Applying Community Engagement to Disaster Planning: Developing the Vision and Design for the Los Angeles County Community Disaster Resilience Initiative

Community resilience (CR) is a priority for preparedness, but few models exist. A steering council used community-partnered participatory research to support workgroups in developing CR action plans and hosted forums for input to design a pilot demonstration of implementing CR versus enhanced individual preparedness toolkits. Qualitative data describe how stakeholders viewed CR, how toolkits were developed, and demonstration design evolution.Stakeholders viewed community engagement as facilitating partnerships to implement CR programs when appropriately supported by policy and CR resources. Community engagement exercises clarified motivations and informed action plans (e.g., including vulnerable populations). Community input identified barriers (e.g., trust in government) and CR-building strategies. A CR toolkit and demonstration comparing its implementation with individual preparedness were codeveloped.Community-partnered participatory research was a useful framework to plan a CR initiative through knowledge exchange.

“We want information about how to identify resilience-building tasks and activities that communities can replicate. How can vulnerable communities fit into these activities to make sure they are also more resilient to disasters?”–Workgroup member

Disasters such as wildfires, tropical storms, hurricanes, earthquakes, and epidemics pose temporary and long-term threats to public health.1,2 Underresourced communities are at high risk for adverse outcomes owing to preexisting disparities in health, access to services, and environmental risks.3–5 Large-scale events disrupt physical, social, and communication infrastructures posing challenges to response, and creating “surge burdens” that overwhelm care resources and strain social supports.6 Events such as Hurricane Katrina, the H1N1 epidemic, and the Gulf oil spill have increased public awareness of the impacts of disasters and of gaps in communication, infrastructure, and resources that limit capacities to respond and recover.3,7,8One paradigm that has emerged in response is community resilience (CR).9,10 Based on a community-systems model,11,12 CR refers to community capabilities that buffer it from or support effective responses to disasters.13,14 Such capabilities include effective risk communications, organizational partnerships and networks, and community engagement to improve, prepare for, and respond to disasters. These capabilities may improve outcomes such as access to response and recovery resources, or return to functioning and well-being.15 Yet there are no operational models of how to build CR.16,17One potential model is community-partnered participatory research (CPPR), a manualized form of community-based participatory research18 that emphasizes power sharing and 2-way knowledge exchange following principles of community engagement to support authentic partnerships.19–21 We define a community as persons who work, share recreation, or live in a given area. A CPPR initiative has 3 stages: vision (planning), valley (implementation), and victory (products, dissemination).22–24 Each stage involves organizing, action, and feedback.20 Community-partnered participatory research was used to support post-Katrina mental health recovery in New Orleans24–28 and to address chronic conditions.29–33 Following successful application of CPPR in a postdisaster context, we proposed that it could support development of predisaster CR programs. We describe here the use of CPPR for the planning or vision stage of the Los Angeles County Community Disaster Resilience (LACCDR) initiative.As described elsewhere, LACCDR was initiated in 2010 by the Los Angeles County Department of Public Health (LACDPH) in collaboration with key academic and community partners based on principles from the National Health Security Strategy.10 Representatives of these partners constitute the LACCDR Steering Council. The Council reviewed the policy background for CR34 and developed a logic model35 that emphasizes the importance of community engagement in developing organizational partnerships to build CR. This article focuses on how the Council then used community engagement principles and the CPPR model to develop the project’s CR intervention framework, propose and develop a toolkit containing training and other resources to improve CR, and design a demonstration to compare the effectiveness of implementing the CR toolkit with the enhanced standard approach that emphasizes individual or family preparedness.15,36     

Building Community Disaster Resilience: Perspectives From a Large Urban County Department of Public Health

An emerging approach to public health emergency preparedness and response, community resilience encompasses individual preparedness as well as establishing a supportive social context in communities to withstand and recover from disasters. We examine why building community resilience has become a key component of national policy across multiple federal agencies and discuss the core principles embodied in community resilience theory—specifically, the focus on incorporating equity and social justice considerations in preparedness planning and response. We also examine the challenges of integrating community resilience with traditional public health practices and the importance of developing metrics for evaluation and strategic planning purposes. Using the example of the Los Angeles County Community Disaster Resilience Project, we discuss our experience and perspective from a large urban county to better understand how to implement a community resilience framework in public health practice.BUILDING COMMUNITY resilience to disasters—the ability to mitigate and rebound quickly—has received increased attention in the relatively new field of public health emergency preparedness and is now a central focus and a required activity for all public health departments that are recipients of Centers for Disease Control and Prevention (CDC) Public Health Emergency Preparedness (PHEP) grants.1 Critical lessons from Hurricane Katrina in 2005, the H1N1 pandemic of 2009, and, most recently, Hurricane Sandy continue to demonstrate that underlying issues of lack of trust and the absence of sustainable engagement with community-based organizations, faith-based organizations, and other neighborhood-level organizations create significant disparities in population health outcomes following emergencies and disasters. This situation hampers public health interventions in both everyday public health work and emergency response.2,3 As a theory and approach, community resilience provides a framework that embraces principles of equity and social justice with a focus on developing the core capacities of populations both to mitigate disasters and to rebound from them.4 The challenge is to clearly and operationally define community resilience, develop principles and practices that expand and enhance current community-based activities, and, through these changes, better align and integrate traditional public health and public health emergency preparedness.Although the term community resilience is relatively new to emergency preparedness, the emerging operational frameworks embrace many of the core components of effective community-based public health practice and, in many ways, represent a reframing of long-standing approaches to improve community well-being that have not been incorporated in preparedness programmatic activities.5We review the origins of the community resilience framework in the multidisciplinary research on individual resilience and assess how community resilience and related frameworks are shaping federal policies in all agencies involved in disaster and public health emergency response. We describe how the community resilience framework augments public health preparedness and reinforces longer-standing public health approaches to improving community health by examining a multiyear process developed by the Los Angeles County Department of Public Health (LACDPH) to implement this approach. The strategy consists of operationalizing community resilience through the following steps:

• Improving the community engagement skills of health department staff and building sustainable community engagement processes;
• Developing a resilience tool kit that can be used by community organizations to build coalitions and coordinated neighborhood strategies to increase community preparedness and specific mitigation skills; and
• Identifying metrics so that systematic interventions that can improve the abilities of communities to promote resilience and mitigate disaster impacts can be measured and evaluated.

     

Psychological First Aid: A Consensus-Derived,Empirically Supported, Competency-Based Training Model

Surges in demand for professional mental health services occasioned by disasters represent a major public health challenge. To build response capacity, numerous psychological first aid (PFA) training models for professional and lay audiences have been developed that, although often concurring on broad intervention aims, have not systematically addressed pedagogical elements necessary for optimal learning or teaching. We describe a competency-based model of PFA training developed under the auspices of the Centers for Disease Control and Prevention and the Association of Schools of Public Health. We explain the approach used for developing and refining the competency set and summarize the observable knowledge, skills, and attitudes underlying the 6 core competency domains. We discuss the strategies for model dissemination, validation, and adoption in professional and lay communities.The beginning of the 21st century has seen considerable attention devoted to improving emergency response capabilities at the national, state, and local levels of the US public health emergency preparedness system. A daunting challenge has been planning for the disproportionally high volume of psychological (vs physical) casualties that attend natural, technological, and intentional hazards.1–7 Evidence suggests that many disaster survivors fail to receive the care they need8 and that care deprivation under such circumstances is associated with mental health morbidity and increased rates of suicide.9,10 The difficulty of managing disaster-occasioned surges of demand for mental and behavioral health services is further compounded by the shortage of able and willing responders.11–14An increasingly popular idea for enhancing surge capacity during disaster scenarios is to develop cadres of potential responders trained in mental and behavioral health management, including psychological first aid (PFA).15–19 The American Red Cross20 and the World Health Organization21 provide PFA training programs, and the National Child Traumatic Stress Network and National Center for PTSD (posttraumatic stress disorder) distribute PFA field operations manuals for both general audiences and specific fields. Specialized PFA curricula have been developed for people working with the homeless,22 those working in nursing homes,23 Medical Reserve Corps volunteers,24 faith and lay community leaders,15,16,25,26 and public health workers.27Despite the virtual cottage industry of PFA training activities and previous efforts to identify core competencies16,26–28 and trauma intervention principles,29 current PFA training programs have significant shortcomings, including variability of content, format, and emphasis (with little motivation for standardization); learning objectives and outcomes defined in nonobservable constructs that preclude meaningful measurement; little external accountability for quality; and no in-depth analysis of the pedagogical principles for optimal learning and teaching of PFA competencies. The result is a dearth of qualified PFA-trained responders available for call-up during public health emergencies11,13,30 and no widely accepted model for training public health workers in PFA competencies.We describe the development of a PFA training curriculum based on sound pedagogical principles applicable to a broad range of learners, including midtier public health professionals and lay community members. The product is a component competency set of the Public Health Preparedness and Response Core Competency Model,31 a proposed national standard of behaviorally based, observable skills for the workforce to prepare for and respond to all-hazards scenarios. The project was conducted as part of a larger effort by 14 Preparedness and Emergency Response Learning Centers (PERLCs) in accredited schools of public health. These centers, funded by the Centers for Disease Control and Prevention (CDC), aim to develop knowledge, skills, and attitudes (KSA) content for each of the competency statements in the model.32 The project could serve as a basis for enhancing consistency in preparedness training curricula and fulfilling mandates in the Pandemic and All-Hazards Preparedness Act 2006.33     

Using Community Arts Events to Enhance Collective Efficacy and Community Engagement toAddress Depression in an African American Community

Objectives. We used community-partnered participatory research (CPPR) to measure collective efficacy and its role as a precursor of community engagement to improve depression care in the African American community of South Los Angeles.Methods. We collected survey data from participants at arts events sponsored by a CPPR workgroup. Both exploratory (photography exhibit; n = 747) and confirmatory (spoken word presentations; n = 104) structural equation models were developed to examine how knowledge and attitudes toward depression influenced community engagement.Results. In all models, collective efficacy to improve depression care independently predicted community engagement in terms of addressing depression (B = 0.64–0.97; P < .001). Social stigma was not significantly associated with collective efficacy or community engagement. In confirmatory analyses, exposure to spoken word presentations and previous exposure to CPPR initiatives increased perceived collective efficacy to improve depression care (B = 0.19–0.24; P < .05).Conclusions. Enhancing collective efficacy to improve depression care may be a key component of increasing community engagement to address depression. CPPR events may also increase collective efficacy. Both collective efficacy and community engagement are relevant constructs in the South Los Angeles African American community.Although depressive disorders are treatable, many people with such disorders, especially members of underserved minority groups, do not receive treatment.^1–7 Access to high-quality depression care can be improved through evidence-based programs,^8,9 but such programs are not widely disseminated in underserved communities.¹⁰ Collective action through cooperative efforts among service agencies and community members may be necessary to increase their implementation.^11–16 However, little is known about how to engage underserved groups in efforts to improve depression care.Perceived racism in health care, the stigma of mental illness, and lack of knowledge about depression may result in individuals in the African American community deciding not to seek help for depression.^17,18 However, as noted by one of the members of the minority community that was the focus of study, “Depression is a silent killer. We need to get the word out to the community that we can do something about it.” In addition, distrust in services and research engendered by travesties such as Tuskegee and experiments on slaves in the antebellum period is a barrier to participation in research among African Americans.^18–22 According to another study participant, “People in our community … have been involved with research before—the problem is universities never come back … and tell us what they did in our community.”Community-based participatory research is recommended as one means of engaging members of minority groups in addressing health issues.^12,15,23,24 In public health, community-based research focuses on social, structural, and physical environmental inequities through active involvement of community members, organizational representatives, and researchers in all aspects of the research process. Partners contribute their expertise to enhance understanding of a given phenomenon and integrate the knowledge gained with action to benefit the community involved.²³Both sides can gain from such an approach, as noted by another participating community member:

To participate with academics, the community can develop expertise in research—like [institutional review boards], data collection, and methods… . The academics get to learn about how to work in [the] community … being transparent, gaining trust, and planning with community instead of on community.

Community-partnered participatory research (CPPR), a variant of community-based participatory research, emphasizes equal power sharing among community and academic participants while engaging stakeholders and community members in planning, action, and research that have a mutual benefit.^24–26 For example, as noted by one of the participants in our study: “Allowing the community to participate in the hypothesis, data collection, analysis, and interpretation gave the community partnership over every aspect of the project.”Our study represented one component of a CPPR initiative called Witness for Wellness (http://www.witness4wellness.org), initiated in 2003 to reduce the burden of depression in underserved communities of color in South Los Angeles.^26–29 In Witness for Wellness, a multi-agency council was developed under the leadership of Healthy African American Families (HAAF), the University of California at Los Angeles, the RAND Corporation, and Charles Drew University.²⁶ The council developed a written agreement to reinforce CPPR principles and initiated 3 working groups including Talking Wellness, the group we studied.^17,25,27,28The Talking Wellness group focused on improving the capacity of the community to discuss depression and reduce stigma; community members suggested the approach of presenting community-generated arts events.²⁷ The Talking Wellness group had 74 participants during January 2004 through November 2007, the period of work leading to this article: 10 academic members (7 White, 2 Asian American, 1 African American) and 64 members of the South Los Angeles African American community. We evaluated 2 events for this study: spoken word and comedy presentations and a photography exhibit. (Spoken word is a form of artistic performance in which poetry or stories are recited aloud.)Our study involved several goals. The first was to explore whether concepts of collective efficacy and community engagement concerning depression care were important in the African American community of South Los Angeles and determine how they were related through causal modeling. Collective efficacy is a group''s shared belief in its conjoint capabilities to improve a problem in the community (in this case, depression care). Community engagement refers to the perception that individual problems (in this case, depression and mental wellness) are problems of the community as a whole.The second goal was to determine whether and how exposure to Talking Wellness arts events and other CPPR initiatives influenced community engagement. The third goal was to determine the feasibility of applying a CPPR paradigm of equal power sharing for community and academic partners through all phases of a rigorous research process, as evidenced through maintaining group membership across phases and completing products such as research protocols, data collection instruments, grant submissions, and research papers.We expected that low levels of knowledge and high levels of stigma about depression would predict lower levels of community engagement or perceived collective efficacy around depression than would high levels of knowledge and low levels of stigma. In addition, we expected that exposure to Talking Wellness events and CPPR initiatives would increase community engagement.We are not aware of other studies identifying pathways to community engagement as a means of addressing depression in minority communities.^15,24 The attitudinal constructs we used in this study were derived from the Health Belief Model (i.e., in terms of perceived importance of a problem and stigma as a barrier),^23,29 the theory of reasoned action and planned behavior (i.e., in terms of perceived norms and attitudes concerning a behavior),³⁰ Bandura''s social cognitive theory of collective efficacy as measured through individual perceptions,^31–38 and the concept of community engagement from the CPPR model.²⁵ Previous studies have shown that measures of collective efficacy are associated with health outcomes.^39–42     

Predictors and a Framework for Fostering Community Advocacy as a Community Health Worker Core Function to Eliminate Health Disparities

Objectives. Using a mixed-method, participatory research approach, we investigated factors related to community health worker (CHW) community advocacy that affect social determinants of health.Methods. We used cross-sectional survey data for 371 CHWs to assess demographics, training, work environment, and leadership qualities on civic, political, and organizational advocacy. We present advocacy stories to further articulate CHW activities. The data reported are from the recently completed National Community Health Workers Advocacy Study.Results. CHWs are involved in advocacy that is community-focused, although advocacy differs by intrinsic leadership, experience, training, and work environment. We propose a framework to conceptualize, support, and evaluate CHW advocacy and the iterative processes they engage in. These processes create opportunities for community voice and action to affect social and structural conditions that are known to have wide-ranging health effects on communities.Conclusions. The framework presented may have utility for CHWs, their training programs, and their employers as well as funders and policymakers aiming to promote health equity.Community health workers (CHWs) are essential to effective and comprehensive health systems throughout the world.1,2 In the United States, CHWs have been recognized as integral to providing patient-centered care and reducing health inequalities among disenfranchised groups.3 The workforce impact of CHWs is far-reaching in the realms of the prevention and control of chronic and infectious disease,4–13 the reduction of health care costs,14–16 and improved outreach, communication, and adherence,17–20 as well as in connecting clients to existing services.21 The recognition of the CHW model has resulted in increased integration of CHWs into the health delivery system. Although beneficial in terms of health care delivery, the institutionalization of the role of CHWs within systems of care may result in the devaluation of another CHW core function, that of building community capacity to address the social determinants of health (SDH) through advocacy and organizing.22–24 Studies have documented the influence of CHWs on the quality of the health care delivery system25,26 and on community-engaged strategies to address public housing27 and decrease community violence.28Balcazar et al.21 underscore the importance of maintaining the full spectrum of CHW roles within a changing health care delivery system, which includes not only influencing how care is delivered but also addressing power relationships that underlie the SDH. The World Health Organization’s Commission for Social Determinants of Health recently revised their conceptualization of SDH to include structural determinants of health, which are defined as macroeconomic and social policies related to labor, housing, and land and public policies concerning health, education, and social protection.29 Such structural determinants have been recognized as powerful predictors of health status.30 In responding to specific disease areas, CHWs report the need for a broad range of skills to effectively address the complex issues that they confront working with individuals and communities.31,32We document the findings of a mixed quantitative–qualitative national survey investigating CHW involvement in community-level advocacy, defined as working for a cause or a change to improve the health of a community. We propose a framework to conceptualize, support, and measure the intrinsic, training, and work environment characteristics associated with CHW community advocacy. The framework also describes the iterative process in which CHWs, by creating opportunities for community voice and action, positively affect social and structural conditions that determine the health of a community.     

Local Health Departments as Essential Community Providers for Health Benefits Exchange Plans

The Affordable Care Act requires health plans’ networks to include “essential community providers” (ECPs). Local health departments (LHDs) can be ECPs, typically for tuberculosis and sexually transmitted disease–related services or family planning. An ECP status may be controversial if it jeopardizes core population health services or competes with community partners. Some LHDs already bill for ECP services, but independent billing functions could exceed projected revenue. Thus, LHDs may wish to investigate contractual arrangements as alternatives to billing multiple issuers.The Affordable Care Act requires health plan issuers to include some essential community providers (ECPs) in their networks to qualify for participation in health benefit exchanges. Essential community providers are entities that help meet the needs of historically underserved areas and populations1; the classification includes federally qualified health centers, critical access hospitals, Ryan White grantees for HIV/AIDS services, and entities that provide services related to tuberculosis and sexually transmitted diseases (STDs), among others. Qualified health plans are required to contract with at least 20% of the ECPs in their service areas and with at least 1 in each service category, or document that doing so is not feasible.2 The rationale for requiring inclusion of ECPs is to ensure continuity of service for newly insured individuals who had received services from ECPs, and to support the health care safety net after Affordable Care Act implementation increases access to third-party coverage.2 The following brief review points to opportunities, challenges, and controversies that the ECP option raises for local health departments (LHDs).     

Social Media Adoption in Local Health Departments Nationwide

Objectives. We examined whether characteristics of local health departments (LHD) and their geographic region were associated with using Facebook and Twitter. We also examined the number of tweets per month for Twitter accounts as an indicator of social media use by LHDs.Methods. In 2012, we searched for Facebook and Twitter accounts for 2565 LHDs nationwide, and collected adoption date and number of connections for each account. Number of tweets sent indicated LHD use of social media. LHDs were classified as innovators, early adopters, or nonadopters. Characteristics of LHDs were compared across adoption categories, and we examined geographic characteristics, connections, and use.Results. Twenty-four percent of LHDs had Facebook, 8% had Twitter, and 7% had both. LHDs serving larger populations were more likely to be innovators, tweeted more often, and had more social media connections. Frequency of tweeting was not associated with adoption category. There were differences in adoption across geographic regions, with western states more likely to be innovators. Innovation was also higher in states where the state health department adopted social media.Conclusions. Social media has the potential to aid LHDs in disseminating information across the public health system. More evidence is needed to develop best practices for this emerging tool.Local health departments (LHDs) are charged with assuring their constituents receive 10 essential public health services.1 Among these services is Essential Service #3 (ES3): inform, educate, and empower people about health issues.1 The Public Health Accreditation Board has included communication with constituents about public health issues and health risks in a recently developed set of standards required of LHDs seeking accreditation.2 As of 2004, only 61% of LHDs were adequately addressing ES3.3One new communication tool that may aid LHDs in educating and informing their constituents and meeting accreditation standards is social media. Web-based social media sites, such as Facebook and Twitter, can facilitate direct, one-to-many communication with a large audience at little to no cost.4,5 Facebook accounts can be liked, and Twitter accounts can be followed by other users, including the general public, allowing individuals or organizations to receive and spread information posted by a source. A recent survey indicated that 65% of online adults in the United States, or half of all US adults, use social media.6 Facebook and Twitter are the most widely used social media platforms7; worldwide more than 845 million people use Facebook, whereas 140 million people are Twitter users.8 Each minute, 695 000 Facebook statuses are updated, and 98 000 tweets are sent.9In the United States, social media is used by many segments of the population. Although overall social media use among adults with Internet access is associated with age, it is independent of educational attainment, race/ethnicity, and health care access.10 Likewise, there are no significant differences in Twitter use by education or income; however, the use of Twitter is significantly higher among Black non-Hispanic Internet users (28%) compared with non-Hispanic White (12%) or Hispanic Internet users (14%).11 Twitter use is also significantly higher in young adults compared with older age groups and in urban and suburban locations compared with rural locations.Use of social media is emerging as a popular way to seek health information for the general public.12,13 For adult Internet users, the Internet is a primary source of health information, second only to health care providers; 80% of US Internet users (or 59% of US adults) have looked online for health information.14,15 Of adult social media users, 23% report following their friends’ personal health experiences or updates, 17% have used social media to remember or memorialize people with a specific health condition, and 15% have obtained health information from social media sites.15Social media platforms are also increasingly used by health care providers and public health organizations and practitioners to share information with each other during training16,17 and practice,18 and to reach consumers with health information.4,19–21 The World Health Organization has Facebook and Twitter accounts, as do the Centers for Disease Control and Prevention (CDC) and numerous health-related schools and departments, scientists, and health-focused news outlets.20 CDC has developed an online toolkit to aid public health practitioners in using social media to disseminate information and foster partnerships with consumers.5 Advocates of social media use in the health community believe social media outlets provide a place for dialogue with consumers,21 and a mechanism for real-time surveillance22 and rapid dissemination of time-sensitive health information.20,23 Challenges identified by health professionals include a lack of understanding of social media23 and the volume of information available online, which can confuse consumers.20Despite numerous barriers that often hinder the adoption of new technology in government organizations,4 studies indicate a majority of state health departments (60%–82%) are using at least 1 social media application.24,25 Those health departments using social media report using it daily to disseminate information on healthy behaviors and health conditions.25 In addition, in studies surveying a sample of LHDs nationwide, up to 30.9% reported having a Facebook page, whereas up to 47.0% reported using Twitter.26,27The adoption of Facebook and Twitter across the public health system constitutes a natural experiment providing insight into how technological innovations spread across this system. Given the potential of social media to reach a large segment of the adult population, many of whom are actively seeking health information online, it is important to better understand the adoption and use of this new tool by public health practitioners. To this end, we were the first that we know of to examine the adoption and use of Facebook and Twitter across all LHDs nationwide. Specifically, we examined whether characteristics of an LHD, and the state and region where it is located, were associated with adoption of social media. We also examined the number of followers or likes for each health department with a Facebook or Twitter account and whether followers and likes were associated with LHD characteristics. Finally, we examined the number of tweets per month for Twitter accounts as a general indicator of social media use by LHDs.     

Community Influences on Young People's Sexual Behavior in 3 African Countries

Objectives. I examined the role of community-level factors in the reporting of risky sexual behaviors among young people aged 15 to 24 years in 3 African countries with varying HIV prevalence rates.Methods. I analyzed demographic and health survey data from Burkina Faso, Ghana, and Zambia during the period 2001 through 2003 to identify individual, household, and community factors associated with reports of risky sexual behaviors.Results. The mechanisms through which the community environment shaped sexual behaviors varied among young men and young women. Community demographic profiles were not associated with reports of risky sexual behavior among young women but were influential in shaping the behavior of young men. Prevailing economic conditions and the behaviors and attitudes of adults in the community were strong influences on young people''s sexual behaviors.Conclusions. These results provide strong support for a focus on community-level influences as an intervention point for behavioral change. Such interventions, however, should recognize specific cultural settings and the different pathways through which the community can shape the sexual behaviors of young men and women.Countries in sub-Saharan Africa are home to only 10% of the world''s population but account for approximately 85% of AIDS deaths worldwide.^1,2 Previous studies have highlighted high levels of sexual activity among young people (i.e., those aged 15–24 years) in many sub-Saharan African countries,^3–7 paralleled by increasing rates of HIV infection among young people.^1,8,9 Although young people in these countries have been shown to have high levels of knowledge regarding HIV/AIDS, studies have demonstrated significant deviation between such knowledge and reported sexual behaviors,^10–12 with high levels of risky sexual activity reported (e.g., failing to use a condom,¹³ engaging in transactional sex,^13,14 having multiple partners.^3,6,15).The health hazards associated with sexual risk taking among young people are well documented, but little is known about the factors associated with sexual behaviors among adolescents in developing countries.^13,15–20 In the few studies that have examined young people''s sexual behavior in these countries, a micro-level approach has been adopted, with a focus on individual characteristics as predictors of behavior²¹ and little consideration of the potential pathways through which the wider community may shape behavior.Condom use has often been the outcome of interest in studies of adolescent sexual behavior,^7,22–25 which is not surprising given the emphasis of many HIV prevention strategies on promoting condom use; other studies have examined factors associated with sexual activity or sexual debut.^1,15,17,26 Higher levels of risky sexual activity have been shown among young people (both male and female) and adult men^24,26 than among adult women.^4,6,27 In many sub-Saharan African countries, young women''s lack of negotiating power in sexual relationships is influenced by the large age differences common in many relationships,^3,14,27,28 the presence of violence or coercion,²⁵ and economic incentives to participate in risky sexual activities.¹⁴Educational attainment has been shown to be associated with young people''s sexual behaviors.^5–7,29 This relationship is more than simply a function of increased knowledge leading to positive health behaviors; the type of educational institution attended and the place of residence of the student have been shown to be influential in determining sexual behaviors,⁵ suggesting that these behaviors are also influenced by the degree of freedom afforded to the young person.Young women from poor households have been shown to be at particular risk of sexual risk taking, with their economic status motivating them to partake in transactional sex and serving as another limitation in their negotiating power with respect to condom use.^6,14 In terms of the influence of knowledge on behavior, some studies have demonstrated a disparity between knowledge regarding HIV risk and sexual behavior^12,22,30 such that many young people, despite knowing the risks associated with unprotected sexual activities, still engage in these activities. There is a limited amount of evidence suggesting that risk knowledge is a more protective factor against risky sexual activity among women than among men,³¹ with fear of unplanned pregnancy providing a greater deterrent for women than for men.Although much is known about the individual characteristics associated with sexual risk taking among young people, the role of the community in shaping such behaviors has been largely overlooked. In a study of adolescents residing in the United States, Billy et al.²¹ suggested that young people''s sexual behavior is strongly influenced by a community''s opportunity structure (i.e., presence of social and economic opportunities), which is composed of 3 key elements. The first element is the presence in the community of reproductive and sexual health services, which determines a young person''s access to information and services. The second element is the demographic profile of the community, which determines the presence of potential sexual partners. The final element is the presence or absence of economic or social opportunities, which influences young people''s perceptions regarding the opportunity costs of sexual behavior.Studies testing the theory of Billy et al. have largely been restricted to developed countries.^21,32 Although some studies have addressed the influence of community factors on young people''s sexual behavior in developing countries, these investigations have focused primarily on indicators of the presence of economic opportunities for young people,^33,34 failing to examine the roles of the cultural and social environments in shaping behavior.I examined community-level factors associated with risky sexual behaviors among young people in the African countries of Burkina Faso, Ghana, and Zambia. The goal of the study was to advance understanding of how the community environment shapes young people''s sexual behavior by considering a broad range of potential community influences, including social, behavioral, and demographic dimensions of the community environment.     

The Adoption and Discontinuation of Clinical Services by Local Health Departments

Objectives. We identified factors associated with local health department (LHD) adoption and discontinuation of clinical services.Methods. We used multivariate regression with 1997 and 2008 LHD survey and area resource data to examine factors associated with LHDs maintaining or offering more clinical services (adopter) versus offering fewer services (discontinuer) over time and with the number of clinical services discontinued among discontinuers.Results. Few LHDs (22.2%) were adopters. The LHDs were more likely to be adopters if operating in jurisdictions with local boards of health and not in health professional shortage areas, and if experiencing larger percentage increase in non-White population and Medicaid managed care penetration. Discontinuer LHDs eliminated more clinical services in jurisdictions that decreased core public health activities’ scope over time, increased community partners’ involvement in these activities, had larger increases in Medicaid managed care penetration, and had lower LHD expenditures per capita over time.Conclusions. Most LHDs are discontinuing clinical services over time. Those that cover a wide range of core public health functions are less likely to discontinue services when residents lack care access. Thus, the impact of discontinuation on population health may be mitigated.The role of local health departments (LHDs) in offering clinical services is hotly contested in public health practice. Some LHD leaders believe that offering clinical services is critical to their mission1 and public image.2 Others embrace the position of the Institute of Medicine (IOM) on the future of public health, which calls for LHDs to focus on core public health functions of assessment, assurance, and policy development and away from clinical services.3,4Most LHDs have decreased clinical service offerings over time (discontinued).1,3,5,6 Some have done so because their leaders believe that offering clinical services is inconsistent with the LHD’s mission,6,7 diverts resources from population-based services,3,8 or distracts from core public health functions.1,7 Leaders of LHDs may rely on non-LHD public health system partner organizations to provide clinical services for vulnerable populations rather than providing them directly.1 They may see the private sector as more appropriate than LHDs in delivering clinical care.1,6,9 For example, in some regions, Medicaid managed care organizations collaborate with LHDs to ensure clinical services.5,10,11However, some LHDs have maintained or increased their clinical service offerings over time (adopted) because their leaders view clinical services as part of their mission,1 derive satisfaction from patient contact,5 or believe that offering such services is part of the core public health function of ensuring access to care to their patients if care is not available elsewhere.2,3,8,12 They offer clinical services if no private sector alternatives exist,6,12 or if the LHD is uniquely qualified in dealing with specific vulnerable populations2,5 or for certain conditions (e.g., infectious disease control).1 These LHDs may offer clinical services if no other safety net providers are available or community need is high. For instance, 63.3% of LHD directors in 2000 believed that LHDs should offer clinical services when no other organization was available to do so, compared with 23.6% of directors who believed that LHDs should offer clinical services unequivocally.7 Other LHDs may offer clinical services to generate revenue to fund other operations.1,13,14We posit that 3 main drivers underlie LHD decisions to offer clinical services. First, a conflicting goal driver suggests that LHD leaders may view offering clinical services as conflicting with core public health functions, particularly when they have few resources.1,7 Performance of these functions by LHDs varies with jurisdiction-level sociodemographic factors, and LHD organizational and public health system attributes.15–18 Second, an assurance driver suggests that LHDs offer clinical services if leaders believe that residents lack access to care, that the LHD has important expertise in providing clinical services to vulnerable patient populations, and that LHDs should provide these services when these services are limited. Third, an entrepreneurial driver suggests that LHDs leverage revenue-generating clinical services to fund needed public health services.5,13,19 The 3 drivers are not mutually exclusive. For instance, an LHD may stop offering comprehensive primary care because of the conflicting goal driver, and simultaneously start offering tuberculosis screening because of the assurance driver.The drivers provide a framework for understanding LHD decisions about the provision of clinical services, elucidating how LHDs change their clinical service offerings in response to strategic and environmental changes. We explored how the 3 drivers relate to 2 decisions: (1) whether an LHD departs from the majority and the IOM recommendations and maintains or offers more clinical services over time (an adoption decision) and (2) conditional on the LHD’s decision to discontinue services, how many fewer clinical services to offer over time (a degree of discontinuation decision). Institutional theory suggests that conformity pressures lead organizations to become more similar in behavior over time,20 but others resist such pressures for strategic reasons.21 Thus, we expected that LHDs adopting clinical services over time (adopters) would do so for different reasons than LHDs following the norm of discontinuing clinical services over time (discontinuers), and that leaders at discontinuer LHDs deciding how many clinical services to discontinue may do so for yet other reasons. Because we compared LHDs that followed the norm of decreasing the number of clinical service offerings1,3,5,6 with those that departed from the norm, we defined adoption to include offering the same number of clinical services over time. Our focus on the number of clinical services does not mean that the actual mix of clinical services offered stayed the same across time.2,5 number of community clinical service providers, and Medicaid reimbursement levels. Public health system attributes measure the LHD jurisdiction’s delivery on core public health functions across 3 dimensions: differentiation, integration, and concentration. Differentiation indicates the jurisdiction’s emphasis on public health needs, with high differentiation indicating that the jurisdiction offers many core programs or services. Integration indicates how different organizations interact in providing these services, with high integration indicating that many partnering organizations offer these services. Concentration measures the LHD’s role, with high LHD concentration indicating that the LHD bears primary responsibility for offering these services. Mays et al.22 described these 3 dimensions in further detail.

TABLE 1—

Conceptual Model Describing the Conflicting Goal, Assurance, and Entrepreneurial Drivers and the Factor Categories Associated With Adoption and Degree of Discontinuation of Clinical Services by Local Health Departments

Demographic and Psychosocial Factors Associated With Psychological Distress and Resilience Among Transgender Individuals

Objectives. We examined the independent demographic and psychosocial factors associated with psychological distress and resilience among transgender men and women.Methods. Our data came from an online survey involving a national Australian sample of 169 transgender men and women in 2011. Survey questions assessed demographics; sources of support; contact with lesbian, gay, bisexual, and transgender peers; and experiences of victimization. We assessed the outcomes with the Kessler Psychological Distress Scale and the Brief Resilience Scale.Results. In all, 46.0% of the sample reported high or very high levels of psychological distress. Multivariable regression analyses identified considerably different independent factors for psychological distress and resilience. Younger age, feeling unable to turn to family for support, and victimization experiences were associated with greater psychological distress, whereas higher income, identifying as heterosexual, and having frequent contact with lesbian, gay, bisexual, and transgender peers were associated with greater resilience.Conclusions. With different factors identified for psychological distress and resilience, these findings may help inform the development of tailored mental health interventions and resilience-building programs for this vulnerable population.Transgender and gender-nonconforming individuals have gender identities, expressions, or behaviors that are not typically associated with the sex they were assigned at birth. They may identify more strongly with the opposite gender (e.g., transgender males who are natal females and transgender females who are natal males), or they may identify outside the gender binary (e.g., individuals who identify with neither or both genders).1,2 It is of concern that psychiatric morbidity prevalence estimates are substantially higher among transgender individuals than that of both the general population and sexual minority subpopulations.3–5An emerging body of research has begun to examine the determinants of psychopathology among transgender people in an attempt to address these disparities in mental health. Through this research, demographic and psychosocial factors that are known determinants of general population mental health have also been identified as risk factors for reduced mental health among this minority group. For example, younger age, low socioeconomic status, living in a rural area, and poor social support have all been linked to poorer mental health outcomes among transgender individuals.3,4,6–11Social determinants that pertain uniquely to the mental health of marginalized people have also been assessed. The Minority Stress Model initially proposed that “minority stressors,” or experiences of stigma, account for the high rates of psychiatric morbidity observed among sexual minority groups.12 More recently, the model has been extended to address the experience of transgender individuals.13 In support of the model, gender-related stressors such as discrimination, victimization, exposure to transphobia, and internalized stigma have all been identified as strong predictors of psychopathology among transgender people,3,4,7,10,14,15 particularly among transgender youths.11,16Although research focusing on the antecedents of psychopathology in the transgender population is growing, little is known about transgender individuals’ capacity for resilience in the face of hardship and long-term stress. Resilience is broadly defined as the capacity to positively adapt (or bounce back) after experiencing adversity,17 and research in this area is particularly vital for vulnerable populations who experience frequent socio-contextual stress.Qualitative studies have identified themes of resilience among transgender individuals, such as connection to the lesbian, gay, bisexual, and transgender (LGBT) community and supportive personal relationships18–20; however, only a few quantitative studies have assessed determinants of resilience in this population. For example, one study found that agentic and communal personality traits were associated with increased levels of resilience among transgender women.21 Some researchers have indirectly assessed resilience factors among transgender individuals through the identification of stress buffers. For example, in a recent study of 1093 transgender men and women, peer support (indexed as social contact with other transgender people) was identified as a stress buffer that moderated the relationship between experiences of gender-related stigma and psychological distress.3 It has been suggested that identifying with similar others allows for the development of a positive in-group identity, encourages a process of positive self-appraisal, and allows access to “group-level coping,” which all have protective benefits for the mental health of marginalized people.12,13 Through these mechanisms, engagement and connection with similar others may also foster an individual capacity for resilience in the face of future stress or adversity.12Recent conceptualizations of resilience attest that the construct extends beyond simply the absence of psychopathology after enduring acute or chronic stress.22–24 It has been demonstrated that psychological immunity to stressors can manifest as competence or positive adaptation in a range of social, psychological, and general health outcomes.25 As such, when resilience is operationalized as the generalized capacity to positively adapt after experiencing hardship and it is assessed as an outcome variable, this permits a more global assessment of the construct without narrowing to the type of stressor, nor the area of adaptation. This broader way of conceptualizing resilience is most relevant when one is researching marginalized populations who experience chronic social stress in many different forms with potentially varying social and psychological sequelae. Furthermore, it is particularly pertinent when one is informing the design of general resilience-building programs. Only 1 quantitative study has examined factors of resilience among transgender individuals in this comprehensive way21; however, that study did not assess social determinants that may be targeted by interventionists.In sum, research on transgender mental health is in its infancy. Although some social determinants of mental health outcomes have been identified among transgender individuals, further research is needed. Studies have tended to focus on a few specific factors rather than provide a thorough assessment of demographic and psychosocial factors. Assessing the relative impact of these factors by conducting analyses within a single sample is needed to inform the development of tailored mental health interventions. Furthermore, there is a need to identify not only the factors that influence psychological distress, but also resilience, as a generalized capacity to positively adapt after experiencing adversity. By canvassing a range of demographic and psychosocial factors, this study had 3 main aims: (1) to identify independent factors associated with psychological distress among transgender men and women, (2) to identify independent factors associated with resilience among transgender men and women, and (3) to examine the extent to which factors that are associated with distress were similar or different to those associated with resilience.     

Declining Trends in Local Health Department Preparedness Capacities

Objectives. We examined local health department (LHD) preparedness capacities in the context of participation in accreditation and other performance improvement efforts.Methods. We analyzed preparedness in 8 domains among LHDs responding to a preparedness capacity instrument from 2010 through 2012. Study groups included LHDs that (1) were exposed to a North Carolina state-based accreditation program, (2) participated in 1 or more performance improvement programs, and (3) had not participated in any performance improvement programs. We analyzed mean domain preparedness scores and applied a series of nonparametric Mann–Whitney Wilcoxon tests to determine whether preparedness domain scores differed significantly between study groups from 2010 to 2012.Results. Preparedness capacity scores fluctuated and decreased significantly for all study groups for 2 domains: surveillance and investigation and legal preparedness. Significant decreases also occurred among participants for plans and protocols, communication, and incident command. Declines in capacity scores were not as great and less likely to be significant among North Carolina LHDs.Conclusions. Decreases in preparedness capacities over the 3 survey years may reflect multiple years of funding cuts and job losses, specifically for preparedness. An accreditation program may have a protective effect against such contextual factors.Federal, state, and local public health agencies have made substantial investments in improving state and local health department (LHD) preparedness capacities and capabilities to effectively prevent, detect, or respond to public health emergencies.1 A lack of valid and reliable data collection instruments as well as evolving preparedness standards has made it difficult to determine the impact of these investments.2,3 As recently as 2011, the Centers for Disease Control and Prevention released 15 public health preparedness capabilities designed to serve as national public health preparedness standards to assist state health departments and LHDs with strategic planning.4 In addition, few studies have examined the impact of LHD contextual factors and participation in improvement efforts on the performance of preparedness capacities.5 We examined LHD preparedness capacities in the context of participation in performance improvement efforts over a 3-year period using a validated survey instrument.6LHDs are essential to emergency preparedness and response activities. They have statutory authority to perform key functions including community health assessments and epidemiologic investigations, enforcement of health laws and regulations, and coordination of the actions of the agencies in their jurisdictions that make up the local public health system.7 Preparedness also involves specialized functions such as incident command, countermeasures and mitigation, mass health care delivery, and management of essential health care supply chains.8 The Centers for Disease Control and Prevention organized these functions into capabilities or standards that are supported by foundational capacities or resources elements in the 15 public health preparedness capabilities.4Despite the considerable investment in public health preparedness after the September 11, 2001, attacks on the United States and the anthrax attack, funding for public health preparedness declined 38% between federal fiscal years 2005 and 2012.9 Although LHDs received funding supplements in 2009 and 2010 to address the H1N1 virus and through the American Recovery and Reinvestment Act,10 median per capita revenues for LHD preparedness activities in the most recently completed fiscal year, 2013, declined to $1.15 from $2.07 in 2010.11,12 In 2012, approximately half of LHDs reported reducing or eliminating services, with preparedness being among the most common services to be affected.12 The specific impact of these and other funding reductions on preparedness capacities has yet to be formally studied.After more than a decade of focused effort, gaps and variation in the performance of preparedness activities remain.6,12 Heterogeneity in the composition and structure of public health systems continues to be an important source of variation in preparedness, as in other aspects of public health practice.14,15 Other factors affecting LHD general performance and preparedness include LHD governance structure, community, and organizational characteristics, such as funding, leadership characteristics, and partnerships.7,16,17Over the past decade, efforts to improve public health infrastructure, and performance more generally, have gathered momentum. These efforts included development and use of the National Public Health Performance Standards Program instruments, the implementation of state-based accreditation programs and the Public Health Accreditation Board, and initiatives to encourage the use of performance management and quality improvement tools.18-22 The Public Health Accreditation Board is charged with developing and managing national voluntary public health accreditation for tribal, state, local, and territorial health departments. The national accreditation final standards, released in 2011, include a specific emergency preparedness standard as well as additional standards that are linked to preparedness measures.23The National Public Health Performance Standards Program provides a framework to assess the capacity and performance of public health systems and public health governing bodies and identify areas for system improvement. LHDs and their partners use tailored instruments to assess the performance of their public health system against model standards, including preparedness standards, which are based on the 10 essential services (National Public Health Performance Standards Program version 2.0; NPHPS Partners, Atlanta, GA). More than 400 public health systems and governing entities used the version 2 assessment instruments (Centers for Disease Control and Prevention, http://www.cdc.gov/nphpsp/archive.html).Preparedness performance improvement programs have also been implemented to address variation. Project Public Health Ready is a standards-based recognition program with 300 LHDs (27 states) recognized as meeting all the Project Public Health Ready requirements individually or working collaboratively as a region since 2004.24 To achieve recognition, LHDs must meet nationally recognized standards in all-hazards preparedness planning, workforce capacity development, and demonstration of readiness through exercises or real events. In addition, the Institute of Medicine has recommended that an accreditation program could be a performance monitoring and accountability system for agency preparedness.25,26One previous study examined the effects of performance and accreditation programs on LHD performance of 8 preparedness domains on a validated instrument.5 Controlling for LHD characteristics, a significant positive effect on domain scores was found for LHDs that participated in the North Carolina state-based accreditation program and select performance improvement programs (National Public Health Performance Standards, the Public Health Accreditation Board beta test, Project Public Health Ready) when compared with a national matched comparison group that did not participate in any program. Findings, however, were limited to 1 year of survey data—2010. In this article, we explore trends in preparedness capacities in the present climate of declining resources for public health preparedness activities.     

Community Engagement in Research: Frameworks for Education and Peer Review

Community engagement in research may enhance a community''s ability to address its own health needs and health disparities issues while ensuring that researchers understand community priorities. However, there are researchers with limited understanding of and experience with effective methods of engaging communities. Furthermore, limited guidance is available for peer-review panels on evaluating proposals for research that engages communities.The National Institutes of Health Director''s Council of Public Representatives developed a community engagement framework that includes values, strategies to operationalize each value, and potential outcomes of their use, as well as a peer-review framework for evaluating research that engages communities.Use of these frameworks for educating researchers to create and sustain authentic community–academic partnerships will increase accountability and equality between the partners.THE SIGNIFICANT RENAISSANCE of community engagement in research stems from demands by community leaders, policymakers, and funders for meaningful community involvement to address health problems facing communities. The published peer-reviewed literature and numerous reports point to the many potential benefits of community engagement in research.^1–16 According to the Institute of Medicine, for example, community-based participatory research increases community understanding of the issues under study and enhances researchers'' ability to understand community priorities, the importance of addressing community priorities, and the need for culturally sensitive communications and research approaches.¹⁷Several models for community engagement in research exist, including community-based participatory research,^18,19 empowerment evaluation,^20,21 participatory or community action research,²² and participatory rapid appraisal.²³ Some confusion exists about the definition of community engagement in research, however, because many researchers use the terms interchangeably.Researchers conducting community engagement in research need appropriate education and training not typically offered by traditional doctoral and master''s level curricula. The field clearly needs long-term programs that integrate the knowledge and skills of experienced community and researcher partners in high-quality participatory research to build the capacity of young and traditionally trained researchers and scientists interested in pursuing community engagement in research.²⁴Funding agencies often find it difficult to assess participatory research proposals, especially if they use traditional review criteria that are not necessarily applicable to participatory research.²⁵ A 2004 review²⁶ points out that when reviewers in typical study sections are not familiar with community-based participatory research or are even skeptical about the approach''s merits, investigators find it challenging to obtain funding for their community-based participatory research projects through conventional peer-review mechanisms.Many funders include members of the lay public in their peer-review panels to evaluate proposals from the patient''s or family member''s perspective.^27,28 Lay public reviewers help scientists understand the impact of the research on the community and help them make appropriate funding recommendations that address the needs and concerns of patients, health care providers, and family members.²⁹ However, many scientists are concerned that lay peer reviewers do not have the scientific expertise required to offer an appropriate evaluation.^30,31 A survey of the National Cancer Institute of Canada''s scientific grant review panel members found that not all scientists value lay contributions and many lay members feel insecure about the importance of their contributions.³²Because of these barriers, community engagement in research is probably underused. The National Institutes of Health (NIH) Director''s Council of Public Representatives (COPR), a federal advisory committee to the NIH director, addressed these issues and produced this article to advance community engagement in research. We describe approaches that funders and educational institutions can use to develop community engagement in research training programs and peer-review processes that can expand the community engagement in research field.     

Stigma,Mental Health,and Resilience in an Online Sample of the US Transgender Population

Objectives. We assessed the association between minority stress, mental health, and potential ameliorating factors in a large, community-based, geographically diverse sample of the US transgender population.Methods. In 2003, we recruited through the Internet a sample of 1093 male-to-female and female-to-male transgender persons, stratified by gender. Participants completed an online survey that included standardized measures of mental health. Guided by the minority stress model, we evaluated associations between stigma and mental health and tested whether indicators of resilience (family support, peer support, identity pride) moderated these associations.Results. Respondents had a high prevalence of clinical depression (44.1%), anxiety (33.2%), and somatization (27.5%). Social stigma was positively associated with psychological distress. Peer support (from other transgender people) moderated this relationship. We found few differences by gender identity.Conclusions. Our findings support the minority stress model. Prevention needs to confront social structures, norms, and attitudes that produce minority stress for gender-variant people; enhance peer support; and improve access to mental health and social services that affirm transgender identity and promote resilience.Transgender people are a diverse population of individuals who cross or transcend culturally defined categories of gender.1 Transgender identities include male-to-female and female-to-male transsexuals (transgender women and men, respectively, who feminize or masculinize their bodies through hormone therapy or surgery), cross dressers or transvestites (who dress in clothes typically worn by another gender as a means of self- or erotic expression), drag queens and kings (female or male impersonators), and other gender-variant individuals, who may describe themselves with labels such as bigender or genderqueer.Transgender people face systematic oppression and devaluation as a result of social stigma attached to their gender nonconformity.2–6 Among a Minnesota sample of 181 transgender participants in a sexual health seminar, 66% reported being discriminated against because of their gender identity or presentation.7 This discrimination can be compounded by multiple stigmas and take on various forms: racial, employment, and economic; it may even be expressed in physical violence.8,9 In a US study of 402 transgender persons, 56% reported experiencing verbal harassment; 37%, employment discrimination; and 19%, physical violence.6The minority stress model10–12 suggests that the stress associated with stigma, prejudice, and discrimination will increase rates of psychological distress in the transgender population. According to this model, minority stress is unique (additive to general stressors experienced by all people); it is also socially based and chronic, stemming from relatively stable social structures and norms beyond the individual. Minority stress processes can be both external—consisting of actual experiences of rejection and discrimination (enacted stigma)—and, as a product of these, internal, such as perceived rejection and expectations of being stereotyped or discriminated against (felt stigma) and hiding minority status and identity for fear of harm (concealment).10,11,13 Social support, self-acceptance, and integration of minority identity can ameliorate minority stress. A community of peers allows for a social environment in which variant identity is not stigmatized and in which self-evaluation can occur in comparison with like others, rather than with members of the majority culture.10,14 Through coming out, people can overcome negative self-evaluation and learn to cope with the adverse effects of minority stress.15 Thus, minority stress and resilience interact in predicting psychological distress.The minority stress model was tested in gay, lesbian, and bisexual individuals to explain their higher prevalence of depression, anxiety, and substance use than is found among heterosexual individuals.10,11 For example, gay men with high levels of minority stress related to stigma and discrimination were 2 to 3 times as likely as respondents with lower stress to report high levels of psychological distress.11 In the transgender population, several qualitative studies strongly suggest that stigma negatively affects mental health,5,16–18 but few studies have examined this relationship quantitatively. Rates of depression were high in a transgender sample in San Francisco, California (n = 515; 62% among transgender women; 55% among transgender men),8,19 and gender-based discrimination was an independent predictor of attempted suicide.19 Among transgender women of color with a history of sex work (n = 327), experiences of discrimination were common (verbal, 37%; physical, 20%; employment, 39%) and more prevalent among depressed than nondepressed individuals.20 Among an expanded, multiethnic sample of these transgender women (n = 573), 49% reported depression, and experiences of discrimination and the need for and satisfaction with social support were positively associated with depression.21 A recent study of transgender women in New York City (n = 571) compared the life chart interviews of 2 age cohorts (19–39 and 40–59 years) and found that gender-related abuse was strongly associated with depression during early stages of life, but, especially for the younger cohort, declined during later stages of life, which the authors attributed to the development of moderately effective coping mechanisms.22For transgender people, coping with stigma can mean concealing transgender identity, which may reinforce their efforts to pass as a nontransgender woman or man, either in the role congruent with their gender assigned at birth or in the cross-gender role.23–25 Transgender men are thought to be able to pass more easily, because of the differential impact of masculinizing versus feminizing hormones.26 This greater ability to pass, along with the belief that gender nonconformity is more stigmatized among men than women, has been invoked as an explanation for the finding that transgender men are better adjusted after transition than are transgender women.27–30 However, successful passing does not necessarily ameliorate minority stress. Concealment is an attempt to avoid the negative consequences of stigma, but it can result in hypervigilance and a preoccupation with hiding, which itself can become a significant source of stress.10,31–35Among gay, lesbian, and bisexual individuals, identity affirmation and disclosure to similar others, friends, family, and therapists have been shown to ameliorate the negative effects of minority stress on mental health.15,36–41 Consistent with the minority stress model, this positive effect was attributed in part to the benefits of group identity and support: those who are invested in concealing their minority identity are less able to benefit from the affirmation and empowerment that a community of similar others can provide.42–44 Thus, disclosure and social support, and developing pride in a minority identity, seem to moderate the negative effects of minority stress on mental health.11,45,46Knowledge of stigma, mental health, and factors of resilience or minority coping remains relatively limited as it applies to sexual and gender minority populations. This is particularly so for the transgender population. The few extant studies involved very high-risk transgender populations in urban settings19–22,47 or clinical or very small samples48–50 or did not use standardized measures of mental health.51,52To address these limitations and gaps in knowledge, we analyzed cross-sectional data from a large and diverse online sample of transgender persons in the United States to obtain prevalence estimates of psychological distress (depression, anxiety, and somatization) and stigma (enacted and felt) and to test the association between these measures. Our hypotheses, informed by the minority stress model, were that the minority stressors of felt stigma, enacted stigma, and concealment of transgender identity (reflected in a stronger investment in passing as a member of the opposite gender and living in stealth, highly closeted) would be negatively associated with mental health and that this association would be moderated by factors of resilience such as family support, peer support, and identity pride. Empirical support for these hypotheses would strongly argue for confronting the social structures, norms, and attitudes that produce minority stress for gender-variant people and improving access to mental health and social services that affirm transgender identity and promote resilience.We also tested a series of related hypotheses regarding the specific associations of concealment or disclosure of transgender identity and stigma with anticipated gender differences (transgender women vs men) in our variables of interest. Because identity concealment offers fewer opportunities to challenge perceived or anticipated negative evaluations of identity by the majority culture, we expected investment in passing to be associated with felt stigma. Conversely, we expected coming out and greater willingness to be open about being transgender to be associated with enacted stigma—actual experiences of rejection and discrimination. In addition, because gender nonconformity is thought to be more stigmatized among men than women,28,30 we expected transgender women to report higher levels of psychological distress than did transgender men.Finally, because passing as the opposite gender is thought to be easier for transgender men than women,29 we expected transgender women to report higher levels of enacted stigma (the negative effect of being visible), but lower levels of felt stigma (the positive effect of being visible, which creates greater opportunities for challenging perceived or anticipated negative evaluations by the majority culture). Empirical support for these hypotheses would enable us to identify subgroups of the transgender population at particularly high risk for the negative impact of minority stress on mental health and to design targeted intervention strategies.     

Community Violence Perpetration and Victimization Among Adults With Mental Illnesses

Objectives. In a large heterogeneous sample of adults with mental illnesses, we examined the 6-month prevalence and nature of community violence perpetration and victimization, as well as associations between these outcomes.Methods. Baseline data were pooled from 5 studies of adults with mental illnesses from across the United States (n = 4480); the studies took place from 1992 to 2007. The MacArthur Community Violence Screening Instrument was administered to all participants.Results. Prevalence of perpetration ranged from 11.0% to 43.4% across studies, with approximately one quarter (23.9%) of participants reporting violence. Prevalence of victimization was higher overall (30.9%), ranging from 17.0% to 56.6% across studies. Most violence (63.5%) was perpetrated in residential settings. The prevalence of violence-related physical injury was approximately 1 in 10 overall and 1 in 3 for those involved in violent incidents. There were strong associations between perpetration and victimization.Conclusions. Results provided further evidence that adults with mental illnesses experienced violent outcomes at high rates, and that they were more likely to be victims than perpetrators of community violence. There is a critical need for public health interventions designed to reduce violence in this vulnerable population.The risk of violence associated with mental illnesses is a topic of research, media coverage, and debate. Research indicates that between 11% and 52% of adults with mental illnesses have been violent within a 12-month period,1–7 and data from the National Comorbidity Survey show that rates of violence for adults with mental illnesses are 2 to 8 times greater than in the general population.8 Other studies show modest but significant relationships between mental illness and violence,3,9,10 even after controlling for substance abuse.11 Although highly publicized cases of violence perpetrated by adults with mental illnesses have highlighted their “dangerousness,” data suggest they experience victimization at rates comparable to or higher than their rates of perpetration.12 Studies show 12-month prevalence rates between 20% and 44%,7,12–15 and indicate the likelihood of experiencing violent victimization is 23 times higher in adults with mental illnesses compared with the general population.12 Despite these findings, there remains a focus on violence perpetration to the neglect of victimization in this vulnerable population.The increased risk of violent outcomes that is associated with mental illnesses represents a substantial public health burden. Violence can be devastating to victims and perpetrators alike, as well as being costly to the public.16,17 In addition to physical injury, violence may precipitate the loss of personal liberty because of incarceration18 or civil commitment,19 require implementation of expensive clinical and risk assessment and management strategies,20 perpetuate the stigma associated with mental illness,21 and disrupt continuity of care.22 Consequently, an understanding of the prevalence and nature of community violence—both perpetration and victimization—among adults with mental illnesses is critical to public health research and practice.Unfortunately, the empirical literature is limited. First, there are many more studies of perpetration than victimization; a review of the literature found 3 times as many publications about the link between mental illness and violence compared with the link between mental illness and victimization.23 Second, although they are risk factors for each other,24–26 there have been few studies of community violence perpetration and victimization. Only a handful of peer-reviewed publications report on both outcomes in the same sample of adults with mental illnesses during the same reference period.27–30 Third, studies that have examined both outcomes have restricted power and generalizability because of the relatively small, nonrepresentative samples. Fourth, there is heterogeneity in the operational definitions of violence, preventing meaningful comparisons or aggregation of findings. Fifth, violent outcomes are frequently measured with a single yes or no question (e.g., “Have you been victimized in the past 12 months?”), a measurement approach with limited sensitivity.31     

A Model to Translate Evidence-Based Interventions Into Community Practice

There is a tension between 2 alternative approaches to implementing community-based interventions. The evidence-based public health movement emphasizes the scientific basis of prevention by disseminating rigorously evaluated interventions from academic and governmental agencies to local communities. Models used by local health departments to incorporate community input into their planning, such as the community health improvement process (CHIP), emphasize community leadership in identifying health problems and developing and implementing health improvement strategies. Each approach has limitations. Modifying CHIP to formally include consideration of evidence-based interventions in both the planning and evaluation phases leads to an evidence-driven community health improvement process that can serve as a useful framework for uniting the different approaches while emphasizing community ownership, priorities, and wisdom.Two approaches to implementing community health improvement interventions are in use, each with strengths and limitations. Research-driven approaches such as evidence-based public health1 emphasize the scientific basis of prevention by disseminating rigorously evaluated interventions from academic and governmental agencies to local communities. These approaches acknowledge that the efficacy of an intervention in controlled trials frequently does not carry over to wide implementation in communities.2 Other approaches to incorporating community input into local health department planning, such as the community health improvement process (CHIP),3 Mobilizing for Action Through Planning and Partnerships,4 and PRECEDE-PROCEED,5 emphasize community leadership in identifying high-priority health problems and in developing and implementing health improvement strategies. We designed the evidence-driven community health improvement process (EDCHIP) to unite these different approaches to community health planning, implementation, and evaluation and emphasize community ownership, priorities, and wisdom.     

Preparedness for Natural Disasters Among Older US Adults: A Nationwide Survey

Objectives. We sought to determine natural disaster preparedness levels among older US adults and assess factors that may adversely affect health and safety during such incidents.Methods. We sampled adults aged 50 years or older (n = 1304) from the 2010 interview survey of the Health and Retirement Study. The survey gathered data on general demographic characteristics, disability status or functional limitations, and preparedness-related factors and behaviors. We calculated a general disaster preparedness score by using individual indicators to assess overall preparedness.Results. Participant (n = 1304) mean age was 70 years (SD = 9.3). Only 34.3% reported participating in an educational program or reading materials about disaster preparation. Nearly 15% reported using electrically powered medical devices that might be at risk in a power outage. The preparedness score indicated that increasing age, physical disability, and lower educational attainment and income were independently and significantly associated with worse overall preparedness.Conclusions. Despite both greater vulnerability to disasters and continuous growth in the number of older US adults, many of the substantial problems discovered are remediable and require attention in the clinical, public health, and emergency management sectors of society.Each of the past few years has witnessed more natural disasters than any year on record, costing billions of dollars, according to the US National Climatic Data Center.1 President Obama declared a record number of federally designated natural disasters in 2011, more in the first 3 years of his presidency than almost any other presidents in their full 4-year terms.2 In 2012, insured economic losses from severe weather-related catastrophes in the United States totaled $57.9 billion.2 We continue to experience aberrant climatic and geologic phenomena that can jeopardize older adults and disproportionately affect them.3 Three quarters of those who perished in Hurricane Katrina in 2005 were aged older than 60 years.4 Natural disasters, such as the earthquake and tsunami in Japan in 2011 and Hurricane Sandy in 2012, continue to occur and impose serious aftermaths on older persons.5,6Having the highest prevalence rates for multiple chronic conditions, limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), physical and cognitive disabilities, and sensory impairments makes older adults particularly vulnerable to physiological stresses during natural disasters.7 However, most fatalities, injuries, and damage caused by natural disasters, such as floods, tornadoes, hurricanes, and earthquakes, are preventable.8 Preparing older adults for disasters by following certain precautionary measures and designing comprehensive disaster management plans can alleviate some proportion of the physical, social, and emotional damage that occurs in these situations. But an important public health question is, How prepared are older US adults for natural disasters? We report the results of a survey of older Americans, part of the Health and Retirement Study (HRS), an ongoing nationwide panel study of the health, social, and economic status among persons, conducted by the University of Michigan.9     

Higher Yet Suboptimal Chlamydia Testing Rates at Community Health Centers and Outpatient Clinics Compared With Physician Offices

To assess chlamydia testing in women in community health centers, we analyzed data from national surveys of ambulatory health care. Women with chlamydial symptoms were tested at 16% of visits, and 65% of symptomatic women were tested if another reproductive health care service (pelvic examination, Papanicolaou test, or urinalysis) was performed. Community health centers serve populations with high sexually transmitted disease rates and fill gaps in the provision of sexual and reproductive health care services as health departments face budget cuts that threaten support of sexually transmitted disease clinics.Community health centers can serve as a key health care venue for the provision of quality sexual and reproductive health care services for persons in medically underserved communities. They are public or nonprofit, community-directed health care facilities that increase access to care for persons who experience barriers to quality health care, such as their inability to pay, geographic location, or language or cultural differences.1With increasing closure of sexually transmitted disease (STD) clinics throughout the United States,2 greater provision of STD services in community settings will be important for protecting the sexual and reproductive health of men and women in minority populations with high prevalence of STDs and limited access to care.3,4 An important STD service is chlamydia testing for persons with symptoms or signs of infection and also for all asymptomatic sexually active women aged 25 years or younger annually, as recommended by the Centers for Disease Control and Prevention and other organizations.5–7 An untreated chlamydial infection can result in serious complications, including pelvic inflammatory disease, infertility, or ectopic pregnancy.8–10 We estimated the proportion of visits made by women to community health centers, physician offices, and outpatient clinics with a chlamydia screening or diagnostic test.     

Feasibility of a Web-Based Training System for Peer Community Health Advisors in Cancer Early Detection Among African Americans

We describe the feasibility of a Web-based portal for training peer community health advisors (CHAs). We conducted a community-based implementation trial in African American churches between 2012 and 2014. The Web-based portal allows CHAs to log in and view 13 training videos, preparing them to deliver 3 cancer early detection workshops in their churches. Of 8 churches, 6 completed the training, each certifying 2 CHAs. These CHAs took an average of 26 days to complete the training, requiring little technical assistance. Additional technical assistance was required to implement the workshops. The Web-based system appears to be a feasible method for training lay individuals for the CHA role and has implications for increasing the reach of evidence-based interventions.It has been well documented that many evidence-based health promotion interventions fail to achieve further implementation or use in the communities they are intended to serve.1 Such interventions, without intentional effort, do not disseminate themselves into practice.2 Interest in dissemination and implementation research is growing. Consistent with Rabin et al.,3 we use the term dissemination to refer to the active process of spreading evidence-based interventions to a particular audience using planned approaches and the term implementation to refer to the processes of integrating evidence-based interventions within a setting. We use the phrase dissemination and implementation to refer to the broader field in general.Previous dissemination and implementation research has mainly focused on health care settings. More research is needed to identify optimal ways to translate research evidence into practice, including interventions in community settings that use community-based participatory methods.4 This includes research on successful implementation of interventions serving culturally and ethnically diverse populations.2 Peer health educators are viewed as a promising strategy to achieve this goal.5 Volunteer laypeople, such as those used in the community health advisor (CHA) model, have been used worldwide to promote health.6 This model for community health promotion recognizes that CHAs are cultural insiders and trusted sources of information and can help increase access to health care while naturally building capacity in the community for sustained positive health outcomes.6–10     

Experiences of Discrimination and Their Impact on the Mental Health Among African American,Asian and Pacific Islander,and Latino Men Who Have Sex With Men

Objectives. We examined the associations between specific types and sources of discrimination and mental health outcomes among US racial/ethnic minority men who have sex with men (MSM) and how these associations varied by race/ethnicity.Methods. A chain-referral sample of 403 African American, 393 Asian and Pacific Islander (API), and 400 Latino MSM recruited in Los Angeles County, California completed a standardized questionnaire. Data were obtained from the Ethnic Minority Men’s Health Study from May 2008 to October 2009.Results. Past-year experiences of racism within the general community and perceived homophobia among heterosexual friends were positively associated with depression and anxiety. Past-year homophobia experienced within the general community was also positively associated with anxiety. These statistically significant associations did not vary across racial/ethnic groups. The positive association of perceived racism within the gay community with anxiety differed by race/ethnicity, and was statistically significant only for APIs. Perceived homophobia within the family was not associated with either depression or anxiety.Conclusions. Higher levels of experiences of discrimination were associated with psychological distress among MSM of color. However, specific types and sources of discrimination were differentially linked to negative mental health outcomes among African American, API, and Latino MSM.Accumulating data indicate that mental health problems are more prevalent among sexual minorities than among heterosexuals.1,2 A recent meta-analysis of 25 epidemiological studies revealed that the lifetime prevalence of depression and anxiety disorders was at least 1.5 times higher among lesbians, gays, and bisexuals, whereas the lifetime risk for suicide attempts was 2.47 times greater in sexual minority groups.2 Research linked a wide range of mental health outcomes among sexual minorities—including depression,3–10 anxiety,6,9,10 panic disorder,6 psychological distress,11–16 suicide attempts,11 and suicidal ideation11,17—to the effects of discrimination. Furthermore, studies showed widespread experiences of discrimination among sexual minorities.6,8,16,18,19 One population-based survey of US adults found that more than three quarters (76%) of gay or bisexual respondents reported a lifetime experience of discrimination.6 In another population-based survey of US adults, close to one quarter (21.4%) of lesbian, gay, or bisexual respondents reported experiencing discrimination in the past year.18Although the disproportionate prevalence of mental health difficulties and experiences of social discrimination among lesbian, gay, and bisexual people are well documented, the association between discrimination and mental health outcomes is not well understood. Among the gaps in our understanding are the following 2 points. First, it is unclear which types and sources of discrimination have an adverse effect on mental health among sexual minorities. Three of the 15 existing studies on the impact of discrimination on mental health outcomes utilized composite measures of overall perceived discrimination that combined various forms of discrimination experiences.6,10,15 Eleven studies examined specific types of discrimination, such as antigay violence,5,9,11,12,14,17 racism,8,16 and homophobia,3,4,8,12,13,16 but made no specific references to their sources (e.g., family, heterosexual friends, a mainstream gay community, a larger general community). One study specified only a single source (i.e., White gay men) for one particular form of discrimination (i.e., perceived devaluation of Asian gay men7).Second, it remains unknown whether previous study findings on the association between discrimination and poor mental health outcomes among sexual minorities are generalizable across racial/ethnic groups, because few studies of sexual minorities have directly compared the effects of discrimination on mental health outcomes among various racial/ethnic minority groups. Studies of discrimination and mental health among sexual minorities have either aggregated multiple racial and ethnic groups,3–6,9,11–14,17 or been limited to 1 (i.e., African Americans,10 Asians,8 Latinos16) or 2 groups (i.e., Asians and Latinos15).The present study addressed these gaps in the literature by examining the associations of specific types and sources of discrimination with mental health outcomes in a sample of African American, Asian or Pacific Islander (API), and Latino men who have sex with men (MSM). First, we examined the prevalence of discrimination based on race/ethnicity and sexual orientation. Second, we determined which types and sources of discrimination were associated with mental health outcomes. Finally, we assessed whether these associations varied by race/ethnicity.