Social network and individual correlates of sexual risk behavior among homeless young men who have sex with men

Social networks, mobility, and HIV risk among women in the fishing communities of Lake Victoria

BACKGROUND

Population mobility is a demonstrated barrier to reducing HIV incidence. A clear understanding of social networks and their influence on mobility among women in the fishing communities of Lake Victoria may contribute to tailoring effective interventions that suit the needs of these mobile women.

METHODS

A cross-sectional qualitative methods study was conducted to understand mobility patterns among women resident and or working in fishing communities of Lake Victoria in Kenya, Tanzania, and Uganda. The study was conducted in six fishing communities from March 2018 to June 2019. The communities were purposively selected, based on population size (1000 people or more) and HIV prevalence of > 15% among women aged 18 years or older who had lived in the fishing community for at least six months. In-depth interviews were conducted with 24 key informants and 72 women from the sites in the three countries. Questions focused on women's social networks and other factors that fuelled or facilitated women's mobility as well as challenges they faced due to mobility. Data analysis followed a thematic framework approach.

RESULTS

Different social groupings/networks existed among women in the fishing communities of Lake Victoria. These included female sex workers, women fish processors/traders, women bar workers/owners, restaurant workers, and family networks. Networks encouraged mobility, supporting finding work opportunities, but also increased sexual risks through partner changes. The benefits of networks included information sharing, financial support, and group protection, especially against violence.

CONCLUSION

Social networks and groupings among women in the fishing communities of Lake Victoria could be useful in tailoring HIV prevention and HIV care interventions to suit the needs of these highly mobile populations.

Sexual risk behaviour among school-going adolescents in Sierra Leone and Liberia: a secondary analysis of the 2017 Global school-based student health surveys

BACKGROUND

Sierra Leone and Liberia have experienced civil wars and, recently, Ebola outbreaks that led to profound economic hardship, psychopathologies and family disruptions. These factors are associated with sexual risk behaviours among youths. However, there is very little information on sexual risk behaviour among Sierra Leonean and Liberian school-going adolescents. The present study assessed the prevalence and determinants of sexual risk behaviours among school-going adolescents (10-19 years) in Sierra Leone and Liberia.  METHOD: We used publicly available nationally representative cross-sectional datasets of the 2017 Sierra Leone and Liberia Global school health survey. The sample consisted of 2798 and 2744 school-going adolescents from Sierra Leone and Liberia, respectively. Complex sample descriptive and regression analysis was used to analyse our data.

RESULTS

The majority of adolescents in the two countries were involved in multiple sexual risk behaviour (80.2%), with a higher prevalence observed in Sierra Leone (85.2%) than in Liberia (75.3%). Liberian adolescents showed lesser odds of indulging in multiple sexual risk behaviours than their Sierra Leonean counterparts (AOR = 0.572; 95%CI: 0.345-0.946). Male, compared to females, were more likely to engage in multiple sexual risk behaviour (AOR = 2.310;95%CI:1.543-3.458), with a similar pattern observed in both countries. Alcohol use was associated with multiple sexual risk behaviour (AOR = 3.064; 95%CI: 2.137-4.392). Also, in Sierra Leone and Liberia, adolescents with one and two or more forms of psychological distress were more likely to have ever had sex than those who did not show any form of psychological distress. Missing class/school was associated with multiple sexual risk behaviour (AOR = 1.655; 95%CI:1.133-2.418). Peer support was only found to be a protective factor against no condom use among Liberian adolescents (AOR = 0.608; 95%CI: 0.435-0.850). Less parental support was only associated with ever had sex among adolescents in Sierra Leone (AOR = 2.027; 95%CI: 1.322-3.107) but not in Liberia (AOR = 1.034; 95%CI: 0.650-1.644).

CONCLUSION

Our study found a high sexual risk behaviour among school-going adolescents in Sierra Leone and Liberia. Our finding highlights the need to strengthen sexual and reproductive health education in schools and communities that incorporate mental health promotion activities tailored to this group.

Precarious manhood and intentions to initiate preexposure prophylaxis among Black sexual minority men

OBJECTIVE

The use of preexposure prophylaxis (PrEP) to prevent HIV infection is significantly low among Black sexual minority men (BSMM), although this group experiences the greatest HIV burden in the United States. One contextual factor suggested to impact BSMM's HIV prevention efforts is the concern about, and adherence to, cultural conceptions and expectations of masculinity. The present study sought to better understand the association between masculinity and PrEP uptake by examining associations between gender-relevant beliefs and perceptions, and intentions to initiate PrEP among a sample of BSMM residing in the U.S. South.

METHOD

Participants (N = 114) completed assessments of precarious manhood beliefs, attitudes toward PrEP, concerns about PrEP use impacting support from social networks, projected perceptions of masculinity, and intentions to initiate PrEP.

RESULTS

Precarious manhood beliefs were associated with greater intention to initiate PrEP; however, the indirect path of this association through attitudes toward PrEP was associated with lower intentions to initiate PrEP. In a hierarchical regression model, projected perceptions of masculinity were associated with intentions to initiate PrEP over and above other factors considered. Specifically, believing that one will be perceived as less masculine for seeking PrEP was associated with lower intentions to initiate PrEP.

CONCLUSIONS

Findings suggest that BSMM's construal of masculinity in relation to HIV and PrEP is associated with intentions to initiate PrEP. Implications for increasing PrEP uptake among BSMM are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Prevalence and Correlates of Illicit Substance Use Among Young Adults Experiencing Homelessness in Seven Cities Across the United States

Background

Young adults experiencing homelessness (YAEH) engage in substantially higher substance use rates than housed young adults. This current study builds on previous research by investigating the prevalence of and salient correlates of illicit substance use across a seven-city sample.

Methods

This study used the Homeless Youth Risk and Resiliency Survey (HYRRS) dataset, n=1426 Young adults experiencing homelessness to study patterns and correlates of illicit substance use.

Results

Multivariate logistic regression analyses were used to assess correlates of substance use. Study site, age, gender identity, sexual orientation, history of suicidal ideation, use of specific substances, and trading sex for drugs were associated with five types of illicit substance use (ecstasy, cocaine, crack, methamphetamine, and injection drug use).

Conclusion

Findings indicate that substance use interventions for YAEH must be multifaceted, addressing illicit and multiple substance use, along with the myriad factors associated with substance use among this at-risk group.

Social Network Change after Moving into Permanent Supportive Housing: Who Stays and Who Goes?

Social relationships are important among persons experiencing homelessness, but there is little research on changes in social networks among persons moving into permanent supportive housing (PSH). Using data collected as part of a longitudinal study of 405 adults (aged 39+) moving into PSH, this study describes network upheaval during this critical time of transition. Interviews conducted prior to and after three months of living in PSH assessed individual-level characteristics (demographics, homelessness history, health and mental health) and included a social network component that assessed network size and composition (demographics, relationship type, social support); interviewers utilized network member characteristics to assess whether network members were new or sustained between baseline and 3 months post-housing. Multilevel logistic regression models assessed what characteristics of network members were associated with being newly-gained or persisting in networks 3 months after moving into PSH. We found that only one-third of social networks were retained during the transition to PSH, and that veterans, African Americans and other persons of racial/ethnic minorities, and those living in scattered-site housing were more likely to experience network disruption. Relatives, romantic partners, and service providers were most likely to be retained after move-in. Some network change was moderated by tie strength, including the retention of street-met persons. Implications are discussed.

Networks Among Racial and Ethnic Minority Men Who Have Sex With Men in HIV Research in the United States: A Concept Analysis

In the past 10 years, research has proliferated investigating the effects of sexual and social networks on the transmission of HIV, especially among racial/ethnic minority men who have sex with men (MSM). This research, however, has been inconsistent in its application of social network theory leading to variations in the measurement of networks and a lack of clarity in the interpretation of results from studies of network data. Efforts to delineate how networks are defined, measured, and interpreted are needed to advance the science of HIV prevention and promote health equity. The aims of this article are to review the literature around networks among racial/ethnic minority MSM, use concept analysis methods to clarify the definition and scope of the concept of networks, and to develop a network typology that can be used to guide measurement and interpretation of networks for HIV research with racial/ethnic minority MSM.

The Role of Networks in Racial Disparities in HIV Incidence Among Men Who Have Sex with Men in the United States

Network factors have been proposed as potential drivers of racial disparities in HIV among Black and Latino men who have sex with men (MSM). This review aimed to synthesize the extant literature on networks and racial disparities in HIV among MSM and identify potential directions for future research. We searched databases for peer-reviewed articles published between January 1, 2008 and July 1, 2018. Articles were included if the sample was comprised primarily of racial/ethnic minority MSM and measured one or more network characteristics. (n = 25). HIV prevalence in networks, social support, and structural barriers were linked to disparities in HIV for Black MSM. Future research should focus on intervention development around social support and other strategies for risk reduction within networks. Given the contribution of structural factors to racial/ethnic HIV disparities, network-level interventions should be paired with policies that improve access to housing, jobs, and education for MSM.

Factors Associated With HIV Testing Among Atlanta's Homeless Youth

Homeless youth experience increased risk of contracting HIV, making HIV testing imperative in this population. We analyzed factors associated with HIV testing among homeless youth in Atlanta, Georgia using data from the 2015 Atlanta Youth Count and Needs Assessment. The analysis included 693 homeless youth aged 14-25 years, of whom 88.4% reported ever being tested for HIV, and 74.6% reported being tested within the previous year. Prevalence of ever testing for HIV was significantly higher among youth who reported risk factors for HIV (sexually active, transactional sex, or ever having an STI). Higher prevalence of testing within the last year was significantly associated with experiencing physical abuse or transactional sex. However, reporting ≥ 4 sexual partners or not using condoms were not associated with higher testing. Although testing prevalence among homeless youth was high, homeless youth engaging in certain high risk behaviors could benefit from further promotion of HIV testing.

Sexual risk classes among youth experiencing homelessness: Relation to childhood adversities, current mental symptoms, substance use, and HIV testing

The aim of this study was to determine whether there are meaningful subgroups with different types of sexual risk behaviors among youth experiencing homelessness and examine the associations between potential classes and other risk variables. A latent class analysis was used to identify classes of youth according to sexual risk behaviors and sexual assault. A two-class solution was found to be the best fit for the data-Lower and Higher Risk groups. The Higher Risk class had significantly higher levels of synthetic marijuana and alcohol use, mental health diagnoses, and were more likely to have been tested for HIV than the Lower Risk group. Youth were more likely to be in the Higher Risk group if they were cisgender female or lesbian, gay, bisexual, or questioning (LGBQ). Nearly all youth (10/11) who reported having HIV infection were in the Higher Risk group. The Lower Risk group were sexually active but had lower rates of risk behaviors and sexual assault. Youth who were not sexually active had the lowest rates of marijuana and alcohol use as well as HIV testing. Health and social service providers should be aware of the added risks for stress, mental distress, mental health diagnoses, and substance use among youth who also report higher risk sexual behaviors and treat as needed.

Mental health change in the transition to permanent supportive housing: The role of housing and social networks

AIMS

Permanent Supportive Housing (PSH) may improve homeless adults' mental health via housing stabilization and/or improved relational factors, however, the role of housing and social networks on PSH residents' mental health change is minimally understood.

METHODS

Interviews were conducted with a baseline sample of adults experiencing homelessness ( N = 421), across their initial year in PSH (3-months, 6-months, and 12-months). Generalized linear mixed models assessed changes in positive past-month psychiatric disability screenings (Modified-Colorado Symptom Index [MCSI]) and probable posttraumatic stress disorder (PC-PTSD) in controlled models, and between and within-subject effects of time-varying social network correlates on mental health changes.

RESULTS

Compared with baseline, positive MCSI screens continuously decreased over time (56%, 54%, and 50%) while PC-PTSD screens declined initially (40%) with marginal decreases at remaining follow-ups (39% and 38%). These differences remained significant in controlled models. Gaining a romantic partner was associated with a longitudinal increase in a positive MCSI screening. Between subjects, emotional health counselors and conflicting network members were associated with an increased likelihood in positive screenings, while doctors and case managers were protective.

CONCLUSION

Housing may facilitate positive changes in PSH residents' mental health, yet positive screenings remain high. Social network interventions that increase residents' positive interpersonal exchanges and prosocial relationships are warranted.

Brief Report: Role of Sociobehavioral Factors in Subprotective TFV-DP Levels Among YMSM Enrolled in 2 PrEP Trials

BACKGROUND

Young men who have sex with men (YMSM) experience disparities in HIV acquisition more than any other group. Daily oral pre-exposure prophylaxis (PrEP) with tenofovir/emtricitabine has been shown to effectively prevent HIV transmission in YMSM; however, recent studies suggest that young Black men who have sex with men experience subprotective levels of tenofovir diphosphate more frequently than other groups.

SETTING

Combined data from Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) 110/113, 2 open-label PrEP studies that provided PrEP and evidence-based behavioral interventions to YMSM aged 15-22 years.

METHODS

Bivariate and logistic regression analyses were used to examine sociodemographic and behavioral factors associated with protective tenofovir diphosphate levels (defined as ≥700 fmol/punch) in ATN 110/113 data.

RESULTS

In bivariate analysis, self-identified Black participants, residential displacement due to sexual orientation, low perceived risk, and stigma with the medication were associated with subprotective levels. Hispanic ethnicity was associated with protective levels. In the final models, Black males were less likely to have subprotective levels than non-Black males at 4, 8, and 12 weeks. Self-reported displacement due to sexual orientation was associated with subprotective levels, whereas older age was as associated with protective levels.

CONCLUSIONS

These findings highlight how future behavioral research and biomedical prevention efforts in YMSM will need to address PrEP disparities that may occur in young Black men who have sex with men, perception of risk, and lack of key supportive housing during this period that may be critical factors that contribute to HIV acquisition.

The Association Between Condomless Anal Sex and Social Support Among Black Men Who Have Sex With Men (MSM) in Six U.S. Cities: A Study Using Data from the HIV Prevention Trials Network BROTHERS Study (HPTN 061)

We assessed how egocentric (i.e., self-generated descriptions of a person's social contacts) network structure and composition corresponded with reported instances of condomless receptive and insertive anal intercourse with men who were reportedly HIV-infected or of unknown HIV serostatus in a sample of black men who have sex with men (MSM) in six U.S. cities. Ratings showing a higher percentage of network members who provided social participation and medical support were positively associated with reporting condomless sex. There were also significant positive associations between stimulant use and condomless insertive and receptive anal sex. Future research should examine the social processes that underlie these associations and explore ways that social support can affect HIV prevention efforts for black MSM.

General practice for the poor and specialist services for the rich: inequality evidence from a cross-sectional survey on Hangzhou residents, China

Background

Inequalities in health care services are becoming an increasing concern in the world including in China. This study measured the income-related inequalities of residents in Hangzhou of China in access to general practice and specialist care and identified socioeconomic factors associated with such inequalities.

Methods

A cross-sectional questionnaire survey was conducted on 1048 residents in ten urban communities in Hangzhou, China. The percentage and frequency of respondents visiting general practice (GP) and hospital specialist clinics over the past four weeks prior to the survey were estimated. Income-related inequalities in access to these services were measured by the concentration index. Logistic regression and Poisson regression models were established to decompose the contributions of socioeconomic factors (residency, income, education, marital status, and social health insurance) to the inequalities in the probability and frequency of accessing these services, respectively, after adjustment for the needs factors (age, sex and illness conditions).

Results

The GP services were in favor of the poor, with a concentration index of − 0.0464 and − 0.1346 for the probability and frequency of GP visits, respectively. In contrast, the specialist services were in favor of the rich, with a concentration index of 0.1258 and 0.1279 for the probability and frequency of specialist visits, respectively. Income is the biggest contributor to the inequalities, except for the frequency of visits to specialists in which education played the greatest role.

Conclusions

Income-related inequalities in GP and specialist care are evident in China. Policy interventions should pay increasing attention to the emergence of a two-tier system, potentially enlarging socioeconomic disparities in health care services.

Electronic supplementary material

The online version of this article (10.1186/s12939-019-0966-6) contains supplementary material, which is available to authorized users.

Social Network Support and Decreased Risk of Seroconversion in Black MSM: Results of the BROTHERS (HPTN 061) Study

BACKGROUND AND SETTING

Black men who have sex with men (BMSM) in the United States have disproportionately high HIV infection rates. Social networks have been shown to influence HIV risk behavior; however, little is known about whether they affect the risk of HIV seroconversion. This study uses data from the BROTHERS (HPTN 061) study to test whether contextual factors related to social networks are associated with HIV seroconversion among BMSM.

METHODS

We analyzed data from the BROTHERS study (2009-2011), which examined a multicomponent intervention for BMSM in 6 US cities. We ran a series of Cox regression analyses to examine associations between time-dependent measures of network support (personal/emotional, financial, medical, and social participation) and time to HIV seroconversion. We ran unadjusted models followed by models adjusted for participant age at enrollment and study location.

RESULTS

A total of 1000 BMSM tested HIV negative at baseline and were followed at 6- and 12-month study visits. Twenty-eight men tested HIV positive. In adjusted hazard ratio models, study participants who remained HIV negative had higher proportions of social network members who provided personal/emotional {0.92 [95% confidence interval (CI): 0.85 to 0.99]}, medical [0.92 (95% CI: 0.85 to 0.99)], or social participation [0.91 (95% CI: 0.86 to 0.97)] support.

CONCLUSION

Findings suggest that the increased presence of social network support can be protective against HIV acquisition. Future research should explore the processes that link social network support with sexual and other transmission risk behaviors as a basis to inform HIV prevention efforts.

Homelessness among youth who identify as LGBTQ+: A systematic review

AIMS AND OBJECTIVES

To explore homelessness among lesbian, gay, bisexual, transgender, queer/questioning plus (LGBTQ+) youth and to identify their support and care requirements.

BACKGROUND

LGBTQ+ youth face many health and societal challenges including issues related to homelessness.

DESIGN

A systematic review of qualitative, quantitative and mixed methods studies.

METHODS

A search of relevant electronic databases was carried out and included the dates August 2008-August 2018 and limited to academic journals and peer-reviewed empirical studies written in English. Included studies specifically addressed the homeless experiences of youth aged 13-24 years old who identified as LGBTQ+. The PRISMA checklist was used in the review. A quality assessment instrument was used to review all of the selected papers and narrative methods utilised in the synthesis of the research evidence.

RESULTS

The search resulted in 319 papers, and after applying distinct inclusion criteria, a total of 14 papers were considered suitable for the systematic review. Following analysis, the four main themes identified were stigma, discrimination and exclusion; mental health issues and substance use; sexual risks and vulnerability; and interventions and supports.

CONCLUSION

LGBTQ+ homeless youth is a major public health concern that has significant consequences for a young person's physical and psychosocial well-being.

RELEVANCE TO CLINICAL PRACTICE

Practitioners need to be aware of the specific health and support requirements of LGBTQ+ youth in relation to homelessness. Inclusive and holistic care plans should exist that are fully responsive to the distinct needs of this group guided by definitive policies and sound clinical research. The implications for future nursing practice are presented and discussed.

But Everyone is Doing It (Sort of)! Perceived Sexual Risks in the Social Environment and the Impact on Homeless Youth Engagement in Concurrent Sexual Relationships

Although homeless youth are likely to engage in concurrent sexual relationships and doing so can accelerate HIV transmission, the issue of sexual concurrency (i.e., having sexual partnerships that overlap in time) has received scarce attention in this vulnerable population. The literature that exists tends to focus on individuals' characteristics that may be associated with concurrency and overlooks the influence of their social environment. Informed by the risk amplification and abatement model (RAAM), this study explored the association between pro-social and problematic social network connections, and sexual concurrency among homeless youth using drop-in center services (N = 841). Nearly 37% of youth engaged in concurrency. Partially consistent with the RAAM, regression analyses showed that affiliation with more problematic ties (i.e., having more network members who practice concurrency and unprotected sex) was associated with greater sexual concurrency. Programs addressing HIV risk among homeless youth in drop-in centers should consider the role youths' network composition may play in concurrency.

Predictors of Retention in an Alcohol and Risky Sex Prevention Program for Homeless Young Adults

Homeless young adults are at risk for alcohol and other drug (AOD) use and risky sexual behavior. Interventions are needed to help these young people reduce their risky behavior, but this population is often difficult to engage and retain in services. We offered a four-session AOD and risky sex reduction program to 100 participants and examined if retention in the program was predicted by a number of factors: demographics, homelessness severity, other service use, AOD behaviors, mental health symptoms, sexual risk behaviors, and readiness to change AOD and condom use. Nearly half (48%) of participants completed all sessions. In bivariate analyses, participants were significantly less likely to be retained in the program if they had slept outdoors in the past month, engaged in more alcohol and marijuana use, experienced more alcohol-related consequences, and received the program in an urban drop-in center (as opposed to a drop-in center near the beach). When controlling for all significant bivariate relationships, only sleeping outdoors and receipt of the program in the urban setting predicted fewer sessions completed. The most endorsed reasons for program non-completion were being too busy to attend and inconvenient day/time of the program. Findings can help outreach staff and researchers better prepare methods to engage higher risk homeless youth and retain them in services. Finding unique ways to help youth overcome barriers related to location of services appears especially necessary, perhaps by bringing services to youth where they temporarily reside or offering meaningful incentives for program attendance.

Group motivational interviewing for homeless young adults: Associations of change talk with substance use and sexual risk behavior

Homeless young adults exhibit high rates of alcohol and other drug (AOD) use and sexual risk behaviors. This study is a secondary analysis of data collected in a randomized clinical trial of AWARE, a new 4 session group motivational interviewing intervention. AWARE mainly focused on alcohol use and sexual risk behavior given focus group feedback. We used sequential coding to analyze how the group process affected both AOD use and sexual risk behavior at 3-month follow up among homeless young adults by examining facilitator behavior and participant change talk (CT) and sustain talk (ST). We analyzed 57 group session digital recordings of 100 youth (69% male, 74% heterosexual, 28% non-Hispanic white, 23% African American, 26% Hispanic, 23% multiracial/other; mean age 21.75). Outcomes included importance and readiness to change AOD use and risky sexual behavior, AOD use and consequences, number of partners and unprotected sex, and condom self-efficacy. Sequential analysis indicated that facilitator open-ended questions and reflections of CT increased Group CT. Group CT was associated with a lower likelihood of being a heavy drinker 3 months later; Group ST was associated with decreased readiness and confidence to change alcohol use. There were no associations with CT or ST for drug use or risky sexual behavior. Facilitator speech and peer responses were related to CT and ST during the group sessions with this high risk population, which were then associated with individual changes for alcohol use. Further research is needed to explore associations with drug use and sexual risk behavior. (PsycINFO Database Record

Social network correlates of HIV risk-related behaviors among male migrants in China

Background

Significant domestic and global research has focused on HIV risk among China’s large internal migrant population. Much of this work takes an individual behavior approach while ignoring the critical role social networks play in shaping HIV risk.

Methods

Based on past studies among migrant men in China of yingchou activities (activities that build and reinforce social networks such as eating, drinking alcohol and patronizing commercial sex), we constructed ego-centric networks for a sample of 385 male migrants recruited from multiple worksites in Beijing. We used a nested-model approach to examine the contribution of social network characteristics to HIV risk at both the variable and model levels.

Results

As compared to an individual-level model, addition of social network variables significantly improved the fit of the models. Commercial sex norms and condom use norms of core yingchou networks were significantly associated with egos’ commercial sex and condom use respectively. The size of yingchou network was associated with egos’ commercial sex. The network models became more sensitive after network norm measures took into account the intimacy of network ties and allowed for egos’ uncertainty when reporting their alters’ sexual behaviors.

Conclusion

Results suggest the importance of social network factors and core network members in HIV transmission and risk-reduction interventions for male migrants. Future studies could explore other important social networks among male migrants, consider the intimacy of network ties and egos’ uncertainty about alters’ situations in constructing network norms, and refine the measurement of network size and density.

A group-based motivational interviewing brief intervention to reduce substance use and sexual risk behavior among homeless young adults

Homeless young adults ages 18-25 exhibit high rates of alcohol and other drug (AOD) use, and sexual risk behaviors such as unprotected sex. Yet few programs exist for this population that are both effective and can be easily incorporated into settings serving this population. This pilot cluster cross-over randomized controlled trial evaluates AWARE, a voluntary four session group-based motivational interviewing (MI) intervention to reduce AOD use and sexual risk behavior. We evaluated AWARE with 200 homeless young adults using drop-in center services in Los Angeles County (mean age=21.8years; 73% male; 79% heterosexual; 31% non-Hispanic White, 25% African American, 24% Hispanic, 21% multiracial/other). Surveys were completed at baseline and three months after program completion. Retention in the AWARE program was excellent (79% attended multiple sessions) and participants reported high levels of satisfaction with the program. AWARE participants self-reported positive change in their past 3month and past 30day alcohol use (ps≤0.05), motivation to change drug use (ps<0.05), and condom use self-efficacy (p=0.05) compared to the control group. Among those with multiple sex partners, AWARE participants showed a decrease in unprotected sexual events (p<0.05), whereas the control group did not. Results from this pilot evaluation are promising, suggesting that a brief group-MI risk reduction intervention can be effective in helping homeless young adults make positive changes in their alcohol and condom use. Further work is needed to more fully evaluate the efficacy of AWARE on AOD behavior and sexual risk behavior outcomes.

Validation of tie corroboration and reported alter characteristics among a sample of young men who have sex with men

The differences between direct ties (i.e., ties between a respondent and their nominees) and ties between nominees (indirect) are key to understanding network structure, yet remain understudied. Within a sample of 175 young men who have sex with men, we explored the corroboration of sex and drug ties, and factors associated with corroboration. The majority of instances in which there was no corroboration for either sex or drug ties was due to one individual not appearing in another respondent's network. When an individual did appear in another respondent's network, direct sex and drug ties were corroborated in most cases. We also found that more indirect sex ties were corroborated than direct sex ties (95.7% vs. 88.9%), but the reverse was true for indirect versus direct drug ties (73.1% vs. 84.1%). Strength of relationship and frequency of communication were both associated with confirmed direct ties, but not with indirect ties. Based on these findings, we recommend that direct and indirect ties be treated differently in network analyses.

Outcomes from a Homegrown HIV Prevention Program for Extremely High-risk, Substance-using Men who have Sex with Men with Multiple Health Disparities

From February 2010 through December 2014, 585 substance-using MSM were enrolled into a "homegrown" risk reduction intervention. Participants evidenced significant iterative factor reductions in the odds of substance use including alcohol (AOR=0.79) and marijuana (AOR=0.78; both p≤0.05) and marginally significant reductions in the odds of methamphetamine use (AOR=0.83; p≤0.07). Participants also evidenced significant reductions in sexual risks including the odds of reporting drug/alcohol use before or during sex (AOR=0.80) and of condomless anal intercourse (AOR=0.72; all significant at p≤0.05). Results demonstrate that the homegrown intervention was effective at reducing HIV risk behaviors among high-risk MSM.

Descriptive and injunctive network norms associated with nonmedical use of prescription drugs among homeless youth

BACKGROUND

Nonmedical use of prescription drugs (NMUPD) among youth and young adults is being increasingly recognized as a significant public health problem. Homeless youth in particular are more likely to engage in NMUPD compared to housed youth. Studies suggest that network norms are strongly associated with a range of substance use behaviors. However, evidence regarding the association between network norms and NMUPD is scarce. We sought to understand whether social network norms of NMUPD are associated with engagement in NMUPD among homeless youth.

METHODS

1046 homeless youth were recruited from three drop-in centers in Los Angeles, CA and were interviewed regarding their individual and social network characteristics. Multivariate logistic regression was employed to evaluate the significance of associations between social norms (descriptive and injunctive) and self-reported NMUPD.

RESULTS

Approximately 25% of youth reported past 30-day NMUPD. However, more youth (32.28%) of youth believed that their network members engage in NMUPD, perhaps suggesting some pluralistic ignorance bias. Both descriptive and injunctive norms were associated with self-reported NMUPD among homeless youth. However, these varied by network type, with presence of NMUPD engaged street-based and home-based peers (descriptive norm) increasing the likelihood of NMUPD, while objections from family-members (injunctive norm) decreasing that likelihood.

CONCLUSIONS

Our findings suggest that, like other substance use behaviors, NMUPD is also influenced by youths' perceptions of the behaviors of their social network members. Therefore, prevention and interventions programs designed to influence NMUPD might benefit from taking a social network norms approach.

Social networks of men who have sex with men and their implications for HIV/STI interventions: results from a cross-sectional study using respondent-driven sampling in a large and a small city in Tanzania

OBJECTIVE

Men who have sex with men (MSM) in sub-Saharan Africa remain hidden and hard to reach for involvement in HIV and sexually transmitted infection (STI) services. The aim of the current study was to describe MSM social networks in a large and a small Tanzanian city in order to explore their utility for peer-based healthcare interventions.

METHODS

Data were collected through respondent-driven sampling (RDS) in Dar es Salaam (n=197) and in Tanga (n=99) in 2012 and 2013, using 5 and 4 seeds, respectively. All results were adjusted for RDS sampling design.

RESULTS

Mean personal network size based on the number of MSM who were reported by the participants, as known to them was 12.0±15.5 in Dar es Salaam and 7.6±8.1 in Tanga. Mean actual RDS network size was 39.4±31.4 in Dar es Salaam and 25.3±9.7 in Tanga. A majority (97%) reported that the person from whom they received the recruitment coupon was a sexual partner, close friend or acquaintance. Homophile in recruitment patterns (selective affiliation) was present for age, gay openness, and HIV status in Dar es Salaam, and for sexual identification in Tanga.

CONCLUSIONS

The personal network sizes and existence of contacts between recruiter and referral indicate that it is possible to use peer-driven interventions to reach MSM for HIV/STI interventions in larger and smaller sub-Saharan African cities. The study was reviewed and approved by the University of Texas Health Science Center's Institutional Review Board (HSC-SPH-10-0033) and the Tanzanian National Institute for Medical Research (NIMR/HQ/R.8a/Vol. IX/1088).

Facilitators and Barriers of Drop-In Center Use Among Homeless Youth

Drop-in centers for homeless youth address basic needs for food, hygiene, and clothing but can also provide critical services that address youth's "higher level" needs (e.g., substance use treatment, mental health care, HIV-related programs). Unlike other services that have restrictive rules, drop-in centers typically try to break down barriers and take a "come as you are" approach to engaging youth in services. Given their popularity, drop-in centers represent a promising location to deliver higher level services to youth that may not seek services elsewhere. A better understanding of the individual-level factors (e.g., characteristics of homeless youth) and agency-level factors (e.g., characteristics of staff and environment) that facilitate and impede youth engagement in drop-in centers will help inform research and outreach efforts designed to engage these at-risk youth in services. Thus, the goal of this review was to develop a preliminary conceptual model of drop-in center use by homeless youth. Toward this goal, we reviewed 20 available peer-reviewed articles and reports on the facilitators and barriers of drop-in center usage and consulted broader models of service utilization from both youth and adult studies to inform model development.

Social Networking Technology Use and Engagement in HIV-Related Risk and Protective Behaviors Among Homeless Youth

Preliminary studies with homeless youth have found surprisingly pervasive social media use and suggest that youth's online interactions may be associated with their HIV-related risk and protective behaviors. As homeless youth are transient and difficult to engage in place-based services, social media may represent a novel venue for intervention. A critical 1st step in intervention development is gaining greater understanding of how homeless youth use social media, especially as it relates to who they connect to and around what topics. Given the salience of social networking sites in the lives of these otherwise difficult-to-reach adolescents, and their potential to disseminate prevention interventions, this study assessed associations between online social networking technology use and HIV risk behaviors among homeless youth in Los Angeles, California. Homeless youth ages 13 through 24 (N = 1,046) were recruited through 3 drop-in centers and surveyed about their social media use and self-reported HIV-related risk behaviors. Results suggest that social media use is widely prevalent among this population, and the content of these online interactions is associated with whether youth engage in risk or protective behaviors. Implications for interventions and further research are discussed.

Substance use network characteristics and drug and alcohol use behaviors among young men who have sex with men (YMSM)

BACKGROUND

Young men who have sex with men (YMSM) use alcohol and other drugs at rates higher than their heterosexual peers. While social networks of YMSM have been acknowledged as an important contextual influence on their health behavior, studies have largely focused on social and sexual networks rather than substance use networks, despite the potential importance of substance use alters in shaping substance use behavior.

METHOD

Using data collected from a diverse sample of YMSM (n=156), two multilevel models examined the associations between network (e.g., degree and transitivity), dyadic (e.g., strength of relationship), and individual characteristics and two alter level dependent variables: recent drug use (versus no recent drug use) and frequency of substance use.

RESULTS

Results indicated that transitivity was associated with both recent drug use (OR=1.21, p=0.012) and more frequent substance use (b=0.08, p=0.002). Degree was not significantly associated with either variable. Furthermore, participants were also less likely to have recently used drugs (OR=0.93, p<0.001) and tended to use substances less frequently (b=-0.01, p=0.028) with older alters.

CONCLUSIONS

Despite substantial interest in network influences on health, much remains unknown about the impact of network structures on substance use. The current findings suggest that structural characteristics of substance use networks may provide important information regarding the drug and alcohol use behavior of YMSM even when controlling for dyadic and individual characteristics.

Substance use homophily among geosocial networking application using gay, bisexual, and other men who have sex with men

Geosocial networking applications (GSN apps) represent important virtual contexts in which gay, bisexual, and other men who have sex with men (MSM) seek affiliation. These apps allow users to create and view public profiles, send photos, and text messages, and connect with other users based on shared interests and geographic proximity. The present study examined substance use homophily among a sample of 295 MSM recruited via a popular GSN app. Comparisons of social network members met via GSN app versus elsewhere and associations between both individual and network characteristics and recent binge drinking, marijuana use, and illicit substance use were explored using bivariate tests of association and multivariate logistic regression analyses. High rates of recent binge drinking (59 %), marijuana use (37 %), and illicit substance use (27 %) were observed among participants. GSN app use greater than 1 year and showing naked chest or abs in a profile picture were positively associated with recent illicit substance use. In multivariate analyses, the strongest predictors of binge drinking (AOR 3.81; 95 % CI 1.86-7.80), marijuana use (AOR 4.12; 95 % CI 2.22-7.64), and illicit substance use (AOR 6.45; 95 % CI 3.26-12.79) were the presence of a social network member who also engaged in these behaviors. Social network interventions that target binge drinking, marijuana use, and illicit substance use may be delivered via GSN apps to reduce the prevalence of substance use and related risks among MSM in these virtual contexts.

A comparative analysis of behaviors and sexual affiliation networks among men who have sex with men in Hong Kong

In Hong Kong, men who have sex with men (MSM) account for a significant proportion of HIV infections. While perceived as a hidden population, they constitute a distinct social network shaped by their differential use of unique channels for sex partnership. To characterize their pattern of connectivity and association with high-risk sexual behaviors, 311 MSM were recruited via saunas and the internet to participate in a questionnaire survey. Internet recruits were younger, and many (31/43) were solely reliant on the internet to seek sex partners, while visiting a similar number of venues as the sauna recruits (p = 0.98). Internet users generally had a high frequency of unprotected anal intercourse (UAI). MSM who had visited only a single venue reported more UAI with their regular partners (adjusted OR 6.86, 1.88-24.96) and sought fewer casual partners than those frequenting multiple venues (adjusted OR 0.33, 0.19-0.60). This study provides evidence for the heterogeneity of the sexual affiliation networks of MSM in Hong Kong. High HIV risk of UAI could be offset by fewer casual partners in certain venues, the implications of which would need to be explored in longitudinal studies. Methodologically, internet sampling was very efficient in identifying sex networking venues, while internet recruits gave a high retention rate for updating profiles. However, sampling at high centrality saunas did not necessarily identify the MSM-affiliating venues in the networks efficiently. The sampling strategy of MSM survey should therefore be objective-driven, which may differ for health message dissemination and social marketing, versus HIV surveillance or risk assessment.

Understanding Consistent Condom Use Among Homeless Men Who Have Sex with Women and Engage in Multiple Sexual Partnerships: A Path Analysis

Consistent condom use is the main strategy aimed at preventing individuals from acquiring HIV through sexual intercourse. The mechanism of consistent condom use among a high-risk homeless subpopulation-homeless men who have sex with women and also engage in multiple sexual partnerships-remains unclear. This study identified 182 homeless men who engaged in multiple sexual partnerships from a representative sample of homeless men, who self-identified as heterosexual, using meal line services in Downtown Los Angeles' Skid Row area. Information such as participants' condom use psychosocial correlates, sexual risk behaviors, and social network characteristics were collected. Results suggested that condom efficacy is a potential intervening mechanism through which condom attitudes (β = -0.199; p = 0.005) and depression (β = -0.156; p = 0.029) are associated with an individual's consistent condom use. Having more network members with whom participants talked about HIV prevention (β = 0.051; p = 0.006) was also found to be associated with an individual's consistent condom use. HIV prevention programs should focus on increasing their condom efficacy to help reduce HIV risks among this vulnerable homeless subpopulation.

Health-promoting lifestyle behaviors and psychological status among Arabs and Koreans in the United Arab Emirates

Cultural variations among ethnic groups may differentially influence health and health behavior. We explored and compared health-promoting lifestyle behaviors and psychological status, including depression, anxiety, and stress, among Korean migrants (n = 117) and Arab nationals (n = 103) in the United Arab Emirates (UAE). Pender's Health Promotion Model guided this research. The Health-Promoting Lifestyle Profile was used to measure health-promoting lifestyle behaviors and Lovibond and Lovibond's Depression, Anxiety, and Stress Scale to measure psychological status. The data were analyzed using bivariate procedures and multiple linear regression. No group differences were found in total scores for health-promoting lifestyle behaviors or psychological status. Both groups scored high on self-actualization and interpersonal support; Arabs scored low on exercise, and Koreans scored low on health responsibility. Across groups, psychological status (β = -.390, p < .001), education (β = .239, p < .001), and gender (β = .238, p < .001) were significant determinants of health-promoting lifestyle behaviors in multivariate analysis. Ethnicity and religious attendance were not significant determinants. Education level had a moderating effect; for those with a lower educational level, psychological distress had a stronger negative effect on health behavior. Findings suggest considering cultural aspects, such as different values placed on physical fitness and social/interpersonal relationships, in developing and implementing health education and/or promotion programs. Assessment of psychological status (i.e., depression, anxiety, and stress) should also be included in health promotion programs and related health policies for Korean migrants and Arab nationals in the UAE.

Methods for Collection of Participant-aided Sociograms for the Study of Social, Sexual and Substance-using Networks Among Young Men Who Have Sex with Men

In this study, we adapted and tested a participant-aided sociogram approach for the study of the social, sexual, and substance use networks of young men who have sex with men (YMSM); a population of increasing and disproportionate risk of HIV infection. We used a combination of two interviewer-administered procedures: completion of a pre-numbered list form to enumerate alters and to capture alter attributes; and a participant-aided sociogram to capture respondent report of interactions between alters on an erasable whiteboard. We followed the collection of alter interactions via the sociogram with a traditional matrix-based tie elicitation approach for a sub-sample of respondents for comparison purposes. Digital photographs of each network drawn on the whiteboard serve as the raw data for entry into a database in which group interactions are stored. Visual feedback of the network was created at the point of data entry, using NetDraw network visualization software for comparison to the network structure elicited via the sociogram. In a sample of 175 YMSM, we found this approach to be feasible and reliable, with high rates of participation among those eligible for the study and substantial agreement between the participant-aided sociogram in comparison to a traditional matrix-based approach. We believe that key strengths of this approach are the engagement and maintenance of participant attention and reduction of participant burden for alter tie elicitation. A key weakness is the challenge of entry of interview-based list form and sociogram data into the database. Our experience suggests that this approach to data collection is feasible and particularly appropriate for an adolescent and young adult population. This builds on and advances visualization-based approaches to social network data collection.

Social networks, sexual networks and HIV risk in men who have sex with men

Worldwide, men who have sex with men (MSM) remain one of the most HIV-vulnerable community populations. A global public health priority is developing new methods of reaching MSM, understanding HIV transmission patterns, and intervening to reduce their risk. Increased attention is being given to the role that MSM networks play in HIV epidemiology. This review of MSM network research studies demonstrates that: (1) Members of the same social network often share similar norms, attitudes, and HIV risk behavior levels; (2) Network interventions are feasible and powerful for reducing unprotected sex and potentially for increasing HIV testing uptake; (3) HIV vulnerability among African American MSM increases when an individual enters a high-risk sexual network characterized by high density and racial homogeneity; and (4) Networks are primary sources of social support for MSM, particularly for those living with HIV, with greater support predicting higher care uptake and adherence.

Tensions between the epidemiology and psychology of HIV risk: implications for pre-exposure prophylaxis

This study focuses on psychological differences in risk-taking patterns and their association with risk compensation motivations in the context of pre-exposure prophylaxis (PrEP). Participants were 257 HIV-negative MSM and transgender women recruited in New York City. The majority of participants (89.5 %, n = 230), could be classified as either: Intimates (40 %), who report unprotected anal intercourse (UAI) only with a main partner believed to be HIV-negative; Trusters (34 %), who engaged in UAI only with casual partners believed to be HIV-negative; and Gamblers (26 %) who report UAI with partners of unknown serostatus. Partner-based classifications were better predictors of HIV risk perception and other traditional correlates of risk-taking (e.g. impulsivity, sexual compulsivity) than rates of UAI. The three groups differed significantly in PrEP-related risk compensation motivations: sexual pleasure (Gamblers), intimacy (Trusters) and partner pressure (Intimates). These data underscore the importance of focusing the psychological dynamics of risk perception and sexual decision-making.

Network correlates of sexual health advice seeking and substance use among members of the Los Angeles House and Ball communities

House and Ball communities (HBCs), represent a prime context for human immunodeficiency virus prevention with African American young men who have sex with men and transgender persons. This study sought to understand the composition and function of social support and sexual networks of HBC members in Los Angeles, California (N = 263). Participants were recruited using venue-based sampling and asked to report on sexual health advice seeking, alcohol use and illicit substance use. Participants were more likely to seek sexual health advice from social support network members compared with sexual network members [odds ratio (OR): 2.50, P < 0.001]. HBC members were more likely to get drunk (OR: 1.57; P < 0.05) and use illicit substances (OR: 1.87; P < 0.10) with House members and sexual network members compared with non-House members and social support network members. Health promotion programs tailored for the HBC should encourage open communication regarding sexual health; these interventions must include information about the role of substance use in sexual risk taking.

High-risk sexual activity in the House and Ball community: influence of social networks

OBJECTIVES

We investigated the roles of House membership and the influence of social and sexual network members on the sexual risk behavior of men in the Los Angeles House and Ball community.

METHODS

From February 2009 to January 2010, male participants (n = 233) completed interviewer-assisted surveys during a House meeting or Ball event. We used logistic regression to model the effects of sexual network size, influence of sexual network members, House membership status, and their interactions on high-risk sex.

RESULTS

Significant predictors of high-risk sex included number of sexual partners in the nominated social network, multiethnicity, and previous diagnosis of sexually transmitted infection. House membership was protective against high-risk sex. Additionally, a 3-way interaction emerged between number of sexual partners in the network, influence, and network members' House membership.

CONCLUSIONS

Future research should assess network members' attitudes and behavior in detail to provide a greater understanding of the dynamics of social influence and to identify additional avenues for intervention.

Social network characteristics and HIV risk among African American, Asian/Pacific Islander, and Latino men who have sex with men

OBJECTIVES

To examine how social networks influence HIV risk among US racial/ethnic minority men who have sex with men (MSM) and whether the associations of social network characteristics with risk vary by race/ethnicity.

METHODS

A chain-referral sample of 403 African American, 393 Asian/Pacific Islander, and 400 Latino MSM recruited in Los Angeles County, California, completed a questionnaire, which asked about their egocentric social networks, safer sex peer norms, and male anal intercourse partners. HIV-nonconcordant partnerships were those reported by respondents as serodisconcordant or where self and/or partner serostatus was unknown.

RESULTS

Overall, 26% of the sample reported HIV-nonconcordant unprotected anal intercourse (UAI) with a nonprimary male partner in the previous 6 months. In a generalized estimating equation (GEE) logistic model that controlled for race/ethnicity, age, nativity, incarceration history, and HIV status, being in a more dense network was associated with less HIV-nonconcordant UAI [adjusted odds ratio (AOR) = 0.92, 95% confidence interval (CI): 0.86 to 0.99, P = 0.0467]. In addition, the effect of safer sex peer norms on HIV-nonconcordant UAI was moderated by ego-alter closeness (P = 0.0021). Safer sex peer norms were protective among those reporting "medium" or "high" ego-alter closeness (AOR = 0.70, 95% CI: 0.52 to 0.95, P = 0.0213 and AOR = 0.48, 95% CI: 0.35 to 0.66, P < 0.0001, respectively), but not among those reporting "low" ego-alter closeness (AOR = 0.96, 95% CI: 0.63 to 1.46, P = 0.8333). The effects of density, closeness, and norms on HIV-nonconcordant UAI did not differ by race/ethnicity.

CONCLUSIONS

The significant association of social network characteristics with UAI point to network-level factors as important loci for both ongoing research and HIV prevention interventions among US MSM of color.

Associations between perceived characteristics of the peer social network involving significant others and risk of HIV transmission among men who have sex with men in China

The HIV epidemic among men who have sex with men (MSM) in China is severe. Peer can induce risky and preventive behaviors among MSM. We interviewed 220 MSM who had at least one significant other who was a peer MSM (SOPM). Interviews were conducted at two gay venues in Suzhou, China, which reported five HIV-related outcomes: HIV (8.2 %), syphilis (16.4 %), self-reported sexually transmitted infection symptoms (14.6 %), unprotected anal intercourse (UAI; 58.6 %) and having had taken up HIV testing (40.4 %). Adjusting for significant background variables, participants' perceived characteristics of the social network of SOPM, such as practicing risk behavior (e.g. UAI) or preventive behaviors (e.g. HIV antibody testing), or possessing HIV-related perceptions (e.g. dislike in condom use), were significantly associated with some of the five aforementioned outcomes (p < 0.05). Peer education and peer-based interventions involving significant others are hence potentially important in HIV prevention targeting MSM. Future pilot intervention studies are warranted.

Multidimensional characterization of sexual minority adolescents' sexual safety strategies

Young adults have high rates of sexually transmitted infections (STIs). Sexual minority youths' risk for STIs, including HIV, is as high as or higher than sexual majority peers'. Sexual safety, while often treated as a single behavior such as condom use, can be best conceptualized as the result of multiple factors. We used latent class analysis to identify profiles based on ever-used sexual safety strategies and lifetime number of partners among 425 self-identified LGBTQ youth aged 14-19. Data collection took place anonymously online. We identified four specific subgroup profiles for males and three for females, with each subgroup representing a different level and type of sexual safety. Profiles differed from each other in terms of age and outness for males, and in outness, personal homonegativity, and amount of education received about sexual/romantic relationships for females. Youths' sexual safety profiles have practice implications for sexuality educators, health care professionals, and parents.

Sexual risk behaviours and their correlates among gay and non-gay identified men who have sex with men and women in Chengdu and Guangzhou, China

To better understand the behavioural characteristics and the factors associated with high risky behaviours among men who have sex with men and women (MSMW) with different orientation, we analyzed data from a cross-sectional survey of 600 MSMW in two large cities in China. Participants completed a questionnaire and underwent serological testing. Overall, human immunodeficiency virus (HIV) prevalence was 26%. In multivariable analysis of risk factors for unprotected anal intercourse in the past six months, factors associated with unprotected vaginal intercourse (UVI) were as follows: gay-identified orientation, having anal sex with a boyfriend, having multiple male partners, and never or sometimes using a condom for vaginal intercourse. In multivariate analyses of risk factors for UVI in the past 12 months, factors associated with UVI were as follows: non-gay-identified MSMW, having multiple male partners, having multiple female partners, and never or sometimes using a condom for anal intercourse. This study revealed a high prevalence of HIV and risky sexual behaviours.

Exploring the potential of expatriate social networks to reduce HIV and STI transmission: a protocol for a qualitative study

INTRODUCTION

HIV diagnoses acquired among Australian men working or travelling overseas including  Southeast Asia are increasing. This change within transmission dynamics means traditional approaches to prevention need to be considered in new contexts. The significance and role of social networks in mediating sexual risk behaviours may be influential. Greater understanding of expatriate and traveller behaviour is required to understand how local relationships are formed, how individuals enter and are socialised into networks, and how these networks may affect sexual intentions and behaviours. This paper describes the development of a qualitative protocol to investigate how social networks of Australian expatriates and long-term travellers might support interventions to reduce transmission of HIV and sexually transmitted infections.

METHODS AND ANALYSIS

To explore the interactions of male expatriates and long-term travellers within and between their environments, symbolic interactionism will be the theoretical framework used. Grounded theory methods provide the ability to explain social processes through the development of explanatory theory. The primary data source will be interviews conducted in several rounds in both Australia and Southeast Asia. Purposive and theoretical sampling will be used to access participants whose data can provide depth and individual meaning.

ETHICS AND DISSEMINATION

The role of expatriate and long-term traveller networks and their potential to impact health are uncertain. This study seeks to gain a deeper understanding of the Australian expatriate culture, behavioural contexts and experiences within social networks in  Southeast Asia. This research will provide tangible recommendations for policy and practice as the findings will be disseminated to health professionals and other stakeholders, academics and the community via local research and evaluation networks, conference presentations and online forums. The Curtin University Human Research Ethics Committee has granted approval for this research.