The Political Economy of Constitutional Choice: A Study of the 2005 Kenyan Constitutional Referendum

Recent studies of the linkages between the wealth of nations and the institutions of governance suggest that concentrating political power in a monarchy or a ruling coalition impedes economic growth and, moreover, that while power-diffusing reforms can enhance the wellbeing of society in general, opposition by groups benefitting from the status quo is predictable. In November 2005, Kenyans rejected a proposed constitution that, despite promises made by their new chief executive, would not have lessened the powers of the presidency. Using a unique, constituency-level dataset on the referendum vote, we estimate a model of the demand for power diffusion and find that ethnic groups' voting decisions are influenced by their expected gains and losses from constitutional change. The results also highlights the importance of ethnic divisions in hindering the power-diffusion process, and thus establish a channel through which ethnic fragmentation adversely impacts economic development.

Ethnicity, Governance and the Provision of Public Goods

Ethnicity is an important institution and one that impacts on the quality of governance. This paper focuses on the behavior of ethnic groups and specifically on their impact on the provision of public goods. The paper shows that ethnic heterogeneity results in under-provision of non-excludable public goods. On the other hand, such societies associate with provision of patronage goods. The paper proposes some areas of research such the economics of ethnic institutions, empirical evidence of the role ethnic groups on public goods provision, tax compliance and institutional reforms to improve governance.

Tribalism as a Minimax-Regret Strategy: Evidence from Voting in the 2007 Kenyan Elections

Although many studies find that voting in Africa approximates an ethnic census in that voting is primarily along ethnic lines, hardly any of the studies have sought to explain ethnic voting following a rational choice framework. Using data of voter opinions from a survey conducted two weeks before the December 2007 Kenyan elections, we find that the expected benefits associated with a win by each of the presidential candidates varied significantly across voters from different ethnic groups. We hypothesize that decision to participate in the elections was influenced by the expected benefits as per the minimax-regret voting model. We test the predictions of this model using data of voter turnout in the December 2007 elections and find that turnout across ethnic groups varied systematically with expected benefits. The results suggest that individuals participated in the elections primarily to avoid the maximum regret should a candidate from another ethnic group win. The results therefore offer credence to the minimax regret model as proposed by Ferejohn and Fiorina (1974) and refute the Downsian expected utility model.

Depressive symptoms and sexual risk behaviors in adolescents

The purpose of this study was to determine whether depression is a factor in explaining the difference in sex behaviors among adolescents with different ethnic backgrounds, family and school contexts. We hypothesize that adolescents with a higher number of depressive symptoms are more likely to engage in sexual risk behaviors than adolescents with fewer depressive symptoms. Further, adolescent depression and sexual behaviors are mediated or moderated by individual characteristics, family and school contexts. ^ Background. large ethnic disparities exist in adolescent engagement in risky sexual behaviors, yet, there is little in the literature that explains these disparities. Studies of sexual behavior of youths abound; yet, there is little literature on the prevalence and correlates of depression or the association between depression and sexual behaviors among different ethnic groups. Objectives. (1) To determine ethnic differences in the prevalence of depressive symptoms using data collected through the National Longitudinal Study of Adolescent Health (Add Health). (2) To determine predictors of sex risk behaviors among adolescents, including the role of depression. (3) To identify predictors of depression among these adolescents. Methods. Add Health data from wave 1 and wave 2 interviews of 7th–12th graders were analyzed using multivariate models constructed with both depression and sexual behavior as outcome variables. Logistic regression models determined whether and to what extent the independent variables, including depression, sex behaviors, demographic factors, individual and family characteristics, and school context were related to the probability of engaging in risky sexual behaviors. Results. Ethnic differences in depressive symptoms did not persist after demographic and contextual variables were included in the model. Sex behaviors all shared the hypothesized relationship with depressive symptoms. The odds of risky sex behaviors increased as number of depressive symptoms increased. Depression was predicted by marijuana use and having a serious argument with father for males at Wave 1 and by age and future orientation for females. Wave 2 depression was predicted by Wave 1 depression. ^

Adolescent tobacco use: Studies of prevalence, factorial validity, and factorial invariance between African Americans and Whites

In the last thirty years, increasing efforts have been made to reduce the prevalence of adolescent tobacco use in the United States. Although the prevalence has declined dramatically over the past decade, there are still sharp differences in adolescent smoking-initiation rates across racial/ethnic groups. Large-scale surveys frequently assess smoking-related attitudes, self-efficacy, and intentions to explain the differences in smoking rates between African Americans and Whites. However, there is little agreement about which constructs are significant. Moreover, the psychometric properties of smoking-related attitude, self-efficacy, and intention constructs have not been fully examined. More studies are needed to understand existing patterns of tobacco use and to validate and fully exploit the constructs' relationship to adolescent smoking initiation across racial/ethnic groups. ^ This dissertation reports on a secondary analysis of data from a large multi-ethnic convenience sample of sixth- through eighth-grade students in 22 schools in East Texas and the city of Houston. The specific aims of this dissertation were to (1) describe smoking and alternate tobacco product use rates by race/ethnicity, gender, age, and grade level (Article 1); (2) test the factorial validity of smoking-related attitudes, self-efficacy, and intentions using confirmatory factor analysis techniques (Article 2); and (3) test the factorial invariance of smoking-related attitudes, self-efficacy, and intentions between African Americans and Whites (Article 3). ^ The prevalence findings confirm the disparities in tobacco use among African American, Hispanic, and White adolescents that other surveys have reported (Article 1). This study also demonstrates the usefulness of examining use patterns of not only cigarettes but also alternative tobacco products in younger multiethnic populations, as well as of providing epidemiological data estimates about different phases of smoking. The confirmatory factor analysis provides evidence of construct validity of attitude, self-efficacy, and intention scales for the multiethnic sample (Article 2). Finally, the factorial invariance analyses indicates that some measures representing smoking-related attitudes, self-efficacy, and intentions may not be appropriate for use among both African Americans and Whites (Article 3). Additional research is needed to further our understanding of the patterns and predictors of youth tobacco use initiation. ^

Effect of maternal weight status on the relationship between prenatal smoking and infant birth weight

The purpose of this study was to assess the effect of maternal pre-pregnancy weight status on the relationship between prenatal smoking and infant birth weight (IBW). Prenatal cigarette smoking and maternal weight exert opposing effects on IBW; smoking decreases birth weight while maternal pre-pregnancy weight is positively correlated with birth weight. As such, mutual effect modification may be sufficiently significant to alter the independent effects of these two birth weight correlates. Finding of such an effect has implications of prenatal smoking cessation education. Perception of risk is an important determinant of smoking cessation, and reduced or low birth weight (LBW) as a smoking-associated risk predominates prenatal smoking counseling and education. In a population such as the US, where obesity is becoming epidemic, particularly among minority and low-income groups, perception of risk may be lowered should increased maternal size attenuate the effect of smoking. Previous studies have not found a significant interaction effect of prenatal smoking and maternal pre-pregnancy weight on IBW; however, use of self-reported smoking status may have biased findings. Reliability of self-reported smoking status reported in the literature is variable, with deception rates ranging from a low of 5% to as high as 16%. This study, using data from a prenatal smoking cessation project, in which smoking status was validated by saliva cotinine, was an opportunity to assess effect modification of smoking and maternal weight using biochemically determined smoking status in lieu of self report. Stratified by saliva cotinine, 151 women from a prenatal smoking cessation cohort, who were 18 years and older and had full-term, singleton births, were included in this study. The effect of smoking in terms of mean birth weight across three levels of maternal pre-pregnancy weight was assessed by general linear modeling procedures, adjusting for other known correlates of IBW. Effect modification was marginally significant, p = .104, but only with control for differential effects among racial/ethnic groups. A smaller than planned sample of nonsmokers, or women who quit smoking during the pregnancy, prohibited rejection of the null hypothesis of no difference in the effect of smoking across levels of pre-pregnancy weight. ^

Access to health care among children in the U.S.: Use of health inequalities measures to evaluate progress in reduction of disparities from 1997 to 2005

Much of the literature on disparities in access to health care among children has focused on measuring absolute and relative differences experienced by race/ethnic groups and, to a lesser extent, socioeconomic groups. However, it is not clear from existing literature how disparities in access to care may have changed over time for children, especially following implementation of the State Children’s Health Insurance Program (SCHIP). The primary objective of this research was to determine if there has been a decrease in disparities in access to care for children across two socioeconomic groups and race/ethnicity groups after SCHIP implementation. Methods commonly used to measure ‘health inequalities’ were used to measure disparities in access to care including population-attributable risk (PAR) and the relative index of inequality (RII). Using these measures there is evidence of a substantial decrease in socioeconomic disparities in health insurance coverage and to a lesser extent in having a usual source of care since the SCHIP program began. There is also evidence of a considerable decrease in non-Hispanic Black disparities in access to care. However, there appears to be a slight increase in disparities in access to care among Hispanic compared to non-Hispanic White children. While there were great improvements in disparities in access to care with the introduction of the SCHIP program, continuing progress in disparities may depend on continuation of the SCHIP program or similar targeted health policy programs. ^

Physician's adherence to the standard protocol for diabetes treatment in Brooke Army Medical Center (BAMC)

The level of compliance with clinical practice guidelines for patients with Type II Diabetes Mellitus was evaluated in 157 patients treated at BAMC from 1 January 2006 to 1 January 2007. This retrospective analysis was conducted reviewing data from medical records and following the VA/DOD protocols that health care providers are expected to follow at this facility. Data collected included patient’s age and gender, presence or absence of complications of diabetes, physical examination findings, glycemic and lipid control, eye care, foot care, kidney function, and self-management and education. Subjects were selected performing systematic random sampling, and included both male and female patients, from a variety of ages and ethnic groups. The Diabetes complications screened for included glycemic and lipid complications, retinopathy, cardiovascular complications, peripheral circulation complications, and nephropathy. The results revealed that 19.10% had no complications and that the most common complications were: cardiovascular (49.68%), glycemic and lipid control (10.82%), retinopathy and peripheral circulation (8.28% each), and nephropathy (2.54%). Only 2.54% of the records reviewed did not include information on complications. Strictly following the Department of Defense guidelines, six treatment modules were evaluated independently and together to get a final percentage of adherence to the clinical practice guidelines. It was established that the level of adherence was going to be graded as follows: Extremely deficient: 0-15%; very poor: 16-30%; Poor and in need of improvement: 31-45%. Acceptable: 46-60%; Good: 61-80%, and Excellent: 81-100%. The results indicated that the percentage of physicians' adherence to each protocol was as follows: 88.31%, 89.93%, 90.63%, 89.42%, 89.42% and 89.64%. When the results were pooled, the level of adherence to the clinical practice guidelines was 89.55%, proving my hypothesis that Brooke Army Medical Center physicians have excellent adherence to the standard protocols for Diabetes Type II to treat their patients. ^

A cross-sectional analysis of physical activity and obesity in inner city Houston Texas Mexican American youth

Obesity prevalence among children and adolescents is rising. It is one of the most attributable causes of hospitalization and death. Overweight and obese children are more likely to suffer from associated conditions such as hypertension, dyslipidemia, chronic inflammation, increased blood clotting tendency, endothelial dysfunction, hyperinsulinemia, and asthma. These children and adolescents are also more likely to be overweight and obese in adulthood. Interestingly, rates of obesity and overweight are not evenly distributed across racial and ethnic groups. Mexican American youth have higher rates of obesity and are at higher risk of becoming obese than non-Hispanic black and non-Hispanic white children. ^ Methods. This cross-sectional study describes the association between rates of obesity and physical activity in a sample of 1313 inner-city Mexican American children and adolescents (5-19 years of age) in Houston, Texas. This study is important because it will contribute to our understanding of childhood and adolescent obesity in this at-risk population. ^ Data from the Mexican American Feasibility Cohort using the Mano a Mano questionnaire are used to describe this population's status of obesity and physical activity. An initial sample taken from 5000 households in inner city Houston Texas was used as the baseline for this prospective cohort. The questionnaire was given in person to the participants to complete (or to parents for younger children) at a home visit by two specially trained bilingual interviewers. Analysis comprised prevalence estimates of obesity represented as percentile rank (<85%= normal weight, >85%= at risk, >95%= obese) by age and gender. The association between light, moderate, strenuous activity, and obesity was also examined using linear regression. ^ Results. Overall, 46% of this Mexican American Feasibility cohort is overweight or obese. The prevalence for children in the 6-11 age range (53.2%) was significantly greater than that reported from NHANES, 1999–2002 data (39.4%). Although the percentage of overweight and obese among the 12-19 year olds was greater than that reported in NHANES (38.5% versus 38.6%) this difference was not statistically significant. ^ A significant association between BMI and sit time and moderate physical activity (both p < 0.05) found in this sample. For males, this association was significant for moderate physical activity (p < 0.01). For the females, this association was significant for BMI and sit time (p < 0.05). These results need to be interpreted in the light of design and measurement limitations. ^ Conclusion. This study supports observations that the inner city Houston Texas Mexican American child and adolescent population is more overweight and obese than nationally reported figures, and that there are positive relationships between BMI, activity levels, and sit time in this population. This study supports the need for public health initiatives within the Houston Hispanic community. ^

Racial disparities in CD4 counts at initial HIV-1 diagnosis: Analysis of the Adult Spectrum of HIV disease dataset and public health implications

Introduction. The HIV/AIDS disease burden disproportionately affects minority populations, specifically African Americans. While sexual risk behaviors play a role in the observed HIV burden, other factors including gender, age, socioeconomics, and barriers to healthcare access may also be contributory. The goal of this study was to determine how far down the HIV/AIDS disease process people of different ethnicities first present for healthcare. The study specifically analyzed the differences in CD4 cell counts at the initial HIV-1 diagnosis with respect to ethnicity. The study also analyzed racial differences in HIV/AIDS risk factors. ^ Methods. This is a retrospective study using data from the Adult Spectrum of HIV Disease (ASD), collected by the City of Houston Department of Health. The ASD database contains information on newly reported HIV cases in the Harris County District Hospitals between 1989 and 2000. Each patient had an initial and a follow-up report. The extracted variables of interest from the ASD data set were CD4 counts at the initial HIV diagnosis, race, gender, age at HIV diagnosis and behavioral risk factors. One-way ANOVA was used to examine differences in baseline CD4 counts at HIV diagnosis between racial/ethnic groups. Chi square was used to analyze racial differences in risk factors. ^ Results. The analyzed study sample was 4767. The study population was 47% Black, 37% White and 16% Hispanic [p<0.05]. The mean and median CD4 counts at diagnosis were 254 and 193 cells per ml, respectively. At the initial HIV diagnosis Blacks had the highest average CD4 counts (285), followed by Whites (233) and Hispanics (212) [p<0.001 ]. These statistical differences, however, were only observed with CD4 counts above 350 [p<0.001], even when adjusted for age at diagnosis and gender [p<0.05]. Looking at risk factors, Blacks were mostly affected by intravenous drug use (IVDU) and heterosexuality, whereas Whites and Hispanics were more affected by male homosexuality [ p<0.05]. ^ Conclusion. (1) There were statistical differences in CD4 counts with respect to ethnicity, but these differences only existed for CD4 counts above 350. These differences however do not appear to have clinical significance. Antithetically, Blacks had the highest CD4 counts followed by Whites and Hispanics. (2) 50% of this study group clinically had AIDS at their initial HIV diagnosis (median=193), irrespective of ethnicity. It was not clear from data analysis if these observations were due to failure of early HIV surveillance, HIV testing policies or healthcare access. More studies need to be done to address this question. (3) Homosexuality and bisexuality were the biggest risk factors for Whites and Hispanics, whereas for Blacks were mostly affected by heterosexuality and IVDU, implying a need for different public health intervention strategies for these racial groups. ^

Validity and reliability of a measure of Latina mother's nutritional self-efficacy

Background. Not only has obesity played a role in Texas adults but it is also becoming a large issue among low-income Latino children. In Latino children between 2-5 years of age, the Pediatric Nutrition Surveillance data in 1997 found the prevalence of obesity was 12 percent, highest among all ethnic groups. Children learn what and how to eat from their environment. Despite many mothers being working mothers they are still the principal caregivers and source of influence on their toddler's diet. Self-efficacy, a concept created by Albert Bandura, one's belief that one is capable of performing a behavior needed to reach an intended goal, is increasingly becoming important in nutrition and health education. This study is important to understand the degree of impact that a mother's self-efficacy will have on a child's diet. This is useful knowing if influencing a mother's self-efficacy could improve a child's diet to prevent certain public health issues such as obesity and diabetes. The purpose of this study was to examine nutrition self-efficacy of Latina mothers, focusing on sweets and beverage and if their self-efficacy impacted their child's diet. Methods. The data was collected during July-September 2008. Mothers were recruited from two federally qualified San Antonio health centers. In order to qualify, participants had to be Hispanic with children of toddler age. Mothers were informed of incentives available upon completion. The interview consisted of demographic info, a set of five self-efficacy questions repeated at completion, testing reliability and a 24-hour food recall diary asked of the participant's child's diet. Results. There were 225 mothers who participated between both clinics. The Crohnbach alpha scores for the two different times the self-efficacy questions were asked were .44 corresponding to the first time and .49 for the second time. The three most common beverages reported were milk, juice, and water. The mothers who met or gave their child more milk than recommended by the scientific community, 800mg of calcium/3 cups (24oz) set, had a higher self-efficacy score than those who did not meet the standard at all. Mothers who gave their children more juice than the standard recommends, 4-6oz for children 1-6 years of age, had slightly higher self-efficacy scores than mother's who simply met the standard. In general, the lower the mother's self-efficacy, the more sweets they gave their child and vice versa. Conclusion. This study's Kappa values were adequate and this research showed that Latina mothers did in fact have high self-efficacy. In general some of the children's diets did not reflect the current scientific nutrition recommendations. In order to improve self-efficacy and have an impact on children's diets, the scientific community has a responsibility to make recommendations that are easily understood and can be put into practice. The public health community needs to ensure that we encourage those we serve to be more active in their health and educate them about what constitutes good health and nutrition for both themselves and their children.^

Gastric cancer survival amongst Hispanics- A Hispanic paradox? A case series study using the SEER 1973--2005 data registry

Stomach cancer is the fourth most common cancer in the world, and ranked 16th in the US in 2008. The age-adjusted rates among Hispanics were 2.8 times that of non-Hispanic Whites in 1998-2002. In spite of that, previous research has found that Hispanics with non-cardia adenocarcinoma of the stomach have a slightly better survival than non-Hispanic Whites. However, such previous research did not include a comparison with African-Americans, and it was limited to data released for the years 1973-2000 in the nine original Surveillance, Epidemiology, and End Results Cancer Registries. This finding was interpreted as related to the Hispanic Paradox, a phenomenon that refers to the fact that Hispanics in the USA tend to paradoxically have substantially better health than other ethnic groups in spite of what their aggregate socio-economic indicators would predict. We extended such research to the SEER 17 Registry, 1973-2005, with varying years of diagnosis per registry, and compared the survival of non-cardia adenocarcinoma of the stomach according to ethnicity (Hispanics, non-Hispanic Whites and African-Americans), while controlling for age, gender, marital status, stage of disease and treatment using Cox regression survival analysis. We found that Hispanic ethnicity by itself did not confer an advantage on survival from non-cardia adenocarcinoma of the stomach, but that being born abroad was independently associated with the apparent 'Hispanic Paradox' previously reported, and that such advantage was seen among foreign born persons across all race/ethnic groups.^

Improving the health and well-being of women at risk for neural tube defect recurrence

There is growing interest in providing women with internatal care, a package of healthcare and ancillary services that can improve their health during the period after the termination of one pregnancy but before the conception of the next pregnancy. Women who have had a pregnancy affected by a neural tube defect can especially benefit from internatal care because they are at increased risk for recurrence and improvements to their health during the inter-pregnancy period can prevent future negative birth outcomes. The dissertation provides three papers that inform the content of internatal care for women at risk for recurrence by examining descriptive epidemiology to develop an accurate risk profile of the population, assessing whether women at risk for recurrence would benefit from a psychosocial intervention, and determining how to improve health promotion efforts targeting folic acid use.^ Paper one identifies information relevant for developing risk profiles and conducting risk assessments. A number of investigations have found that the risk for neural tube defects differs between non-Hispanic Whites and Hispanics. To understand the risk difference, the descriptive epidemiology of spina bifida and anencephaly was examined for Hispanics and non-Hispanic Whites based on data from the Texas Birth Defects Registry for the years 1999 through 2004. Crude and adjusted birth prevalence ratios and corresponding 95% confidence intervals were calculated between descriptive epidemiologic characteristics and anencephaly and spina bifida for non-Hispanic Whites and for Hispanics. In both race/ethnic groups, anencephaly expressed an inverse relationship with maternal age and a positive linear relationship with parity. Both relationships were stronger in non-Hispanic Whites. Female infants had a higher risk for anencephaly in non-Hispanic Whites. Lower maternal education was associated with increased risk for spina bifida in Hispanics.^ Paper two assesses the need for a psychosocial intervention. For mothers who have children with spina bifida, the transition to motherhood can be stressful. This qualitative study explored the process of becoming a mother to a child with spina bifida focusing particularly on stress and coping in the immediate postnatal environment. Semi-structured interviews were conducted with six mothers who have children with spina bifida. Mothers were asked about their initial emotional and problem-based coping efforts, the quality and kind of support provided by health providers, and the characteristics of their meaning-based coping efforts; questions matched Transactional Model of Stress and Coping (TMSC) constructs. Analysis of the responses revealed a number of modifiable stress and coping transactions, the most salient being: health providers are in a position to address beliefs about self-causality and prevent mothers from experiencing the repercussions that stem from maintaining these beliefs. ^ Paper three identifies considerations when creating health promotion materials targeting folic acid use. A brochure was designed using concepts from the Precaution Adoption Process Model (PAPM). Three focus groups comprising 26 mothers of children with spina bifida evaluated the brochure. One focus group was conducted in Spanish-only, the other two focus groups were conducted in English and Spanish combined. Qualitative analysis of coded transcripts revealed that a brochure is a helpful adjunct. Questions about folic acid support the inclusion of an insert with basic information. There may be a need to develop different educational material for Hispanics so the importance of folic acid is provided in a situational context. Some participants blamed themselves for their pregnancy outcome which may affect their receptivity to messages in the brochure. The women's desire for photographs that affect their perception of threat and their identification with the second role model indicate they belong to PAPM Stage 2 and 3. Participants preferred colorful envelopes, high quality paper, intimidating photographs, simple words, conversational style sentences, and positive messages.^ These papers develop the content of risk assessment, psychosocial intervention, and health promotion components of internatal care as they apply to women at risk for recurrence. The findings provided evidence for considering parity and maternal age when assessing nutritional risk. The two dissimilarities between the two race/ethnic groups, infant sex and maternal education lent support to creating separate risk profiles. Interviews with mothers of children with spina bifida revealed the existence of unmet needs-suggesting that a psychosocial intervention provided as part of internatal care can strengthen and support women's well-being. Segmenting the audience according to race/ethnicity and PAPM stage can improve the relevance of print materials promoting folic acid use.^

The impact of host immunity on oscillating rates of syphilis when gender and race are considered

The rates of syphilis in the United States have increased since the all time low in 2000. In 2003, the rates of syphilis in the United States were 2.5 cases per 100,000. There were 178 reported cases of primary and secondary syphilis (8.9 cases per 100,000) in Houston, Texas, which was a 58.9% increase from 2002. While syphilis can be completely treated now, unlike in times past, it is still a public health concern. The purpose of this study is to examine the possibility of modeling the impact of an immune response in primary and secondary syphilis in 63 major cities across the United States, stratified by gender and racial-ethnic groups. A Fourier analysis will be performed by SAS. Subsequently, this study will compare the results to a similar study of syphilis in 68 US cities, that focused on immune response, however, did not stratified by race and gender. This study will help determine if the oscillating rates of syphilis are due to biological factors of the disease or to behavioral changes in the population. This study will use surveillance data from 63 major cities across the United States. The data will be provided by the Centers of Disease Control. Ultimately, this study will expand the knowledge of the effect of immunity on endemics.^

The application of latent variable models to the assessment of determinants of HIV risk behavior

Studies on the relationship between psychosocial determinants and HIV risk behaviors have produced little evidence to support hypotheses based on theoretical relationships. One limitation inherent in many articles in the literature is the method of measurement of the determinants and the analytic approach selected. ^ To reduce the misclassification associated with unit scaling of measures specific to internalized homonegativity, I evaluated the psychometric properties of the Reactions to Homosexuality scale in a confirmatory factor analytic framework. In addition, I assessed the measurement invariance of the scale across racial/ethnic classifications in a sample of men who have sex with men. The resulting measure contained eight items loading on three first-order factors. Invariance assessment identified metric and partial strong invariance between racial/ethnic groups in the sample. ^ Application of the updated measure to a structural model allowed for the exploration of direct and indirect effects of internalized homonegativity on unprotected anal intercourse. Pathways identified in the model show that drug and alcohol use at last sexual encounter, the number of sexual partners in the previous three months and sexual compulsivity all contribute directly to risk behavior. Internalized homonegativity reduced the likelihood of exposure to drugs, alcohol or higher numbers of partners. For men who developed compulsive sexual behavior as a coping strategy for internalized homonegativity, there was an increase in the prevalence odds of risk behavior. ^ In the final stage of the analysis, I conducted a latent profile analysis of the items in the updated Reactions to Homosexuality scale. This analysis identified five distinct profiles, which suggested that the construct was not homogeneous in samples of men who have sex with men. Lack of prior consideration of these distinct manifestations of internalized homonegativity may have contributed to the analytic difficulty in identifying a relationship between the trait and high-risk sexual practices. ^