The lived experiences of rural HIV social workers.

HIV service providers are the primary implementers of HIV care services, but rural HIV service providers are under researched. We used an interpretative phenomenological analysis to explore rural HIV service providers' lived experiences of working in HIV care, who work in a rural region of a Midwestern state in the United States. From July to August 2019, 15 HIV service providers participated in a one-hour semi-structured telephone interview that elicited their experiences working in the rural HIV care continuum. Participants were tired of constantly educating and working to reduce HIV stigma; however, they received support from family and friends once they educated them about HIV. Participants felt they lacked control over systems and they developed emotional-based coping to address constant occupational stressors. Findings highlight the importance of resiliency and advocacy research and practice across ecological levels.

From crisis to crisis: impacts of the COVID-19 pandemic on people living with HIV and HIV/AIDS service organizations in Indiana.

BACKGROUND: The COVID-19 pandemic thrust people living with HIV (PLWH) and HIV/AIDS service organizations into an environment ripe with uncertainty. This study examined Indiana HIV/AIDS service provider perceptions of how COVID-19 affected the overall health and access to care of their clients, and how the organizations prepared for, adapted, and responded to the needs of PLWH during the pandemic. METHODS: Guided by the socioecological model, fifteen semi-structured interviews were conducted with ten different HIV/AIDS service organizations across the state of Indiana. RESULTS: Despite the profound disruptions experienced by HIV programs, HIV/AIDS service organizations responded quickly to the challenges posed by the COVID-19 pandemic through myriad innovative strategies, largely informed by prior experiences with the HIV epidemic. CONCLUSIONS: The lessons provided by HIV/AIDS service organizations are invaluable to informing future pandemic response for PLWH. Service delivery innovations in response to the COVID-19 crisis may provide insights to improve HIV care continuity strategies for vulnerable populations far beyond the pandemic.

Barriers to sexual and reproductive care among cisgender, heterosexual and LGBTQIA + adolescents in the border region: provider and adolescent perspectives.

INTRODUCTION: The United States (U.S.) has higher rates of sexually transmitted infections (STIs) and adolescent pregnancy than most other industrialized countries. Furthermore, health disparities persist among racial and ethnic minority adolescents (e.g., African American and Latinx) and in counties located along the U.S.-Mexico border region-they demonstrate the highest rates of STIs and unintended pregnancy among adolescents. METHODS: Qualitative data were collected as part of formative research for the development of a mobile app that provides gender-inclusive sexual education to adolescents living in the U.S.-Mexico border region. From August 2019 to March 2020, the study team conducted 11 in-depth interviews with healthcare providers and three focus groups with cisgender, heterosexual, and SGM adolescents ages 15-18 (n = 20). RESULTS: Providers and adolescents reported similar barriers to accessing SRH in this region such as transportation, lack of insurance and cost of services or accessing services without their parent's knowledge. However, providers shared that some adolescents in this region face extreme poverty, family separation (i.e., parent has been deported), have a mixed family legal status or are binational and have to travel every day from Mexico to the U.S. for school. These challenges further limit their ability to access SRH. CONCLUSIONS: Adolescents in the U.S.-Mexico border region face unique economic and social challenges that further limit their access to SRH care, making them uniquely vulnerable to STIs and unintended pregnancy. The prototype of the app was developed based on the needs expressed by providers and adolescents, including providing comprehensive Sex Ed and mapping of free comprehensive and confidencial SRH services available in the region and is being pilot tested. Our findings provide further evidence for the need for interventions and service delivery, programs tailored for residents in the border region.

COVID-19 vaccine hesitancy among rural Oklahomans.

INTRODUCTION: COVID-19 vaccination is widely recommended as a prevention strategy; however, vaccine uptake is disproportionately lower among rural Americans compared to their urban counterparts. Development of public health activities to address the rural-urban vaccine gap requires an understanding of determinants of vaccine hesitation. The present study explores perceptions of and barriers to COVID-19 vaccination among rural Oklahomans. METHODS: Between March and May 2021, 222 residents, unvaccinated for COVID-19, within rural Oklahoma counties completed a cross-sectional, online questionnaire to qualitatively assess perceptions, benefits, and concerns regarding getting vaccinated for COVID-19. RESULTS: Approximately two-fifths of rural respondents in the present study were hesitant to get vaccinated, even when a vaccine was made available to them. Major factors included limited knowledge and understanding about the vaccine, including potential side-effects and long-term complications, as well as skepticism surrounding COVID-19 vaccine development and efficacy. Among the potential perceived benefits of vaccination were protecting the health of vulnerable individuals and the ability to return to normal day-to-day activities. CONCLUSION: Increases in COVID-19 cases and deaths in rural areas are expected to continue as new variants are introduced within communities. The present findings highlight the need for the development of culturally tailored vaccine information, to be disseminated by local leaders within rural communities.

The impact of initial social distancing measures on individuals' anxiety and loneliness depending on living with their romantic/sexual partners.

In response to the COVID-19 pandemic, large swaths of the U.S. were under stay-at-home orders, thus preventing many individuals from leaving their homes. While previous studies have shown that such orders can be detrimental to mental health, specific mental health outcomes, such as loneliness and anxiety, have yet to be fully explored, particularly among various living situation contexts (e.g., living alone, with romantic/sexual partners, without romantic/sexual partners). The current study explores this using a mixed-methods approach. Data were collected via Amazon's M-Turk (N = 85). Kruskal-Wallis tests revealed significant differences between the three groups with respect to loneliness. Statistically significant greater levels of loneliness were found in individuals living alone compared to those living with romantic/sexual partners and those living with non-romantic/sexual partners. No significant differences in anxiety levels were detected. Qualitative analysis revealed similar themes among all groups regarding anxiety. When asked about loneliness, however, those living alone shared more about feeling isolated, unwanted feelings of solitude, and how technology only mitigates a portion of these feelings. Those living with others and sexual partners shared desires to see friends and co-workers, yet not to the severity described by individuals living alone. Romantic/sex life themes are also discussed.

Rural College Students' Amenability Toward Using At-Home Human Immunodeficiency Virus and Sexually Transmitted Infection Testing Kits.

BACKGROUND: College students residing in rural areas of the United States have limited access to human immunodeficiency virus (HIV) and sexually transmitted infection (STI) screening programs; yet, have increased rates of infection. METHODS: Students (N = 326), attending a state university located within a rural community, completed an online survey containing open-ended questions that gauged their perceptions and experiences with HIV/STI testing, amenability to at-home testing technology, and preferences for obtaining at-home testing kits. Inductive coding was used to create themes for each open-ended question. RESULTS: Students encounter a number of perceived barriers to accessing clinical HIV/STI testing venues including cost, utilization of parents' medical insurance, and stigma. Students desired screening paradigms that allow for a greater sense of privacy and the ability to be empowered through self-sampling methods. This includes the use of at-home testing kits, which could be accessed via mail, campus, or the local community. Although students were overwhelmingly amenable to using at-home testing, students discussed concerns with potential user error that could impact testing accuracy. CONCLUSIONS: Study findings suggest the importance of developing less clinically oriented systems of HIV/STI screening, which allow students to choose from an array of screening options. Removing perceived barriers, notably access and privacy concerns, to HIV/STI testing by leveraging at-home testing is one potential method to increase screening uptake among this at-risk population.

Perceived Confidentiality Risks of Mobile Technology-Based Ecologic Momentary Assessment to Assess High-Risk Behaviors Among Rural Men Who Have Sex with Men.

Although men who have sex with men (MSM) within rural communities are disproportionately impacted by HIV, limited HIV research and programmatic resources are directed to these communities within the U.S. There is a need for improved behavioral data collection methods to obtain more detailed information on the relationship between rural environments, sexual behavior, and substance use. Utilization of mobile health (mHealth) technologies, such as ecologic momentary assessment (EMA), has been advocated for; however, limited research has evaluated its utility among rural MSM. Forty MSM residing in rural Oklahoma were recruited to complete in-depth interviews related to participating online/mobile-based HIV prevention research. Men described a willingness to participate in HIV and substance use studies that use EMA methodologies for data collection; however, they raised various research-related concerns. In particular, participants indicated potential privacy and confidentiality concerns related to the use of the mobile technology-based EMA in public and the storage of data by researchers. Given the varying degree of sexual orientation and substance use disclosure by participants, rural MSM were largely concerned with being inadvertently "outed" within their communities. Men described the various strategies they could employ to protect private information and methods to minimize research risk. Study findings suggest that EMA is an acceptable research methodology for use among rural MSM in the context of HIV and sexual health information, when privacy and confidentiality concerns are adequately addressed. Input from community members and stakeholders is necessary to identify potential areas of concerns for participants prior to data collection.

The Effects of Individual and Dual ACE Domains on Binge Drinking: Comparisons by Gender.

BACKGROUND: Adverse Childhood Experiences (ACEs) show predictive utility concerning binge drinking. However, the literature is limited by 1. a focus on cumulative ACEs with little regard to specific domains, 2. a focus on those with the highest ACE scores, and 3. little consideration for gender differences. These approaches are problematic as ACE categories are fundamentally different, yet little distinction is given to specific ACE domains. The current study investigates which individual and dual ACE domain combinations are associated with binge drinking. METHODS: Data were obtained from the Behavioral Risk Factor Surveillance System (2011-2017; N = 80,391). A series of ANCOVAs were conducted to determine the association between single and dual combination ACE domains and binge drinking. RESULTS: Results show gendered effects of ACEs on binge drinking such that at 0, 1, and 2 ACEs, males reported statistically higher rates. For males with exactly two ACEs, combinations of either sexual abuse or family incarceration presented the highest levels of binge drinking- with the highest mean binge drinking score being the exact combination of the two. This contrasts with males with 1 ACE, where experiencing family incarceration or sexual abuse, as a single domain, did not represent significant risk above the average of having a single ACE. CONCLUSIONS: Results suggest that males may be resilient to either of these domains as singular events, yet when found in combination, may present a synergistic effect that increases the likelihood of binge drinking. Due to lower overall binge drinking rates, no significant patterns were found among females.

The Role of State Medicaid Expansions in Integrating Comprehensive Mental Health Services into Opioid Treatment Programs: Differences Across the Rural/Urban Continuum.

Co-occurring mental health (MH) problems are common among those with opioid use disorders (OUDs). However, most opioid treatment programs (OTPs) do not provide MH services. We measured the association between state level characteristics (Medicaid expansion status and rurality) and MH/OUD services integration. We used a generalized linear model to estimate how the association between integration and Medicaid expansions varied across levels of rurality (National Survey on Substance Abuse Treatment Services; 2018; n = 1507 OTPs). The predicted probability of OTPs offering MH services decreased as rurality increased, and the strength of the negative association was greater in non-expansion states ([Formula: see text]=-0.038, SE = 0.005, p < 0.0001) than in expansion states ([Formula: see text]=-0.020, SE = 0.003, p < 0.0001). Access to integrated MH services was lowest in rural non-Medicaid expansion states, despite the high risk of opioid misuse and a high need for MAT and MH services in this population.

US trends in mask wearing during the COVID-19 pandemic depend on rurality.

INTRODUCTION: Face masks are widely recommended as a COVID-19 prevention strategy. State mask mandates have generally reduced the spread of the disease, but decisions to wear a mask depend on many factors. Recent increases in case rates in rural areas following initial outbreaks in more densely populated areas highlight the need to focus on prevention and education. Messaging about disease risk has faced challenges in rural areas in the past. While surges in cases within some communities are likely an impetus for behavior change, rising case rates likely explain only part of mask-wearing decisions. The current study examined the relationship between county-level indicators of rurality and mask wearing in the USA. METHODS: National data from the New York Times' COVID-19 cross-sectional mask survey was used to identify the percentage of a county's residents who reported always/frequently wearing a mask (2-14 July 2020). The New York Times' COVID-19 data repository was used to calculate county-level daily case rates for the 2 weeks preceding the mask survey (15 June - 1 July 2020), and defined county rurality using the Index of Relative Rurality (n=3103 counties). Multivariate linear regression was used to predict mask wearing across levels of rurality. The model was adjusted for daily case rates and other relevant county-level confounders, including county-level indicators of age, race/ethnicity, gender, political partisanship, income inequality, and whether each county was subject to a statewide mask mandate. RESULTS: Large clusters of counties with high rurality and low mask wearing were observed in the Midwest, upper Midwest, and mountainous West. Holding daily case rates and other county characteristics constant, the predicted probability of wearing a mask decreased significantly as counties became more rural (β=-0.560; p<0.0001). CONCLUSION: Upticks in COVID-19 cases and deaths in rural areas are expected to continue, and localized outbreaks will likely occur indefinitely. The present findings highlight the need to better understand the mechanisms underlying perceptions of COVID-19 risk in rural areas. Dissemination of scientifically correct and consistent information is critical during national emergencies.

Recovering from an Epidemic of Teen Pregnancy: The Role of Rural Faith Leaders in Building Community Resilience.

This study explores the role of faith leaders and congregations in preventing teen pregnancy and enhancing overall health. Seventeen faith-based leaders responded to an invitation to participate. Participants were recruited from two counties within Oklahoma, based on desired community characteristics. Findings were directly related to: (1) the vulnerability of rural communities to negative health outcomes; (2) resiliency of rural faith communities to address health issues; and (3) the adaptive capacity of rural faith leaders and their communities to decrease teen pregnancy and maximize community health. Culturally relevant public health programming is necessary to engage this at risk population; however, it requires engaging faith leaders in efforts to build congregation-based and community-based capacity.

Assessing determinants of pre-exposure prophylaxis (PrEP) adherence among a sample of rural Midwestern men who have sex with men (MSM).

Pre-exposure prophylaxis (PrEP) efficacy in preventing HIV among gay, bisexual, and other men who have sex with men (MSM) is dependent upon adherence. Little is known about the PrEP adherence experiences among MSM who live in rural areas of the US. This qualitative study was informed by a modified version of Straussian Grounded Theory. Thirty-four 34 rural Midwestern MSM participated in telephone interviews that assessed their PrEP adherence factors. Overall, participants adhered to the PrEP regimen, ranging from missing none to a couple of doses per month. Participants had high self-efficacy (competence) and self-reliance (autonomy) in taking PrEP daily. Participants incorporated PrEP into their already existing routines. Participants were motivated to adhere to prevent HIV acquisition and be financially responsible. All participants mentioned their PrEP provider discussed the importance of adherence with PrEP's effectiveness, but future patient-provider PrEP adherence communication varied among participants. Future PrEP adherence interventions should address counseling strategies that leverage these constructs to support pill taking. Future research should explore patient-provider conversations surrounding PrEP adherence to inform provider- and patient-level interventions.

Facilitators and Barriers of Pre-exposure Prophylaxis (PrEP) Uptake Among Rural Men who have Sex with Men Living in the Midwestern U.S.

Facilitators and barriers of Pre-exposure Prophylaxis (PrEP) uptake have been established in prior studies; however, most of these studies comprise samples of MSM from metropolitan cities and hypothetical PrEP use. There is a dearth of literature on the uptake factors among rural U.S. MSM who are prescribed PrEP. Thirty-four rural Midwestern MSM who currently take PrEP participated in semi-structured telephone interviews about their barriers and facilitators to their PrEP use. Interviews were analyzed using an inductive thematic analysis approach. There were four barriers: (1) lack of rural dissemination of PrEP information, (2) concern about side and adverse effects of using PrEP, (3) cost of PrEP uptake and engagement, and (4) lack of access to PrEP care and PrEP care quality. Individual and social facilitators that participants utilized to overcome these barriers are discussed. Findings elevate the importance of multilevel interventions that address PrEP adoption from a patient, provider, and healthcare system perspective.

The frequencies and disparities of adverse childhood experiences in the U.S.

BACKGROUND: Adversity experienced during childhood manifests deleteriously across the lifespan. This study provides updated frequency estimates of ACEs using the most comprehensive and geographically diverse sample to date. METHODS: ACEs data were collected via BRFSS (Behavioral Risk Factor Surveillance System). Data from a total of 211,376 adults across 34 states were analyzed. The ACEs survey is comprised of 8 domains: physical/emotional/sexual abuse, household mental illness, household substance use, household domestic violence, incarcerated household member, and parental separation/divorce. Frequencies were calculated for each domain and summed to derive mean ACE scores. Findings were weighted and stratified by demographic variables. Group differences were assessed by post-estimation F-tests. RESULTS: Most individuals experienced at least one ACE (57.8%) with 21.5% experiencing 3+ ACEs. F-tests showed females had significantly higher ACEs than males (1.64 to 1.46). Multiracial individuals had a significantly higher ACEs (2.39) than all other races/ethnicities, while White individuals had significantly lower mean ACE scores (1.53) than Black (1.66) or Hispanic (1.63) individuals. The 25-to-34 age group had a significantly higher mean ACE score than any other group (1.98). Generally, those with higher income/educational attainment had lower mean ACE scores than those with lower income/educational attainment. Sexual minority individuals had higher ACEs than straight individuals, with significantly higher ACEs in bisexual individuals (3.01). CONCLUSION: Findings highlight that childhood adversity is common across sociodemographic, yet higher in certain categories. Identifying at-risk populations for higher ACEs is essential to improving the health outcomes and attainment across the lifespan.

Motivations for Nonuniversity-Based Adults Who Sext Their Relationship Partners.

Little is known about motivations of adults who sext their relationship partners. Participants (N = 126, 71 male) completed an online questionnaire to assess their motivations for sexting their current relationship partner(s). The results of a MANOVA indicated the overwhelming motivation was to initiate sexual behaviors for all groups. Other motivations of instrumental/aggressive reasons were significantly higher for heterosexual men, and body image reinforcement was significantly higher for sexual-minority men. With results indicating the main motivation to sext was to initiate sexual behaviors, the potential of using sexting as an intervention to increase sexual intimacy in relationships is discussed.

"What Should Sex Look Like?" Students' Desires for Expanding University Sexual Assault Prevention Programs to Include Comprehensive Sex Education.

Rates of sexual assault and sexual violence among college-aged adults are much higher than the national rates of sexual assault and sexual violence. Therefore, reduction and prevention of sexual violence among university students is critical and is consistent with national public health priorities. Often times, messages to students focus only on sexual assault and omit larger notions of sexual health. Four focus groups with a total of 24 participants (nine men, 15 women) highlighted three main perceptions about the sexual assault programming offered at this large university: themes of resistance to traditional programming, a need for holistic sexual health programming, and a desire to have an environment, which normalizes conversations surrounding sex, sexuality, and sexual health.

Sexting Leads to "Risky" Sex? An Analysis of Sexting Behaviors in a Nonuniversity-Based, Older Adult Population.

Since few researchers have analyzed sexting behaviors in nonuniversity-based adult samples, we sought to determine if sexting is associated with negative psychological correlates and risky sexual behaviors in this population. Analysis of individuals who indicated having vaginal or anal sex in the past 12 months and who identified as single (n = 377) showed that condomless sex is independent of sexting behaviors. Results for those in committed relationships (n = 374) and having had vaginal or anal sex in the past 12 months also demonstrated condomless sex and sexting behaviors were not related. Furthermore, alcohol consumption and relational health were predictive of sexting behaviors in adults in committed relationships. These findings demonstrate that while risky sexual behavior and negative psychological correlates are associated with sexting and younger populations, the same might not be true for a nonuniversity-based, older adult sample.

Sexual self-identification among behaviorally bisexual men in the midwestern United States.

Previous social and behavioral research on identity among bisexual men, when not subsumed within the category of men who have sex with men (MSM), has primarily focused on samples of self-identified bisexual men. Little is known about sexual self-identification among men who are behaviorally bisexual, regardless of sexual identity. Using qualitative data from 77 in-depth interviews with a diverse sample of behaviorally bisexual men (i.e., men who have had sex with at least one woman and at least one man in the past six months) from a large city in the Midwestern United States, we analyzed responses from a domain focusing on sexual self-identity and related issues. Overall, participants' sexual self-identification was exceptionally diverse. Three primary themes emerged: (1) a resistance to, or rejection of, using sexual self-identity labels; (2) concurrent use of multiple identity categories and the strategic deployment of multiple sexual identity labels; and (3) a variety of trajectories to current sexual self-identification. Based on our findings, we offer insights into the unique lived experiences of behaviorally bisexual men, as well as broader considerations for the study of men's sexuality. We also explore identity-related information useful for the design of HIV/STI prevention and other sexual health programs directed toward behaviorally bisexual men, which will ideally be variable and flexible in accordance with the wide range of diversity found in this population.