A Moderated Mediation Analysis of HIV and Intersectional Stigmas and Antiretroviral Adherence in People Living with HIV in the Dominican Republic.

Experiencing HIV and intersectional stigmas in healthcare settings may affect antiretroviral treatment (ART) adherence among people with HIV (PWH), given their need for frequent interactions with clinical settings and healthcare providers. Considering the importance of reducing stigmas to promote well-being and the need to elucidate how stigma influences health across various settings, we examined how experienced HIV stigma in Dominican Republic healthcare settings impacts ART adherence through internalized HIV stigma and whether race or sexual orientation stigma moderates this relationship. Participants were 471 PWH (aged 17-71) who were recruited from two HIV clinics in the Dominican Republic in 2021-2022. Results revealed a significant mediation effect (B=-0.10, SE = 0.05, CI [-0.234, - 0.014]) after adjusting for effect of age and time since HIV diagnosis, suggesting that experienced HIV stigma in healthcare settings was associated with more internalized HIV stigma (B = 0.39, SE = 0.11, p = .001), subsequently linked to lower ART adherence (B=-0.26, SE = 0.11, p = .016). The indirect effect was significant at low levels of race stigma (B=-0.16, SE = 0.09, CI [-0.369, - 0.001]) but not at high levels of race stigma (B=-0.06, SE = 0.05, CI [-0.175, 0.038]). This indirect effect was also significant at low levels of sexual orientation stigma (B=-0.19, SE = 0.10, CI [-0.401, - 0.023]) but not at high levels of sexual orientation stigma (B=-0.04, SE = 0.06, CI [-0.160, 0.074]). These findings suggest that addressing experienced HIV stigma in Dominican Republic healthcare settings, along with various dimensions of HIV-related stigma (e.g., internalized stigma) and intersecting stigmas (e.g., race, sexual orientation), is vital for improving health outcomes, such as optimal ART adherence.

RESUMEN: Experimentar estigmas relacionados con el VIH e interseccionales en entornos de atención médica puede afectar la adherencia al tratamiento antirretroviral (TAR) entre las personas que viven con VIH (PVVIH), dado que necesitan interacciones frecuentes con entornos clínicos y proveedores de atención médica. Considerando la importancia de reducir los estigmas para promover el bienestar y la necesidad de esclarecer cómo el estigma influye en la salud en diversos contextos, examinamos cómo el estigma del VIH experimentado en entornos de atención médica en la República Dominicana impacta la adherencia al TAR a través del estigma internalizado del VIH y si el estigma racial o de orientación sexual modera esta relación. Los participantes fueron 471 PVVIH (de 17 a 71 años) que fueron reclutados de dos clínicas de VIH en la República Dominicana en 2021­2022. Los resultados revelaron un efecto de mediación significativo (B=-0.10, SE = 0.05, CI [-0.234, − 0.014]) después de ajustar por el efecto de la edad y el tiempo desde el diagnóstico de VIH, sugiriendo que el estigma del VIH experimentado en entornos de atención médica estaba asociado con un mayor estigma internalizado del VIH (B = 0.39, SE = 0.11, p = .001), vinculado posteriormente a una menor adherencia al TAR (B=-0.26, SE = 0.11, p = .016). El efecto indirecto fue significativo en niveles bajos de estigma racial (B=-0.16, SE = 0.09, CI [-0.369, − 0.001]) pero no en niveles altos de estigma racial (B=-0.06, SE = 0.05, CI [-0.175, 0.038]). Este efecto indirecto también fue significativo en niveles bajos de estigma por orientación sexual (B=-0.19, SE = 0.10, CI [-0.401, − 0.023]) pero no en niveles altos de estigma por orientación sexual (B=-0.04, SE = 0.06, CI [-0.160, 0.074]). Estos hallazgos sugieren que abordar el estigma del VIH experimentado en entornos de atención médica en la República Dominicana, junto con diversas dimensiones del estigma relacionado con el VIH (por ejemplo, estigma internalizado) y estigmas interseccionales (por ejemplo, raza, orientación sexual), es vital para mejorar los resultados de salud, como la adherencia óptima al TAR.

Living a private lie: intersectional stigma, depression and suicidal thoughts for selected young key populations living with HIV in Zambia.

BACKGROUND: Limited research has been conducted on the forms, manifestations and effects of intersectional stigma among young HIV-positive men who have sex with men (MSM) and transgender women (TGW) in Zambia. In this study, we aimed to address this gap by elucidating the experiences of these in a small group of young, HIV + MSM and TGW in Zambia. METHODS: We applied a mixed-methods design. Data were collected from January 2022 to May 2022. Qualitative data were collected using in-depth interviews while quantitative data were collected using a questionnaire. Qualitative transcripts were coded using thematic analysis while paper-based questionnaire data were entered into Kobo Connect. Descriptive statistics, using chi-squared tests were calculated using Excel. In this paper, we provide a descriptive profile of the sample and then focus on the qualitative findings on intersectional stigma, depression, and contemplation of suicide. RESULTS: We recruited 56 participants from three sites: Lusaka, Chipata, and Solwezi districts. Participants' mean age was 23 years. The study found that 36% of all participants had moderate to significant symptoms of depression, 7% had major depression, 30% had moderate signs of anxiety, 11% had high signs of anxiety, 4% had very high signs of anxiety and 36% had contemplated suicide at least once. A greater proportion of TGW had moderate to significant symptoms of depression (40%) or major depression (10%) compared to MSM, at 33% and 6%, respectively (X2 = 0.65; p = 0.42). Similarly, more TGW (55%) had contemplated suicide than MSM peers (36%, X2=1.87; p = 0.17). In the qualitative data, four emergent themes about the forms, manifestations, and effects of intersectional stigma were (1) HIV, sexual orientation, and gender identity disclosure; (2) Dual identity; (3) Challenges of finding and maintaining sexual partners; (4) Coping and resilience. Overall, having to hide both one's sexuality and HIV status had a compounding effect and was described as living "a private lie." CONCLUSION: Effectively addressing stigmas and poor mental health outcomes among young HIV-positive MSM and TGW will require adopting a socio-ecological approach that focuses on structural interventions, more trauma-informed and identity-supportive care for young people with HIV, as well as strengthening of authentic community-informed public health efforts.

Structural barriers to maternity care in Cameroon: a qualitative study.

BACKGROUND: The maternal mortality and perinatal mortality rate in Cameroon are among the highest worldwide. To improve these outcomes, we conducted a formative qualitative assessment to inform the adaptation of a mobile provider-to-provider intervention in Cameroon. We explored the complex interplay of structural barriers on maternity care in this low-resourced nation. The study aimed to identify structural barriers to maternal care during the early adaptation of the mobile Medical Information Service via Telephone (mMIST) program in Cameroon. METHODS: We conducted in-depth interviews and focus groups with 56 key stakeholders including previously and currently pregnant women, primary healthcare providers, administrators, and representatives of the Ministry of Health, recruited by purposive sampling. Thematic coding and analysis via modified grounded theory approach were conducted using NVivo12 software. RESULTS: Three main structural barriers emerged: (1) civil unrest (conflict between Ambazonian militant groups and the Cameroonian government in the Northwest), (2) limitations of the healthcare system, (3) inadequate physical infrastructure. Civil unrest impacted personal security, transportation safety, and disrupted medical transport system. Limitations of healthcare system involved critical shortages of skilled personnel and medical equipment, low commitment to evidence-based care, poor reputation, ineffective health system communication, incentives affecting care, and inadequate data collection. Inadequate physical infrastructure included frequent power outages and geographic distribution of healthcare facilities leading to logistical challenges. CONCLUSION: Dynamic inter-relations among structural level factors create barriers to maternity care in Cameroon. Implementation of policies and intervention programs addressing structural barriers are necessary to facilitate timely access and utilization of high-quality maternity care.

Development and Validation of the Youth Pre-Exposure Prophylaxis (PrEP) Stigma Scale.

To date, there are no established scales to assess PrEP stigma among youth. We validated the Youth PrEP Stigma Scale within the Adolescent Trials Network P3 study (2019-2021). Data from sexual and gender minority youth (16-24 years) who were prescribed PrEP across nine domestic sites were evaluated (N = 235). Descriptive statistics, exploratory factor analysis, and correlation coefficients are reported. Results yielded a three-factor solution (PrEP Disapproval by Others, Enacted PrEP Stigma, and PrEP User Stereotypes) with strong factor loadings and Cronbach's alphas ranging from 0.83 to 0.90, suggesting excellent internal consistency. Correlations between this Scale, anticipated HIV stigma, perceived HIV risk, and disclosure of sexual identity were significant, indicating potential for robust application. Given the persistence of HIV infections among youth, stigma as a barrier to prevention, and expansion of PrEP modalities, the Youth PrEP Stigma Scale could enhance intervention and mechanistic research among youth at elevated risk for HIV acquisition.

RESUMEN: Hasta la fecha, no existen escalas establecidas para evaluar el estigma de la PrEP entre los jóvenes. Validamos la Escala de estigma de la PrEP para jóvenes dentro del estudio P3 de la Red de ensayos para adolescentes (2019­2021). Se evaluaron los datos de jóvenes de minorías sexuales y de género (16­24 años) a quienes se les recetó PrEP en nueve sitios domésticos (N = 235). Se informan estadísticas descriptivas, análisis factorial exploratorio y coeficientes de correlación. Los resultados arrojaron una solución de tres factores (desaprobación de PrEP por parte de otros, estigma de PrEP promulgado y estereotipos de usuarios de PrEP) con fuertes cargas factoriales y alfas de Cronbach que oscilan entre 0.83 y 0.90, lo que sugiere una excelente consistencia interna. Las correlaciones entre esta Escala, el estigma anticipado del VIH, el riesgo percibido del VIH y la divulgación de la identidad sexual fueron significativas, lo que indica un potencial para una aplicación sólida. Dada la persistencia de las infecciones por el VIH entre los jóvenes, el estigma como una barrera para la prevención y la expansión de las modalidades de PrEP, la Escala de estigma de la PrEP para jóvenes podría mejorar la intervención y la investigación mecánica entre los jóvenes con un riesgo elevado de contraer el VIH.

Patient and Provider Perspectives on HIV Stigma in Healthcare Settings in Underserved Areas of the US South: A Mixed Methods Study.

Stigma experienced in healthcare settings is a barrier to ending the HIV epidemic. Using a convergent parallel mixed methods approach, we collected qualitative data from 14 focus groups with People with HIV (PWH) and Healthcare workers (HCW) and quantitative survey data (N = 762 PWH and N = 192 HCW) from seven HIV healthcare clinics outside of major urban areas in the southeastern US. Four key themes emerged: (1) HIV-related stigma and discrimination in healthcare settings; (2) experiences of intersectional stigma; (3) disclosure concerns in healthcare settings; and (4) impact of stigma on HIV-related health behavior. Implications for future stigma interventions in healthcare settings include the importance of engaging PWH in the development of interventions, the need for interventions in settings that do not specialize in HIV care, and the importance of engaging all staff when addressing HIV-related stigma.

RESUMEN: El estigma experimentado en los entornos de atención médica es una barrera para poner fin a la epidemia del VIH. Utilizando un enfoque convergente de métodos mixtosparalelos, recopilamos datos cualitativos de 14 grupos focales con personas con VIH y trabajadores de la salud y datos de encuestas cuantitativas (N = 762 personas con VIH y N = 192 trabajadores de la salud) de siete clínicas de atención médica de VIH fuera de las principales áreas urbanas en el sureste de los Estados Unidos. Surgieron cuatro temas clave: (1) el estigma y la discriminación relacionados con el VIH en los entornos de atención médica; (2) experiencias de estigma interseccional; (3) preocupaciones de divulgación en entornos de atención médica; y (4) el impacto del estigma en el comportamiento de salud relacionado con el VIH. Las implicaciones para futuras intervenciones de estigma en entornos de atención médica incluyen la importancia de involucrar a las personas con VIH en el desarrollo de intervenciones, la necesidad de intervenciones en entornos que no se especializan en la atención del VIH y la importancia de involucrar a todo el personal al abordar el estigma relacionado con el VIH.

Patient Health Literacy and Communication with Providers Among Women Living with HIV: A Mixed Methods Study.

In this mixed-methods study, we examine the relationship between provider communication and patient health literacy on HIV continuum of care outcomes among women living with HIV in the United States. We thematically coded qualitative data from focus groups and interviews (N = 92) and conducted mediation analyses with quantitative survey data (N = 1455) collected from Women's Interagency HIV Study participants. Four qualitative themes related to provider communication emerged: importance of respect and non-verbal cues; providers' expressions of condescension and judgement; patient health literacy; and unclear, insufficient provider communication resulting in diminished trust. Quantitative mediation analyses suggest that higher health literacy is associated with higher perceived patient-provider interaction quality, which in turn is associated with higher levels of trust in HIV providers, improved antiretroviral medication adherence, and reduced missed clinical visits. Findings indicate that enhancing provider communication and bolstering patient health literacy could have a positive impact on the HIV continuum of care.

RESUMEN: En este estudio de métodos mixtos, examinamos la relación entre la comunicación del proveedor y la alfabetización sanitaria del paciente sobre los resultados de la atención continua del VIH entre las mujeres que viven con el VIH en los Estados Unidos. Codificamos temáticamente datos cualitativos de grupos focales y entrevistas (N = 92) y realizamos análisis de mediación con datos de encuestas cuantitativas (N = 1455) recopilados de participantes del Estudio de VIH entre agencias de mujeres. Surgieron cuatro temas cualitativos relacionados con la comunicación con el proveedor: la importancia del respeto y las señales no verbales; las expresiones de condescendencia y juicio de los proveedores; alfabetización en salud del paciente; y una comunicación poco clara e insuficiente con el proveedor que da como resultado una disminución de la confianza. Los análisis de mediación cuantitativa sugieren que una mayor alfabetización en salud se asocia con una mayor calidad de interacción percibida entre el paciente y el proveedor, que a su vez se asocia con niveles más altos de confianza en los proveedores de VIH, una mejor adherencia a la medicación antirretroviral y una reducción de las visitas clínicas perdidas. Los resultados indican que mejorar la comunicación con los proveedores y reforzar la alfabetización sanitaria del paciente podría tener un impacto positivo en la atención continua del VIH.

Barriers and facilitators to implementing a motivational interviewing-based intervention: a multi-site study of organizations caring for youth living with HIV.

Understanding possible barriers and facilitators to effective implementation of evidence-based interventions to help high-risk youth prevent and manage HIV is crucial for their scale-up. This manuscript analyzes qualitative interview data collected during the early phase implementation of a motivational interviewing (MI) based intervention at 10 HIV care clinics in the United States providing services to youth. Using the Exploration-Preparation-Implementation-Sustainment (EPIS) framework to understand the implementation and the dynamic adaptation process (DAP) model to balance notions of intervention fidelity and flexibility, providers and stakeholders at each site (N = 97) were interviewed prior to implementation to gather their perspectives on organizational readiness for the intervention, as well as provider and client characteristics. The interviewers summarized their experience with rapid feedback forms (RFFs). Data extracted from the RFFs highlighted anticipated barriers to and facilitators of the proposed MI-based intervention, with the EPIS framework used to organize these findings. Study findings illustrate the inner and outer contextual factors that affect implementation and denote the points at which the MI-based intervention may be tailored to fit the unique context of a clinic while remaining faithful to the intervention's original design.

Healthy Choices Intervention is Associated with Reductions in Stigma Among Youth Living with HIV in the United States (ATN 129).

Considering the lack of validated stigma reduction interventions for youth living with HIV (YLWH), we evaluated effects of the Healthy Choices intervention on HIV-related stigma among YLWH. We analyzed data from the Adolescent Medicine Trials Network protocol 129, multi-site randomized controlled trial, applying latent growth curve modeling with two linear slopes estimating changes in Berger's Stigma Scale pre-intervention, 16, 28, and 52 weeks post-intervention, as well as the trajectory of stigma scores over the follow-up period (N = 183). Expected value for the growth intercept was statistically significant (Bintercept = 2.53; 95% CI 2.32, 2.73; p < 0.001), as were differences in the change from baseline to 16-week follow-up (Bintercept slope1 = - 0.02; 95% CI - 0.04, 0.01; p = 0.034). Expected value of the slope factor measuring growth over the follow-up period was non-significant suggesting that stigma scores were stable from 28 to 52 weeks. Our findings warrant replication and additional research comparing effects of this intervention to counterfactual controls.

RESUMEN: Teniendo en cuenta la falta de intervenciones validadas de reducción del estigma para los jóvenes que viven con el VIH (PVVS), evaluamos los efectos de la intervención Healthy Choices sobre el estigma entre los PVVS. Analizamos los datos del ensayo controlado aleatorio de múltiples sitios del protocolo 129 de Adolescent Medicine Trials Network, aplicando un modelo de curva de crecimiento latente con dos pendientes lineales que estiman los cambios de Berger's Stigma Scale antes de la intervención, ya a las 16, 28 y 52 semanas después de la intervención, así como la trayectoria de los niveles de estigma durante el período de seguimiento (N = 183). El valor esperado para el intercepto de crecimiento fue estadísticamente significativo (Bintercept = 2.53 IC del 95%: 2.32, 2.73 p < 0.001), así como las diferencias en el cambio desde el inicio hasta el seguimiento de 16 semanas (Bintercept slope 1 = -0.02 IC del 95% IC: -0.04, 0.01 p = 0.034). El valor esperado del factor que mide el crecimiento durante el período de seguimiento no fue significativo, sugiere que los niveles de estigma se mantuvieron estables de 28 a 52 semanas. Nuestros resultados justifican la replicación y la investigación adicional al comparar la intervención con comparativos.

HIV testing barriers and intervention strategies among men, transgender women, female sex workers and incarcerated persons in the Caribbean: a systematic review.

BACKGROUND: This systematic review summarises evidence on the HIV testing barriers and intervention strategies among Caribbean populations and provides pertinent implications for future research endeavours designed to increase rates of HIV testing in the region. METHODS: We used a systematic approach to survey all literature published between January 2008 and November 2018 using four electronic databases (MEDLINE/PubMed, Embase, Web of Science and Global Health). Only peer-reviewed articles published in English that examined HIV testing uptake and interventions in the Caribbean with men, men who have sex with men, female sex workers, transgender women and incarcerated individuals were included. RESULTS: Twenty-one studies met the inclusion criteria. Lack of confidentiality, access to testing sites, stigma, discrimination, poverty and low HIV risk perception were identified as key barriers to HIV testing. These barriers often contributed to late HIV testing and were associated with delayed treatment initiation and decreased survival rate. Intervention strategies to address these barriers included offering rapid HIV testing at clinics and HIV testing outreach by trained providers and peers. CONCLUSION: HIV testing rates remain unacceptably low across the Caribbean for several reasons, including stigma and discrimination. Future HIV testing interventions should target places where at-risk populations congregate, train laypersons to conduct rapid tests and consider using oral fluid HIV self-testing, which allows individuals to test at home.

Creating COVID-19 Stigma by Referencing the Novel Coronavirus as the "Chinese virus" on Twitter: Quantitative Analysis of Social Media Data.

BACKGROUND: Stigma is the deleterious, structural force that devalues members of groups that hold undesirable characteristics. Since stigma is created and reinforced by society-through in-person and online social interactions-referencing the novel coronavirus as the "Chinese virus" or "China virus" has the potential to create and perpetuate stigma. OBJECTIVE: The aim of this study was to assess if there was an increase in the prevalence and frequency of the phrases "Chinese virus" and "China virus" on Twitter after the March 16, 2020, US presidential reference of this term. METHODS: Using the Sysomos software (Sysomos, Inc), we extracted tweets from the United States using a list of keywords that were derivatives of "Chinese virus." We compared tweets at the national and state levels posted between March 9 and March 15 (preperiod) with those posted between March 19 and March 25 (postperiod). We used Stata 16 (StataCorp) for quantitative analysis, and Python (Python Software Foundation) to plot a state-level heat map. RESULTS: A total of 16,535 "Chinese virus" or "China virus" tweets were identified in the preperiod, and 177,327 tweets were identified in the postperiod, illustrating a nearly ten-fold increase at the national level. All 50 states witnessed an increase in the number of tweets exclusively mentioning "Chinese virus" or "China virus" instead of coronavirus disease (COVID-19) or coronavirus. On average, 0.38 tweets referencing "Chinese virus" or "China virus" were posted per 10,000 people at the state level in the preperiod, and 4.08 of these stigmatizing tweets were posted in the postperiod, also indicating a ten-fold increase. The 5 states with the highest number of postperiod "Chinese virus" tweets were Pennsylvania (n=5249), New York (n=11,754), Florida (n=13,070), Texas (n=14,861), and California (n=19,442). Adjusting for population size, the 5 states with the highest prevalence of postperiod "Chinese virus" tweets were Arizona (5.85), New York (6.04), Florida (6.09), Nevada (7.72), and Wyoming (8.76). The 5 states with the largest increase in pre- to postperiod "Chinese virus" tweets were Kansas (n=697/58, 1202%), South Dakota (n=185/15, 1233%), Mississippi (n=749/54, 1387%), New Hampshire (n=582/41, 1420%), and Idaho (n=670/46, 1457%). CONCLUSIONS: The rise in tweets referencing "Chinese virus" or "China virus," along with the content of these tweets, indicate that knowledge translation may be occurring online and COVID-19 stigma is likely being perpetuated on Twitter.

Human papillomavirus (HPV) and influenza vaccine behavior among Muslim women in the United States.

In this study, we examined vaccination behaviors-single dose human papillomavirus (HPV) vaccination, triple dose HPV vaccination, and influenza vaccination-among Muslim women residing in the United States. Using logistic regression models, we analyzed self-reported survey. We found that respondents had lower rates of HPV vaccination and higher rates of influenza vaccination, relative to the general American population. The respondents in our sample who reported contraceptive use had higher odds of vaccination. In this study the authors provide a springboard for the enhancement of patient-centered care through better understanding of health behaviors and cultural preferences of underrepresented communities in research.

Is Perceived Stigma in Clinical Settings Associated With Poor Health Status Among New York City's Residents of Color?

OBJECTIVES: Our objectives were to assess rates of perceived stigma in health care (clinical) settings reported by racially diverse New York City residents and to examine if this perceived stigma is associated with poorer physical and mental health outcomes. METHODS: We analyzed data from the 2016 New York City Community Health Survey. We applied bivariable and multivariable methods to assess rates of perceived stigma, and perceived stigma's statistical relationship with health care access, physical health status, and mental health status controlling for sociodemographics and health insurance status. RESULTS: Perceived stigma was associated with poorer health care access [odds ratio (OR)=7.07, confidence interval (CI)=5.32-9.41), depression (OR=3.80, CI=2.66-5.43), diabetes (OR=1.86, CI=1.36-2.54), and poor overall general health (OR=0.43, CI=0.33-0.57). Hispanic respondents reported the highest rate of perceived stigma among racial and ethnic minority groups (mean=0.07, CI=0.05-0.08). CONCLUSIONS: We found that perceived stigma in health care settings was a potential barrier to good health. Prior studies have illustrated that negative health outcomes are common for patients who avoid or delay care; thus, the unfortunate conclusion is that even in a diverse, heterogeneous community, stigma persists and may negatively affect well-being. Therefore, eliminating stigma in clinical settings should be a top priority for health care providers and public health professionals seeking to improve health equity.

Alcohol Use, High Risk Behaviors, and Experiences of Discrimination Among Transgender Women in the Dominican Republic.

Objectives: This study examines associations between alcohol use, high risk sexual behaviors, and experiences of stigma among transgender women across the Dominican Republic. Data from the 2015 Transgender Health Needs Study were analyzed using bivariate analyses (N = 291). Results: High rates of stigma, verbal abuse, alcohol use, and sex work are found and are associated with each other. Almost 45% of regular alcohol users are engaging in sex work (43.6%), compared with 31.1% of the non-regular alcohol users (χ2=4.82, p < .05). Having sex under the influence of alcohol is statistically associated with high risk behaviors, such as engaging in sex work, sometimes or never using a condom when receiving anal sex, and higher numbers of sexual partners. Furthermore, transgender women who have had sex under the influence of alcohol report statistically significantly higher levels of verbal abuse, discrimination, and levels of perceived transgender stigma. Conclusions/Importance: Findings suggest that although anti-discrimination laws exist, policies may not protect transgender women from experiencing stigma and discrimination at work, potentially forcing them to seek alternative careers and engage in behaviors that expose them to greater personal risk and harm. This intersection of factors may indicate a notable public health gap in transgender health in the Dominican Republic.

Sex work, social support, and stigma: Experiences of transgender women in the Dominican Republic.

Background: Transgender populations, and especially those in resource-limited settings, are at an elevated risk of experiencing stigma and discrimination. Aims: This study sought to examine the relationship between parental, familial, and other social support, experiences of stigma and discrimination, quality of life, and sex work in a national sample of transgender women in the Dominican Republic (n = 291). Methods: Descriptive analyses for the outcome variable, sex work, as well as for measures associated with socio-demographics, social support, stigma, quality of life, and experiences of abuse and violence were performed. Bivariate analysis examined differences between respondents involved in sex work and those not involved in sex work. Results: We found that participation in sex work was associated with low social support and quality of life and increased experiences of stigma, discrimination, and abuse. Specifically, Dominican transgender women involved in sex work received less social support than their non-sex working peers; they experienced heightened arguments and problems with non-parental family members, professors or bosses, classmates, and close friends, as well of loss of friendships. Involvement in sex work was also associated with higher levels of stigma and discrimination, lower quality of life, and experiences of sexual abuse, torture, and experiences of attempted murder on one's life. Discussion: Transgender women participating in sex work require more rather than less social support from family members and loved ones, especially in areas where workplace discrimination policies that affect transgender individuals are nebulous, such as the Dominican Republic.

Examining the Relationship Between Individual Characteristics, Community-Level Traits, Multidimensional Empowerment, and Maternal Health Care Utilization in the Islamic Republic of Pakistan.

Introduction The Islamic Republic of Pakistan's maternal mortality ratio is particularly high, and the nation ranks 126 out of 149 countries on the Human Development Report-Gender Inequality Index. This is because Pakistani women have low levels of empowerment, make limited economic contributions, and underutilization of maternal health care. The aim of this study is to create a multidimensional index of women's empowerment and assess the association between this index and maternal health care utilization in Pakistan, controlling for individual characteristics and community-level traits. Methods Data from the 2012-2013 Pakistan Demographic and Health Surveys were employed to investigate the relationship between this index and the latent construct of maternal health care utilization. Results Using exploratory factor analysis, four indicators of maternal health care utilization were loaded onto a single latent factor. Multivariate analyses found support for the association between empowerment and health care utilization, despite adjustments for individual and area level factors. Positive associations between education, wealth, and maternal health care utilization were found. Conclusions Although we find support for the association of educational attainment with maternal health care utilization, the multidimensional women's empowerment index was independently a consistent associate of maternal health care utilization. This illustrates a complex mechanism with both-education and empowerment, being necessary for improved maternal health care utilization. Policy makers seeking to improve outcomes should expand their focus beyond simply improving rates of education to examining effects of cultural norms which constrain the independence of women in making decisions about their own health care.

Muslim Women's use of contraception in the United States.

BACKGROUND: American Muslim women are an understudied population; thus, significant knowledge gaps exist related to their most basic health behaviors and indicators. Considering this, we examined American Muslim women's contraception utilization patterns. METHODS: Self-reported data collected in late 2015 were analyzed. Women who identified as Muslim, were at least 18 years old, sexually active, and current residents of the United States (n = 224) met the inclusion criteria. Convenience sampling was employed. Multivariate logistic regression models estimated associations between demographics, marital status, ethnicity, nativity, health insurance, religious practice, and contraception use. RESULTS: Identifying as Muslim, in general, was significantly associated with greater odds of using contraception in general and condoms compared to American Muslim women who identify as Sunni. Identifying as Shia was associated with greater odds of using oral contraceptive pills relative to Sunni respondents. South Asian ethnicity was associated with higher odds of using oral contraceptive pills compared to those of Middle Eastern or North African ethnicity. CONCLUSIONS: Findings suggest American Muslim women's contraception utilization patterns share certain similarities with both American women in general and disadvantaged racial and ethnic minority groups in the United States, implying that factors that influence American Muslim women's use of contraceptives are possibly countervailing and likely multifaceted. More research is needed to accurately identify associates of contraceptive use in this population. This work serves as a starting point for researchers and practitioners seeking to better understand reproductive health decision in this understudied population.

How Does Stigma Affect People Living with HIV? The Mediating Roles of Internalized and Anticipated HIV Stigma in the Effects of Perceived Community Stigma on Health and Psychosocial Outcomes.

Few researchers have attempted to examine the mechanisms through which HIV-related stigma in the community is processed and experienced at an individual level by people living with HIV. We examined how the effects of perceived HIV stigma in the community on health outcomes for people living with HIV are mediated by internalized stigma and anticipated stigma. Participants (N = 203) from an HIV clinic completed self-report measures and their clinical data were obtained from medical records. Results suggested that the association between perceived community stigma and affective, cognitive, and mental health outcomes (self-esteem, depressive symptoms, avoidance coping, self-blame) are mediated by internalized stigma. Furthermore, a serial mediation model suggested that perceived community stigma leads to internalized stigma, which leads to anticipated community stigma, which in turn leads to lower medication adherence. The associations between perceived community stigma and interpersonal outcomes (social support, trust in physicians) were mediated by internalized stigma and anticipated stigma, again in a serial fashion (perceived community stigma leads to internalized stigma, which leads to anticipated stigma, which in turn leads to interpersonal outcomes). These results suggest that perceived HIV-related stigma in the community may cause people living with HIV to internalize stigma and anticipate stigmatizing experiences, resulting in adverse health and psychosocial outcomes-information that can be used to shape interventions.

Associates of Neonatal, Infant and Child Mortality in the Islamic Republic of Pakistan: A Multilevel Analysis Using the 2012-2013 Demographic and Health Surveys.

Objectives Pakistan is one of five nations contributing to half of the world's child mortality and holds under-five mortality rates which are nearly double global targets. Reasons for this shortfall include civil conflicts, political uncertainty, low education, poverty, rural-urban disparities, and limited health care access. The aim of this study was to explore associations between individual characteristics, community factors, and child mortality in Pakistan. Methods Data were derived from the 2012 to 2013 Pakistan Demographic and Health Survey, and included 7399 live births and 380 child deaths. Multivariate, multilevel logistic regression was used to model risk of neonatal, infant and under-five child deaths. Results Seventy-one percent of child deaths occurred during the neonatal period. Significant factors (p < 0.05) associated with lower odds of child mortality included adhering to recommended minimum of 24 months interpregnancy interval and higher household wealth. These were significant for neonatal (OR 0.448; 0.871), infancy (OR 0.465; 0.881), and under-five deaths (OR 0.465; 0.879). Employed mothers had higher odds of neonatal (OR 1.479), infant (OR 1.506), and child mortality (OR 1.459). Likewise, women living in consanguineous marriages had higher odds of infant (OR 1.454) and under-five deaths (OR 1.381). Children in Balochistan, Punjab, and Sindh, regions disproportionately poor, rural with low levels of education, were at highest risk of dying. Conclusions for Practice Findings may assist in designing targeted interventions, developing appropriate public health messaging, and implementing policies designed to lower child mortality. Focusing on lowering rates of maternal poverty, increasing opportunities for education, and improving access to health care could assist in reducing child mortality in Pakistan.

Statistical Effects of Religious Participation and Marriage on Substance Use and Abuse in Racial and Ethnic Minorities.

Substance use and abuse, which includes alcohol use, alcohol dependence, drug use, and drug dependence, inflicts a substantial toll on Americans. Although studies have demonstrated the protective effect of social support, such as religious participation and via marriage, understanding their influence on racial and ethnic minorities is limited. Thus, the aim of this study is to assess the impact of social support on substance use and abuse in racial and ethnic minorities. The Collaborative Psychiatric Epidemiology Surveys, sponsored by the National Institute of Mental Health, a repository of race, ethnicity, and mental health data, was leveraged to develop four models using multivariate analysis, specifically logistic regression to estimate the probability of meeting the criteria for substance use and abuse. Racial and ethnic minorities were found to have lower rates of substance use and abuse compared to Whites, and foreign-born individuals were consistently less likely to use or abuse substances compared to American-born minorities. Mental health conditions were highly associated with substance use and abuse, and social support by way of religious participation and marriage was protective against substance use and abuse. In racial and ethnic minorities, nativity and social support were protective against substance use and abuse; however, these protective factors did not completely eliminate risk. Thus, although race and ethnicity are important to understanding health outcomes and health behaviors, such as substance use and abuse, it is the intersection of multiple factors, representing internal and external forces, which may be more informative and offer a more comprehensive picture of the landscape influencing drug and alcohol use and dependence. Targeted interventions should consider leveraging religious spaces and bilingual materials when attempting to reach racial and ethnic minorities.