The Healthy Young Men's Cohort: Health, Stress, and Risk Profile of Black and Latino Young Men Who Have Sex with Men (YMSM).

Young men who have sex with men (YMSM), especially YMSM of color, are at increased risk for a wide range of threats to their health and well-being. In this study, we recruited and surveyed an urban sample of 448 young African American/Black (Black), Hispanic/Latino (Latino), and multi-racial/ethnic YMSM, ages 16-24 years (mean = 22.3 years), about stressful life events, their health and mental health, their access to and utilization of care, and their involvement in risk-related behaviors. We found that the majority reported experiences of racism (87%) and homophobia (76%). A high percentage reported food insecurity/hunger (36%), residential instability (15%), financial hardship (63%), and conflict with family/friends (62%). The prevalence of risk behaviors was also high, including recent use of tobacco (46%), alcohol (88%), and marijuana (72%), and 41% tested positive for 1+ drugs. Furthermore, 26% tested positive for 1+ sexually transmitted infections (STIs). Over half (56%) reported being worried about their health, 33% reported having a chronic health condition and 31% a mental health condition, and 45% had wanted/needed mental health services during the past year. Further, 17% reported suicidal ideation/had planned a suicide attempt and 26% had ever engaged in self-injurious behaviors. Significant differences by race/ethnicity and HIV status included residential status/food insecurity, type of racism/homophobia, drug use, and STIs. These findings demonstrate how vulnerable this population is with respect to a wide range of structural and social determinants of health that may be important drivers of behavioral, health, mental health outcomes, and potentially long-term health disparities.

Use of pre-exposure prophylaxis increases the odds of condomless anal sex among young men who have sex with men (MSM) of colour.

This study tested the hypothesis that people using pre-exposure prophylaxis (PrEP) would be more likely to report condomless anal sex than those not taking PrEP. Data were from an ongoing study conducted with a cohort of Black and Latino young men who have sex with men (YMSM) recruited in Los Angeles (CA, USA). Of the 399 YMSM in the sample, 14% were currently using PrEP. Using three different measures of condom use, across two different recall periods all except one test result supported an inverse relationship between PrEP and condom use for anal sex. Tests of a risk index provided further significant findings supporting this hypothesis.

Viewpoints from families for improving transition from NICU-to-home for infants with medical complexity at a safety net hospital: a qualitative study.

BACKGROUND: We have limited information on families' experiences during transition and after discharge from the neonatal intensive care unit. METHODS: Open-ended semi-structured interviews were conducted with English or Spanish- speaking families enrolled in Medicaid in an urban high-risk infant follow up clinic at a safety-net center, which serves preterm and high-risk term infants. We generated salient themes using inductive-deductive thematic analysis. RESULTS: Twenty-one participants completed the study. The infant's median (IQR) birth weight was 1750 (1305, 2641) grams; 71% were Hispanic and 10% were Black non-Hispanic; 62% reported living in a neighborhood with 3-4th quartile economic hardship. All were classified as having chronic disease per the Pediatric Medical Complexity Algorithm and 67% had medical complexity. A conceptual model was constructed and the analysis revealed major themes describing families' challenges and ideas to support transition centered on the parent-child role and parent self-efficacy. The challenges were: (1) comparison to normal babies, (2) caregiver mental health, (3) need for information. Ideas to support transition included, (1) support systems, (2) interventions using mobile health technology (3) improved communication to the primary care provider and (4) information regarding financial assistance programs. Specific subthemes differed in frequency counts between infants with and without medical complexity. CONCLUSIONS: Families often compare their preterm or high-risk infant to their peers and mothers feel great anxiety and stress. However, families often found hope and resilience in peer support and cited that in addition to information needs, interventions using mobile health technology and transition and financial systems could better support families after discharge.

Attitudes and perceptions of biomedical HIV prevention methods: voices from young men who have sex with men.

In the third decade of the HIV/AIDS epidemic in the United States, the prevalence rates of new HIV infections among young men who have sex with men (YMSM) continue to increase. As new and emerging HIV prevention methods are developed, it is important to understand the perceptions of this vulnerable population-as they may be an ideal target for these intervention methods. This pilot study provides an overview of YMSM of color's awareness and perceptions of pre-exposure prophylaxis (PrEP) and rectal microbicides (RM). A total of 6 focus groups were convened with 53 YMSM (23 Latino/Hispanic and 30 Black/African American). Findings indicate a lack of knowledge of biomedical interventions and high perceived acceptability. Concerns regarding PrEP included potential side effects, potential for misinterpretation of its use and cost. RMs were perceived to be more acceptable than PrEP, but the limited knowledge about their potential was emphasized by YMSM. Results are discussed in relation to the need for providers to continue to provide general health education about safe sexual practices. As PrEP and other biomedical interventions are introduced into community settings, caution should be taken with regards to determining the appropriate target user and sufficient education.

High-risk sexual activity in the House and Ball community: influence of social networks.

OBJECTIVES: We investigated the roles of House membership and the influence of social and sexual network members on the sexual risk behavior of men in the Los Angeles House and Ball community. METHODS: From February 2009 to January 2010, male participants (n = 233) completed interviewer-assisted surveys during a House meeting or Ball event. We used logistic regression to model the effects of sexual network size, influence of sexual network members, House membership status, and their interactions on high-risk sex. RESULTS: Significant predictors of high-risk sex included number of sexual partners in the nominated social network, multiethnicity, and previous diagnosis of sexually transmitted infection. House membership was protective against high-risk sex. Additionally, a 3-way interaction emerged between number of sexual partners in the network, influence, and network members' House membership. CONCLUSIONS: Future research should assess network members' attitudes and behavior in detail to provide a greater understanding of the dynamics of social influence and to identify additional avenues for intervention.

Perceptions of successful cues to action and opportunities to augment behavioral triggers in diabetes self-management: qualitative analysis of a mobile intervention for low-income Latinos with diabetes.

BACKGROUND: The increasing prevalence of diabetes and the associated cost of managing this complicated disease have a significant impact on public health outcomes and health expenditures, especially among resource-poor Latino patients. Mobile health (mHealth) may be the solution to reaching this group and improving their health. OBJECTIVE: In this qualitative study, we examined nuances of motivation, intention, and triggers to action effected by TExT-MED (Trial to Examine Text Messaging for Emergency Department patient with Diabetes), an mHealth intervention tailored to low-income, urban Latinos with diabetes. TExT-MED is a fully-automated, text message-based program designed to increase knowledge, self-efficacy, and subsequent disease management and glycemic control. METHODS: We conducted 5 focus group interviews with 24 people who participated in TExT-MED. We employed a modified grounded theory analytic approach-an iterative process of coding and immersion in the data used to recognize the patterns and links between concepts voiced by the participants. We coded data to identify themes of participant experiences, motivations, and responses to the program. We organized themes into a theory of TExT-MED's action. RESULTS: Participants enjoyed their experience with TExT-MED and believed it improved their diabetes management. Through analysis of the transcripts, we identified that the strengths of the program were messages that cued specific behaviors such as medication reminders and challenge messages. Our analysis also revealed that increasing personalization of message delivery and content could augment these cues. CONCLUSIONS: This in-depth qualitative analysis of TExT-MED shows that low-income Latino patients will accept text messages as a behavioral intervention. This mHealth intervention acts as a behavioral trigger rather than an education platform. Personalization is an opportunity to enhance these cues to action and further research should be conducted on the ideal forms of personalization.

Laying the groundwork for an HIV prevention intervention: a descriptive profile of the Los Angeles House and Ball communities.

African American young men who have sex with men (AAYMSM) represent the largest proportion of new HIV infections among MSM. While evidence-based interventions are lacking, all too often HIV interventions are implemented in a community without thoroughly understanding its needs, risks and assets. AAYMSM are not homogenous; subgroups exist that may require different approaches to be effective. The House and Ball communities represent one such subgroup. A community-engaged, mixed-methods approach was used. Participant observations, qualitative interviews (N = 26), and a survey at House/Ball events (N = 252) were completed. Survey data broadly describe the community. For example: 69 % of survey respondents identify as gay; 25 % as bisexual; 13 % reported recent use of ecstasy and 11 % recently participated in sex exchange. The depth of qualitative data is key for intervention development. For example, while the survey provides broad descriptions of respondents' involvement in the House and Ball communities, leaders provided in-depth descriptions of the structure of the House and Ball scene-something vital to the development of HIV prevention programs within these communities. This kind of rigorous study is recommended prior to implementing an intervention. Findings are discussed in relation to leveraging the communities' supportive aspects to design culturally relevant HIV prevention programs.

"It's like our own little world": resilience as a factor in participating in the Ballroom community subculture.

We are well into the third decade of the HIV epidemic. While strides have been made in HIV prevention, rates for African American men who have sex with men (AAMSM) and young AAMSM continue to increase-perhaps indicating that traditional deficit-approaches of HIV prevention are not effective for all populations. Following a recent call to investigate the resiliency of young gay men, this study identifies sources of resilience and strength within the House and Ball communities, a subculture comprised primarily of AAMSM. The mixed-methods design included survey data (N = 263) collected at community events, interviews with Ball attendees and focus group data with House members. Survey data indicate a relationship between participating in the House and Ball communities and seeking support, acceptance and entertainment. Qualitative data validate these findings and provide detail on motivations for AAMSM to participate and the perceived benefits of participation. Findings are discussed in relation to building strengths-based interventions, using concepts of resiliency including shamelessness, social creativity, social support and volunteerism.

A profile of nonurgent emergency department use in an urban pediatric hospital.

OBJECTIVES: This study was designed to develop a descriptive profile of parents and caregivers who bring their children to the emergency department (ED) for nonurgent issues and to explore the reasons for presenting to an urban hospital pediatric ED for nonurgent conditions. Such work is necessary to develop effective interventions. METHODS: A total of 106 parents/caregivers whose child was triaged with a nonemergent/urgent condition completed a 15- to 20-minute computerized survey (English and Spanish) in an urban pediatric ED. RESULTS: Most respondents described themselves as Latino (76%) and foreign born (62%). About one half (49%) reported having an annual income of less than $20,000, and 43% of respondents did not have health insurance for themselves. Almost all (95%) of the index children had a primary care physician and health insurance. Despite being triaged as nonurgent, more than one half (63%) described their child's condition as "very" or "extremely" urgent. About one half of the respondents reported not receiving basic information on childhood illnesses from their child's physician. Reasons for nonurgent visits seemed to revolve around issues of convenience and perception of quality of care. CONCLUSIONS: Interventions should focus on health literacy and ensure that parents are provided relevant and accurate education on pediatric illnesses and common safety concerns; by increasing parental education on pediatric health, parents may be better able to assess acuity of their child's health issues.

Photovoice as a tool to adapt an HIV prevention intervention for African American young men who have sex with men.

Objective. HIV rates for African American young men who have sex with men (AAYMSM) have reached as much as 14.7%, compared with 2.5% and 3.5% among Caucasian and Latino YMSM. However, there remains a lack of HIV prevention interventions for this population. This study describes the use of Photovoice in the adaptation process of an evidence-based intervention (Adult Identity Mentoring) to make it developmentally and culturally appropriate for AAYMSM. Method. A total of 36 AAYMSM (aged 18-24 years) participated in weekly working group sessions to conduct a community-, youth-, and data-driven adaptation process. Photovoice was used as a technique to facilitate guided discussions on topics that were identified for the new curriculum. Results. Through Photovoice discussions, we identified a new focus for the adapted intervention, Young Men's Adult Identity Mentoring (YM-AIM): development and maintenance of healthy intimate relationships. This new focus and the resulting curriculum are rooted in the voices and perceptions of the target population. Conclusions. Including youth was integral to the adaptation process and the use of techniques such as Photovoice helped ensure that the resulting adaptation was relevant to the target population.

Use and perceptions of the internet for sexual information and partners: a study of young men who have sex with men.

The Internet has opened many doors with its accessibility to information, entertainment and web-based communities. For young men who have sex with men (YMSM), the Internet can provide access to information on relevant sexual behavior and health information, stories from other men about relationship issues, and a venue for locating potential sexual and dating partners. Understanding YMSM's motivations for going online for information, advice or sexual relationships, is important as the Internet becomes increasingly used not only as a space to find sexual partners, but also as a venue for HIV and STI interventions. Having an understanding of the risks associated with searching for partners online, and how and why YMSM use the Internet for a variety of purposes, can inform the development of more effective Internet-based risk reduction programs. This article presents qualitative and quantitative data from the Healthy Young Men's Study, a longitudinal study of an ethnically diverse cohort of 526 YMSM. Qualitative interviews (N = 24) described not only the prevalence of using the Internet for finding sexual partners and the possible benefits and risks associated with that practice, but also the processes and perceptions of using this mechanism. Our data indicate that YMSM used the Internet to find information related to sex and sexuality, seek friendships, sexual partners as well as "hook-ups" or casual sex. Findings were presented in relation to how YMSM researchers and interventionists can identify how to most effectively reach YMSM through online methods.

Deconstructing the complexity of substance use among young men who have sex with men (YMSM) by optimizing the role of qualitative strategies in a mixed methods study.

Qualitative data can be a powerful tool in developing interventions for substance use and other HIV-risk behaviors. Mixed methods design offers researchers the ability to obtain data that provides both breadth and depth to their research questions. However, the integration of qualitative data in mixed methods research has been limited. This paper describes the qualitative study design of the Healthy Young Men's Study, a longitudinal mixed method study with an ethnically diverse cohort of young men who have sex with men (YMSM) (N = 526) in Los Angeles. Integral to this discussion is how a mixed methods study can address common challenges such as sampling, representation and integration of both datasets.

Sexual Racism, Psychological Symptoms, and Mindfulness Among Ethnically/Racially Diverse Young Men Who Have Sex with Men: a Moderation Analysis.

OBJECTIVES: This study examined the potential moderating role of trait mindfulness on the association between perceived sexual racism and psychological symptoms among a community-based sample of ethnic/racial minority young men who have sex with men (MSM) residing in greater Los Angeles. METHODS: From a cross-sectional sample of 448 participants, aged 16-24 years, survey data were analyzed to examine rates of perceived sexual racism, mindfulness, psychological symptoms, and moderation by mindfulness through various analyses, including analysis of variance and logistic regression. RESULTS: Results indicated that Latino young MSM reported the lowest scores of sexual racism, and sexual racism was associated with higher odds of psychological symptoms, suicidal ideation with a plan in the past year, and self-injury in the past 3 months. The protective potential of mindfulness was suggested by its main effects on psychological symptoms; however, it only buffered the effects of sexual racism on suicidal ideation with a plan and self-injury, with marginal buffering effects on depression. CONCLUSIONS: Findings underscore the potential utility of assessing sexual racism among young MSM of color, as well as the potential benefit of mindfulness approaches to buffer the effects of sexual racism on symptoms of depression. Interpretation of these findings is briefly discussed.

Accountability and assessment of emergency drill performance at schools.

Many schools throughout the United States are mandated to hold drills, or operational exercises, to prepare for fires, earthquakes, violence, and other emergencies. However, drills have not been assessed for their effectiveness in improving preparedness at schools. This mixed-methods study measures the quantity and the quality of drills in an urban school district in Los Angeles. Compliance with California mandates was fair; most schools barely met requirements. Drills were not used as opportunities to improve procedures. Sites neither conducted any self-assessments nor made changes to procedures on the basis of performance. Suggestions include developing realistic simulated exercises, debriefing, and better school accountability for drills.

"God Made me Gay for a Reason": Young Men who have Sex with Men's Resiliency in Resolving Internalized Homophobia from Religious Sources.

Research investigating the role of religion in the lives of young men who have sex with men (YMSM) is limited. Given the unique developmental stage of emerging adults and the fact that most religions have restrictions on homosexual behavior, it is important to understand how YMSM integrate their sexual and religious/spiritual identities. Drawing upon a longitudinal, mixed methods study, we explore the role of religion and spirituality in the lives of a sample of YMSM. Presented are descriptions of messages about homosexuality from religious contexts and how these messages are internalized. The process used to resolve the conflict between these messages and their sexual identity is then described. Findings discuss how to help YMSM retain the more supportive and nurturing aspects of religion to integrate their sexual and religious identities for a functional support system.

Engaging Young Men in the HIV Prevention and Care Continua: Experiences From Young Men of Color Who Have Sex With Men.

Sexual minority individuals experience barriers to receiving equitable health care. Research also indicates that young men who have sex with men (YMSM), particularly young men of color, have limited engagement in the HIV care continuum and there are significant disparities across the continuum. This study aims to uncover how providers can engage YMSM of color in all forms of care, including primary care and HIV prevention through an HIV prevention continuum. This qualitative study reports data from the Healthy Young Men's Cohort Study; a total of 49 YMSM participated in the eight focus groups. This study provides a description of YMSM's overall health concerns, experiences with health care, and under what circumstances YMSM seek care. We then present a model describing the salient characteristics of a HIV prevention continuum for YMSM of color and provide clear areas for education, intervention, and policy change to support better overall health for YMSM of color.

A Focus on the HIV Care Continuum Through the Healthy Young Men's Cohort Study: Protocol for a Mixed-Methods Study.

BACKGROUND: No group is at greater risk for acquiring HIV than young men who have sex with men (YMSM), particularly black or African American (AA) and Hispanic or Latino (L) YMSM living in inner cities, who account for the largest number of new HIV infections each year. Although pre-exposure prophylaxis (PrEP), postexposure prophylaxis (PEP), and treatment as prevention hold enormous promise for changing the course of the epidemic, AA/L-YMSM are the least likely population to be receiving primary health care and HIV prevention/care and are the least likely to be using PrEP and PEP. OBJECTIVE: The overarching aim of the Healthy Young Men's (HYM) cohort study is to conduct longitudinal research with a cohort of AA/L-YMSM to prevent new HIV infections, reduce transmission, and reduce HIV/AIDS-related disparities by focusing on successful engagement in care. Findings from this research will be used to inform the development of new interventions designed to engage AA/L-YMSM in the HIV prevention and care continua. METHODS: Longitudinal research (baseline and follow-up assessments every 6 months for a total of 8 waves of data collection) is ongoing with a new cohort of 450 high-risk AA/L-YMSM in Los Angeles. Participants were recruited using a venue-based and social media sampling design. In addition to self-report surveys, the study protocol includes the collection of urine to assess recent use of illicit drugs and the collection of blood and rectal/throat swabs to test for current sexually transmitted infection (STI)/HIV infection. An additional sample of blood/plasma (10 mL for 4 aliquots and 1 pellet) is also collected and stored in the HYM cohort study biorepository for future research. By design, we recruited 400 HIV-negative participants and 50 HIV-positive (HIV+) participants. This mixed-methods study design includes collection and triangulated analysis of quantitative, qualitative, and biological measures (ie, drug use, STI/HIV testing, and adherence to antiretroviral therapy among HIV+ participants) at baseline and every 6 months. The HYM cohort study will provide a platform from which new and emerging biomedical prevention strategies (eg, PrEP, rectal microbicides, and PEP) and other HIV prevention and care engagement interventions can be developed and evaluated with AA/L-YMSM. RESULTS: To date, all participants in the HYM cohort study have been recruited and baseline assessment has been conducted. CONCLUSIONS: The findings from this research will be used to inform the development of new and/or adaptation of existing evidence-based HIV prevention interventions and interventions designed to engage this population in the HIV prevention and care continua. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/10738.

Integrating professional and folk models of HIV risk: YMSM's perceptions of high-risk sex.

Risks associated with HIV are well documented in research literature. Although a great deal has been written about high-risk sex, little research has been conducted to examine how young men who have sex with men (YMSM) perceive and define high-risk sexual behavior. In this study, we compare the "professional" and "folk" models of HIV risk based on YMSM's understanding of high-risk sex and where and how they gathered their understanding of HIV risk behaviors. The findings reported here emerged from the quantitative and qualitative interviews from the Healthy Young Men's Study, a longitudinal study examining risk and protective factors for substance use and sexual risk among an ethnically diverse sample of YMSM. Findings are discussed in relation to framing how service providers and others can increase YMSM's knowledge of sexual behavior and help them build solid foundations of sexual health education to protect them from sexually transmitted infections and HIV.

Setting an Agenda to Address Intimate Partner Violence Among Young Men Who Have Sex With Men: A Conceptual Model and Review.

Research investigating intimate partner violence (IPV) among sexual minorities is limited. The research that does exist has found that rates of IPV are similar to or higher than the rates found for heterosexual women, the most commonly studied population in this area. This limited research has resulted in a dearth of prevention/intervention programs targeted for these populations. While some may argue that existing IPV programs can be used for these populations, this review presents an argument for more targeted work with sexual minority populations, using young men who have sex with men (YMSM) as an example. Drawing on the framework of intersectionality, this article argues that the intersectionality of age, sexual identity, and gender combines to create a spectrum of unique factors that require specific attention. This framework allows for the identification of known correlates for IPV as well as factors that may be unique to YMSM or other sexual minority populations. The article presents a conceptual model that suggests new areas of research as well as a foundation for the topics and issues that should be addressed in an intervention.

Perceptions of Family Among Low-Income Patients With Diabetes in a Text-Based Mobile Health Intervention.

BACKGROUND: Diabetes disproportionately affects the US Latino population, due to socioeconomic pressures, genetics, reduced access to care and cultural practices. While efforts to improve self-care through interventions incorporating family are highly rated by Latinos, family can be both supportive and obstructive. To develop effective interventions, this role needs clarification. METHODS: We conducted group interviews in Spanish and English with 24 participants with diabetes from a mobile health diabetes self-care intervention. We imported transcripts into Dedoose, a qualitative computer analysis program and analyzed them with a modified grounded theory technique. Utilizing an iterative process, we reexamined transcripts with new codes derived in each round of analysis until saturation was reached. We employed techniques to improve trustworthiness (co-coding, member checking). Broad categorical themes arose from the initial codes and were developed into a conceptual model of barriers to and strategies for diabetes management. RESULTS: Family and family responsibilities emerged as both a supportive and obstructive force for diabetes self-care. While the desire to care for family motivated patients, food at family gatherings and pressure from managing multiple family responsibilities contributed to poor diet choices. Yet, some patients believed their diabetes caused their immediate family to make healthier choices. CONCLUSIONS: Among these predominantly Latino patients, family and family responsibilities were key motivators as well as obstacles to self-care, particularly regarding nutrition. Finding the ideal design for social support mHealth-based interventions will require careful study and creation of culturally based programs to match the needs of specific populations, and may require educating family members to provide effective social support.