Interagency Coordination to Manage Co-Occurring Intellectual and Developmental Disabilities and Mental Health Conditions.

OBJECTIVE: The authors aimed to identify barriers to and strategies for supporting coordination between state agencies for intellectual and developmental disability (IDD) or mental health to meet the mental health needs of people with co-occurring IDD and mental health conditions. METHODS: Forty-nine employees of state agencies as well as advocacy and service delivery organizations across 11 U.S. states with separate IDD and mental health agencies were interviewed between April 2022 and April 2023. Data were analyzed with a thematic analysis approach. RESULTS: Interviewees reported that relationships between the IDD and mental health agencies have elements of both competition and coordination and that coordination primarily takes place in response to crisis events. Barriers to interagency coordination included a narrow focus on the populations targeted by each agency, within-state variation in agency structures, and a lack of knowledge about co-occurring IDD and mental health conditions. Interviewees also described both administrative (e.g., memorandums of understanding) and agency culture (e.g., focusing on whole-person care) strategies that are or could be used to improve coordination to provide mental health services for people with both IDD and a mental health condition. CONCLUSIONS: Strategies that support state agencies in moving away from crisis response toward a focus on whole-person care should be prioritized to support coordination of mental health services for individuals with co-occurring IDD and mental health conditions.

Reported xylazine exposure highly associated with overdose outcomes in a rapid community assessment among people who inject drugs in Baltimore.

BACKGROUND: Addressing xylazine harms are now a critical harm reduction priority, but relatively little epidemiological information exists to determine prevalence, magnitude, and correlates of xylazine use or related outcomes. METHODS: We conducted a rapid behavioral survey among people who inject drugs (n = 96) in Baltimore November-December 2022. Using a novel indicator of self-reported presumed xylazine effects, we examined prevalence and sociodemographic correlates of past year presumed xylazine effects and association with overdose and wound-related outcomes. Chi-square and descriptive statistics were used to examine bivariate associations overall and separately for those who reported xylazine by name and by reported fentanyl use frequency. RESULTS: Almost two-thirds (61.5%) reported experiencing xylazine effects. There were no differences by socio-demographics, but xylazine effects were more commonly reported among those who reported injecting alone (66% vs 38%%, p < 0.007) and daily fentanyl use (47% vs 24% p < 0.003). Those reporting xylazine exposure was three times as likely to report overdose (32% vs 11%, p < 0.03) and twice as likely to have used naloxone (78% vs 46%, p < 0.003). They also more commonly reported knowing someone who died of an overdose (92% vs 76%, p < 0.09) and to report an abscess requiring medical attention (36% vs 19%, p < 0.80). These associations were higher among respondents who specifically named xylazine and those who used fentanyl more frequently, but fentanyl frequency did not fully explain the heightened associations with xylazine effects. CONCLUSIONS: This study provides insight into the scope of xylazine exposure and associated health concerns among community-based PWID and suggests measures that may be instrumental for urgently needed research.

Feasibility, acceptability and effectiveness of a culturally informed intervention to decrease stress and promote well-being in reservation-based Native American Head Start teachers.

BACKGROUND: While benefiting from strong cultural ties to family, land and culture Native Americans residing on reservations experience psychological distress at rates 2.5 times that of the general population. Treatment utilization for psychological health in reservation-based communities is low with access to culturally appropriate care lacking. Evidence suggests that for mental health treatment, Native Americans prefer culturally informed care that respects Native perspectives on health and well-being. METHODS: To decrease stress and promote well-being in tribal Head Start teachers we adapted and implemented a culturally focused intervention within a community-based participatory research framework using mixed methods. Feasibility and acceptability of the adapted 5-session curriculum was tested in a single arm intervention study with a sample of 18 teachers on the Fort Peck Reservation. Participants completed surveys at baseline and upon completion of the intervention. Within session observations and two post-intervention focus groups (n = 8, n = 10) were conducted to elaborate and explain the quantitative results eliciting participant experience of intervention effectiveness and feasibility, acceptably and appropriateness. Implementation outcomes were assessed quantitatively using the Acceptability of Intervention, Intervention Appropriateness, and Feasibility of Intervention measures. RESULTS: Quantitively, attendance rate overall was 93% with no dropouts. Pretest/posttest surveys were analyzed using t-tests and Hedges g to measure effect size. Contrary to our hypothesis, self-perceived stress showed a small positive effect size, indicating that participants were more stressed post intervention. However, depression decreased, with tribal identity and resilience showing positive effect sizes. Content analysis for the qualitative data collected within session observations and post intervention focus groups revealed how lifetime traumas were affecting participants, providing some explanation for the increase in stress. Teachers reported that the sessions helped their psychological health and well-being, supporting feasibility of future interventions. Acceptability scored highest with a mean (SD) of 4.25 (.84) out of 5, appropriateness 4.18 (.86) and feasibility 4.06 (.96) supporting intervention to be acceptable, appropriate, and feasible. CONCLUSION: Utilizing a culturally based intervention to buffer stress and support the well-being of reservation-based teachers showed promise in helping them recognize their cultural strengths, stress, and need for ongoing support. Implementation outcomes show that intervention scale-out is feasible.

Health Inequalities by Sexual Orientation: Results from the 2016-2017 Barcelona Health Survey.

Purpose: The aim of this study was to assess health inequalities by sexual attraction in the 2016-2017 Barcelona population, stratifying by sex. Methods: Data came from the 2016-2017 Barcelona Health Survey, where 3362 adults answered among other instruments the EuroQol-5 dimensions-5 levels (EQ-5D-5L), which measures five dimensions and summarizes health-related quality of life into a single utility index score. To assess health differences by sexual attraction, we constructed Tobit models for the EQ-5D index score and Poisson regression models for the EQ-5D dimensions. Nested models were constructed to examine the mediating role of discrimination and health-related variables. Results: After adjusting for sociodemographic variables, women feeling attraction to more than one sex showed a lower EQ-5D index score (worse health) than those with only other sex attraction (-0.042, p = 0.012), and higher prevalence of problems with mobility, usual activities, and anxiety/depression with the following adjusted prevalence ratios (aPR) and confidence intervals (CIs): 1.79 (95% CI 1.05-3.05), 1.84 (95% CI 1.05-3.21), and 1.76 (95% CI 1.27-2.43). Women feeling attraction only to their same sex also presented higher prevalence of anxiety/depression (aPR = 1.46, CI 95% 1.10-1.92). In contrast, differences were not observed for men. Conclusion: Women, but not men, feeling attraction to more than one sex and only same-sex attraction in Barcelona in 2016-2017 presented worse health than those feeling only other sex attraction, with discrimination playing a mediating role in explaining such inequalities. These results among women indicate the need to develop public health strategies in Barcelona addressed to lesbian and bisexual women, considering the intersection of gender and sexual orientation.

State-Level Alcohol Environments and Sexual Identity Disparities in Binge Drinking in the Behavioral Risk Factor Surveillance System.

Purpose: Binge drinking disparities by sexual identity are well documented. Stronger alcohol policy environments reduce binge drinking in the general population. We examined whether state-level alcohol policy environments have the same association with binge drinking among lesbian, gay, and bisexual (LGB) adults as among heterosexual adults. Methods: Binge drinking, sexual identity, and demographic characteristics were extracted from the 2015 to 2018 Behavioral Risk Factor Surveillance System. The strength of the alcohol policy environment was measured by using the Alcohol Policy Scale (APS) score. We estimated the association between APS score and binge drinking by using logistic regression and included an interaction term between APS score and sexual identity. Results: The interaction between APS score and sexual identity was not significant, and findings differed between women and men. Among women, a higher APS score was associated with lower odds of binge drinking (adjusted odds ratio [aOR]: 0.96, 95% confidence interval [CI]: 0.94-0.99). Differences in binge drinking by sexual identity remained after adjusting for individual and state-level factors (e.g., the percentage of LGB adults in the state). Compared with heterosexual women, the odds of binge drinking were 43% higher (aOR: 1.43, 95% CI: 1.17-1.75) among lesbian women and 58% higher (aOR: 1.58, 95% CI: 1.40-1.79) among bisexual women. A higher APS score was not associated with binge drinking among men. Conclusion: Stronger state-level alcohol policy environments were associated with lower binge drinking among women. Lesbian and bisexual women were still more likely to engage in binge drinking compared with heterosexual women even in states with stronger alcohol policy environments.

Social Stability Relates Social Conditions to the Syndemic of Sex, Drugs, and Violence.

The distribution of violence, sexually transmitted infections, and substance use disorders is not random, but rather the product of disease, behavior, and social conditions that co-occur in synergistic ways (syndemics). Syndemics often disproportionately affect urban communities. Studies of syndemics, however, rarely apply consistent measures of social conditions. Here, the construct of social stability (SS) (housing, legal, residential, income, employment, and relationship stability) was evaluated as a consistent measure of social conditions related to sex, drug, and violence exposures in a new population in a Mid-Atlantic urban center. Lower SS predicted greater likelihood of any and combinations of risk. The magnitude varied based on specification: odds of sex-drug-violence exposure were greater for low vs. high latent SS class (OR = 6.25; 95%CI = 2.46, 15.96) compared with low vs. high SS category (OR = 2.64; 95%CI = 1.29, 5.39). A latent class characterized by residential instability was associated with greater likelihood of risk-a relationship that would have been missed with SS characterized only as an ordinal category. SS reliably captured social conditions associated with sexual, drug, and violence risks, and both quantity and quality of SS matter.

A Review of Tools to Screen for Social Determinants of Health in the United States: A Practice Brief.

Increasingly, health care institutions are called on to address social determinants of health (SDH) given the connection to morbidity and mortality across populations. However, widespread implementation of screening for health-related social conditions (HRSC) is lagging. It is estimated that half of patients who have such needs may be missed by failure to screen routinely. Health care institutions face gaps in information related to screening tools. A review of tools that screen for HRSC at the individual level is needed to share readily available and applicable tools for integration in various settings, to communicate how tools are typically administered, and to assess whether tools capture domains corresponding with Institute of Medicine (IOM) core measures. To address these gaps, an unsystematic rapid review of the literature was conducted. In addition to peer-reviewed literature, Google, PubMed, and CINAHL databases and grey literature were searched with a focus on lead agencies or scholars in the field. English language publications from 2008-2018 with content related to SDH or health-related social condition screening tools were included. Nine commonly applied tools were selected and reviewed for content, setting, and method of administration. Fifteen common domains were identified and assessed for alignment with IOM recommendations and correspondence with the construct of social stability. This review consolidates essential information about HRSC screening tools in 1 place and provides practice, policy, and research recommendations to improve HRSC screening. This review is a practice brief that can help health care institutions and clinicians implement screening and interventions related to HRSC.

Association of Enacted Stigma with Depressive Symptoms Among Gay and Bisexual Men Who Have Sex with Men: Baltimore, 2011 and 2014.

Purpose: We assessed differences between gay and bisexual men in enacted stigma, and how the association between stigma and depressive symptoms may vary according to sexual orientation identity. Methods: Participants (671 gay and 331 bisexual men who have sex with men) in Baltimore's 2011 and 2014 National HIV Behavioral Surveillance completed an anonymous survey, including 3 enacted stigma dimensions and the Center for Epidemiologic Studies Depression Scale. Adjusted prevalence ratios were calculated through Generalized Estimating Equation models adjusting for theorized confounders (demographic, socioeconomic, and relational factors). Results: Bisexual men reported stigma experiences less frequently than did gay men (verbal harassment 22.7% vs. 32.3%, and discrimination 15.7% vs. 23.0%). Relevant depressive symptoms were reported by 43.1% of bisexual men and 34.2% of gay men (p < 0.001). Statistically significant differences in depressive symptoms between bisexual and gay men disappeared after adjusting for socioeconomic factors. The three enacted stigma dimensions were significantly associated with depressive symptoms, but their interaction with sexual orientation identity was not. Conclusion: This study confirms the association between enacted stigma and depressive symptoms among gay and bisexual men. However, sexual orientation identity did not modify this association as hypothesized. The bisexual men presented other psychosocial stressors that may explain their higher prevalence of depressive symptoms. The high levels of verbal harassment, discrimination, and physical assault reported by gay and bisexual men and their negative effect on mental health indicate the need to develop new effective public health strategies to avoid these consequences of homophobic and biphobic culture.

Health-related quality of life inequalities by sexual orientation: Results from the Barcelona Health Interview Survey.

BACKGROUND: Studies on health-related quality of life (HRQoL) inequalities according to sexual orientation are scarce. The aim of this study was to assess HRQoL inequalities between lesbian, gay, and bisexual (LGB) people and heterosexuals in the 2011 Barcelona population, to describe the extent to which sociodemographic characteristics, health-related behaviors, and chronic conditions could explain such inequalities, and to understand if they are sexual orientation inequities. METHODS: In the 2011 Barcelona Health Interview Survey 3277 adults answered the EQ-5D, which measures five dimensions of HRQoL summarized into a single utility index (1 = perfect health, 0 = death). To assess HRQoL differences by sexual orientation we constructed Tobit models for the EQ-5D index, and Poisson regression models for the EQ-5D dimensions. In both cases, nested models were constructed to assess the mediator role of selected variables. RESULTS: After adjusting by socio-demographic variables, the LGB group presented a significantly lower EQ-5D index than heterosexuals, and higher prevalence ratios of problems in physical EQ-5D dimensions among both genders: adjusted prevalence ratio (aPR) = 1.70 for mobility (p = 0.046) and 2.11 for usual activities (p = 0.019). Differences in mental dimensions were only observed among men: aPR = 3.15 for pain/discomfort (p = 0.003) and 2.49 for anxiety/depression (p = 0.030). All these differences by sexual orientation disappeared after adding chronic conditions and health-related behaviors in the models. CONCLUSION: The LGB population presented worse HRQoL than heterosexuals in the EQ-5D index and most dimensions. Chronic conditions, health-related behaviors and gender play a major role in explaining HRQoL differences by sexual orientation. These findings support the need of including sexual orientation into the global agenda of health inequities.

Assessment of Patient-Centered Approaches to Collect Sexual Orientation and Gender Identity Information in the Emergency Department: The EQUALITY Study.

Importance: Health care and government organizations call for routine collection of sexual orientation and gender identity (SOGI) information in the clinical setting, yet patient preferences for collection methods remain unknown. Objective: To assess of the optimal patient-centered approach for SOGI collection in the emergency department (ED) setting. Design, Setting, and Participants: This matched cohort study (Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity [EQUALITY] Study) of 4 EDs on the east coast of the United States sequentially tested 2 different SOGI collection approaches between February 2016 and March 2017. Multivariable ordered logistic regression was used to assess whether either SOGI collection method was associated with higher patient satisfaction with their ED experience. Eligible adults older than 18 years who identified as a sexual or gender minority (SGM) were enrolled and then matched 1 to 1 by age (aged ≥5 years) and illness severity (Emergency Severity Index score ±1) to patients who identified as heterosexual and cisgender (non-SGM), and to patients whose SOGI information was missing (blank field). Patients who identified as SGM, non-SGM, or had a blank field were invited to complete surveys about their ED visit. Data analysis was conducted from April 2017 to November 2017. Interventions: Two SOGI collection approaches were tested: nurse verbal collection during the clinical encounter vs nonverbal collection during patient registration. The ED physicians, physician assistants, nurses, and registrars received education and training on sexual or gender minority health disparities and terminology prior to and throughout the intervention period. Main Outcomes and Measures: A detailed survey, developed with input of a stakeholder advisory board, which included a modified Communication Climate Assessment Toolkit score and additional patient satisfaction measures. Results: A total of 540 enrolled patients were analyzed; the mean age was 36.4 years and 66.5% of those who identified their gender were female. Sexual or gender minority patients had significantly better Communication Climate Assessment Toolkit scores with nonverbal registrar form collection compared with nurse verbal collection (mean [SD], 95.6 [11.9] vs 89.5 [20.5]; P = .03). No significant differences between the 2 approaches were found among non-SGM patients (mean [SD], 91.8 [18.9] vs 93.2 [13.6]; P = .59) or those with a blank field (92.7 [15.9] vs 93.6 [14.7]; P = .70). After adjusting for age, race, illness severity, and site, SGM patients had 2.57 (95% CI, 1.13-5.82) increased odds of a better Communication Climate Assessment Toolkit score category during form collection compared with verbal collection. Conclusions and Relevance: Sexual or gender minority patients reported greater comfort and improved communication when SOGI was collected via nonverbal self-report. Registrar form collection was the optimal patient-centered method for collecting SOGI information in the ED.

Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity : The EQUALITY Study.

Importance: The Institute of Medicine and The Joint Commission recommend routine documentation of patients' sexual orientation in health care settings. Currently, very few health care systems collect these data since patient preferences and health care professionals' support regarding collection of data about patient sexual orientation are unknown. Objective: To identify the optimal patient-centered approach to collect sexual orientation data in the emergency department (ED) in the Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity study. Design, Setting, and Participants: An exploratory, sequential, mixed-methods design was used first to evaluate qualitative interviews conducted in the Baltimore, Maryland, and Washington, DC, areas. Fifty-three patients and 26 health care professionals participated in the qualitative interviews. Interviews were followed by a national online survey, in which 1516 (potential) patients (244 lesbian, 289 gay, 179 bisexual, and 804 straight) and 429 ED health care professionals (209 physicians and 220 nurses) participated. Survey participants were recruited using random digit dialing and address-based sampling techniques. Main Outcomes and Measures: Qualitative interviews were used to obtain the perspectives of patients and health care professionals on sexual orientation data collection, and a quantitative survey was used to gauge patients' and health care professionals' willingness to provide or obtain sexual orientation information. Results: Mean (SD) age of patient and clinician participants was 49 (16.4) and 51 (9.4) years, respectively. Qualitative interviews suggested that patients were less likely to refuse to provide sexual orientation than providers expected. Nationally, 154 patients (10.3%) reported that they would refuse to provide sexual orientation; however, 333 (77.8%) of all clinicians thought patients would refuse to provide sexual orientation. After adjustment for demographic characteristics, only bisexual patients had increased odds of refusing to provide sexual orientation compared with heterosexual patients (odds ratio, 2.40; 95% CI, 1.26-4.56). Conclusions and Relevance: Patients and health care professionals have discordant views on routine collection of data on sexual orientation. A minority of patients would refuse to provide sexual orientation. Implementation of a standardized, patient-centered approach for routine collection of sexual orientation data is required on a national scale to help to identify and address health disparities among lesbian, gay, and bisexual populations.

Identifying Patterns of Social and Economic Hardship Among Structurally Vulnerable Women: A Latent Class Analysis of HIV/STI Risk.

Women who are structurally vulnerable are at heightened risk for HIV/STIs. Identifying typologies of structural vulnerability that drive HIV/STI risk behavior is critical to understanding the nature of women's risk. Latent class analysis (LCA) was used to classify exotic dancers (n = 117) into subgroups based on response patterns of four vulnerability indicators. Latent class regression models tested whether sex- and drug-related risk behavior differed by vulnerability subgroup. Prevalence of vulnerability indicators varied across housing instability (39%), financial insecurity (39%), limited education (67%), and arrest history (36%). LCA yielded a two-class model solution, with 32% of participants expected to belong to a "high vulnerability" subgroup. Dancers in the high vulnerability subgroup were more likely to report sex exchange (OR = 8.1, 95% CI, 1.9-34.4), multiple sex partnerships (OR = 6.4, 95% CI, 1.9-21.5), and illicit drug use (OR = 17.4, 95% CI, 2.5-123.1). Findings underscore the importance of addressing inter-related structural factors contributing to HIV/STI risk.

Risks, Benefits, and Importance of Collecting Sexual Orientation and Gender Identity Data in Healthcare Settings: A Multi-Method Analysis of Patient and Provider Perspectives.

PURPOSE: Research suggests that LGBT populations experience barriers to healthcare. Organizations such as the Institute of Medicine recommend routine documentation of sexual orientation (SO) and gender identity (GI) in healthcare, to reduce LGBT disparities. We explore patient views regarding the importance of SO/GI collection, and patient and provider views on risks and benefits of routine SO/GI collection in various settings. METHODS: We surveyed LGBT/non-LGBT patients and providers on their views on SO/GI collection. Weighted data were analyzed with descriptive statistics; content analysis was conducted with open-ended responses. RESULTS: One-half of the 1516 patients and 60% of 429 providers were female; 64% of patients and 71% of providers were White. Eighty percent of providers felt that collecting SO data would offend patients, whereas only 11% of patients reported that they would be offended. Patients rated it as more important for primary care providers to know the SO of all patients compared with emergency department (ED) providers knowing the SO of all patients (41.3% vs. 31.6%; P < 0.001). Patients commonly perceived individualized care as an SO/GI disclosure benefit, whereas providers perceived patient-provider interaction improvement as the main benefit. Patient comments cited bias/discrimination risk most frequently (49.7%; N = 781), whereas provider comments cited patient discomfort/offense most frequently (54.5%; N = 433). CONCLUSION: Patients see the importance of SO/GI more in primary care than ED settings. However, many LGBT patients seek ED care due to factors including uninsurance; therefore, the ED may represent an initial point of contact for SO/GI collection. Therefore, patient-centered approaches to collecting SO/GI are needed. Patients and providers differed in perceived risks and benefits to routine SO/GI collection. Provider training in LGBT health may address patients' bias/discrimination concerns, and ultimately reduce LGBT health disparities.

Is It Okay To Ask: Transgender Patient Perspectives on Sexual Orientation and Gender Identity Collection in Healthcare.

OBJECTIVE: The National Academy of Medicine and Joint Commission recommend routine documentation of sexual orientation (SO) and gender identity (GI) in healthcare to address lesbian, gay, bisexual, or transgender (LGBT) health disparities. We explored transgender patient-reported views on the importance on SO/GI collection, their willingness to disclose, and their perceived facilitators of SO/GI collection in primary care and emergency department (ED) settings. METHODS: We recruited a national sample of self-identified transgender patients. Participants completed demographic questions, survey questions, and free-response comments regarding their views on SO/GI collection. Data were analyzed using descriptive statistics; inductive content analysis was conducted with open-ended responses. RESULTS: Patients mostly self-identified as male gender (54.5%), white (58.4%), and SO other than heterosexual or LGB (33.7%; N = 101). Patients felt that it was more important for primary care providers to know their GI than SO (89.1% vs. 57%; p < 0.001); there was no difference among reported importance for ED providers to know the patients' SO versus GI. Females were more likely than males to report medical relevance to chief complaint as a facilitator to SO disclosure (89.1% vs. 80%; p = 0.02) and less likely to identify routine collection from all patients as a facilitator to GI disclosure (67.4% vs. 78.2%; p = 0.09). Qualitatively, many patients reported that medical relevance to chief complaint and an LGBT-friendly environment would increase willingness to disclose their SO/GI. Patients also reported need for educating providers in LGBT health prior to implementing routine SO/GI collection. CONCLUSIONS: Patients see the importance of providing GI more than SO to providers; nonetheless they are willing to disclose SO/GI in general.. Findings also suggest that gender differences may exist in facilitators of SO/GI disclosure. Given the underrepresentation of transgender patients in healthcare, it is crucial for providers to address their concerns with SO/GI disclosure, which include LGBT education for medical staff and provision of a safe environment.

Implementing Sexual Orientation and Gender Identity Data Collection in Emergency Departments: Patient and Staff Perspectives.

PURPOSE: To identify patient and provider perspectives concerning collection of sexual orientation and gender identity (SO&GI) information in emergency departments (EDs). METHODS: Semistructured interviews were conducted during the period of 2014-2015 with a diverse purposive sample of patients across the spectrum of sexual orientation and gender identities (n = 53) and ED nurses, physician assistants, physicians, and registrars (n = 38) in a major metropolitan area. Interviews were recorded, transcribed verbatim, and analyzed by multiple coders using constant comparative methods. RESULTS: Patients were willing to provide SO&GI information if collected safely and appropriately, and staff described willingness to collect SO&GI information to inform understanding of health disparities. Key themes across respondents were as follows: What will be done with the data? How will it be collected? Who will collect it? Is the environment conducive to safe disclosure? Confidentiality and potential sensitivity; standardized collection emphasizing population health; nurse intake and/or nonverbal data collection; and environmental cues and cultural competency promoting comfort for sexual and gender minorities emerged as critical considerations for effective implementation. CONCLUSION: Staff and patients are amenable to SO&GI data collection in EDs, but data quality and patient and provider comfort may be compromised without attention to specific implementation considerations.

The conflation of gender and sex: Gaps and opportunities in HIV data among transgender women and MSM.

Historically, HIV studies have conflated men who have sex with men (MSM) with transgender (trans) women, explicitly excluded trans individuals, or included sample sizes of trans people that are too small to reach meaningful conclusions. Despite the heavy burden of HIV among trans women, conflation of this population with MSM has limited the information available on the social and behavioural factors that increase HIV vulnerability among trans women and how these factors may differ from MSM. Using data sets from quantitative studies among MSM (n = 645) and trans women (n = 89), as well as qualitative in-depth interviews with 30 trans women in Baltimore, we explore what these data tell us about similarities and differences in HIV vulnerability between the two groups and where they leave gaps in our understanding. We conclude with implications for data collection and intervention development.

Managing uncertainty: a grounded theory of stigma in transgender health care encounters.

A growing body of literature supports stigma and discrimination as fundamental causes of health disparities. Stigma and discrimination experienced by transgender people have been associated with increased risk for depression, suicide, and HIV. Transgender stigma and discrimination experienced in health care influence transgender people's health care access and utilization. Thus, understanding how stigma and discrimination manifest and function in health care encounters is critical to addressing health disparities for transgender people. A qualitative, grounded theory approach was taken to this study of stigma in health care interactions. Between January and July 2011, fifty-five transgender people and twelve medical providers participated in one-time in-depth interviews about stigma, discrimination, and health care interactions between providers and transgender patients. Due to the social and institutional stigma against transgender people, their care is excluded from medical training. Therefore, providers approach medical encounters with transgender patients with ambivalence and uncertainty. Transgender people anticipate that providers will not know how to meet their needs. This uncertainty and ambivalence in the medical encounter upsets the normal balance of power in provider-patient relationships. Interpersonal stigma functions to reinforce the power and authority of the medical provider during these interactions. Functional theories of stigma posit that we hold stigmatizing attitudes because they serve specific psychological functions. However, these theories ignore how hierarchies of power in social relationships serve to maintain and reinforce inequalities. The findings of this study suggest that interpersonal stigma also functions to reinforce medical power and authority in the face of provider uncertainty. Within functional theories of stigma, it is important to acknowledge the role of power and to understand how stigmatizing attitudes function to maintain systems of inequality that contribute to health disparities.

The wire and urban health education.

As urban health has emerged as a distinct field, experts have collaborated to develop models for interdisciplinary education to train health professionals. Interdisciplinary learning is an important yet challenging imperative for urban health education. This paper explores lessons learned from a 2010 speaker series at the Johns Hopkins Bloomberg School of Public Health. The television show, The Wire, was used as a teaching tool to illustrate the context of health disparities in American cities and to explore the complex factors perpetuating urban health outcomes. We suggest that individuals interested in developing interdisciplinary teaching models can learn from both the form and the content of The Wire. As a popular televised serial narrative, The Wire prompts an investigation into the forms and circulation of academic research in a fractured and specialized media landscape. The formal narrative structure of the show provides mental scaffolding from which epidemiological, historical, geographical, anthropological, and other relevant disciplinary learning can build. The Wire encourages critical reflection among public health professionals about the forces that shape public health training, research, and practice and offers creative expansions to existing urban health educational efforts.

Smoking, HIV status, and HIV risk behaviors in a respondent-driven sample of injection drug users in Baltimore, Maryland: The BeSure Study.

Tobacco use is the largest preventable cause of death in the United States. Associations between cigarette smoking and HIV risk behaviors were examined among 669 injection drug users (IDU) in the 2006 wave of the National HIV Behavioral Surveillance System in Baltimore, Maryland, using respondent-driven sampling. The adjusted prevalence of smoking among IDU was 92.1%, with 32.7% smoking < 1 pack of cigarettes per day (light smoking) and 59.3% smoking ≥ 1 packs per day (heavy smoking). Self-reported HIV prevalence decreased as smoking frequency increased (p = 0.001). In multivariate analysis, heavy smokers were more likely to report painkiller use and binge drinking and less likely to report anal sex or health care use in the past year than light smokers. Results suggest that health care use mediates the relationship between heavy smoking and self-reported HIV. Integrating smoking cessation with HIV prevention services could address unmet health needs in IDU.

Social stability and health: exploring multidimensional social disadvantage.

Social stability is an understudied construct in public health that offers a useful framework for understanding social disadvantage across multiple domains. This study investigated prevalence and patterns of cooccurrence among a hypothesized set of social stability characteristics (housing, residential transition, employment, income, incarceration, and partner relationship), evaluated the possibility of underlying subgroups of social stability, and investigated the association between social stability and health outcomes. Data were from comprehensive interviews with primarily African-American low income urban women and their female social network members (n = 635) in Baltimore. Analysis included exploratory statistics, latent class analysis, and latent class regression accounting for clustered data using Stata and Mplus software. Social stability characteristics cooccurred in predictable directions, but with heterogeneity. Respondents had an average of three stability characteristics (S.D.: 1.4). Latent class analysis identified two classes of social stability: low (25%) and high (75%), with the higher class less likely to experience each of the included indicators. In controlled models, higher social stability was significantly correlated with social network characteristics and neighborhood integration. Higher social stability was independently associated with reduced risk of chronic illness (AOR: 0.54, 95% C.I.: 0.31, 0.94), mental illness history (AOR: 0.24, 95% CI: 0.15, 0.39), and current depressive symptoms (AOR: 0.35, 95% C.I.: 0.22, 0.57). The current set of social stability characteristics appears to represent a single construct with identifiable underlying subgroups and associated health disparities. Findings suggest a need for comprehensive policies and programs that address structural determinants of cooccurring social disadvantage and help to mitigate the likely spiral effect of instability experiences.