Partnering With Immigrant Patients and Families to Move Beyond Cultural Competence: A Role for Clinicians and Health Care Organizations.

The delivery of culturally competent health care is recognized as critical to providing quality, equitable care for marginalized groups. This includes immigrant patients and families who experience significant barriers to health care and poor health outcomes. However, operationalization of cultural competence challenges health care delivery. Complementary concepts have also emerged such as cultural humility, cultural safety, and structural competence, recognizing the need for multi-level approaches involving patients, families, clinicians, health care organizations, the larger community, and policymakers. In this review, we define cultural competency and related frameworks and their applicability to immigrant patients and families. The evolution in terminology reflects an increasingly more comprehensive approach to understanding culture as multidimensional and shaped by social and structural factors. We then highlight strategies at each level, focusing on clinicians and organizations to leverage loci of control most directly within clinicians' reach. Community-level strategies include community engagement (ie, vis-à-vis community health workers or community advisory boards) for clinical and research practice. Organization-level strategies include "immigrant-friendly," or "immigration-informed" policies aimed at reducing immigration-related stressors, like limiting cooperation with immigration enforcement agencies or developing medical-legal partnerships to assist with patients' legal needs. Lastly, policy-level strategies seek to change local and federal policies to address needs beyond health care (eg, education, housing, other social services), taking a "Health in All" policies approach that articulates health considerations into policymaking across sectors. Finally, we conclude with suggestions for future directions that center the experiences of immigrants, with the ultimate goal of sustainably meeting the complex needs of immigrant patients and families.

Factors associated with cancer disclosure in adolescent and young adult cancer survivors: An integrative review from the social-ecological model perspective.

PURPOSE: Young cancer survivors ("young survivors") may need to disclose their cancer experiences to reintegrate into society. In such cases, the recognition of social support through the disclosure of cancer experiences may prevent potential social disadvantages． This review aimed to describe the motivations, strategies and outcomes, and benefits and disadvantages of disclosure in young survivors based on the social-ecological model (SEM) to identify the support survivors need when disclosing their cancer experiences. METHODS: Using the integrated review methodology, we systematically searched six databases in English and Japanese as well as searched the reference lists of the selected studies. The themes identified via thematic analysis were categorized within the SEM levels. RESULTS: This review analyzed 14 studies and identified four themes, including "Motivation for Cancer Disclosure," "Barriers to Cancer Disclosure," "Consequences of Cancer Disclosure: Benefits," and "Consequences of Cancer Disclosure: Disadvantages." Motivations for young survivors to disclose their cancer involved post-cancer differences, perceptions, relationships, and social context. In navigating barriers, including self-stigma, peer exclusion, and discrimination, they employed strategies such as reassurance and information limitation. Tailored disclosure strategies at each SEM level offered social and psychological benefits, however, disadvantages, including stress, vulnerability, employment issues, and limited insurance coverage, were experienced by young survivors due to cancer disclosure. CONCLUSIONS: To optimize the benefits of cancer disclosure for young survivors, addressing psychological burdens, enhancing disclosure skills, offering familial psychological support, and fostering public awareness of cancer are essential.

Parents' and Caregivers' Support for in-School COVID-19 Mitigation Strategies: A Socioecological Perspective.

Informed by the social ecological model, which asserts that health behaviors and beliefs are the result of multiple levels of influence, we examined factors related to parents' support for in-school COVID-19 mitigation strategies. Using data from a survey of 567 parents/caregivers of public elementary and middle school students in eight Maryland counties, we employed regression models to examine relationships between parent-, child-, family-, school-, and community-level factors and acceptability of mitigation strategies. Acceptance of COVID-19 mitigation strategies was positively correlated with child- and family-level factors, including child racial identity (parents of Black children were more accepting than those of White children, odds ratio [OR]: 2.5, 95% confidence interval [CI] = [1.5, 4.1]), parent receipt of the COVID-19 vaccine (OR: 2.4, 95% CI = [1.5, 3.7]), and parent Democrat or Independent political affiliation (compared with Republican affiliation, OR: 4.2, 95% CI = [2.6, 6.7]; OR: 2.2, 95%CI = [1.3, 3.8], respectively). Acceptance was also positively associated with parents' perceptions of their school's mitigation approach, including higher school mitigation score, indicating more intensive mitigation policies (OR: 1.1, 95% CI = [1.0, 1.1]), better school communication about COVID-19 (OR: 1.7, 95% CI = [1.4, 1.9]) and better school capacity to address COVID-19 (OR: 1.9, 95% CI = [1.5, 2.4]). Community-level factors were not associated with acceptance. Child- and parent-level factors identified suggest potential groups for messaging regarding mitigation strategies. School-level factors may play an important role in parents' acceptance of in-school mitigation strategies. Schools' capacity to address public health threats may offer an underappreciated and modifiable setting for disseminating and reinforcing public health guidance.

Applying the Social-Ecological Framework to Link the Drivers of Intimate Partner Violence Among Women in the Caribbean and Their Risk for HIV Infection.

For countries with a high prevalence of HIV such as in the Caribbean, intimate partner violence (IPV) may increase the chances for acquiring HIV infection. Using secondary data, we compared findings from studies conducted in five Caribbean countries measuring the prevalence of gender-based violence among women in Grenada, Jamaica, Guyana, Suriname, and Trinidad and Tobago. The Social-Ecological Framework was used to categorize women's dual risk for intimate partner violence and HIV. We found that younger age, lower education, childhood experiences of abuse, income dependency, controlling behaviors of partners, non-disclosure of violence, and early sexual experiences were associated with intimate partner violence. These factors also predispose women in the Caribbean to HIV infection. The Social-Ecological Framework is applicable to understanding the drivers of intimate partner violence and HIV infection at multiple levels and for the design and promotion of combined prevention interventions. Our study also demonstrated the applicability of the Social-Ecological Framework as an analytical and predictive model underscoring the need for increased coordination across multiple actors to strengthen advocacy, given the pervasiveness of harmful social norms and gender inequalities which undermine IPV and HIV control efforts.

Using Medical Cannabis for Chronic Pain: A Social-Ecological Framework.

Early studies suggest medical cannabis (MC) has the potential to benefit people who suffer from chronic pain by offering a less addictive alternative to opioids; however, most investigators agree more research is indicated. Today, in 2023, cannabis remains a Schedule I drug and is an illegal substance in the United States under the Controlled Substances Act of 1970. Despite this designation, as of February 2022, 37 states, three territories, and the District of Columbia allowed using cannabis products to treat certain painful medical conditions. The contradictory status of federal and state legislation regarding cannabis use has resulted in delays and restrictions on relevant research. As a result, an inadequate foundation of knowledge exists needed to inform policy, program, and practice decisions concerning MC to treat pain. Implementing and controlling access to MC is influenced by overlapping individual, interpersonal, community, and organizational influences that all fall under the umbrella of federal and state policies. Increasingly, the legalization and expanded access to MC necessitates the integration of evidence, policy, and social-ecological reality. To adequately delineate these complex factors to anticipate and plan future interventions at multiple levels, we propose a social-ecological framework (SEF) for using MC to treat pain. This SEF assumes the transactional relationship between the individual and the environment and that no single factor can predict behavior or health outcomes. Our framework illustrates five dynamic levels of analysis that interact between dimensions. Key elements and intersections are discussed at the intrapersonal, interpersonal, institutional, community, and policy levels.

Integrated assessment and critical obstacle diagnosis of rural resource and environmental carrying capacity with a social-ecological framework: a case study of Liyang county, Jiangsu Province.

The contradiction among human being, resources, and environment has become a significant obstacle to achieving sustainable development, especially in rural areas subject to the spillover of urban development elements. With the immense strain of resources and environment, it is critical to assess whether human activities fall within the carrying capacity range of a natural ecosystem in a rural system. Taking the rural areas of Liyang county as an example, this study aims to assess the rural resource and environmental carrying capacity (RRECC) and diagnose its critical obstacles. Firstly, a social-ecological framework focusing on human-environment interaction was employed to construct the RRECC indicator system. Subsequently, the entropy-TOPSIS method was introduced to assess the performance of the RRECC. Finally, the obstacle diagnosis method was applied to identify the critical obstacles of RRECC. Our results show that the distribution of RRECC presents a spatial heterogeneity, with high- and medium-high-level villages primarily concentrated in the south of the study area, where there are abundant hills and ecological lakes. Medium-level villages are scattered throughout each town, and low and medium-low level villages are concentrated across all the towns. Moreover, the resource subsystem of RRECC (RRECC_RS) exhibits a similar spatial distribution to RRECC, while the outcome subsystem of RRECC (RRECC_OS) has a comparable quantity proportion of different levels to RRECC. Furthermore, the diagnosis results of critical obstacle vary between the town scale divided by administrative units and the regional scale divided by RRECC values. In detail, arable land occupied by construction is the main critical obstacle at the town scale, while the poor people in villages, people left-behind, and arable land occupied by construction are the main critical obstacles at the regional scale. Targeted differentiated improvement strategies for RRECC at regional scale from various perspectives of global, local, and single are proposed. This research can serve as a theoretical foundation for assessing RRECC and developing differentiated sustainable development strategies for the path forward to rural revitalization.

The Other Side of the ACEs Pyramid: A Healing Framework for Indigenous Communities.

For over two decades, extensive research has demonstrated significant associations between adverse childhood events (ACEs) and a wide range of negative health, mental health, and social outcomes. For Indigenous communities globally, colonization and historical trauma are commonly associated with ACEs, and these effects reverberate through generations. While the ACEs conceptual framework expanded pyramid is a useful model and a visual aid for understanding the historical and present-day dimensions of ACEs in Indigenous communities, a healing conceptual framework is needed to outline a path toward increased community well-being. In this article, we provide a holistic Indigenous Wellness Pyramid that represents the other side of the ACEs pyramid to guide pathways toward healing in Indigenous communities. In this article, the authors describe the Indigenous Wellness Pyramid according to each of the following contrasts with the ACEs pyramid: Historical Trauma-Intergenerational Healing/Indigenous Sovereignty; Social Conditions/Local Context-Thriving Economic and Safe Communities; ACEs-Positive Childhood, Family, and Community Experiences; Disrupted Neurodevelopment-Consistent Corrective Experiences/Cultural Identity Development; Adoption of Health Risk Behaviors-Cultural Values and Coping Skills; Disease Burden and Social Problems-Wellness and Balance; Early Death-Meaningful Life Longevity. We provide examples, supporting research, and implications for implementing the Indigenous Wellness Pyramid.

RISE FOR HEALTH: Rationale and protocol for a prospective cohort study of bladder health in women.

INTRODUCTION: The spectrum of bladder health and the factors that promote bladder health and prevent lower urinary tract symptoms (LUTS) among women are not well understood. This manuscript describes the rationale, aims, study design, sampling strategy, and data collection for the RISE FOR HEALTH (RISE) study, a novel study of bladder health in women conducted by the Prevention of Lower Urinary Tract Symptom (PLUS) Research Consortium. METHODS AND RESULTS: RISE is a population-based, multicenter, prospective longitudinal cohort study of community-dwelling, English- and Spanish-speaking adult women based in the United States. Its goal is to inform the distribution of bladder health and the individual factors (biologic, behavioral, and psychosocial) and multilevel factors (interpersonal, institutional, community, and societal) that promote bladder health and/or prevent LUTS in women across the life course. Key study development activities included the: (1) development of a conceptual framework and philosophy to guide subsequent activities, (2) creation of a study design and sampling strategy, prioritizing diversity, equity, and inclusion, and (3) selection and development of data collection components. Community members and cross-cultural experts shaped and ensured the appropriateness of all study procedures and materials. RISE participants will be selected by simple random sampling of individuals identified by a marketing database who reside in the 50 counties surrounding nine PLUS clinical research centers. Participants will complete self-administered surveys at baseline (mailed paper or electronic) to capture bladder health and LUTS, knowledge about bladder health, and factors hypothesized to promote bladder health and prevent LUTS. A subset of participants will complete an in-person assessment to augment data with objective measures including urogenital microbiome specimens. Initial longitudinal follow-up is planned at 1 year. DISCUSSION: Findings from RISE will begin to build the necessary evidence base to support much-needed, new bladder health promotion and LUTS prevention interventions in women.

COVID-19 Mental Health Stressors of Health Care Providers in the Pandemic Acceptance and Commitment to Empowerment Response (PACER) Intervention: Qualitative Study.

BACKGROUND: Since the pandemic, more Canadians have reported poorer mental health. A vital group experiencing a high level of stressors consists of health care providers (HCPs) caring for COVID-19 patients, carrying out public health responses, or working with vulnerable populations. The mental health of HCPs is negatively affected by the pandemic, not only at work but also at home and in the community. Intersecting stressors at multiple levels contribute to HCPs' experiences of fatigue, insomnia, anxiety, depression, and posttraumatic stress symptoms. OBJECTIVE: The aim of this qualitative study was to explore the pandemic stressors experienced by HCPs at work, at home, and in the community before participating in the Pandemic Acceptance and Commitment to Empowerment Response (PACER) online intervention. METHODS: Informed by a social ecological approach, we used a qualitative reflective approach to engage 74 HCPs in diverse roles. Data were collected during the first 2 waves of the COVID-19 pandemic (June 2020 to February 2021) in Canada. RESULTS: Informed by a social ecological framework, 5 overarching themes were identified in our thematic analysis: (1) personal level stressors that highlight HCPs' identities and responsibilities beyond the workplace; (2) interpersonal level stressors from disrupted social relationships; (3) organizational stressors that contributed to unsettled workplaces and moral distress; (4) community and societal stressors attributed to vicarious trauma and emotional labor; and (5) the multilevel and cumulative impacts of COVID-19 stressors on HCPs' health. CONCLUSIONS: COVID-19 is not merely a communicable disease but also a social and political phenomenon that intensifies the effects of social inequities. Current understanding of pandemic stressors affecting HCPs is largely partial in nature. Although workplace stressors of HCPs are real and intense, they need to be explored and understood in the context of stressors that exist in other domains of HCPs' lives such as family and community to ensure these experiences are not being silenced by the "hero" discourses or overshadowed by professional demands.

Health Promotion Planning and an Interview With Dr Andrea Gielen.

This editorial features an interview with Dr. Andrea Gielen and the newly released book Health Program Planning, Implementation and Evaluation: Creating Behavioral, Environmental and Policy Change, published by Johns Hopkins University Press. Co-Editors for this edition are Lawrence Green, Andrea Gielen, Judith Ottoson, Darleen Peterson, and Marshall Kreuter. The PRECEDE/PROCEED planning model is summarized and the interview features research examples and practical applications of components of the model. PRECEDE, developed in 1974, stands for Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation. PROCEED, added in 1991, stands for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development. Each chapter of this 5th edition of "Health Program Planning" details the specific public health competencies needed to meet ever more rigorous certification and accreditation standards.

Stability of context in sport and exercise across educational transitions in adolescence: hello work, goodbye sport club?

BACKGROUND: The present study firstly aimed to identify context patterns in sport and exercise among adolescents at lower and upper secondary education. The organisational, social and competitive contexts of leisure-time sport and exercise were included as pattern indicators. The second aim was to examine the stability of these patterns across educational transition. The last aim was to investigate whether a subjective evaluation of the transition influences whether people stay in the same pattern across time. METHODS: One-year longitudinal data of 392 adolescents were analysed. RESULTS: Both before and after the educational transition, four context patterns were identified: the traditional competitive club athletes with friends, the self-organised individualists, the non-club-organised sportspersons and the mostly inactives. More than half of the individuals stayed in the same pattern across time. When individuals changed pattern, their change was most often from the self-organised individualists and the non-club-organised to the mostly inactives. A subjective evaluation of the transition influenced the stability of only the traditional competitive club athletes with friends. The chance of these people staying in the same pattern decreased with increased transitional stress. CONCLUSIONS: Knowledge about the stability and change of context patterns can be used to make recommendations for policy strategies and to develop more individually-tailored promotion programs.

Applying the social ecological framework to enhance wellness for student veterans.

ObjectiveTo increase campus-wide wellness for student service members/veterans (SSM/Vs), student services professionals, healthcare providers, and faculty collaborated to implement the Social Ecological Framework (SEF) over a three-year project.ParticipantsOne thousand six hundred and seventy eight SSM/Vs enrolled at a medium-sized doctoral granting institution with high-research activity (R2). SSM/Vs were directly and indirectly impacted through a series of initiatives, including stigma reduction efforts, wellness promotion, faculty training, therapeutic services, and peer-advising.MethodsData collection included student success measures such as retention, student satisfaction/feedback, peer-advising meetings, psychotherapy sessions, TBI screenings, and growth measures from a mental health stigma scale.ResultsA significant increase in therapy sessions conducted at the Wellness Center, increased faculty trainings, new and strengthened partnerships, and an increase in SSM/V retention.ConclusionsResults suggest that collaborative efforts applying the SEF can create improved educational conditions and outcomes for SSM/Vs. A review of SSM/V wellness literature and suggestions for other campuses are offered.

Living the journey to school: Conceptual asymmetry between parents and planners on the journey to school.

Research about school travel and the built environment developed using positivist and post-positivist onto-epistemologies often relies heavily on travel surveys, activity diaries, GPS tracking, and the "objective" measurement of built environment features using geographical information systems and planimetric data. That work takes up and applies specialized disciplinary and practice-based language (e.g., planning and engineering) and concepts that are used to describe, measure, and design the built environment. In this paper, we explore differences in how parents think about the built environment and school transport and the ways in which the built environment and transport are conceptualized in planning. The presence of conceptual asymmetry between a scholar's "model" and the "lived experience" of parents and children may have implications for the efficacy of school travel-related policy and planning. We use Bronfenbrenner's social ecological model to guide a thematic analysis of 37 interviews with parents about school travel behaviour in Toronto, Canada. We found that parents' experiences of the built environment are complex and varied, with different features influencing individual parents differently, and at varying levels of the ecological model. For example, mixed-use development, often held up as a necessary condition for tackling automobility, was cited as a desirable aesthetic background for driving. We were able to locate examples of conceptual asymmetry but also agreement - particularly about traffic around schools. For example, parents expressed divergent views on the impact of heavy traffic on walking, with some describing traffic and traffic safety as barriers to walking, while others indicated that resistance to driving in traffic motivated a choice to walk. Our study serves as a call to planners and geographers to better attend to the lay, everyday onto-epistemologies that shape parents' lived experiences of travel to school.

Health Promotion Planning and an Interview With Dr. Lawrence Green.

"If we are to have more evidence-based practice, we need more practice-based evidence." This quote has become something of a mantra for the health promotions profession's most pre-eminent scholar, Dr. Lawrence W. Green. This editorial features an interview with Dr. Green and previews the forthcoming 5th edition of Green and Kreuter's seminal health promotion planning textbook. The new title will be Health Program Planning, Implementation and Evaluation: Creating Behavioral, Environmental and Policy Change, with the Johns Hopkins University Press as the new publisher. Co-Editors for this new edition are Larry Green, Andrea Gielen, Judith Ottoson Darleen Peterson, and Marshall Kreuter. This edition shows the vital progression from planning and implementation to evaluation and has further refined and simplified the visual representation of the planning model. The "enabling factors" that will spawn more practice based evidence are discussed. To enable practice-based research will mean that end users of a service or intervention must be taught to be leaders and advocates for approaches that are responsive to their needs, preferences and values.

Place, Power, and Premature Mortality: A Rapid Scoping Review on the Health of Women in Appalachia.

OBJECTIVE: Appalachian women continue to die younger than in other US regions. We performed a rapid scoping review to summarize women's health research in Appalachia from 2000 to 2019, including health topics, study populations, theoretical frameworks, methods, and findings. DATA SOURCE: We searched bibliographic databases (eg, PubMed, PsycINFO, Google Scholar) for literature focusing on women's health in Appalachia. STUDY INCLUSION AND EXCLUSION CRITERIA: Included articles were: (1) on women's health in Appalachia; (2) published January 2000 to June 2019; (3) peer-reviewed; and (4) written in English. We excluded studies without reported data findings. DATA EXTRACTION: Two coders reviewed articles for descriptive information to create summary tables comparing variables of interest. DATA SYNTHESIS: Two coders co-reviewed a sub-sample to ensure consensus and refine data charting categories. We categorized major findings across the social-ecological framework. RESULTS: A search of nearly 2 decades of literature revealed 81 articles, which primarily focused on cancer disparities (49.4%) and prenatal/pregnancy outcomes (23.5%). Many of these research studies took place in Central Appalachia (eg, 42.0% in Kentucky) with reproductive or middle-aged women (82.7%). Half of the studies employed quantitative methods, and half used qualitative methods, with few mixed method or community-engaged approaches (3.7%). Nearly half (40.7%) did not specify a theoretical framework. Findings included complex multi-level factors with few articles exploring the co-occurrence of factors across multiple levels. CONCLUSIONS: Future studies should: 1) systematically include Appalachian women at various life stages from under-represented sub-regions; 2) expand the use of rigorous methods and specified theoretical frameworks to account for complex interactions of social-ecological factors; and 3) build upon existing community assets to improve health in this vulnerable population.

Expanding the Conceptualization of Support in Low-Wage Carework: The Case of Home Care Aides and Client Death.

Home care aides are a rapidly growing, non-standard workforce who face numerous health risks and stressors on the job. While research shows that aides receive limited support from their agency employers, few studies have explored the wider range of support that aides use when navigating work stress and considered the implications of these arrangements. To investigate this question, we conducted 47 in-depth interviews with 29 home care aides in New York City, focused specifically on aides' use of support after client death. Theories of work stress, the social ecological framework, and feminist theories of care informed our research. Our analysis demonstrates aides' extensive reliance on personal sources of support and explores the challenges this can create in their lives and work, and, potentially, for their communities. We also document aides' efforts to cultivate support stemming from their home-based work environments. Home care aides' work stress thus emerges as both an occupational health and a community health issue. While employers should carry responsibility for preventing and mitigating work stress, moving toward health equity for marginalized careworkers requires investing in policy-level and community-level supports to bolster employer efforts, particularly as the home care industry becomes increasingly fragmented and non-standard.

Exploring Social Ecological Determinants of Physical Activity Among Adult Survivors of Childhood Cancer.

Purpose: Adult survivors of childhood cancer (ASCCs) are at high risk for cardiovascular disease from chemotherapy- and radiation therapy-related cardiotoxicity. Physical activity (PA) can reduce this risk, but the majority of ASCCs do not engage in sufficient PA. The purpose of this study was to identify barriers, facilitators, and resources for PA among ASCCs using the ecological model of physical activity (EMPA) as a theoretical framework. Methods: A concept elicitation survey was distributed independently to ASCCs (diagnosed with cancer before the age of 18, and currently 18-39 years old) and parents/legal guardians of an ASCC. The survey consisted of open-ended questions asking about barriers, facilitators, and resources for PA. Content analysis of open-ended questions categorized responses into levels of the EMPA and identified key themes. Results: Seventeen ASCCs and eight parents of ASCCs completed the survey. The majority of barriers, facilitators, and resources reported were at the individual and microsystem level of the EMPA. Six themes emerged, suggesting that ASCC's PA was related to proximity/access, social support, equipment, time/schedule, finances, and health-related barriers. Conclusion: This is the first study to examine barriers, facilitators, and resources of PA among ASCCs using the EMPA. Findings from this study provide a multilevel perspective on the influences of PA among ASCCs, and can be used for future, in-depth qualitative studies and quantitative survey development, and as a foundational step toward supportive efforts in increasing PA among ASCCs.

The opioid crisis: a contextual, social-ecological framework.

The prevalence of opioid use and misuse has provoked a staggering number of deaths over the past two and a half decades. Much attention has focused on individual risks according to various characteristics and experiences. However, broader social and contextual domains are also essential contributors to the opioid crisis such as interpersonal relationships and the conditions of the community and society that people live in. Despite efforts to tackle the issue, the rates of opioid misuse and non-fatal and fatal overdose remain high. Many call for a broad public health approach, but articulation of what such a strategy could entail has not been fully realised. In order to improve the awareness surrounding opioid misuse, we developed a social-ecological framework that helps conceptualise the multivariable risk factors of opioid misuse and facilitates reviewing them in individual, interpersonal, communal and societal levels. Our framework illustrates the multi-layer complexity of the opioid crisis that more completely captures the crisis as a multidimensional issue requiring a broader and integrated approach to prevention and treatment.

A social ecological approach to understanding service utilization barriers among male survivors of sexual violence in three refugee settings: a qualitative exploratory study.

BACKGROUND: Post-sexual violence service utilization is often poor in humanitarian settings. Little is known about the service uptake barriers facing male survivors specifically. METHODS: To gain insights into this knowledge gap, we undertook a qualitative exploratory study to better understand the barriers to service utilization among male survivors in three refugee-hosting countries. The study sites and populations included refugees who had travelled the central Mediterranean migration route through Libya living in Rome and Sicily, Italy; Rohingya refugees in Cox's Bazar, Bangladesh; and refugees from eastern Democratic Republic of the Congo, Somalia, and South Sudan residing in urban areas of Kenya. Methods included document review, 55 semi-structured focus group discussions with 310 refugees, semi-structured key informant interviews with 148 aid workers and human rights experts, and observation of service delivery points. Data were thematically analyzed using NVivo 12. RESULTS: We identified eleven key barriers and situated them within a social ecological framework to describe impediments at the policy, community (inter-organizational), organizational, interpersonal, and individual levels. Barriers entailed: 1) restrictions to accessing legal protection, 2) legislative barriers such as the criminalization of same-sex sexual relations, 3) few designated entry points, 4) poor or nonexistent referral systems, 5) lack of community awareness-raising and engagement, 6) limited staff capacity, 7) negative provider attitudes and practices, 8) social stigma, 9) limited knowledge (at the individual level), 10) self-stigma, and 11) low formal help-seeking behaviors. CONCLUSION: The social ecological framework allowed us to better understand the multifaceted ways that the barriers facing male survivors operate and reinforce one another, and may be useful to inform efforts promoting service uptake. Additional research is warranted in other refugee settings.

The interaction of behavioral context and motivational-volitional factors for exercise and sport in adolescence: patterns matter.

BACKGROUND: In order to generate more effective interventions to promote exercise and sport in adolescence, a better understanding of the interaction of influencing factors across different levels is needed. In particular, motivation and volition for exercise and sport, as well as the context in which adolescents are doing exercise and sport, have been identified as important factors. Behavioral context refers to both the organizational setting, e.g., doing exercise and sport in a club, and the social setting, e.g., doing exercise and sport with friends. Extending previous research, the present study applies a person-oriented approach and aims to identify typical behavioral context patterns and motivational-volitional patterns. To validate the patterns, it was examined whether they differ concerning the exercise and sport activity level. Furthermore, the study investigated how behavioral context patterns and motivational-volitional patterns interact. METHOD: A cross-sectional design with 1155 adolescents (Mage = 15.29; 53% female) was applied. A latent profile analysis was used twice to identify typical patterns: once with eight organizational and social setting factors to examine behavioral context patterns, and once with five motivational-volitional factors to examine motivational-volitional patterns. To validate the patterns identified, the exercise and sport activity level were compared across the patterns using Wald-tests. Finally, transition probabilities and odds ratios were calculated in order to investigate the interaction of the behavioral context and motivational-volitional patterns. RESULTS: Four behavioral context patterns - differing in activity level - were identified: Mostly inactive, non-club-organized individualists, self-organized individualists and family sportspersons, and traditional competitive club athletes with friends. Furthermore, five motivational-volitional patterns emerged with differing activity levels: three level patterns with overall low, moderate or high motivation and volition, and two shape patterns called the intention- and plan-less and the plan-less motivated. Regarding interaction, the results indicate that one behavioral context pattern is not solely responsible for moderate to high motivation and volition in adolescents. CONCLUSION: Applying a person-oriented approach allows a more differentiated view of how behavioral context and motivational-volitional factors interact within homogenous subgroups. This, in turn, provides a basis to design tailored multilevel interventions which account for the interaction of influencing factors across different levels.