The document reviews literature on HIV status disclosure across diverse settings. Some key findings from the literature include:
- The majority of people disclosed their HIV status to someone, though disclosure rates varied from about 2/3 to 3/4 of respondents. Disclosure was generally higher in high-income countries.
- Gender shaped disclosure motivations and reactions, with women more likely to disclose to other women like mothers and sisters. Disclosure rates to partners varied between studies and by gender.
- Involuntary disclosure and low levels of disclosure to partners highlight the difficulties faced by health workers in facilitating disclosure while protecting privacy.
- Stigmatization increased fears of disclosure. The meaning and process of disclosure differed across settings.
HIV Prevention And Health Service Needs Of The Transgender Community In San F...Santé des trans
HIV Prevention and Health Service Needs of the Transgender Community in San Francisco by Kristen Clements, MPH, Willy Wilkinson, Kerrily Kitano, Rani Marx.
Il s'agit de l'un des articles parus dans le numéro spécial de l'International Journal of Transgenderism consacré en 1999 à "Transgenders and HIV : risks, prevention and care" (référence : IJT Volume 3, Number 1+2, January - June 1999).
Il s'agit d'une fiche technique sur la prévention du VIH parmi les trans.
Non datée, elle est le fruit du travail de Rita Melendez, de la San Francisco State University, Valerie Spencer de la Charles R. Drew University, et David Whittier, du Centers for Disease Control and Prevention.
Branch vital, angela condom use among african-american women-nfmij-6-1-09William Kritsonis
Dr. William Allan Kritsonis, Editor-in-Chief, NATIONAL FORUM JOURNALS (Founded 1982). Dr. Kritsonis has served as an elementary school teacher, elementary and middle school principal, superintendent of schools, director of student teaching and field experiences, professor, author, consultant, and journal editor. Dr. Kritsonis has considerable experience in chairing PhD dissertations and master thesis and has supervised practicums for teacher candidates, curriculum supervisors, central office personnel, principals, and superintendents. He also has experience in teaching in doctoral and masters programs in elementary and secondary education as well as educational leadership and supervision. He has earned the rank as professor at three universities in two states, including successful post-tenure reviews.
Il s'agit d'une présentation powerpoint de la Directrice du Center Of Excellence For Transgender HIV Prevention,UCSF (2009)
Il y est question d'épidémiologie, bien évidemment, dans un contexte où n'existe aux Etats-Unis (comme en France) aucune donnée nationale sur le nombre de personnes trans, et donc encore moins sur le nombre de trans vivant avec le VIH. La présentation donne des pistes de recommandation concernant la production de données épidémiologiques spécifiques.
La présentation est également l'occasion de passer en revue les enjeux et déterminants de santé liés à l'épidémie de VIH chez les trans, et plus largement à leur état de santé.
Objectifs de l'épidémiologie du VIH chez les personnes trans :
- comprendre les tendances épidémiologiques en cours dans les populations transgenres ;
- comprendre les facteurs favorisant le risque de dissémination du VIH parmi les femmes transgenres
(déterminants négatifs) ;
- comprend les facteurs protecteurs contre les "facteurs négatifs du point de vue de la santé" (negative health outcomes) parmi les transgenres (déterminants positifs).
Running Head FINDINGS USED TO MAKE PUBLIC HEALTH PLANNING AND POL.docxcowinhelen
Running Head: FINDINGS USED TO MAKE PUBLIC HEALTH PLANNING AND POLICY DECISIONS 5
Findings Used to Make Public Health Planning and Policy Decisions
Unit 4 - HA560
March 28, 2016
There has been increased concern among policy makers, scientists and communities that health is greatly affected by a number of factors that occur in a person’s lifetime and in multi levels. Prevention is sententious to curb occurrence of any disease within the population, and it has to come first even if access to quality healthcare services is provided. To adequately promote health and prevent diseases, certain policies and factors need to be addressed mostly factors that are related to health behaviors.
Social psychology is all about understanding individuals’ behavior specifically in a social setting. Basically, social psychology focuses on factors that influence people to behave in certain ways in presence of others. The two greatest contributors in the field of social psychology were Allport (1920) and Bandura (1963). To begin with, according to Allport; he argued that the interaction of individuals with others or the presence of social groups can encourage the development of certain behaviors (Kassin, 2014). This is what Allport referred to as social facilitation, in his research he identified that an audience will facilitate the performance of an actor in a well learnt and understood task; however the performance of the same actor will decrease in performance on difficult tasks which are newly learnt, and this is contributed by social inhibition. The second contributor in the field of social psychology is Bandura (1963), in his work he developed a notion that behavior in the social world could be possibly modeled, and this is what he referred to as social learning theory. He gave his explanation with three groups of children who were watching a video where in the video an adult showed aggressiveness towards a “bobo doll” and the adults who displayed such behavior were awarded by another adult or were just punished. Therefore Bandura found that children who saw the adult being rewarded were found to be more likely to imitate that adult’s behavior.
Certain theories plays important roles in health assessment, and a theory is defined as a collection of concepts in specific area of concern or interest in the world that need explanations, intervening and prediction. Theories need to be backed up with evidence that tend to explain why things will happen in relation to current situations, and followed with some actions to turn situations in certain desirable ways. Health assessment can be defined as a plan of care that recognizes specific person’s health needs and how such needs will be addressed by healthcare system or any other health institutions (Jarvis, 2008). Generally, health assessment is the evaluation of health status through examination of physical and psychological concerns after looking at the health history of the victim assess ...
Running head POPULATION STUDY1POPULATION STUDY5.docxtoltonkendal
Running head: POPULATION STUDY 1
POPULATION STUDY 5
Population Study
Student’s Name
University Affiliation
Population Study: Adolescents of Age 14-24 Years
Population study typically refers to a study of a group of individuals that is taken from the general population, have similar characteristics, for example, health condition, sex or age. There are several reasons for taking such studies related to such a specific group, and this may include the risk of contracting a disease or response to a drug. Examples of such study groups include school going age adolescents, newborn babies, pregnant women between the age of 20 and 40 years, aged population, among others.
Awareness and Knowledge of HIV and Other Sexually Transmitted Diseases among Adolescents of Age 14-24 Years
HIV, as well as other sexually transmitted diseases, constitutes the largest portion of health cases affecting the youths globally. Such diseases if not taken care of may lead to more complicated cases in future such as cancer, AIDS, infertility, among other cases. Such cases occur mostly in youths due to a vulnerability to which they are exposed to. And thus, there is need to create awareness as well as health education among such school-going adolescents so as to reduce these cases (Berglund, 2001).
Criteria for Inclusion
For this kind of study group, it should include all school attending students of ages between 14 years and 24 years, should be conducted and published between 1990 and 2015, be a cross-sectional studies, the studies should focus on knowledge as well as awareness of HIV and other sexually transmitted diseases among the adolescents, and lastly the studies should have measurement of knowledge or awareness (Health protection Surveillance Centre, 2005).
Exclusion Criteria
The exclusion criteria should include case reports, non-specific risk groups (such as the drug users, homosexuals, etc.), studies that seek to evaluate intervention programs, review, expert opinions, editorials, letters, and studies that are mainly on sexual activities and or behaviors.
The study group should be chosen randomly and be done majorly by targeting the institutions of learning where there is a normal distribution of such youths. In this manner, the results obtained will likely be accurate since the equal distribution represents the reality about the population.
Risk Factors: Health risk factors includes young adolescents who are exposed to sex and possess little knowledge and awareness concerning safe sex. In targeting such population, it should be taken into account that there could be an increase in the number of infections facing adolescents of age between 14 and 18 years (World Health Organisation, 2001).
Demographics: The population understudies will include all young adolescents both girls and boys falling under the age bracket that has been considered for the study.
Socio-economics: Knowledge and awareness of sexually transmitted diseases will majorl ...
httpswww.azed.govoelaselpsUse this to see the English Lang.docxpooleavelina
https://www.azed.gov/oelas/elps/
Use this to see the English Language Proficiency Standards of Arizona-Pick a grade level
https://cms.azed.gov/home/GetDocumentFile?id=54de1d88aadebe14a87070f0
http://www.corestandards.org/ELA-Literacy/introduction/how-to-read-the-standards/
how to read standards
Week 04
Acquisition and Customer Lifetime Value (CLV)
https://www.smh.com.au/politics/federal/nbn-customers-face-higher-prices-or-poorer-internet-connection-audit-warns-20190813-p52go7.html
Customer Relationship Management?
CRM is the process of carefully managing detailed information about individual
customers and all customer touch points to maximize customer loyalty.
Now closely associated with data warehousing and mining
Relationship
Relationship
Identifying good customers: RFM Model
Recency
Frequency
Monetary Value
Time/purchase occasions since the last purchase
Number of purchase occasions since first purchase
Amount spent since the first purchase
R
F
M
Total RFM Score: R Score + F score + M Score
CASE: Database for BookBinders Book Club
Predict response to a mailing for the book, Art History of Florence, based on the
following variables accumulated in the database and the responses to a test mailing:
Gender
Amount purchased
Months since first purchase
Months since last purchase
Frequency of purchase
Past purchases of art books
Past purchases of children’s books
Past purchases of cook books
Past purchases of DIY books
Past purchases of youth books
Recency
Frequency
Monetary
Example: RFM Model Scoring Criteria
R
Months from last
purchase
13-max 10-12 7-9 3-6 0-2
Score 5pts 10 15 20 25
F
Frequency > 30 21-30 16-20 11-15 0-10
Score 25pts 20 15 10 5
M
Amount
purchased
> 400 301-400 201-300 101- 200 100
Score 50 45 30 15 10
Implement using Nested If statements in Excel
Decile Classification
• Standard Assessment Method
• Apply the results of approach and
calculate the “score” of each individual
• Order the customers based on “score”
from the highest to the lowest
• Divide into deciles
• Calculate profits per deciles
Customer 1 Score 1.00
Customer 2 Score 0.99
….
Customer 230 Score 0.92
Customer 2300 Score 0.00
Decile1
Decile10
…
..
…
..
Output for Bookbinders club
Decile Score RFM No. of Mailings Cost of mailing RFM Units sold RFM Profit
10 17.6% 5000 $3,250 783 $4,733
20 34.8% 10000 $6,500 1,543 $9,243
30 46.1% 15000 $9,750 2,043 $11,093
40 53.4% 20000 $13,000 2,370 $11,170
50 65.2% 25000 $16,250 2,891 $13,241
60 77.9% 30000 $19,500 3,457 $15,757
70 83.3% 35000 $22,750 3,696 $14,946
80 91.7% 40000 $26,000 4,065 $15,465
90 97.5% 45000 $29,250 4,326 $14,876
100 100.0% 50000 $32,500 4,435 $12,735
Note: Market Potential = 4435 units and margin = $10.20
Leaky bucket
New customer
acquisition
Purchase increase by
current customers
Purchase decrease by
current customers
Lost customers
Lost customers
Credit Card Rewards Program ...
HIV Prevention And Health Service Needs Of The Transgender Community In San F...Santé des trans
HIV Prevention and Health Service Needs of the Transgender Community in San Francisco by Kristen Clements, MPH, Willy Wilkinson, Kerrily Kitano, Rani Marx.
Il s'agit de l'un des articles parus dans le numéro spécial de l'International Journal of Transgenderism consacré en 1999 à "Transgenders and HIV : risks, prevention and care" (référence : IJT Volume 3, Number 1+2, January - June 1999).
Il s'agit d'une fiche technique sur la prévention du VIH parmi les trans.
Non datée, elle est le fruit du travail de Rita Melendez, de la San Francisco State University, Valerie Spencer de la Charles R. Drew University, et David Whittier, du Centers for Disease Control and Prevention.
Branch vital, angela condom use among african-american women-nfmij-6-1-09William Kritsonis
Dr. William Allan Kritsonis, Editor-in-Chief, NATIONAL FORUM JOURNALS (Founded 1982). Dr. Kritsonis has served as an elementary school teacher, elementary and middle school principal, superintendent of schools, director of student teaching and field experiences, professor, author, consultant, and journal editor. Dr. Kritsonis has considerable experience in chairing PhD dissertations and master thesis and has supervised practicums for teacher candidates, curriculum supervisors, central office personnel, principals, and superintendents. He also has experience in teaching in doctoral and masters programs in elementary and secondary education as well as educational leadership and supervision. He has earned the rank as professor at three universities in two states, including successful post-tenure reviews.
Il s'agit d'une présentation powerpoint de la Directrice du Center Of Excellence For Transgender HIV Prevention,UCSF (2009)
Il y est question d'épidémiologie, bien évidemment, dans un contexte où n'existe aux Etats-Unis (comme en France) aucune donnée nationale sur le nombre de personnes trans, et donc encore moins sur le nombre de trans vivant avec le VIH. La présentation donne des pistes de recommandation concernant la production de données épidémiologiques spécifiques.
La présentation est également l'occasion de passer en revue les enjeux et déterminants de santé liés à l'épidémie de VIH chez les trans, et plus largement à leur état de santé.
Objectifs de l'épidémiologie du VIH chez les personnes trans :
- comprendre les tendances épidémiologiques en cours dans les populations transgenres ;
- comprendre les facteurs favorisant le risque de dissémination du VIH parmi les femmes transgenres
(déterminants négatifs) ;
- comprend les facteurs protecteurs contre les "facteurs négatifs du point de vue de la santé" (negative health outcomes) parmi les transgenres (déterminants positifs).
Running Head FINDINGS USED TO MAKE PUBLIC HEALTH PLANNING AND POL.docxcowinhelen
Running Head: FINDINGS USED TO MAKE PUBLIC HEALTH PLANNING AND POLICY DECISIONS 5
Findings Used to Make Public Health Planning and Policy Decisions
Unit 4 - HA560
March 28, 2016
There has been increased concern among policy makers, scientists and communities that health is greatly affected by a number of factors that occur in a person’s lifetime and in multi levels. Prevention is sententious to curb occurrence of any disease within the population, and it has to come first even if access to quality healthcare services is provided. To adequately promote health and prevent diseases, certain policies and factors need to be addressed mostly factors that are related to health behaviors.
Social psychology is all about understanding individuals’ behavior specifically in a social setting. Basically, social psychology focuses on factors that influence people to behave in certain ways in presence of others. The two greatest contributors in the field of social psychology were Allport (1920) and Bandura (1963). To begin with, according to Allport; he argued that the interaction of individuals with others or the presence of social groups can encourage the development of certain behaviors (Kassin, 2014). This is what Allport referred to as social facilitation, in his research he identified that an audience will facilitate the performance of an actor in a well learnt and understood task; however the performance of the same actor will decrease in performance on difficult tasks which are newly learnt, and this is contributed by social inhibition. The second contributor in the field of social psychology is Bandura (1963), in his work he developed a notion that behavior in the social world could be possibly modeled, and this is what he referred to as social learning theory. He gave his explanation with three groups of children who were watching a video where in the video an adult showed aggressiveness towards a “bobo doll” and the adults who displayed such behavior were awarded by another adult or were just punished. Therefore Bandura found that children who saw the adult being rewarded were found to be more likely to imitate that adult’s behavior.
Certain theories plays important roles in health assessment, and a theory is defined as a collection of concepts in specific area of concern or interest in the world that need explanations, intervening and prediction. Theories need to be backed up with evidence that tend to explain why things will happen in relation to current situations, and followed with some actions to turn situations in certain desirable ways. Health assessment can be defined as a plan of care that recognizes specific person’s health needs and how such needs will be addressed by healthcare system or any other health institutions (Jarvis, 2008). Generally, health assessment is the evaluation of health status through examination of physical and psychological concerns after looking at the health history of the victim assess ...
Running head POPULATION STUDY1POPULATION STUDY5.docxtoltonkendal
Running head: POPULATION STUDY 1
POPULATION STUDY 5
Population Study
Student’s Name
University Affiliation
Population Study: Adolescents of Age 14-24 Years
Population study typically refers to a study of a group of individuals that is taken from the general population, have similar characteristics, for example, health condition, sex or age. There are several reasons for taking such studies related to such a specific group, and this may include the risk of contracting a disease or response to a drug. Examples of such study groups include school going age adolescents, newborn babies, pregnant women between the age of 20 and 40 years, aged population, among others.
Awareness and Knowledge of HIV and Other Sexually Transmitted Diseases among Adolescents of Age 14-24 Years
HIV, as well as other sexually transmitted diseases, constitutes the largest portion of health cases affecting the youths globally. Such diseases if not taken care of may lead to more complicated cases in future such as cancer, AIDS, infertility, among other cases. Such cases occur mostly in youths due to a vulnerability to which they are exposed to. And thus, there is need to create awareness as well as health education among such school-going adolescents so as to reduce these cases (Berglund, 2001).
Criteria for Inclusion
For this kind of study group, it should include all school attending students of ages between 14 years and 24 years, should be conducted and published between 1990 and 2015, be a cross-sectional studies, the studies should focus on knowledge as well as awareness of HIV and other sexually transmitted diseases among the adolescents, and lastly the studies should have measurement of knowledge or awareness (Health protection Surveillance Centre, 2005).
Exclusion Criteria
The exclusion criteria should include case reports, non-specific risk groups (such as the drug users, homosexuals, etc.), studies that seek to evaluate intervention programs, review, expert opinions, editorials, letters, and studies that are mainly on sexual activities and or behaviors.
The study group should be chosen randomly and be done majorly by targeting the institutions of learning where there is a normal distribution of such youths. In this manner, the results obtained will likely be accurate since the equal distribution represents the reality about the population.
Risk Factors: Health risk factors includes young adolescents who are exposed to sex and possess little knowledge and awareness concerning safe sex. In targeting such population, it should be taken into account that there could be an increase in the number of infections facing adolescents of age between 14 and 18 years (World Health Organisation, 2001).
Demographics: The population understudies will include all young adolescents both girls and boys falling under the age bracket that has been considered for the study.
Socio-economics: Knowledge and awareness of sexually transmitted diseases will majorl ...
Similar to HEALTH POLICY AND ETHICSFacilitating HIV DisclosureFac.docx (20)
httpswww.azed.govoelaselpsUse this to see the English Lang.docxpooleavelina
https://www.azed.gov/oelas/elps/
Use this to see the English Language Proficiency Standards of Arizona-Pick a grade level
https://cms.azed.gov/home/GetDocumentFile?id=54de1d88aadebe14a87070f0
http://www.corestandards.org/ELA-Literacy/introduction/how-to-read-the-standards/
how to read standards
Week 04
Acquisition and Customer Lifetime Value (CLV)
https://www.smh.com.au/politics/federal/nbn-customers-face-higher-prices-or-poorer-internet-connection-audit-warns-20190813-p52go7.html
Customer Relationship Management?
CRM is the process of carefully managing detailed information about individual
customers and all customer touch points to maximize customer loyalty.
Now closely associated with data warehousing and mining
Relationship
Relationship
Identifying good customers: RFM Model
Recency
Frequency
Monetary Value
Time/purchase occasions since the last purchase
Number of purchase occasions since first purchase
Amount spent since the first purchase
R
F
M
Total RFM Score: R Score + F score + M Score
CASE: Database for BookBinders Book Club
Predict response to a mailing for the book, Art History of Florence, based on the
following variables accumulated in the database and the responses to a test mailing:
Gender
Amount purchased
Months since first purchase
Months since last purchase
Frequency of purchase
Past purchases of art books
Past purchases of children’s books
Past purchases of cook books
Past purchases of DIY books
Past purchases of youth books
Recency
Frequency
Monetary
Example: RFM Model Scoring Criteria
R
Months from last
purchase
13-max 10-12 7-9 3-6 0-2
Score 5pts 10 15 20 25
F
Frequency > 30 21-30 16-20 11-15 0-10
Score 25pts 20 15 10 5
M
Amount
purchased
> 400 301-400 201-300 101- 200 100
Score 50 45 30 15 10
Implement using Nested If statements in Excel
Decile Classification
• Standard Assessment Method
• Apply the results of approach and
calculate the “score” of each individual
• Order the customers based on “score”
from the highest to the lowest
• Divide into deciles
• Calculate profits per deciles
Customer 1 Score 1.00
Customer 2 Score 0.99
….
Customer 230 Score 0.92
Customer 2300 Score 0.00
Decile1
Decile10
…
..
…
..
Output for Bookbinders club
Decile Score RFM No. of Mailings Cost of mailing RFM Units sold RFM Profit
10 17.6% 5000 $3,250 783 $4,733
20 34.8% 10000 $6,500 1,543 $9,243
30 46.1% 15000 $9,750 2,043 $11,093
40 53.4% 20000 $13,000 2,370 $11,170
50 65.2% 25000 $16,250 2,891 $13,241
60 77.9% 30000 $19,500 3,457 $15,757
70 83.3% 35000 $22,750 3,696 $14,946
80 91.7% 40000 $26,000 4,065 $15,465
90 97.5% 45000 $29,250 4,326 $14,876
100 100.0% 50000 $32,500 4,435 $12,735
Note: Market Potential = 4435 units and margin = $10.20
Leaky bucket
New customer
acquisition
Purchase increase by
current customers
Purchase decrease by
current customers
Lost customers
Lost customers
Credit Card Rewards Program ...
httpfmx.sagepub.comField Methods DOI 10.117715258.docxpooleavelina
http://fmx.sagepub.com
Field Methods
DOI: 10.1177/1525822X04269550
2005; 17; 30 Field Methods
Don A. Dillman and Leah Melani Christian
Survey Mode as a Source of Instability in Responses across Surveys
http://fmx.sagepub.com/cgi/content/abstract/17/1/30
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10.1177/1525822X04269550FIELD METHODSDillman, Christian / SURVEY MODE AS SOURCE OF INSTABILITY
Survey Mode as a Source of Instability
in Responses across Surveys
DON A. DILLMAN
LEAH MELANI CHRISTIAN
Washington State University
Changes in survey mode for conducting panel surveys may contribute significantly to
survey error. This article explores the causes and consequences of such changes in
survey mode. The authors describe how and why the choice of survey mode often
causes changes to be made to the wording of questions, as well as the reasons that
identically worded questions often produce different answers when administered
through different modes. The authors provide evidence that answers may change as a
result of different visual layouts for otherwise identical questions and suggest ways
to keep measurement the same despite changes in survey mode.
Keywords: survey mode; questionnaire; panel survey; measurement; survey error
Most panel studies require measurement of the same variables at different
times. Often, participants are asked questions, several days, weeks, months,
or years apart to measure change in some characteristics of interest to the
investigation. These characteristics might include political attitudes, satis-
faction with a health care provider, frequency of a behavior, ownership of
financial resources, or level of educational attainment. Whatever the charac-
teristic of interest, it is important that the question used to ascertain it perform
the same across multiple data collections.
In addition, declining survey response rates, particularly for telephone
surveys, have encouraged researchers to use multiple modes of data collec-
tion during the administration of a single cross-sectional survey. Encouraged
by the availability of more survey modes than in the past and evidence that a
change in modes produces higher response rates (Dillman 2002), surveyors
This is a revision of a paper presented at t ...
https://iexaminer.org/fake-news-personal-responsibility-must-trump-intellectual-laziness/
Fake news: Personal responsibility must trump intellectual laziness
By Matt Chan January 4, 2017
Where do you get your news? That question has become incredibly important given the results of our Presidential Election. How many times have you heard, “I read a news story on Facebook and …” The problem: Facebook is not a news service; it’s a “social media” site whose purpose is to connect like-minded friends and family, to provide you with social connections, and online entertainment.
For Asian Americans social media provides an important and useful way of connecting socially and in some cases politically, but there is a downside. The downside is how social media actually works. These sites employ elaborate algorithms to track and analyze your posts, likes, and dislikes to provide you with a custom experience unique to you. The truth is you are being marketed to, not informed. What looks like news, is not really news, it’s personal validation. All in an attempt to keep you on the site longer, to click a few more things, to make you feel good about what you’re reading. It makes it seem like most people agree with you because you’re only fed information and stories that validate your worldview.
On the other hand, real news is hard work. Its fact-based information presented by people who have checked, researched, and documented what they are presenting as the truth. Real news can be verified.
“Fake News” is, well, fake, often times entirely made-up or containing a hint of truth. Social media was largely responsible for pushing “fake news” stories that were entirely made up to drive clicks on websites. These clicks in turn generated money for the people promoting the stories. The more outrageous the story, the more clicks, the more revenue. When you factor in the algorithms that feed you what you like, you can clearly see the more “fake news” you consume on social media, the more is pushed your way. There’s an abundance of pseudo news sites that merely re-post and curate existing stories, adding their bias to validate their audience’s beliefs, no matter how crazy or mainstream. It is curated solely for you. Now factor in that nearly 44% of Americans obtain some or most of their news from social media and you have a very toxic mix.
The mainstream news media has also fallen into this validation trap. You have one news network that solely reflects the right wing, others that take the view of the left-center leaning, and what is lost are the facts and context, the balance we need to evaluate, learn, and understand the world. People seeking fact-based journalism lose, because the more extreme the media becomes to entice consumers with provocative headlines and click-bait to earn more money, the less their news is fact-based and becomes more opinion driven.
There was a time when fact-based reporting was required of broadcast news. It was called “The Fairness Doctrin ...
http1500cms.comBECAUSE THIS FORM IS USED BY VARIOUS .docxpooleavelina
http://1500cms.com/
BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY
APPLICABLE PROGRAMS.
NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may
be guilty of a criminal act punishable under law and may be subject to civil penalties.
REFERS TO GOVERNMENT PROGRAMS ONLY
MEDICARE AND CHAMPUS PAYMENTS: A patient’s signature requests that payment be made and authorizes release of any information necessary to process
the claim and certifies that the information provided in Blocks 1 through 12 is true, accurate and complete. In the case of a Medicare claim, the patient’s signature
authorizes any entity to release to Medicare medical and nonmedical information, including employment status, and whether the person has employer group health
insurance, liability, no-fault, worker’s compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made. See 42
CFR 411.24(a). If item 9 is completed, the patient’s signature authorizes release of the information to the health plan or agency shown. In Medicare assigned or
CHAMPUS participation cases, the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge,
and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the charge
determination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted. CHAMPUS is not a health insurance program but
makes payment for health benefits provided through certain affiliations with the Uniformed Services. Information on the patient’s sponsor should be provided in those
items captioned in “Insured”; i.e., items 1a, 4, 6, 7, 9, and 11.
BLACK LUNG AND FECA CLAIMS
The provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA instructions regarding required procedure and
diagnosis coding systems.
SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK LUNG)
I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished
incident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS
regulations.
For services to be considered as “incident” to a physician’s professional service, 1) they must be rendered under the physician’s immediate personal supervision
by his/her employee, 2) they must be an integral, although incidental part of a covered physician’s service, 3) they must be of kinds commonly furnished in physician’s
offices, and 4) the services of nonphysicians must be included on the physician’s bills.
For CHA ...
https://www.medicalnewstoday.com/articles/323444.php
https://ascopubs.org/doi/full/10.1200/JCO.2008.16.0333
https://journals.lww.com/co-hematology/Abstract/2007/03000/Influence_of_new_molecular_prognostic_markers_in.5.aspx
Influence of new molecular prognostic markers in patients with karyotypically normal acute myeloid leukemia: recent advances
Mrózek, Krzysztofa; Döhner, Hartmutb; Bloomfield, Clara Da
Current Opinion in Hematology: March 2007 - Volume 14 - Issue 2 - p 106–114
doi: 10.1097/MOH.0b013e32801684c7
Myeloid disease
Purpose of review Molecular study of cytogenetically normal acute myeloid leukemia is among the most active areas of leukemia research. Despite having the same normal karyotype, adults with de-novo cytogenetically normal acute myeloid leukemia who constitute the largest cytogenetic group of acute myeloid leukemia, are very diverse with respect to acquired gene mutations and gene expression changes. These genetic alterations affect clinical outcome and may assist in selection of proper treatment. Herein we critically summarize recent clinically relevant molecular genetic studies of cytogenetically normal acute myeloid leukemia.
Recent findings NPM1 gene mutations causing aberrant cytoplasmic localization of nucleophosmin have been demonstrated to be the most frequent submicroscopic alterations in cytogenetically normal acute myeloid leukemia and to confer improved prognosis, especially in patients without a concomitant FLT3 gene internal tandem duplication. Overexpressed BAALC, ERG and MN1 genes and expression of breast cancer resistance protein have been shown to confer poor prognosis. A gene-expression signature previously suggested to separate cytogenetically normal acute myeloid leukemia patients into prognostic subgroups has been validated on a different microarray platform, although gene-expression signature-based classifiers predicting outcome for individual patients with greater accuracy are still needed.
Summary The discovery of new prognostic markers has increased our understanding of leukemogenesis and may lead to improved prognostication and generation of novel risk-adapted therapies.
http://www.bloodjournal.org/content/127/1/53?sso-checked=true
An update of current treatments for adult acute myeloid leukemia
Hervé Dombret and Claude Gardin
Abstract
Recent advances in acute myeloid leukemia (AML) biology and its genetic landscape should ultimately lead to more subset-specific AML therapies, ideally tailored to each patient's disease. Although a growing number of distinct AML subsets have been increasingly characterized, patient management has remained disappointingly uniform. If one excludes acute promyelocytic leukemia, current AML management still relies largely on intensive chemotherapy and allogeneic hematopoietic stem cell transplantation (HSCT), at least in younger patients who can tolerate such intensive treatments. Nevertheless, progress has been made, notably in terms of standard drug dose in ...
httpstheater.nytimes.com mem theater treview.htmlres=9902e6.docxpooleavelina
https://theater.nytimes.com/ mem/ theater/ treview.html?res=9902e6db1639f931a25753c1a962948260
THEATER: WILSON'S 'MA RAINEY'S' OPENS
By FRANK RICH
Published: October 12, 1984, Friday
LATE in Act I of ''Ma Rainey's Black Bottom,'' a somber, aging band trombonist (Joe Seneca) tilts his head heavenward to sing the blues. The setting is a dilapidated Chicago recording studio of 1927, and the song sounds as old as time. ''If I had my way,'' goes the lyric, ''I would tear this old building down.''
Once the play has ended, that lyric has almost become a prophecy. In ''Ma Rainey's Black Bottom,'' the writer August Wilson sends the entire history of black America crashing down upon our heads. This play is a searing inside account of what white racism does to its victims - and it floats on the same authentic artistry as the blues music it celebrates. Harrowing as ''Ma Rainey's'' can be, it is also funny, salty, carnal and lyrical. Like his real-life heroine, the legendary singer Gertrude (Ma) Rainey, Mr. Wilson articulates a legacy of unspeakable agony and rage in a spellbinding voice.
The play is Mr. Wilson's first to arrive in New York, and it reached here, via the Yale Repertory Theater, under the sensitive hand of the man who was born to direct it, Lloyd Richards. On Broadway, Mr. Richards has honed ''Ma Rainey's'' to its finest form. What's more, the director brings us an exciting young actor - Charles S. Dutton - along with his extraordinary dramatist. One wonders if the electricity at the Cort is the same that audiences felt when Mr. Richards, Lorraine Hansberry and Sidney Poitier stormed into Broadway with ''A Raisin in the Sun'' a quarter-century ago.
As ''Ma Rainey's'' shares its director and Chicago setting with ''Raisin,'' so it builds on Hansberry's themes: Mr. Wilson's characters want to make it in white America. And, to a degree, they have. Ma Rainey (1886-1939) was among the first black singers to get a recording contract - albeit with a white company's ''race'' division. Mr. Wilson gives us Ma (Theresa Merritt) at the height of her fame. A mountain of glitter and feathers, she has become a despotic, temperamental star, complete with a retinue of flunkies, a fancy car and a kept young lesbian lover.
The evening's framework is a Paramount-label recording session that actually happened, but whose details and supporting players have been invented by the author. As the action swings between the studio and the band's warm-up room - designed by Charles Henry McClennahan as if they might be the festering last- chance saloon of ''The Iceman Cometh'' - Ma and her four accompanying musicians overcome various mishaps to record ''Ma Rainey's Black Bottom'' and other songs. During the delays, the band members smoke reefers, joke around and reminisce about past gigs on a well-traveled road stretching through whorehouses and church socials from New Orleans to Fat Back, Ark.
The musicians' speeches are like improvised band solos - variously fiz ...
https://fitsmallbusiness.com/employee-compensation-plan/
The puzzle of motivation | Dan Pink [Video file]. Retrieved from https://www.youtube.com/watch?v=rrkrvAUbU9Y
Refining the total rewards package through employee input at MillerCoors [Video file]. Retrieved from https://www.youtube.com/watch?v=_I7nv0B4_NU&feature=youtu.be
How to design an employee compensation plan [SlideShare slides]. Retrieved from http://www.slideshare.net/FitSmallBusiness/how-to-design-a-compensation-plan-dave?ref=http://fitsmallbusiness.com/how-to-pay-employees/
Compensation strategies [Video file]. Retrieved from https://youtu.be/U2wjvBigs7w
· Expectations for Power Point Presentations in Units IV and V
I would like to provide information about what needs to be included in presentations. Please review the rubric prior to submitting any assignment. If you don't know where to find this, please contact me.
1. You need a title slide.
2. You need an overview of the presentation slide (slide after the title slide). This is how you would organize a presentation if you were presenting it at work.
3. You need a summary slide (before the reference slide); same reason as above.
4. Please do not forget to cite on slides where you are writing about something related to what you have read. Please consider each slide a paragraph. You can cite on the slides or in the notes. If you do not cite, you will not get credit for the slide.
- Direct quotes should not be used in this presentation as they are not analysis.
5. Remember, all I can evaluate is what you submit, so please consider using notes to explain what you are writing in further detail. Bullets are great and you can use these but then provide more detail in the notes.
6. Graphics - Please include graphics/charts/graphs as this is evaluated in the rubric (quality of the presentation).
7. References - For all references, you need citations. For all citations, you need references. They must match. All must be formatted using APA requirements. Please review the Quick Reference Guide that was posted in the announcements.
Please never hesitate to email me with any questions. If you need further clarification about feedback or if you do not agree with any of the feedback, please contact me. My door is always open.
Assignment 1
Positioning Statement and Motto
Use the provided information, as well as your own research, to assess one (1) of the stated brands (Tesla, SmoothieKing, Suave, or Nintendo) by completing the questions below with an ORIGINAL response to each. At the end of the worksheet, be sure to develop a new ORIGINAL positioning statement and motto for the brand you selected. Submit the completed template in the Week 4 assignment submission link.
Name:
Professor’s Name:
Course Title:
Date:
Company/Brand Selected (Tesla, SmoothieKing, Suave or Nintendo):
1. Target Customers/Users
Who are the target customers for the company/brand? Make sure you tell why you selected each item that you did. (NOTE: DO NO ...
http://hps.org/documents/pregnancy_fact_sheet.pdf
https://www.asge.org/docs/default-source/education/practice_guidelines/doc-5c7150fd-910a-4181-89bf-bc697b369103.pdf?sfvrsn=6
http://hps.org/hpspublications/articles/pregnancyandradiationexposureinfosheet.html
Data Science
and
Big Data Analytics
Chapter 12: The Endgame, or Putting It All Together
1
Chapter Contents
12.1 Communicating and Operationalizing an Analytics Project
12.2 Creating the Final Deliverables
Developing core material for multiple audiences, project goals, main findings, approach, model description, key points supported with data, model details, recommendations, tips on final presentation, providing technical specifications and code
12.3 Data Visualization Basics
Key points supported with data, evolution of a graph, common representation methods, how to clean up a graphic, additional considerations
Summary
2
12.1 Communicating and Operationalizing an Analytics Project
3
12.1 Communicating and Operationalizing an Analytics Project
Deliverables and Stakeholders
4
12.1 Communicating and Operationalizing an Analytics Project
Deliverables
General Deliverables – from Textbook
Presentation for Project Sponsors
Presentation for Analysts
Code
Technical Specifications
Deliverables For This Course
Presentation for Analysts – half hour per team, next week
Technical Paper for Research Day Conference
Submit CD – Presentation, Paper, Data or URL, Code
5
12.2 Creating the Final Deliverables
Case Study – Fictional Bank Churn Prediction
This section describes a scenario of a fictional bank and a churn prediction model of its customers
The analytic plan contains components that can be used as inputs for writing the final presentations
scope
underlying assumptions
modeling techniques
initial hypotheses
and key findings
6
12.2 Creating the Final Deliverables
Case Study – Fictional Bank Churn Prediction
7
12.2 Creating the Final Deliverables
Case Study – Fictional Bank Analytics Plan
8
12.2 Creating the Final Deliverables
12.2.1 Developing Core Material for Multiple Audiences
Some project components have dual use
Create core materials used for both analyst and business audiences
Three areas on the next slide used for both audiences
Sections after the following overview slide
12.2.2 – Project Goals
12.2.3 – Key Findings
12.2.4 – Approach
12.2.5 – Model Description
12.2.6 – Key Points Supported by Data
12.2.7 – Model Details
12.2.8 – Recommendations
12.2.9 – Additional Tips on the Final Presentation
12.2.10 – Providing Technical Specifications and Code
9
12.2 Creating the Final Deliverables
12.2.1 Developing Core Material for Multiple Audiences
10
12.2 Creating the Final Deliverables
12.2.2 Project Goals
The project goals portion of the final presentation is generally the same for sponsors and analysts
The project goals are described first to lay the groundwork for the solution and recommendations
Generally, the goals are agreed on earl ...
https://www.worldbank.org/en/country/vietnam/overview
-------------- Context ----------------
Vietnam’s development over the past 30 years has been remarkable. Economic and political reforms under Đổi Mới, launched in 1986, have spurred rapid economic growth, transforming what was then one of the world’s poorest nations into a lower middle-income country. Between 2002 and 2018, more than 45 million people were lifted out of poverty. Poverty rates declined sharply from over 70% to below 6% (US$3.2/day PPP), and GDP per capita increased by 2.5 times, standing over US$2,500 in 2018.
In the medium-term, Vietnam’s economic outlook is positive, despite signs of cyclical moderation in growth. After peaking at 7.1% in 2018, real GDP growth in 2019 is projected to slightly decelerate in 2019, led by weaker external demand and continued tightening of credit and fiscal policies. Real GDP growth is projected to remain robust at around 6.5% in 2020 and 2021. Annual headline inflation has been stable for the seven consecutive years – at single digits, trending towards 4% and below in recent years. The external balance remains under control and should continue to be financed by strong FDI inflows which reached almost US$18 billion in 2018 – accounting for almost 24% of total investment in the economy.
Vietnam is experiencing rapid demographic and social change. Its population reached 97 million in 2018 (up from about 60 million in 1986) and is expected to expand to 120 million before moderating around 2050. Today, 70% of the population is under 35 years of age, with a life expectancy of 76 years, the highest among countries in the region at similar income levels. But the population is rapidly aging. And an emerging middle class, currently accounting for 13% of the population, is expected to reach 26% by 2026.
Vietnam ranks 48 out of 157 countries on the human capital index (HCI), second in ASEAN behind Singapore. A Vietnamese child born today will be 67% as productive when she grows up as she could be if she enjoyed complete education and full health. Vietnam’s HCI is highest among middle-income countries, but there are some disparities within the country, especially for ethnic minorities. There would also be a need to upgrade the skill of the workforce to create productive jobs at a large scale in the future.
Over the last thirty years, the provision of basic services has significantly improved. Access of households to modern infrastructure services has increased dramatically. As of 2016, 99% of the population used electricity as their main source of lighting, up from 14 % in 1993. Access to clean water in rural areas has also improved, up from 17% in 1993 to 70% in 2016, while that figure for urban areas is above 95%.
Vietnam performs well on general education. Coverage and learning outcomes are high and equitably achieved in primary schools — evidenced by remarkably high scores in the Program for International Student Assessment (PISA) in 2012 and 2015, ...
HTML WEB Page solutionAbout.htmlQuantum PhysicsHomeServicesAbou.docxpooleavelina
HTML WEB Page solution/About.htmlQuantum PhysicsHomeServicesAboutContact Me
This website gives a detail inward look in quantam physics as it is a evolving field now-a-days and has many upcoming changes that is going to leave the world in shock. There has been a lot of confusion lately related to this topics in people so it is encourage that people visit this website and get to know more about this field and explore the horizons there is yet to come.
HTML WEB Page solution/FirstLastHomePage.htmlQuantum PhysicsHomeServicesAboutContact Me
Definition
Quantum mechanics is the part of material science identifying with the little.
It brings about what may have all the earmarks of being some extremely peculiar decisions about the physical world. At the size of particles and electrons, a significant number of the conditions of old style mechanics, which depict how things move at ordinary sizes and speeds, stop to be helpful. In traditional mechanics, objects exist in a particular spot at a particular time. Be that as it may, in quantum mechanics, protests rather exist in a fog of likelihood; they have a specific possibility of being at point An, another possibility of being at point B, etc.Three revolutionary principles
Quantum mechanics (QM) created over numerous decades, starting as a lot of questionable scientific clarifications of tests that the math of old style mechanics couldn't clarify. It started at the turn of the twentieth century, around a similar time that Albert Einstein distributed his hypothesis of relativity, a different numerical unrest in material science that portrays the movement of things at high speeds. In contrast to relativity, nonetheless, the sources of QM can't be credited to any one researcher. Or maybe, various researchers added to an establishment of three progressive rules that bit by bit picked up acknowledgment and exploratory confirmation somewhere in the range of 1900 and 1930. They are:
Quantized properties:
Certain properties, for example, position, speed and shading, can once in a while just happen in explicit, set sums, much like a dial that "clicks" from number to number. This tested a crucial presumption of old style mechanics, which said that such properties should exist on a smooth, ceaseless range. To portray the possibility that a few properties "clicked" like a dial with explicit settings, researchers begat the word "quantized".
Particles of light:
Light can now and again act as a molecule. This was at first met with unforgiving analysis, as it negated 200 years of trials indicating that light acted as a wave; much like waves on the outside of a quiet lake. Light acts comparatively in that it ricochets off dividers and twists around corners, and that the peaks and troughs of the wave can include or counteract. Included wave peaks bring about more splendid light, while waves that counterbalance produce obscurity. A light source can be thought of ...
https://www.huffpost.com/entry/online-dating-vs-offline_b_4037867
For your initial post, provide a sentence to share which article you are referring to so that you can best communicate with your peers. Include a link to your selection.
· Explain how the argument contains or avoids bias.
i. Provide specific examples to support your explanation.
ii. What assumptions does it make?
· Discuss the credibility of the overall argument.
i. Were the resources the argument was built upon credible?
ii. Does the credibility support or undermine the article’s claims in any important ways?
In response to your peers, provide an additional resource to support or refute the argument your peer makes. Do you agree with their claims of credibility? Are there any other possible bias not identified?
Response #1
Allysa Tantala posted Sep 22, 2019 10:17 PM
Subscribe
The article that I am looking at is Online Dating Vs. Offline Dating: Pros and Cons.It was written by Julie Spira, an online dating expert, bestselling author, and CEO of Cyber-Dating Expert. The name of the article is spot on in describing what it is about. The author goes through the pros and cons of dating online and offline in today’s day and age. The author avoids bias because she looks at both options in both their positive and negative attributes. She comes at the issues from both angles and I believe she does a very good job at remaining unbiased. She states that “if you're serious about meeting someone special, you must include a combination of both online and offline dating in your routine” (Spira, 2013, par. 18). She’s stating that both options have their pros and cons and that really a combination of both is needed to find someone. The only bias I could see anyone pointing out would be that she is a woman, so you do not get the male perspective on these things. That being said, I one hundred percent think she covers all of the questions people may have about online and offline dating in today’s world. The only assumption being made here is that the reader wants to be out in the dating world and they need to know what is best. But, the title of the article is pretty self-explanatory so if someone did not want to know these things, they would not have to waste their time reading it all because they could tell what it would be about by the title.
The resource that she used was herself, and like I stated above, she is an online dating expert, bestselling author, and CEO of Cyber-Dating Expert; so she is more than qualified to give her perspective on these issues. I find her to be credible and thought provoking. Her credibility supports everything the article says and makes the reader feel like they are being told the truth by someone who completely understands all of the pros and cons.
Resource:
Spira, J. (2013, December 3). Online Dating Vs. Offline Dating: Pros and Cons. Retrieved from https://www.huffpost.com/entry/online-dating-vs-offline_b_4037867
Response #2
Jennifer Caforio posted Se ...
https://www.vitalsource.com/products/comparative-criminal-justice-systems-harry-r-dammer-jay-s-v9781285630779
THE ASSIGNMENT IS BASED ON CHAPTER 1 (ONE)
Login : [email protected]
Password: Greekyogurt13!
1
3Defining the Problem
Rigina CochranMPA/593
August 19, 2019
Peter ReevesDefining the Problem
The health care system in Colorado is a composition of medical professionals providing services such as diagnosis, treatment, as well as preventive measures to mental illness and injuries ("Healthcare policy in Colorado - Ballotpedia," 2019). Health care policy involves the establishment and implementation of legislation and other regulations that the states use to manage its health care system effectively. Further, this sector consists of other participants, such as insurance and health information technology. The cost citizens pay for medical care and also the access to quality care influence the overall health care providers in Colorado. Therefore, the need for the creation and implementation of laws that help the state maintain efficiency in the health sector in Colorado.
Problem Statement
The declining standards of medical care within the United States has caused significant concern in the world. Due to these rising concerns, there have been various policies implemented, leading to mixed reactions among the different states. Some of the active policies implemented offer a long-term solution to this problem including Medicaid and Medicare. After acquiring state control, the Republicans dismissed the idea to expand and create medical insurance for Medicaid in Colorado. Sustaining the structure of the health care payroll calls for the deductions from the employees and the employers, which may lead to loss of jobs and increased burden of expenditure (Garcia, 2019).
Identify the Methodology
The main objective of this policy plan is to investigate the role of legislation in the management of the health care sector in the United States. Due to the need for achieving in-depth exploration, this paper uses a combination of both qualitative and quantitative methods of data collection by addressing both practical and theoretical aspects of the research. Based on the answers that the policy requires, choosing survey as the research design. This method involves collecting and analyzing data from a few people who represent the principal group within health care. However, the survey method faces some challenges such as attitudes and perception of the health workers leading to the delimitation of the study. The target population for the study includes the nurses within the health sectors in Colorado. The selection of the participants involved in the use of stratified random sampling.
Identify your Stakeholders
The major stakeholders in the creation and implementation of the policy plan include the legislatures, local government, patients, and other private parties such as the insurance companies. Collectively, these bodies are involved in the makin ...
https://www.nationaleatingdisorders.org/learn/by-eating-disorder/arfid
AVOIDANT RESTRICTIVE FOOD INTAKE DISORDER (ARFID)
Avoidant Restrictive Food Intake Disorder (ARFID) is a new diagnosis in the DSM-5, and was previously referred to as “Selective Eating Disorder.” ARFID is similar to anorexia in that both disorders involve limitations in the amount and/or types of food consumed, but unlike anorexia, ARFID does not involve any distress about body shape or size, or fears of fatness.
Although many children go through phases of picky or selective eating, a person with ARFID does not consume enough calories to grow and develop properly and, in adults, to maintain basic body function. In children, this results in stalled weight gain and vertical growth; in adults, this results in weight loss. ARFID can also result in problems at school or work, due to difficulties eating with others and extended times needed to eat.
DIAGNOSTIC CRITERIA
According to the DSM-5, ARFID is diagnosed when:
· An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
· Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
· Significant nutritional deficiency.
· Dependence on enteral feeding or oral nutritional supplements.
· Marked interference with psychosocial functioning.
· The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
· The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
· The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
RISK FACTORS
As with all eating disorders, the risk factors for ARFID involve a range of biological, psychological, and sociocultural issues. These factors may interact differently in different people, which means two people with the same eating disorder can have very diverse perspectives, experiences, and symptoms. Researchers know much less about what puts someone at risk of developing ARFID, but here’s what they do know:
· People with autism spectrum conditions are much more likely to develop ARFID, as are those with ADHD and intellectual disabilities.
· Children who don’t outgrow normal picky eating, or in whom picky eating is severe, appear to be more likely to develop ARFID.
· Many children with ARFID ...
https://www.youtube.com/watch?time_continue=59&v=Bh_oEYX1zNM&feature=emb_logo
BA 325 Pivot Table Assignment Answer Sheet
Name:
Before you do anything fill out your name on the assignment and save your file as BA325 Firstname Lastname (use your actual name).
The table has all of the questions from the DuPont Assignment. Fill in your answers to the questions in the corresponding cell in the Answer column. Below the table there is a spot for the Screen Clippings from both the Practice Assignment, and the DuPont Assignment.
After you have filled out all of the answers and Screen Clippings submit the file to the Assignments folder in D2L.
Q Number
Question
Answer
Q1
How much was American Airlines’ Net Revenues in 2013?
Q2
What was the Return on Equity for Apple in 2015?
Q3
Which company had the highest Net Income and in which year? What was the value?
Q4
Which company had the lowest Net Income and in which year? What was the value?
Q5
How many unique companies in your sample had Net Losses exceeding one billion dollars? Which companies, and what years?
Q6
What was the Sum of the Net Income for all companies in the sample for 2015?
Q7
Which company had the highest total Net Income over the three year period? What was the value?
Q8
Which company had the lowest total Net Income over the three year period? What was the value?
Q9
Which industry had the highest Average Profit Margin over the three year period? What was the value?
Q10
In which year was the Average Profit Margin the highest for the entire sample? What was the value?
Q11
For how many companies do you have Profit Margin ratio data in 2013?
Q12
For what Industry do you have the most Profit Margin ratio data in the sample? What was the value? For that Industry what year was the highest? What was the value?
Q13
Which Industry has the highest Average Asset Turnover over the three year period? What was the value?
Q14
Which of the remaining Industries has the highest Asset Turnover in 2014? What was the value?
Q15
Which Industry has the highest Average Financial Leverage over the three year period? What was the value?
Q16
Which Industry has the lowest Average Financial Leverage that does not include negative numbers in any year? What was the value?
Q17
What is the Average Financial Leverage for the Transportation Industry in 2013?
Note: The answer is odd. You will have to use Data Cleaning to resolve the issue.
Q18
Which Industry has the highest Average Return on Equity over the three year period and which company is the highest within that Industry? What are the values?
Q19
Which two companies in the Public Utilities Industry have the highest Average Return on Equity during the period? What are the values?
Q20
Which Industry had the largest decrease in Average Return on Equity between 2013 and 2014? What was the value?
Q21
Which Industry had the largest increase in Average Return on Equity between 2014 and 2015? What was the value?
Q22
Bonus Question 1: How many industrie ...
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
HEALTH POLICY AND ETHICSFacilitating HIV DisclosureFac.docx
1. HEALTH POLICY AND ETHICS
Facilitating HIV Disclosure
Facilitating HIV Disclosure Across Diverse Settings: A Review
Carla Makhlouf Obermeyer, DSc, Parijat Baijal, MA, and
Elisabetta Pegurri, MSc
HIV status disclosure is cen-
tral to debates about HIV be-
cause of its potential for HIV
prevention and its links to pri-
vacy and confidentiality as hu-
man-rights issues.
Our review of the HIV-dis-
closure literature found that
few people keep their status
completely secret; disclosure
tends to be iterative and to be
higher in high-income coun-
2. tries; gender shapes disclosure
motivations and reactions; in-
voluntary disclosure and low
levels of partner disclosure
highlight the difficulties faced
by health workers; the mean-
ing and process of disclosure
differ across settings; stigmati-
zation increases fears of disclo-
sure; and the ethical dilemmas
resulting from competing
values concerning confidenti-
ality influence the extent to
which disclosure can be facil-
itated.
Our results suggest that
structural changes, including
making more services avail-
3. able, could facilitate HIV dis-
closure as much as individual
approaches and counseling
do. (Am J Public Health. 2011;
101:1011–1023. doi:10.2105/
AJPH.2010.300102)
THE TOPIC OF HIV STATUS
disclosure is central to debates
about HIV, because of its links to
confidentiality and privacy as hu-
man-rights issues and its potential
role in prevention.1 Disclosure is
also considered a way to ‘‘open up’’
the HIV epidemic2 and hence is
a crucial step toward ending stigma
and discrimination against people
living with HIV and AIDS
(PLWHA). Recognizing its impor-
tance, a number of researchers
have reviewed the literature on
disclosure by women,3 by men,4 or
by parents to children.5 Others
have reviewed what is known
about the factors associated with
disclosure, including the connec-
tions among stigma, disclosure, and
social support for PLWHA6; the
links among disclosure, personal
4. identity, and relationships7; and
client and provider experiences
with HIV partner counseling and
referral.8 We sought to comple-
ment existing reviews by including
available information on low- and
middle-income countries, which are
poorly represented in all but 1 of
the extant literature reviews, and by
focusing on the role of health ser-
vices and health care providers in
HIV disclosure.
Recently, increased attention to
transmission within serodiscordant
couples has highlighted the po-
tential role of disclosure as a way
to encourage prevention.9 More-
over, as countries scale up HIV
testing, counseling, and treatment,
better evidence is needed to inform
laws and policies, particularly re-
garding how best to facilitate dis-
closure while protecting medical
confidentiality. Ongoing debates
about mandatory disclosure to
partners, health workers’ role in
disclosing without patients’ consent,
and the criminalization of HIV
transmission raise important ques-
tions about the place of disclosure
in the fight against HIV and about
the human-rights dimension of dis-
closure policies. These debates
also underscore the need for a
5. careful review of the evidence on
disclosure, an examination of in-
dividual motivations and experi-
ences around disclosure, an as-
sessment of the role of health
workers, and a better understand-
ing of the societal determinants
and consequences of disclosure in
diverse settings.
METHODS
We conducted an electronic
search of databases for journal
articles and abstracts, focusing on
HIV disclosure by adults living
with HIV. Disclosure is defined
here as the process of revealing
a person’s HIV status, whether
positive or negative. HIV status is
usually disclosed voluntarily by
the index person, but it can also be
revealed by others with or without
the index person’s consent. We
conducted the search in PubMed,
PsychINFO, Social Sciences Cita-
tion Index, and the regional data-
bases of the World Health Orga-
nization, including African Index
Medicus, Eastern Mediterranean,
Latin America, and Index Medicus
for South-East Asia Region. The
search used the keywords ‘‘disclo-
s(ure), notif(ication)’’ and ‘‘HIV or
AIDS.’’ The search retrieved a to-
6. tal of 3463 titles published be-
tween January 1997 and October
2008. After a scan of titles and
abstracts, we retained 231 sources,
including 15 abstracts from the
2008 International AIDS Confer-
ence and 11 reviews or commen-
taries.
We included sources in this re-
view if they were original studies
or literature reviews that had
appeared in peer-reviewed publi-
cations and if they reported on the
levels or process of disclosure (to
whom, when, and how), the de-
terminants of and reasons for dis-
closure, and the consequences of
and incidents associated with dis-
closure, such as life events, risk
behavior, stigma, and discrimina-
tion. Articles that focused exclu-
sively on children’s HIV status
were excluded, but we refer to
children if their parents disclosed
to them. We consulted the
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1011
regional databases of the World
Health Organization to find arti-
cles about resource-limited set-
7. tings. This review also drew on
related reviews of the literature on
HIV testing, stigma, treatment, and
prevention by Obermeyer et al.10,11
Studies published after October
2008 were not included in the
tabulations, although they may be
cited in the discussion.
Table 1 presents the character-
istics of the studies included in this
review. Of the 231 articles in-
cluded, more than two thirds (157
studies) came from high-income
countries, mainly the United
States. Most studies in low- and
middle-income countries (49 out
of 76) were from sub-Saharan
Africa. A total of 98 studies were
conducted among heterosexual
adults of both sexes, 49 specifi-
cally among women, and 35
among men who have sex with
men, of which 31 were conducted
in the United States.
Most of these studies (134 of
231) were based on quantitative
surveys, and they provide fre-
quencies on different aspects of
disclosure. However, a consider-
able number (74 studies) used
qualitative methods, including
in-depth interviews and focus-
8. group discussions, and some (11
studies) combined questionn-
aires with qualitative methods,
often to explore the relational
context of disclosure and how
individuals coped with their HIV
status.
LEVELS AND PATTERNS OF
DISCLOSURE
Table 2 summarizes the results
of studies on levels and patterns of
disclosure in general as well as
disclosure to specific categories of
people, such as sexual partners,
family members, and friends.
Overall, a striking finding of this
review was that the majority of
people disclosed their HIV status
to someone. The levels of reported
disclosure to anyone, as shown in
Table 2, ranged mostly from
about two thirds to about three
fourths of respondents, with a few
lower rates in sub-Saharan Africa.
Three studies explicitly refered to
involuntary disclosure, but the rest
were concerned with voluntary
disclosure exist, suggesting that
most people willingly disclosed
their HIV status.
The frequencies summarized in
Table 2 indicate that gender dif-
9. ferences in levels and patterns of
disclosure exist. Women (as
mothers and sisters) were more
frequently mentioned than were
men as recipients of disclo-
sure. Only a few studies have in-
vestigated gender differences
in HIV-positive disclosure rates
to partners, and the findings have
been mixed. Some found no
gender differences, as in Ethio-
pia103,104 and Mali,105 or higher
disclosure rates by HIV-positive
men (84%) than HIV-positive
women (78%).71 Several found
higher rates by women, as in
Burkina Faso and Mali,105 South
Africa,73 and the United States.17
Regardless of whether there were
significant gender differences in
disclosure rates, most studies docu-
mented substantial gender differ-
ences in the contexts of, barriers
to, and outcomes of disclosure.
Other differences in disclosure
frequency had to do with HIV
status and to whom status was
TABLE 1—Characteristics of Studies on Disclosure of HIV
Status, January 1997–October 2008
Populations Sampled
11. United Kingdom 4 . . . 2 1 . . . . . . 7
Western Europeb 7 . . . . . . . . . 1 2 10
Australia 4 . . . . . . . . . . . . . . . 4
Canada 1 . . . . . . 1 . . . . . . 2
Saudi Arabia 1 . . . . . . . . . . . . . . . 1
Low and middle income
Sub-Saharan Africa 25 . . . 1 20 . . . 3 49
Asia 12 1 . . . 5 2 . . . 20
Eastern Europe 1 . . . . . . . . . . . . . . . 1
Latin America, Caribbean 2 1 1 . . . . . . . . . 4
Total 98 8 35 49 13 28 231c
Note. PMTCT = prevention of mother-to-child transmission.
Ellipses indicate that no studies were reviewed from that
country or region.
aMarks and Crepaz12 includes both homosexual and
heterosexual men.
bWestern Europe does not include the United Kingdom.
cMedley et al.3 covers both Africa and Asia; Grinstead et al.13
covers both Africa and Latin America.
HEALTH POLICY AND ETHICS
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12. TABLE 2—Studies (n = 96) on Levels and Patterns of HIV
Status Disclosure, January 1997–October 2008
Population (Location) No. of Studies Disclosure to Anybody, %
Disclosure to Sexual Partners, % Disclosure to Family, %
Disclosure to Friends, %
United States (n = 46)
Adults14–23 10 82 56–81 (casual partners 25;
main partners 74)
70–87 (77–79 to mothers;
47–65 to fathers)
26–88
Parent to children
24–34,a,b
11 30–75 to parents;
32–62 to children
Men
35–36
2 53–60
Women37–45 9 96–100 68–92 60–84 (66–81 to mothers;
13. 25–51 to fathers)
28–83
MSM12,17,46–55,c 12 80–97 54–80 (38-42
casual partners)
50 (37–67 to mothers;
23–47 to fathers)
85
Injection drug users
56,57
2 61–86
Europe (n = 10)
Adults (France,
58–60
Russian Federation,
61
Sweden,
62
United Kingdom
63–65
)
8 85–97 88–97 53–77 57–79
14. Parent to children (Belgium66) 1 10 to children
Women (United Kingdom67) 1 81
Sub-Saharan Africa (n = 26)
Adults (Burkina Faso,68 Ethiopia,69 Kenya13,d,
Nigeria,
70
South Africa,
71–74
Uganda,
75
Tanzania,
76,77
Zambia
78
)
12 22–96 28–91 (65 by men;
73 by women)
60–75 6–43
Parent to children (South Africa,
79
Uganda
15. 80
) 2 44–50
e
Women (Burkina Faso,
81,82
Côte d’Ivoire,
83
Kenya,84,85 Malawi,86 South Africa,87–89
Tanzania90–92)
12 22–94
(46 HIV + ; 97 HIV–)
17–90 (64 HIV + ;
80 HIV–)
20–22 15
Asia (n = 8)
Adults (China,93 India94–96,f) 4 (35 involuntary;
65 voluntary)
70 (100 by women;
65 by men)
78 7
16. Men (Taiwan
97
) 1 72
Women (India,
98
Thailand
99
) 2 37–84 34 family or friends 34 family or friends
Injection drug users (Vietnam
100
) 1 0 (no respondents
disclosed)e
Caribbean (n = 1)
Adults (French Antilles/Guyana101) 1 70 85 56
Reviews (n = 5)
Adults
7,8,102
3 68–97 22–86 (70-92 LIC; 44–67 HIC) 61–86
Men
4
1 67–88
17. Women
3
1 17–86
Note. HIC = high-income countries; LIC = low-income
countries; MSM = men who have sex with men. For multiple
studies on a country or population, the table presents the range
of disclosure rates
(minimum and maximum) reported in the studies.
aEmlet also reported that adults aged 50 years or older
disclosed their HIV status to those in their social networks less
frequently than younger adults did.34
b
Two statistics are included: the percentage of parents who
reported disclosing to children and the percentage of children
who were told by their parents.
c
The study by Marks and Crepaz of HIV-positive men
(homosexual, bisexual, and heterosexual) is counted under
MSM, who represent the majority of the study sample.
12
Similarly, the Weinhardt
et al. study of MSM, women, and heterosexual men is counted
under MSM, who represent the majority of the study sample.
17
dGrinstead et al. covers Kenya, Tanzania, and Trinidad, but it is
listed under Africa and counted once under Kenya.13
eIncludes data from studies with fewer than 25 participants.
fIn Mulye et al., patients’ spouses (23%) and relatives (2%–
12%) knew patients’ HIV status after it was disclosed to
18. patients in their presence.94
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HEALTH POLICY AND ETHICS
disclosed. Studies that included
information on HIV status almost
always reported that disclosure
was lower when HIV status was
positive. Disclosure to relatives
was higher than was disclosure to
friends. Partner disclosure varied
greatly, but it was generally lower
with casual partners than it was
with steady partners.
Some studies explored sociode-
mographic factors that influence
disclosure, principally residence
and ethnicity. For example, re-
search in South Africa found
higher disclosure rates in urban
settings than in rural settings.106 In
the United Kingdom, studies found
that African men were less likely
than were White men to tell their
partners about their HIV infection
(66% vs 86%, respectively63) and
were less likely than were White
men to disclose to relatives, part-
ners, or work colleagues.64 Simi-
19. larly, a study in French Antilles and
French Guyana found that non-
French citizens were less likely to
disclose to a steady partner than were
French citizens,101 and studies in the
United States found that African
Americans disclosed less often than
did European Americans.34,107
Such results suggest that indi-
viduals from racial/ethnic minor-
ity groups have greater concerns
about stigmatization if they dis-
close their status. Socioeconomic
factors and access to resources
also appear to play an important
role. In the South African study
mentioned earlier,106 urban com-
munities with higher disclosure
rates had more institutional sources
of support, including nongovern-
mental organizations and hospitals.
Research from Nigeria and among
migrants from Africa in Sweden
revealed that more educated re-
spondents disclosed more often
than did their less educated coun-
terparts.62,70 Similarly, a study
from India found a higher rate of
disclosure to partners by literate
respondents compared with illiter-
ate respondents (86% vs 44%, re-
spectively96). Conversely, low-wage
employment and economic vul-
nerability reduced disclosure by
20. Tanzanian women,91 Dominican
male sex workers,108 and Canadian
female sex workers.109 Such results
suggest that economic and social
disadvantage make disclosure more
difficult. This finding is consistent
with the frequencies in Table 2,
which tended to be higher in
higher-income countries (the
United States and Europe), whereas
levels in developing countries of
Africa, Asia, and the Caribbean
showed much greater variation.
VARIATIONS IN THE
CONCEPT AND PROCESS
OF DISCLOSURE
We found that different pro-
cesses have been subsumed under
the concept of disclosure, under-
scoring the need for researchers to
clarify more consistently how dis-
closure is measured. Quantitative
studies have shown large differ-
ences in disclosure frequencies
depending on what information
was given and by whom, whether
HIV status was positive or nega-
tive, and whether that status was
disclosed to 1 or more persons, to
anyone, to sexual partners, to
friends, or to family. Qualitative
studies, on the other hand, have
raised questions about the multi-
ple dimensions and meanings of
21. disclosure.
Disclosure is not always volun-
tary, an issue raised primarily
(though not exclusively) in studies
conducted outside Europe and the
United States. Varga et al.88
reported that in South Africa, 32%
of disclosure to family members
was involuntary. Similarly, in India,
35% of male and female respon-
dents reported that their HIV status
had been disclosed without con-
sent,95 and relatives sometimes
found out a person’s HIV status
when it was disclosed in their pres-
ence by someone else.94
Research has found large vari-
ations in the amount of informa-
tion that people reveal. For exam-
ple, only about half of respondents
in a study from India disclosed
the exact nature of their illness
to those around them; others pre-
ferred partial disclosure or re-
ferred to a less stigmatizing illness,
such as fever, heart problems, or
general illness.95 A US study found
that 54% of respondents reported
having received full disclosure.15
Parents tended to disclose partially
to their young children and more
fully to their adolescent children.110
22. Rather than being a one-time
event, as it is sometimes assumed
to be, disclosure is often a gradual
process of disclosing to an in-
creasing number of others in one’s
networks over time. For example,
a study among homosexual and
bisexual men in the United King-
dom found that immediately after
diagnosis, respondents were more
likely to opt for nondisclosure,
but later they used disclosure as
a mechanism for coping with the
disease.111 In a study in South
Africa, many HIV-positive men and
women waited substantial periods
of time before disclosing to their
partners, including 15% who
waited more than a year.71 Among
a sample of gay Latino men in the
United States, half disclosed to
someone on the day they found out,
and another 15% disclosed within
a few days, but about 20% did not
tell anyone for 1 year or more.54
Among a sample of HIV-positive
pregnant women in Tanzania, dis-
closure to a partner increased from
22% within 2 months of diagnosis
to 40% after nearly 4 years.91
Other studies among heterosexual
men and women, young people,
23. and attendees of an outpatient HIV
clinic found that disclosure had
a positive association with the
length of time since diagno-
sis15,20,34,65,112 and with disease
progression.19,74,113
Some qualitative studies ex-
plored differences among those
who disclose and those who do
not, such as the criteria motivating
decisions, the process of commu-
nication, and coping styles. The
results of these studies tended to
converge around certain key
points: selective disclosure is the
most frequent strategy, a minority
of people fall in the ‘‘never dis-
close’’ or ‘‘always disclose’’ cate-
gories, disclosure decisions have
to be made repeatedly, and dis-
closure decisions change over
time.7,41,114---117 Other qualitative
studies have provided insight into
the process whereby individuals
weigh the risks (fear of abandon-
ment and discrimination) and ben-
efits (need for support) of disclosure
before making a decision.118 These
studies underscore the importance
of relationships, trust, emotions,
perceptions of self, and perceptions
of HIV status. Most of these studies
were conducted in the United
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24. al. American Journal of Public Health | June 2011, Vol 101, No.
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HEALTH POLICY AND ETHICS
States, tended to emphasize the
psychological aspects of disclosure,
and focused on individual factors
and processes, but some considered
the social context of disclosure in
Africa,77,106 and others analyzed
the connections between the
choices made by individuals and
the ethical debates and social poli-
cies around HIV disclosure.119
ATTITUDES, REACTIONS,
AND BEHAVIORS AFTER
DISCLOSURE
Much has been written about
the stigma associated with disclo-
sure of HIV-positive status. Fear of
stigma is thought to discourage
disclosure, and disclosure has of-
ten been considered a proxy
measure for stigma, because peo-
ple living with HIV are more likely
to disclose in low-stigma contexts,
where they expect fewer nega-
tive consequences.120 Conversely,
there is a vast literature on dis-
crimination (sometimes defined as
enacted stigma) faced by those
25. whose HIV status is disclosed by
others, often without their consent.
Women are thought to face spe-
cial barriers related to fears of
stigma, as documented in numerous
sources.3,41,42,76,84,90,92,99,115,121---123
Research has drawn attention to
negative consequences of disclosure,
such as disrupted relationships with
families and communities124,125;
isolation, criticism, and ostracism
by family members68,126; abuse,
violence, divorce, or separation
from partners; and rejection by
friends.43,84,89,127
However, it has been difficult to
document the causal link between
HIV disclosure and adverse
events, in part because baseline
rates of negative experiences such
as violence are often unknown,
and because HIV-positive individ-
uals who eventually face negative
reactions often come from disad-
vantaged groups that are already
at high risk for violence.128 For
example, although some evidence
suggests that women with risk fac-
tors such as a history of drug use
are more likely to experience neg-
ative social and physical conse-
quences when their infection be-
comes known,43,129 violence was
26. not significantly higher among a
sample of HIV-positive women
compared with demographically and
behaviorally similar HIV-negative
women in the United States.130
Nevertheless, evidence indicates
that fear of stigma, discrimination,
and violence decreases willingness
to disclose HIV status in many
settings.3,115,121,125,131---138
Reviews of the literature have
shown that reactions to disclosure
ranged from negative to neutral to
supportive, and that negative re-
actions from family, friends, em-
ployers, and the community were
relatively low––about 3% to 15%
of cases.3,8,43,96,129 Studies in di-
verse contexts have documented
high levels of supportive reactions
to HIV-positive persons.68,119,139,140
For example, nearly half of the HIV-
positive women in the often-cited
study from Tanzania90 reported
that their partners were supportive,
as did 73% of women in a Kenyan
study.84 Studies in South Africa
found that reactions to disclosure
included trust, support, and under-
standing,74 and that 19% of disclo-
sures resulted in kindness and 70%
in no change of attitude.89 A posi-
tive correlation between disclosure
27. and social support has been
documented in a meta-analysis6 as
well as in studies from contexts as
varied as Greece, Kenya, South
Africa, Tanzania, Trinidad, and the
United States.13,18,44,71,90,139,141
However, these results must be
interpreted in light of differences in
types of populations and levels of
disclosure. Reactions of support are
more likely where HIV-positive in-
dividuals are not seen as responsi-
ble for getting HIV, whereas those
seen as having been infected be-
cause of their own behavior may
face negative reactions. In addition,
low disclosure and high support
may indicate that individuals are
careful not to disclose their HIV
status if they expect negative re-
actions.92
Studies have also examined the
behavioral outcomes of disclosure,
including its possible effect on
safer sex. Disclosure of HIV-posi-
tive status to partners has been
associated with safer sexual prac-
tices in the United States,17,21,142,143
France,60 and Cameroon.144 Simi-
larly, a study in South Africa found
that condom use was higher (57%)
among women who disclosed
28. their status than it was among those
who did not (38%).73 Unprotected
sex was also more frequent among
groups of men who have sex
with men, heterosexual men, and
women who did not disclose than
it was among those in each cate-
gory who did.145 Other risk be-
haviors, such as having multiple
sexual partners, have also been
associated with nondisclosure, as
documented in a review.4 Studies
among injection drug users and
men who have sex with men in the
United States revealed that sexual
risk behaviors were highest among
inconsistent disclosers, followed by
nondisclosers; consistent disclosers
reported fewer sexual risk behav-
iors, although the evidence was not
always unequivocal.51,56
Indeed, not all studies have
found an association between
disclosure and safer behav-
iors.12,22,50,55,146,147 The difficulties
of documenting effects and estab-
lishing the direction of causality are
common to studies of prevention in
general, and we found a literature
review on disclosure that reported
contradictory results, with positive
effects sometimes limited to a sub-
group of participants, such as HIV-
negative partners or nonprimary
29. partners.148 These inconsistent re-
sults may be partly attributable to
confounding factors such as alcohol
or drug consumption, which in-
crease risk-taking regardless of dis-
closure. In addition, because safer
sex requires explicit discussions be-
yond simply disclosing HIV sta-
tus,35 the effect of disclosure needs
to be considered in relation to other
behaviors and attitudes.
DISCLOSURE, HEALTH
SERVICES, AND HEALTH
PROVIDERS
The influence of health services
on disclosure has not been sys-
tematically examined, but we can
piece together information on 3
interrelated questions: first,
whether staff at health facilities
contribute to reducing stigma and
discrimination, thus normalizing
HIV; second, whether they en-
courage disclosure by HIV-posi-
tive persons and promote testing
and referral of partners and family
members; and third, whether they
are prepared to counsel and sup-
port those who are tested, to
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30. HEALTH POLICY AND ETHICS
facilitate voluntary disclosure and
support.
The extent to which health fa-
cilities promote disclosure de-
pends in part on whether they
provide a supportive context for
the difficult experience of being
HIV positive. Evidence suggests
that health facilities sometimes fall
short in this regard. Discrimination
against HIV-positive individuals
was reported to occur when health
workers treat them differently,
use excessive precautions, or
withhold appropriate care.149---151
Fears of being treated poorly were
reported more frequently by
women than men. In Australian
health facilities, more women than
men reported fearing discrimina-
tion in the form of avoidance of
treatment, extra precautions, and
confidentiality problems, and in
Kenyan maternity wards, health
workers expressed anxiety when
caring for women who may have
been HIV positive and admitted
that they used ‘‘extra care’’ in han-
dling them; such situations contrib-
uted to delays and suboptimal care,
31. such as reluctance to take HIV
tests or to give birth at health
facilities.152---154 These studies also
reported that stigma and discrimi-
nation are declining.
Another indication of how dis-
closure is linked to health services
comes from studies that examined
its connection with adherence to
antiretroviral therapy. Initiatives
to provide antiretroviral therapy
sometimes require that patients
disclose to a supportive individual
in their network, on the basis of
a large body of evidence indicating
that disclosure facilitates initiation
of and adherence to antiretro-
viral therapy, whereas worries
about disclosure contribute to se-
crecy and missed medica-
tions.88,155---160 Most studies on the
subject focus on adherence, and
more information is needed about
the process of disclosure when it
is a condition for antiretroviral
therapy.
Health facilities are often ill
equipped to reassure PLWHA that
they will be treated well, and
health workers may not have the
training to counsel patients or the
competence to judge how to dis-
close patients’ HIV status or to
32. whom it should be disclosed.161,162
For example, a study from Vietnam
found that health workers felt so
uncomfortable discussing HIV with
patients that they avoided giving
women their HIV test results di-
rectly; instead, they relied on the
official notification system, which
informs local district officials about
the HIV status of people living in
their catchment area without pa-
tients’ consent.163 This nonconfi-
dential process sometimes has seri-
ous social, economic, and health
consequences for HIV-positive
women and their children.
In addition, health workers
sometimes communicate test re-
sults to individuals other than
HIV-positive patients, as docu-
mented in numerous settings. For
example, in a comparative study in
India, Indonesia, the Philippines,
and Thailand, 34% of HIV-posi-
tive respondents reported that
health care workers had revealed
their HIV status to someone else
without their consent.151 One In-
dian study found that 61% of
women reported that family mem-
bers were given test results without
the patient being consulted164; an-
other found that 35% of
33. respondents (male and female)
reported that their HIV status was
disclosed to friends or relatives
without their consent (in 75% of
cases the disclosure was made by
health workers).95 Similarly, a study
in China found that health pro-
viders often informed family mem-
bers of an HIV diagnosis before
informing the patient.165 One study
suggested that privacy breaches by
health workers in India were more
frequent for female clients and in
the private sector.161
Involuntary disclosure by
health workers has been attrib-
uted in part to circumstances at
health facilities, which often lack
private spaces and where it is
difficult to manage patient files
without compromising confidenti-
ality. More importantly, however,
the issue of involuntary disclosure
by health workers highlights the
difficulty of balancing medical
confidentiality with the need to
facilitate disclosure to those
around an HIV-positive person.
Health workers are supposed to
encourage testing of partners and
family members and to promote
disclosure to mobilize support for
treatment and prevention, but
these objectives are often incom-
patible with guaranteeing absolute
34. patient confidentiality.
The difficulty of promoting
partner disclosure is manifested
in the low rates of partner refer-
ral.21,82,90,166 A review of 15 studies
from sub-Saharan Africa and Asia
found that partner disclosure by
HIV-positive women ranged from
17% to 80%, with lower rates
generally reported by women
tested during antenatal care, com-
pared with women undergoing
voluntary HIV testing and
counseling.3 This finding suggests
that the mode of testing makes
a difference to HIV disclosure, but
also that women’s vulnerability
during pregnancy increases their
reluctance to disclose.11 For exam-
ple, only 23% of partners of HIV-
positive women attending a pro-
gram on prevention of mother-to-
child transmission in Côte d’Ivoire
were subsequently tested for
HIV.83 Only 17% of HIV-positive
pregnant women in a study in
Tanzania reported their test results
to their partners.92 The fact that
69% of partners who agreed
to test were seropositive under-
scores the missed opportunity for
prevention.
Some studies suggest that HIV-
35. positive health workers find dis-
closure difficult because they
worry that they may be stigma-
tized or that a positive diagnosis
will mean they have failed as
a role model. These fears may
hamper their own ability to be
tested, to disclose, and to promote
testing, as documented among
health workers in Kenya162 and
Malawi.167
Despite these difficulties, some
studies have shown that health
workers can help people cope with
disclosure and its aftermath. In
Sweden, contact with counselors
increased the probability of disclo-
sure by immigrant African families,
filling a gap in their disrupted social
network.62 In a study in China,
good relations between patients
and providers led to positive health
outcomes after disclosure, particu-
larly when families were unsup-
portive because of HIV-related
stigma.165 More evidence is needed
to demonstrate how health workers
can support HIV disclosure.
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HEALTH POLICY AND ETHICS
36. SOCIAL CONTEXT OF
DISCLOSURE
Although frequencies and sta-
tistical associations provide useful
information about levels of dis-
closure and their possible deter-
minants, they also raise questions
about differences in the meaning
of disclosure, the consequences of
disclosure, and the roles of health
providers in different sociocultural
settings. The evidence suggests
that social context influences key
dimensions of disclosure, in par-
ticular the notion of support, the
role of the family, and the values
surrounding disclosure.
Qualitative studies that examine
individual experiences have
shown that disclosure is closely
related to expectations of support.
These studies have also shown
that disclosure is higher when in-
dividuals hope to receive help
from those around them, and it is
lower when they expect blame
and discrimination. As a lengthy,
potentially fatal illness, HIV infec-
tion represents a possible rupture
of the rules of reciprocity that are
the basis of social interactions,
and a potential drain on resources
37. for those around the ill person.168
That is why, in diverse contexts––
such as the Dominican Republic,
Malawi, and Tanzania––individuals
thinking about disclosure try to
predict how others will react,
based on the disclosers’ perceived
responsibility for the infection and
on the quality of their relationships
with those around them.76,77,86,133
Emotional support is important
everywhere, but in low-resource
settings where services are defi-
cient and individuals need mate-
rial support from their families and
communities, there are stronger in-
centives to disclose. At the same
time, however, there are also more
risks in disclosing in these settings,
precisely because PLWHA are
explicitly or implicitly making im-
mediate or future demands on
those around them. Hence, a sub-
tle difference can be discerned
when comparing both qualitative
and quantitative studies in re-
source-rich settings to those in re-
source-poor settings. Respondents
in resource-rich settings, such as
the United States and France,
tended to describe disclosure as a
way to obtain psychological sup-
port and relief from the stress of
38. harboring a secret,18,58,102 whereas
those in resource-poor settings,
such as China, India, Kenya, Nigeria,
and South Africa, mentioned ex-
pectations of financial and social
support,70,72,169 emotional and ma-
terial support,95 and help with
medical care and counseling.93
Social context also shapes the
extent to which disclosure deci-
sions are made by others beyond
the individual, as documented in
both quantitative and qualitative
research. In settings where ade-
quate health services and social
services are lacking and kinship
bonds continue to be strong, fam-
ilies and communities may be seen
as having responsibilities toward
ill individuals and therefore as
having a right to be informed about
an HIV-positive result.93,125,147 If,
as in India, close involvement of the
family is thought to be in the best
interest of the patient, then a
health worker’s breach of confi-
dence can be seen as choosing to
conform to local social norms
rather than to national stan-
dards.161 In many settings,
physicians are thought to have the
authority to decide on disclosure, as
documented in a comparative study
in Asia and the Middle East, where
39. 80% of Saudi physicians reported
that they would disclose a patient’s
HIV status to their family without
his or her consent.170 Practitioners
often think they know better than
poor or uneducated clients, partic-
ularly women, and they involve
families as a way of recognizing
hierarchies within families that lead
some members to make health de-
cisions on behalf of others.95,171 A
qualitative study from Lesotho
found that when health workers
kept patients’ HIV status strictly
confidential, family caregivers
sometimes lacked crucial informa-
tion needed to secure appropriate
medical care.172
Thus, the social context of dis-
closure may define 2 competing
sets of values: those designed to
respect patients’ privacy and con-
fidentiality, and those meant to
assist and protect those around the
patient. Health workers may be
caught between these conflicting
values and may feel that they
should provide information to
family members, either to rally
support for an HIV-positive per-
son or because they feel some
responsibility to those around that
person if patients themselves re-
fuse to disclose.173
40. The legal context also influ-
ences the extent of disclosure and
its consequences. A number of
countries have enacted laws or
formulated policies to encourage
disclosure or to mandate disclo-
sure to partners. This has hap-
pened in the United States,174,175
Canada,176 Singapore,177 and
countries of west and central
Africa.178,179 In addition, manda-
tory premarital HIV testing and so-
called ‘‘beneficial disclosure,’’ which
allows health workers to disclose
patients’ status without their con-
sent, are being discussed in African
countries.180,181 Elsewhere, as in
some countries of the Middle East
and north Africa, the majority of
HIV testing appears to be manda-
tory, with no guidance on disclo-
sure.182 These situations raise
a number of ethical and legal issues
that are beyond the scope of this
article and about which much has
been written. Here, it is important to
note that the legal context has an
impact on institutional support for
disclosure at health facilities in the
form of guidelines, protocols, pro-
grams, and other resources that
enable health workers to help
around disclosure. The legal con-
text also affects individuals’ per-
41. ceived incentives and motivations
for disclosure.
As a process of sharing infor-
mation about a sensitive topic,
HIV status disclosure takes on
different meanings in different
contexts. The absence of exact
equivalents for the term ‘‘disclo-
sure’’ in languages other than
English testifies to the different
connotations it can have (e.g., re-
vealing a secret, admitting guilt, or
simply stating a medical fact).
These complex meanings are
linked to moral and ethical valua-
tions. The ethical and moral di-
mensions of deeply personal
choices around sex and dis-
closure have been highlighted in a
thoughtful US study,119 and com-
parable analyses are sorely needed
to better understand the reality of
moral challenges and how they are
addressed in other settings. It has
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HEALTH POLICY AND ETHICS
been claimed that a policy focused
on individual rights, confidentiality,
42. and professional counseling dis-
tances the family and community
from their role in providing HIV
support173 and may be incompati-
ble with traditional notions of col-
lective family responsibility.165
The tension between the ethics
of individualism and communal-
ism is beyond the scope of this
article, but it is clear that the
difficulties of disclosure reflect the
potential conflict between com-
peting ethical values. Some au-
thors argue that the right of sexual
partners to be informed and pro-
tected is as important as the pri-
vacy of PLWHA183 and that when
respect for confidentiality increases
the risks to third parties, then rou-
tine third-party disclosure may be
the lesser of the evils.184 Managing
the value conflict underlying rec-
ommendations about disclosure rep-
resents an important challenge for
all the actors involved––individual
partners, health workers, and
policymakers.41
CONCLUSIONS
The studies on disclosure that
we have reviewed here show that,
first, although disclosure is diffi-
cult, few people keep their HIV
status completely secret. Levels of
43. disclosure are generally high, but
lower levels are documented
among certain populations, partic-
ularly women tested during pre-
natal care. This finding suggests
that attention should be directed
to these groups to better under-
stand circumstances that favor or
hinder disclosure. Second, not all
studies on disclosure disaggregate
results by respondents’ HIV status;
but this information is essential,
because HIV-positive status is
consistently linked to lower dis-
closure rates, a point that under-
scores the prevention implications
of lower disclosure among those
more likely to transmit the infec-
tion. Third, disclosure is more
uniformly high in the high-income
countries of Europe and the
United States, and frequency var-
iations are wider in low- and mid-
dle-income countries. These dif-
ferences likely reflect differential
availability of and access to re-
sources to deal with HIV and its
consequences. Fourth, women
appear to disclose, and to receive
disclosure, more frequently than
do men, but married and preg-
nant women encounter special
difficulties with partner disclo-
sure. Further research should
seek to identify those specific
44. gender-related factors that may
facilitate disclosure and mitigate
its negative consequences.
Analyses of disclosure as a pro-
cess show that decisions regarding
what information to disclose, to
whom, and when are iterative and
selective, such that partial and
gradual disclosure to a growing
number of people is more com-
mon than is one-time full disclo-
sure to all; also, disclosure to
sexual partners is often more dif-
ficult than to others. The implica-
tions of these results are clear:
partner disclosure deserves special
attention, given its consequences
for transmission; initiatives to
support disclosure need to be on-
going, rather than focusing on
a single point in time; and coun-
seling cannot be the same at all
stages but should consider evolving
motivations and consequences.
A main goal of this review was
to assess the extent to which
health facilities and health work-
ers facilitated disclosure. We
found that health worker facilita-
tion of disclosure was limited by
the potential for discrimination at
health facilities, the limited coun-
seling abilities of many health
workers, and health workers’ own
45. fears and concerns regarding HIV.
The relatively high frequencies
of health workers disclosing peo-
ple’s HIV status without their
consent and the low levels of
partner disclosure, particularly in
less developed countries, testify to
the difficult balance between en-
couraging disclosure and keeping
HIV status confidential. Health
workers on the front lines need
support as they negotiate these
complicated situations.
At the same time, however,
a number of reports indicate that
health workers can help with dis-
closure, provided that they are
supported in multiple ways. There
have been calls to give nurses
a role in assisting women with
their disclosure decisions,115 to
support community- or home-based
HIV care programs,185 to facilitate
couple counseling, and to promote
disclosure while reducing the risk of
discrimination and violence against
women. The successes reported
by some programs suggest promis-
ing possibilities, such as strength-
ening health workers’ communica-
tion skills and increasing their
perceived self-efficacy, providing
ongoing support for women
working through disclosure deci-
sions, and mediating disclosure
46. through counselors in the clinic or
through friends or family mem-
bers outside the clinic.186 In
Rwanda, a package of strategies––
including systematic couple coun-
seling and community-based cam-
paigns––seems to have overcome
some barriers to disclosure and has
increased the uptake of HIV testing
by male partners of pregnant
women from 7% in 1999 to 84%
in 2009.187 Further evidence is
needed to identify the optimal
combination of interventions that
would support health workers’ ef-
forts to facilitate disclosure while
ensuring that disclosure is used as
the basis for mobilizing support
for those who need it.
We also found differences in
the meaning of disclosure across
settings. Although emotional fac-
tors related to relationships and
trust influenced motivations to
disclose everywhere, respon-
dents from resource-rich settings
put a somewhat greater emphasis
on psychological relief, whereas
those in resource-poor settings
more often referred to needs for
material support and caregiving as
a reason for disclosing. These mo-
tivations may change with in-
creased access to free treatment,
47. however, as individuals have less
need to disclose to their families to
obtain material support and have
greater access to support groups.
Thus, the meaning of disclosure
may shift from divulging a secret to
sharing a new identity built on
serostatus.
The ethical dilemmas resulting
from competing values––the con-
fidentiality of patient informa-
tion versus the need to inform
and protect others around the
PLWHA––are especially marked
in contexts in which family and
community remain important
structures and in which relatives
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6
HEALTH POLICY AND ETHICS
and community members are
expected to play a major role in
medical decision-making, care
giving, and material support for
PLWHA. Cross-cultural compari-
sons of what constitutes commu-
nities and of the values attached to
consent and confidentiality show
a great deal of variation.188---190 A
48. better understanding of how confi-
dentiality is perceived in different
cultural contexts can help identify
areas of flexibility that can be used
to facilitate disclosure where
appropriate. Support for disclosure
cannot wait for a resolution of
the ethical dilemmas around confi-
dentiality, but the debates around
disclosure and the policies that
are formulated to promote it
should, at a minimum, be in-
formed by evidence on how in-
dividuals in the field address
these situations.
Research also confirms the re-
ciprocal connections among
stigma, social support, and disclo-
sure. Expectations of support are
a crucial factor in the decisions of
PLWHA to disclose, and reactions
to these disclosures are, in part,
influenced by the sacrifices that
may be required from those
around them. Stigmatization in-
creases these potential sacrifices,
and support services reduce them.
Thus, fears around disclosure re-
flect available levels of resources
and social support. Taken to-
gether, these results suggest that
structural changes––including
making more services available
to support PLWHA, their families,
and communities––could be as
49. important as individual ap-
proaches or the provision of
counseling. j
About the Authors
Carla Makhlouf Obermeyer is with the
Department of HIV/AIDS, World Health
Organization, Geneva, Switzerland. Parijat
Baijal is with the Global Fund to Fight
AIDS, Tuberculosis and Malaria, Geneva,
Switzerland. Elisabetta Pegurri is with
UNAIDS, Geneva, Switzerland.
Correspondence should be sent to Carla
Makhlouf Obermeyer, Department of
HIV/AIDS, World Health Organization,
20 Ave Appia, 1211 Geneva, Switzerland
(e-mail: [email protected]). Reprints
can be ordered at http://www.ajph.org by
clicking the ‘‘Reprints/Eprints’’ button.
This article was accepted December 9,
2010.
Note. The views expressed here are those
of the authors and do not represent those of
the World Health Organization; the Global
Fund to Fight AIDS, Tuberculosis and
Malaria; or UNAIDS.
Contributors
C. M. Obermeyer conceptualized the
study, coordinated the analyses, and led
the writing of the article. P. Baijal and E.
Pegurri conducted the searches, summa-
rized the results, and participated in
50. writing the article.
Human Participant Protection
No protocol approval was necessary be-
cause the study did not involve any
human research participants.
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June 2011, Vol 101, No. 6 | American Journal of Public Health
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HEALTH POLICY AND ETHICS
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By Amy D.
Leonard, Christine
M. Markham,
Thanh Bui,
Ross Shegog and
Mary E. Paul
Amy D. Leonard is a
research coordinator,
and Mary E. Paul is
associate professor,
both in the Depart-
ment of Allergy and
Immunology, Texas
Children’s Hospital,
Baylor College of
Medicine, Houston.
Christine M.
85. Markham and Ross
Shegog are assistant
professors, and Thanh
Bui is a doctoral stu-
dent, all at the Center
for Health Promo-
tion and Prevention
Research, School
of Public Health,
University of Texas
Health Science Center
at Houston.
110 Perspectives on Sexual and Reproductive Health
Lowering the Risk of Secondary HIV Transmission: Insights
From HIV-Positive Youth and Health Care Providers
CONTEXT: Both perinatally and behaviorally infected HIV-
positive youth engage in sexually risky behaviors, and a
better understanding of the perceptions of these youth and of
health care providers regarding disclosure of HIV status
and risk reduction would aid in the development of behavioral
interventions for such youth.
METHODS: In spring 2007, some 20 HIV-positive inner-city
youth (aged 13–24) and 15 health care providers who
work with HIV-infected youth participated in in-depth,
semistructured interviews. Youth were recruited at an HIV
clinic, AIDS clinics and an AIDS service organization, and had
86. received care from participating providers. Detailed
contextual and thematic discourse analysis was performed on
interview transcriptions.
RESULTS: Eighteen of the 20 youth had disclosed their HIV
status to another individual at least once. Eleven reported
being sexually active, and three of these had been perinatally
infected. Qualitative analysis revealed four subthemes
related to disclosure: stigma and emotions, trust issues, reasons
for disclosing and strategies for addressing disclo-
sure. Five subthemes were identifi ed related to sexual risk
reduction: dating challenges, attitudes toward condom use,
self-effi cacy for condom use negotiation, pregnancy attitudes
and sexual risk reduction strategies. Providers reported
that access to more engaging and interactive educational tools
within the clinic setting could enhance their risk
reduction counseling with HIV-positive youth.
CONCLUSIONS: HIV-positive youth experience multiple
challenges regarding disclosure and sexual risk reduction,
and health care providers need innovative tools that can be used
in clinic settings to improve adolescents’ skills in
reducing risky sexual behavior.
Perspectives on Sexual and Reproductive Health, 2010,
42(2):110–116, doi: 10.1363/4211010
Improvements in the medical management of HIV have
reduced the rate of perinatal transmission from mothers
to their children, and 91% of U.S. children with perina-
tally acquired HIV survive into adolescence and young
adulthood.1 Nevertheless, youth continue to acquire HIV
through risky behaviors such as unprotected sex and
injection-drug use. The Centers for Disease Control and
Prevention (CDC) estimates that at least half of all new HIV
infections in the United States are among people younger
87. than 25 and are largely due to these two risk behaviors.1
The extended survival of perinatally infected youth, com-
bined with rising numbers of behaviorally infected youth,
presents health care providers with the critical challenge of
providing HIV-positive youth with information and meth-
ods to prevent secondary HIV transmission.
Successes in HIV medical management have not been
matched by successes in behavioral interventions to cur-
tail risky behaviors among HIV-positive youth. Despite
researchers’ advanced understanding of the pathophysiol-
ogy and transmission of HIV, as well as the use of clinic-
based education relating to risk reduction, the translation
of relevant health messages into behavioral practice remains
fl awed, as HIV-positive youth continue to engage in risky
behaviors.2–6 In one study, 43% of HIV-positive youth
reported not using a condom at last intercourse.2 A small
number of behavioral interventions for HIV-positive youth
have been rigorously evaluated, but the assessment of their
effectiveness has been hampered by poor attendance.5,7,8
To fully understand the challenges of preventing sec-
ondary HIV transmission among youth, the experiences of
both HIV-positive youth and health care providers need to
be explored. Although quantitative studies9–11 have exam-
ined the attitudes and perceptions of such youth toward
sexual risk reduction and disclosure of their HIV status,
qualitative data to inform the development of interventions
have been limited.12,13 Furthermore, little is known about
providers’ attitudes toward risk reduction and disclosure
among HIV-positive youth.14 The present study explores
the views of health care providers and HIV-positive youth
about disclosure and sexual risk reduction, and suggests
how prevention efforts and clinical behavioral interven-
tions might be strengthened.
88. METHODS
This study was conducted in spring 2007 as a forma-
tive component for the development and evaluation of
a computer-based clinical intervention for HIV-positive
youth. Purposive sampling was used to recruit youth
participants at a pediatric HIV clinic, AIDS clinics and a
local AIDS service organization. Case managers referred
Volume 42, Number 2, June 2010 111
potential participants to the study coordinator. To be eli-
gible, participants had to be HIV-positive and aged 13–24
(the age-group defi ned as adolescents by the CDC15). Prior
to the interview, informed consent was obtained from par-
ents and adolescents. For participants who were younger
than 18 and not emancipated, their assent and consent
from one parent were obtained. Youth completed a survey
that assessed gender, age, race or ethnicity, HIV status and
mode of infection. Health care providers were recruited by
personal contact; to be eligible, providers had to have more
than a year of pediatric HIV-positive care experience.
In-depth interviews were conducted with the youth at
the clinic or agency from which they were recruited, and
with the providers in private offi ces at their hospital or
clinic. All interviews were recorded and transcribed ver-
batim; each interview lasted approximately one hour, and
the youth received a $10 gift certifi cate at its completion.
The interviews followed a semistructured format with
open-ended probes, and focused on the two principal
themes of interest: disclosure of HIV status and sexual risk
reduction. The interview guide was developed by a panel
consisting of a pediatric HIV specialist, a health educa-
89. tor experienced with HIV-positive youth and behavioral
scientists experienced in adolescent HIV prevention. To
enhance rapport with the youth, interviewers progressed
from less sensitive to more sensitive topics. Regardless of
personal experiences, respondents were asked to report
any thoughts or opinions they had about HIV disclosure
or sexual risk reduction.
Detailed contextual and thematic discourse analysis
was performed with the aid of ATLAS.ti, version 5.2.20,
software. Transcriptions were entered into the computer
program, and the text was analyzed using constant com-
parative and thematic analysis. For each transcription,
at least two investigators independently performed the
coding and categorized codes into themes and sub-
themes, which were then compared and contrasted
for interrater reliability. Results of youth and provider
groups were compared to evaluate trends that emerged
from the data.
RESULTS
Thirty-fi ve interviews were conducted: 20 with HIV-
positive youth (fi ve males, 15 females)* and 15 with health
care providers. Twelve youth (four males, eight females)
had been infected perinatally, and eight (one male, seven
females) behaviorally. Participants were 17 years old, on
average; 16 identifi ed themselves as black, three as Latino
and one as white. The provider sample consisted of three
pediatricians, two obstetrician-gynecologists, three nurse
practitioners, one nurse and six social workers. Although
it was not an inclusion criterion, all youth participants had
received medical care from the health care providers tak-
ing part in this research.
Eighteen of the 20 youth had disclosed their HIV status
to another individual at least once, though not necessarily
90. to a sexual partner. Of the 11 who reported being sexually
active, three had been perinatally infected. Responses from
both youth and health care providers revealed a number
of common subthemes regarding the principal themes of
disclosure and sexual risk reduction.
Disclosure
�Stigma and emotions. When asked “What is the most
diffi cult thing about living with HIV?” more than a third of
the youth responded that it was not being able to disclose
their status. A 19-year-old behaviorally infected black
male stated that the biggest burden related to HIV was
“keeping it a secret, because the people I hang around talk
about [HIV] a lot.” Some youth said keeping their HIV
status a secret was a barrier to obtaining the emotional
support they desperately desired. Expressing the feelings
of several youth, one adolescent commented:
“I was so scared. I was like, worried, and I was kind of
nervous. I didn’t know what to say, how exactly to say it
and how to put it. … I got mixed feelings that day [I dis-
closed]. I swear I thought I was sick. I was just, like, oh my
God.”—18-year-old perinatally infected Hispanic female
Health care providers also believed that nondisclosure
was the most diffi cult thing for youth living with HIV.
Providers noted that many youth associated nondisclosure
with societal stigma. A pediatrician explained:
“Because of stigma, they don’t get much community
support like other chronic diseases. [HIV is] not like
cancer, [where] at the convenience store there’s a picture
of the child and they’re collecting donations.”
In addition, some providers attributed nondisclosure to
91. an adolescent’s acceptance or internalizing of the disease.
As one pediatrician stated, “I think it becomes really
diffi cult for many of them to adjust to that transition of
‘I’m a teen, I am HIV-positive,’ and that whole societal
piece of the [stigma].”
Both youth and providers said that fear of a negative
reaction prevented youth from disclosing their HIV sta-
tus. One 15-year-old perinatally infected black female
recalled hearing, “Oh, don’t touch this person, because
you are going to have AIDS,” or “Don’t touch that,
because you’re going to catch AIDS and die.” Trepidation
over possible gossip or rejection was cited by the major-
ity of youth and providers as barriers to disclosure. One
pediatrician reported, “There’s that question of, ‘If I tell
him now, will he leave?’ And for [youth] who’ve tried,
they have found that that is exactly what happened.”
Another 15-year-old perinatally infected black female
explained her fear of gossip: “Because people are [stu-
pid]. They talk too much. … Like, if I tell my friend, my
friend goes to tell her friend, and she tells her friends,
[and] it gets around.”
*The gender distribution of our sample refl ects that of HIV-
infected indi-
viduals of this age in the local study area (source: Houston
Department
of Health and Human Services, Bureau of Epidemiology, AIDS:
summary
of Houston/Harris County cases, 2009,
<http://www.houstontx.gov/
health/HIV-STD/1stQRT2009.pdf>, accessed July 29, 2009).
92. Lowering Secondary HIV Transmission Among HIV-Positive
Youth
112 Perspectives on Sexual and Reproductive Health
•Trust issues. Health care providers reported emphasizing
trust issues when discussing disclosure with their patients.
A nurse practitioner explained:
“They really have to feel like they trust the person with
that information. … But I advise them not to tell some-
body that might turn around and try to hurt them, …
because it’s a big piece of information to give anybody.”
Youth also emphasized the importance of trusting a
person before disclosing, but “trust” emerged as a vague,
undefi ned concept. Only one youth offered a defi nition:
“loyalty, respect and honor.” The majority appeared unsure
about how to handle disclosure, even with someone they
knew they “could trust.” A few participants described
methods of gauging a person’s reaction before they dis-
closed their status. For example, one youth explained:
“First I would ask them, ‘Well, what do you think about
HIV?’ … If they tell me, ‘Oh, I don’t like to hang out with
[HIV-positive] people and everything,’ I just stay back.
And I’m like, ‘Oh, I’m not going to tell them.’ If they give
me another [answer], like ‘Oh, no matter if somebody has
that; I’ll be his friend,’ or ‘I’ll be there for him,’ I’ll be like,
‘Oh. Well, I have HIV.’”—16-year-old behaviorally infected
Hispanic female
�Disclosure reasons. Fourteen of the 18 youth who had
disclosed their HIV status said they desired a closer rela-
93. tionship with another person, and described their postdis-
closure relationship as more open than before. All providers
reported spending time with their adolescent patients
discussing the pros and cons of disclosure. Providers’
responses revealed that they encouraged disclosure so that
the youth would have someone to talk with to lessen their
isolation, would have someone to assist with medication
reminders and would ensure that their potential sexual
partners were aware of the importance of using condoms.
When asked to describe a disclosure incident, eight youth
described disclosure to a friend, six to a signifi cant other
and four to a family member. All youth who had disclosed
their HIV status reported at least one compassionate reac-
tion. Half agreed that this supportive experience encouraged
them to consider future disclosure. Only two participants
recounted a negative reaction to their disclosure, including
a 19-year-old behaviorally infected black female, who said:
“He told me he loved me so much, he wanted to marry me.
Then I told him [my HIV status]. He walked away. [Now],
he just treats me like an outsider.” These two participants
said the negative reactions would not prevent them from
disclosing again, but they would be more selective in whom
they would tell.
Other youth described the medical and emotional ben-
efi ts of disclosure. For example:
“Now [my friend] protects me. She’s like my guard. …
She tries to keep me from certain things. Like when she
knows someone’s sick, she’s like, ‘Don’t go by them.’ …
She’s like another person that tells me to take my medi-
cine.”—14-year-old perinatally infected black female
Some youth indicated that another reason to disclose
was to warn others of the risk of infection: