Aging With HIV: Health Policy and Advocacy Priorities

The aging of people with HIV (PWH) is a major public health accomplishment and a social and cultural phenomenon. It highlights the human capacity to overcome adversity, the effectiveness of public health strategies (e.g., prevention and treatment), and the new challenges as well. Our societies are not well prepared to address the needs of older PWH and the changes they are creating. Stigma toward HIV, older age, and homosexuality, along with racism, have kept PWH largely invisible, resulting in limited investment in prevention and medical and social services. It is imperative that we develop an effective policy response to address the unique needs of PWH. The purpose of this article is to highlight current knowledge and emerging issues in HIV and aging to serve as a foundation on which to develop policy and program recommendations that will meet the new challenge.

Public Health Has an Equity Problem: A Latinx's Voice

Public health has an equity problem. One of the main pillars of our public health system, schools and academic programs of public health, are under the control of white (heterosexual) faculty. They continue to exclude brown, black, and indigenous people from their faculty and leadership ranks. This racism pervades institutional policies and culture and is a major fault in the quest for health equity. In this essay, I center on the experience of Latinx faculty to examine the roots of this inequity and the arguments for diversity and inclusion. I also propose avenues for change and argue for institutional transformation that goes beyond adding people of color to faculty and leadership roles.

Fostering health equity research: Development and implementation of the Center for Health Equity Research (CHER) Chicago

INTRODUCTION

The purpose of this article is to describe the process of developing and implementing a transdisciplinary community-based research center, the Center for Health Equity Research (CHER) Chicago, to offer a model for designing and implementing research centers that aim to address structural causes of health inequality.

METHODS

Scholars from diverse backgrounds and disciplines formed a multidisciplinary team for the Center and adopted the structural violence framework as the organizing conceptual model. All Center activities were based on community partnership. The Center activities were organized within three cores: administrative, investigator development, and community engagement and dissemination cores. The key activities during the first year were to develop a pilot grant program for early-stage investigators (ESIs) and to establish community partnership mechanisms.

RESULTS

CHER provided more than 60 consultations for ESIs, which resulted in 31 pilot applications over the three application cycles. Over 200 academic and community partners attended the community symposium and discussed community priority. Some challenges encountered were to improve communication among investigators, to clarify roles and responsibilities of the three cores, and to build consensus on the definition and operationalization of the concept of structural violence.

CONCLUSION

There is an increasing need for local hubs to facilitate transdisciplinary collaboration and community engagement to effectively address health inequity. Building consensus around a shared vision among partners is a difficult and yet important step toward achieving equity.

"Anywhere but here": Querying spatial stigma as a social determinant of health among youth of color accessing LGBTQ services in Chicago's Boystown

The link between stigma and negative health outcomes is established, yet available research infrequently considers the complex intersection of place, race, and class-based stigma and how this stigma shapes opportunities and health among marginalized groups. Furthermore, scholarship on the relationship between stigma and health often fails to include the voices of the stigmatized themselves. This exclusion renders their lived-experiences hidden and their insight devalued, producing findings with limited validity to promote health equity and social change. In this article, we explore intersecting place, race, and class-based stigmas, or spatial stigma, as a social determinant of health among youth of color (YoC) accessing LGBTQ-specific services in the Chicago's White, middle-class gay enclave, Boystown. Qualitative data were collected within the context of a youth participatory action research study with 11 youth researchers (ages 18-24). Data sources included critical autoethnography, focus groups with current and former LGBTQ service patrons, and individual interviews with LGBTQ service providers. Emergent thematic patterns illuminate how the stigmatization of YoC based on place, race, and class (i.e., being from poor and low-income, racialized South and West sides communities) impacts their opportunities in the neighborhood and access to health-supporting resources. These findings may be useful for practitioners and policy makers who aim to promote health equity among marginalized young people and add to the growing body of literature on health effects of spatial stigma among marginalized communities.

White Paper from a CTSA Workshop Series on Special and Underserved Populations: Enhancing Investigator Readiness to Conduct Research Involving LGBT Populations

Despite the significant health disparities experienced by lesbian, gay, bisexual and transgender (LGBT) populations, few investigators affiliated with NIH-funded Clinical and Translational Science Award (CTSA) programs are conducting research related to this underserved population. We provide recommendations shared during a half-day workshop aimed at increasing researcher readiness to conduct LGBT research. This workshop was presented as part of a series on conducting research with underserved populations offered by the Recruitment, Retention, and Community Engagement Program of the Center for Clinical and Translational Science at the University of Illinois at Chicago. Six LGBT health research experts provided focused presentations. The workshop presentations included a summary of significant health inequality issues, theoretical models relevant to research on LGBT health, best practices in measuring sexual orientation and gender identity, recommendations for recruitment and retention, a discussion of community engagement, and ethical considerations in conducting LGBT research. We provide a summary of recommendations to guide future research, training, and public policy related to LGBT health. The information can increase capacity among CTSA affiliated researchers in conducting research in this special population.

Global Citizen, Immigrant, Survivor, Activist, Gayby Boomer, Academic, and Editor: Dr. Sy and the History of AIDS Education and Prevention

In this 30th anniversary of AIDS Education and Prevention, we turn our attention to its founder and editor, Dr. Francisco Sy. I trace Dr. Sy's trajectory, from growing up in a Filipino-Chinese family in Manila to Harvard, Johns Hopkins, South Carolina, and then to the journal. The loss of friends and colleagues to the AIDS epidemic stands out as Sy's driving force behind the journal. AIDS Education and Prevention was also created to fill a tremendous gap in the field: a scientific platform to circulate and discuss research on HIV and AIDS prevention. Over its life course, the content of the journal has mirrored the life of epidemic. Initially, the articles focused on knowledge, attitudes, and behaviors, mostly in the United States. Now, the articles deal with health interventions and pre-exposure prophylaxis, with authors coming from all over the globe. In Sy's opinion, HIV will become endemic, as other infectious diseases have over our history of epidemics, so the role of journals such as AIDS Education and Prevention will remain vital.

Burnout in HIV/AIDS Volunteers: A Socio-Cultural Analysis among Latino Gay, Bisexual Men, and Transgender People

Understanding factors associated with burnout among HIV/AIDS volunteers has long-ranging implications for community organizations and prevention. Using a cross-sectional sample of Latino gay/bisexual men and transgender people (N=309), we assess potential correlates of burnout identified by multiple theories, including factors associated with volunteering (experiences, motives) and contextual factors (stigma, sense of community). Reporting negative volunteering experiences was positively associated with burnout, while being motivated by personal HIV/AIDS experiences and having a greater sense of GLBT community was negatively related to burnout. The study highlights central challenges and opportunities to retain volunteers from marginalized communities.

Trends in HIV Risk, Testing, and Treatment among MSM in Chicago 2004-2014: Implications for HIV Elimination Planning

Men who have sex with men (MSM) in the USA continue to have high rates of HIV infection. Increasingly, in addition to behavioral factors, biomedical interventions have been found to play important roles in HIV prevention. In this analysis, we used four waves of cross-sectional data (2004, 2008, 2011, and 2014) from the National HIV Behavioral Surveillance System (NHBS) to examine trends in key behaviors and biomedical interventions among MSM in Chicago (N = 3298). Logistic regression was used to determine changes in behaviors and use of biomedical interventions. Condomless sex increased significantly in waves 3 and 4, compared to wave 1: wave 3 (AOR = 2.07; 95% CI 1.53, 2.78) and wave 4 (AOR = 2.19; 95% CI 1.62, 2.96). Compared to those aged 18-24, older participants were significantly less likely to be routinely tested for HIV: 30-39 (AOR = 0.63; 95% CI 0.48, 0.83), 40-49 (AOR = 0.40; 95% CI 0.29, 0.55), and >50 (AOR = 0.28; 95% CI 0.18, 0.43). Awareness of both post-exposure prophylaxis (PEP)(​AOR = 3.13; 95% CI 1.22, 8.03) and pre-exposure prophylaxis (PrEP)(​AOR = 10.02; 95% CI 2.95, 34.01) increased significantly in wave 4, compared to wave 3. These results suggest a potential increase in HIV rates among men with main and casual partners and should be monitored closely as PrEP becomes more widespread among MSM of all races and ethnicities in Chicago. This study also suggests that further analyses of the barriers to PEP and PreP uptake among high-risk populations are necessary.

Sexual identity development: relationship with lifetime suicidal ideation in sexual minority women

AIMS AND OBJECTIVES

This study draws on a life course perspective to evaluate in a sample of sexual minority women: (1) the relationship between age at reaching sexual identity milestones and risk of suicidal ideation, (2) developmental stages or stages of sexual identity development that represent greatest risk and (3) the relationship between age of reaching milestones and parental support.

BACKGROUND

Research shows higher rates of suicidal ideation among sexual minority women than heterosexual women. Evidence suggests this is partly accounted for by risk factors including sexual identity development and parental support. However, it remains unclear whether there are stages of particularly high risk.

DESIGN

This is a cross-sectional study. Data come from a prospective study of sexual minority women that used convenience and respondent-driven sampling methods.

METHODS

Using logistic regression, we examined associations among age at sexual identity developmental milestones, parental support and suicidal ideation in a large (N = 820), ethnically diverse sample of sexual minority women.

RESULTS

Compared with women who first wondered about their sexual identity in adulthood, those who first wondered in early, middle or late adolescence had greater odds of lifetime suicidal ideation. Younger age at subsequent milestones (first decided or first disclosed) was not associated with heightened risk of suicidal ideation. Parental support was independently associated with suicidal ideation.

CONCLUSIONS

Findings suggest that where one is in the process of identifying as a sexual minority may be more important than age in understanding risk of suicidal ideation in this population. As individuals come to accept and integrate their sexual minority identity risks associated with younger age diminish.

RELEVANCE TO CLINICAL PRACTICE

Nurses and other healthcare providers who work with youth should routinely ask about sexual orientation and suicidal ideation and be aware that youth in the earliest stages of coming out as sexual minority may be at particularly high risk of suicide.

Confronting Stigma: Community Involvement and Psychological Well-Being Among HIV-Positive Latino Gay Men

Theories of social integration and stress process posit that community involvement may buffer or may compensate the adverse effects of stigma on psychological well-being. In this article, the authors explore this thesis in a stigmatized and seldom studied group of HIV-positive Latino gay men. Specifically, they examine the effects of community involvement in AIDS and gay-related organizations (e.g., volunteerism and activism) and experienced homosexual stigma on three psychological well-being indicators (i.e., self-esteem, depression, and loneliness). The cross-sectional sample includes 155 HIV-positive men living in New York City and Washington, DC. Results suggest that experienced stigma attributed to homosexuality is associated with psychological well-being. Community involvement, however, seems to compensate the association between stigma and depression and loneliness, while buffering the association with self-esteem. Furthermore, community involvement appears to also heighten the perception of stigma.

HIV Prevalence and Awareness of Positive Serostatus Among Men Who Have Sex With Men and Transgender Women in Bogotá, Colombia

OBJECTIVES

We estimated HIV prevalence among men who have sex with men (MSM) and transgender women in Bogotá, Colombia, and explored differences between HIV-positive individuals who are aware and unaware of their serostatus.

METHODS

In this cross-sectional 2011 study, we used respondent-driven sampling (RDS) to recruit 1000 MSM and transgender women, who completed a computerized questionnaire and received an HIV test.

RESULTS

The RDS-adjusted prevalence was 12.1% (95% confidence interval [CI] = 8.7, 15.8), comparable to a previous RDS-derived estimate. Among HIV-positive participants, 39.7% (95% CI = 25.0, 54.8) were aware of their serostatus and 60.3% (95% CI = 45.2, 75.5) were unaware before this study. HIV-positive-unaware individuals were more likely to report inadequate insurance coverage, exchange sex (i.e., sexual intercourse in exchange for money, goods, or services), and substance use than other participants. HIV-positive-aware participants were least likely to have had condomless anal intercourse in the previous 3 months. Regardless of awareness, HIV-positive participants reported more violence and forced relocation experiences than HIV-negative participants.

CONCLUSIONS

There is an urgent need to increase HIV detection among MSM and transgender women in Bogotá. HIV-positive-unaware group characteristics suggest an important role for structural, social, and individual interventions.

GayBy Boomers' social support: exploring the connection between health and emotional and instrumental support in older gay men

We evaluate the association between emotional and instrumental support and perceived health and depression symptoms in a sample of 182 gay/bisexual men age ≥ 55. Perceived health was positively correlated with number of sources of emotional support and depression was negatively associated with instrumental support and health care providers' knowledge of patients' sexual orientation. Depression mediates the connection between providers' knowledge of patients' sexual orientation and perceived health. Number of sources of emotional support varied negatively with age and ethnic minority status, and positively with living with a partner. Instrumental support seemed to be dependent on living with a partner.

Tal Como Somos/just as we are: an educational film to reduce stigma toward gay and bisexual men, transgender individuals, and persons living with HIV/AIDS

In this article, the authors describe the development and dissemination of a film-based educational intervention to reduce negative attitudes toward gay and bisexual men, transgender women, and people living with HIV/AIDS in Latino communities, with a focus on youth. The intervention, Tal Como Somos/Just as We Are, is based on stigma and attribution theories, extensive formative research, and community input. Evaluation findings among educators and school youth suggest the film has the potential to effectively influence attitudes toward gay and bisexual men, transgender women, and people living with HIV/AIDS. The film and intervention are being disseminated using diffusion of innovations theory through community-based organizations, schools, television broadcasting, and film festivals.

Getting Involved: Exploring Latino GBT Volunteerism and Activism in AIDS and LGBT Organizations

The purpose of this paper is to investigate the community involvement (e.g., volunteerism, activism) of Latino gay and bisexual men and transgender persons (GBT) in two areas: AIDS/GLBT and other general causes. Drawing from volunteering and identity theories, we explore: Who is likely to get involved? What factors affect variation in the levels of involvement? Where do Latino GBT participate and what do they do? Data come from a cross-sectional sample (N=643) of Latino GBT in Chicago and San Francisco. We find high levels of involvement, but primarily focused on AIDS/GLBT. Involvement appears to be driven by income, early involvement, role modeling, and childhood stigmatization of gender nonconformity.

Stigma towards PLWHA: the role of internalized homosexual stigma in Latino gay/bisexual male and transgender communities

Stigma negatively affects the health of people living with HIV/AIDS (PLWHA). Negative attitudes and discriminatory actions towards PLWHA are thought to be based, among other factors, on stigma towards sexual minorities and beliefs about personal responsibility. Yet, there is little evidence to support these linkages and explain how they take place, especially among Latinos. This study analyzes attitudes towards PLWHA among 643 Latino gay/bisexual men and transgender (GBT) people. It examines whether discriminatory actions are predicted by beliefs about personal responsibility and internalized homosexual stigma. Results indicate that Discriminatory Actions towards PLWHA is associated with HIV/AIDS Personal Responsibility Beliefs and Internalized Homosexual Stigma. Further, HIV/AIDS Personal Responsibility Beliefs partially mediates the relationship between Internalized Homosexual Stigma and Discriminatory Actions towards PLWHA. Latino GBT persons who have internalized negative views about homosexuality may project those onto PLWHA. They may think PLWHA are responsible for their serostatus and, hence, deserving of rejection.

HIV/AIDS stigma: measurement and relationships to psycho-behavioral factors in Latino gay/bisexual men and transgender women

Despite the increased interest in HIV/AIDS stigma and its negative effects on the health and social support of people living with HIV/AIDS (PLWHA), little attention has been given to its assessment among Latino gay/ bisexual men and transgender women (GBT) living with HIV/AIDS. The purpose of this paper is twofold: to develop a multidimensional assessment of HIV/AIDS stigma for Latino GBT living with HIV/AIDS, and to test whether such stigma is related to self-esteem, safe sex self-efficacy, social support, and alcohol, and drug use. The sample included 170 HIV+ Latino GBT persons. The results revealed three dimensions of stigma: internalized, perceived, and enacted HIV/AIDS stigma. Enacted HIV/AIDS stigma comprised two domains: generalized and romantic and sexual. Generalized enacted HIV/AIDS stigma was related to most outcomes. Internalized HIV/AIDS stigma mediated the associations between generalized enacted HIV/AIDS stigma and self-esteem and safe sex self-efficacy. In addition, romantic and sexual enacted HIV/AIDS stigma significantly predicted drug use. Perceived HIV/AIDS stigma was not associated with any outcome. These findings expand the understanding of the multidimensionality of stigma and the manner in which various features impact marginalized PLWHA.

Work stress and depression among direct support professionals: the role of work support and locus of control

BACKGROUND

Although work stress can impede the capacity of direct support professionals and contribute to mental health challenges, external (i.e. work social support) and internal resources (i.e. an internal locus of control) have been shown to help DSPs cope more actively. We examined how work stress was associated with depression, with a particular focus on the role of resources.

METHOD

Direct support professionals (n = 323) who serve adults with intellectual and developmental disabilities from five community-based organisations completed a cross-sectional, self-administered survey which measured work stress, work support, locus of control, and depression.

RESULTS

Multiple regression analyses demonstrated that work stress was positively associated with depression, while resources were negatively associated with depression. In particular, work support moderated the effects of client disability stress, supervisory support lessened the effects of role conflict, and locus of control moderated the effects of workload.

CONCLUSIONS

Such findings suggest the importance of external and internal resources for staff mental health. This research underscores the need for strong work social support systems and interventions to help staff manage work stressors.

Navigating partnerships and addressing tough issues in promoting health among GLBTQ youth: an interview with Jesus Ramirez-Valles. Interview by Carmen J. Head

Gay, lesbian, bisexual, transgendered, and questioning (GLBTQ) youth have a number of challenges to face as they develop socially and sexually. Acceptance, discrimination, violence, and a sense of belonging are just a number of issues that complicate the life of GLBTQs as they seek to establish their identity. Many of the challenges that GLBTQ youth are faced with make them more susceptible to practicing risky behaviors that can lead to HIV/AIDS and STDS. When GLBTQ youth of color are living in poor neighborhoods or suffer from some form of racial discrimination, they face even greater challenges.

Social integration and health: community involvement, stigmatized identities, and sexual risk in Latino sexual minorities

The purpose of this study is to contribute to the conceptual understanding and practical application of social integration theory to health behaviors. We test whether community involvement in AIDS and GLBT organizations moderates the relationship of racial and homosexual stigmata to sexual risk behavior among gay and bisexual men and transgender persons of Latin American origin or descent. We use structural equation modeling to analyze data from a sample of 643 individuals recruited via respondent-driven sampling. Among those not involved in community organizations, homosexual and racial stigmata are related to sexual activity under the influence of alcohol and drugs, which is linked to sexual risk behavior. Among the involved group, the stigmata are not linked to sexual activity under the influence of alcohol and drugs, or to sexual risk behavior. The moderating role of community involvement seems to be more salient in those currently involved than those ever involved.

Researching special populations: retention of Latino gay and bisexual men and transgender persons in longitudinal health research

Few studies have sought to assess predictors of retention of racial/ethnic or sexual minorities in longitudinal health research. The purpose of this study is to investigate predictors of retention of Latino gay and bisexual men and transgender (GBT) research participants after the baseline interview. Data come from a sample of 643 Latino GBT individuals in two cities (Chicago and San Francisco). We assessed potential predictors of retention (operationalized as successful re-contact) using binary logistic regression of retention on five factors (sociodemographic/health, residential stability, acculturation/attachment to the United States, gay community attachment/stigmatization and research process/design). Our overall follow-up rate was 83 and 80% at 3 and 6 months, respectively. We found that traditional factors (e.g. education, income) were not associated with retention among Latino GBT. The strongest predictors of successful retention were the number of pieces of contact information provided by participants and city of residence (San Francisco). Furthermore, successful methods of contact (i.e. telephone, email) varied by city. We conclude that a largely immigrant urban population of Latino GBT individuals can be successfully followed in longitudinal research. The strong relationship between study design variables and successful retention indicates that collection of thorough contact information is vital to successful follow-up with this population.

HIV infection, sexual risk behavior, and substance use among Latino gay and bisexual men and transgender persons

OBJECTIVES

We examined HIV prevalence and the socioeconomic correlates of HIV infection, sexual risk behaviors, and substance use among Latino gay and bisexual men and transgender persons in Chicago and San Francisco.

METHODS

Data were collected from a sample of 643 individuals (Chicago: n=320; San Francisco: n=323) through respondent-driven sampling and computer-assisted self-administered interviews.

RESULTS

HIV prevalence in San Francisco (0.325; 95% confidence interval [CI]=0.260, 0.393) was higher than in Chicago (0.112; 95% CI=0.079, 0.163). In San Francisco, HIV prevalence was higher among US-born residents than among those born outside the country; in Chicago, the opposite was true. Heavy use of alcohol was prevalent, especially in Chicago (0.368; 95% CI=0.309, 0.432; San Francisco: 0.154; 95% CI=0.116, 0.192). Drug use and more education were positively correlated and greater age was negatively correlated with unprotected anal intercourse.

CONCLUSIONS

Heavy alcohol drinking and use of drugs remain a significant public health problem in this population. Drug use was more closely linked to HIV sexual risk behaviors than was heavy drinking.

"The priest obviously doesn't know that I'm gay": the religious and spiritual journeys of Latino gay men

In the United States, most adults state that religion plays an important role in their lives and claim a religious affiliation. For gay, bisexual, and transgender persons (GBT), the story is unique because their sexual and gender identity is not accepted by most religions. The purpose of this article is to analyze the role of religiosity in the life course of Latino GBTs raised as Catholics. Data come from 66 life history interviews with Latino GBTs living in Chicago and San Francisco, who grew up as Catholics. We found a religious trajectory that mirrored participants' developmental stages. During childhood, religion was inculcated by the family, culture, and schools. In adolescence, many experienced a conflict between their religion and their GBT identity, and in adulthood, they reached a resolution. Most participants abandoned Catholicism to join other religions or spiritual groups that they perceived to be welcoming. We found participants engaging in a remedial ideological work to reconcile their religious values and their identity.

Stigmatization, Substance Use, and Sexual Risk Behavior among Latino Gay and Bisexual Men and Transgender Persons

Following the minority stress model as a framework, we examine the associations between racial and homosexual stigma, substance use, and sexual risk behavior among a respondent-driven sample of Latino gay and bisexual men and male-to-female transgender persons (GBT) in Chicago and San Francisco (N = 643). We use structural equations to test such a model and disentangle the possible effects of the different stigmas and their corresponding dimensions (i.e., perception, experience, internalization). Findings revealed distinct pathways to sexual risk. Two are typified by experienced homosexual stigma and internalized racial stigma via multiple drug use, and two are characterized by experienced racial stigma and internalized homosexual stigma via alcohol use.

From networks to populations: the development and application of respondent-driven sampling among IDUs and Latino gay men

One of the challenges in studying HIV-risk behaviors among gay men is gathering information from a non-biased sample, as traditional probability sampling methods cannot be applied in gay populations. Respondent-Driven Sampling (RDS) has been proposed as a reliable and bias-free method to recruit "hidden" populations, such as gay men. The aim of this study is to assess the feasibility and effectiveness of RDS to sample Latino gay men and transgender persons. This was carried out when we used RDS to recruit participants into a study that investigated community involvement on HIV/AIDS sexual risk behaviors among Latino gay and bisexual men, and transgender (male-to-female) persons in Chicago and San Francisco. The population coverage of RDS was then compared to simulated time-location sampling (TLS). Recruitment differences were observed across cities, but the samples were comparable. RDS showed broader population coverage than TLS, especially among individuals at high risk for HIV.

Latinos' community involvement in HIV/AIDS: organizational and individual perspectives on volunteering

Community involvement (e.g., volunteerism, activism) in HIV/AIDS may be an effective prevention strategy. Through involvement in HIV/AIDS-related organizations, individuals may develop a positive sense of themselves, maintain HIV preventive behaviors, and create community change. In this paper we examine the types of activities, motives, consequences, and deterrents to community involvement among Latino gay men using both community organizations' and Latino gay men's perspectives. Data come from an exploratory study in Chicago. It included telephone interviews with HIV/AIDS organizations (N = 62) and in-depth interviews with Latino gay men (n = 6 volunteers; n = 7 no volunteers). We found that organizations have few Latino volunteers and that the deterrents to involvement are stigma of HIV/AIDS and homosexuality, racism, and apathy. Among the positive consequences, we found an increase in self-esteem, sense of empowerment, and safer sex behaviors.

The protective effects of community involvement for HIV risk behavior: a conceptual framework

This paper presents a conceptual framework of the protective effects of community involvement in HIV/AIDS-related groups and organizations for HIV sexual risk behavior among gay and bisexual men. The framework delineates hypotheses for future research, and provides a guide for prevention programs based on the active and direct involvement of participants, particularly communities of color. The framework (1) argues that community involvement moderates the association between three socio-structural risk factors (i.e. poverty, homophobia and racism) and sexual risk behavior; (2) posits that community involvement in HIV/AIDS reduces sexual risk behavior via its effects on four mediating factors (i.e. peer norms, self-efficacy, positive self-identity and alienation); (3) proposes five socio-cultural barriers to and facilitators of community involvement in HIV/AIDS (i.e. motives for participation, poverty, acculturation, stigma and perceived opportunities); and (4) addresses burnout as one potential negative consequence of community involvement in HIV/AIDS-related organizations and groups. The conceptual framework advances the understanding of HIV sexual risk behavior by integrating both its socio-structural risk and protective factors. It contributes to health education by specifying how interventions based on collective action (e.g. community involvement) for social change may be effective in generating healthy behaviors at individual and community levels.

"I was not invited to be a [CHW] ... I asked to be one": motives for community mobilization among women community health workers in Mexico

Despite health educators' revitalized interest in community mobilization for health, little attention has been given to participants' motives for mobilizing. The purpose of this article is to contribute to the understanding of community mobilizing by analyzing the motives for mobilization among a group of women community health workers (CHWs), members of a community-based organization in Mexico. The study is guided by critical feminist and social constructivist theories. It aims at identifying the categories of motives used by women CHWs and exploring how these motives are created while presenting women's own voices. Women's motives fall into four categories: getting out, serving, learning, and women's betterment. These motives blend personal andpublic motives. The analysis suggests that mobilization for health may be enhanced by addressing both the personal satisfaction of individuals and the accomplishment of public goods. The study of motives may be useful for the recruitment and retention of participants in community mobilization efforts.

Women, the welfare state, and their transnational dimension: the case of Mexico's community health worker programs

Feminist scholarship has shown that the welfare state is not only a set of agencies and policies to distribute services, but is engaged in the promotion of normative concepts of the female through its structural arrangements and the content of its programs and policies. Yet, this scholarship conceptualizes the state as a national entity and free from external influences, ignoring its transnational dimension. States are embedded in an international network consisting of other states, international agencies, and corporations that influence the practices and discursive frame of the welfare state. To uncover the process by which the welfare state institutionalizes and promotes female identities and the transnational dimension of this process, the author analyzes the case of community health worker programs conducted by the Mexican state from the 1970s to the early 1990s. The analysis corroborates the gender practices of the welfare state and suggests a reconceptualization that takes into account the transnational dimension of the state practices. The implications for feminist theories on the welfare state and for analyses of health promotion policies and programs are discussed.

Changing women: the narrative construction of personal change through community health work among women in Mexico

A major premise of health education is that people can and do change their lives. Personal changes and the events that precipitate them are often told in a form of narrative and are accompanied by a new sense of oneself. This research draws on the study of narratives and women's community activism to explore processes of personal change in women's activism as community health workers in Mexico. The research is a case study based on in-depth semistructured interviews. Two major categories of narratives of change emerged: change of the self and little or no change. Within these categories, changes are defined as development of the self, becoming a new and different person, actualization of the self, and little or no change. Although women experience significant changes, their changes are based on normative female identities. Implications for the study of narratives and personal change in health education are discussed.

Promoting health, promoting women: the construction of female and professional identities in the discourse of community health workers

Community health worker (CHW) programs are implemented in the third world and among racial minorities in the U.S. by public health professionals with the goal of improving people's access to basic health services. There is a shared view that women's roles as mothers make them effective CHWs because most health practices are located within the realm of the family. The objective of this paper is to inquire how and what concepts of woman are constructed and promoted in CHW programs. Viewing CHW as a discourse, I examine literature on CHWs using a critical feminist perspective and insights from narrative and rhetorical analyses. I argue that CHW positions women living in the third world and non-white Hispanic women in the U.S. as the "other" woman. The natural attributes of this other woman include mother, care giver, oppressed, child-like, and victim of patriarchy, religion, poverty, and diseases. These attributes are used to define categories of the female such as "the third world woman" and "Hispanic woman". These categories, in turn, define two unnamed opposite categories: "the first world woman" and "the public health professional". I conclude that CHW is a colonizing discourse and that public health professionals and feminists need to practice reflexivity.

Sexual risk behavior among youth: modeling the influence of prosocial activities and socioeconomic factors

Sexual activity among high-school-aged youths has steadily increased since the 1970s, emerging as a significant public health concern. Yet, patterns of youth sexual risk behavior are shaped by social class, race, and gender. Based on sociological theories of financial deprivation and collective socialization, we develop and test a model of the relationships among neighborhood poverty; family structure and social class position; parental involvement; prosocial activities; race; and gender as they predict youth sexual risk behavior. We employ structural equation modeling to test this model on a cross-sectional sample of 370 sexually active high-school students from a midwestern city; 57 percent (n = 209) are males and 86 percent are African American. We find that family structure indirectly predicts sexual risk behavior through neighborhood poverty, parental involvement, and prosocial activities. In addition, family class position indirectly predicts sexual risk behavior through neighborhood poverty and prosocial activities. We address implications for theory and health promotion.

An HIV/AIDS prevention project for Mexican homosexual men: an empowerment approach

In this intervention, participants design and implement an HIV/AIDS prevention project for Mexican homosexual men. The intervention is consistent with, and contributes to, empowerment theory because it enhances collective action, provides opportunities to develop knowledge and skills, creates needed resources, and includes shared control with professional and among participants. The intervention described provides an illustration of an empowering process and distinguishes itself from empowerment outcomes. An evaluation of the project is also described, but the outcomes were HIV/AIDS-related behaviors rather than psychological empowerment of the participants. The results suggest that the participants' HIV/AIDS knowledge and preventive behavior improved when compared to individuals who did not participate in the intervention. In addition, the intervention generated community change initiated by participants. Implications for designing interventions using an empowerment approach are discussed.

The development of a measure of enculturation for Native American youth

Enculturation is the process by which individuals learn about and identify with their ethnic minority culture. It is distinguished from acculturation which refers to the process by which an ethnic minority individual is assimilated into the majority culture. Three studies with Native American youths are reported that describe the development of a measure of enculturation for Native American youths. Development of a measure of enculturation provides a foundation upon which to build a body of literature that focuses on strengths in a youth's life rather than on deficits. Results of the first study (n = 120), a confirmatory factor analysis, indicated that cultural affinity, native American identity, and family involvement in traditional activities adequately represent the construct of ecnulturation. The study also provides some convergent validity for this interpretation. The second study examines factor invariance for enculturation among youths with data from over 2 years (n = 69). The factor structure was similar across time. The third study replicates the factor structure and validity analyses with a new sample (n = 42). Usefulness of the measure for assessing protective factors and stressing ethnicity over simple assessment of race categories is discussed.