Promoting Health from the Pulpit: A Process Evaluation of HIV Sermons to Reduce HIV Stigma and Promote Testing in African American and Latino Churches.

Embedding health messages into sermons is a potentially valuable strategy to address HIV and other health disparities in churches that predominantly serve racial and ethnic minorities. This study explores implementation of an HIV sermon as part of a multi-component intervention in three churches (Latino Catholic, Latino Pentecostal, and African American Baptist) in high HIV prevalence areas of Los Angeles County, California. Clergy were given an HIV sermon guide that included local public health data, stigma reduction cues, HIV testing messages, and a sample sermon. Findings are based on a process evaluation (i.e., reach, dose delivered, fidelity, and implementation) and in-depth content analysis to explore HIV frames and messages used by clergy. Sermons were audio-recorded, transcribed verbatim, and coded using an inductive approach. Complementary data were collected through systematic observation. Overall, five clergy delivered nine HIV sermons to majority African American or Latino audiences. On average, 174 congregants were reached per sermon. We found large variation in fidelity to communicating key HIV messages from the sermon guide. While promoting HIV testing from the pulpit seemed viable and acceptable to all the participating clergy, fewer embedded explicit stigma reduction cues. Most spoke about HIV using compassionate and non-judgmental terms, however, issue framing varied across clergy. Structured training of clergy may be necessary to implement the more theoretically driven stigma reduction cues included in the sermon guide. More research is needed on the viability and acceptability of embedding specific health promotion messages into sermons.

Urban Religious Congregations' Responses to Community Substance Use: An Exploratory Study of Four Cases.

Faith-based drug treatment programs are common, and many are implemented through congregations; however, little is documented about how congregations conceptualize and implement these programs. We use case study analysis to explore congregational approaches to drug treatment; qualitative findings emerged in three areas: (1) religion's role in congregational responses to substance use, (2) relationships between program participants and the broader congregation, and (3) interactions between congregational programs and the external community. Congregational approaches to drug treatment can be comprehensive, but work is needed to evaluate such efforts. Congregants' attitudes may influence whether program participants become members of a sustaining congregational community.

How Patient Comments Affect Consumers' Use of Physician Performance Measures.

BACKGROUND: Patients' comments about doctors are increasingly available on the internet. The effects of these anecdotal accounts on consumers' engagement with reports on doctor quality, use of more statistically reliable performance measures, and ability to choose doctors wisely are unknown. OBJECTIVE: To examine the effects of providing patient comments along with standardized performance information in a web-based public report. DESIGN: Participants were randomly assigned to view 1 of 6 versions of a website presenting comparative performance information on fictitious primary care doctors. Versions varied by the combination of information types [Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS), and patient comments] and number of doctors. PARTICIPANTS: A random sample of working-age adults (N=848) from an online panel representing the noninstitutionalized population of the United States. MAIN MEASURES: Time spent and actions taken on the website, probing of standardized measures, and decision quality (chosen doctor rated highest on quantifiable metrics, chosen doctor not dominated by another choice). Secondary outcomes were perceived usefulness and trustworthiness of performance metrics and evaluations of the website. KEY RESULTS: Inclusion of patient comments increased time spent on the website by 35%-42% and actions taken (clicks) by 106%-117% compared with versions presenting only CAHPS and HEDIS measures (P<0.01). It also reduced participants' attention to standardized measures (eg, percentage of time probing HEDIS measures dropped by 67%, P<0.01). When patient comments were present, fewer participants chose the doctor scoring highest on standardized metrics (44%-49% vs. 61%-62%, P<0.01). CONCLUSIONS: Including patient comments in physician performance reports enhances consumers' engagement but reduces their attention to standardized measures and substantially increases suboptimal choices. More research is needed to explore whether integrated reporting strategies could leverage the positive effects of patient comments on consumer engagement without undermining consumers' use of other important metrics for informing choice among doctors.

Effects of a Pilot Church-Based Intervention to Reduce HIV Stigma and Promote HIV Testing Among African Americans and Latinos.

HIV-related stigma and mistrust contribute to HIV disparities. Addressing stigma with faith partners may be effective, but few church-based stigma reduction interventions have been tested. We implemented a pilot intervention with 3 Latino and 2 African American churches (4 in matched pairs) in high HIV prevalence areas of Los Angeles County to reduce HIV stigma and mistrust and increase HIV testing. The intervention included HIV education and peer leader workshops, pastor-delivered sermons on HIV with imagined contact scenarios, and HIV testing events. We surveyed congregants at baseline and 6 month follow-up (n = 1235) and found statistically significant (p < 0.05) reductions in HIV stigma and mistrust in the Latino intervention churches but not in the African American intervention church nor overall across matched African American and Latino pairs. However, within matched pairs, intervention churches had much higher rates of HIV testing (p < 0.001). Stigma reduction and HIV testing may have synergistic effects in community settings.

Predictors of HIV-related stigmas among African American and Latino religious congregants.

OBJECTIVES: To inform church-based stigma interventions by exploring dimensions of HIV stigma among African American and Latino religious congregants and determining how these are related to drug addiction and homosexuality stigmas and knowing someone HIV-positive. METHOD: In-person, self-administered surveys of congregants 18+ years old across 2 African American and 3 Latino churches (n = 1,235, response rate 73%) in a western U.S. city with high HIV prevalence. Measures included 12 items that captured dimensions of HIV stigma, a 5-item scale that assessed attitudes toward people who are addicted to drugs, a 7-item scale assessing attitudes toward homosexuality, and questions regarding sociodemographics and previous communication about HIV. RESULTS: Of the survey participants, 63.8% were women, mean age was 40.2 years, and 34.4% were African American, 16.8% were U.S.-born Latinos, 16.0% were foreign-born, English-speaking Latinos, and 32.9% were foreign-born, Spanish-speaking Latinos. Exploratory and confirmatory factor analyses identified 4 dimensions of HIV stigma: discomfort interacting with people with HIV (4 items, α = .86), feelings of shame "if you had HIV" (3 items, α = .78), fears of rejection "if you had HIV" (3 items, α = .71), and feelings of blame toward people with HIV (2 items, α = .65). Across all dimensions, after controlling for sociodemographic characteristics and previous communication about HIV, knowing someone with HIV was associated with lower HIV stigma, and greater stigma concerning drug addiction and homosexuality were associated with higher HIV stigma. CONCLUSIONS: Congregation-based HIV stigma reduction interventions should consider incorporating contact with HIV-affected people. It may also be helpful to address attitudes toward drug addiction and sexual orientation. (PsycINFO Database Record

Racial and ethnic health disparities among fifth-graders in three cities.

BACKGROUND: For many health-related behaviors and outcomes, racial and ethnic disparities among adolescents are well documented, but less is known about health-related disparities during preadolescence. METHODS: We studied 5119 randomly selected public-school fifth-graders and their parents in three metropolitan areas in the United States. We examined differences among black, Latino, and white children on 16 measures, including witnessing of violence, peer victimization, perpetration of aggression, seat-belt use, bike-helmet use, substance use, discrimination, terrorism worries, vigorous exercise, obesity, and self-rated health status and psychological and physical quality of life. We tested potential mediators of racial and ethnic disparities (i.e., sociodemographic characteristics and the child's school) using partially adjusted models. RESULTS: There were significant differences between black children and white children for all 16 measures and between Latino children and white children for 12 of 16 measures, although adjusted analyses reduced many of these disparities. For example, in unadjusted analysis, the rate of witnessing a threat or injury with a gun was higher among blacks (20%) and Latinos (11%) than among whites (5%), and the number of days per week on which the student performed vigorous exercise was lower among blacks (3.56 days) and Latinos (3.77 days) than among whites (4.33 days) (P<0.001 for all comparisons). After statistical adjustment, these differences were reduced by about half between blacks and whites and were eliminated between Latinos and whites. Household income, household highest education level, and the child's school were the most substantial mediators of racial and ethnic disparities. CONCLUSIONS: We found that harmful health behaviors, experiences, and outcomes were more common among black children and Latino children than among white children. Adjustment for socioeconomic status and the child's school substantially reduced most of these differences. Interventions that address potentially detrimental consequences of low socioeconomic status and adverse school environments may help reduce racial and ethnic differences in child health. (Funded by the Centers for Disease Control and Prevention.).

Sexual minorities in England have poorer health and worse health care experiences: a national survey.

BACKGROUND: The health and healthcare of sexual minorities have recently been identified as priorities for health research and policy. OBJECTIVE: To compare the health and healthcare experiences of sexual minorities with heterosexual people of the same gender, adjusting for age, race/ethnicity, and socioeconomic status. DESIGN: Multivariate analyses of observational data from the 2009/2010 English General Practice Patient Survey. PARTICIPANTS: The survey was mailed to 5.56 million randomly sampled adults registered with a National Health Service general practice (representing 99 % of England's adult population). In all, 2,169,718 people responded (39 % response rate), including 27,497 people who described themselves as gay, lesbian, or bisexual. MAIN MEASURES: Two measures of health status (fair/poor overall self-rated health and self-reported presence of a longstanding psychological condition) and four measures of poor patient experiences (no trust or confidence in the doctor, poor/very poor doctor communication, poor/very poor nurse communication, fairly/very dissatisfied with care overall). KEY RESULTS: Sexual minorities were two to three times more likely to report having a longstanding psychological or emotional problem than heterosexual counterparts (age-adjusted for 5.2 % heterosexual, 10.9 % gay, 15.0 % bisexual for men; 6.0 % heterosexual, 12.3 % lesbian and 18.8 % bisexual for women; p < 0.001 for each). Sexual minorities were also more likely to report fair/poor health (adjusted 19.6 % heterosexual, 21.8 % gay, 26.4 % bisexual for men; 20.5 % heterosexual, 24.9 % lesbian and 31.6 % bisexual for women; p < 0.001 for each). Adjusted for sociodemographic characteristics and health status, sexual minorities were about one and one-half times more likely than heterosexual people to report unfavorable experiences with each of four aspects of primary care. Little of the overall disparity reflected concentration of sexual minorities in low-performing practices. CONCLUSIONS: Sexual minorities suffer both poorer health and worse healthcare experiences. Efforts should be made to recognize the needs and improve the experiences of sexual minorities. Examining patient experience disparities by sexual orientation can inform such efforts.

Correlates of HIV testing among African American and Latino church congregants: the role of HIV stigmatizing attitudes and discussions about HIV.

Faith-based organizations can be key settings in which to reach African Americans and Latinos for HIV prevention, but little is known regarding factors that predict congregants' HIV testing behaviors. We examined the extent to which sociodemographic factors, HIV-related cues to action (e.g., knowing someone who is HIV-positive), and the social climate surrounding HIV (stigma toward a hypothetical HIV-positive congregant, HIV-related discussions at church about abstinence, condoms, and testing) were associated with willingness to be tested in church and with ever having been tested among 1211 African American and Latino congregants. Multivariate analyses indicated that congregants were more open to church-based testing if they were younger and had discussed condoms at church. They were less open if they expressed stigmatizing attitudes toward a hypothetical congregant. Foreign-born Latinos with low English proficiency were more willing to be tested at church than were African Americans. Congregants were more likely to have ever been tested if they were younger, African American, female, or married; if they knew someone who was HIV-positive; and if they had discussed testing and condoms at church. They were less likely if they had discussed abstinence. Open dialogue around HIV may activate congregants to be more receptive to church-based prevention.

The Abbreviated Dimensions of Temperament Survey: Factor Structure and Construct Validity Across Three Racial/Ethnic Groups.

The factor structure, reliability, and construct validity of an abbreviated version of the Revised Dimensions of Temperament Survey (DOTS-R) were evaluated across Black, Hispanic, and White early adolescents. Primary caregivers reported on 5 dimensions of temperament for 4,701 children. Five temperament dimensions were identified via maximum likelihood exploratory factor analysis and were labeled flexibility, general activity level, positive mood, task orientation, and sleep rhythmicity. Multigroup mean and covariance structures analysis provided partial support for strong factorial invariance across these racial/ethnic groups. Mean level comparisons indicated that relative to Hispanics and Blacks, Whites had higher flexibility, greater sleep regularity, and lower activity. They also reported higher positive mood than Blacks. Blacks, relative to Hispanics, had higher flexibility and lower sleep regularity. Construct validity was supported as the 5 temperament dimensions were significantly correlated with externalizing problems and socioemotional competence. This abbreviated version of the DOTS-R could be used across racial/ethnic groups of early adolescents to assess significant dimensions of temperament risk that are associated with mental health and competent (healthy) functioning.

Parental and peer factors associated with body image discrepancy among fifth-grade boys and girls.

Many young adolescents are dissatisfied with their body due to a discrepancy between their ideal and actual body size, which can lead to weight cycling, eating disorders, depression, and obesity. The current study examined the associations of parental and peer factors with fifth-graders' body image discrepancy, physical self-worth as a mediator between parental and peer factors and body image discrepancy, and how these associations vary by child's sex. Body image discrepancy was defined as the difference between young adolescents' self-perceived body size and the size they believe a person their age should be. Data for this study came from Healthy Passages, which surveyed 5,147 fifth graders (51 % females; 34 % African American, 35 % Latino, 24 % White, and 6 % other) and their primary caregivers from the United States. Path analyses were conducted separately for boys and girls. The findings for boys suggest father nurturance and getting along with peers are related negatively to body image discrepancy; however, for girls, fear of negative evaluation by peers is related positively to body image discrepancy. For both boys and girls, getting along with peers and fear of negative evaluation by peers are related directly to physical self-worth. In addition, mother nurturance is related positively to physical self-worth for girls, and father nurturance is related positively to physical self-worth for boys. In turn, physical self-worth, for both boys and girls, is related negatively to body image discrepancy. The findings highlight the potential of parental and peer factors to reduce fifth graders' body image discrepancy.

Facilitators and barriers to HIV activities in religious congregations: perspectives of clergy and lay leaders from a diverse urban sample.

This paper examines facilitators and barriers to HIV activities within religious congregations, the relative internal or external sources of these influences, and suggestive differences across congregational types. Results are based on in-depth interviews with clergy and lay leaders (n = 57) from 14 congregations in Los Angeles County, California, purposively selected to reflect diversity in racial-ethnic composition, denomination, size, and HIV activity level. Many common facilitators and barriers were related to norms and attitudes, only a few of which appeared overtly associated with theological orientations. Clergy support was a facilitator particularly prevalent among congregations having higher HIV activity levels, indicating its importance in sustaining and expanding HIV programs. Resource issues were also prominent, with material resource barriers more frequently mentioned by smaller congregations and human resource barriers more among larger congregations. Organizational structure issues were mostly centered on external linkages with various social service, public health, and faith-based entities. Analysis of internal versus external sources highlights the roles of different stakeholders within and outside congregations in promoting HIV activities. Potential differences across congregational types represent fruitful areas for future research.

Association between perceived discrimination and racial/ethnic disparities in problem behaviors among preadolescent youths.

OBJECTIVES: We examined the contribution of perceived racial/ethnic discrimination to disparities in problem behaviors among preadolescent Black, Latino, and White youths. METHODS: We used cross-sectional data from Healthy Passages, a 3-community study of 5119 fifth graders and their parents from August 2004 through September 2006 in Birmingham, Alabama; Los Angeles County, California; and Houston, Texas. We used multivariate regressions to examine the relationships of perceived racial/ethnic discrimination and race/ethnicity to problem behaviors. We used values from these regressions to calculate the percentage of disparities in problem behaviors associated with the discrimination effect. RESULTS: In multivariate models, perceived discrimination was associated with greater problem behaviors among Black and Latino youths. Compared with Whites, Blacks were significantly more likely to report problem behaviors, whereas Latinos were significantly less likely (a "reverse disparity"). When we set Blacks' and Latinos' discrimination experiences to zero, the adjusted disparity between Blacks and Whites was reduced by an estimated one third to two thirds; the reverse adjusted disparity favoring Latinos widened by about one fifth to one half. CONCLUSIONS: Eliminating discrimination could considerably reduce mental health issues, including problem behaviors, among Black and Latino youths.

Consumer response to patient experience measures in complex information environments.

BACKGROUND: As indicators of clinician quality proliferate, public reports increasingly include multiple metrics. This approach provides more complete performance information than did earlier reports but may challenge consumers' ability to understand and use complicated reports. OBJECTIVES: To assess the effects of report complexity on consumers' understanding and use of patient experience measures derived from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey. RESEARCH DESIGN: In an Internet-based experiment, participants were asked to compare information on physician quality and choose a primary care doctor. Participants were randomly assigned to choice sets of varied complexity (CAHPS alone vs. CAHPS with other measures) and number of doctors. Participants completed surveys before and after this choice task. SUBJECTS: A total of 555 US residents, aged 25-64, who had Internet access through computer were recruited from an existing online panel. MEASURES: Recall seeing CAHPS measures; use of CAHPS measures for making choices; ratings of ease of use, usefulness and trustworthiness of CAHPS ratings; concerns about usefulness and trustworthiness. RESULTS: Participants presented with CAHPS information and other performance indicators relied less on CAHPS than did those presented with CAHPS information only, although they considered CAHPS information as valuable as did other respondents. Participants presented with smaller choice sets also judged CAHPS information as less easy to use when accompanied by other metrics than when it was presented alone.

A field experiment on the impact of physician-level performance data on consumers' choice of physician.

BACKGROUND: In 2008, HealthPlus of Michigan introduced an online primary care provider (PCP) report that displays clinical quality data and patients' ratings of their experiences with PCPs on a public web site. DESIGN AND PROCEDURE: A randomized encouragement design was used to examine the impact of HealthPlus's online physician-quality report on new plan members' choice of a PCP. This study evaluated the impact of an added encouragement to utilize the report by randomizing half of new adult plan members in 2009-2010, who were required to select a PCP (N=1347), to receive a 1-page letter signed by the health plan's chief medical officer emphasizing the importance of the online report and a brief phone call reminder. We examined the use of the report and the quality of PCPs selected by participants. RESULTS: Twenty-eight percent of participants in the encouragement condition versus 22% in the control condition looked at the online report before selecting a PCP. Although participants in the encouragement condition selected PCPs with higher patient experience ratings than did control participants, this difference was not explained by their increased likelihood of accessing the online report. CONCLUSIONS: Health plan members can be encouraged successfully to access physician-level quality data using an inexpensive letter and automated phone call. However, a large proportion of missing data in HealthPlus's online report may have limited the influence of the physician-quality report on consumer choice.

Religious congregations' involvement in HIV: a case study approach.

Comparative case studies were used to explore religious congregations' HIV involvement, including types and extent of activities, interaction with external organizations or individuals, and how activities were initiated and have changed over time. The cases included 14 congregations in Los Angeles County representing diverse faith traditions and races-ethnicities. Activities fell into three broad categories: (1) prevention and education; (2) care and support; and (3) awareness and advocacy. Congregations that engaged early in the epidemic focused on care and support while those that became involved later focused on prevention and education. Most congregations interacted with external organizations or individuals to conduct their HIV activities, but promoting abstinence and teaching about condoms were conducted without external involvement. Opportunities exist for congregations to help address a variety of HIV-related needs. However, activities that are mission-congruent, such as providing pastoral care for people with HIV, raising HIV awareness, and promoting HIV testing, appear easier for congregations to undertake than activities aimed at harm reduction.

Off-premise alcohol sales policies, drinking, and sexual risk among people living with HIV.

Drinking among HIV-positive individuals increases risks of disease progression and possibly sexual transmission. We examined whether state alcohol sales policies are associated with drinking and sexual risk among people living with HIV. In a multivariate analysis combining national survey and state policy data, we found that HIV-positive residents of states allowing liquor sales in drug and grocery stores had 70% to 88% greater odds of drinking, daily drinking, and binge drinking than did HIV-positive residents of other states. High-risk sexual activity was more prevalent in states permitting longer sales hours (7% greater odds for each additional hour). Restrictive alcohol sales policies may reduce drinking and transmission risk in HIV-positive individuals.

The relationships between states' DUI penalties and HIV-positive adults' drinking behaviors.

Evidence that persons with HIV who reside in states with stricter DUI penalties drink less might suggest that changes to alcohol policy might improve the health of persons with HIV and reduce the rate of new infections. Using multi-level modeling and data from the national HIV Cost and Services Utilization Study, we examined how states' DUI-related fines, jail time, license suspension, and court-referred treatment/education policies were related to past month drinking/not (n = 2,255) and among drinkers (n = 1,117), drinking frequency, drinks per occasion, and engagement in frequent heavy drinking. Fine strictness was negatively related to all outcomes. Residents in states with court-referred treatment/education had more current drinkers. Results suggested that punitive DUI policies might curb a variety of drinking behaviors whereas harm reduction DUI policies (e.g., court treatment programs) might have been established in response to higher drinking rates.

Learning about urban congregations and HIV/AIDS: community-based foundations for developing congregational health interventions.

Religious congregations are important community institutions that could help fight HIV/AIDS; however, barriers exist, particularly in the area of prevention. Formative, participatory research is needed to understand the capacity of congregations to address HIV/AIDS. This article describes a study that used community-based participatory research (CBPR) approaches to learn about congregation-sponsored HIV activities. CBPR strategies were used throughout the study, including proposal development, community expert interviews, Community Advisory Board, congregational telephone survey, congregational case studies, and congregational feedback sessions. Involving community consultants, experts, and advisory board members in all stages of the study helped the researchers to conceptualize congregational involvement in HIV, be more sensitive to potential congregational concerns about the research, achieve high response rates, and interpret and disseminate findings. Providing preliminary case findings to congregational participants in an interactive feedback session improved data quality and relationships with the community. Methods to engage community stakeholders can lay the foundation for future collaborative interventions.

Parenting predictors of early-adolescents' health behaviors: simultaneous group comparisons across sex and ethnic groups.

The purpose of this study was to evaluate the invariance of predictive relations across early-adolescent sex and ethnic groups regarding parenting factors and externalizing and internalizing problems and victimization. Data (n = 598; 54% female) from a triethnic (Hispanic, non-Hispanic white, and non-Hispanic black) probability sample of fifth graders collected from three sites (Birmingham, AL, Houston, TX, and Los Angeles, CA) were used in the analyses. Simultaneous group structural equation modeling supported the invariance of parenting-early adolescent outcomes across sex and ethnic groups. Parental monitoring and parental norms were relatively robust predictors of early-adolescent externalizing problems and victimization, and to a lesser extent, of internalizing problems. A maternal nurturance by parental monitoring interaction was statistically significant for all outcome behaviors, indicating that higher monitoring in conjunction with higher maternal nurturance was associated with lower levels of early-adolescent problem behaviors. The findings suggest that core parenting factors such as nurturance, monitoring, and normative expectations for early adolescent problem behaviors may serve as a foundation for parenting components of multi-component intervention studies.