Exploring Psychosocial and Structural Syndemic Effects as Predictors of HIV Risk Behaviors Among Black Women (HPTN 064)

Background: Syndemic models have been used in previous studies exploring HIV-related outcomes; however, these models do not fully consider intersecting psychosocial (e.g., substance use, depressive symptoms) and structural factors (unstable housing, concentrated housing vacancy) that influence the lived experiences of women. Therefore, there is a need to explore the syndemic effects of psychosocial and structural factors on HIV risk behaviors to better explain the multilevel factors shaping HIV disparities among black women. Methods: This analysis uses baseline data (May 2009-August 2010) from non-Hispanic black women enrolled in the HIV Prevention Trials Network 064 Women's Seroincidence Study (HPTN 064) and the American Community Survey 5-year estimates from 2007 to 2011. Three parameterizations of syndemic factors were applied in this analysis a cumulative syndemic index, three syndemic groups reflecting the level of influence (psychosocial syndemic group, participant-level structural syndemic group, and a neighborhood-level structural syndemic group), and syndemic factor groups. Clustered mixed effects log-binomial analyses measured the relationship of each syndemic parameterization on HIV risk behaviors in 1,347 black women enrolled in HPTN 064. Results: A higher syndemic score was significantly associated with increased prevalence of unknown HIV status of the last male sex partner (adjusted prevalence ratio (aPR) = 1.07, 95% confidence interval or CI 1.04-1.10), involvement in exchange sex (aPR = 1.17, 95% CI: 1.14-1.20), and multiple sex partners (aPR = 1.07, 95% CI: 1.06-1.09) in the last 6 months. A dose-response relationship was observed between the number of syndemic groups and HIV risk behaviors, therefore, being in multiple syndemic groups was significantly associated with increased prevalence of reporting HIV risk behaviors compared with being in one syndemic group. In addition, being in all three syndemic groups was associated with increased prevalence of unknown HIV status of the last male sex partner (aPR = 1.67, 95% CI: 1.43-1.95) and multiple sex partners (aPR = 1.53, 95% CI: 1.36-1.72). Conclusions: Findings highlight syndemic factors influence the lived experiences of black women.

Preliminary Psychometric Evaluation of Novel Measures of Therapist Practice Related to LGBTQ+ Clients

BACKGROUND

Culturally competent and equitable mental healthcare for LGBTQ+ people is critical for addressing mental health inequities for this population. Tools to assess therapists' practice with LGBTQ+ clients are needed for research and clinical efforts related to mental healthcare equity goals.

METHODS

We conducted a preliminary assessment of the reliability and validity of a novel 28-item self-report measure assessing therapist practice with LGBTQ+ clients. We examined the construct validity using factor analyses, the convergent and criterion validity using intercorrelations with LGBTQ-affirming knowledge, self-efficacy, and attitudes, and the internal consistency using Cronbach alpha.

RESULTS

Our overall total LGBTQ+ practice measure demonstrated excellent internal consistency (Cronbach's alpha = 0.91) and was strongly associated with LGBTQ+ knowledge (rho = 0.377), self-efficacy (rho = 0.633), and LGBTQ+ attitudes (rho = 0.305). We also identified two subscales: "Commitment to Continued Learning" and "Affirmative Practices", which demonstrated similarly strong internal consistency and tests of validity.

CONCLUSIONS

Our novel measure of overall LGBTQ+ practice, including two subscales, demonstrated strong reliability and validity. These findings have important implications for practice and research in mental healthcare for LGBTQ+ clients. Future research exploring these measures in relationship to mental healthcare outcomes is recommended.

Challenges Unique to Transgender Persons in US Correctional Settings: a Scoping Review

US correctional facilities operate under a binary interpretation of gender, which can yield inherent risks and conflicts for incarcerated transgender people. We conducted a scoping literature review on challenges unique to transgender individuals within US correctional settings. Online databases were searched to identify papers that addressed the challenges of incarcerated transgender adults age 18 + within US correctional institutions. A concurrent analysis of legal literature was reviewed with key policy recommendations extracted. A total of 33 papers (21 scientific studies and 12 legal analyses) met criteria for inclusion. Of the 21 scientific studies, the majority of papers (n = 14) focused on transgender women and most (n = 13) utilized qualitative methods. Emerging themes revealed challenges in key domains of violence, health, healthcare access, housing, and a pervasive culture of transphobia. Legal analyses supported policy changes such as implementing case-by-case housing classification systems, providing all forms of gender-affirming care, and safeguarding gender expression. Transgender persons face distinct obstacles while incarcerated in US correctional facilities and are in need of expanded protections. Working in tandem with efforts to decarcerate and reduce criminal legal involvement, widespread institutional policy change, such as redefining housing assignment policies, ensuring gender-affirming healthcare, and expanding transgender-specific competency trainings for correctional staff, is necessary.

LGBTQ+ cultural-competence training effectiveness: Mental health organization and therapist survey outcome results from a pilot randomized controlled trial

Lesbian, gay, bisexual, transgender, queer/questioning and other sexual and gender diverse (LGBTQ+) persons frequently lack access to mental health service organizations (MHOs) and therapists who are competent with LGBTQ+ clients. Existing continuing education programmes to better equip therapists to work with LGBTQ+ clients are often not widely accessible or skills focused, evaluated for effectiveness and inclusive of MHO administrators who can address the organizational climate needed for therapist effectiveness. A virtual, face-to-face, multi-level (administrators and therapists) and multi-strategy (technical assistance, workshop and clinical consultations) LGBTQ+ cultural competence training-the Sexual and Gender Diversity Learning Community (SGDLC)-was tested in a pilot randomized controlled trial. Ten organizations were randomly assigned to the intervention (SGDLC plus free online videos) or control (free online videos only) group. Pretest/posttest Organization LGBTQ+ Climate Surveys (n = 10 MHOs) and pretest/posttest Therapist LGBTQ+ Competence Self-Assessments (n = 48 therapists) were administered. Results showed that at pretest, average ratings across organization LGBTQ+ climate survey items were low; twice as many items improved on average in the intervention (10/18 items) than control (5/18 items) group organizations. At pretest, therapist average scores (range 0-1) were highest for knowledge (0.88), followed by affirmative attitudes (0.81), practice self-efficacy (0.81), affirmative practices (0.75) and commitment to continued learning (0.69). Pretest/posttest change scores were higher for the intervention relative to the control group regarding therapist self-reported affirmative attitudes (cumulative ordinal ratio [OR] = 3.29; 95% confidence interval [CI] = 1.73, 6.26), practice self-efficacy (OR = 5.28, 95% CI = 2.00, 13.93) and affirmative practices (OR = 3.12, 95% CI = 1.18, 8.25). Average therapist and administrator satisfaction scores were high for the SGDLC. These findings suggest the SGDLC training can affect organizational- and therapist-level changes that may benefit LGBTQ+ clients.

Mediation of the Effect of Incarceration on Selling Sex Among Black Sexual Minority Men and Black Transgender Women in the HPTN 061 Study

Incarceration among Black sexual minority men and Black transgender women (BSMM/BTW) is disproportionately high in the United States. Limited research has documented the disruptive effect of incarceration on sexual networks and sexual partnership exchange among BSMM/BTW. We estimate the influence of incarceration on selling sex and mediating pathways among 1169 BSMM/BTW enrolled in the HIV Prevention Trials Network (HPTN) 061 cohort to assess this relationship. Mediators investigated were social support, violence, illicit drug use, and distress due to experienced racism and homophobia. During the 6 months following baseline, 14% of the cohort was incarcerated, including 24% of BTW. After adjustment, recent incarceration was associated with 1.57 (95% CI 1.02, 2.42) times the risk of subsequently selling sex. The hypothesized mediators together explained 25% of the relationship, with an indirect effect risk ratio of 1.09 (95% CI 0.97, 1.24). Our results document an association and call for more research investigating mechanisms.

Pandemic distress associated with segregation and social stressors

Background

Racial/ethnic minorities are disproportionately impacted by the COVID-19 pandemic, as they are more likely to experience structural and interpersonal racial discrimination, and thus social marginalization. Based on this, we tested for associations between pandemic distress outcomes and four exposures: racial segregation, coronavirus-related racial bias, social status, and social support.

Methods

Data were collected as part of a larger longitudinal national study on mental health during the pandemic (n = 1,309). We tested if county-level segregation and individual-level social status, social support, and coronavirus racial bias were associated with pandemic distress using cumulative ordinal regression models, both unadjusted and adjusted for covariates (gender, age, education, and income).

Results

Both the segregation index (PR = 1.19; 95% CI 1.03, 1.36) and the coronavirus racial bias scale (PR = 1.17; 95% CI 1.06, 1.29) were significantly associated with pandemic distress. Estimates were similar, after adjusting for covariates, for both segregation (aPR = 1.15; 95% CI 1.01, 1.31) and coronavirus racial bias (PR = 1.12; 95% CI 1.02, 1.24). Higher social status (aPR = 0.74; 95% CI 0.64, 0.86) and social support (aPR = 0.81; 95% CI 0.73, 0.90) were associated with lower pandemic distress after adjustment.

Conclusion

Segregation and coronavirus racial bias are relevant pandemic stressors, and thus have implications for minority health. Future research exploring potential mechanisms of this relationship, including specific forms of racial discrimination related to pandemic distress and implications for social justice efforts, are recommended.

Latent syndemic profiles among sexual and gender minority college students and psychological distress amid the COVID-19 pandemic

Sexual and gender minority (SGM) college students experience compounding psychological effects as a result of the COVID-19 pandemic. Using latent profile analysis of cross-sectional data from a sample of SGM students (n=565) we tested for a syndemic of victimization, internalized LGBTQ+ stigma, racism, racialized heterosexism/cisgenderism, family rejection, and isolation associated with psychological distress. We also tested if increases in these factors since the start of the COVID-19 pandemic were associated with greater psychological distress among syndemic profiles. We identified four profiles: "Lowest syndemic factors" (reference), "High isolation only," "High isolation and rejection only," and "High syndemic." The greatest distress was observed among the "High syndemic" profile (aPR=2.99, 95% CI 2.20, 4.06), followed by the "High isolation and rejection only" profile (aPR=2.11, 95% CI 1.61, 2.76), and the "High isolation only" profile (aPR=1.32, 95% CI 1.03, 1.70). Among the "High syndemic profile," increases in every factor since the start of the COVID-19 pandemic were associated with greater psychological distress. The strongest associations were seen among increased victimization (aPR=5.85, 95% CI 1.33, 25.71). Victimization, internalized LGBTQ+ stigma, racism, family rejection, and isolation form a syndemic among SGM students, which has magnified since the start of the COVID-19 pandemic.

Retrospective reports of socioeconomic disadvantage in childhood and mortality risk: are associations consistent across measures and sex?

Although prior research has established associations between childhood socioeconomic disadvantage and all-cause mortality, there is still limited research investigating (1) the consistency between subjective and objective reports of childhood socioeconomic status, (2) sex differences in the associations between childhood socioeconomic disadvantage and all-cause mortality, and (3) potential mediators within these associations. Drawing on data from the Midlife in the United States (MIDUS) cohort (N = 7425), we examined the associations between three distinct indicators of childhood socioeconomic disadvantage and all-cause mortality risk, and whether these associations differ for males and females. Among males only, lower perceived relative childhood financial status, lower levels of parents' education, and receipt of welfare during childhood were associated with excess mortality risk, adjusted for age and minority status, with adjusted hazard ratios ranging from 1.24 (95% confidence interval (CI): 1.02, 1.51) for perceived childhood financial status to 1.28 (95% CI: 1.11, 1.47) for welfare in childhood. When additionally adjusted for education, substance use, depression, and underlying health conditions, only childhood welfare status maintained an association with mortality (AHR, 1.17; 95% CI, 1.02-1.35). Mediation analyses among males revealed that education, substance use, depression, and underlying health conditions accounted for substantial proportions of these associations, ranging from 31.03 to 57.63%, across indicators of childhood socioeconomic disadvantage. Future research is needed to clarify the developmental mechanisms that lead to sex differences and identify effective strategies to intervene on the relation between childhood socioeconomic position and excess mortality risk among males.

Evaluation of Factors Underlying Sex-Based Disparities in Cardiovascular Care in Adults With Self-reported Premature Atherosclerotic Cardiovascular Disease

IMPORTANCE

There are limited data regarding sex-based differences in physical and mental health domains and health care access in adults with premature atherosclerotic cardiovascular disease (ASCVD).

OBJECTIVE

To study the association of sex with physical and mental health domains as well as health care access-related factors among adults with self-reported premature ASCVD.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort analysis of 748 090 adults aged 18 to 55 years in the Behavioral Risk Factor Surveillance System 2016 to 2019 in the US. Data were analyzed from June to July 2021.

EXPOSURES

Self-reported ASCVD, defined as having a history of coronary artery disease, myocardial infarction, or stroke.

MAIN OUTCOMES AND MEASURES

Self-reported physical and mental health and measures of health care access, including self-reported cost-related medication nonadherence and inability to see a physician due to cost.

RESULTS

Between 2016 and 2019, 748 090 adults aged 18-55 years were identified, of whom 28 522 (3.3%) had self-reported premature ASCVD. Of these, 14 358 (47.0%) were women. Compared with men, women with premature ASCVD were more likely to report being clinically depressed (odds ratio [OR], 1.73; 95% CI, 1.41-2.14; P < .001), have cost-related medication nonadherence (OR, 1.42; 95% CI, 1.11-1.82; P = .005), have not seen a physician due to cost-related issues (OR, 4.52; 95% CI, 2.24-9.13; P < .001), and were more likely to report overall poor physical health (OR, 1.39; 95% CI, 1.09-1.78; P = .008) despite being more likely to have health care coverage (85.3% vs 80.8%; P = .04) and a primary care physician (84.2% vs 75.7%; P < .001).

CONCLUSIONS AND RELEVANCE

Results from this study indicate that women with premature ASCVD were more likely to report worse overall physical and mental health, inability to see a physician due to cost, and cost-related medical nonadherence. Interventions addressing mental health and out-of-pocket costs are needed in adults with premature ASCVD.

Assessing proximate intermediates between ambient temperature, hospital admissions, and mortality in hemodialysis patients

BACKGROUND

Typical thermoregulatory responses to elevated temperatures among healthy individuals include reduced blood pressure and perspiration. Individuals with end-stage kidney disease (ESKD) are susceptible to systemic fluctuations caused by ambient temperature changes that may increase morbidity and mortality. We investigated whether pre-dialysis systolic blood pressure (preSBP) and interdialytic weight gain (IDWG) can independently mediate the association between ambient temperature, all-cause hospital admissions (ACHA), and all-cause mortality (ACM).

METHODS

The study population consisted of ESKD patients receiving hemodialysis treatments at Fresenius Medical Care facilities in Philadelphia County, PA, from 2011 to 2019 (n = 1981). Within a time-to-event framework, we estimated the association between daily maximum dry-bulb temperature (TMAX) and, as separate models, ACHA and ACM during warmer calendar months. Clinically measured preSBP and IDWG responses to temperature increases were estimated using linear mixed effect models. We employed the difference (c-c') method to decompose total effect models for ACHA and ACM using preSBP and IDWG as time-dependent mediators. Covariate adjustments for exposure-mediator and total and direct effect models include age, race, ethnicity, blood pressure medication use, treatment location, preSBP, and IDWG. We considered lags up to two days for exposure and 1-day lag for mediator variables (Lag 2-Lag 1) to assure temporality between exposure-outcome models. Sensitivity analyses for 2-day (Lag 2-only) and 1-day (Lag 1-only) lag structures were also conducted.

RESULTS

Based on Lag 2- Lag 1 temporal ordering, 1 °C increase in daily TMAX was associated with increased hazard of ACHA by 1.4% (adjusted hazard ratio (HR), 1.014; 95% confidence interval, 1.007-1.021) and ACM 7.5% (adjusted HR, 1.075, 1.050-1.100). Short-term lag exposures to 1 °C increase in temperature predicted mean reductions in IDWG and preSBP by 0.013-0.015% and 0.168-0.229 mmHg, respectively. Mediation analysis for ACHA identified significant indirect effects for all three studied pathways (preSBP, IDWG, and preSBP + IDWG) and significant indirect effects for IDWG and conjoined preSBP + IDWG pathways for ACM. Of note, only 1.03% of the association between temperature and ACM was mediated through preSBP. The mechanistic path for IDWG, independent of preSBP, demonstrated inconsistent mediation and, consequently, potential suppression effects in ACHA (-15.5%) and ACM (-6.3%) based on combined pathway models. Proportion mediated estimates from preSBP + IDWG pathways achieved 2.2% and 0.3% in combined pathway analysis for ACHA and ACM outcomes, respectively. Lag 2 discrete-time ACM mediation models exhibited consistent mediation for all three pathways suggesting that 2-day lag in IDWG and preSBP responses can explain 2.11% and 4.41% of total effect association between temperature and mortality, respectively.

CONCLUSION

We corroborated the previously reported association between ambient temperature, ACHA and ACM. Our results foster the understanding of potential physiological linkages that may explain or suppress temperature-driven hospital admissions and mortality risks. Of note, concomitant changes in preSBP and IDWG may have little intermediary effect when analyzed in combined pathway models. These findings advance our assessment of candidate interventions to reduce the impact of outdoor temperature change on ESKD patients.

Perceived Stress and Molecular Bacterial Vaginosis in the National Institutes of Health Longitudinal Study of Vaginal Flora

Vaginal microbiota provide the first line of defense against urogenital infections primarily through protective actions of Lactobacillus species Perceived stress increases susceptibility to infection through several mechanisms, including suppression of immune function. We investigated whether stress was associated with deleterious changes to vaginal bacterial composition in a subsample of 572 women in the Longitudinal Study of Vaginal Flora, sampled from 1999 through 2002. Using Cox proportional hazards models, both unadjusted and adjusted for sociodemographic factors and sexual behaviors, we found that participants who exhibited a 5-unit-increase in Cohen's Perceived Stress Scale had greater risk (adjusted hazard ratio (HR) = 1.40, 95% confidence interval (CI): 1.13, 1.74) of developing molecular bacterial vaginosis (BV), a state with low Lactobacillus abundance and diverse anaerobic bacteria. A 5-unit increase in stress score was also associated with greater risks of transitioning from the L. iners-dominated community state type (26% higher) to molecular-BV (adjusted HR = 1.26, 95% CI: 1.01, 1.56) or maintaining molecular-BV from baseline (adjusted HR = 1.23, 95% CI: 1.01, 1.47). Inversely, women with baseline molecular-BV reporting a 5-unit stress increase were less likely to transition to microbiota dominated by L. crispatus, L. gasseri, or L. jensenii (adjusted HR = 0.81, 95% CI: 0.68, 0.99). These findings suggest that psychosocial stress is associated with vaginal microbiota composition, inviting a more mechanistic exploration of the relationship between psychosocial stress and molecular-BV.

Bacterial Vaginosis and Behavioral Factors Associated With Incident Pelvic Inflammatory Disease in the Longitudinal Study of Vaginal Flora

BACKGROUND

Pelvic inflammatory disease (PID) leads to long-term reproductive consequences for cisgender women. Bacterial vaginosis (BV) and behavioral factors may play a role in PID pathogenesis. We assessed associations between BV, behavioral factors, and incident PID.

METHODS

We analyzed participants (N = 2956) enrolled in the National Institutes of Health Longitudinal Study of Vaginal Flora, a cohort of nonpregnant cisgender women followed quarterly for 12 months. PID was defined by at least 1 of the following: cervical motion tenderness, uterine tenderness, or adnexal tenderness (160 cases). We tested associations between BV (measured using Nugent and Amsel criteria) and PID at the subsequent visit. Sociodemographic factors, sexual behaviors, and Chlamydia trachomatis (CT), untreated at baseline and concurrent with BV, were covariates in Cox proportional hazards models. Adjusting for the few Neisseria gonorrhoeae and Trichomonas vaginalis cases did not alter results.

RESULTS

In multivariable modeling, Nugent-BV (adjusted hazard ratio [aHR], 1.53 [95% confidence interval {CI}, 1.05-2.21]), symptomatic Amsel-BV (aHR, 2.15 [95% CI, 1.23-3.75]), and vaginal douching (aHR, 1.47 [95% CI, 1.03-2.09]) were associated with incident PID.

CONCLUSIONS

BV was associated with incident PID in a large prospective cohort, controlling for behavioral factors and sexually transmitted infections (STIs). Larger studies on how BV, STIs, behaviors, and host responses interactively affect PID risk are needed.

Ecological and Syndemic Predictors of Drug Use During Sex and Transactional Sex among U.S. Black Men Who Have Sex with Men: A Secondary Data Analysis from the HPTN 061 Study

Threats to sexual health among U.S. Black men who have sex with men (MSM) may manifest in a context of social adverse experiences. Situational sex is one such context, which we characterize as sexual behaviors driven either by a desire to cultivate a specific sexual experience or attributable to social vulnerability. Two characterizations of situational sex explored in this study were drug use during sex and transactional sex. Guided by ecological and syndemic frameworks, we conducted a secondary data analysis of social conditions and sexual behaviors among a prospective cohort of Black MSM from the HIV Prevention Trial Network (HPTN) 061 study. Using structural equation modeling, this analysis examined the indirect effect of syndemic factors (substance use, depression, violence exposure) in the relationship between ecological constructs (anti-Black/homophobic stigma, childhood violence, and economic vulnerability) and situational sex (drug use during sex, transactional sex). Model fit indices, CFI (.870) and SRMR (.091), demonstrated reasonable fit. Significant indirect effects emerged via substance use for economic vulnerability (indirect effect = .181, 95% CI [.078, .294]) and anti-Black/homophobic violence and stigma (indirect effect = .061, 95% CI [.008, .121]) on drug use during sex; as well as on transactional sex (economic vulnerability indirect effect = .059, 95% CI [.018, .121] and anti-Black/homophobic stigma and violence indirect effect = .020, 95% CI [.003, .051]). Findings implicate the need for social and fiscal intervention to address upstream, ecological, and syndemic factors that influence inherent vulnerability of situational sex and overall threats to sexual health among Black MSM.

Testing a Syndemic Index of Psychosocial and Structural Factors associated with HIV Testing among Black Men

Black populations in the United States are disproportionately affected by HIV. This disparity may be affected by social and structural barriers to HIV testing, leading to undiagnosed infection and prolonged HIV transmissibility. Using data from a nationally representative sample of 1,727 Black men in the 2015 Behavioral Risk Factor Surveillance System we tested for differences in poverty, depression, and health care barriers between Black men who had been HIV tested in the past year and those who had not. We also tested a syndemic index of these factors. Number of syndemic factors was linearly associated with less HIV testing (aPR=0.79, 95% CI 0.66-0.95). Assumptions of unidimensionality were met. The use of a syndemic index was a superior approach to analyzing these factors individually, both in terms of model fit and associations detected. The accumulation of poverty, depression, and health care barriers has an adverse impact on HIV testing among Black men.

Classes of Sexual Identity, Homophobia, and Sexual Risk among Black Sexual Minorities in HPTN 061

Homophobia is associated with sexual risk among sexual minorities, including Black sexual minority men, though experienced homophobia may differ across sexual identities. We conducted latent class analysis of sexual identities and experienced homophobia associated with sexual risk, and tested mediators of this association. We used longitudinal data from the HIV Prevention Trials Network Study 061 (n = 1,553). We generated rate ratios between baseline latent classes of experienced homophobia and sexual identity and 12-month outcomes: Condomless receptive anal intercourse (CRAI), number of partners, and transactional sex. Mediators included 6-month internalized homophobia, depression, social support, and substance use. We selected the following 7-class model: "Bisexual, rare homophobia" (reference), "Mixed identities, mixed homophobia", "Bisexual, frequent homophobia", "Heterosexual/Same-gender loving, frequent homophobia", "Gay, frequent homophobia", " Gay/Same-gender loving, frequent homophobia," and "Gay, rare homophobia." All other classes had greater CRAI than the reference. For bisexual/mixed/heterosexual classes, approximately 20% of this association was positively mediated through our mediators (p < .05). The Heterosexual/Same-gender loving class had the largest proportion mediated through internalized homophobia. For gay-identifying classes, mediation was marginally significant (.05 < p < .10). Classes of sexual identity and experienced homophobia were associated with CRAI among Black sexual minority men, partially mediated through internalized homophobia, depression, social support, and substance use.

Estimating the Roles of Racism and Homophobia in HIV Testing Among Black Sexual Minority Men and Transgender Women With a History of Incarceration in the HPTN 061 Cohort

Black sexual minority men (BSMM) and Black transgender women (BTW) have disproportionately high HIV prevalence, making HIV testing critical for treatment and prevention. Racism and homophobia may be barriers to testing among BSMM/BTW, particularly in the context of previous incarceration. We analyzed a subsample (n = 655) of HIV-negative, previously incarcerated BSMM/BTW in the HIV Prevention Trials Network 061 study, generating prevalence ratios and interaction terms testing associations between experienced racism and homophobia with past-year HIV testing. Both racism (aPR = 0.83, 95% CI [0.70, 0.98]) and homophobia (aPR: 0.68, 95% CI [0.48, 0.98]) were associated with lower testing, although their interaction was associated with unexpectedly higher testing (Interaction aPR = 1.77, 95% CI [1.25, 2.49]). Among BSMM/BTW with a history of incarceration, racism and homophobia are barriers to HIV testing. Positive interactions between racism and homophobia could be explained by numerous factors (e.g., resilience, coping) and warrants further study.

Police harassment and psychosocial vulnerability, distress, and depressive symptoms among black men who have sex with men in the U.S.: Longitudinal analysis of HPTN 061

The mental health impact of exposure to police harassment is understudied, particularly among Black men who have sex with men (BMSM), a group at elevated risk of exposure to such discrimination. This study aimed to identify the associations among BMSM between recent police harassment and psychosocial vulnerability, psychological distress, and depression measured six months later. Data come from the HIV Prevention Trials Network (HPTN) 061 Study, a cohort study of BMSM recruited in 6 U.S. cities (Atlanta, GA, Boston, MA, Los Angeles, CA, New York, NY, San Francisco, CA, and Washington DC). Participants completed baseline, 6-month follow-up, and 12-month follow-up interviews. A convenience sample of 1553 BMSM was recruited between July 2009 and October 2010 of whom 1155 returned for a follow-up interview 12 months later. Accounting for previous police interaction, poverty, psychopathology, drug use, and alcohol use, we estimated associations between recent police harassment reported at the 6 month follow-up interview and 12 month outcomes including psychosocial vulnerability (elevated racial/sexual identity incongruence), psychological distress (being distressed by experiences of racism and/or homophobia), and depression. About 60% of men reported experiencing police harassment between the baseline and 6-month interview due to their race and/or sexuality. Adjusted analyses suggested police harassment was independently associated with a 10.81 (95% CI: 7.97, 13.66) point increase and 8.68 (95% CI: 6.06, 11.30) point increase in distress due to experienced racism and distress due to experienced homophobia scores, respectively. Police harassment perceived to be dually motivated predicted disproportionate levels of distress. Police harassment is prevalent and associated with negative influences on psychosocial vulnerability and psychological distress among BMSM. Reducing exposure to police harassment may improve the psychosocial health of BMSM.

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We examine the impact of police harassment on Black men who have sex with men.

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Data from the HPTN 061 Study show that police harassment is highly prevalent.

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Police harassment is associated with psychosocial vulnerability.

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Police harassment is associated with psychological distress.

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Harassment motivated by racism and homophobia is associated with added distress.

Barriers to syphilis testing among men who have sex with men: a systematic review of the literature

Men who have sex with men (MSM) represent the highest risk group for syphilis in the United States and several other countries. Improving uptake of syphilis testing among MSM requires understanding key barriers to testing in this population. Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, a systematic review to assess proportions of syphilis testing among MSM and identify social, structural, and individual barriers to syphilis testing was conducted. All searches were conducted through the University of Maryland world catalogue search engine. Studies that measured syphilis testing in a sample of MSM were included. All studies were assessed for bias using JBI-MAStARI instruments. Studies were synthesised based on sample size, years of data collection, study selection method (e.g. hospital or clinic-based, community/venue-based), location (e.g. USA-based, other countries) and results of the bias assessment. For studies measuring barriers associated with testing, the measure of association, point estimate and statistical significance was assessed. Of 848 studies found in the initial search, 24 were included in the final review. The largest difference in syphilis testing proportions was based on hospital or clinic-based sampling (50-87%) compared with venue/community-based and online sampling (31-38%). Socioeconomic factors (four items, four studies, OR 0.23 to 0.68), healthcare interactions six items, five studies, OR 0.09 to 0.69) and community/interpersonal factors (seven items, five studies, OR 0.07 to 0.58) were identified as barriers to testing. Barriers to syphilis testing among MSM include socioeconomic factors, healthcare-related factors and community/interpersonal factors. Improving overall routine utilisation of healthcare services is an especially important focal point in testing promotion.

Perceived stress and incident sexually transmitted infections in a prospective cohort

PURPOSE

Psychosocial stress has been associated with susceptibility to many infectious pathogens. We evaluated the association between perceived stress and incident sexually transmitted infections (STIs; Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis genital infections) in a prospective study of women. Stress may increase vulnerability to STIs by suppressing immune function and altering the protective vaginal microbiota.

METHODS

Using the 1999 Longitudinal Study of Vaginal Flora (n = 2439), a primarily African American cohort of women, we fitted Cox proportional hazards models to examine the association between perceived stress and incident STIs. We tested bacterial vaginosis (measured by Nugent Score) and sexual behaviors (condom use, number of partners, and partner concurrence) as mediators using VanderWeele's difference method.

RESULTS

Baseline perceived stress was associated with incident STIs both before and after adjusting for confounders (adjusted hazard ratio = 1.015; 95% confidence interval, 1.005-1.026). Nugent score and sexual behaviors significantly mediated 21% and 65% of this adjusted association, respectively, and 78% when included together in the adjusted model.

CONCLUSIONS

This study advances understanding of the relationship between perceived stress and STIs and identifies high-risk sexual behaviors and development of bacterial vaginosis-both known risk factors for STIs-as mechanisms underlying this association.

The Role of Racial Identity and Implicit Racial Bias in Self-Reported Racial Discrimination: Implications for Depression Among African American Men

Racial discrimination is conceptualized as a psychosocial stressor that has negative implications for mental health. However, factors related to racial identity may influence whether negative experiences are interpreted as instances of racial discrimination and subsequently reported as such in survey instruments, particularly given the ambiguous nature of contemporary racism. Along these lines, dimensions of racial identity may moderate associations between racial discrimination and mental health outcomes. This study examined relationships between racial discrimination, racial identity, implicit racial bias, and depressive symptoms among African American men between 30 and 50 years of age (n = 95). Higher racial centrality was associated with greater reports of racial discrimination, while greater implicit anti-Black bias was associated with lower reports of racial discrimination. In models predicting elevated depressive symptoms, holding greater implicit anti-Black bias in tandem with reporting lower racial discrimination was associated with the highest risk. Results suggest that unconscious as well as conscious processes related to racial identity are important to consider in measuring racial discrimination, and should be integrated in studies of racial discrimination and mental health.

Comparison of field and laboratory methods for monitoring metallic mercury vapor in indoor air

Real-time metallic mercury vapor levels of the indoor air were monitored at several mercury spill sites around the US in order to evaluate the effectiveness of site cleanup operations. Mercury readings taken in the field with a Jerome 431 Mercury Vapor Analyzer were compared with laboratory analysis using a modified National Institute for Occupational Safety and Health (NIOSH) 6009 method. Statistical evaluation showed that the data were highly comparable except at low concentrations, due to the large degree of uncertainty associated with measuring low levels of mercury with the Jerome analyzer. Regression analysis indicated that Jerome measurements of 10 microg/m(3) or greater are comparable for field analysis of mercury vapor in air.

Prevalence and impact of wrist and shoulder pain in patients with spinal cord injury

Spinal cord injury (SCI) patients experience varying degrees of wrist and shoulder pain. Previous studies indicated that 30 to 64 percent of SCI patients reported chronic shoulder pain. The purpose of this study was to identify the prevalence of chronic wrist and shoulder pain, to determine which activities caused or exacerbated the pain, and assess functional and emotional responses to chronic pain and identify ways in which the pain might be reduced. Eight hundred SCI patients were surveyed by questionnaire with 451 (66 percent) responding. In addition, 30 patients were available for clinical observation and evaluation. Data was evaluated using the Statistical Analysis System and the Cornell Personal Adjustment Scale. Results indicated that wrist and shoulder pain were more prevalent than previously indicated (72.7 percent of respondents reported some degree of chronic pain in one or both of these areas), wheelchair propulsion and transfers caused most pain and also increased the degree of pain. Patient's age, neurologic level and time since injury were not statistically significant in the study and emotional responses did not significantly vary between groups with and without pain. Further, it was noted that among the pain group, various routine therapies were not effective. We conclude that alternative methods for wheelchair propulsion and transfers, which lessen stress and cumulative trauma, need to be developed for SCI patients in order to diminish the incidence of chronic upper limb pain.

Data-driven performance improvement in health care: the Joint Commission's Indicator Measurement System (IMSystem)

BACKGROUND

Since 1986, the Joint Commission has worked to create an evaluation system that would remain standards based but would accent an organization's performance as well as its capability to provide care. One component is the Indicator Measurement System (IMSystem), which involves continuous data collection and periodic feedback about specific performance measures, or indicators. An indicator is a quantitative measure of an aspect of patient care. It is not a direct measure of quality; rather it is a screen or flag which indicates areas for more detailed analysis.

METHODOLOGY

Sets of indicators, each set related to specific important health care functions such as perioperative care, are established by expert task forces and are then subject to two phases of testing. Alpha testing addresses face validity and feasibility of data collection and may result in indicator revision. In the beta phase, a large group of organizations test the indicators for validity, reliability, and usefulness in improving performance.

OPERATIONAL ISSUES

In 1994, the IMSystem will contain ten indicators and participation by hospitals will be voluntary. Once the value of these data in the accreditation process has been demonstrated--possibly as early as 1996--participation will become an integral component of accreditation. Hospitals will transmit indicator data to the Joint Commission but no patient or physician identifiers will leave the hospital. The system will provide organizations with information they can use to monitor and improve their performance, while helping meet external needs for performance measurement.

Accounting practice diversity in the healthcare industry

A recent study examining accounting practices currently being used to prepare annual hospital financial statements indicates relatively little diversity, regardless of organizational type or size. The study's findings should interest those concerned with healthcare accounting and financial reporting issues, especially healthcare administrators and members of standards setting boards who participate in accounting policy deliberations.