.64 (0.47-0.86) and 0.67 (0.48-0.95), respectively, for nonfatal CHD. Similar patterns were present among men ≥65 years of age in CHS and REGARDS. Among women 45 to 64 years of age in ARIC and REGARDS, age-adjusted hazard ratios comparing blacks versus whites were 2.61 (95% confidence interval, 1.57-4.34) and 1.79 (1.06-3.03), respectively, for fatal CHD, and 1.47 (1.13-1.91) and 1.29 (0.91-1.83), respectively, for nonfatal CHD. After multivariable adjustment, hazard ratios in ARIC and REGARDS were 0.67 (95% confidence interval, 0.36-1.24) and 1.00 (0.54-1.85), respectively, for fatal CHD, and 0.70 (0.51-0.97) and 0.70 (0.46-1.06), respectively, for nonfatal CHD. Racial differences in CHD incidence were attenuated among older women. CHD case fatality was higher among black versus white men and women, and the difference remained similar after multivariable adjustment.

CONCLUSIONS

After accounting for social determinants of health and risk factors, black men and women have similar risk for fatal CHD compared with white men and women, respectively. However, the risk for nonfatal CHD is consistently lower for black versus white men and women.

Decrements in health-related quality of life associated with gender nonconformity among U.S. adolescents and young adults

PURPOSE

Gender nonconformity, that is, transgressing conventionally "masculine" vs. "feminine" characteristics, is often stigmatized. Stigmatization and discrimination are social stressors that raise risk of adverse mental and physical health outcomes and may drive health inequities. However, little is known about the relationship between such social stressors and health-related quality of life (HRQOL). This paper aimed to examine associations between perceived gender nonconformity and HRQOL in a cohort of U.S. adolescents and young adults.

METHODS

Using data from 8408 participants (18-31 years) in the U.S. Growing Up Today Study (93% white, 88% middle-to-high income), we estimated risk ratios (RRs) for the association of gender nonconformity (three levels: highly gender conforming, moderately conforming, and gender nonconforming) and HRQOL using the EuroQol questionnaire (EQ-5D-5L). Models were adjusted for demographic characteristics, including sexual orientation identity.

RESULTS

Gender nonconformity was independently associated with increased risk of having problems with mobility [RR (95% confidence interval): 1.76 (1.16, 2.68)], usual activities [2.29 (1.67, 3.13)], pain or discomfort [1.59, (1.38, 1.83)], and anxiety or depression [1.72 (1.39, 2.13)], after adjusting for sexual orientation and demographic characteristics. Decrements in health utility by gender nonconformity were observed: compared to persons who were highly gender conforming, mean health utility was lower for the moderately gender conforming [beta (SE): -0.011 (.002)] and lowest for the most gender nonconforming [-0.034 (.005)].

CONCLUSIONS

In our study, HRQOL exhibited inequities by gender nonconformity. Future studies, including in more diverse populations, should measure the effect of gender-related harassment, discrimination, and violence victimization on health and HRQOL.

The differences between medical trust and mistrust and their respective influences on medication beliefs and ART adherence among African-Americans living with HIV

OBJECTIVE

The purpose of this study was to examine the relationships between medical mistrust and trust and to determine if these measures differentially predict antiretroviral therapy (ART) medication adherence for African-American adults living with HIV.

DESIGN

A total of 458 HIV positive African-Americans completed a cross-sectional survey.

MAIN OUTCOME MEASURES

Self-reported ART adherence was collected using the visual-analog scale. The Beliefs About Medicines Questionnaire was used to assess medication necessity and concern beliefs.

RESULTS

All measures of medical mistrust and trust were significantly negatively correlated, ranging from r = -.339 to -.504. Race-based medical mistrust significantly predicted medication necessity and concern beliefs, whereas general medical mistrust only significantly predicted medication concerns. Both measures of trust significantly predicted medication necessity beliefs and medication concerns. Higher levels of race-based medical mistrust predicted lower medication adherence, whereas, neither trust in own physician nor trust in health care provider significantly predicted medication adherence. However, trust in own physician significantly predicted medication necessity beliefs, which predicted medication adherence.

CONCLUSION

Trust and mistrust are not simply opposites of one another. These findings provide evidence for the complexity of understanding the relationship between health care trust, mistrust and patient-related health beliefs and behaviours.

Knowledge, attitudes, and beliefs related to hypertension and hyperlipidemia self-management among African-American men living in the southeastern United States

OBJECTIVE

Perceptions of illness affect cardiovascular disease (CVD) self-management. This study explores knowledge, attitudes, and beliefs regarding hypertension and hyperlipidemia management among 34 African-American men with hypertension and/or hyperlipidemia, age 40-65, living in the Southeastern United States.

METHODS

In-person focus groups were conducted using semi-structured interview questions informed by the Health Belief Model (HBM).

RESULTS

Participants had a high level of knowledge about hypertension self-management, but less about cholesterol self-management. Perceived severity of both conditions was acknowledged, though participants perceived hypertension as more severe. Barriers to self-management included medication side effects and unhealthy dietary patterns. Facilitators included social support, positive healthcare experiences, and the value placed on family. Cultural implications highlighted the importance of food in daily life and social settings. Participants expressed how notions of masculinity affected self-management-noting the impact of feelings of vulnerability and perceived lack of control stemming from diagnosis and treatment expectations.

CONCLUSIONS

The findings highlight gaps in knowledge of hyperlipidemia versus hypertension, and the impact of cultural context and perceptions on engagement in self-management behaviors.

PRACTICE IMPLICATIONS

Public health practitioners and healthcare providers serving African-American men should address cultural factors and notions of masculinity which can hinder effective disease management among this population.

Feasibility of Using Soccer and Job Training to Prevent Drug Abuse and HIV

Many young, South African men use alcohol and drugs and have multiple partners, but avoid health care settings-the primary site for delivery of HIV intervention activities. To identify the feasibility of engaging men in HIV testing and reducing substance use with soccer and vocational training programs. In two Cape Town neighborhoods, all unemployed men aged 18-25 years were recruited and randomized by neighborhood to: (1) an immediate intervention condition with access to a soccer program, random rapid diagnostic tests (RDT) for alcohol and drug use, and an opportunity to enter a vocational training program (n = 72); or (2) a delayed control condition (n = 70). Young men were assessed at baseline and 6 months later by an independent team. Almost all young men in the two neighborhoods participated (98 %); 85 % attended at least one practice (M = 42.3, SD = 34.4); 71 % typically attended practice. Access to job training was provided to the 35 young men with the most on-time arrivals at practice, drug-free RDT, and no red cards for violence. The percentage of young men agreeing to complete RDT at soccer increased significantly over time; RDTs with evidence of alcohol and drug use decreased over time. At the pre-post assessments, the frequency of substance use decreased; and employment and income increased in the immediate condition compared to the delayed condition. HIV testing rates, health care contacts, sexual behaviors, HIV knowledge, condom use and attitudes towards women were similar over time. Alternative engagement strategies are critical pathways to prevent HIV among young men. This feasibility study shows that soccer and job training offer such an alternative, and suggest that a more robust evaluation of this intervention strategy be pursued.

Factors Associated With Black Men's Preference for Health Information

Black men are less likely to seek routine health care examinations or preventative care compared with their racial/ethnic and gender counterparts. Because of Black men's limited engagement with the health system, Black men's preference to receive health information is unclear. Guided by a revised version of the Andersen Healthcare Utilization Model, the aim of the study is to examine factors associated with Black men's preference for informal or formal health information. Findings from the study demonstrate that financial barriers to care (odds ratio [OR] = 0.65, 95% confidence interval [CI] = 0.43-0.98) and higher income (OR = 2.44, 95% CI = 1.49-4.00) were most predictive of using a formal source for health information. Furthermore, age (OR = 1.02, 95% CI = 1.01-1.03) and having a college education (OR = 0.44, 95% CI = 0.26-0.76) were associated with using a formal place for health information. Interestingly, health care discrimination was not associated with preferred source or place for health information. Results from the study suggest that predisposing and enabling factors are most salient to the use of formal sources of health information among Black men.

Masculinity and Race-Related Factors as Barriers to Health Help-Seeking Among African American Men

Men's tendency to delay health help-seeking is largely attributed to masculinity, but findings scarcely focus on African American men who face additional race-related, help-seeking barriers. Building principally on reactance theory, we test a hypothesized model situating racial discrimination, masculinity norms salience (MNS), everyday racism (ERD), racial identity, sense of control (SOC), and depressive symptomatology as key barriers to African American men's health help-seeking. A total of 458 African American men were recruited primarily from US barbershops in the Western and Southern regions. The primary outcome was Barriers to Help-Seeking Scale (BHSS) scores. The hypothesized model was investigated with confirmatory factor and path analysis with tests for measurement invariance. Our model fit was excellent [Formula: see text] CFI = 0.99; TLI = 1.00; RMSEA = 0.00, and 90% CI [0.00, 0.07] and operated equivalently across different age, income, and education strata. Frequent ERD and higher MNS contributed to higher BHHS scores. The relationship between ERD exposure and BHHS scores was partially mediated by diminished SOC and greater depressive symptomatology. Interventions aimed at addressing African American men's health help-seeking should not only address masculinity norms but also threats to sense of control, and negative psychological sequelae induced by everyday racism.

Masculinity Beliefs and Colorectal Cancer Screening in Male Veterans

As the third most common cause of cancer death among United States men, colorectal cancer (CRC) represents a significant threat to men's health. Although adherence to CRC screening has the potential to reduce CRC mortality by approximately half, men's current rates of adherence fall below national screening objectives. In qualitative studies, men have reported forgoing screenings involving the rectum (e.g., colonoscopy) due to concern about breaching masculinity norms. However, the extent to which masculinity beliefs predict men's CRC screening adherence has yet to be examined. The current study tested the hypothesis that greater endorsement of masculinity beliefs (i.e., self-reliance, risk-taking, heterosexual self-presentation, and primacy of work) would be associated with a lower likelihood of adherence to CRC screening with any test and with colonoscopy specifically. Participants were 327 men aged 51-75 at average risk for CRC who were accessing primary care services at a Midwestern Veterans Affairs Medical Center. Contrary to hypotheses, masculinity beliefs did not predict CRC screening outcomes in hierarchical regression analyses that controlled for demographic predictors of screening. Although results are largely inconsistent with masculinity theory and prior qualitative findings, further research is needed to determine the degree to which findings generalize to other populations and settings.

Race, Medical Mistrust, and Segregation in Primary Care as Usual Source of Care: Findings from the Exploring Health Disparities in Integrated Communities Study

Compared to White Americans, African-Americans are less likely to use primary care (PC) as their usual source of care. This is generally attributed to race differences in socioeconomic status and in access to primary care services. Little is known about the relationship between race differences in medical mistrust and the usual source of care disparity. Using data from the Exploring Health Disparities in Integrated Communities (EHDIC) study, we examined the role of medical mistrust in choosing usual source of care in 1408 black and white adults who were exposed to the same healthcare facilities and low-income racially integrated community. Multinomial logistic regression models were estimated to examine the relationship between race, medical mistrust, and usual source of care. After adjusting for demographic and health-related factors, African-Americans were more likely than whites to use the emergency department (ED) (relative risk ratio [RRR] = 1.43 (95 % confidence interval (CI) [1.06-1.94])) and hospital outpatient department (RRR1.50 (95 %CI [1.10-2.05])) versus primary care as a usual source of care. When medical mistrust was added to the model, the gap between African-Americans' and whites' risk of using the ED versus primary care as a usual source of care closed (RRR = 1.29; 95 % CI [0.91-1.83]). However, race differences in the use of the hospital outpatient department remained even after accounting for medical mistrust (RRR = 1.67; 95 % CI [1.16-2.40]). Accounting for medical mistrust eliminated the ED-as-usual-source of care disparity. This study highlights the importance of medical mistrust as an intervention point for decreasing ED use as a usual source of care by low-income, urban African-Americans.

Understanding help-seeking intentions in male military cadets: An application of perceptual mapping

Background

Research suggests that men are less likely to seek help for depression, substance abuse, and stressful life events due to negative perceptions of asking for and receiving help. This may be exacerbated in male military cadets who exhibit higher levels of gender role conflict because of military culture.

Methods

This exploratory study examined the perceptions of 78 male military cadets toward help-seeking behaviors. Cadets completed the 31-item Barriers to Help Seeking Scale (BHSS) and a component factor analysis was used to generate five composite variables and compare to validated factors. Perceptual mapping and vector modeling, which produce 3-dimensional models of a group’s perceptions, were then used to model how they conceptualize help-seeking.

Results

Factor analysis showed slightly different groupings than the BHSS, perhaps attributed to different characteristics of respondents, who are situated in a military school compared to general university males. Perceptual maps show that cadets perceive trust of doctors closest to them and help-seeking farthest, supporting the concept that these males have rigid beliefs about having control and its relationship to health seeking. Differences were seen when comparing maps of White and non-White cadets. White cadets positioned themselves far away from all variables, while non-White cadets were closest to “emotional control”.

Conclusion

To move these cadets toward help-seeking, vector modeling suggests that interventions should focus on their general trust of doctors, accepting lack of control, and decreasing feelings of weakness when asking for help. For non-White cadets a focus on self-reliance may also need to be emphasized. Use of these unique methods resulted in articulation of specific barriers that if addressed early, may have lasting effects on help-seeking behavior as these young men become adults. Future studies are needed to develop and test specific interventions to promote help-seeking among military cadets.

Medical mistrust among social network members may contribute to antiretroviral treatment nonadherence in African Americans living with HIV

RATIONALE

African Americans living with HIV are less likely to adhere to antiretroviral treatment (ART) compared to other racial/ethnic groups. Medical mistrust is thought to be a factor in this disparity.

OBJECTIVE

We examined (1) whether exposure to HIV conspiracy beliefs, a specific type of HIV-related mistrust (about the origins and treatment of HIV) in social networks is associated with ART nonadherence among African Americans living with HIV; and (2) the characteristics of individuals who discuss HIV-related mistrust in the social networks of African Americans living with HIV.

METHODS

At baseline and 6- and 12-months post-baseline, 175 African Americans living with HIV on ART completed egocentric social network assessments, from which we assessed the structure and composition of their personal networks (the social context immediately surrounding them). HIV-related mistrust was operationalized with an indicator of whether any social network member had expressed HIV conspiracy beliefs to the participant. Daily medication adherence was monitored electronically.

RESULTS

At baseline, 63% of participants agreed with at least one conspiracy belief, and 55% reported hearing at least one social network member ("alter") express conspiracy beliefs. In a multivariate linear repeated measures regression, expression of conspiracy beliefs by similar others in the network (in terms of age, gender, HIV status, sexual orientation, and race/ethnicity) was associated with ART nonadherence (i.e., percentage of prescribed doses taken). In a multivariate logistic regression, expression of conspiracy beliefs was more likely among social network members who were HIV-positive, who knew the participants' serostatus, and with whom participants interacted frequently, and less likely among more well-connected social network members.

CONCLUSION

HIV-related mistrust in the network may be most influential when expressed by similar others who may be HIV-positive themselves.

Using the Bem and Klein Grid Scores to Predict Health Services Usage by Men

We examined the association between scores on the Bem Sex Roles Inventory (BSRI), Klein Sexual Orientation Grid, and utilization of hospital inpatient services, emergency departments, and outpatient clinic visits in the past 12 months among 53 men (mean age 39 years). The femininity subscale score on the BSRI, ever having had gonorrhea and age were the three variables identified in a multivariate linear regression significantly predicting use of total health services. This supports the hypothesis that sex roles can assist our understanding of men's use of health services.

The Interdependence of African American Men's Definitions of Manhood and Health

In this article, we explore themes that cut across how 24- to 77-year-old African American men define manhood and health. Utilizing a thematic approach, we analyzed data from 9 focus groups (N = 73). We found that manhood and health were relational constructs that are interrelated in men's minds and experiences. Manhood and health were defined by the characteristics men embody, the behaviors men engage in, and the goals and values men had to positively influence their families and communities. Thus, manhood and health are interdependent constructs and their interrelationship should be considered in efforts to promote African American men's health.

Marketing a Healthy Mind, Body, and Soul: An Analysis of How African American Men View the Church as a Social Marketer and Health Promoter of Colorectal Cancer Risk and Prevention

The Centers for Disease Control and Prevention ranks colorectal cancer (CRC) as the third most commonly diagnosed cancer among men in the United States; African American (AA) men are at even greater risk. The present study was from a larger study that investigates the church's role as a social marketer of CRC risk and prevention messages, and whether religiously targeted and tailored health promotion materials will influence screening outcome. We used an integrated theoretical approach to explore participants' perceptions of CRC risk and prevention and how promotion messages should be developed and socially marketed by the church. Six focus groups were conducted with men from predominately AA churches in the Midwest. Themes from focus group discussions showed participants lacked knowledge about CRC, feared cancer diagnosis, and feared the procedure for screening. Roles of masculinity and the mistrust of physicians were also emergent themes. Participants did perceive the church as a trusted marketer of CRC but believed that promotional materials should be cosponsored and codeveloped by reputable health organizations. Employing the church as a social marketer of CRC screening promotion materials may be useful in guiding health promotions and addressing barriers that are distinct among African American men.

Age cohort differences in illicit drug use and hepatitis C among African American substance users

Identifying prognostic indicators for undiagnosed Hepatitis C is crucial to attenuate the negative impact of this disease. This study explored the influence of recent and more distal injection drug use on biologically confirmed Hepatitis C infection among a sample (N = 260) of older and younger African Americans. Data from the baseline assessment of the NEURO-HIV epidemiologic study was analyzed using confounder adjusted regression techniques. Older adults were more likely to test positive for Hepatitis C (OR = 2.80, 95% CI = 1.53-5.11) due to lifetime injection drug use (AOR = 5.37, 95% CI = 3.10-9.28). Clinical implications are discussed.

Chill, be cool man: African American men, identity, coping, and aggressive ideation

Aggression is an important correlate of violence, depression, coping, and suicide among emerging young African American males. Yet most researchers treat aggression deterministically, fail to address cultural factors, or consider the potential for individual characteristics to exert an intersectional influence on this psychosocial outcome. Addressing this gap, we consider the moderating effect of coping on the relationship between masculine and racial identity and aggressive ideation among African American males (N = 128) drawn from 2 large Midwestern universities. Using the phenomenological variant of ecological systems theory and person-centered methodology as a guide, hierarchical cluster analysis grouped participants into profile groups based on their responses to both a measure of racial identity and a measure of masculine identity. Results from the cluster analysis revealed 3 distinct identity clusters: Identity Ambivalent, Identity Appraising, and Identity Consolidated. Although these cluster groups did not differ with regard to coping, significant differences were observed between cluster groups in relation to aggressive ideation. Further, a full model with identity profile clusters, coping, and aggressive ideation indicates that cluster membership significantly moderates the relationship between coping and aggressive ideation. The implications of these data for intersecting identities of African American men, and the association of identity and outcomes related to risk for mental health and violence, are discussed.

Why do people avoid medical care? A qualitative study using national data

BACKGROUND

Many studies have examined barriers to health care utilization, with the majority conducted in the context of specific populations and diseases. Less research has focused on why people avoid seeking medical care, even when they suspect they should go.

OBJECTIVE

The purpose of the study was to present a comprehensive description and conceptual categorization of reasons people avoid medical care.

DESIGN

Data were collected as part of the 2008 Health Information National Trends Survey, a cross-sectional national survey.

PARTICIPANTS

Participant-generated reasons for avoiding medical care were provided by 1,369 participants (40% male; M age =48.9; 75.1% non-Hispanic white, 7.4% non-Hispanic black, 8.5% Hispanic or Latino/a).

MAIN MEASURES

Participants first indicated their level of agreement with three specific reasons for avoiding medical care; these data are reported elsewhere. We report responses to a follow-up question in which participants identified other reasons they avoid seeking medical care. Reasons were coded using a general inductive approach.

KEY RESULTS

Three main categories of reasons for avoiding medical care were identified. First, over one-third of participants (33.3% of 1,369) reported unfavorable evaluations of seeking medical care, such as factors related to physicians, health care organizations, and affective concerns. Second, a subset of participants reported low perceived need to seek medical care (12.2%), often because they expected their illness or symptoms to improve over time (4.0%). Third, many participants reported traditional barriers to medical care (58.4%), such as high cost (24.1%), no health insurance (8.3%), and time constraints (15.6%). We developed a conceptual model of medical care avoidance based on these results.

CONCLUSIONS

Reasons for avoiding medical care were nuanced and highly varied. Understanding why people do not make it through the clinic door is critical to extending the reach and effectiveness of patient care, and these data point to new directions for research and strategies to reduce avoidance.

Cognition and health in African American men

OBJECTIVE

Despite high rates of poor health outcomes, little attention has been focused on associations between prominent health factors and cognitive function in African American men, exclusively. The objective was to examine relationships between cardiovascular and pulmonary health, and cognitive function in African American men.

METHOD

Data from 257 men were pooled from two studies of African American aging. The mean age of participants was 58.15 and mean educational attainment was 11.78 years. Participants provided self-reported health and demographic information, completed cognitive measures, and had their blood pressure and peak expiratory flow assessed.

RESULTS

After adjustment, significant relationships were found between average peak expiratory flow rate (APEFR) and cognitive performance measures.

DISCUSSION

Results suggest that lung function is important to consider when examining cognitive function in African American men. Understanding the role of health in cognition and implications for quality of life in this population will be critical as life expectancies increase.

Informal and Formal Help Seeking Among Older Black Male Foster Care Youth and Alumni

Using the behavioral model for vulnerable populations as a framework, this study examined predisposing, enabling, and need factors related to seeking help from formal and informal sources among older Black male foster youth and alumni. Results of logistic regression analyses showed that emotional control, a predisposing variable, was related to help-seeking. Specifically, greater adherence to the norm of emotional control was related to lower likelihood of using informal or formal sources of help. These results support the literature on males, in general, and Black males, in particular, that posits that inhibitions to express emotions are a barrier to their help seeking. Implications for help seeking among vulnerable populations of adolescent and young adult Black males are discussed.

The Relationship Between Education and Prostate-Specific Antigen Testing Among Urban African American Medicare Beneficiaries

PURPOSE

We examined the association between socioeconomic status (SES) and prostate-specific antigen (PSA) cancer screening among older African American men.

METHODS

We analyzed baseline data from a sample of 485 community-dwelling African American men who participated in the Cancer Prevention and Treatment Demonstration Trial. The outcome was receipt of PSA screening within the past year. SES was measured using income and educational attainment. Sequential multivariate logistic regression models were performed to study whether health care access, patient-provider relationship, and cancer fatalism mediated the relationship between SES and PSA screening.

RESULTS

Higher educational attainment was significantly associated with higher odds of PSA screening in the past year (odds ratio (OR) 2.08 for college graduate compared to less than high school graduate, 95 % confidence interval (CI) 1.03-4.24); income was not. Health care access and patient-provider communication did not alter the relationship between education and screening; however, beliefs regarding cancer fatalism partially mediated the observed relationship.

CONCLUSION

Rates of prostate cancer screening among African American men vary by level of educational attainment; beliefs concerning cancer fatalism help explain this gradient. Understanding the determinants of cancer fatalism is a critical next step in building interventions that seek to ensure equitable access to prostate cancer screening.

Medical mistrust is related to lower longitudinal medication adherence among African-American males with HIV

African-Americans living with HIV show worse health behaviors (e.g. medication adherence) and outcomes (e.g. viral suppression) than do their White counterparts. In a 6-month longitudinal study, we investigated whether medical mistrust among African-American males with HIV (214 enrolled, 140 with longitudinal data) predicted lower electronically monitored antiretroviral medication adherence. General medical mistrust (e.g. suspicion toward providers), but not racism-related mistrust (e.g. belief that providers treat African-Americans poorly due to race), predicted lower continuous medication adherence over time (b = -.08, standard error = .04, p = .03). Medical mistrust may contribute to poor health outcomes. Intervention efforts that address mistrust may improve adherence among African-Americans with HIV.

Masculinity impediments: Internalized masculinity contributes to healthcare avoidance in men and women

Gender beliefs contribute to men's healthcare avoidance, but little research examines these outcomes in women. This article models healthcare avoidance related to masculine contingencies of self-worth in men and women. Nested path modelling tested relationships between social role beliefs, masculine contingencies of self-worth, barriers to help seeking and avoidance of health care in university and non-university-student adult samples. Results indicated social role beliefs predicted masculine contingencies of self-worth in men but not in women. Regardless of gender, masculine contingencies of self-worth predicted barriers to help seeking, which predicted healthcare avoidance in both men and women. Thus, masculine contingencies of self-worth have downstream consequences for men and women through barriers to help seeking.

Forests, Trees, and Streams: Why an Integration of Discursive Psychological Frameworks and Gender Role Strain Paradigms Is Needed

The current article provides commentary on Wetherell and Edley's (2014) article, "A Discursive Psychological Framework for Analyzing Men and Masculinities." Using examples from their published research, the authors present and challenge methodologies stemming from the gender role strain paradigm (GRSP). The core argument presented in their article is that discursive psychological approach (DP) provides a better framework for capturing situational masculinities. In this commentary, I argue for less methodological essentialism in the psychology of men and masculinities. DP has great utility for examining the ways men talk about situational enactment of masculinities. However, they do not resolve all of our methodological dilemmas. Chiefly, I suggest that we have more to gain from integrating DP frameworks and GRSP than from using either of these methods alone.

The characteristics and impact of a hospitalist-staffed post-discharge clinic

BACKGROUND

Limited primary care access and care discontinuities hamper care for patients following hospital discharge. As the proportion of inpatient care delivered by hospitalists continues to increase, hybrid models that incorporate hospitalists in post-discharge care may ameliorate this problem.

METHODS

We established a post-discharge clinic staffed by hospitalists in a large academic urban primary care practice in October 2009. We compared visits of recently hospitalized patients seen in the post-discharge clinic with post-discharge visits elsewhere in the practice, including patient demographics, health care utilization, and duration from discharge, using generalized estimating equations to account for repeated hospitalizations.

RESULTS

Patients seen in the post-discharge clinic and elsewhere in the practice were generally similar, although patients seen in the post-discharge clinic were particularly likely to be black and receive primary care from residents. Relative to other patients seen following discharge, patients in the post-discharge clinic were seen 8.45 ± 0.43 days earlier (P <.001). Among all 10,845 discharges of Healthcare Associates patients between 2009 and 2011, patients were 40% more likely to be seen within a week of discharge when the post-discharge clinic was open than when it was closed (adjusted odds ratio 1.41; 95% confidence interval, 1.25-1.57).

CONCLUSION

In this primary care practice, a hospitalist-staffed post-discharge clinic was associated with substantially shorter time to first post-hospitalization visit and with improvement in the overall likelihood of an early visit among all hospitalized patients. It was particularly used by black patients and those seen by residents, in whom access tends to be most fragmented, and may represent a novel approach to the problem of post-discharge care.

Shared decision-making about colorectal cancer screening: a conceptual framework to guide research

OBJECTIVE

To develop a conceptual framework to guide research on shared decision-making about colorectal cancer (CRC) screening among persons at average risk and their providers.

METHODS

Based upon a comprehensive review of empirical literature and relevant theories, a conceptual framework was developed that incorporated patient characteristics, cultural beliefs, provider/health care system variables, health belief/knowledge/stage of adoption variables, and shared decision-making between patients and providers that may predict behavior. Relationships among concepts in the framework, shared decision-making process and outcomes, and CRC screening behavior were proposed. Directions for future research were presented.

RESULTS

Many of the concepts in the proposed framework have been examined in prior research. However, these elements have not been combined previously to explain shared decision-making about CRC screening.

CONCLUSION

Research is needed to test the proposed relationships and hypotheses and to refine the framework.

PRACTICE IMPLICATIONS

Findings from future research guided by the proposed framework may inform clinical practice to facilitate shared decision-making about CRC screening.

Health-Related Stereotype Threat Predicts Health Services Delays Among Blacks

To our knowledge, no published research has developed an individual difference measure of health-related stereotype threat (HRST). We adapted existing measures of academic stereotype threat to the health domain on a sample of black college students (N = 280). The resulting health-related stereotype threat scale-24 (HRST-24) was assessed for internal consistency, construct and incremental validity, and whether it explains variance in self-reported delays among four preventive health behaviors-blood pressure and cholesterol assays, physical exams, and routine checkups. After adjusting for several control variables, the HRST-24's (full scale α = 0.96) perceived black health inferiority (18 items; α = 0.96) and perceived physician racial bias (6 items; α = 0.85) sub-scales explained unique variance in delays among two of the four behaviors including a blood cholesterol check (p < .01) and routine checkup-albeit at marginal levels (p = .063) in the case of the latter. Overall, these data provide preliminary evidence of construct and incremental validity for the HRST-24 among blacks. Recommendations for administering the scale are provided and future directions for HRST research are discussed.

Health care and HIV testing experiences among Black men in the South: implications for "Seek, Test, Treat, and Retain" HIV prevention strategies

Few studies have explored how overall general health care and HIV/STI testing experiences may influence receipt of "Seek, Test, Treat, and Retain" (STTR) HIV prevention approaches among Black men in the southern United States. Using in-depth qualitative interviews with 78 HIV-negative/unknown Black men in Georgia, we explored factors influencing their general health care and HIV/STI testing experiences. The Andersen behavioral model of health care utilization (Andersen model) offers a useful framework through which to examine the general health care experiences and HIV testing practices of Black men. It has four primary domains: Environment, Population characteristics, Health behavior, and Outcomes. Within the Andersen model framework, participants described four main themes that influenced HIV testing: access to insurance, patient-provider communication, quality of services, and personal belief systems. If STTR is to be successful among Black men, improving access and quality of general health care, integrating HIV testing into general health care, promoting health empowerment, and consumer satisfaction should be addressed.

Racial Discrimination and Depressive Symptoms Among African-American Men: The Mediating and Moderating Roles of Masculine Self-Reliance and John Henryism

Despite well-documented associations between everyday racial discrimination and depression, mechanisms underlying this association among African-American men are poorly understood. Guided by the Transactional Model of Stress and Coping, we frame masculine self-reliance and John Henryism as appraisal mechanisms that influence the relationship between racial discrimination, a source of significant psychosocial stress, and depressive symptoms among African-American men. We also investigate whether the proposed relationships vary by reported discrimination-specific coping responses. Participants were 478 African-American men recruited primarily from barbershops in the West and South regions of the United States. Multiple linear regression and Sobel-Goodman mediation analyses were used to examine direct and mediated associations between our study variables. Racial discrimination and masculine self-reliance were positively associated with depressive symptoms, though the latter only among active responders. John Henryism was negatively associated with depressive symptoms, mediated the masculine self-reliance-depressive symptom relationship, and among active responders moderated the racial discrimination-depressive symptoms relationship. Though structural interventions are essential, clinical interventions designed to mitigate the mental health consequences of racial discrimination among African-American men should leverage masculine self-reliance and active coping mechanisms.

The potential influence of masculine identity on health-improving behavior in midlife and older African American men

OBJECTIVE

To gain a greater understanding of masculinity and its potential influence on health-improving behavior in midlife and older African American (AA) men.

METHODS

Forty-nine AA men aged 45-88 years completed in-depth interviews to ascertain their perspectives on masculinity, how masculine identity in this population might be influenced by age and physical activity level, or how it might impact health. Taped interviews were transcribed and organized for analysis with common themes identified by multiple researchers.

RESULTS

Most often cited attributes of someone considered "manly" included a leader of a family/household, provider, strong work ethic, and masculine physique. Terms such as responsible, principled, and man of character also described the typical man. Potential negative and positive influences of manhood on health included avoiding health care appointments and being a good example to children/others, respectively. Themes associated with age-related changes in manhood were acceptance and being more health conscious. Elements associated with how manhood was influenced by AA race included stress and perseverance.

CONCLUSIONS

Midlife and older AA men in this study primarily expressed views of masculinity that fit the traditional perception of manhood. However, the attributes revealed, such as family provider, responsibility, self-reliance, and perseverance, were viewed as having potential for both negative and positive impacts on health and health-improving behaviors. It will be essential to integrate these prevalent attributes of masculine identity into health promotion interventions such that they facilitate positive behavior change while not competing with gender role norms among this vulnerable group of men.

Taking it like a man: masculine role norms as moderators of the racial discrimination-depressive symptoms association among African American men

OBJECTIVES

I examined the association between everyday racial discrimination and depressive symptoms and explored the moderating role of 2 dimensions of masculine role norms, restrictive emotionality and self-reliance.

METHODS

Cross-sectional survey data from 674 African American men aged 18 years and older recruited primarily from barbershops in 4 US regions (2003-2010) were used. Direct and moderated associations were assessed with multivariate linear regression analyses for the overall sample and different age groups. Models were adjusted for recruitment site, sociodemographics, masculine role norms salience, and general social stress.

RESULTS

Everyday racial discrimination was associated with more depressive symptoms across all age groups. Higher restrictive emotionality was associated with more depressive symptoms among men aged 18 to 29 and 30 to 39 years. Self-reliance was associated with fewer depressive symptoms among men aged 18 to 29 years and 40 years and older. The positive association between everyday racial discrimination and depressive symptoms was stronger among men with high restrictive emotionality, but this moderated effect was limited to men older than 30 years.

CONCLUSIONS

Interventions designed to reduce African American men's depression instigated by racism should be life-course specific and address masculine role norms that encourage emotion restriction.

Measuring masculinity in research on men of color: findings and future directions

The purpose of this study was to examine the association between masculinity and the health of US men of color aged 18 years and older. We identified 22 population-based studies that included a measure of masculinity and a measure of health behavior, mental health, or physical health. The associations between masculinity and health were complex and varied by construct and health outcome, though they generally were significant in the hypothesized directions. Future research should explore the centrality of masculinity versus other identities and characteristics, how the relationship between masculinity and health varies by health outcome, and the identification of the conceptions and aspects of masculinity that are most relevant to and associated with specific health behaviors and health outcomes.

Impact of an electronic alert and order set on smoking cessation medication prescription

INTRODUCTION

Tobacco cessation medication use increases the likelihood of a successful quit attempt, but few smokers are prescribed medications. Electronic health records (EHRs) may increase cessation medication prescription. This study aimed to assess the impact of an electronic alert and linked order set on cessation medication prescription.

METHODS

This pre- and postintervention cohort study was conducted in an urban academic general internal medicine practice with a comprehensive EHR. All active smokers with 2 or more visits to the practice in 2008 (preintervention cohort) or 2009 (postintervention cohort) were included. An electronic alert and linked order set were designed and implemented. The primary outcome was prescription of any cessation medication (nicotine replacement therapy, bupropion, or varenicline). Secondary outcomes included counseling referral and change in smoking status to quit during the study period (i.e., "quit rate").

RESULTS

There were 1,349 and 1,346 smokers in the pre- and postintervention cohorts, respectively. Cessation medication prescription did not significantly change after the intervention (14.4% vs. 13.4% of smokers in the preintervention cohort, p = .5). Counseling referrals increased from 2.0% to 7.2% in the postintervention cohort (p < .001). More smokers in the postintervention cohort changed their smoking status to quit during the study period (20.5% vs. 17.1%, p = .06).

CONCLUSIONS

This provider-directed electronic alert and linked order set failed to increase cessation medication prescription. The consistent failure of provider-directed efforts to increase cessation medication use suggests that this is a patient-limited process. Future efforts to improve tobacco treatment should focus on overcoming patient-level barriers to cessation medication use.

Determinants of usual source of care disparities among African American and Caribbean Black men: findings from the National Survey of American Life

PURPOSE

The Aday-Andersen model was used as a framework for investigating the contribution of immigration status (i.e., nativity and acculturation), socioeconomic factors, health care access, health status, and health insurance to usual source of health care (USOC) in a nationally representative sample of African American (n=551) and Caribbean Black men (n=1,217).

METHODS

We used the 2001-2003 National Survey of American Life, a nationally representative household survey of non-institutionalized U.S. Blacks to conduct descriptive and logistic regression analyses.

RESULTS

Older age, more health conditions, neighborhood medical clinic access, and health insurance were associated with higher odds of reporting a USOC. Odds were lower for men with lower-middle incomes and poorer mental health status. Having health insurance was associated with higher odds of reporting a USOC for African American men but lower odds among Caribbean Black men. Odds were higher in the presence of more health conditions for African American men than for Caribbean Black men.

CONCLUSIONS

Health care reform policies aimed solely at increasing health insurance may not uniformly eliminate USOC disparities disfavoring U.S. and foreign-born non-Hispanic Black men.