Use of Digital Health Resources by Sexual and Gender Minority Caregivers of Older Adults: Findings From the 2020 Caregiving in the U.S. Survey.

We applied Andersen's Behavioral Model of Health Services Use to investigate the health needs and use of digital health resources among sexual and/or gender minority (SGM) caregivers. Data were from the Caregiving in the U.S. 2020 survey. Regression analyses were used to describe associations between predisposing, enabling, and need factors and usage of digital health resources. SGM caregivers provided more hours of care per week, reported higher levels of care intensity, and reported higher physical, emotional, and financial strain compared with non-SGM caregivers. Regression analyses indicated SGM status was a significant predictor of overall use of digital health resources. Younger caregivers, racial minority caregivers, those providing higher levels of care, and those reporting a poorer health status were more likely to use digital health resources. Digital health resources may be useful tools for SGM caregivers of older adults. More research is needed to investigate the reasons SGM caregivers use these resources.

Food insecurity and SNAP use among sexual minority people: analysis of a population-based sample from National Health Interview Survey, 2017.

BACKGROUND: Food insecurity is a pressing public health problem. Lesbian, gay, and bisexual (LGB) people are at increased risk for food insecurity, yet this issue remains grossly understudied among this population. The purpose of this study was to add to the existing literature surrounding food insecurity and the use of federal food assistance programs (SNAP) among LGB people. METHODS: This study used publicly available, de-identified data from the 2017 National Health Interview Survey (NHIS). Primary variables were sexual orientation, food security status, and receipt of SNAP. Food security was assessed using the 10-item USDA Family Food Security measure. RESULTS: In our sample, people who identified as bisexual had the highest rates of food insecurity (23.8%, n = 76). Female sexual minorities were 52% more likely to experience food insecurity (aOR = 1.518, 95% CI 1.105-2.087, p = .01) and 44% more likely to report household SNAP assistance than their heterosexual counterparts (aOR = 1.441, 95% CI 1.025-2.028, p = .03). SNAP partially mediated the association between sexual orientation and food insecurity for LGB females. CONCLUSIONS: Our findings add to the growing empirical evidence documenting food insecurities among sexual minority adults. Our results reiterate the need for sexual orientation to be included in nationally representative federal food security measures.

A Comparative Analysis of Family Quality of Life Between Heterosexual and Sexual Minority Caregivers of People with Dementia.

Providing care for someone with Alzheimer's disease or related dementias (ADRD) is associated with significant physical and mental strain affecting quality of life among caregivers. However, little attention has been given to sexual minority (SM; lesbian, gay, bisexual, queer) people caring for those with ADRD. In this cross-sectional study, we used psychosocial measures to describe the characteristics and family quality of life of SM and heterosexual caregivers for people with ADRD. SM caregivers were significantly younger and more frequently reported full or part-time employment compared with their heterosexual counterparts. Lesbian and bisexual caregivers reported more difficulty in paying for everyday basics. After controlling for demographic covariates, SM caregivers had significantly higher family quality of life scores compared with heterosexual caregivers. This study is among the first to compare family quality of life between SM and heterosexual caregivers. Findings can guide development of targeted interventions for SM caregivers.

Characteristics of Sexual and Gender Minority Caregivers of People With Dementia.

Objectives: Given what little is known about the experiences of sexual and gender minority (SGM) caregivers of people with Alzheimer's disease and related dementias (ADRD), the aim of the current study was to describe psychosocial measures among these caregivers. Methods: We used an online survey and social media recruitment strategies. Results: Of 286 caregivers, the majority were gay men. Most respondents were white, with a third identifying as Latino American. The plurality of caregivers identified as a spouse/partner and were providing care for someone who identified as a sexual minority; one-fifth cared for someone transgender. Sexual orientation, perceived stress, caregiver stigma, and microaggressions were psychosocial factors associated with family quality of life and depressive symptoms in the caregivers. Discussion: This study is the first to provide a focused description of the characteristics and psychosocial needs of SGM caregivers of someone with ADRD, supporting development of targeted interventions for this population.

Attitudes of East Tennessee residents towards general and pertussis vaccination: a qualitative study.

BACKGROUND: Despite vaccination being one of the safest and most successful public health tools to control infectious diseases, some people still doubt the efficacy and safety of vaccines. In order to address vaccine hesitancy and anti-vaccination sentiment, it is necessary to understand vaccination attitude development and vaccination behaviors. The objective of this project was to qualitatively investigate general vaccination attitudes and behavior with an additional emphasis on pertussis vaccination. METHODS: To identify factors that influence attitudes toward vaccination and behaviors in East Tennessee, eleven one-on-one interviews were conducted with participants recruited through convenience and purposive sampling. Interview protocol and deductive codes were developed using the Triadic Theory of Influence as a theoretical framework. Interview transcripts were analyzed qualitatively and themes were identified through constant comparison of interviews, considering both deductively and inductively coded data. RESULTS: Most participants (8) held positive attitudes towards vaccination. Participants (8) comfortable with vaccinating themselves or their children said they followed recommendations of doctors. Vaccine hesitant participants' (3) most frequently cited concern was safety and concern about side effects. These participants also reported that they referenced non-academic or professional sources and felt confident about their knowledge of vaccines and diseases. Vaccine hesitant participants had low perception of risk of vaccine-preventable diseases, particularly pertussis. Participants with children reported that friends and family were influential when deciding to vaccinate their children. CONCLUSIONS: This study identified themes in the attitudes towards vaccination of participants recruited in East Tennessee. We found that risk perception and family and social group attitudes were the primary influences on vaccination decision making. We recommend that future research includes anti-vaccination participants in their research, if possible, and further explore the relationship between perception of one's own knowledge and health behavior outcomes.

Predictors of Mind-Body Therapy Use Among Sexual Minority Older Adults.

Introduction: Sexual minority (SM; lesbian, gay, bisexual) older adults age 50+ experience a higher prevalence of chronic disease and disability, as well as a poorer physical and mental health status, compared with their heterosexual peers. Many adults use complementary and integrative therapies, particularly mind-body therapies, as health-enhancing approaches and to support well-being. However, no study to date has examined the use of mind-body therapies among SM older adults. Materials and Methods: Data were from the 2017 National Health Interview Survey. Descriptive and summary statistics were calculated to describe use of mind-body therapies by SM older adults (aged 50+). The authors also tested associations between use of mind-body therapies and health and well-being among SM older adults and compared associations with their non-SM counterparts. Results: SM older adults reported higher usage (36%) of mind-body therapies compared with heterosexual adults (22%), with lesbian women reporting the highest use (39.4%). Having a SM identity was associated with mind-body therapy use; SM older adults were 57% more likely to use a mind-body therapy. Conclusion: Mind-body therapies may be a useful tool for SM older adults to enhance their health and well-being. Future qualitative research is needed to investigate more deeply the reasons SM older adults use mind-body therapies. To advance the health and well-being of SM older adults, the authors also need intervention studies that explore the effectiveness of mind-body interventions and the possible need for tailoring these to the unique needs of this population.

What Is Successful Aging in Lesbian and Bisexual Women? Application of the Aging-Well Model.

OBJECTIVES: Most evidence concerning aging ignores women's sexual orientation, yet sexual orientation-related discrimination across the life course may influence older lesbian and bisexual women's risk for poorer health. Understanding aging-well in this group is vital to development, testing, and implementation of evidence-based health promotion programming and services for aging sexual minority women. METHOD: Data were from the Women's Health Initiative (N = 15,691; heterosexual n = 15,002, lesbian n = 440, bisexual n = 249) extension study. Multivariable linear and logistic regression tested associations between sexual orientation and indicators of successful, effective, and optimal aging-well in age-stratified groups of women (60-74 and 75+). RESULTS: Lesbians aged 60-74 were more likely (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.16, 2.18) to report good self-mastery, more social support (b = 2.92, 95% CI, 1.99, 3.85), and greater likelihood of enjoying life (OR 1.46, 95% CI 1.06, 2.01) compared with heterosexual women. Bisexual women aged 75+ reported increased personal growth (b = 1.09, 95% CI 0.23, 1.95) compared to heterosexuals. While lesbians aged 75+ had greater likelihood of living in a nursing home (OR 1.96; 95% CI 1.01, 3.82) and were less likely to be happy at least most of the time (OR 0.68, 95% CI 0.49, 0.99), they reported greater self-mastery (OR 1.55; 95% CI 1.06, 2.26) than their heterosexual peers. DISCUSSION: Aging-well is not the same for all women. Health promotion programs may consider maximizing sexual minority women's internal and external resources-including social supports, self-mastery, and personal growth-to promote wellness in older age.

Disparities in food insecurity at the intersection of race and sexual orientation: A population-based study of adult women in the United States.

Food insecurity affects 1 in 8 American adults annually, and is more prevalent in Black and sexual minority women. We applied an intersectional approach to investigate food insecurity prevalence in women with intersecting minority race and sexual orientation. We used two United States surveillance systems-National Health Interview Survey (NHIS) 2013-2018 and National Health and Nutrition Examination Survey (NHANES) 2005-2014, to estimate how race and sexual orientation jointly influence food insecurity prevalence in women aged 18-59 years (NHIS: N = 47596; NHANES: N = 5106). All analyses were stratified for Supplemental Nutrition Assistance Program (SNAP) use. Relative measures estimated weighted prevalence ratios (PR) comparing Black and White sexual minority women (SMW) to heterosexual White women. Absolute prevalence measures estimated the excess prevalence of food insecurity due to multiple marginalization. Patterns of food insecurity prevalence were similar across NHIS and NHANES, and differed only for non-SNAP users. Relative prevalence of food insecurity was greater in Black SMW than heterosexual White women in NHIS (PR: 2.16; 95% confidence interval [CI], 1.41-3.30) and NHANES (PR: 2.79; 95% CI, 1.73-4.51). The strength of the association between multiple marginalization and food insecurity was stronger for Black SMW than White SMW. Absolute measures were significant only for NHIS and did not support our a priori hypothesis: For non-SNAP users, being Black and sexual minority reduced the joint disparity in food insecurity by approximately 50% (Synergy Index: 0.52; 95% CI, 0.11-0.93). Overall, our study illuminated population-level differences in food insecurity among women of diverse minority races and sexual orientations. Black SMW experienced high rates of food insecurity, which may contribute to chronic disease disparities. Yet, intersecting minority social positions (race and sexual orientation) reduced food insecurity; these findings are unexpected and must be further investigated. Increasing SNAP use among multiply marginalized women may attenuate food insecurity disparities.

Sexual orientation disparities in food insecurity and food assistance use in U.S. adult women: National Health and Nutrition Examination Survey, 2005-2014.

BACKGROUND: Nearly 40 million American adults report past year food insecurity. This is concerning, as food insecurity is associated with chronic disease morbidity and premature mortality. Women disproportionately experience food insecurity, and sexual minority women (i.e., lesbian, bisexual, and heterosexual women reporting same-sex behavior; SMW) may be at greater risk for experiencing food insecurity disparities. The purpose of this study was to investigate patterns and prevalence of food insecurity and food assistance use in sexual minority and exclusively heterosexual women using population-level health surveillance data. METHODS: Using pooled 2004-2014 National Health and Nutrition Examination Survey data (N = 7379), we estimated weighted point prevalence of past 12-month food insecurity, severe food insecurity, Supplemental Nutrition Assistance Program (SNAP) use, and emergency food assistance use. We then used Poisson regression with robust variance to estimate prevalence ratios comparing SMW to exclusively heterosexual women on all outcomes. Women were classified by sexual identity and lifetime same-sex behavior as lesbian (n = 88), bisexual (n = 251), heterosexual and reporting same-sex behavior (heterosexual WSW; n = 366), or exclusively heterosexual women (referent; n = 6674). RESULTS: Between 20.6-27.3% of lesbian, bisexual, and heterosexual WSW reported past 12-month food insecurity (versus 13.1% of exclusively heterosexual women). All SMW reported greater prevalence of past 12-month food insecurity and severe food insecurity than exclusively heterosexual women: prevalence ratios (PR) ranged from 1.34 (95% confidence interval [CI], 1.05-1.70) to 1.84 (95% CI, 1.13-3.01). No differences were found in SNAP participation by sexual orientation, but more lesbians and heterosexual WSW reported using emergency food assistance in the past 12-months (PR = 1.89; 95% CI, 1.29-2.79 and PR = 1.43; 95% CI, 1.03-2.00 respectively). CONCLUSIONS: All SMW reported higher prevalence of food insecurity than exclusively heterosexual women. Lesbians and heterosexual WSW were also more likely to rely on emergency food assistance. This is problematic as SNAP use may reduce food insecurity over time, but emergency food resources (e.g., food pantries) do not. More evidence is needed to understand the multilevel factors driving food insecurity in this population to develop policy and community-based efforts to increase SNAP participation and decrease food insecurity.

Food insecurity and food pantry use among transgender and gender non-conforming people in the Southeast United States.

BACKGROUND: Transgender and gender non-conforming (TGNC) people face high rates of poverty, joblessness, and homelessness, rendering this population vulnerable to experiencing food insecurity. Yet, there is almost no empirical evidence concerning food insecurity and the use of local and federal food assistance resources in the TGNC community. Food insecurity, the use of local and Federal food assistance resources, and associations with gender-related minority stressors and resilience using the Gender Minority Stress and Resilience (GMSR) scale among TGNC individuals living in the Southeast United States (U.S.) were documented in this study. METHODS: A cross-sectional online survey was conducted with TGNC people living in the Southeast U.S. Participants were recruited via targeted Facebook advertisements. RESULTS: In total, 105 TGNC people completed the survey; 79% of survey participants experienced food insecurity, 19% utilized Federal, and 22% utilized local food assistance resources. High levels of minority stress and community resilience were reported. The GMSR resilience scale Pride (aOR = 1.09, 95% CI 1.00-1.19, p = .04) was significantly associated with the use of local food pantries, but minority stressors were not. No significant associations were found between GMSR and food security. CONCLUSION: TGNC people living in the Southeast U.S. experienced food insecurity, unstable housing, low wages, and social stigma that were a barrier to using emergency food resources. Multi-level public health solutions that address discriminatory legislative policies and create linkages between TGNC people and local and federal food assistance are required to address issues of food insecurity in the TGNC population.

Social Media Recruitment of Marginalized, Hard-to-Reach Populations: Development of Recruitment and Monitoring Guidelines.

BACKGROUND: Social media can be a useful strategy for recruiting hard-to-reach, stigmatized populations into research studies; however, it may also introduce risks for participant and research team exposure to negative comments. Currently, there is no published formal social media recruitment and monitoring guidelines that specifically address harm reduction for social media recruitment of marginalized populations. OBJECTIVE: The purpose of this research study was to investigate the utility, successes, challenges, and positive and negative consequences of using targeted Facebook advertisements as a strategy to recruit transgender and gender nonconforming (TGNC) people into a research study. METHODS: TGNC adults living in the Southeast Unites States were recruited via targeted Facebook advertisements over two cycles in April and June 2017. During cycle 1, researchers only used inclusion terms to recruit the target population. During cycle 2, the social media recruitment and monitoring protocol and inclusion and exclusion terms were used. RESULTS: The cycle 1 advertisement reached 8518 people and had 188 reactions, comments, and shares but produced cyberbullying, including discriminatory comments from Facebook members. Cycle 2 reached fewer people (6976) and received 166 reactions, comments, and shares but produced mostly positive comments. CONCLUSIONS: Researchers must consider potential harms of using targeted Facebook advertisements to recruit hard-to-reach and stigmatized populations. To minimize harm to participants and research staff, researchers must preemptively implement detailed social media recruitment and monitoring guidelines for monitoring and responding to negative feedback on targeted Facebook advertisements.

A Test of Feasibility and Acceptability of Online Mindfulness-Based Stress Reduction for Lesbian, Gay, and Bisexual Women and Men at Risk for High Stress: Pilot Study.

BACKGROUND: In conservative and rural areas, where antidiscrimination laws do not exist, lesbian, gay, and bisexual (LGB) people are at risk for excess stress arising from discrimination. Stress-reducing interventions delivered via innovative channels to overcome access barriers are needed. OBJECTIVE: This study aimed to investigate the feasibility and acceptability of online mindfulness-based stress reduction (OMBSR) with LGB people in Appalachian Tennessee at high risk for stress. METHODS: In 2 pilot studies involving pre-post test designs, participants completed 8 weeks of OMBSR, weekly activity logs, semistructured interviews, and surveys of perceived and minority stress. RESULTS: Overall, 24 LGB people enrolled in the study and 17 completed OMBSR. In addition, 94% completed some form of mindfulness activities daily, including meditation. Participants enjoyed the program and found it easy to use. Perceived stress (Cohen, perceived stress scale-10) decreased by 23% in women (mean 22.73 vs mean 17.45; t10=3.12; P=.01) and by 40% in men (mean 19.83 vs mean 12.00; t5=3.90; P=.01) between baseline and postprogram. Women demonstrated a 12% reduction in overall minority stress (Balsam, Daily Experiences with Heterosexism Questionnaire) from baseline to 12-week follow-up (mean 1.87 vs mean 1.57; t10=4.12; P=.002). Subscale analyses indicated that women's stress due to vigilance and vicarious trauma decreased by 21% and 20%, respectively. CONCLUSIONS: OMBSR may be a useful tool to help LGB people reduce general and minority-specific stress in socially conservative regions lacking antidiscrimination policies.

Cultural competency and microaggressions in the provision of care to LGBT patients in rural and appalachian Tennessee.

PURPOSE: Lack of provider training in lesbian, gay, bisexual, and transgender (LGBT) cultural competence may diminish healthcare access. Culturally competent providers may enact microaggressions when providing LGBT patient care, especially in sociopolitically conservative areas. Our study examined LGBT cultural competence and microaggressions among healthcare providers in rural Tennessee. METHODS: Providers (n = 85) completed a self-report survey on LGBT cultural competence. Post-survey, we invited respondents to provide an interview to contextualize quantitative findings and identify barriers to LGBT patient care (n = 6). RESULTS: Most quantitative respondents disagreed that they preferred not to care for LGBT patients (85.9%) or that they would refuse care to LGBT patients (92.9%). Only half felt competent to provide LGBT patient care (54.1%). Fewer oncology than primary care providers felt competent treating LGBT patients, and more physicians than nurses reported their training did not adequately address LGBT issues. Qualitatively, interviewees reported serving patients "equally", yet described discomfort with LGBT patients and LGBT microaggressions in clinical practice. PRINCIPAL CONCLUSIONS: While many providers felt competent to provide LGBT patient care, they described behaviors and attitudes that may contribute to LGBT healthcare inequities. PRACTICE IMPLICATIONS: Provider training must address how microaggressions negatively influence patient-provider interactions and LGBT patient care.