Addressing Health Disparities Through Deliberative Methods: Citizens' Panels for Health Equity

Trauma and mental health in Pacific Islanders

BACKGROUND

Little is known about trauma and its mental health impact on Native Hawaiians/Pacific Islanders (NH/PI), an understudied Indigenous-colonized population that endures severe mental health disparities.

AIMS

This novel investigation assessed trauma prevalence and its mental health and substance use correlates in NH/PIs in the U.S.

METHOD

Using community-based participatory research methods, survey data on NH/PI trauma, depression, anxiety, substance use, and treatment need were collected from 306 NH/PI adults using online, telephone, and in-person methods. Descriptive statistics and adjusted regression models were employed.

RESULTS

Sixty-nine percent of participants experienced lifetime trauma, reporting mean exposure to 2.5 different trauma types. Childhood physical and sexual abuse, and lifetime forced sexual assault rates were 34%, 25%, and 27%, respectively, exceeding general population rates. Women and men reported equivalent total mean exposure to different trauma types, as well as equal prevalence for every trauma type examined (e.g. sexual abuse/assault). Confirming hypotheses, after controlling for key demographic and mental health risk factors, increased exposure to multiple trauma types uniquely associated with greater depression, anxiety, alcohol symptomology, and greater likelihood for needing treatment and using illicit substances.

CONCLUSIONS

Trauma is prevalent in NH/PI populations and significantly impacts NH/PI mental health; serving as an important but overlooked contributor to NH/PI mental health disparities. Current findings fill critical gaps in our knowledge of NH/PI trauma and mental health while revealing the importance of screening and treating NH/PIs for trauma exposure to alleviate existing mental health disparities.

The "Birth-Centered Outcomes Research Engagement (B-CORE) in Medi-Cal" Project: Community-Generated Recommendations to Decrease Maternal Mortality and Severe Maternal Morbidity

BACKGROUND

Through applied research and health care quality improvement, California has achieved a maternal mortality (MM) rate significantly lower than that measured nationally. However, Medicaid (Medi-Cal)-insured births in the state continue to experience disproportionate shares of MM and severe maternal morbidity (SMM), which often precedes death. Failure to engage the Medi-Cal community in this work may impede efforts to increase equity.

METHODS

This community engagement project used deliberative democracy methods to engage stakeholders with lived experience in California's Medi-Cal perinatal care system to generate an actionable and specific agenda of recommendations to decrease MM and SMM in the Medi-Cal population.

FINDINGS

A total of 37 Medi-Cal stakeholders-representing birthing people, providers, health plan administrators, and advocates-participated in longitudinal co-learning sessions on the topics of MM/SMM in Medi-Cal. Most of these stakeholders (75.7%) then participated in deliberation sessions. Deliberation recommendations fell into five distinct categories: Medi-Cal perinatal covered benefits, data collection and dissemination, patient experience and its link to care quality, Medi-Cal reimbursement rates, and accountability with respect to racism in perinatal care. Stakeholders identified the Medi-Cal system actors best positioned to implement specific recommendations to directly impact MM/SMM.

CONCLUSIONS

This project demonstrates the feasibility and success of using deliberative democracy methods to generate local and community-generated solutions to critical problems in health equity. Active and engaged stakeholders were keen to identify both immediate actions and long-term research and quality improvement paradigm shifts to support birth equity in Medi-Cal.

CRISPR in Public Health: The Health Equity Implications and Role of Community in Gene-Editing Research and Applications

CRISPR (clustered regularly interspaced short palindromic repeats) is a Nobel Prize-winning technology that holds significant promise for revolutionizing the prevention and treatment of human disease through gene editing. However, CRISPR's public health implications remain relatively uncertain and underdiscussed because (1) targeting genetic factors alone will have limited influence on population health, and (2) minority populations (racial/ethnic, sexual and gender)-who bear the nation's greatest health burdens-historically suffer unequal benefits from emerging health care innovations and tools. This article introduces CRISPR and its potential public health benefits (e.g., improving virus surveillance, curing genetic diseases that pose public health problems such as sickle cell anemia) while outlining several major ethical and practical threats to health equity. This includes minorities' grave underrepresentation in genomics research, which may lead to less effective and accepted CRISPR tools and therapies for these groups, and their anticipated unequal access to these tools and therapies in health care. Informed by the principles of fairness, justice, and equitable access, ensuring gene editing promotes rather than diminishes health equity will require the meaningful centering and engagement of minority patients and populations in gene-editing research using community-based participatory research approaches. (Am J Public Health. 2023;113(8):874-882. https://doi.org/10.2105/AJPH.2023.307315).

Barriers and facilitators to HPV and meningococcal vaccination among men who have sex with men: a qualitative study

BACKGROUND

Men who have sex with men (MSM) have suboptimal uptake of human papillomavirus (HPV) and meningococcal vaccines. This study examines barriers and facilitators to HPV and meningococcal vaccination among MSM in a large, racially/ethnically diverse, and medically underserved U.S. region.

METHODS

In 2020, we conducted five focus groups with MSM living in the Inland Empire, California. Participants discussed (1) their knowledge about and attitudes toward HPV, meningococcal disease, and related vaccines; and (2) factors that would encourage or discourage vaccine uptake. Data were systematically analyzed to identify salient barriers and facilitators to vaccination.

RESULTS

Participants (N = 25) had a median age of 29. Most were Hispanic (68%), self-identified as gay (84%), and had college degrees (64%). Key barriers to vaccination included: (1) limited awareness and knowledge about HPV and meningococcal disease, (2) reliance on mainstream healthcare providers for vaccine information, (3) stigma and reluctance to disclose sexual orientation, (4) uncertainty about health insurance coverage and vaccine costs, and (5) distance and time required to access vaccines. Key facilitators to vaccination were: (1) vaccine confidence, (2) perceived severity of HPV and meningococcal disease, (3) bundling vaccination into routine healthcare, and (4) pharmacies as vaccination sites.

CONCLUSIONS

Findings highlight opportunities for HPV and meningococcal vaccine promotion, including targeted education and awareness campaigns for MSM, LGBT inclusivity training for healthcare providers, and structural interventions to improve vaccine accessibility.

Conceptualizing the Carrying Function of Community Advisory Boards

Community Advisory Boards (CABs) often, “carry” important ideas and concepts for the larger organization of which they are a part. The word “carry” in this context, means that a person or group expresses verbal and nonverbal messages that inform others of what the institution acknowledges, and also what it cannot bear to feel or talk about. These expressions may include attitudes and expectations, values, risks, or disowned features and qualities. A group can contain, “carry,” and express formal, informal, and unconscious issues for a department or system. In this article, we situate our theoretical underpinning of this carrying function by relying on a number of literatures: identified patient, splitting and projection, parallel process, and container and contained. Specifying and examining the dynamics of what CABs carry for an institution can prevent common pitfalls for these groups, such as mistrust, feelings of disrespect, lack of productivity, and thwarted expectations.

"Data makes the story come to life:" understanding the ethical and legal implications of Big Data research involving ethnic minority healthcare workers in the United Kingdom-a qualitative study

The aim of UK-REACH ("The United Kingdom Research study into Ethnicity And COVID-19 outcomes in Healthcare workers") is to understand if, how, and why healthcare workers (HCWs) in the United Kingdom (UK) from ethnic minority groups are at increased risk of poor outcomes from COVID-19. In this article, we present findings from the ethical and legal stream of the study, which undertook qualitative research seeking to understand and address legal, ethical, and social acceptability issues around data protection, privacy, and information governance associated with the linkage of HCWs' registration data and healthcare data. We interviewed 22 key opinion leaders in healthcare and health research from across the UK in two-to-one semi-structured interviews. Transcripts were coded using qualitative thematic analysis. Participants told us that a significant aspect of Big Data research in public health is varying drivers of mistrust-of the research itself, research staff and funders, and broader concerns of mistrust within participant communities, particularly in the context of COVID-19 and those situated in more marginalised community settings. However, despite the challenges, participants also identified ways in which legally compliant and ethically informed approaches to research can be crafted to mitigate or overcome mistrust and establish greater confidence in Big Data public health research. Overall, our research indicates that a "Big Data Ethics by Design" approach to research in this area can help assure (1) that meaningful community and participant engagement is taking place and that extant challenges are addressed, and (2) that any new challenges or hitherto unknown unknowns can be rapidly and properly considered to ensure potential (but material) harms are identified and minimised where necessary. Our findings indicate such an approach, in turn, will help drive better scientific breakthroughs that translate into medical innovations and effective public health interventions, which benefit the publics studied, including those who are often marginalised in research.

Testing a deliberative democracy method with citizens of African ancestry to weigh pros and cons of targeted screening for hereditary breast and ovarian cancer risk

Background

Democratic deliberation (DD), a strategy to foster co-learning among researchers and communities, could be applied to gain informed public input on health policies relating to genomic translation.

Purpose

We evaluated the quality of DD for gaining informed community perspectives regarding targeting communities of African Ancestry (AAn) for Hereditary Breast and Ovarian Cancer (HBOC) screening in Georgia.

Methods

We audiotaped a 2.5 day conference conducted via zoom in March 2021 to examine indicators of deliberation quality based on three principles: (1) inclusivity (diverse viewpoints based on participants' demographics, cancer history, and civic engagement), (2) consideration of factual information (balanced and unbiased expert testimonies, participant perceived helpfulness), and (3) deliberation (speaking opportunities, adoption of a societal perspective on the issue, reasoned justification of ideas, and participant satisfaction).

Results

We recruited 24 participants who reflected the diversity of views and life experiences of citizens of AAn living in Georgia. The expert testimony development process we undertook for creating balanced factual information was endorsed by experts' feedback. Deliberation process evaluation showed that while participation varied (average number of statements = 24, range: 3-62), all participants contributed. Participants were able to apply expert information and take a societal perspective to deliberate on the pros and cons of targeting individuals of AAn for HBOC screening in Georgia.

Conclusions

The rigorous process of public engagement using deliberative democracy approach can successfully engage a citizenry with diverse and well-informed views, do so in a relatively short time frame and yield perspectives based on high quality discussion.

Using Focus Group Feedback to Identify Patient-Centered Initiatives for Older Persons with HIV

Objectives: This study assessed how few community-based programs target older people living with HIV.Methods: We conducted four focus groups comprised of people 50 and older with HIV (N = 32; gay/bisexual men, heterosexual men, women, and Spanish-speakers) to inform HIV program development by exploring the services in which participants were actively involved, along with the services they wanted to receive.Results: Using inductive thematic qualitative analysis, four themes were identified pertaining to program development: (a) types of currently utilized HIV service organizations; (b) dissatisfaction with HIV programming and services; (c) participants' preferred programming, courses, groups, or activities; and (d) desire to serve as peer mentors.Conclusions: Results highlight the need for community-based organizations to address social engagement and isolation among older people living with HIV.Clinical implications: These findings exemplify the need for programs to be specifically designed for OPH, and created with the primary goals of socialization and helping develop social support networks.

Public understandings of potential policy responses to health inequalities: Evidence from a UK national survey and citizens' juries in three UK cities

A substantial body of research describes the distribution, causes and potential reduction of health inequalities, yet little scholarship examines public understandings of these inequalities. Existing work is dominated by small-scale, qualitative studies of the experiences of specific communities. As a result, we know very little about what broader publics think about health inequalities; and even less about public views of potential policy responses. This is an important gap since previous research shows many researchers and policymakers believe proposals for 'upstream' policies are unlikely to attract sufficient public support to be viable. This mixed methods study combined a nationally representative survey with three two-day citizens' juries exploring public views of health inequalities and potential policy responses in three UK cities (Glasgow, Manchester and Liverpool) in July 2016. Comparing public opinion elicited via a survey to public reasoning generated through deliberative processes offers insight into the formation of public views. The results challenge perceptions that there is a lack of public support for upstream, macro-level policy proposals and instead demonstrate support for proposals aiming to tackle health inequalities via improvements to living and working conditions, with more limited support for proposals targeting individual behavioural change. At the same time, some macro-economic proposals, notably those involving tax increases, proved controversial among study participants and results varied markedly by data source. Our analysis suggests that this results from three intersecting factors: a resistance to ideas viewed as disempowering (which include, fundamentally, the idea that health inequalities exist); the prevalence of individualising and fatalistic discourses, which inform resistance to diverse policy proposals (but especially those that are more 'upstream', macro-level proposals); and a lack of trust in (local and national) government. This suggests that efforts to enhance public support for evidence-informed policy responses to health inequalities may struggle unless these broader challenges are also addressed.

Living With HIV During the COVID-19 Pandemic: Impacts for Older Adults in Palm Springs, California

We conducted surveys in March 2020 with 100 older adults living in Palm Springs, CA, to (1) report the impact of the COVID-19 pandemic on their day-to-day well-being and (2) describe the factors related to missing HIV medication during the pandemic. Respondent's mean age was 64.2 and the majority identified as White, men, and gay. The majority stated that the pandemic had impacted their lives "much," "very much," or "extremely." One-third experienced financial challenges and 46.0% experienced disruptions to health care. Almost a quarter (24.0%) reported missing a dose of their HIV medication during the pandemic. Compared to those ages 64+, younger respondents were more likely to report some negative impacts like changes in sleep patterns, financial challenges, and missed HIV medication doses, and had higher PTSD severity scores. In adjusted logistic regression, higher PTSD severity scores and disruption to health care were associated with missed doses of medications (ps < .05).

Survey on the indexes of health equity in the physical environment and infrastructures of Kermanshah province, Iran

BACKGROUND

Health equity is directly associated with the proper distribution of resources, the existence of infrastructures, and the balanced physical environment. The present study aimed to survey the indexes of health equity in the physical environment and infrastructures of Kermanshah province based on the national indexes.

RESULTS

The results revealed that access to transportation, health centers, solid waste management, and green and sports per capita had the least distance from the negative ideal whereas the noise pollution index had the greatest distance. However, house hygiene and air pollution indexes were within the negative and positive ideal ranges.

CONCLUSIONS

The health equity indexes were not distributed equitably across counties and geographical regions of Kermanshah province.

"We are becoming older women and then we have two stigmas": voicing women's biopsychosocial health issues as they age with HIV

In April 2019, nine older women (age 50+) living with HIV in Palm Springs, California, participated in a 90-minute focus group to identify their major health issues, strengths, and HIV and aging-related health priorities. Using the rigorous and accelerated data reduction (RADaR) technique, we identified four major themes: (1) mental health, (2) HIV comorbidities, (3) social determinants of health, and (4) resiliencies. These results reinforce the need to conduct additional research focused on women aging with HIV, an understudied population that requires more effective, tailored interventions to promote better quality of life and healthy aging.

Hazardous drinking, alcohol use disorders, and need for treatment among Pacific Islander young adults

Pacific Islander (PI) young adults are suspected to bear heavy risk for hazardous drinking, alcohol use disorders (AUD), and alcohol-related harms. Yet, PIs remain among the most understudied racial groups in the United States-creating a lack of empirical data documenting their alcohol use problems and treatment needs. The present study presents the first known data on PI young adults' hazardous drinking, possible AUDs, alcohol-related harms, and treatment needs. Survey data were collected from 156 community-dwelling PI young adults (40% women, age 18-30 years) in 2 large PI communities: Los Angeles County and Northwest Arkansas. We screened participants for alcohol, cigarette, and marijuana use, hazardous drinking, possible AUD, alcohol-related harms, and past-year need for mental health and substance use disorder (SUD) treatment. Logistic regressions examined whether experiencing possible AUD and alcohol-related harms were associated with past-year need for treatment. PI young adults reported 78% lifetime rate of alcohol use with 56% screening positive for hazardous drinking, 49% for any possible AUD, and 40% experiencing significant alcohol-related harm (e.g., health, finances). Yet, just 25% of participants reported past-year need for SUD treatment. Although having possible AUD was not associated with perceived SUD treatment need, experiencing any alcohol-related harm associated with 4.7-13.2 times greater adjusted odds for needing treatment. Therefore, despite having low self-perceived treatment need, PI young adults experience excessive burden of hazardous drinking and alcohol-related harms. Given the profound negative social and health effects of AUDs, culturally grounded interventions should be designed to reduce PI young adults' elevated rates of hazardous drinking and alcohol-related harms. (PsycInfo Database Record (c) 2020 APA, all rights reserved).