Intervention Adaptation and Implementation Method for Real-World Constraints and Using New Technologies.

Purpose: Rigorous adaptation methods are needed to revise existing evidence-based behavioral interventions for implementation for new target populations, revised/updated outcomes, new delivery modalities, recent advances, and new technologies. We describe an adaptation method designed to overcome the real-world challenges of having very limited existing expertise, resources, and time. Method: This adaptation method and accompanying visualization tool ("Deconstruction/Reconstruction Matrix") preserves theoretical mechanisms of behavior change, accounts for challenges in utilizing new technologies, and strengthens clinical processes, with an emphasis on safety. Results: The adaptation of an in-person HIV behavioral intervention for sexual and gender diverse men in Kazakhstan to one delivered remotely via telecommunication and social media technologies exemplifies the process and strengths of the method, concomitantly resulting in recommendations for adaptation and implementation of mobile health (mHealth) and digital health interventions. Discussion: This method allows researchers and clinicians to adapt interventions rapidly and rigorously and to benefit from new technologies.

Designing a Road Map for Action to Address Bias and Racism Within a Large Academic Medical Center.

ABSTRACT: The convergence of the COVID-19 pandemic, the Black Lives Matter Movement, and the public anguish and outrage resulting from the murder of George Floyd in 2020 intensified the commitment of many health care institutions to pursue racial and social justice and achieve health equity. The authors describe the Road Map for Action to Address Racism, which was developed to unify and systematize antiracism efforts across the Mount Sinai Health System. A 51-member Task Force to Address Racism, comprising faculty, staff, students, alumni, health system leaders, and trustees, developed recommendations to achieve the goal of becoming an antiracist and equitable health care and learning institution by intentionally addressing all forms of racism and promoting greater diversity, inclusion, and equity for its workforce and community. Grounded in the principles of Collective Impact, the Task Force developed a set of 11 key strategies to effect systemwide change. The strategies affected all aspects of the organization: business systems and financial operations, delivery of care, workforce development and training, leadership development, medical education, and community engagement. The authors describe Road Map implementation, currently in process, including the appointment of strategy leaders, evolution of a governance structure integrating stakeholders from across the health system, development of an evaluation framework, communication and engagement efforts, and process measures and progress to date. Lessons learned include the importance of recognizing the work of dismantling racism as integral to, not apart from, the institution's day-to-day work, and the need for specialized expertise and a significant investment of time to coordinate Road Map implementation. Going forward, rigorous assessment of quantitative and qualitative outcomes and a commitment to sharing successes and challenges will be critical to eradicating systems that have perpetuated inequities in the biomedical sciences and medicine and in the delivery of health care.

Medical Student-Driven Efforts to Incorporate Segregated Care Education Into Their Curriculum.

US health care is segregated by insurance status and de facto by race; however, traditional models of medical education do not teach students about segregated care, and the authors know of no examples in the literature problematizing segregated care in medical education. To fill this gap, this article describes a student-led effort to disseminate peer-to-peer segregated care education at a single-site, large academic health system in New York City. It also provides educational resources that other student-advocates can adopt to drive curricular inclusion efforts at their own institutions. This article concludes that the primary goal of advocacy to teach segregated care is always desegregation, so curricular inclusion efforts are needed to educate students about the inequitable systems they are entering and to provide them with tools to advocate against such systems.

"Time-In": A Tool for Interrupting Bias in Medical School Admissions Committee Meetings.

PROBLEM: During high-stakes committee meetings, bias is often expressed but goes uninterrupted because there is no formal structure to interrupt it. Bias impacts decision making and can further disadvantage those from backgrounds that have been marginalized. APPROACH: The MD and MD-PhD admissions committees at the Icahn School of Medicine at Mount Sinai in NY in the 2020-2021 admissions season introduced a "Time-In" tool to interrupt bias during committee meetings. This study aimed to evaluate the impact of implementing the "Time-In" tool on committee members' perception of bias as a problem and the likelihood of committee members recognizing, reporting, discussing, and educating others about bias after implementation. OUTCOMES: There were 117 responses to the pre- and postseason surveys. In aggregate, respondents reported a statistically significant reduction in the perception of bias in the admissions process from preseason to postseason. There was no change in the likelihood of committee members in aggregate endorsing comfort in recognizing, reporting, discussing, and educating about bias; however, notable gaps existed in the comfort of groups discussing bias publicly, i.e., respondents who are from backgrounds underrepresented in science and medicine, students, and new committee members were less comfortable than their comparators. By the postseason survey, these gaps were closed. NEXT STEPS: Implementing a "time-in" allows for interruption of bias, with an impact of reducing the perception of bias, empowering individuals, and reducing gaps among groups to discuss bias publicly. A "time-in" can profoundly impact decision-making bodies that are critical gatekeepers to the composition of the physician workforce. Future directions will focus on enhancing committee members' skills in educating others about bias.

Social Determinants, Risk Factors, and Needs: A New Paradigm for Medical Education.

COVID-19 and the escalation of racism and bias that has come in its wake have had a devastating impact on health professions students. In addition to academic challenges and personal health risks, aspects of students' lives that have often gone unnoticed or inadequately addressed have come to light. Financial constraints that impact access to housing and food, neighborhood safety in light of the spike in hate crimes, and the bias inherent in the continuum from premedical education to undergraduate and graduate medical education are some examples. The authors believe that to better understand students' lived experiences and determine how to best support them, the social determinants of health framework should be applied. This framework, the social determinants of education, encompasses concepts such as social risk factors and social needs in an effort to focus more intentionally on what can be done at a policy, institutional, and individual level. In response to the pandemic, the authors expanded their appreciation of students' risk factors and needs by advancing the scope and refining the definitions of 3 key determinants: from well-being to the power of individual and communal resilience, from equity to centering racial justice, and from student health to public health and infection prevention. The authors propose applying this same paradigm to the lived experiences of staff in medical education, whose needs are often neglected in favor of students and faculty, and who, in many cases, were the most negatively impacted by COVID-19 of all the constituents in an academic health center.

Addressing and Undoing Racism and Bias in the Medical School Learning and Work Environment.

Racism and bias are American medicine's fatal flaw. They permeate clinical practice and biomedical research, and their influence on medical education is even more profound because it is through medical education that racism and bias are perpetuated across generations and throughout history. This insidious influence has persisted despite the stated values of the medical profession and well-intentioned efforts to lessen their impact. The authors assert that racism and bias in the learning and work environment of medical school can be mitigated only through a formal change management process that leads to change that is institutionally transformational and individually transformative. The authors describe the sequence of events at one U.S. medical school, beginning in 2016, that led from student activism to an initiative that encompasses every functional sphere within medical education. They also reflect on personal and structural lessons learned during the course of designing and implementing this initiative. Eliminating racism and bias demands that medical educators embrace a change process that is lifelong, people-centered, incremental, and nonlinear. It requires the courage to constantly course correct while never losing sight of the ultimate goal: health care and medical education that are free of racism and bias.

The association between substance use and intimate partner violence within Black male same-sex relationships.

Compared with the extant research on heterosexual intimate partner violence (IPV)-including the knowledge base on alcohol and illicit drug use as predictors of such IPV-there is a paucity of studies on IPV among men who have sex with men (MSM), especially Black MSM. This study investigates the prevalence of experiencing and perpetrating IPV among a sample of Black MSM couples and examines whether heavy drinking and/or illicit substance use is associated with IPV. We conducted a secondary analysis on a data set from 74 individuals (constituting 37 Black MSM couples) screened for inclusion in a couple-based HIV prevention pilot study targeting methamphetamine-involved couples. More than one third (n= 28, 38%) reported IPV at some point with the current partner: 24 both experiencing and perpetrating, 2 experiencing only, and 2 perpetrating only. IPV in the past 30 days was reported by 21 (28%) of the participants: 18 both experiencing and perpetrating, 1 experiencing only, and 2 perpetrating only. Heavy drinking and methamphetamine use each was associated significantly with experiencing and perpetrating IPV throughout the relationship as well as in the past 30 days. Rock/crack cocaine use was significantly associated with any history of experiencing and perpetrating IPV. Altogether, IPV rates in this sample of Black MSM couples equal or exceed those observed among women victimized by male partners as well as the general population of MSM. This exploratory study points to a critical need for further efforts to understand and address IPV among Black MSM. Similar to heterosexual IPV, results point to alcohol and illicit drug use treatment as important avenues to improve the health and social well-being of Black MSM.

Prior incarceration and barriers to receipt of services among entrants to alternative to incarceration programs: a gender-based disparity.

The high levels of health and psychosocial needs among correctional populations strongly shape the well-being of the urban communities from which a large number of criminal justice-involved individuals come or to which they return. The benefits of providing services to correction-involved individuals and linking them to providers such as with alternative to incarceration (ATI) programs may be limited if they encounter difficulties accessing such services. This study identified the types of barriers that have prevented entrants into ATI programs from receiving health and psychosocial services. We then tested the association between number of prior incarcerations and number of barriers by gender. From a random sample of adults (N = 322; 83 women and 239 men) entering ATI programs in New York City, data were collected via structured interviews that elicited self-reported sociodemographics, substance use, prior incarcerations, and barriers that had actually prevented a participant from visiting or returning to a service provider. Participants reported an average of 3.0 barriers that have prevented them from receiving health and psychosocial services. The most prevalent barriers predominantly concerned service providers' inability to accommodate constraints on participants' time availability or flexibility, transportation, and money. Compared to women, men had a significantly different association that was in the adverse direction--i.e., more prior incarcerations was associated with more barriers--between prior incarcerations and encountering service barriers. Findings indicate that ATI program entrants experience many barriers that have prevented them from receiving health and/or psychosocial services. Furthermore, men with more extensive incarceration histories particularly are disadvantaged. ATI programs can improve the public health of urban communities if such programs are prepared and resourced to facilitate the receipt of services among program participants, especially men who have more extensive incarceration histories.

Feasibility and promise of a couple-based HIV/STI preventive intervention for methamphetamine-using, black men who have sex with men.

Accumulating evidence supports couple-based approaches for HIV/STI preventive interventions. Yet, to date, no studies have examined couple-based sexual risk reductions intervention specifically for men who have sex with men (MSM) from populations with elevated rates of HIV/STI transmission, such as black MSM and methamphetamine-involved MSM. We pilot tested-using a pre-/post-test design-a seven-session couple-based intervention for black, methamphetamine-using, black MSM couples engaging in sexual risk. Feasibility was assessed via recruitment and retention rates; potential efficacy relied on self-reported sexual risk and drug use prior to and two months following intervention delivery. We enrolled 34 couples (N = 68 men). Over 80% attended all seven intervention sessions, and retention exceeded 95% at two-month follow-up. At follow-up, participants reported significantly fewer sexual partners, fewer episodes of unprotected anal sex, and greater condom use with their main partner; participants also reported significantly less methamphetamine use, any illicit drug use, and number of illicit drugs used. These findings indicate that couple-based HIV/STI intervention is feasible and promising for at-risk black MSM couples.

Adaptation of a Couple-Based HIV Intervention for Methamphetamine-Involved African American Men who have Sex with Men.

In the U.S., incidence of HIV infection among men who have sex with men (MSM) has steadily increased since the 1990s. This points to a need for innovation to address both emerging trends as well as longer-standing disparities in HIV risk and transmission among MSM, such as the elevated rates of HIV/STIs among African American MSM and methamphetamine users. While couple-based sexual risk reduction interventions are a promising avenue to reduce HIV/STI transmission, prior research has been almost exclusively with heterosexual couples. We sought to adapt an existing, evidence-based intervention-originally developed and tested with heterosexual couples-for a new target population consisting of African American MSM in a longer-term same-sex relationship where at least one partner uses methamphetamine. The adaptation process primarily drew from data obtained from a series of focus groups with 8 couples from the target population. Attention is given to the methods used to overcome challenges faced in this adaptation process: limited time, a lead investigator who is phenotypically different from the target population, a dearth of descriptive information on the experiences and worldviews among the target population, and a concomitant lack of topical experts. We also describe a visualization tool used to ensure that the adaptation process promotes and maintains adherence to the theory that guides the intervention and behavior change. The process culminated with an intervention adapted for the new target population as well as preliminary indications that a couple-based sexual-risk reduction intervention for African American, methamphetamine-involved male couples is feasible and attractive.