An Identity-Affirming Web Application to Help Sexual and Gender Minority Youth Cope With Minority Stress: Pilot Randomized Controlled Trial.

BACKGROUND: Efficacious mental health interventions for sexual and gender minority youth have had limited reach, given their delivery as time-intensive, in-person sessions. Internet-based interventions may facilitate reach to sexual and gender minority youth; however, there is little research examining their efficacy. OBJECTIVE: This study aims to describe the results of a pilot randomized controlled trial of imi, a web application designed to improve mental health by supporting lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority identity affirmation, coping self-efficacy, and coping skill practice. METHODS: Sexual and gender minority youth (N=270) aged 13 to 19 (mean 16.5, SD 1.5) years and living in the United States were recruited through Instagram advertisements. Approximately 78% (210/270) of the sample identified as racial or ethnic minorities. Participants were randomized in a 1:1 fashion to the full imi intervention web application (treatment; 135/270, 50%) or a resource page-only version of the imi site (control; 135/270, 50%). The imi application covered four topical areas: gender identity; lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority identity; stress and coping; and internalized homophobia and transphobia. Participants explored these areas by engaging with informational resources, exercises, and peer stories at a self-guided pace. Both arms were assessed via web-based surveys at baseline and 4-week follow-up for intervention satisfaction, stress appraisals (ie, challenge, threat, and resource), coping skills (ie, instrumental support, positive reframing, and planning), and mental health symptoms among other outcomes. Main intent-to-treat analyses compared the arms at week 4, controlling for baseline values on each outcome. RESULTS: Survey retention was 90.4% (244/270) at week 4. Participants in the treatment arm reported greater satisfaction with the intervention than participants in the control arm (t241=-2.98; P=.003). The treatment arm showed significantly greater improvement in challenge appraisals (ie, belief in one's coping abilities) than the control (Cohen d=0.26; P=.008). There were no differences between the arms for threat (d=0.10; P=.37) or resource (d=0.15; P=.14) appraisals. The treatment arm showed greater increases in coping skills than the control arm (instrumental support: d=0.24, P=.005; positive reframing: d=0.27, P=.02; planning: d=0.26, P=.02). Mental health symptoms improved across both the treatment and control arms; however, there were no differences between arms. Within the treatment arm, higher engagement with imi (≥5 sessions, >10 minutes, or >10 pages) predicted greater improvement in stress appraisals (all P values <.05). CONCLUSIONS: The results provide initial evidence that asynchronous psychosocial interventions delivered via a web application to sexual and gender minority youth can support their ability to cope with minority stress. Further research is needed to examine the long-term effects of the imi application. TRIAL REGISTRATION: ClinicalTrials.gov NCT05061966; https://clinicaltrials.gov/ct2/show/NCT05061966.

Implementing Goal Mama: Barriers and Facilitators to Introducing Mobile Health Technology in a Public Health Nurse Home-Visiting Program.

The present study explores barriers and facilitators experienced by public health nurses introducing a mobile health technology platform (Goal Mama) to the Nurse-Family Partnership home-visiting program. Goal Mama is a HIPAA-compliant goal-coaching and visit preparation platform that clients and nurses use together to set and track goals. Forty-two nurses across five sites, including urban, suburban, and rural communities, piloted the platform with clients for 6 months. The mixed method, QUAL+quan pilot evaluation focused on deeply understanding the implementation process. Data were analyzed via iterative content analysis and multivariate regression analysis, and triangulated to identify salient findings. Over 6 months of use participants identified critical areas for product and implementation improvement, but still viewed the platform favorably. Key opportunities for improving sustained use revolved around supporting the technological and programmatic integration needed to lower key barriers and further facilitate implementation.

Sexual Health Transformation Among College Student Educators in an Arts-Based HIV Prevention Intervention: A Qualitative Cross-Site Analysis.

We examined the sexual health change process experienced by 26 college student sexual health educators from three geographic regions of the United States who participated in a multisite arts-based sexual health prevention program. We conducted eight focus groups and used a phenomenological approach to analyze data. We drew from social cognitive theory (SCT) to examine how sexual health knowledge, attitudes, self-efficacy, and communication shifted across the duration of participation. Findings suggest that the college student sexual health educators (a) developed enhanced sexual health awareness and critical consciousness, (b) questioned their own sexual health education and challenged previous beliefs, and (c) demonstrated self-efficacy related to intended behavior change and their perceived role as social justice advocates. We present both similarities and differences regarding the sexual health change process among the college student sexual health educators across the three sites.

Marginalisation, discrimination and the health of Latino immigrant day labourers in a central North Carolina community.

The morbidity and mortality of Latino immigrants in the United States (US) stem from a complex mix of policy, culture, discrimination and economics. Immigrants working as day labourers may be particularly vulnerable to the negative influences of these social factors due to limited access to social, financial and legal resources. We aimed to understand how the health of male Latino day labourers in North Carolina, US is influenced by their experiences interacting with their community and perceptions of their social environment. To respond to our research questions, we conducted three focus groups (n = 9, n = 10, n = 10) and a photovoice project (n = 5) with Latino male immigrants between October 2013 and March 2014. We conducted a thematic analysis of transcripts from the discussions in the focus groups and the group discussions with Photovoice participants. We found that men's health and well-being were primarily shaped by their experiences and feelings of discrimination and marginalisation. We identified three main links between discrimination/marginalisation and poor health: (i) dangerous work resulted in workplace injuries or illnesses; (ii) unsteady employment caused stress, anxiety and insufficient funds for healthcare; and (iii) exclusionary policies and treatment resulted in limited healthcare accessibility. Health promotion with Latino immigrant men in new settlement areas could benefit from community-building activities, addressing discrimination, augmenting the reach of formal healthcare and building upon the informal mechanisms that immigrants rely on to meet their health needs. Reforms to immigration and labour policies are also essential to addressing these structural barriers to health for these men.

Aging in rural, indigenous communities: an intercultural and participatory healthcare approach in Mexico.

From an ethno-gerontological perspective, new models are needed to fulfill the health needs of the indigenous older adult population in Mexico. In this paper we developed a comprehensive healthcare model, interculturally appropriate, designed to meet the needs of Mexican indigenous older adults. The model was constructed using a qualitative design with semi-structured interviews of older adults, health providers, and available health resources in three Mexican indigenous regions. An ethnographical review was carried out to contextually characterize these communities. At the same time, a comprehensive bibliographic revision was made to identify socio-demographic markers. Results pointed out that Mexican indigenous older adults are not covered by any type of social health insurance program. Their health problems tend in large part to be chronic in nature due to the lack of early diagnosis and treatment. There is a need for trained human resources in the field of gerontology encompassing the sociocultural context of the indigenous groups. The geographical location of these communities limits the permanent presence of healthcare givers and thus limits access to continuous care. Traditional healthcare givers, able to speak the native language, are a great asset allowing the invaluable possibility of direct verbal communication. Based upon the data gathered from indigenous older adults and service providers, in tandem with evidence from the literature, we identified key elements for successful intervention and designed an intervention model. We concluded that indigenous older adults are a more vulnerable group, given that aside from being elderly in a country where the health needs of these populations exceed the capacity of existing healthcare services, their ethnicity serves as an added barrier preventing their access to the limited available healthcare resources. To achieve uniformity in providing health care, today's health systems need to address intercultural and participative aspects of healthcare models.

"Because We All Trust and Care about Each Other": Exploring Tensions Translating a Theater-based HIV Prevention Intervention into a New Context.

BACKGROUND: A theater-based human immunodeficiency virus (HIV) prevention intervention developed in urban California was piloted with a new partnership in North Carolina. OBJECTIVES: This work describes the experience of translating a complex program with an enhanced partnership approach, barriers and facilitators of implementation in the new setting, and the challenges and benefits of interdisciplinary, collaborative interventions. METHODS: We gathered perspectives of local stakeholders involved in program implementation through process evaluation interviews and focus groups with undergraduates, a college instructor, school district administrators, and high school teachers. RESULTS: Implementing the intervention in a new setting proved feasible and successful; however, misunderstandings arose among stakeholder groups regarding teaching priorities, philosophies, and values, and were a limiting factor in partnership functioning. CONCLUSIONS: Implementing a cross-disciplinary intervention in a new setting is best achieved through a local community-engaged process, with active involvement of relevant stakeholders. We suggest strategies to strengthen community partnerships cooperating in implementation of complex, context-tailored interventions.

AMP!: A Cross-site Analysis of the Effects of a Theater-based Intervention on Adolescent Awareness, Attitudes, and Knowledge about HIV.

AMP! (Arts-based, Multiple component, Peer-education) is an HIV intervention developed for high school adolescents. AMP! uses interactive theater-based scenarios developed by trained college undergraduates to deliver messages addressing HIV/STI prevention strategies, healthy relationships, and stigma reduction towards people living with HIV/AIDS. We used a pre-test/post-test, control group study design to simultaneously assess intervention effect on ninth grade students in an urban county in California (N = 159) and a suburban county in North Carolina (N = 317). In each location, the control group received standard health education curricula delivered by teachers; the intervention group received AMP! in addition to standard health education curricula. Structural equation modeling was used to determine intervention effects. The post-test sample was 46 % male, 90 % self-identified as heterosexual, 32 % reported receiving free or reduced lunch, and 49 % White. Structural models indicated that participation in AMP! predicted higher scores on HIV knowledge (p = 0.05), HIV awareness (p = 0.01), and HIV attitudes (p = 0.05) at the post-test. Latent means comparison analyses revealed post-test scores were significantly higher than pre-test scores on HIV knowledge (p = 0.001), HIV awareness (p = 0.001), and HIV attitudes (p = 0.001). Further analyses indicated that scores rose for both groups, but the post-test scores of intervention participants were significantly higher than controls (HIV knowledge (p = 0.01), HIV awareness (p = 0.01), and HIV attitudes (p = 0.05)). Thus, AMP!'s theater-based approach shows promise for addressing multiple adolescent risk factors and attitudes concerning HIV in school settings.

A Critical Review of the Characteristics of Theater-Based HIV Prevention Interventions for Adolescents in School Settings.

Theater-based interventions are a viable prevention strategy for changing sexual health knowledge, attitudes, and behaviors related to HIV prevention. However, few studies have explored interventions in English-speaking, high-income countries such as the United States, Canada, or the United Kingdom. This article critically reviews the literature to identify key characteristics of theater-based HIV prevention strategies used for adolescents in school-settings in the United States, Canada, and the United Kingdom. Specifically, we identify the theatrical approach used in HIV prevention interventions, the behavioral theories that inform such interventions, and the study design and results of existing evaluation studies conducted in school settings. In the 10 articles reviewed, we found limited grounding in theory and the use of nonrigorous study design. To strengthen the evidence and practical application of theater-based HIV prevention interventions, we highlight three specific recommendations for practitioners and researchers: (1) define and operationalize the theater approach and techniques used, (2) ensure theater-based interventions are grounded in theory, and (3) conduct rigorous evaluation of theater-based interventions. These recommendations are key to strengthening future research on and implementation of theater-based interventions for HIV prevention.

Prevalence and factors associated with violence and abuse of older adults in Mexico's 2012 National Health and Nutrition Survey.

BACKGROUND: Factors associated with violence and the abuse of older adults are understudied and its prevalence in Mexico has not been reported. The aim of this study was to identify the prevalence and factors associated with violence and abuse of older adults in Mexico. METHODS: We used Mexico's 2012 National Health and Nutrition Survey, which included a sample of 8,894 individuals who are 60 years or older and who self-reported a negative health event related to robbery, aggression or violence in the previous 12 months. We used chi-squared test and Fisher's exact test to analyze the variables related to violence. Adjusted estimates were completed with multiple logistic regression models for complex surveys. RESULTS: The prevalence of violence was 1.7 % for both men and women. In 95 % of the cases, the aggression was from an unknown party. Verbal aggressions were the most prevalent (60 %). Among men, physical aggression was more common. Violence frequently occurred in the home (37.6 %); however, men were primarily assaulted in public places (42.4 %), in comparison to women (30.7 %). There were also differences in the risk factors for violence. Among men, risk was associated with younger age (60-64 years), higher education (secondary school or above) and higher socioeconomic status. Among women, risk was associated with depression, not being the head of the family, and region of the country. CONCLUSIONS: Violence against older adults presents differently for men and women, which means it is necessary to increase knowledge about the dynamics of the social determinants of violence, particularly in regards to the role of education among men. The relatively low prevalence found in this study may reflect the difficulty and fear of discussing the topic of violence. This may occur because of cultural factors, as well as by the perception of helplessness perpetuated by the scarce access to social programs that ensure protection and problem solving with regards to the complex social determinants of individual and family violence that this population group endures.

Surviving the Distance: The Transnational Utilization of Traditional Medicine Among Oaxacan Migrants in the US.

Transnational health practices are an emergent and understudied phenomenon, which provide insight into how migrants seek care and tend to their health care needs in receiving communities. We conducted in depth interviews with return migrants (N = 21) and traditional healers (N = 11) to explore transnational health practices among Mixtec migrants from Oaxaca, specifically in relation to their utilization of traditional healers, medicinal plants, and folk remedies. In established migrant destination points, folk remedies and plants are readily available, and furthermore, these resources often travel alongside migrants. Traditional healers are integral to transnational networks, whether they migrate and provide services in the destination point, or are providing services from communities of origin. Findings encourage us to rethink migrants' communities of origin typically thought of as "left behind," and instead reposition them as inherently connected by transnational channels. Implications for transnational health care theory and practice are addressed.

'I learned to be okay with talking about sex and safety': assessing the efficacy of a theatre-based HIV prevention approach for adolescents in North Carolina.

Adolescents are at increased risk of HIV and sexually transmitted infections (STIs) in the Southern states of the USA, where rates among youth are higher than in the rest of the nation. This paper reports on findings from a pilot study of an HIV prevention intervention that uses interactive theatre to educate young people about sexual health. The intervention was developed in Los Angeles and adapted for testing in the South of the USA, with its legacy of abstinence-based approaches to sexual health education. This study assessed intervention effects among a sample of young people in two public high schools in North Carolina. We used a pre-test, post-test quasi-experimental evaluation design to assess changes in 317 ninth grade participants' knowledge and attitudes about HIV. At post-test, we found statistically significant increases in participants' HIV knowledge (t= 60.14; p=.001), as well as changes in attitudes (X2 =8.23; p=.042) and awareness (X2 =4.94; p=.026). Focus group data corroborated increase in HIV knowledge and reduction in HIV stigma as successful outcomes of intervention participation. The findings make an important contribution to the literature on theatre-based interventions for sexual health education. Furthermore, they highlight the importance of considering socio-cultural and political context in implementing HIV prevention interventions in schools.

'I learned to accept every part of myself': the transformative impact of a theatre-based sexual health and HIV prevention programme.

Theatre-based interventions have been used in health promotion activities among young people to address HIV and sexual health. In this study, we explored the experience of undergraduate student performers participating in a theatre-based HIV prevention and sexual health education intervention for high school students in the USA. Undergraduate students enrolled in a credit-bearing course to learn about HIV and sexual health, participatory theatre and health education techniques. We analysed students' reflective essays written throughout the semester to identify any changes and the intervention processes that promoted these changes. Students experienced five interrelated forms of transformation: (1) increased knowledge about HIV and sexual health; (2) changes in attitude and communication about sex; (3) artistic growth; (4) emotional growth; and (5) clarification of career goals and future plans. Intervention processes that contributed to these transformations included improvisation, guided writing exercises, the creation of a close-knit cohesive group, and interactions with a group of HIV-positive speakers. Theatre-based, peer-led sexual health programmes can provide a transformative experience for undergraduate student performers. The transformative effects are linked to specific activities and processes of the intervention and require examination in future research.

Community-based health care for indigenous women in Mexico: a qualitative evaluation.

INTRODUCTION: Indigenous women in Mexico represent a vulnerable population in which three kinds of discrimination converge (ethnicity, gender and class), having direct repercussions on health status. The discrimination and inequity in health care settings brought this population to the fore as a priority group for institutional action. The objective of this study was to evaluate the processes and performance of the "Casa de la Mujer Indígena", a community based project for culturally and linguistically appropriate service delivery for indigenous women. The evaluation summarizes perspectives from diverse stakeholders involved in the implementation of the model, including users, local authorities, and institutional representatives. METHODS: The study covered five Casas implementation sites located in four Mexican states. A qualitative process evaluation focused on systematically analyzing the Casas project processes and performance was conducted using archival information and semi-structured interviews. Sixty-two interviews were conducted, and grounded theory approach was applied for data analysis. RESULTS: Few similarities were observed between the proposed model of service delivery and its implementation in diverse locations, signaling discordant operating processes. Evidence gathered from Casas personnel highlighted their ability to detect obstetric emergencies and domestic violence cases, as well as contribute to the empowerment of women in the indigenous communities served by the project. These themes directly translated to increases in the reporting of abuse and referrals for obstetric emergencies. CONCLUSIONS: The model's cultural and linguistic competency, and contributions to increased referrals for obstetric emergencies and abuse are notable successes. The flexibility and community-based nature of the model has allowed it to be adapted to the particularities of diverse indigenous contexts. Local, culturally appropriate implementation has been facilitated by the fact that the Casas have been implemented with local leadership and local women have taken ownership. Users express overall satisfaction with service delivery, while providing constructive feedback for the improvement of existing Casas, as well as more cost-effective implementation of the model in new sites. Integration of user's input obtained from this process evaluation into future planning will undoubtedly increase buy-in. The Casas model is pertinent and viable to other contexts where indigenous women experience disparities in care.

Privilege, power, and public health programs: a student perspective on deconstructing institutional racism in community service learning.

The Association of Schools of Public Health has identified "diversity and culture" as 1 of 7 crosscutting competencies that public health students are expected to achieve. This competency is traditionally incorporated into the curriculum through a community service-learning (CSL) component that aims to expose students to racial/ethnic health disparities. However, this model of CSL is problematic because although students are directly engaging with community members, it does not ensure long-term sustainable changes or benefits for the host community. Moreover, academic institutions have developed significant critiques of traditional CSL models where white middle-class students engage with low-income clients and communities of color, potentially reinforcing Eurocentric power and privilege. As such, public health programs require a shift in both pedagogy and curricula that more directly addresses underlying institutional racism in health disparities. Consistent with the principles of public health, a social justice framework is imperative in teaching cultural competency and should facilitate discussion of racial injustice and privilege in the students' own lives. This brief presents an autobiographical personal narrative of my experiences with CSL as a racial/ethnic minority student in a California graduate school of public health. Although autoethnography is inherently limited, this brief highlights my observations of the limitations of the service-learning model to adequately educate students on the intersection of racism and health outcomes. In addition, the brief includes suggestions for creating inclusive curricula that critically examine issues of privilege, oppression, and power dynamics related to race/ethnicity.