Congregational involvement in HIV: A qualitative comparative analysis of factors influencing HIV activity among diverse urban congregations.

Religious congregations can potentially reach disproportionately affected populations with HIV programming, however, factors that influence congregational involvement in HIV are not well-studied. Utilizing comparative case methods and in-depth qualitative data from a diverse sample of 14 urban congregations, we examine a range of attitudinal, organizational, resource, and demographic factors to systematically identify different case scenarios-i.e., combinations of characteristics-associated with the level and types of HIV activities in which the congregational cases tended to be involved. For example, White or mixed race congregations with active gay constituencies and an African-American congregation with a strong lay HIV champion were among the high HIV involvement case scenarios, compared to African-American congregations with a health emphasis but no lay HIV champion among the medium HIV involvement scenarios, and fundamentalist African-American and Latino congregations among the low HIV involvement scenarios. Two key factors that appeared influential across case scenarios included the existence of lay champions for HIV activities and the general theological orientation of the congregation.

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.

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.

Can a More User-Friendly Medicare Plan Finder Improve Consumers' Selection of Medicare Plans?

OBJECTIVE: To evaluate the efficacy for consumers of two potential enhancements to the Medicare Plan Finder (MPF)-a simplified data display and a "quick links" home page designed to match the specific tasks that users seek to accomplish on the MPF. DATA SOURCES/STUDY SETTING: Participants (N = 641) were seniors and adult caregivers of seniors who were recruited from a national online panel. Participants browsed a simulated version of the MPF, made a hypothetical plan choice, and reported on their experience. STUDY DESIGN: Participants were randomly assigned to one of eight conditions in a fully factorial design: 2 home pages (quick links, current MPF home page) × 2 data displays (simplified, current MPF display) × 2 plan types (stand-alone prescription drug plan [PDP], Medicare Advantage plan with prescription drug coverage [MA-PD]). PRINCIPAL FINDINGS: The quick links page resulted in more favorable perceptions of the MPF, improved users' understanding of the information, and increased the probability of choosing the objectively best plan. The simplified data display resulted in a more favorable evaluation of the website, better comprehension of the displayed information, and, among those choosing a PDP only, an increased probability of choosing the best plan. CONCLUSIONS: Design enhancements could markedly improve average website users' understanding, ability to use, and experience of using the MPF.

Firearm Ownership and Acquisition Among Parents With Risk Factors for Self-Harm or Other Violence.

OBJECTIVE: Recent policy initiatives aiming to reduce firearm morbidity focus on mental health and illness. However, few studies have simultaneously examined mental health and behavioral predictors within families, or their longitudinal association with newly acquiring a firearm. METHODS: Population-based, longitudinal survey of 4251 parents of fifth-grade students in 3 US metropolitan areas; 2004 to 2011. Multivariate logistic models were used to assess associations between owning or acquiring a firearm and parent mental illness and substance use. RESULTS: Ninety-three percent of parents interviewed were women. Overall, 19.6% of families reported keeping a firearm in the home. After adjustment for confounders, history of depression (adjusted odds ratio [aOR], 1.36; 95% confidence interval [CI], 1.04-1.77), binge drinking (aOR 1.75; 95% CI, 1.14-2.68), and illicit drug use (aOR 1.75; 95% CI, 1.12-2.76) were associated with a higher likelihood of keeping a firearm in the home. After a mean of 3.1 years, 6.1% of parents who did not keep a firearm in the home at baseline acquired one by follow-up and kept it in the home (average annual likelihood = 2.1%). No risk factors for self-harm or other violence were associated with newly acquiring a gun in the home. CONCLUSIONS: Families with risk factors for self-harm or other violence have a modestly greater probability of having a firearm in the home compared with families without risk factors, and similar probability of newly acquiring a firearm. Treatment interventions for many of these risk factors might reduce firearm-related morbidity.

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.

Church-Based HIV Screening in Racial/Ethnic Minority Communities of California, 2011-2012.

Community-based human immunodeficiency virus (HIV) testing at religious congregations has been proposed as a potentially effective way to increase screening among disproportionately affected populations, such as those self-identifying as African American and Latino. Although congregations may provide reach into these communities, the extent to which church-based HIV testing alleviates access barriers, identifies new cases, and reaches people at increased risk for HIV is not well documented. We examined the results of an HIV testing program that was conducted as part of a larger intervention aimed at reducing HIV stigma at five churches in Los Angeles County, California, in 2011-2012. HIV screening identified one positive result in 323 tests but reached a substantial proportion of people who had not been tested before, including many who lacked health insurance. Although this approach may not be an efficient way to identify cases of previously unknown HIV infection, it could help achieve universal testing goals.

Comparing the Health Care Experiences of Medicare Beneficiaries with and without Depressive Symptoms in Medicare Managed Care versus Fee-for-Service.

OBJECTIVE: To compare patient experiences and disparities for older adults with depressive symptoms in managed care (Medicare Advantage [MA]) versus Medicare Fee-for-Service (FFS). DATA SOURCES: Data came from the 2010 Medicare CAHPS survey, to which 220,040 MA and 135,874 FFS enrollees aged 65 and older responded. STUDY DESIGN: Multivariate linear regression was used to test whether case-mix-adjusted associations between depressive symptoms and patient experience differed for beneficiaries in MA versus FFS. Dependent measures included four measures of beneficiaries' experiences with doctors (e.g., reports of doctor communication) and seven measures of beneficiaries' experiences with plans (e.g., customer service). PRINCIPAL FINDINGS: Beneficiaries with depressive symptoms reported worse experiences than those without depressive symptoms regardless of coverage type. For measures assessing interactions with the plan (but not for measures assessing interactions with doctors), the disadvantage for beneficiaries with versus without depressive symptoms was larger in MA than in FFS. CONCLUSIONS: Disparities in care experienced by older Medicare beneficiaries with depressive symptoms tend to be more negative in managed care than in FFS. Efforts are needed to identify and address the barriers these beneficiaries encounter to help them better traverse the managed care environment.

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.

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

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.

DISC Predictive Scales (DPS): Factor structure and uniform differential item functioning across gender and three racial/ethnic groups for ADHD, conduct disorder, and oppositional defiant disorder symptoms.

The factor structure and potential uniform differential item functioning (DIF) among gender and three racial/ethnic groups of adolescents (African American, Latino, White) were evaluated for attention deficit/hyperactivity disorder (ADHD), conduct disorder (CD), and oppositional defiant disorder (ODD) symptom scores of the DISC Predictive Scales (DPS; Leung et al., 2005; Lucas et al., 2001). Primary caregivers reported on DSM-IV ADHD, CD, and ODD symptoms for a probability sample of 4,491 children from three geographical regions who took part in the Healthy Passages study (mean age = 12.60 years, SD = 0.66). Confirmatory factor analysis indicated that the expected 3-factor structure was tenable for the data. Multiple indicators multiple causes (MIMIC) modeling revealed uniform DIF for three ADHD and 9 ODD item scores, but not for any of the CD item scores. Uniform DIF was observed predominantly as a function of child race/ethnicity, but minimally as a function of child gender. On the positive side, uniform DIF had little impact on latent mean differences of ADHD, CD, and ODD symptomatology among gender and racial/ethnic groups. Implications of the findings for researchers and practitioners are discussed.

Acculturation and Drug Use Stigma Among Latinos and African Americans: An Examination of a Church-Based Sample.

Substance use patterns among Latinos likely reflect changes in attitudes resulting from acculturation, but little is known about Latinos' attitudes regarding drug addiction. We surveyed a church-based sample of Latinos and African Americans (N = 1,235) about attitudes toward drug addiction and socio-demographics. Linear regression models compared Latino subgroups with African-Americans. In adjusted models, Latinos had significantly higher drug addiction stigma scores compared to African Americans across all subgroups (US-born Latinos, ß = 0.22, p < .05; foreign-born Latinos with high English proficiency, ß = 0.30, p < .05; and foreign-born Latinos with low English proficiency, ß = 0.49, p < .001). Additionally, Latinos with low English proficiency had significantly higher mean levels of drug use stigma compared Latinos with high proficiency (both foreign-born and US-born). In this church-affiliated sample, Latinos' drug addiction stigma decreases with acculturation, but remains higher among the most acculturated Latinos compared to African-Americans. These attitudes may pose a barrier to treatment for Latino drug users.

Predictors of the Existence of Congregational HIV Programs: Similarities and Differences Compared With Other Health Programs.

PURPOSE: Identify and compare predictors of the existence of congregational human immunodeficiency virus (HIV) and other health programs. DESIGN: Cross-sectional study. SETTING: United States. SUBJECTS: A nationally representative sample of 1506 U.S. congregations surveyed in the National Congregations Study (2006-2007). MEASURES: Key informants at each congregation completed in-person and telephone interviews on congregational HIV and other health programs and various congregation characteristics (response rate = 78%). County-level HIV prevalence and population health data from the Robert Wood Johnson Foundation's 2007 County Health Rankings were linked to the congregational data. ANALYSIS: Multinomial logistic regression was used to assess factors that predict congregational health programs relative to no health programs; and of HIV programs relative to other health activities. RESULTS: Most congregations (57.5%) had at least one health-related program; many fewer (5.7%) had an HIV program. Predictors of health vs. HIV programs differed. The number of adults in the congregation was a key predictor of health programs, while having an official statement welcoming gay persons was a significant predictor of HIV programs (p < .05). Other significant characteristics varied by size of congregation and type of program (HIV vs. other health). CONCLUSION: Organizations interested in partnering with congregations to promote health or prevent HIV should consider congregational size as well as other factors that predict involvement. Results of this study can inform policy interventions to increase the capacity of religious congregations to address HIV and health.

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.

Daily violent video game playing and depression in preadolescent youth.

Most studies on the impact of playing violent video games on mental health have focused on aggression. Relatively few studies have examined the relationship between playing violent video games and depression, especially among preadolescent youth. In this study, we investigated whether daily violent video game playing over the past year is associated with a greater number of depressive symptoms among preadolescent youth, after controlling for several well-known correlates of depression among youth. We analyzed cross-sectional data collected from 5,147 fifth-grade students and their primary caregivers who participated in Wave I (2004-2006) of Healthy Passages, a community-based longitudinal study conducted in three U.S. cities. Linear regression was conducted to determine the association between violent video game exposure and number of depressive symptoms, while controlling for gender, race/ethnicity, peer victimization, witnessing violence, being threatened with violence, aggression, family structure, and household income level. We found that students who reported playing high-violence video games for ≥2 hours per day had significantly more depressive symptoms than those who reported playing low-violence video games for <2 hours per day (p<0.001). The magnitude of this association was small (Cohen's d=0.16), but this association was consistent across all racial/ethnic subgroups and among boys (Cohen's d values ranged from 0.12 to 0.25). Our findings indicate that there is an association between daily exposure to violent video games and number of depressive symptoms among preadolescent youth. More research is needed to examine this association and, if confirmed, to investigate its causality, persistence over time, underlying mechanisms, and clinical implications.

Tobacco use and smoking intentions among U.S. fifth-grade students.

PURPOSE: To identify the risk and protective factors for cigarette smoking and future intentions among racially/ethnically diverse preadolescent children. METHODS: We analyzed data from 5,119 fifth-grade children and their parents living in three U.S. metropolitan areas. Using the multivariate logistic regression models, we examined how cigarette smoking and intentions to smoke within 1 year are associated with (1) number of friends who smoke, (2) parental disapproval of smoking, (3) parental communication about not smoking, (4) performance in school, and (5) educational aspirations. RESULTS: Twenty-nine percent of the children were black, 44% were Hispanic, 22% were white, and 5% were of another race/ethnicity. Mean age was 11.1 years. The prevalence of ever smoking a cigarette among black, Hispanic, and white children was 9.8%, 5.6%, and 4.9%, respectively. In adjusted analyses, children were more likely to have smoked a cigarette if their friends smoked (adjusted odds ratio [aOR] 5.1, 95% confidence interval [CI] 3.8-6.9), they frequently had trouble with schoolwork (aOR 2.1, 95% CI 1.5-3.1), or their parents were not college graduates (aOR 2.0, 95% CI 1.2-3.5 for high school graduate). They were less likely to have smoked cigarettes if their parents disapproved of smoking (aOR .3, 95% CI .1-.6). Parental communication (aOR .1, 95% CI .0-.6) and disapproval (aOR .2, 95% CI .1-.7) had protective associations for future intentions among children who had ever and had never smoked, respectively. CONCLUSIONS: Fifth-graders share many of the same risk factors for smoking identified in older adolescents, some of which are modifiable. Antismoking policies and programs should be designed for preadolescents as well as adolescents, and campaigns targeting parents should place greater emphasis on communication and expressed disapproval of smoking.

An intervention to reduce HIV-related stigma in partnership with African American and Latino churches.

HIV-related stigma negatively affects prevention and care, and community-based interventions are needed. Here we describe the development of a multi-ethnic, faith-based intervention to reduce HIV stigma that included: educational workshops on HIV, testing, and stigma; peer leader workshops using role plays and drawing on principles of motivational interviewing; a pastor-delivered sermon on HIV that incorporated theological reflection and an imagined contact scenario; and congregation-based HIV testing events. Lessons learned include: partnership development is essential and requires substantial investment; tailoring intervention components to single race-ethnic groups may not be preferable in diverse community settings; and adapting testing processes to be able to serve larger numbers of people in shorter time frames is needed for congregational settings. This development process successfully combined the rigorous application of social science theory and community engagement to yield a multifaceted HIV stigma reduction intervention appropriate for Protestant and Catholic churches in African American and Latino communities.