"It Was as Though My Spirit Left, Like They Killed Me": The Disruptive Impact of an HIV-Positive Diagnosis among Women in the Dominican Republic.

An HIV diagnosis may be associated with severe emotional and psychological distress, which can contribute to delays in care or poor self-management. Few studies have explored the emotional, psychological, and psychosocial impacts of an HIV diagnosis on women in low-resource settings. We conducted in-depth interviews with 30 women living with HIV in the Dominican Republic. Interviews were audio-recorded, transcribed, and analyzed using the biographical disruption framework. Three disruption phases emerged (impacts of a diagnosis, postdiagnosis turning points, and integration). Nearly all respondents described the news as deeply distressful and feelings of depression and loss of self-worth were common. Several reported struggling with the decision to disclose-worrying about stigma. Postdiagnosis turning points consisted of a focus on survival and motherhood; social support (family members, friends, HIV community) promoted integration. The findings suggest a need for psychological resources and social support interventions to mitigate the negative impacts of an HIV diagnosis.

City of Los Angeles Neighborhood Parks: Research Findings and Policy Implications (2003-2015).

This study summarizes more than a decade of research on how well neighborhood parks in Los Angeles support physical activity. Between 2003 and 2015, researchers at the RAND Corporation studied 83 parks in the city of Los Angeles, conducting thousands of observations and fielding nearly 28,000 surveys of park users and local residents. About half of all residents said that they used their neighborhood parks, most of them routinely. Parks are also the top venue that people choose for engaging in routine exercise. The majority of residents, including residents of low-income, high-crime neighborhoods, consider their neighborhood parks safe or very safe. We also found that parks get more use when they are larger, when they have more facilities, when they offer more planned activities and events, and when their services and activities are marketed to the public. While there is frequent activity in city parks, there is room for improvement. Parks are underutilized by girls and teenage girls, and they are especially underutilized by seniors. Overall, nearly half of all Los Angeles city residents living within 1 mile of a park did not use that park. Most did not know about the activities that were offered, and the majority of residents and more than a third of park users did not know the park's staff. Recommendations include devoting more resources to outreach and marketing. Los Angeles should also devote a larger proportion of its budget to city parks: Park spending per capita in Los Angeles is currently less than half of the per capita amounts that are spent by New York, Seattle, and San Francisco.

Achieving Broad Participation in Congregational Health Surveys at African American and Latino Churches.

Congregation-based health program evaluations often rely on surveys, but little documentation is available regarding specific methods and challenges. Here we describe methods used to achieve acceptable response rates (73-79%) to a survey of HIV-related attitudes and behaviors in 2 African American and 3 Latino churches in high HIV prevalence communities in Los Angeles County. Survey participation was enhanced by: conducting survey sessions at church-based meetings (e.g., women's Bible study) and after worship services; employing diverse survey staff; providing participation incentives for pastors, church coordinators, and survey participants; and working collaboratively and respectfully with congregational leaders. Achieving broad participation in church-based surveys on sensitive health topics is feasible when done collaboratively with congregational leaders and with a flexible protocol, which permits tailoring survey approaches to cultural and organizational contexts and leverages available resources appropriately.

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.

Validation of a New Counter for Direct Observation of Physical Activity in Parks.

PURPOSE: This study aims to examine the reliability of a 12-button counter to simultaneously assess physical activity (PA) by age and gender subgroups in park settings. METHODS: A total of 1,160 pairs of observations were conducted in 481 target areas of 19 neighborhood parks in the great Los Angeles, California, area between June 2013 and March 2014. Interrater reliability was assessed by Pearson's correlation, intraclass correlation (ICC), and agreement probability in metabolic equivalents (METs). Cosine similarity was used to check the resemblance of distributions among age and gender categories. Pictures taken in a total of 112 target areas at the beginning of the observations were used as a second reliability check. RESULTS: Interrater reliability was high for the total METs and METs in all age and gender categories (between 0.82 and 0.97), except for male seniors (correlations and ICC between 0.64 and 0.77, agreement probability 0.85 to 0.86). Reliability was higher for total METs than for METs spent in moderate-to-vigorous PA. Correlation and ICC between observers' measurement and picture-based counts are also high (between 0.79 and 0.94). CONCLUSION: Trained observers can reliably use the 12-button counter to accurately assess PA distribution and disparities by age and gender.

US Religious Congregations' Programming to Support Veterans: A Mixed Methods Study.

Religious congregations may be well equipped to address veterans' reintegration needs, but little is known about the prevalence and nature of such support. We conducted a mixed methods study using nationally representative congregational survey data and in-depth interviews with congregational leaders. Overall, 28% of congregations nationally reported having programming to support veterans and positive, independent predictors included: community context (county veteran presence, high-poverty census tract, rural compared to urban location); congregational resources (more adult attendees, having a paid employee that spent time on service programs); and external engagement (assessing community needs, collaboration, and social service participation). Qualitative interviews revealed a range of activities, including attending to spiritual issues, supporting mental, physical and social well-being, and addressing vocational, legal, financial, and material needs.

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

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

Racial-Ethnic Variation in Park Use and Physical Activity in the City of Los Angeles.

Racial-ethnic disparities in physical activity present important challenges to population health. Public parks provide access to free or low-cost physical activity opportunities, but it is unclear to what extent parks are utilized by various race-ethnic groups in diverse urban settings. Here, we examine racial ethnic differences in park use and physical activity among adult residents (n = 7506) living within 1 mi of 50 parks in the city of Los Angeles. In multivariate analyses, we find few differences among race-ethnic groups in terms of their frequency of having visited the park in the past 7 days; however, we find numerous differences in how the groups used the park and in their levels of physical activity: Blacks and English-speaking Latinos were less likely than whites to report being physically active, exercising in the park, and exercising outside the park; Spanish-speaking Latinos were equally likely as whites to report exercising in park but less likely to report exercising outside the park and more likely to report using the parks for social interactions; Asians/Pacific Islanders (PI)/others were more likely than whites to report visiting the park in the past 7 days and using the parks for social interactions. Urban parks appear to be an important resource for physical activity and socialization, in particular among Spanish-speaking Latino and Asians/PI groups. Additional efforts may be needed for other racial-ethnic minorities to experience the same benefits.

Promotoras as data collectors in a large study of physical activity in parks.

There is a large literature on promotores' involvement in health promotion and a smaller literature on their roles in data collection, most often among predominantly Latino populations. But the extent to which promotores can be successful as the primary data collectors across racially/ethnically and socioeconomically diverse neighborhoods is less well documented. In a study of physical activity in 50 urban neighborhood parks, we found that a team of Spanish/English bilingual promotoras (female promotores) successfully implemented a direct observation protocol in all participant neighborhoods and achieved high interrater reliability (.80-.98). Overall, they were also effective in administering surveys to park users and residents across the racially/ethnically diverse neighborhoods. The promotoras brought to the project important language skills and cultural sensitivity, surveying experience, and familiarity with human subjects and confidentiality issues. Their extensive field experience gained over the course of a long-term collaborative effort helped improve survey and observation protocols. The promotoras reported gaining professional skills, which can strengthen their contributions to other projects. The promotoras were accustomed to being a source of information, and collecting rather than providing information was challenging for some and had to be addressed in order to avoid contamination across study groups.

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.

Impact of food support on food security and body weight among HIV antiretroviral therapy recipients in Honduras: a pilot intervention trial.

Optimal strategies to improve food security and nutrition for people living with HIV (PLHIV) may differ in settings where overweight and obesity are prevalent and cardiovascular disease risk is a concern. However, no studies among PLHIV have investigated the impact of food support on nutritional outcomes in these settings. We therefore assessed the effect of food support on food insecurity and body weight in a population of PLHIV with high prevalence of overweight and obesity. We implemented a pilot intervention trial in four government-run HIV clinics in Honduras. The trial tested the effect of a monthly household food ration plus nutrition education (n = 203), compared to nutrition education alone (n = 197), over 12 months. Participants were clinic patients receiving antiretroviral therapy (ART). Assessments were obtained at baseline, 6 and 12 months. Primary outcomes for this analysis were food security, using the validated Latin American and Caribbean Food Security Scale and body weight (kg). Thirty-one percent of participants were overweight (22%) or obese (8%) at baseline. At 6 months, the probability of severe food insecurity decreased by 48.3% (p < 0.01) in the food support group, compared to 11.6% in the education-only group (p < 0.01). Among overweight or obese participants, food support led to average weight gain of 1.13 kg (p < 0.01), while nutrition education alone was associated with average weight loss of 0.72 kg (p < 0.10). Nutrition education alone was associated with weight gain among underweight and normal weight participants. Household food support may improve food security but not necessarily nutritional status of ART recipients above and beyond nutrition education. Improving nutritional tailoring of food support and testing the impact of nutrition education should be prioritized for PLHIV in Latin America and similar settings.

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.

Faith-Based Organizations and Veteran Reintegration: Enriching the Web of Support.

Faith-based organizations (FBOs) are an important community-based resource for veterans as they readjust to civilian life. Through interviews with both national-level and smaller, local FBOs, the authors sought to understand better the current and potential roles for FBOs in veteran reintegration. Interviewees suggested that veterans may look to FBOs for support because they offer privacy and confidentiality, two features that may be especially critical when a potential stigma is involved. Some FBOs have also developed a reputation as safe places for veterans, providing supportive, judgment-free environments. FBOs not only help veterans with spiritual matters but address diverse areas of veteran health and wellness, including vocation, education, financial and legal stability, shelter, access to goods and services, mental health, access to health care, physical health, family, and social networks. In some cases, the support is offered to veterans directly; in other instances, the support is indirect, via training individuals to help veterans or educating the public about them. In the process of providing support, FBOs interact with varied organizations, including government entities, private nonprofits, and one another, for training, outreach, referrals, information exchange, obtaining donations, and collaboration. Yet challenges exist, including insufficient connections with chaplains working in different settings and others in the web of support, resource and capacity constraints, lack of awareness of experience with veterans, issues related to religious philosophy or orientation, and characteristics of veterans themselves. To move forward, the authors offer recommendations for policymakers, organizations that interact with FBOs, and FBOs themselves to help FBOs engage fully in the web of reintegration support.

How much neighborhood parks contribute to local residents' physical activity in the City of Los Angeles: a meta-analysis.

OBJECTIVE: To quantify the contribution of neighborhood parks to population-level, moderate-to-vigorous physical activity (MVPA). METHOD: We studied park use in 83 neighborhood parks in Los Angeles between 2003 and 2014 using systematic observation and surveys of park users and local residents. We observed park use at least 3-4 times per day over 4-7 clement days. We conducted a meta-analysis to estimate total, age group and gender-specific park use and total MVPA time in parks. RESULTS: An average park measuring 10 acres and with 40,000 local residents in a one-mile radius accrued 5301 h of use (SE=1083) during one week, with 35% (1850 h) spent in MVPA and 12% (635 h) spent in vigorous physical activity (VPA). As much as a 10.7-fold difference in weekly MVPA hours was estimated across study parks. Parks' main contribution to population-level MVPA is for males, teenagers, and residents living within a half mile. CONCLUSION: Neighborhood parks contribute substantially to population MVPA. The contribution may depend less on size and facilities than on "demand goods" - programming and activities--that draw users to a park.

Whose social capital matters? The case of U.S. urban public hospital closures and conversions to private ownership.

Prior literature on social capital and health has predominantly focused on health outcomes and individual access to healthcare services. It is not known to what degree, if any, community social capital influences the performance or behaviors of public hospitals, a key source of healthcare for disadvantaged communities in the United States. In this study we developed measures of community bridging social capital - horizontal social networks between heterogeneous groups of similar social position - and linking social capital - vertical networks across the status hierarchy - relevant to public hospitals. We examined associations between social capital, and U.S. urban public hospital closures and conversions to private ownership from 1987 to 2007. We found that higher voting participation was associated with a greater hazard of public hospital closure over time (p < 0.01), whereas the number of business, professional and political organizations per 10,000 residents was associated a greater hazard of conversion (p < 0.05). Additional measures of bridging and linking social capital were not associated with either outcome. Taken together, our findings suggest that, at least historically, horizontal forms of social capital among more privileged groups (e.g., business, professional, and political associations) bear influence on public hospital outcomes. Specific efforts to increase engagement of disadvantaged groups and connect them with decision-makers may be needed to fully realize the potential of linking social capital to influence local healthcare policy promoting social protection.

Tailored nutrition education and food assistance improve adherence to HIV antiretroviral therapy: evidence from Honduras.

Food insecurity and malnutrition negatively affect adherence to antiretroviral therapy (ART) and are associated with poor HIV clinical outcomes. We examined the effect of providing household food assistance and nutrition education on ART adherence. A 12-month prospective clinical trial compared the effect of a monthly household food basket (FB) plus nutrition education (NE) versus NE alone on ART adherence on 400 HIV patients at four clinics in Honduras. Participants had been receiving ART for an average of 3.7 years and were selected because they had suboptimal adherence. Primary outcome measures were missed clinic appointments, delayed prescription refills, and self-reported missed doses of ART. These three adherence measures improved for both groups over 12 months (p < 0.01), mostly within 6 months. On-time prescription refills improved for the FB plus NE group by 19.6 % more than the group receiving NE alone after 6 months (p < 0.01), with no further change at 12 months. Change in missed appointments and self-reported missed ART doses did not significantly differ by intervention group.

Involving community stakeholders to increase park use and physical activity.

OBJECTIVE: The aim of this study is to describe implementation of a randomized controlled trial of community-based participatory research (CBPR) approaches to increase park use and physical activity across 33 diverse neighborhoods in Los Angeles. METHODS: Fifty parks were randomly assigned based on park size, facilities and programs, and neighborhood socio-demographic characteristics to: park director (PD, 17 parks); PD and park advisory board of interested community members (PD+PAB, 16 parks); and no-intervention control (17 parks) arms. Between 2007 and 2012, PDs and PABs from the 33 intervention parks participated in community engagement, baseline assessment, marketing training, intervention design and implementation, and follow-up assessment. RESULTS: Intervention parks (PD and PD+PAB) invested in new and diversified signage, promotional items, outreach or support for group activities like fitness classes and walking clubs, and various marketing strategies. Scaling up CBPR methods across parks in 33 diverse neighborhoods was challenging. Working with departmental management and established structures for community input (PABs) and park policy (PDs) facilitated implementation and sustainability. CONCLUSION: Scaling up CBPR methods across diverse communities involved tradeoffs. CBPR is useful for tailoring research and enhancing community impact and sustainability, but more work is needed to understand how to conduct multi-site trials across diverse settings using CBPR.

The potential for pocket parks to increase physical activity.

PURPOSE: To assess the use of new pocket parks in low-income neighborhoods. DESIGN: The design of the study was a quasi-experimental post-test only comparison. SETTING: Los Angeles, California, was the setting for the study. SUBJECTS: Subjects were park users and residents living within .5 mile of three pocket parks and 15 neighborhood parks. INTERVENTION: The creation of pocket parks. MEASURES: We used the System of Observing Play and Recreation in Communities (SOPARC) tool to measure park use and park-based physical activity, and then surveyed park users and residents about their park use. ANALYSIS: We surveyed 392 and 432 household members within .5 mile of the three pocket parks before and after park construction, respectively, as well as 71 pocket park users, and compared them to 992 neighborhood park users and 342 residents living within .5 mile of other neighborhood parks. We compared pocket park use to playground area use in the larger neighborhood parks. We used descriptive statistics and generalized estimating equations for the analysis. RESULTS: Overall, pocket park use compared favorably in promoting moderate-to-vigorous physical activity with that of existing playground space in nearby parks, and they were cost-effective at $0.73/MET hour (metabolic equivalent hour) gained. Pocket park visitors walked an average of .25 miles to get to a park. CONCLUSIONS: Pocket parks, when perceived as attractive and safe destinations, may increase physical activity by encouraging families with children to walk there. Additional strategies and programs may be needed to encourage more residents to use these parks.