Implementing Triage-Bot: Supporting the Current Practice for Triage Nurses.

In Canada, emergency departments (ED) have 15.1 million unscheduled visits every year; this has been suggested to indicate that patients rely on ED to address the gaps experienced by 6.5 million Canadians who lack a primary care provider. When this large number of visits is coupled with a predicted shortage of 100,000 nurses in Canada by 2030, ED can be expected to face resource limitations, which highlights the importance of triage systems as a source of immediate support. Technology that incorporates innovative analytical methods, automation of routine, and efficient processing can be leveraged to enhance patient outcomes, streamline clinical processes, and improve the overall quality and efficiency of healthcare delivery. This paper aims to highlight how the Triage-Bot, a proposed AI system, can assist ED nurses when triaging patients. The Triage-Bot system is based on the Canadian Triage and Acuity Scale (CTAS), which currently serves as a standardized and highly effective tool for prioritizing patient care in emergency departments across the country. Pre-set and open-ended questions are asked using voice and video, allowing patients to describe their health concerns and conditions. Triage-Bot automatically measures the following vital signs: heart rate (HR), heart rate variability (HRV), oxygen saturation (SpO2), respiratory rate (RR), blood pressure (BP), blood glucose (BG), and stress. The system uses artificial intelligence models, particularly those with a deep learning approach that simultaneously analyzes both the user's facial expression and voice tone. Implementation: A systematic review addressed the implications of AI in nursing and concluded that it could contribute to patient care by providing personalized instructions and/or remotely monitoring patients. The Triage-Bot system can be implemented in healthcare facilities, such as emergency department waiting rooms. The information it collects can then be added to a patient's health records to support nurses in assessing the severity of each patient's condition. Limitations: If the system is accessed without a nurse's guidance, it is imperative that the user receives information regarding when to visit a healthcare provider or ED. Continuous improvements in Triage-Bot's accessibility for patients with varying abilities are required to ensure that the system remains user-friendly during times of illness. The voice and text interaction can also be influenced by a user's understanding of language, culture, and age-related factors.

Reconnecting Homeless Adolescents and Their Families: Correlates of Participation in a Family Intervention.

Behavioral family interventions are an effective way to intervene to prevent negative developmental outcomes for adolescents. Participation in family interventions encompasses behavioral and cognitive/attitudinal dimensions, among others, indicated by retention and engagement, respectively. Two dimensions of participation, retention and engagement, in a family intervention were examined in a sample of newly homeless adolescents and their parents or guardians. Correlates of participation included parents with more income and less perceived family conflict and adolescents with higher endorsement of depression, anxiety, somatization, obsessive-compulsive, phobic, and psychotic symptoms on the Brief Symptom Inventory (BSI). Stronger therapeutic alliance was correlated with being more distressed (i.e., lower income, more hostility), being a female adolescent participant, and having greater comfort discussing sex with parents. Furthermore, parents and adolescents with greater distress and thus greater need were more apt to finish the intervention. The finding that families who were experiencing more distress had higher alliance scores suggests that there is an additional need for development of interventions for families in crisis. Both participant and provider perceptions are also important in development of a strong therapeutic alliance. This study's findings have implications for further exploration of the development of cultural humility and improving mental health literacy among facilitators of behavioral interventions.

Families and the Juvenile Justice System: Considerations for Family-Based Interventions.

We conducted focus groups with defense lawyers, clinicians, and education advocates to gather their perspectives on families' experiences with the juvenile justice system. Our quantitative descriptive analysis identified a range of themes such as discussions about the poor treatment of families as well as recommendations for a shifting of power to families. These perspectives may provide insights about the context in which families are expected to participate in interventions, meet probationary demands, and provide for their youth's well-being. The results support evidence gathered from families about the impact of youth incarceration on their lives and has implications for practitioners and researchers working with families whose youth have been incarcerated.

"They Don't Care If We Live or Die": A Qualitative Analysis Examining the US Immigration System's Treatment of Undocumented Communities during the COVID-19 Pandemic.

Historically, the US immigration system (ie, institutions, agencies, and laws) has served the goals and principles of white supremacy through its treatment of globally displaced people and this appears to have continued through the COVID pandemic. Yet, the implications for immigrant health are not routinely addressed in mainstream public health discourse, and especially so in regard to public health disasters. This study conducted a series of focus groups with participants from social justice organizations working with immigrants, migrants, undocumented persons, refugees, persons seeking asylum, and persons detained in immigration jails to collect stories on how the immigration system undermined efforts to control the spread of COVID-19 and exacerbated health inequity within immigrant jails and across related community contexts during the pandemic. Focus groups were conducted to explore issues related to immigrants and immigration detention during the COVID-19 pandemic. There was a total of N=14 participants across the 4 focus groups with a dedicated focus group on perspectives of Black immigrants/from Black immigrant organizations only. Each focus group consisted of 3 to 4 participants. Five key themes emerged: 1) dehumanization of immigrants and migrants and devaluation of their lives; 2) inhumane conditions of confinement that propagate risk of disease; 3) denial of resources for COVID-19 prevention and mitigation; 4) expansion of intersecting oppressive systems; and 5) community-based resistance and mobilization against immigration policies and enforcement. Our findings highlight the harms from policing, criminalization, and exclusion that racialized communities face as a result of the (in)actions within the immigration system during a public health disaster including the COVID context.

An Equity-Based Scoring System for Evaluating Surveillance-Related Harm in Public Health Crises.

Background: Although surveillance systems used to mitigate disasters serve essential public health functions, communities of color have experienced disproportionate harms (eg, criminalization) as a result of historic and enhanced surveillance. Methods: To address this, we developed and piloted a novel, equity-based scoring system to evaluate surveillance systems regarding their potential and actual risk of adverse effects on communities made vulnerable through increased exposure to policing, detention/incarceration, deportation, and disruption of access to social services or public resources. To develop the scoring system, we reviewed the literature and surveyed an expert panel on surveillance to identify specific harms (eg, increased policing) that occur through surveillance approaches. Results: Scores were based on type of information collected (individual and/or neighborhood level) and evidence of sharing information with law enforcement. Scores were 0 (no risk of harm identified), 1 (potential for risk), 2 (evidence of risk), and U (data not publicly accessible). To pilot the scoring system, 44 surveillance systems were identified between June 2020 and October 2020 through an environmental scan of systems directly related to COVID-19 (n=21), behavioral and health-related services (n=11), and racism and racism-related factors (n=12). A score of 0-2 was assigned to 91% (n=40) of the systems; 9% were scored U; 30% (n=13) scored a 0. Half scored a 1 (n=22), indicating a "potential for the types of harm of concern in this analysis." "Evidence of harm," a score of 2, was found for 12% (n=5). Conclusions: The potential for surveillance systems to compromise the health and well-being of racialized and/or vulnerable populations has been understudied. This project developed and piloted a scoring system to accomplish this equity-based imperative. The nobler pursuits of public health to improve the health for all must be reconciled with these potential harms.

Barely Tweeting and Rarely About Racism: Assessing US State Health Department Twitter Use During the COVID-19 Vaccine Rollout.

Introduction: The general public was discussing racism and potential inequities in COVID-19 vaccinations among African Americans on Twitter before the first COVID-19 vaccine received emergency use authorization, but it is unclear how US state health departments (SHDs) were using Twitter to address the inequities. This study examines the frequency, content and timing of SHD tweets during the US rollout of the first SARS Co-V2 vaccine. Methods: This was a prospective study of tweets posted from the official Twitter accounts of each of the 50 US SHDs and the DC health department from October 19, 2020 to February 28, 2021. We retrieved the content and metadata of 100% of their tweets; calculated frequencies and proportions of tweets containing key terms related to COVID-19 vaccines, equity and racism; stratified the data by region; and charted longitudinal trends. Results: Overall, SHDs tweeted infrequently, and rarely tweeted about inequities, mistrust or racism. Though 55.48% of all SHD tweets were about COVID-19, hardly any tweets contained the terms: race/ethnicity (1.20%); equity (1.09); mistrust (.59%); or racism (.06%). Similar patterns existed among vaccination-related tweets, which accounted for 24.38% of all tweets. Only 21.64% of vaccination-related tweets containing any race/ethnicity, equity, mistrust, or racism terms were posted prior to the first Emergency Use Authorization (EUA). Those about African Americans (70.45%) were posted ≥8 weeks after EUA. Conclusions: Concerns about racism and inequities in COVID-19 vaccination continue on Twitter, but SHDs rarely tweet about them. This strikes a worrisome chord of disconnection from the science linking health inequities to racism.

Using COVID-19 Surveillance Systems to Identify and Monitor Disparities: Best Practices and Recommendations.

Inadequate attention to racial health equity is a common challenge to effective, reliable monitoring and mitigation of COVID-19 disparities. Efforts to monitor and mitigate COVID-19 disparities continue to be hampered by inadequacies in how surveillance systems collect, tabulate, and report COVID-19-related outcomes. We conducted environmental scans of existing public health surveillance systems and reporting standards, literature reviews, focus groups with surveillance experts, and consultations with the Centers for Disease Control and Prevention (CDC) and an expert panel on surveillance to identify and explore strengths, weaknesses, and gaps in how existing systems monitor COVID-19 and their implications for addressing disparities in related outcomes. We present recommendations based on these reviews and propose a core minimum set of health indicators and best-practice standards for reporting these indicators by COVID-19 surveillance systems to monitor racial/ethnic and other disparities in the pandemic. These recommendations are relevant to monitoring disparities in the ongoing COVID-19 pandemic and may inform monitoring of future epidemics. This discussion is part of an effort by Project REFOCUS to develop syndemic surveillance systems for monitoring the intersecting pandemics of COVID-19 and racism.

A Qualitative Analysis on Sexual and Reproductive Health Needs and Issues During COVID-19 Using a Reproductive Justice Framework.

The COVID-19 pandemic exacerbated existing health inequities, further exposing the challenges in meeting the sexual and reproductive health (SRH) needs, particularly for Black, Indigenous and People of Color (BIPOC). We interviewed 11 key informants through three focus groups to explore barriers and pathways to SRH care for BIPOC during COVID-19 in the United States. Reimagining reproductive health practices requires holistic practices and multisector pathways, a comprehensive reproductive justice approach. This includes interventions across the sexual and reproductive health continuum. Using a deductive-dominant approach grounded in reproductive justice values, we explore themes around SRH during COVID-19. Five themes for advancing reproductive justice were identified: "supremacy of birth"; police violence as a determinant of SR mental health; addressing quality of care outside of hospital settings; digital redlining; and centering joy, liberation, and humanity.

Integrated Methods for Applying Critical Race Theory to Qualitative COVID-19 Equity Research.

Background: Racism persists, underscoring the need to rapidly document the perspectives and experiences of Black, Indigenous and People of Color (BIPOC) groups as well as marginalized populations (eg, formerly incarcerated people) during pandemics. Objective: This methods paper offers a model for using Public Health Critical Race Praxis (PHCRP) and related critical methodologies (ie, feminist and decolonizing methods) to inform the conceptualization, methods, and dissemination of qualitative research undertaken in response to the evolving COVID-19 pandemic. Sample: Using purposive snowball sampling, we identified organizations involved with health equity and social justice advocacy among BIPOC and socially marginalized populations. Focus group participants (N=63) included community members, organizers, activists, and health workers. Design: We conducted topic-specific (eg, reproductive justice) and population-specific (eg, Asian and Pacific Islander) focus groups (N=16 focus groups) in rapid succession using Zoom software. Methods: A self-reflexive, iterative praxis guided theorization, data collection and analysis. We obtained community input on study design, the semi-structured discussion guide, ethical considerations and dissemination. Applying PHCRP, we assessed our assumptions iteratively. We transcribed each interview verbatim, de-identified the data, then used two distinct qualitative techniques to code and analyze them: thematic analysis to identify unifying concepts that recur across focus groups and narrative analysis to keep each participant's story intact. Results: The praxis facilitated relationship-building with partners and supported the iterative assessment of assumptions. Logistical constraints included difficulty ensuring the confidentiality of virtual discussions. Conclusions: These novel approaches provide an effective model for community-engaged qualitative research during a pandemic.

Adequacy of Existing Surveillance Systems to Monitor Racism, Social Stigma and COVID Inequities: A Detailed Assessment and Recommendations.

The populations impacted most by COVID are also impacted by racism and related social stigma; however, traditional surveillance tools may not capture the intersectionality of these relationships. We conducted a detailed assessment of diverse surveillance systems and databases to identify characteristics, constraints and best practices that might inform the development of a novel COVID surveillance system that achieves these aims. We used subject area expertise, an expert panel and CDC guidance to generate an initial list of N > 50 existing surveillance systems as of 29 October 2020, and systematically excluded those not advancing the project aims. This yielded a final reduced group (n = 10) of COVID surveillance systems (n = 3), other public health systems (4) and systems tracking racism and/or social stigma (n = 3, which we evaluated by using CDC evaluation criteria and Critical Race Theory. Overall, the most important contribution of COVID-19 surveillance systems is their real-time (e.g., daily) or near-real-time (e.g., weekly) reporting; however, they are severely constrained by the lack of complete data on race/ethnicity, making it difficult to monitor racial/ethnic inequities. Other public health systems have validated measures of psychosocial and behavioral factors and some racism or stigma-related factors but lack the timeliness needed in a pandemic. Systems that monitor racism report historical data on, for instance, hate crimes, but do not capture current patterns, and it is unclear how representativeness the findings are. Though existing surveillance systems offer important strengths for monitoring health conditions or racism and related stigma, new surveillance strategies are needed to monitor their intersecting relationships more rigorously.

Concurrency, sex partner risk, and high-risk human papillomavirus infection among African American, Asian, and Hispanic women.

BACKGROUND: Although the role of concurrent sexual partnerships (i.e., having sexual activity with another partner after a current partnership has been established) has been most strongly associated with the transmission of bacterial sexually transmitted infections, its role in the transmission of viral sexually transmitted infections, specifically human papillomavirus (HPV) is less clear. METHODS: Analysis of risk behavior data collected from 812 women screened for HPV as part of a sentinel surveillance project conducted in a family planning clinic, a primary care clinic, and 2 sexually transmitted disease clinics in Los Angeles, CA. RESULTS: The mean age of participants was 34.2 years (range: 18-65), with 31.8% identifying as African American 32.8% as Asian, and 28.4% as Hispanic. The overall prevalence of high-risk HPV (HR-HPV) was 21.7% and was higher among women who reported a concurrent partnership (25.7%) as compared to those who reported no concurrency (17.1%; P = 0.004). In multivariate analysis, concurrency was associated with HR-HPV and this relationship varied by race/ethnicity. Among Hispanic women those reporting a concurrent partnership were nearly twice as likely to have HR-HPV as compared to those who did not report concurrency (adjusted odds ration [AOR] = 1.71; 95% confidence interval [CI]: 1.13-2.58). However, among African American women those who reported a concurrent partnership were less likely to be diagnosed with HR-HPV (AOR = 0.60; 95% CI: 0.37-0.98). CONCLUSIONS: This study demonstrates that concurrency is associated with HR-HPV and that there may be differences by race/ethnicity in the individual or partnership characteristics of those who report concurrency.

Lessons Learned: Challenges and Strategies for Conducting Family-Based Intervention Research in Juvenile Justice Settings.

Greater than 60% of youths in the juvenile justice system have a diagnosable mental health disorder, with substance use-related and addictive disorders being among the most common mental health disorders.1 Research studies have shown that family-based interventions targeting substance use-related and addictive disorders have two to nine times greater effect sizes compared with individual-based interventions.2 Family-based interventions, most notably, functional family therapy,3 multidimensional family therapy,4 and multisystemic therapy,5 have been shown to reduce substance use among justice-involved youths. Given the complex and multiple demands facing justice-involved youths, conducting family-based research within juvenile justice populations can be challenging. This article provides insights into the operational challenges and innovative strategies to address these challenges to conduct family-based intervention research with reentry youths.

Trauma, Family Factors and the Mental Health of Homeless Adolescents.

Family factors, such as poor family functioning and trauma, have been associated with negative outcomes for homeless adolescents. Further study is needed to better understand how family factors and trauma jointly relate to mental health problems and externalizing behaviors among homeless adolescents. Structural equation modeling was used to examine the influence of trauma (encompassing traumatic events experienced prior to, and after, becoming homeless) and family factors (poor family functioning and family conflict) on mental health problems and externalizing behaviors (substance use, delinquent behaviors, and sexual risk) among 201 homeless adolescents, ages 12 to 17 years. Trauma, poor family functioning, and family conflict significantly predicted greater mental health problems, delinquent behaviors, high-risk sexual behaviors and substance use. Overall, the findings suggest that family factors appear to be key to understanding mental health problems and externalizing behaviors among homeless adolescents. Implications, limitations and future directions are addressed.

Understanding interactions of formerly incarcerated HIV-positive men and transgender women with substance use treatment, medical, and criminal justice systems.

BACKGROUND: Low levels of medical care engagement have been noted for HIV-positive people leaving systems of incarceration in the United States. Substance misuse frequently co-occurs with criminal justice involvement in individuals who are living with HIV. METHODS: We analyzed data from in-depth interviews with 19 HIV-positive individuals who were currently or formerly incarcerated in order to elucidate challenges faced in accessing care and maintaining HIV treatment regimens when cycling out of (and often back into) custody. Our thematic analysis used an ecosocial framework to describe participants' shifts between substance use treatment, medical care, and criminal justice systems. RESULTS: Dominant themes included the dramatic increase in HIV-treatment-related autonomy required following release from jail because of differences in care delivery between custody-based and community-based care systems; the important, but temporary stabilization provided by residential substance use treatment programmes; and the inconsistency of substance use treatment approaches with chronic care models of disease management. CONCLUSION: Enhanced integration of criminal justice, medical care, and substance use treatment institutions in planning for reentry of HIV populations may ease the impact of the dramatic shifts in context that often dissuade linkage and retention. This integration should include coordination with custody release processes, periodic assessments for active substance misuse in HIV treatment settings, support for (re)establishing health-promoting social networks, and options for long-term, residential substance use treatment programmes.

Interventions for families affected by HIV.

Family-based interventions are efficacious for human immunodeficiency virus (HIV) detection, prevention, and care, but they are not broadly diffused. Understanding intervention adaptation and translation processes can support evidence-based intervention (EBI) diffusion processes. This paper provides a narrative review of a series of EBI for families affected by HIV (FAH) that were adapted across five randomized controlled trials in the US, Thailand, and South Africa over 15 years. The FAH interventions targeted parents living with HIV and their children or caregiver supports. Parents with HIV were primarily mothers infected through sexual transmission. The EBIs for FAH are reviewed with attention to commonalities and variations in risk environments and intervention features. Frameworks for common and robust intervention functions, principles, practice elements, and delivery processes are utilized to highlight commonalities and adaptations for each location, time period, and intervention delivery settings. Health care, housing, food, and financial security vary dramatically in each risk environment. Yet, all FAH face common health, mental health, transmission, and relationship challenges. The EBIs efficaciously addressed these common challenges and were adapted across contexts with fidelity to robust intervention principles, processes, factors, and practices. Intervention adaptation teams have a series of structural decision points: mainstreaming HIV with other local health priorities or not; selecting an optimal delivery site (clinics, homes, community centers); and how to translate intervention protocols to local contexts and cultures. Replication of interventions with fidelity must occur at the level of standardized functions and robust principles, processes, and practices, not manualized protocols. Adopting a continuous quality improvement paradigm will enhance rapid and global diffusion of EBI for FAH.