Erika L. Austin

Sexual Orientation Disclosure to Health Care Providers Among Urban and Non-Urban Southern Lesbians

Concerns regarding sexual orientation disclosure to health care providers have been suggested as a barrier to care which may account for documented differences in the health care utilization of lesbians relative to heterosexual women. This study explored the correlates of sexual orientation disclosure to health care providers among 934 lesbian women living in urban and non-urban areas of the South. Psychosocial resources, such as self-esteem, social support, and mastery, along with several lesbian-specific experiences (proportion of lesbian, gay, bisexual, or transgender friends, access to the lesbian, gay, bisexual, or transgender community, degree of being “out”), were all independently associated with greater likelihood of having disclosed to a health care provider. Internalized homophobia and lesbian-related stigma decreased the likelihood of disclosure. Lesbians living in non-urban areas were significantly less likely to have disclosed than women in urban areas, suggesting that disclosure may present a special concern for populations in non-urban areas.

Added Benefit of Nucleic Acid Amplification Testing for the Diagnosis of Trichomonas vaginalis Among Men and Women Attending a Sexually Transmitted Diseases Clinic

BACKGROUND Trichomonas vaginalis (TV) is the most common nonviral sexually transmitted infection (STI) in the world. However, TV is not a reportable STI and, with the exception of HIV-positive women, there are no guidelines for screening in women or men. The objective of this study was to determine the added value of nucleic acid amplification tests (NAATs) for detection of TV in men and women at high risk for infection as well as correlates of infection. METHODS This was a review of clinical and laboratory data of men and women presenting to the Jefferson County Department of Health Sexually Transmitted Diseases (STD) Clinic and receiving a TV NAAT. RESULTS During 2012-2013, 6335 patients (3821 women and 2514 men) received a TV NAAT on endocervical, urethral, or urine specimens. Overall TV prevalence was 20.2%; 27.0% in women and 9.8% in men. Correlates of TV among men included age >40 years, African American race, and ≥5 polymorphonuclear cells per high-power field on urethral Gram stain. Age >40 years, African American race, leukorrhea on wet mount, elevated vaginal pH, positive whiff test, and concurrent gonococcal infection were positively associated with TV among women. TV NAAT detected approximately one-third more infections among women than wet mount alone. CONCLUSIONS TV prevalence among men and women was high in this study, suggesting that both groups should be routinely screened, including those aged >40 years. Improved detection of TV by routine implementation of NAATs should result in better control of this common, treatable STI.

VA’s Expansion of Supportive Housing: Successes and Challenges on the Path Toward Housing First

OBJECTIVES The U.S. Department of Veterans Affairs (VA) is transitioning to a Housing First approach to placement of veterans in permanent supportive housing through the use of rental vouchers, an ambitious organizational transformation. This qualitative study examined the experiences of eight VA facilities undertaking this endeavor in 2012. METHODS A multidisciplinary team interviewed facility leadership, midlevel managers, and frontline staff (N=95 individuals) at eight VA facilities representing four U.S. regions. The team used a semistructured interview protocol and the constant comparative method to explore how individuals throughout the organizations experienced and responded to the challenges of transitioning to a Housing First approach. RESULTS Frontline staff faced challenges in rapidly housing homeless veterans because of difficult rental markets, the need to coordinate with local public housing authorities, and a lack of available funds for move-in costs. Staff sought to balance their time spent on housing activities with intensive case management of highly vulnerable veterans. Finding low-demand sheltering options (that is, no expectations regarding sobriety or treatment participation, as in the Housing First model) for veterans waiting for housing presented a significant challenge to implementation of Housing First. Facility leadership supported Housing First implementation through resource allocation, performance monitoring, and reliance on midlevel managers to understand and meet the challenges of implementation. CONCLUSIONS The findings highlight the considerable practical challenges and innovative solutions arising from a large-scale effort to implement Housing First, with particular attention to the experiences of individuals at all levels within an organization.

Sexual partnership characteristics of African American women who have sex with women; impact on sexually transmitted infection risk.

Background African American women who have sex with women (WSW) are emerging as a population at risk for sexually transmitted infections (STIs). The objectives of this study were to explore partnership characteristics for a cohort of African American WSW and evaluate those characteristics as potential risk factors for STIs. In addition, we aimed to determine STI diagnoses and identify predictors of STI infection. Methods Women who have sex with women presenting to a sexually transmitted disease clinic in Birmingham, AL, completed a questionnaire and were tested for bacterial vaginosis, trichomoniasis, chlamydia, gonorrhea, Mycoplasma genitalium, syphilis, HIV, and herpes simplex virus type 2. Results A total of 163 women were enrolled: 78 WSW and 85 women who have sex with women and men (WSWM) (based on report of past year sexual behavior). Both WSW and WSWM reported similar numbers of female partners over the lifetime, past year, and past month; however, WSWM reported significantly more lifetime male partners, thus having a higher overall number of sexual partners. Women who have sex with women and men were more likely to report new or casual partner(s), group sex, history of STIs, and sex with partner(s) known to have STIs. Overall, WSWM were more likely to have a current diagnosis of bacterial vaginosis, a current diagnosis of a curable STI, or a diagnosis of a noncurable STI (85% vs. 56%, P < 0.01). Conclusions African American WSW are not a homogeneous group, and their sexual health may be directly or indirectly influenced by male partners. A better understanding of the distinctions and differences between African American WSW and WSWM will enable health care providers to improve the quality of care provided.

Sexual behaviors, perception of sexually transmitted infection risk, and practice of safe sex among southern African American women who have sex with women.

Background Women who have sex with women (WSW) and women who have sex with women and men (WSWM) are frequently perceived to be at low risk for sexually transmitted infections (STIs), although data show that their STI rates are similar to heterosexual women. Little research has examined sexual behaviors, perceptions of STI risk, and practice of safe sex among African American WSW/WSWM living in the Southern United States, a population of women likely to be at high risk for STIs. Methods Focus group discussions were conducted with African American WSW/WSWM living in Birmingham, Alabama, to explore their sexual behaviors with women, perceptions of STI risk from female (and male) sexual partners, and practice of safe sex. Digital audio-recordings were transcribed and analyzed using HyperRESEARCH software. Results Seven focus groups were conducted between August 2011 and March 2012, with 29 total participants. Women reported a broad range of sexual behaviors with female partners. They were more aware of their risk for STI acquisition from male partners than from female partners and felt that their best options for safe sex in their relationships with women were practicing good hygiene and requiring proof of STI testing results. Conclusions African American WSW/WSWM in this study were aware of their STI risk, more so with regard to men, and desired accurate information on safer sex options in their sexual relationships with women. Health care providers can assist these women by helping them apply their existing knowledge of heterosexual STI transmission to their female sexual partnerships.

Suicide Ideation and Suicide Attempts Among White Southern Lesbians

Several studies find suicide behaviors to be more prevalent among lesbian, gay, and bisexual (LGB) populations than their heterosexual counterparts. Studies of non-LGB populations reveal 13% prevalence of lifetime ideation and 4% prevalence of lifetime attempts. This study analyzed data from the Lesbian Social Life (LSL) study, a primarily online, survey-based research project focusing on lesbians living in the southern United States, and found that more than 40% of participants had seriously considered suicide and more than 15% had attempted suicide. We estimated the likelihood of suicide ideation and attempts by utilizing known general risk factors and lesbian-specific indicators within hierarchical logistic regression. Predictors of suicide ideation and attempts included depressive symptoms, discrimination, social support, self-esteem, and stigma. Results highlight the magnitude of suicide behaviors in southern lesbians and important predictor variables. Analysis shows support for the minority stress theory, and policy and clinical recommendations are provided.

Bacterial vaginosis among African American women who have sex with women.

Background Bacterial vaginosis (BV) is a frequent cause of vaginal discharge that may be more common among women reporting sex with women (WSW). The objective of this study was to determine the prevalence of BV and predictors of infection among a sample of African American WSW. Methods African American WSW aged 18 years or older presenting to the Mississippi State Department of Health STD Clinic between 2009 and 2010 and reporting a history of sexual activity with a female partner during the preceding year were invited to participate. A survey on sexual history and sexual behavior characteristics was completed. Bacterial vaginosis was defined by Amsel criteria. Associations with participant characteristics were determined using logistic regression analysis. Results Bacterial vaginosis was diagnosed in 93 (47.4%) of 196 women. Bisexual identity (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.03–3.66; P = 0.04), douching within the past 30 days (OR, 1.93; 95% CI, 1.09–3.43; P = 0.02), age 18 years or less at first sexual encounter with a female partner (OR, 3.18; 95% CI, 1.16–8.71; P = 0.02), and report of more than 1 lifetime male sexual partners (OR, 1.94; 95% CI, 1.01–3.74; P = 0.04) were significant predictors of BV in bivariate analysis. Bacterial vaginosis was less common among women who reported more than 1 lifetime female sexual partner (OR, 0.26; 95% CI, 0.09–0.76; P = 0.01). In multivariable analysis, age 18 years or less at first sex with a female partner approached significance, while report of 1 lifetime female sexual partner remained strongly associated with BV. Conclusions Bacterial vaginosis was common in this sample of African American WSW and significantly associated with report of 1 lifetime female sexual partner.

Making housing first happen: organizational leadership in VA's expansion of permanent supportive housing.

ABSTRACTBACKGROUNDWhile most organizational literature has focused on initiatives that transpire inside the hospital walls, the redesign of American health care increasingly asks that health care institutions address matters outside their walls, targeting the health of populations. The US Department of Veterans Affairs (VA)’s national effort to end Veteran homelessness represents an externally focused organizational endeavor.OBJECTIVEOur aim was to evaluate the role of organizational practices in the implementation of Housing First (HF), an evidence-based homeless intervention for chronically homeless individuals.DESIGNThis was an interview-based comparative case study conducted across eight VA Medical Centers (VAMCs).PARTICIPANTSFront line staff, mid-level managers, and senior leaders at VA Medical Centers were interviewed between February and December 2012.APPROACHUsing a structured narrative and numeric scoring, we assessed the correlation between successful HF implementation and organizational practices devised according to the organizational transformation model (OTM).KEY RESULTSScoring results suggested a strong association between HF implementation and OTM practice. Strong impetus to house Veterans came from national leadership, reinforced by Medical Center directors closely tracking results. More effective Medical Center leaders differentiated themselves by joining front-line staff in the work (at public events and in process improvement exercises), by elevating homeless-knowledgeable persons into senior leadership, and by exerting themselves to resolve logistic challenges. Vertical alignment and horizontal integration advanced at sites that fostered work groups cutting across service lines and hierarchical levels. By contrast, weak alignment from top to bottom typically also hindered cooperation across departments. Staff commitment to ending homelessness was high, though sustainability planning was limited in this baseline year of observation.CONCLUSIONKey organizational practices correlated with more successful implementation of HF for homeless Veterans. Medical Center directors substantively influenced the success of this endeavor through their actions to foster impetus, demonstrate commitment and support alignment and integration.

Sexual orientation and sexual health services utilization among women in the United States

Although sexual minority women are at risk of sexually transmitted infections (STIs) and cervical cancer, few nationally representative studies have assessed sexual orientation disparities in sexual health care among women. Using data from the 2011-2013 and 2013-2015 waves of the National Survey of Family Growth, which provide a national probability sample of U.S. women aged 15-44years (N=11,300), we used multivariable logistic regression to examine the associations between sexual behavior and sexual identity (modeled separately) and STI testing in the past year, Pap test use in the last 3years, lifetime HIV testing, and lifetime human papillomavirus (HPV) testing. Women with male and female lifetime sexual partners had higher adjusted odds of being tested for STIs ([odds ratio:] 1.61; [95% confidence interval:] 1.37-1.89), HIV (1.66; 1.29-2.14), and HPV (1.79; 1.41-2.25) and similar adjusted odds of obtaining a Pap test (0.98; 0.76-1.27) than women with only male lifetime sexual partners. Self-identified bisexual women had higher adjusted odds of obtaining an STI (1.43; 1.10-1.86) and HIV (1.69; 1.24-2.30) test but lower adjusted odds of obtaining a Pap test in the last 3years (0.66; 0.47-0.93) than heterosexual-identified women. Women with only female lifetime sexual partners had lower adjusted odds of receiving an STI (0.14; 0.07-0.28) and Pap (0.10; 0.03-0.27) test than women with only male lifetime sexual partners. Results comparing self-identified lesbian and heterosexual women were similar. Health care facilities should monitor and address sexual orientation disparities in womens sexual health care and ensure the provision of high-quality sexual health services to all women.

Development of the Primary Care Quality-Homeless (PCQ-H) instrument: a practical survey of homeless patients' experiences in primary care.

Background:Homeless patients face unique challenges in obtaining primary care responsive to their needs and context. Patient experience questionnaires could permit assessment of patient-centered medical homes for this population, but standard instruments may not reflect homeless patients’ priorities and concerns. Objectives:This report describes (a) the content and psychometric properties of a new primary care questionnaire for homeless patients; and (b) the methods utilized in its development. Methods:Starting with quality-related constructs from the Institute of Medicine, we identified relevant themes by interviewing homeless patients and experts in their care. A multidisciplinary team drafted a preliminary set of 78 items. This was administered to homeless-experienced clients (n=563) across 3 VA facilities and 1 non-VA Health Care for the Homeless Program. Using Item Response Theory, we examined Test Information Function (TIF) curves to eliminate less informative items and devise plausibly distinct subscales. Results:The resulting 33-item instrument (Primary Care Quality-Homeless) has 4 subscales: Patient-Clinician Relationship (15 items), Cooperation among Clinicians (3 items), Access/Coordination (11 items), and Homeless-specific Needs (4 items). Evidence for divergent and convergent validity is provided. TIF graphs showed adequate informational value to permit inferences about groups for 3 subscales (Relationship, Cooperation, and Access/Coordination). The 3-item Cooperation subscale had lower informational value (TIF<5) but had good internal consistency (&agr;=0.75) and patients frequently reported problems in this aspect of care. Conclusions:Systematic application of qualitative and quantitative methods supported the development of a brief patient-reported questionnaire focused on the primary care of homeless patients and offers guidance for future population-specific instrument development.