Background:Depressive and anxiety disorders, together contribute to over 50% of the Disability-Adjusted Life Years (DALYs). While outcomes for severe mental illnesses have been extensively studied, outcome-based research on CMDs remains limited. Aim:To evaluate the needs, barriers, caregiver involvement, recovery and service satisfaction of patients with CMDs as a measure of service outcome. Methods:This prospective cohort study included 274 patients with CMDs diagnosed per ICD-10 criteria. Participants were assessed at baseline and six months using researcher-rated and service user-rated outcome measures. Instruments included the Camberwell Assessment of Needs-Research (CAN-R), Client Satisfaction Questionnaire (CSQ), Barriers to Access to Care Evaluation (BACE v3), Involvement Evaluation Questionnaire (IEQ), and Importance of Services in Recovery (INSPIRE). Generalized Linear Mixed Models (GLMM) and negative binomial regression were employed to analyze outcomes over time. Results:At baseline, 90.9% of participants had needs, with unmet needs comprising 80.7%. Major unmet needs were psychological distress (73.4%), looking after the home (57.7%), and daytime activities (50.7%). Depression had the highest impact on unmet needs, contributing to a 32% increase per unit rise in depression severity (IRR = 1.318, P < 0.001). Stigma accounted for only about one-fifth of the total perceived barriers to accessing care, with worrying and urging behaviors among the caregivers. At the end of six months, the unmet needs significantly improved, but caregivers were still concerned about the well-being of the participants, associated with improvements in service satisfaction. Conclusions:CMD patients had significant unmet needs, especially for psychological distress, household, and daily activities. Depression was the largest contributor to unmet needs, while panic and somatic disorders were lower. Caregiver burden evolved, and non-stigma-related barriers to care were significant.

In the USA, gay Latino men living with HIV face compounding marginalisation within both Latino and LGBTQ communities that shapes engagement across the HIV care continuum. The role of machismo and familismo in HIV status disclosure and antiretroviral therapy (ART) adherence among members of this population remains understudied, particularly in the Southern USA, where cultural values and conservative norms converge. Guided by an intersectional framework, the theory of planned behaviour, and cognitive appraisal theory, between September and October 2022, semi-structured interviews were conducted with 11 gay Latino men living with HIV (ages 21 to 60 or older) in South Texas. All interviews were conducted in English. Data were analysed using thematic analysis. Two themes revealed how machismo and familismo shaped HIV care engagement in contrasting ways. Latino cultural expectations and Southern conservatism created barriers through machismo expectations, a 'double silence', triple identity conflict, and gendered disclosure patterns. These same values became facilitators of ART adherence when support existed, through 'staying alive for family' and 'chosen family' motivations. Machismo and familismo simultaneously act as barriers to HIV status disclosure and motivators for ART adherence among gay Latino men living with HIV in South Texas. HIV care models should leverage familismo-driven motivations while addressing disclosure barriers.

Advance care planning (ACP) allows individuals to specify preferences for care and surrogate decision makers that may be needed during a serious illness or at the end of life. Cisgender sexual minority men (SMM) are an overlooked population in most ACP research. We used latent class analysis and data from a sample of midlife and older adult SMM in the Multicenter AIDS Cohort Study. Pre-contemplators (28%) were unlikely to have engaged in any ACP. Contemplators (17%) had thought about ACP but had not taken action. Formal Preparers (22%) had completed documents and asked someone to be their surrogate decision-maker but were unlikely to have thought about specific values or the flexibility afforded to their surrogate. Full Preparers (33%) had completed documents and also considered specific values and the flexibility afforded to their surrogate. Pre-Contemplators and/or Contemplators generally reported less socially supportive relationships, greater loneliness, less optimism, and less resilience than Formal Preparers and Full Preparers. Full Preparers had the highest level of AIDS-related bereavement. To maximize self-determination and preference concordant care, future ACP research and direct practice with SMM should be cognizant of underlying constellations of planning behaviors and psychosocial factors that may act as barriers or facilitators to planning.

To redress systemically biased approaches to health interventions and service design, it is critical that public health researchers employ frameworks that are intentional in their approach to recognizing and working against existing power structures to advance equity in public health. Design Justice represents an approach to design which centers marginalized people and uses collaborative design processes to address community needs and challenges. The purpose of this paper is to describe our process for applying a Design Justice framework to Project XX. Project XX is a study funded by XX designed to develop and test an eHealth-enhanced peer navigation intervention to improve engagement in substance use and HIV-related services for young adults with recent carceral system involvement. We situate the project within the theoretical foundation of Design Justice and community-engaged research, describe its development and implementation, and analyze the application of Design Justice principles from an implementation science perspective by overlaying them with Stanford University’s Center for Dissemination and Implementation’s five key dimensions of dissemination and implementation methods. We highlight successes, challenges, and lessons learned, offering recommendations to guide more equitable and inclusive approaches for future research and practice.

Social media is commonly used by lesbian, gay, bisexual, transgender, and queer (LGBTQ+) youth to connect and communicate with their peers; however, little is known about strategies LGBTQ+ youth use to safely navigate social media. Individuals aged 14-18 living in the United States who identified as LGBTQ+ (n = 14) were recruited online. During virtual interviews, participants described how they connected with other LGBTQ+ youth on social media and their strategies for creating affirming and positive experiences. Additionally, they talked about their negative experiences online, and ways they avoid discriminatory behavior on various platforms. Many used social media to connect with friends from their home community or school, while others used social media to find new friends and community. Participants often used social media to connect with LGBTQ+ resources, posts, and creators. Many participants faced bullying online, including one participant who experienced "going viral" on social media. To avoid discriminatory behavior, LGBTQ+ youth employed strategies such as using private accounts and blocking negative and discriminatory content. These results can be used to inform future research and clinical practice to help LGBTQ+ youth stay safe on social media.

Mass incarceration in the United States is a social-structural driver of health for sexual and gender minoritized adults (SGMA). The aim of this study was to develop a conceptual framework for post-release healthcare to use in adapting a mobile health unit (MHU) for SGMA returning from jail. We used concept mapping to answer a focal prompt regarding health-related needs for SGMA post-release. We recruited SGMA with recent incarceration experience and relevant community partners to participate in 4 concept mapping sessions. Multidimensional scaling produced a two-dimensional point map of all statements and their relative relationships and hierarchical cluster analysis illustrated clusters of needs. SGMA community members (n = 16) and community partners (n = 13) generated 109 unique statements describing post-release healthcare-related needs for SGMA. Participants sorted and rated these items, creating a map of 10 clusters of needs: Physical Health, LGBTQ-Affirming Mental Health Care, Release Planning, Release Aftercare, Peer Support, Immediate Needs, Stabilizing Needs, Resources to Thrive, Access to Education, and Structural Healthcare Advantages. While HIV prevention and treatment were identified as the most important and the best fitting, the vast majority of post-release healthcare needs identified by SGMA related to other social and structural drivers of health to reduce stigma and risk, increase access to important health services like harm reduction and gender-affirming care, improve their economic conditions, and provide social support and safety. This participant-led conceptual framework provides insight regarding important components to include in development and adaptation of interventions to address HIV and other health inequities for SGMA produced and exacerbated by the CLS.

Background: In addition to structural interventions such as syringe services and naloxone distribution, harm reduction (HR) is also a relational approach to care encompassing principles such as patient autonomy and pragmatism that can be implemented in healthcare teams to improve outcomes for people with HIV (PWH) who use drugs. Evidence suggests that using a relational HR framework to operationalize care for PWH who use drugs may improve the patient-provider relationship, thus positively impacting HIV outcomes. We previously found that negative attitudes toward people who use drugs are negatively associated with acceptance of HR; however, little is known about how HIV providers conceptualize the patient-provider relationship with PWH who use drugs. Objectives: The aim of this study was to describe the ways healthcare workers (HCWs) characterize interactions with PWH who use drugs and if these characterizations reflect relational HR or missed opportunities to improve the patient-provider relationship. Design: We used a qualitative descriptive design to characterize HCWs’ descriptions of their interactions with PWH who use drugs. Methods: We interviewed providers ( n = 23) working at three HIV clinics in the United States to assess their interactions with patients. Providers included anyone who had worked at their respective clinic for ⩾1 year and who had face-to-face contact with patients (e.g., front desk staff, nurses, physicians, and social workers). Data were coded thematically via Dedoose. Results: We discovered that HCWs characterize positive patient-provider interactions that both reflect HR principles and may not align with the principles of HR. Examples include when patients appear comfortable with and trusting of their provider, when patients feel heard by their provider, and when providers feel they are responsive to patient needs. However, other HCWs described positive interactions as counter to relational HR. Conclusion: HCW descriptions of positive interactions in line with relational HR in their conceptualization of patient-provider interactions with PWH who use drugs have the potential to guide efforts in increasing the acceptability of HR in HIV care. Given evidence showing HR improves outcomes for those who use substances, findings suggest missed opportunities to incorporate relational HR into the patient-provider relationship in HIV primary care settings. Registration: NCT05404750.

Sexual minority men (SMM) in the US are twice as likely to experience mental health challenges, including depressive symptoms, compared with their heterosexual counterparts. Having a like-mentor, or a sexual minority mentor, is associated with improved mental well-being among SMM mentees. However, few studies have explored the potential benefits to mentors. Using confirmatory factor analysis, we calculated a perceptions of mentoring score that encompasses experiences and beliefs regarding mentoring of SMM from the Healthy Aging Substudy of the Multicenter AIDS Cohort Study. We used a generalized estimating equations model to assess associations between perceptions of mentoring and clinically significant depressive symptoms adjusted for key covariates; models were also stratified by HIV serostatus. Among 1,246 men aged 40+ years, the strongest agreement was with the statement "I have encouraged people to be proud of their sexual orientation," for which 770 individuals (72%) indicated "Agree" or "Strongly Agree." Each unit increase in the mean perceptions of mentoring score was associated with 8% decreased odds of having clinically significant depressive symptoms (adjusted odds ratio: 0.92; 95% CI: 0.85-0.99). We show that SMM reported like-mentoring experiences and had positive mentoring beliefs, and that these were associated with a decreased odds of having depressive symptoms. Encouraging SMM to serve as like-mentors could be a way to counter depressive symptoms among this key population. There is a need for increased research regarding how mentoring programs can best be designed to benefit sexual minority mentees and mentors.

Background The Pitt Public Health evaluation team used a mixed-methods, community-based participatory research method of concept mapping to evaluate factors affecting the Overdose Data to Action (OD2A) opioid overdose surveillance and prevention project outcomes for Allegheny County, Pennsylvania. Methods In June 2021 we developed the focal prompt: “What factors work to help or limit OD2A program outcomes at the individual, community, and or/system level?”Community partners participated in three phases: Brainstorming, Sorting and Rating, and Interpretation. Using concept mapping software, we applied multidimensional scaling to visualize a point map displaying factors and their relative relationships, and hierarchical cluster analysis to generate concept maps displaying clusters of factors. Results During the brainstorming phase community partners (N = 18) generated 69 unique statements describing factors impacting OD2A work and community partners (N = 16) sorted and rated statements using concept mapping software. In the interpretation community partners (N = 26) selected the 10-cluster map as the most salient cluster solution. Using this cluster map and cluster ratings, we identified Stigma, Criminalization and Marginalization, and Racial Equity as factors of highest importance to overdose prevention success but lowest in success thus far. Discussion Using concept mapping to evaluate factors affecting OD2A outcomes was a successful method of engaging community partners in considering opportunities to strengthen OD2A and future overdose prevention efforts.

Sexual history screening (SHS) is recommended to determine risk for acquisition of human immunodeficiency virus (HIV) and eligibility for pre-exposure prophylaxis (PrEP). SHS and PrEP are underutilized, sequential screening, and prevention practices. This study aimed to understand factors impacting the implementation of SHS and PrEP at a multi-site federally qualified health center (FQHC) in Connecticut. Guided by the Consolidated Framework for Implementation Research, semistructured interviews were conducted on Zoom with primary care providers (PCPs), medical assistants, clinical leadership, and PrEP navigators. Convenience and purposive sampling took place via email until thematic saturation was achieved. Thematic analysis was conducted. Twenty-two participants were interviewed for this study. PCPs lacked knowledge and reported limited or no use of SHS to determine patients' level of HIV risk, which may explain why most PCPs relied on patients to request PrEP. While PCPs perceived organizational support to prescribe PrEP, clinical staff were unaware of structural resources. Lastly, participants described a vertical trajectory of influence from external sources (policies and insurance) to time allocated to appointments that limits their ability to implement SHS and PrEP, further complicated by the electronic health record and disparities in structural resources across clinical sites. This study provides foundational evidence for future research on implementation strategies to improve HIV prevention through universal, comprehensive SHS to identify patients for PrEP. Overcoming barriers to SHS and PrEP, particularly in clinical settings such as FQHCs that care for vulnerable populations, may improve identification, prevention, and treatment of HIV and aid in ending the HIV epidemic.

Interpersonal management of homophobic stigma (e.g., selectively constructing one's social network; confronting stigma) is an understudied area of resilience among sexual minority people. Among a sample of cisgender sexual minority men (SMM; N = 798) in midlife and older adulthood, we assessed the psychometric properties and characterized the sociodemographic differences of our newly developed, theory-informed homophobia management scale. Data come from the Healthy Aging substudy of the Multicenter AIDS Cohort Study, which is a prospective longitudinal study implemented to evaluate the natural trajectories of HIV risk and treatment among sexual minority men. Guided by the proactive coping processes model, the Healthy Aging team proposed eight items to measure homophobia management, which were included at four waves of survey data collection completed at semiannual study visits. Using factor analyses and linear regressions, we assessed our scale's construct validity, convergent validity, and internal consistency, and characterized scores by age, race/ethnicity, sexual orientation, and HIV status. Factor analyses yielded a six-item scale with adequate construct validity and acceptable internal consistency (Cronbach's alpha = .69). Our final scale exhibited convergent validity given its statistically significant inverse association with internalized homophobia and positive association with psychological connections to the gay community. Bivariate differences in homophobia management emerged by age, race/ethnicity, and sexual orientation but were not statistically significant in multivariable analyses. Our study provides a validated, unidimensional scale to assess homophobia management among SMM in midlife and older adulthood. We provide recommendations to improve the implementation of our scale in future surveillance. Public Significance Statement The present study advocates for assessments of homophobia management (i.e., coping behaviors to minimize exposure or consequences of homophobia) to inform resilience among sexual minority people in midlife and older adulthood. Upon psychometric testing with a large community cohort of midlife and older adult cisgender sexual minority men, the study's findings offer a unique and acceptable instrument to measure sexual minority people's capacity to enact homophobia management when faced with instances of homophobic stigma.

The Rethinking Incarceration and Empowering Recovery (RIvER) Clinic was launched in June 2021 to address the health disparities experienced during and after incarceration. The RIvER Clinic’s multidisciplinary, community-centered team engages patients during jail detention and after release via telehealth, collocated in community locations, on a mobile van, and in clinic. The clinic serves as a bridge between incarceration and the establishment of permanent health care and social services in the community. In 2022, a total of 479 visits were completed. The clinic provided multidisciplinary substance use support to all eligible patients, paying for 104 medication for opioid use disorder (MOUD) prescriptions for uninsured patients. Twenty-five percent of patients were transitioned to community-based care, and less than 5% of patients were reincarcerated. Despite some limitations, results demonstrate that the RIvER Clinic is successfully reintegrating a marginalized population into its community. The purpose of this article is to describe the implementation and preliminary outcomes of this postincarceration clinic.

Objectives: Advance care planning (ACP) specifies decision-making surrogates and preferences for serious illness or end-of-life medical care. ACP research has largely neglected sexual minority men (SMM), a population that experiences disparities in health care and health status. Methods: We examined formal and informal ACP among SMM ages 40+ in the Multicenter AIDS Cohort Study (N = 1,071). Results: For informal ACP (50%), younger SMM and men with past cardiovascular events had greater odds of planning; single men had lower odds of planning. For formal ACP (39%), SMM with greater socioeconomic status had greater odds of planning; SMM who were younger, of racial/ethnic minority identities, who were single or in a relationship without legal protections, and who lacked a primary care home had lower odds of planning. Discussion: Findings warrant further exploration of both informal and formal planning. More equitable, culturally-humble engagement of SMM may facilitate access, uptake, and person-centered planning.

This cross-sectional study examined the relationships between sexual history screening (SHS) and referrals to a pre-exposure prophylaxis (PrEP) navigator (non-clinical staff member who assists patients in overcoming structural barriers to PrEP) on the proportion of days covered by PrEP for adult patients at a federally qualified health center. Patients' sociodemographics, PrEP prescriptions, referral to a PrEP navigator, and SHS data were extracted from the electronic health record (EHR). The analytic sample was 214 adult patients who were human immunodeficiency virus (HIV) negative and taking PrEP to prevent infection from January 2016 to December 2019. Mixed-effects negative binomial models were conducted accounting for clustering by patients' primary care providers. Documentation of SHS was associated with a higher proportion of days covered by PrEP (incidence rate ratio = 1.44, 95% confidence interval: 1.17-1.77). There was no significant effect of having a referral to the PrEP navigator on the proportion of days covered by PrEP, nor did having a referral to the PrEP navigator moderate the relationship between having SHS documented in the EHR and the proportion of days covered by PrEP. This study is the first to investigate the relationship between having sexual history documented in the EHR, referrals to a PrEP navigator, and their combined effect on the proportion of days covered by PrEP. Results of this study provide foundational evidence for future studies examining SHS as an opportunity to improve PrEP access and adherence and indicate the need for additional research exploring the value of PrEP navigators as an implementation strategy to overcome social and structural barriers to care.

BACKGROUND:Sexual and gender minority (SGM; ie, lesbian, gay, bisexual, transgender, and otherwise queer) young adults experience disparities in depression and other internalizing psychopathology. Although social media use is widespread and SGM people have more social media accounts and are more socially active on them than non-SGM individuals, few studies have examined the impact of social media on depression in this group. OBJECTIVE:The PRIDE iM study will be the first longitudinal, mixed methods research conducted to determine the impact of social media interactions and behaviors as pathways to depressive symptoms among SGM young adults living in the United States. METHODS:PRIDE iM uses a bookends variation of the longitudinal sequential mixed methods design. Participants will be recruited nationally from social media. First, between July 2019 and February 2020, we conducted a qualitative phase (T1) comprising web-based individual interviews (N=58) to inform the building and content of the quantitative survey. Second, from February 2022 to September 2022, we will conduct a series of web-based surveys (N=1000 at baseline) with 4 data points (T2-T5), each one collected every 6 to 8 weeks. Third, from October 2022 to December 2022, we will conduct a second qualitative phase (T6) of web-based interviews using outcome trajectories found in the longitudinal survey analyses to purposively sample survey participants and conduct web-based interviews to contextualize and explain survey findings. Qualitative data from T1 and T6 will be analyzed using a reflexive thematic analysis approach. As we sought to capture change over time in the association between the main predictors (ie, social media interactions and behaviors) and depressive symptoms, we propose analyzing T2 to T5 data using latent growth models with a structural equation modeling framework. Data integration at the method, interpretation, and reporting levels will be achieved through building and connecting and the use of a staged approach and joint displays, respectively. At all stages, we will assess the fit of data integration as recommended by the principles of best practice for mixed methods research in psychology. RESULTS:Data collection will be completed by December 2022. Qualitative data analyses will be completed by March 2023, and quantitative analyses of the primary outcome of interest will be completed by June 2023. CONCLUSIONS:PRIDE iM will confirm, reject, or uncover the presence of potential relationships between social media interactions and behaviors and depressive symptoms among SGM people. This study represents fundamental groundwork to develop social media-based interventions that target modifiable interactions and behaviors that are most likely to influence mental health outcomes, thus seizing the opportunity to merge the popularity of this medium among SGM people with evidence-based approaches. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):DERR1-10.2196/43627.

PURPOSE:In 2018, there were 68 million sexually transmitted infections in the United States. Sexual history screening is an evidence-based practice endorsed by guidelines to identify risk of these infections and adverse sexual health outcomes. In this mixed methods study, we investigated patient- and clinician-level characteristics associated with receipt of sexual history screening, and contextualized these differences in more depth.METHODS:We collected sociodemographics of patients from the electronic health record and sociodemographics of their primary care clinicians via a census survey. Semistructured interviews were conducted with key practice staff. We conducted multilevel crossed random effects logistic regression analysis and thematic analysis on quantitative and qualitative data, respectively.RESULTS:A total of 53,246 patients and 56 clinicians from 13 clinical sites participated. Less than one-half (42.4%) of the patients had any sexual history screening documented in their health record. Patients had significantly higher odds of documented screening if they were gay or lesbian (OR = 1.23), were cisgender women (OR = 1.10), or had clinicians who were cisgender women (OR = 1.80). Conversely, patients' odds of documented screening fell significantly with age (OR per year = 0.99) and with the number of patients their clinicians had on their panels (OR per patient = 0.99), and their odds were significantly lower if their primary language was not English (OR = 0.91). In interviews, key staff expressed discomfort discussing sexual health and noted assumptions about patients who are older, in long-term relationships, or from other cultures. Discordance of patient-clinician gender and patients' sexual orientation were also noted as barriers.CONCLUSIONS:Interventions are needed to address the interplay between the social and contextual factors identified in this study, especially those that elicited discomfort, and the implementation of sexual history screening.

HIV remains a significant health issue for women, and multiple overlapping factors shape women's HIV-related risk. Pre-exposure prophylaxis (PrEP) offers critical advantages over other existing options, yet it remains significantly underused among women in the USA where limited work has explored women's opinions on barriers to potential PrEP use. Using open-ended text responses from a sample of women seeking care at a US urban family planning health centre, this study aimed to understand perceptions of factors affecting potential PrEP use. Three themes concerning key factors impacting potential PrEP use emerged: HIV risk assessment, relationship dynamics, and anticipated stigma. Women's assessment of HIV risk suggests that identifying women in clinical settings as having low self-perceived risk may overlook the complexity of how women determine HIV-related risk and prevention needs. Women frequently referenced relationship dynamics when considering PrEP and discussed anticipated partner reactions about use contributing to non-use. Fear or worry of stigma were expressed as motivations to not use PrEP. Study results highlight the importance of public health and health care professionals normalising PrEP as a strategy in women's HIV prevention and sexual health decision-making. Woman-centred PrEP education, screening and communication strategies reflective of their unique HIV-related risk context are needed.

Objective:This study examines the association between social support and cognitive function among midlife and older MSM living with or without HIV.Design:We analyzed longitudinal data from participants enrolled from October 2016 to March 2019 in the Patterns of Healthy Aging Study, a substudy of the Multicenter AIDS Cohort Study.Methods:We conducted a cross-sectional analysis to estimate the association between social support and three measures of cognitive function [Trail Making Test (TMT) Part A, TMT Part B to A ratio, and Symbol Digit Modalities Tasks (SDMT)]. We also used linear mixed-effects models to estimate the association between baseline social support and cognitive function across four subsequent time points. We evaluated a multiplicative interaction term between baseline social support and time, in order to determine whether cognitive trajectories over time vary by baseline social support.Results:Social support was associated with lower TMT Part A scores at baseline and over the subsequent 2 years, indicating better psychomotor ability. Social support was associated with higher SDMT scores at baseline and across 2 years, indicating better information processing. We observed no association between social support and TMT B to A ratio at baseline or across 2 years, indicating no effect on set-shifting ability. Longitudinal cognition outcome trajectories did not vary by the level of baseline social support.Conclusion:Social support and cognitive function were associated in this sample over a short time period. Further research should explore causal relationships over the lifespan.

Objectives: Mental health concerns (e.g. depression, anxiety) that negatively impact gay, bisexual, and other men who have sex with men (GBMSM) persist over the life course and into old age, but less is known about potential contributors to GBMSM's mental health. Close relationships can be a source of risk or resilience from stress, exerting direct relationships on mental health, and may mediate well-established associations between minority stress and mental health. This study examined whether primary partner relationship support and strain were uniquely associated with, and mediated the association between internalized homophobia, and mental health among older GBMSM.Methods: GBMSM (N = 517, M age = 60) from the Multicenter AIDS Cohort Study, who were in primary relationships with men, provided self-report data at four timepoints. We used multilevel modeling to examine longitudinal associations among relationship support and strain and internalized homophobia with depression and anxiety.Results: Relationship strain, but not support, was positively associated with mental health concerns longitudinally. There was a significant, positive indirect effect of internalized homophobia on depression and anxiety through strain, but no support. Internalized homophobia was positively associated with relationship strain, which was positively associated with mental health symptoms longitudinally.Conclusions: Relationship strain was associated with depression and anxiety longitudinally among middle-aged and older GBMSM and mediated associations of internalized homophobia with mental health. The role of partner support warrants further investigation. Mental health interventions are critically needed for older GBMSM and, for partnered GBMSM, should include strategies for reducing relationship strain to foster well-being.