Identifying Gay Neighborhoods and Estimation of the Size of the Men who have Sex with Men Population in Florida who would benefit from Pre-exposure Prophylaxis

Given the potential benefit of pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) at risk for human immunodeficiency virus (HIV), it would be useful to assess the size of the at-risk population and their geographic distribution to target PrEP and other prevention programs efficiently. In 2017, Florida ranked third for HIV diagnosis rates in the US, and 63% of those who received a new HIV diagnosis in Florida were MSM. The purpose of this dissertation was to 1) summarize population-based methods to estimate the size of the population of MSM, 2) identify gay neighborhoods using latent class analysis (LCA), and 3) estimate the size of the MSM population in Florida. A systematic review of population-based methods to estimate the size of the MSM population was conducted. Twenty-eight studies met inclusion criteria. Sixteen studies were conducted in the US, five in European countries, two in Canada, three in Australia, one in Israel, and one in Kenya. Men who have sex with men made up 0.03–6.4% of men among all studies and ranged from 3.8–6.4% in the US, 7,000–39,100 in Canada, 0.03–6.5% in European countries, and 127,947–182,624 in Australia. Latent class analysis was used to identify gay neighborhoods in Florida. Data at the ZIP code level was drawn from the 2011–2015 ACS, website lists of gay bars and neighborhoods, and the Florida Department of Health’s HIV surveillance system. A two-class model was selected. About 9% of the ZIP code data were in class two (gay neighborhoods). Cohen’s kappa coefficient was used to examine agreement between the classification of ZIP codes from LCA and gay neighborhoods from websites. Fair agreement was found (0.2501). Three methods were used to estimate the MSM population in Florida with high-risk behaviors that would indicate eligibility for PrEP use. The resulting three estimates were averaged, and the number of MSM living with HIV infection in each ZIP code was subtracted. The average MSM estimate in ZIP codes ranged from 1–2,184 men (1.5–22.9%). The presumed HIV-negative MSM estimate in ZIP codes ranged from 1–1,346 men (0.02–12.7%). Indications for PrEP were highest for MSM with more than one sex partner in the past year and lowest when the estimate was multiplied by 24.7% (percent of MSM with PrEP indications from other studies). In conclusion, there is no widely accepted method to estimate the size of the MSM population, and estimates vary substantially based on the method used. Therefore, it would be prudent to consider a range of estimates in planning HIV prevention efforts

A Qualitative Analysis of End-of-Life Healthcare in Tennessee: Politics, Principles, and Perceptions

The unprecedented growth of the aging population in Tennessee is a significant demographic trend that highlights the necessity for healthcare policy that tackles end-of-life issues. This study examined the perceived quality of end-of-life healthcare in Tennessee, areas that are in need of improvement, policies that have the potential to influence improvements, and the role of politics in end-of-life healthcare policy. It also assessed the support for end-of-life healthcare policy that would advance quality of care and expand end-of-life choices for Tennesseans, while evaluating the policy-making process that legislators employ. For this study, data were collected using semi-structured, in-depth interviews with an open interview guide. These interviews were conducted in a two-tiered format. Tier 1 included ten leading experts in various areas of end-of-life healthcare and aging in Tennessee. Tier 2 included nine legislators who were members of the health committees of either the Tennessee House of Representatives or the Tennessee Senate. Qualitative data were organized into numerous categories, and an initial phase of open coding was completed. From this phase of coding, emergent themes and focuses were discovered. This was followed by focused coding on all nineteen interviews using coding software to organize subtleties. Findings of the Tier 1 interviews indicated that there are many areas of end-of-life healthcare that need improvement including increased funding, expanded caregiver support, improved doctor-patient communication, and increased use of advance directives. Emergent themes included the influence of money, having difficult conversations, the stigma of death and dying, and supporting the caregiver. Tier 2 findings highlighted the motivations behind voting decisions and the level of awareness legislators have in areas of end-of-life healthcare policy. Both tiers also explored the support and opposition of physician-assisted death. The findings of this dissertation are intended to inform health professionals and state legislators. The data gathered through this exploratory research and the knowledge gained will lead to a greater understanding of end-of-life healthcare in Tennessee, and what needs to be done to improve its quality. This will allow individuals and families faced with end-of-life decisions to navigate the process with expanded options, access, and support

Masculine Gender Role Stress and Shame Proneness as Serial Mediators in the Relation Between Intimate Partner Aggression Victimization and Psychological Symptom Status in Men

The current study examined the indirect effect of male intimate partner aggression victimization on psychological symptom status through masculine gender role stress (MGRS) and shame proneness operating as serial mediators. Male college students (N = 74) completed self-report measures of intimate partner aggression, psychological symptoms, MGRS, and shame proneness. Results indicated a significant indirect effect of physical victimization on psychological symptom status through MGRS and shame proneness operating in sequence; results showed no significant indirect effect for psychological victimization. These results suggest that, perhaps, physical victimization creates increased MGRS, which, in turn, leads to greater shame proneness, which, likewise, produces increased psychological symptoms. Possible interpretations of differential findings for physical and psychological victimization are discussed in relation to differential threat to masculinity. Additionally, exploratory analyses for specific psychological symptom clusters (i.e., depression, anxiety, and hostility) are presented and discussed