The importance of developmental assets in HIV prevention behaviors among young black men who have sex with men (MSM)

Developmental assets are critical to the health and wellbeing of youth. The current study examines the influence of developmental assets on PrEP use and HIV testing among YBMSM ages 18–24. Using a cross-sectional survey of YBMSM (N = 225), this study explored the role of external (e.g., family support, other adult support) and internal (e.g., personal responsibility) assets in explaining HIV prevention behaviors. Participants were recruited from Mechanical Turk (M-Turk) internet-based platform, social media sites, and community-based organizations. A path analysis was conducted to investigate the direct/indirect effects of internal and external assets on PrEP use and HIV testing. Family support (β = 0.40, p < 0.001) and other adult support (β = 0.22, p = 0.004) were both associated with personal responsibility. Personal Responsibility (β = 0.15, p = 0.03) and positive identity (β = 0.28, p < 0.001) were both associated with an increase HIV testing. Personal responsibility was positively associated with increased PrEP use (β = 0.30, p < 0.001). Our study results indicated that external assets play a role in helping to build internal assets that support increased HIV testing and PrEP use among YBMSM. Our findings suggest the need for strength-based interventions that help YBMSM build assets and increase HIV prevention behaviors.

competencies, and positive identity) [11][12][13][14][15] .More assets correspond to fewer risk behaviors and increased positive outcomes.Consideration of the intersecting identities of YBMSM is crucial for understanding how assets function in different contexts based on the significant benefits associated with developmental assets.Previous research has shown that having more assets is linked to reduced levels of suicide ideation, violence, and depression 12,13 .In a recent study involving a national sample of YBMSM aged 18-29 (N = 400), researchers examined external assets like family support and open communication in relation to positive attitudes toward PrEP and PrEP stigma.The findings indicated that family support decreased PrEP stigma, while discussing sex and drugs with parents increased it.This study was the first to apply the DAF to HIV prevention behaviors in YBMSM 16 .However, additional research is necessary to gain a deeper understanding of how the DAF can positively impact HIV-related outcomes among YBMSM.This framework holds promise for designing and implementing HIV prevention programs aimed at increasing HIV testing and PrEP use within this population.Guided by DAF, this study seeks to investigate whether external assets (e.g., family support) and internal assets (e.g., personal responsibility) impact HIV testing and PrEP use among YBMSM.

External and internal assets
Studies investigating the DAF have focused on external resources like family support and communication 11 .Notably, youth well-being is significantly influenced by support from family, other adults, friends, and romantic partners, particularly for LGBTQ + youth [17][18][19] .Findings from these studies suggest that supportive families increase the likelihood of disclosure of sexual orientation 12 .Communication between parents and adolescents has also been found to be essential for healthy development, to reduce sexual risk behaviors, and to promote safer sexual practices [20][21][22][23][24][25] .While studies find that parents could be the primary source of sex education 26 , many avoid discussing sex with their children 27 .Limited research, however, has explored family communication among YBMSM regarding HIV prevention, and due to challenges like limited sexual health communication within families, YBMSM often seek support from other community adults.Therefore, further research is needed to involve parents and supportive adults in HIV prevention to support PrEP uptake among YBMSM.Internal assets are the personal skills, commitments, and values that can help YBMSM make healthier choices, take responsibility for their own lives, and be independent and fulfilled 10,11 .Prior research suggests that family support is linked to self-esteem and positive identity and has been shown to reduce depression and suicidality 10,11 .Another study reported that internal assets (e.g., personal responsibility) were a predictor of life satisfaction among Latino youth 28 .Other research indicates self-identity disclosure is associated with positive outcomes 29 .However, limited research has explored internal assets for LGBTQ + youth 15 including YBMSM.This limits our understanding of the impact of internal assets on the health behaviors of YBMSM; meanwhile, cultivating assets at a young age can have positive lifelong implications.

Study purpose
The objective of this study, incorporating a developmental assets framework 16 , is to investigate how external and internal assets influence HIV prevention behaviors among YBMSM.For this study, we tested a total of 15 assets, including both internal and external ones.This is the one of the first studies to examine internal assets as mediators for YBMSM.Our first hypothesis posits that external assets are associated with internal assets.Secondly, we hypothesize that internal assets will be associated with increased HIV testing and PrEP use.Our third hypothesis proposes that internal and external assets indirectly affect HIV prevention efforts, HIV testing, and PrEP utilization (See Fig. 1).

Participants
Consistent inclusion/exclusion criteria were applied across all sampling sites.Eligible participants for the study were those who self-identified as Black or African American, were aged 18-24, lived in the United States, were assigned male at birth, were proficient in English, currently identified as a man, and reported sexual contact with a male in the past year.Respondents who did not meet these criteria were promptly exited from the survey.We enforced a forced response option in Qualtrics to ensure every participant answered each question.After clicking the survey link, participants received information about the study and were requested to complete a screening tool to determine their eligibility.The verified participants answered questions on demographics, developmental assets, and HIV prevention behaviors.
Majority of the sample identified as Black or African American (94%), followed by Caribbean (4%), Afro-Latino (1%) and 1% self-identified as continental African.Thirty one percent of the sample never attended high school, while 33% completed college or were post graduate.The average household income ranged from ˂ $20,000 to $150,000, the average being $57,499.All the participants (100%) self-reported having anal sex with another male within the last 12 months; 54% reported being gay, 27% straight or heterosexual, 16% bisexual, 1% questioning, and 2% other.

Measures
Outcome variable PrEP use was measured using a single item based on a dichotomous response (0 = No, I have not used PrEP in the past 12 months, and 1 = Yes, I have used PrEP in the past 12 months).Participants were asked the following question and given the following definition: "Have you used PrEP in the past 12 months?PrEP is medicine people at risk for HIV take to prevent getting HIV from sex or injection drug use." HIV testing was defined by participants responses to the following: "Have you, yourself, ever been tested for HIV in the last 12 months?"The responses were coded using a dichotomous response (0 = "No", 1 = "Yes").

Mediators
Internal assets.Positive Identity was measured using six items based on a 5-point Likert scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree).Positive Identity asset category was recognized into two assets: hope (a combination of personal power, sense of purpose, and positive view the future) and self-esteem (three items; subset of items from Rosenberg).Participants were asked questions such as "I feel I do not have much to be proud of ".The Cronbach alpha was 0.90 32 .Personal Responsibility was measured using three items based on a Vol:.(1234567890 www.nature.com/scientificreports/5-point, Likert scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree).Participants were asked statements such as "Telling the truth, even when it's not easy".The Cronbach's alpha was 0.88 32 .

Independent variables
External assets.Parental Support was measured using three items based on a 5-point, Likert scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree).Participants were asked statements such as "My parents give me help and support when I need it." We averaged responses to these three items, with higher scores indicating more parent support 16,33 .The Cronbach's alpha was 0.95.Open parent communication was measured using a single item with values ranging from 1 (Strongly Disagree) to 5 (Strongly Agree).Participants were asked to rate the following statement: "I have lots of good conversations with my parents" 16,32 .Higher scores indicated increased open family communication.Communication with parents about sex and drugs was measured using a single item, rated from 1 (Never) to 5 (All Of The Time), which asked respondents, "If you had an important concern about drugs, alcohol, sex, or some other serious issue, would you talk to your parent(s) about it?" 16,33.Higher scores indicated an increase in communication with parents about sex and drugs.Other Adults Support was measured using a single item, with values ranging from 1 (Strongly Disagree) to 5 (Strongly Agree), asking participants to rate the statement, "Adults in my town or city make me feel important." A higher score indicated that adults in the community support the young men 16,32 .

Statistical analysis
Table 1 provides means and standard deviations for the study's continuous variables.Table 2 provides frequencies and percentages of categorical variables.M-plus version 8.7 was used to conduct a path analysis to test hypotheses examining whether external and internal assets were associated with HIV testing and PrEP use (Table 3, Fig. 2).Path analysis also allowed us to test the indirect effects of external assets on HIV test and PrEP use (Table 4).We applied the means-and variance-adjusted weighted least squares estimator instead of maximum likelihood estimation, as this estimator is preferred when the dependent variable is categorical and when the data are not normally distributed 33 .The percentage of missing data was ˂ 5%.Regarding missing data, we used full information maximum likelihood 33 .The goodness-of-fit was assessed with measures using the chi-square test, Akaike information criterion (AIC) and Bayes information criterion (BIC) because the dependent variable was categorical.Alternatively, we included correlation coefficients and standardized beta coefficients and p-values to examine the associations among the study variables.

Results
YBMSM reported high levels of parent support (M = 3.78, SD = 1.10), open parent communication (M = 3.84, SD = 1.07), other adult support (M = 3.77, SD = 1.00) and personal responsibility (M = 4.01, SD = 0.75).Communication about sex and drugs with parents (M = 3.41, SD = 1.22) and positive identity (M = 3.34, SD = 0.78) were both moderate (Table 1).Majority of the sample lived with their parents (44%) and their siblings (22%).Fifty eight percent of the sample disclosed their sexuality to their parents.Thirty three percent of their mothers had a high school diploma, and 19% of their fathers.Seventy-nine percent of the sample reported using PrEP in the past 12 months and 84% reported receiving an HIV test in the past 12 months (see Table 2).
Our results indicated that parental support (B = 0.10, p < 0.001; 95% CI 0.04, 0.13) and other adult support (B = 0.03, p < 0.001; 95% CI 0.00, 0.05) were indirectly and positively associated with HIV testing.However, communication about sex and drugs with parents was indirectly and negatively associated with HIV testing

Discussion
Although young Black MSM are disproportionately affected by HIV, advancements in HIV testing and biomedical tools such as PrEP have presented the opportunity to help end the epidemic sooner rather than later.In this sample, 79% self-reported using PrEP, and 84% reported receiving an HIV test.Based on our knowledge, this is the first study to investigate how developmental assets-both internal and external-influence HIV testing and PrEP uptake.Consistent with prior literature, our results indicated that external assets such as family and other supportive adults contributed to increasing HIV testing among YBMSM 18,19,21 .In addition, external assets were associated with positive internal assets 18,20 .Our results also indicated external assets indirectly increased PrEP use.This finding is critical because PrEP uptake remains low among YBMSM.Notably, our results indicated that internal assets (personal responsibility and positive identity) directly increased HIV testing and PrEP use.There is important because there is a dearth of literature that has examined internal assets among LGBTQ + individuals.Overall, our results suggest that by integrating developmental assets into ongoing HIV prevention programs and interventions, the DAF may work similarly for increasing HIV testing rates and PrEP use among YBMSM.
Our results confirmed the first hypothesis that external assets were associated with internal assets.With family support, more YBMSM felt personally responsible and had a positive identity.Having other adult support was also associated with YBMSM feeling personally responsible, which contributes to the literature about the impact of family and other adult support on responsibility among YBMSM.It is plausible that families and other positive adults have healthy boundaries and relationships with their sons and other young people in the community, or www.nature.com/scientificreports/ that families and some adults effectively communicate when engaging with young people 20 .A sense of personal responsibility and an understanding of what responsibility means may help the overall development and engagement of YBMSM in safer sex practices.Similar to prior literature, our study linked family support to positive identity 12,13 .Parent and family support shapes the development of many young adults, and in this study sample, majority self-reported that they had positive family support, suggesting that there may be healthy family dynamics that allows YBMSM to be more comfortable in who they are as individuals.Family Support was also indirectly associated with HIV testing and PrEP use.This is consistent with prior literature and extends the literature to include PrEP use and YBMSM 20 .Prior longitudinal studies indicated that family support increased HIV testing among Black youth 20,21 .Results also indicated other adult support was indirectly associated with HIV testing and PrEP use.The support that these young men may feel within their families and from other adults may influence their decision-making around their sexual behaviors and whether or not they engage in HIV prevention behaviors such as HIV testing and PrEP use.These findings also suggest that having a village of positive support may be critical to the well-being of YBMSM.These findings suggest that external assets play a critical role in young Black males' development  Findings from our study suggest that internal assets were associated with both HIV testing and PrEP use.These findings are consistent with those from prior literature, and show that the more assets youth have, the more likely they will engage in positive behaviors such as life satisfaction [12][13][14][15] .YBMSM may feel it is their personal responsibility to get tested for HIV and use PrEP to protect themselves and others.Positive identity was also associated with HIV testing among YBMSM.Most of the literature that has examined positive identity among Black LGBTQ people have examined it as a part of sexual orientation disclosure 12,13 ; only few studies have examined its influence on HIV testing, and none among YBMSM 34 .This finding is consistent with prior literature that suggests positive identity influences HIV testing.However, this study extends how positive identity is operationalized by moving past mere disclosure of one's sexual orientation to including personal power, sense of purpose, positive view of the future, and self-esteem.This is critical because a positive identity can influence the overall health and well-being of YBMSM.Future research is needed to understand how developmental assets influence HIV prevention behaviors and other health outcomes.
Although the present study contributes to the knowledge-base of developmental assets and their positive or protective effect, it is not exempt from limitations.This study did not use all 40 developmental assets, which means that it cannot state what other assets may increase HIV testing and PrEP use among YBMSM.This was a national sample of YBMSM; however, it was not a representative sample, and as such, the results may not be generalizable.Furthermore, this was a cross-sectional study; hence, causality cannot be determined.The temporal link between the outcome and the exposure cannot be determined because both are examined simultaneously.
Despite these limitations, the present study provides research on the direct and indirect effects between developmental assets and HIV prevention behaviors among YBMSM.Our findings suggest that developmental assets can help increase the low numbers of YBMSM engagement in PrEP use and HIV testing.In addition, findings suggest that interventions are needed to help young men and people cultivate external and internal assets.
YBMSM continue to be burdened by HIV despite the effectiveness of biomedical preventions like PrEP and HIV testing.However, the developmental assets framework offers a way to increase engagement in these prevention efforts.Developmental assets have a positive influence on a plethora of outcomes such depression, suicidality and now HIV testing and PrEP use.The present study adds to the HIV and positive youth development literature by bringing to the table critical findings regarding the associations between developmental assets, and HIV prevention behaviors for YBMSM.The developmental assets framework gives us an opportunity to humanize YBMSM in society and promote a positive attitude and wellbeing.

Figure 1 .
Figure 1.Developmental assets and HIV prevention model.

Figure 2 .
Figure 2. Path model testing direct and indirect effects from external to PrEP use and HIV testing through external assets (n = 225).

Table 2 .
Frequency and percentages of categorical study variables (N = 225).