HIV-positive, Asian Pacific Islander (API) men who have sex with men (MSM) experience triple minority stigma including HIV, sexual orientation, and minority ethnicity. To date, there is no research that examines the influence of cultural factors, level of acculturation, social determinants of health, and other confounding variables (e.g., age, education, level of income, and length of time since diagnosis) on HIV-positive disclosure behaviors, attitudes, and intentions to casual sexual partners for API MSM. The theoretical framework for this study was based on Hofstede's original cultural values and Triandis's cultural dimensions. In this 2-phase, mixed methods, sequential explanatory study, 24 API MSM participants who are members of Fridae and other API organizations in the United States completed an anonymous online survey and 8 participants in Southern California completed in-depth semistructured phenomenological qualitative interviews. None of the regressions produced significant findings at the requested significance level (i.e., p < 0.5). The findings from the 2 phases of the study were integrated to facilitate a deeper, richer, and better understanding and explanation of those results than either approach alone. This mixed methods study was unique because it addressed an under-researched and poorly understood population of API MSM. The findings from this study have implications for positive social change for practitioners to incorporate culturally sensitive counseling strategies and for policymakers to develop or modify existing HIV preventive health education and health promotion programs for HIV-positive API MSM to negotiate safer sex behaviors, improve well-being, provide informed choice, and protect life that would promote competent quality care.

Public concern about teenage pregnancy and the threat of sexually transmitted diseases like AIDS make sex education information vital for today's teenagers. A 1986 Harris survey of 1,000 teenagers cited parents as their primary source of sex education information, but 42% said they would be too nervous or afraid to bring up the subject of contraception or birth control with their parents. States like Kentucky have mandated sex education courses for all public schools to provide necessary instruction for teenagers. This study identifies communication barriers which teenagers say prevent communication with their parents about sex and sex-related topics. Questionnaires were administered to 249 high school sex education students. The majority of teenagers (71%) said they could communicate freely with their parents about most topics, but only half (52%) said they could communicate freely with their parents about sex or sex-related topics. Thirty percent of the teenagers said they could not talk comfortably with their mothers about sex as compared to 47% who said they could not talk with their fathers. Results showed gender differences in the ability to talk with fathers about sex. Fifty-eight percent of the females reported closed communication with fathers about sex topics as compared to 33 percent of males. Teenagers cited 13 main reasons why they could not talk with their parents about sex or sex-related topics: embarrassment (20%), poor communication in general (11%), different values about sex and dating (11%), avoidance of conflict (10%), teenager chooses not to discuss it with parents (10%), it's a topic simply not discussed (9%), parents might accuse them of being sexually active (7%), parents think they are too young (5%), they are too busy to talk about it (5%), parents don't want to discuss it (4%), parents are overprotective (4%), teenager is not close to parents (3%), and parents wouldn't understand (2%). Items which teenagers say would make it more comfortable to discuss sex topics with parents include: parents being more understanding, non-accusing, not embarrassed, willing to listen, closer in age, less old fashioned, more informed about today's teens, open minded and less judgmental.

In July 1980, the Barren River District Health Department (BRDHD), serving eight counties (combined population approximately 204,000) in Southcentral Kentucky, was selected as a demonstration site under the auspices of the federal Health Education Risk Reduction (HERR) Program. With continued HERR funding for eight years, the BRDHD developed several successful health promotion projects. Major components of these projects include: 1) community health promotion, which serves to identify high -risk groups in the community and provide them with health education-health promotion services, 2) school health education which included the development of a preschool health education curriculum, 3) teacher education workshop, which instructs primary and secondary public school teachers in health education methods, 4) smoking cessation. and 5) a large industrial wellness program. This study reports on an eight year program evaluation of the HERR demonstration. Overall, the program evaluation suggests an increase in health knowledge and some attitude and behavior change for many of the participants ii BRDHD programs.

Sex and morals have often been factors in custody disputes. Courts have felt that giving custody of children to homosexual parents would create an environment not in the best interest of the child. Many mental health professionals argue that these decisions have been based on prejudice and homophobia. The purpose of this study was to evaluate research on the sexual orientation of children raised by homosexual parents and review data on the mental/psychosexual health of these children. These studies revealed no difference between children raised by gay/lesbian parents versus those raised by heterosexual parents on IQ scores, gender identity, or peer group relations. Daughters raised by lesbian mothers tended to choose more masculine toys and engage in more masculine activities than daughters raised by single heterosexual mothers. Nearly all of the adolescent children of homosexual parents experienced periods of questioning their sexual orientation. They also expressed the possibility of changing their sexual orientation later in life. Problems in research methodology (i.e., pre-experimental designs and lack of external validity) however, severely limit the validity and generalizability of these conclusions. Given the absence of externally valid, rigorous research on the relationship between homosexual parents and the sexual orientation of their children, these authors conclude that this question remains unanswered. These authors argue that custodial decisions regarding children of homosexual parents be based on sound information in the best interest of both children and parents and not rooted in homophobia.

Parent-child sexual health communication (PCSHC) can have a positive impact on adolescents’ sexual health choices, outcomes, and capabilities for communicating with others about sexual health. Many parents are hesitant and feel unprepared for and uncomfortable with communicating about sexual health with their children. Other parental factors as well as child factors can impact the quality, frequency, coverage, and effectiveness of PCSHC. Some adolescent sexual health outcomes have improved, however, teen birth rates in the United States are elevated compared to other developed countries and half of all sexually transmitted infection (STI) diagnoses are made to adolescents and emerging adults. This emphasizes the importance of PCSHC as a protective factor for children and opportunity for them to develop understanding and skills for good sexual health decision-making. While challenging to recruit and retain participants, parent sex education programming designed to promote PCSHC can instill a sense of parental necessity and responsibility, and equip parents with knowledge and skills to confidently and successfully engage their children. The theory of planned behavior (TPB) provided the framework for this mixed methods study designed to learn more about PCSHC, differences in PCSHC based on gender of children, parental beliefs about PCSHC, intentions for and actual engagement in PCSHC. Included in the literature review for this study is a systematic review of literature focused on parent education programming designed to improve PCSHC. Parents of children in grades 4 – 11 completed a pencil/paper or an electronic Qualtrics baseline survey containing questions about their perceptions of and engagement in PCSHC. The quantitative data collection instrument included items measuring TPB constructs of behavioral, normative, and control beliefs, intentions for and actual engagement in PCSHC and condom use instruction delivery, communication openness, communication ability, sexual health topics discussed with children, and respondents’ demographics Many of the respondents (N = 205) were residents of the program target community, Winchester/Clark County, Kentucky, and were eligible to participate in parent programming, as were all residents that were parents of children in grades 4 – 11. The program, I’ll Have a Side of Sex Education, was designed as a six-week series of 50 minute lunch time sessions with the intention to improve parents’ sense of comfort, confidence, and skills in communicating with their children in general, and particularly about sexual health. Of the 205 parents who completed the baseline survey, 50 enrolled in and attended some or all of one of five offerings of the six-week parent education series and were invited to complete a post-program and six-week follow up surveys. Post-program data were collected with a paper- pencil survey and six-week follow up data were collected with a Qualtrics survey. The systematic review of parent sex education literature provided insight into components of programming related to successful program delivery and positive parental outcomes. The systematic analysis of the baseline data including examining PCSHC factors from the parental perspective and how these related to the gender of children and determining the usefulness of the TPB constructs for understanding PCSHC Results of Chi-square tests of mean differences showed a significant difference in parents actually providing their children with instructions for correct condom usage, χ2(2, N = 203) = 6.96, p = 0.03, and MANOVA results revealed the degree to which parents address certain sexual health topics with their children related to the gender of their children. Results of logistic regression showed behavioral beliefs having the greatest predictive power of parents’ intentions to give condom use instructions (p < 0.01) and actual delivery of condom use instructions (p = 0.04) and engagement in PCSHC, generally (p = 0.03). The current study contributes to the greater body of literature addressing parental and child factors related the promotion, delivery, and effectiveness of PCSHC and parent education programming designed to improve the quality, frequency, and impact of PCSHC. Its findings expand our understanding of how gender of children and parental beliefs relate to PCSHC and lend themselves to the consideration of the greater social influences impacting parents’ ability and motivation to engage their children in communication about sexual health. Differences in communication based on gender of children signal to a double standard in the messaging about sexual health and behaviors related to gender and these discrepancies leave adolescents and emerging adults, both males and females, vulnerable at worst to poor sexual health choices and outcomes and at least to being undereducated about sexual health topics. Although these findings give little support for the overall TPB model contributing to the understanding of parental intentions and behavior related PCSHC, the relationship between behavioral beliefs informed by attitudes about the value of PCSHC and parental intentions and behaviors does provide insight to health promoters and educators. Assessing parental attitudes toward PCSHC and tailoring messages and educational opportunities that may improve these attitudes and motivate parents to engage in and seek support for effective PCSHC holds promise. The piloting of a parent education program adapted from a previously evaluated parent sex education programming and the summative evaluation offered by participants gives support for efforts on the part of health promotion and education professionals to invest time, energy, and resources into program design and delivery and recruitment and retention of parents.

Individuals with type 2 diabetes mellitus (T2DM) are at risk for developing life-threatening comorbidities such as cardiovascular disease (CVD). As a consequence, T2DM is associated with increased morbidity and mortality and decreased quality of life, thus highlighting the importance of prevention of T2DM. Further, the prevalence of T2DM is substantially greater in rural populations compared to urban populations, making rural individuals particularly appropriate targets for T2DM prevention. T2DM is a largely preventable disease that is associated with modifiable risk factors such as poor diet, sedentary lifestyle, and obesity. Lifestyle interventions to improve these modifiable risk factors have been used to decrease the risk of developing T2DM. There is little evidence that supports lifestyle interventions as a means to decrease T2DM risk in rural populations with prediabetes, the precursor of T2DM. The purpose of this dissertation was to determine whether rural-living individuals with prediabetes would improve modifiable risk factors, specifically diet quality by following a lifestyle intervention; thereby, decreasing their risk of developing T2DM. Specific aims for this dissertation were to, 1) examine and synthesize data from dietary interventions used to reduce risk of T2DM in rural populations on order to identify gaps and guide future research, 2) critically evaluate validity and reliability of indices used to determine diet quality in research, and 3) determine the effect of a risk reduction program on improving diet quality and glucose control (as a measure of T2DM risk) in rural adults with prediabetes and CVD risk factors. Specific aim one was achieved by a review and synthesis of literature focused on lifestyle and dietary interventions used in rural populations to decrease the risk of developing T2DM. Common goals in these studies were a decrease in weight, decrease in dietary fat and calories, and an increase in physical activity. Decreased weight and increased physical activity were demonstrated in all eight studies, and a decrease in T2DM incidence was also demonstrated in one of the studies. However, diet quality was not adequately assessed in the majority of the studies. Furthermore, none of the studies were randomized controlled trials and only half used a control group. It was concluded that research using a more robust design is needed to determine the effect of lifestyle changes, specifically diet, on T2DM risk in rural populations. Specific aim two was addressed by a critical analysis of six common indices of dietary quality. Validity and reliability of the Healthy Eating Index, the Alternative Healthy Eating Index, the DASH diet score, the Diet Quality Index-Revised, the Healthy Diet Indicator, and the Diet Quality Score were examined. Five of the six indices are valid and reliable tools for measure diet quality but all five rely on an extensive food frequency questionnaire that may be burdensome for participants. The Diet Quality Score does not provide adequate evidence to support its use in research. It was concluded that a short, reliable, and validated diet screener may be useful in research. Specific aim three was addressed by a secondary data analysis of a longitudinal, randomized controlled study of rural residents with CVD risk factors and prediabetes. Diet quality, measured by the Mediterranean Diet Adherence Screener (MEDAS), and glucose control, measured by hemoglobin A1c, were analyzed in a subpopulation of 62 participants with prediabetes. Neither diet quality nor glucose control improved between baseline, four month, and 12 month post intervention. The reliability and validity of the MEDAS in this population is not known and may have been a factor in the lack of intervention effect related to diet quality. Participants were also not informed of their prediabetes status, thus it is not known if this knowledge would have made an impact on the outcomes of the study. In addition, the small sample size limits the statistical power to determine changes between the intervention and control groups. It was concluded that further research is needed to determine if a high quality diet will reduce T2DM risk in this rural population Considering the disproportionate prevalence of T2DM in rural populations compared to their urban counterparts, the results of this dissertation demonstrate a continued need for interventions that decrease modifiable risk factors associated with this disease. Interventions that target obesity, poor diet quality, and sedentary lifestyles in at-risk rural populations that are culturally tailored are needed to decrease risk of developing T2DM and the comorbidities associated with this preventable disease.

Many college students across the nation are going hungry and struggling with food insecurity, as their access to food is becoming more challenging to attain. The purpose of this study is to explore the experiences of college students and components that lead them to becoming food insecure. Studies indicate that food insecurity is a critical issue in a college students’ life, but there is not an established approach to adequately help the students address this issue. The data will be collected through self-administered surveys and participant ratings will be reviewed for any common themes and correlations. Results from this study will provide significant material to assist social workers in addressing food insecurity with a systematic approach and influence further research. This study will also present findings to universities to secure supplementary resources and services to prevent food insecurity on campus.

Background: Sexual consent is often defined as the voluntary agreement to participate in a sexual act, though the differing definitions across and within countries make legal consensus difficult. In recent years, due to popularization through social media, nonconsensual condom removal, termed stealthing, is becoming common, especially among young adults. Yet, little to no empirical evidence exists on this sexual behavior. Methods: In this exploratory sequential mixed methods approach, we aimed to address the current perception of stealthing among young adults. College students were recruited from general education courses at a medium-sized four- year public university. Focus groups were conducted to understand the current perception of stealthing, including knowledge, perceived influence, and outcome, followed by quantitative assessment of knowledge, attitude, and self-efficacy of sexual consent. Results: Results demonstrated central theme of health-decision making with associated themes of consent, which further included subthemes of privacy, trust, and violation, followed by consideration of stealthing as sexual assault and social norm and acceptance of stealthing. Quantitative assessment showed that knowledge and awareness of stealthing remains low, though sex differences exist on the perception of stealthing being considered sexual assault; with higher rates among males as compared to females. Conclusion: The act of stealthing has been popularized in social media. Our results demonstrate that there is a need for health educators to assess the prevalence of such a behavior among young adults and policy makers to assess the legal implications of nonconsensual condom removal.

African American women have the highest rates of HIV infection among women of all racial/ethnic groups in the United States, and over 50% of HIV infected young adults are unaware of their infection. HIV testing is a cost-effective mechanism for reducing HIV transmission. Despite this, limited research has been devoted to developing interventions specifically promoting HIV testing. This two-part study proposed to address this gap through developing a culturally tailored HIV testing message aimed at increasing HIV test intentions among young African American women. Study 1 was a quantitative study that examined predictors of HIV testing history and future HIV test intentions among 109 African American women aged 18-24. Measures on sexual behavior, HIV knowledge, HIV conspiracy beliefs, gender role beliefs, gender ratio imbalance beliefs were included in the survey. Next, a culturally tailored HIV testing message was developed based on findings from Study 1 which identified significant predictors of HIV testing and HIV test intentions. Findings revealed that number of sexual partners, perceived barriers, and perceived benefits were significant predictors of past HIV testing. Number of sexual partners, perceived importance of HIV testing, and perceived seriousness were significant predictors of HIV test intentions in the next 3 months. Study 2 compared the exposure effect of the tailored health message to a generic HIV testing message on self-reported future HIV test intentions. Findings revealed no significant differences between the health message groups on future HIV test intentions. There were also no significant differences between groups on the message acceptability outcomes.

Hospital readmissions are a major burden for patients with end stage renal disease (ESRD). On average, one in three hospital discharges among patients with ESRD are followed by a readmission within 30 days. Currently, dialysis facilities are held accountable for readmissions via the ESRD Quality Incentive Program standardized readmission ratio (SRR) clinical measure. However, little is known about facility-level factors associated with readmission. Additionally, unlike other standardized measures of quality in the dialysis setting, incident patients within their first 90-days of dialysis are included in the performance calculation. This study analyzed CMS Dialysis Facility Report data from 2013 to 2016 to examine dialysis facility and incident patient factors associated with SRR using multivariate mixed models. Among 5,419 dialysis facilities treating 104,768 incident patients, the mean SRR remained stable across all four study years at 0.99. Factors significantly associated with a lower SRR (p<0.0001) included Western geographic region and higher patient care technician ratios. Several incident patient pre-dialysis nephrology care characteristics were associated with lower SRRs including higher percentages of patients with a fistula present at first dialysis treatment, higher percentages of patients receiving 6-12 months or greater than 12 months of nephrology care prior to dialysis and higher facility average hemoglobin. Factors significantly associated with a higher SRR (p<0.0001) included Northeastern geographic region, higher registered nurse ratios, higher percentage of incident patients, and higher facility average GFR. Understanding facility-level and patient-level factors associated with higher SRRs may inform interventions to reduce 30-day hospital readmission among patients receiving dialysis.