Application of a Heuristic Framework for Multilevel Interventions to Eliminate the Impact of Unjust Social Processes and Other Harmful Social Determinants of Health

There is consensus about the importance of developing a strong cadre of effective multilevel interventions to eliminate the impacts of unjust social processes, such as structural racism and other harmful social determinants of health (SDOH), on health inequities in the USA. However, the available cadre of rigorously evaluated evidence-based interventions for SDOH mitigation remains underdeveloped relative to the magnitude of historic and current health inequities. The proposed manuscript addresses this gap in two ways: first, by introducing a heuristic framework to inform decisions in multilevel intervention development, study design, and selection of analytic methods and, second, by providing a roadmap for future applications of the framework in multilevel intervention research through an exemplar application using the ongoing NIH-funded evaluation study of the Nurse-Community-Family Partnership (NCFP) intervention. NCFP leverages individual, family, institutional, and system factors to shape COVID-19 mitigation outcomes at the individual and household levels. NCFP takes an approach informed by the heuristic framework to addressing and mitigating unjust social processes and other harmful SDOH. We discuss the application of a two-arm parallel explanatory group randomized trial to evaluate the efficacy of NCFP in improving the primary (COVID-19 testing uptake) and secondary (adoption of COVID-19 control measures, COVID-19 vaccine uptake, mutual aid capacity, etc.) outcomes at the individual and household levels. The analysis approach relies on random-intercept models, and we calculate the variance partitioning coefficient to estimate the extent to which household- and individual-level variables contribute to the outcome, allowing examination of NCFP effects at multiple levels.

Paternal Perspectives on Latino and Black Sons' Readiness for Sex and Condom Guidance: A Mixed Methods Study

PURPOSE

Although a large proportion of males in the United States become sexually active during high school, condom use is decreasing and contributing to negative sexual health outcomes. Fathers are influential in promoting adolescent male sexual health; however, factors that shape fathers' decisions about when to discuss condom use with their sons remain understudied. We examined paternal perceptions of adolescent males' readiness for sex relative to fathers providing guidance for condom use in Latino and Black families.

METHODS

We recruited 191 Latino and Black males aged 15-19 years and their fathers in the South Bronx, New York City. Dyads completed surveys, and a subset of fathers participated in audio-recorded sessions with a father coach, which included conversations about adolescent male condom use. A sequential explanatory mixed methods design identified adolescent male developmental predictors for paternal guidance for condom use and explored how fathers perceive their sons' readiness for sex.

RESULTS

The quantitative findings indicate that paternal perception of their sons' readiness for sex is an important predictor of providing guidance for condom use, and that fathers consider other factors (beyond age and perceived sexual activity) in understanding their sons' developmental readiness for sex. The qualitative findings provide insights into these additional factors, which should be considered when engaging fathers in primary care around issues of adolescent male condom use.

CONCLUSIONS

Fathers' perception of their sons' readiness for sex is a predictor of providing condom guidance. We provide practical suggestions for engaging fathers in primary care to promote correct and consistent condom use by adolescent males.

Nurse-led approaches to address social determinants of health and advance health equity: A new framework and its implications

BACKGROUND

The U.S. health care system is burdened by inefficiencies, longstanding health inequities, and unstainable costs. Within the nursing profession and the broader health care sector, there is growing recognition of the need for a paradigm shift that addresses persistent structural problems and advances health equity.

PURPOSE

Despite evidence of the importance of the social determinants of health (SDOH) in shaping inequitable health outcomes, practical tools for applying SDOH theory in the development of effective nurse-led programs to mitigate harmful SDOH remain scarce.

METHODS

We synthesize extant SDOH literature into a heuristic framework for conceptualizing core SDOH mechanisms, constructs, and principles.

FINDINGS

To illustrate how nurse scientists can use the framework to guide the development of programs for SDOH mitigation, we outline a three-step exemplar application to the U.S. Latino HIV epidemic.

DISCUSSION

Our framework can inform a paradigm shift toward nurse-led, multi-level SDOH mitigation across practice, education, and research.

Paternal Communication and Sexual Health Clinic Visits Among Latino and Black Adolescent Males With Resident and Nonresident Fathers

PURPOSE

Latino and Black adolescent males experience sexual health inequities, and their engagement in sexual health services remains low. Parents shape adolescent sexual health behavior and other youth outcomes. However, the role of Latino and Black fathers in promoting male adolescent sexual health is understudied, in part because about one in four fathers resides apart from their children and nonresident fathers are presumed to be less influential. We examined associations of paternal communication with sexual health service use and perceived paternal role modeling among Latino and Black adolescent males with resident and nonresident fathers.

METHODS

We recruited 191 Latino and Black adolescent males aged 15-19 years and their fathers in the South Bronx, New York City, using area sampling methods; dyads completed surveys. We estimated bivariate and adjusted associations of paternal communication with adolescent male sexual health service use and perceived paternal role modeling using logistic and linear regressions. Effect measure modification by paternal residence was assessed.

RESULTS

A unit increase on a five-point paternal communication scale was associated with approximately twice and 1.7 times the likelihood of clinical sexual health service use during adolescent males' lifetime and in the past 3 months, respectively; there was no significant effect measure modification by paternal residence. Paternal communication was associated with increased levels of perceived paternal role modeling and usefulness of paternal advice, with stronger associations for nonresident fathers.

DISCUSSION

Both resident and nonresident Latino and Black fathers warrant greater consideration as partners in promoting male adolescent sexual health service use.

Is the USA on track to end the HIV epidemic?

Despite progress in reducing new HIV infections in the USA, publicly available data suggest that new HIV infections continue to occur at an alarming rate. In this Viewpoint, we highlight the regularity with which the existing systems for HIV prevention and treatment delivery in the USA fail and the clearly inequitable effect of the systems' failure among several priority populations of the Ending the HIV Epidemic (EHE) initiative. Existing data cast doubt on whether the current EHE efforts will suffice to achieve its 2030 goal of reducing annual new HIV infections to fewer than 3000. We outline future directions in four priority areas to regain lost ground in pursuit of the 2030 EHE goals: reducing the stigma affecting people living with and most at risk of HIV; broadening the HIV workforce; mitigating harmful social determinants of health; and recommitting and reinvesting in health in the USA more broadly.

Conceptualizing the Mechanisms of Social Determinants of Health: A Heuristic Framework to Inform Future Directions for Mitigation

Policy Points A large body of scientific work examines the mechanisms through which social determinants of health (SDOH) shape health inequities. However, the nuances described in the literature are infrequently reflected in the applied frameworks that inform health policy and programming. We synthesize extant SDOH research into a heuristic framework that provides policymakers, practitioners, and researchers with a customizable template for conceptualizing and operationalizing key mechanisms that represent intervention opportunities for mitigating the impact of harmful SDOH. In light of scarce existing SDOH mitigation strategies, the framework addresses an important research-to-practice translation gap and missed opportunity for advancing health equity.

CONTEXT

The reduction of health inequities is a broad and interdisciplinary endeavor with implications for policy, research, and practice. Health inequities are most often understood as associated with the social determinants of health (SDOH). However, policy and programmatic frameworks for mitigation often rely on broad SDOH domains, without sufficient attention to the operating mechanisms, and effective SDOH mitigation strategies remain scarce. To expand the cadre of effective SDOH mitigation strategies, a practical, heuristic framework for policymakers, practitioners, and researchers is needed that serves as a roadmap for conceptualizing and targeting the key mechanisms of SDOH influence.

METHODS

We conduct a critical review of the extant conceptual and empirical SDOH literature to identify unifying principles of SDOH mechanisms and to synthesize an integrated framework for conceptualizing such mechanisms.

FINDINGS

We highlight eight unifying principles of SDOH mechanisms that emerge from landmark SDOH research. Building on these principles, we introduce and apply a conceptual model that synthesizes key SDOH mechanisms into one organizing, heuristic framework that provides policymakers, practitioners, and researchers with a customizable template for conceptualizing and operationalizing the key SDOH mechanisms that represent intervention opportunities to maximize potential impact for mitigating a given health inequity.

CONCLUSIONS

Our synthesis of the extant SDOH research into a heuristic framework addresses a scarcity of peer-reviewed organizing frameworks of SDOH mechanisms designed to inform practice. The framework represents a practical tool to facilitate the translation of scholarly SDOH work into evidence-based and targeted policy and programming. Such tools designed to close the research-to-practice translation gap for effective SDOH mitigation are sorely needed, given that health inequities in the United States and in many other parts of the world have widened over the past two decades.

Evaluating the efficacy of an online, family-based intervention to promote adolescent sexual health: a study protocol for a randomized controlled trial

BACKGROUND

Adolescents in the U.S. experience significant negative sexual health outcomes, representing a public health priority in the U.S. Research shows that while parents play an influential role in shaping adolescent sexual behavior, surprisingly few programs engage parents in existing programming. Moreover, most efficacious parent-based programs focus on young adolescents, and few utilize delivery mechanisms that facilitate broad reach and scale-up. To address these gaps, we propose to test the efficacy of an online-delivered, parent-based intervention adapted to address both younger and older adolescent sexual risk behavior.

METHODS

In this parallel, two-arm, superiority randomized controlled trial (RCT), we propose to evaluate Families Talking Together Plus (FTT+), an adaptation of an existing and efficacious FTT parent-based intervention, in shaping sexual risk behavior among adolescents aged 12-17 and delivered via a teleconferencing application (e.g., Zoom). The study population will include n=750 parent-adolescent dyads recruited from public housing developments in the Bronx, New York. Adolescents will be eligible if they are between the ages of 12 and 17 years of age, self-report as Latino and/or Black, have a parent or primary caregiver, and are South Bronx residents. Parent-adolescent dyads will complete a baseline survey, after which they will be assigned to either the FTT+ intervention condition (n=375) or the passive control condition (n=375) in a 1:1 allocation ratio. Parents and adolescents in each condition will complete follow-up assessments 3 and 9 months post-baseline. The primary outcomes will include sexual debut and ever sex, and the secondary outcomes will include the frequency of sex acts, number of lifetime sexual partners, number of unprotected sex acts, and linkage to health and educational/vocational services in the community. We will utilize intent-to-treat analyses of 9-month outcomes and single degree of freedom contrasts comparing the intervention to the control group for primary and secondary outcomes.

DISCUSSION

The proposed evaluation and analysis of the FTT+ intervention will address gaps in the current cadre of parent-based programs. If efficacious, FTT+ would represent a model for scale-up and adoption of parent-based approaches designed to address adolescent sexual health in the U.S.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04731649. Registered on February 1, 2021.

Reconsidering Assumptions of Adolescent and Young Adult Severe Acute Respiratory Syndrome Coronavirus 2 Transmission Dynamics

Evidence regarding the important role of adolescents and young adults (AYA) in accelerating and sustaining coronavirus disease 2019 (COVID-19) outbreaks is growing. Furthermore, data suggest that 2 known factors that contribute to high severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmissibility-presymptomatic transmission and asymptomatic case presentations-may be amplified in AYA. However, AYA have not been prioritized as a key population in the public health response to the COVID-19 pandemic. Policy decisions that limit public health attention to AYA and are driven by the assumption of insignificant forward transmission from AYA pose a risk of inadvertent reinvigoration of local transmission dynamics. In this viewpoint, we highlight evidence regarding the increased potential of AYA to transmit SARS-CoV-2 that, to date, has received little attention, discuss adolescent and young adult-specific considerations for future COVID-19 control measures, and provide applied programmatic suggestions.

The National Academies Report on Sexually Transmitted Infections: Implications for Clinical Training, Licensing, and Practice Guidelines

STIs represent a sizable, longstanding, and growing challenge and a national public health priority. A recent National Academies report outlines new directions for STI prevention and control, including the adoption of a new sexual health paradigm and broader ownership and accountability for addressing sexual health and STIs among diverse clinical and nonclinical actors. These recommendations have important implications for infectious disease providers with STI and HIV expertise. As part of the envisioned shift toward greater prioritization of sexual health across systems for healthcare and health promotion, STI and HIV specialty providers will need to increasingly take on responsibilities as leaders in the provision of STI-related training; provision of technical assistance; and alignment of clinical training curricula, licensing criteria, and practice guidelines for healthcare generalists.

A Triadic Intervention for Adolescent Sexual Health: A Randomized Clinical Trial

OBJECTIVES

In this study, we evaluate the efficacy of Families Talking Together (FTT), a triadic intervention to reduce adolescent sexual risk behavior.

METHODS

Adolescents aged 11 to 14 and their female caregivers were recruited from a pediatric clinic; 900 families were enrolled; 84 declined. Families were randomly assigned to FTT or 1 of 2 control conditions. The FTT triadic intervention consisted of a 45-minute face-to-face session for mothers, health care provider endorsement of intervention content, printed materials for families, and a booster call for mothers. The primary outcomes were ever having had vaginal intercourse, sexual debut within the past 12 months, and condom use at last sexual intercourse. Assessments occurred at baseline, 3 months post baseline, and 12 months post baseline.

RESULTS

Of enrolled families, 73.4% identified as Hispanic, 20.4% as African American, and 6.2% as mixed race. Mean maternal age was 38.8 years, and mean adolescent grade was seventh grade. At the 12-month follow-up, 5.2% of adolescents in the experimental group reported having had sexual intercourse, compared with 18% of adolescents in the control groups (P < .05). In the experimental group, 4.7% of adolescents reported sexual debut within the past 12 months, compared with 14.7% of adolescents in the control group (P < .05). In the experimental group, 74.2% of sexually active adolescents indicated using a condom at last sexual intercourse, compared with 49.1% of adolescents in the control group (P < .05).

CONCLUSIONS

This research suggests that the FTT triadic intervention is efficacious in delaying sexual debut and reducing sexual risk behavior among adolescents.

The Invisible US Hispanic/Latino HIV Crisis: Addressing Gaps in the National Response

The federal government has proposed an end to HIV transmission in the United States by 2030. Although the United States has made substantial overall progress in the fight against HIV/AIDS, data released by the Centers for Disease Control and Prevention have raised concerns about widening, yet largely unrecognized, HIV infection disparities among Hispanic and Latino populations.This commentary identifies underlying drivers of increasing new HIV infections among Hispanics/Latinos, discusses existing national efforts to fight HIV in Hispanic/Latino communities, and points to gaps in the federal response. Consideration of the underlying drivers of increased HIV incidence among Hispanics/Latinos is warranted to achieve the administration's 2030 HIV/AIDS goals.Specifically, the proposed reinforcement of national efforts to end the US HIV epidemic must include focused investment in four priority areas: (1) HIV stigma reduction in Hispanic/Latino communities, (2) the availability and accessibility of HIV treatment of HIV-positive Hispanics/Latinos, (3) the development of behavioral interventions tailored to Hispanic/Latino populations, and (4) the engagement of Hispanic/Latino community leaders.

Shifting the Paradigm in HIV Prevention and Treatment Service Delivery Toward Differentiated Care for Youth

Despite significant progress in the fight against HIV/AIDS in the United States, HIV prevention and treatment disparities among key populations remain a national public health concern. While new HIV diagnoses are increasing among people under age 30—in particular among racial, ethnic, and sexual minority adolescents and young adults (AYA)—dominant prevention and treatment paradigms too often inadequately consider the unique HIV service needs of AYA. To address this gap, we characterize persistent and largely overlooked AYA disparities across the HIV prevention and treatment continuum, identify AYA-specific limitations in extant resources for improving HIV service delivery in the United States, and propose a novel AYA-centered differentiated care framework adapted to the unique ecological and developmental factors shaping engagement, adherence, and retention in HIV services among AYA. Shifting the paradigm for AYA to differentiated HIV care is a promising approach that warrants implementation and evaluation as part of reinforced national efforts to end the HIV epidemic in the United States by 2030.

Father-Son Communication About Consistent and Correct Condom Use

: media-1vid15852345835001PEDS-VA_2018-1609Video Abstract OBJECTIVES: With this study, we explore communication about consistent and correct condom use among African American and Latino male adolescents ages 15 to 19 and their fathers.

METHODS

Twenty-five father-son dyads completed semistructured interviews designed to elicit specific preferences for teaching and learning about consistent and correct condom use and strategies for addressing common condom use errors and problems. For analysis, we used in vivo coding and vertical and horizontal analysis techniques.

RESULTS

Fathers and sons agreed that communication about condom use is feasible and acceptable. However, fathers tended to convey vague messages regarding protecting oneself from the negative consequences of sexual activity. Furthermore, both fathers and sons reported barriers hindering conversations. Secondly, the style and frequency of condom use conversations can help overcome barriers and support father-son relationship management. Talking frequently in 1-on-1 settings and using strategies to reduce discomfort made communication easier. Lastly, fathers and sons reported distinct preferences for teaching and learning about condom use. Sons wanted fathers to give specific guidance on the use and management of condoms. Fathers expressed interest in opportunities for improving their own condom knowledge and skills. Fathers identified gaps in their own condom use knowledge as a limitation to effective instruction of their sons.

CONCLUSIONS

A father-focused communication intervention about condom use is feasible and acceptable. Enhancing the intergenerational benefits of father-son communication by addressing specific father-son preferences and learning needs for condom use instruction, as well as communication barriers, represents a novel mechanism for reducing male sexual reproductive health disparities.

Misalignment of sexual and reproductive health priorities among older Latino adolescents and their mothers

OBJECTIVE

The study describes maternal and adolescent perspectives on sexual decision making and the role of mothers in shaping use of contraception for the prevention of unplanned pregnancies and sexually transmitted infections (STIs) among older Latino adolescents.

STUDY DESIGN

Researchers used a semistructured interview guide to conduct focus group discussions with 21 mother-adolescent Latino dyads (n=42). Latino adolescents ages 17-19 were eligible for the study. We recruited families from the South Bronx, New York City, using area sampling methodology. For analysis of qualitative data, we used the framework method involving open coding, identification of dominant themes, refining of codebooks and indexing.

RESULTS

Overwhelmingly, results suggest asymmetric priorities and preferences regarding maternal involvement in older adolescent sexual and contraceptive decision making. Mothers primarily employed practices designed to prevent adolescent sexual activity. Most teens reported already having experienced sexual debut and were currently sexually active. Adolescents expressed a strong interest in practical support for sexual decision making, including maternal guidance regarding effective access to and use of contraception. Mothers offered limited guidance or support with such matters. Maternal views focused entirely on the health and social consequences of sex in lieu of specific guidance on contraception for older sexually active adolescents. The findings highlight a missed opportunity for Latino mothers to support their older adolescent children to prevent unplanned pregnancies, STIs and HIV.

CONCLUSION

Mothers have the potential to positively shape adolescent contraceptive decision making and behavior. Misalignment of priorities between mothers and adolescents diminishes the potential of reducing adolescent sexual and reproductive health (SRH) disparities.

IMPLICATIONS

Mothers are influential in reducing adolescent SRH risk. However, asymmetric priorities among Latino adolescents and their mothers regarding support for SRH reduce likelihood of reducing adolescent negative SRH outcomes and supporting adolescent health. Programs supporting better alignment of maternal guidance and adolescent SRH needs are warranted.

Purification and characterization of a glutathione S-transferase Omega in pig: evidence for two distinct organ-specific transcripts

A cytosolic glutathione S-transferase (GST, EC 2.5.1.18) from the recently characterized Omega class [GSTO; Board et al. 2000, J. Biol. Chem. 275, 24798-24806] has been identified in pig organs. It was found widely distributed in the different tissues investigated and especially abundant in liver and muscle. The hepatic enzyme has been purified to homogeneity by using its selective affinity for S-hexylglutathione over GSH, thus providing a simple method to isolate mammalian GSTO. The dimeric protein has a subunit molecular mass of 27328 Da as measured by electrospray ionization MS. Internal peptide sequencing and complete cDNA sequencing revealed strong similarities with its human recombinant orthologue and two rodent GST-like proteins with the ability to catalyse the GSH-dependent reduction of dehydroascorbate. Additional similarities, including the presence of a specific N-terminal extension and of immunological cross-reactivity, support the results. Moreover, this gene encoding GSTO generates two organ-specific transcripts, suggesting transcriptional mechanisms with a significance that is as yet uncharacterized.