Complicating critical discussions in gender sexuality alliances: Youth desire for intersectional conversations and the experience of fragmentation.

Gender sexuality alliances (GSAs) represent consciousness-raisings that hold potential for critical consciousness development in youth. In this study, we focus on critical reflection-the understanding that oppression is structured and maintained by human action. We engage intersectionality as our analytical framework and analyze both student interview data (n = 38) and advisor closed-ended and open-ended survey data (n = 58) to examine: (1) the nature/content of critically reflective discussions in GSAs and (2) how advisors support critically reflective discussions in GSAs and their role in these discussions. Our findings suggest that (1) conversations centering race and its intersections with other socio-structural axes occur, albeit infrequently; (2) youth recognize and understand the concept of intersectionality in nuanced ways, desire to have critical intersectional conversations, and experience fragmentation from conversations around race, sexuality, and gender if they are situated at privileged locations on those axes; and (3) students want advisors to engage in critically reflective discussions in GSAs. The findings suggest that interventions and programming are needed that could cultivate advisors' and youth leaders' skills in facilitating intersectional dialogues for critical reflection among members.

Study protocol: Project 2VIDA! SARS-CoV-2 vaccine intervention delivery for adults in Southern California.

Background: To date, the United States (US) leads the world in the number of infections and deaths due to the Coronavirus Disease 2019 (COVID-19). Racial and ethnic disparities in COVID-19 morbidity and mortality are staggering. Age-adjusted data show that AA and Latino individuals have had higher rates of death over most of the pandemic and during surges. Project 2VIDA! is community-based participatory research (CBPR) that was developed to address individual, social, and contextual factors related to access and acceptance of the COVID-19 vaccine among African American and Latino communities in Southern California. This paper describes the study protocol and overarching objectives. Methods and design: Project 2VIDA! is a multilevel intervention that builds on the principals of CBPR and is designed to increase uptake of the COVID-19 vaccine among African American and Latino individuals (≥16 years and older) in San Diego County. The intervention was developed with a working group comprised of representatives from community and academia and centers on targeted COVID-19 individual awareness and education, linkage to medical and supportive services, COVID-19 community outreach and health promotion and offering the COVID-19 vaccine through community pop-up clinics. Discussion: Findings from 2VIDA! will provide data on the impact, feasibility, and acceptability of the intervention which are all crucial for the adaptation, refinement, and improvement of vaccine outreach interventions for COVID-19 and other vaccine preventable infectious diseases that severely impact African American and Latino communities. Clinical trial registration: https://clinicaltrials.gov/ct2/show/NCT05022472?term=Project+2VIDA&draw=2&rank=1, NCT05022472.

Adaptation of the brainwriting premortem technique to inform the co-creation of COVID-19 testing strategies in underserved communities in South San Diego.

INTRODUCTION: Meaningful engagement of partners in co-creating and refining health-related programs can increase the initial uptake, sustained implementation, broad reach, and effectiveness of these programs. This is especially important for underserved communities where resources are limited and need to be prioritized. Brainwriting premortem is a novel qualitative approach to partner engagement that combines the strengths of individual idea generation with the concept of premortem exercise that addresses failure points prior to the implementation of new programs. METHODS: An adapted form of brainwriting premortem was used to inform iterative refinements to a COVID-19 testing program at a Federally Qualified Health Center (FQHC) in San Diego. Patients and providers from the FQHC participated in interviews at two time points (early- and mid-implementation of the program). Interview data were transcribed, translated, and analyzed using a rapid qualitative approach. Key themes and sub-themes were identified and used to inform refinements to the program. RESULTS: A total of 11 patients (7 Spanish- and 4 English-speaking) and 8 providers participated in the brainwriting premortem interviews. Key themes related to possible reasons for COVID-19 testing program failure: advertising/sharing information; access to testing; handling of test results; staff and patient safety; patient beliefs and views regarding the SARS-CoV-2 virus; and COVID-19 testing options offered. Proposed solutions were offered for the key failures except for patient beliefs and views regarding the SARS-CoV-2 virus. Additional solutions offered were related to education, physical operations, and recruitment strategies. Real-time changes to the program flow and components were made in response to 7 suggestions from patients and 11 from providers. Changes related to the process of returning results were the most common, and included sending results via email with distinct workflows based on the test result. CONCLUSION: The implementation of the adapted brainwriting premortem technique allowed us to incorporate the perspective of key partners in the delivery and iterative refinement of the COVID-19 testing program. This was an effective tool in the context of an FQHC and can be a promising and approach to incorporate iterative input from patients and providers to ensure successful program implementation. Future studies, particularly those requiring rapid response to public health emergencies, should consider the use of this technique.

Community-engaged optimization of COVID-19 rapid evaluation and testing experiences: roll-out implementation optimization trial.

BACKGROUND: There continues to be a need for COVID-19 testing that is pragmatic, community-centered, and sustainable. This study will refine and test implementation strategies prioritized by community partners: (1) walk-up no-cost testing, (2) community health worker (promotores)-facilitated testing and preventive care counseling, (3) vending machines that dispense no-cost, self-testing kits. METHODS: A co-designed Theory of Change from an earlier study phase and the Practical, Robust Implementation and Sustainment Model (PRISM) will guide the study design, measures selection, and evaluation. The first aim is to refine and operationalize a multi-component implementation strategy bundle and outcome measures for COVID-19 testing. A Community and Scientific Advisory Board (CSAB) will be established and include community members, clinical providers/staff from the partnering Federally Qualified Health Center (FQHC), public health researchers, policymakers, and a county health department ambassador. Engagement of CSAB members will be assessed through structured ethnography and a survey about the quality and quantity of engagement practices. The second aim is to implement and evaluate the impact of the implementation strategy bundle to optimize COVID-19 testing in communities using a roll-out implementation optimization (ROIO) design. Seven thousand and five hundred community members will be enrolled across four FQHC clinics over 18 months. Participants will be invited to complete an electronic survey about their demographics, health, and COVID-19 testing results and experiences. CSAB members and clinic partners will participate in PRISM fit and determinant assessments prior to each clinic rollout and post-trial. Interviews will be conducted with 60 community participants and 12 providers/staff following a 3-month rollout period at each clinic, inquiring about their experiences with the implementation strategies. Quantitative data will be analyzed using hierarchical multilevel models to determine the impact of implementation strategies. Qualitative data will be analyzed using rapid qualitative approaches to summarize implementation experiences and identify necessary changes prior to subsequent rollouts. A matrix approach will be used to triangulate data from quantitative and qualitative sources based on PRISM domains. DISCUSSION: This is one of the first pragmatic implementation trials to use a ROIO design and aims to co-create a sustainable and equitable COVID-19 testing program. Findings are likely to generalize to other public health prevention efforts. TRIAL REGISTRATION: NCT05894655 March 2, 2023.

Factors associated with COVID-19 vaccine uptake in a US/Mexico border community: demographics, previous influenza vaccination, and trusted sources of health information.

Background: COVID-19 vaccine uptake has been uneven, particularly across racial/ethnic and age groups. This study seeks to understand factors associated with COVID-19 vaccine uptake in a large cross-sectional sample of predominantly Latinos/Latinas individuals living near the US/Mexico border. Methods: Data are extracted from a 176-item survey conducted as part of a parent study focused on the co-creation of a COVID-19 testing program for underserved communities developed through a partnership between an academic institution and a Federally Qualified Health Center. The following participant variables were examined: health history, COVID-19 symptoms, COVID-19 testing and vaccine experiences, and perceptions of sources of health information. Participant characteristics were compared using chi-square tests. Multivariate logistic regressions were used for the final statistical model. Results: From 1 May 2021 to 30 April 2022, 4,964 adults, 66% of whom were identified as women, completed the survey. Approximately 80% of participants reported having received at least one COVID-19 vaccine. Female sex, older age, Hispanic/Latino(a) ethnicity, previous influenza vaccination, advanced education, and perceived elevated risk of COVID-19 were significantly (p < 0.05) associated with having received a COVID-19 vaccine. Regarding sources of health information, individuals who indicated they trust their doctor, healthcare provider, or the US government "a great deal" were more likely to have received a COVID-19 vaccine compared to individuals who indicated that they trusted these sources "not at all." In contrast, those who reported having "a great deal" of trust in their faith leader or their social media contacts were significantly less likely to have received a COVID-19 vaccine than those who reported that they trusted these sources "not at all." Conclusion: Sex, education, past influenza vaccination, perceived risk of COVID-19 infection, and trust in specific sources of information were correlated with the uptake of COVID-19 vaccination. Additional research is needed to better understand why this confluence of factors, particularly the unique findings about trusted sources of information, are associated with vaccine uptake. Understanding these associations, specifically within underserved, Latino/Hispanic communities, is an important first step to inform efforts aimed at increasing and sustaining COVID-19 vaccine uptake and adoption of other public health interventions.

Scaling and sustaining COVID-19 vaccination through meaningful community engagement and care coordination for underserved communities: hybrid type 3 effectiveness-implementation sequential multiple assignment randomized trial.

BACKGROUND: COVID-19 inequities are abundant in low-income communities of color. Addressing COVID-19 vaccine hesitancy to promote equitable and sustained vaccination for underserved communities requires a multi-level, scalable, and sustainable approach. It is also essential that efforts acknowledge the broader healthcare needs of these communities including engagement in preventive services. METHODS: This is a hybrid type 3 effectiveness-implementation study that will include a multi-level, longitudinal, mixed-methods data collection approach designed to assess the sustained impact of a co-created multicomponent strategy relying on bidirectional learning, shared decision-making, and expertise by all team members. The study capitalizes on a combination of implementation strategies including mHealth outreach with culturally appropriate messaging, care coordination to increase engagement in high priority preventive services, and the co-design of these strategies using community advisory boards led by Community Weavers. Community Weavers are individuals with lived experience as members of an underserved community serving as cultural brokers between communities, public health systems, and researchers to co-create community-driven, culturally sensitive public health solutions. The study will use an adaptive implementation approach operationalized in a sequential multiple assignment randomized trial design of 300 participants from three sites in a Federally Qualified Health Center in Southern California. This design will allow examining the impact of various implementation strategy components and deliver more intensive support to those who benefit from it most. The primary effectiveness outcomes are COVID-19 vaccine completion, engagement in preventive services, and vaccine confidence. The primary implementation outcomes are reach, adoption, implementation, and maintenance of the multicomponent strategy over a 12-month follow-up period. Mixed-effects logistic regression models will be used to examine program impacts and will be triangulated with qualitative data from participants and implementers. DISCUSSION: This study capitalizes on community engagement, implementation science, health equity and communication, infectious disease, and public health perspectives to co-create a multicomponent strategy to promote the uptake of COVID-19 vaccination and preventive services for underserved communities in San Diego. The study design emphasizes broad engagement of our community and clinic partners leading to culturally sensitive and acceptable strategies to produce lasting and sustainable increases in vaccine equity and preventive services engagement. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05841810 May 3, 2023.

Perceived COVID-19 risk and testing experiences in the San Ysidro U.S./Mexico border region.

Racial and ethnic disparities in COVID-19 incidence are pronounced in underserved U.S./Mexico border communities. Working and living environments in these communities can lead to increased risk of COVID-19 infection and transmission, and this increased risk is exacerbated by lack of access to testing. As part of designing a community and culturally tailored COVID-19 testing program, we surveyed community members in the San Ysidro border region. The purpose of our study was to characterize knowledge, attitudes, and beliefs of prenatal patients, prenatal caregivers, and pediatric caregivers at a Federally Qualified Health Center (FHQC) in the San Ysidro region regarding perceived risk of COVID-19 infection and access to testing. A cross-sectional survey was used to collect information on experiences accessing COVID-19 testing and perceived risk of COVID-19 infection within San Ysidro between December 29, 2020 and April 2, 2021. A total of 179 surveys were analyzed. Most participants identified as female (85%) and as Mexican/Mexican American (75%). Over half (56%) were between the age of 25 and 34 years old. Perceived Risk: 37% reported moderate to high risk of COVID-19 infection, whereas 50% reported their risk low to none. Testing Experience: Approximately 68% reported previously being tested for COVID-19. Among those tested, 97% reported having very easy or easy access to testing. Reasons for not testing included limited appointment availability, cost, not feeling sick, and concern about risk of infection while at a testing facility. This study is an important first step to understand the COVID-19 risk perceptions and testing access among patients and community members living near the U.S./Mexico border in San Ysidro, California.

COVID-19 testing strategies that fail to incorporate culturally competent methods to reach traditionally underserved communities can lead to persistent transmission and increased infection rates. During the early stages of the COVID-19 pandemic, we surveyed 179 people living in a community with high burden of COVID-19 infection about their perception of infection risk and their experiences accessing testing. Capturing and understanding these community perceptions on COVID-19 risk are vital when developing a testing program that is accessible and appropriate for the target population. In our study, we found half of survey respondents thought their risk of COVID-19 infection as low to none and over half of respondents stated they had already been tested for COVID-19. These findings provide insight to the beliefs of individuals who live and seek health care in communities with high rates of COVID-19 infection and will help guide the design and implementation of culturally tailored testing strategies.

Gender-Sexuality Alliance meeting experiences predict weekly variation in hope among LGBTQ+ youth.

Hope is considered a marker of resilience among youth facing oppression, including LGBTQ+ youth. This 8-week weekly diary study among 94 LGBTQ+ youth (ages 14-19; Mage  = 15.91, 46% youth of color, 44% transgender or nonbinary) in 2021 considered whether a youth's meeting-to-meeting experiences in Gender-Sexuality Alliances (GSAs; LGBTQ+ affirming school clubs) predicted subsequent hope from week to week. Youth reported greater hope on days following meetings where they felt more group support, greater advisor responsiveness, and had taken on more leadership responsibilities. Group support and advisor responsiveness were stronger predictors of a youth's hope on days closer to GSA meetings; leadership's effect was stronger when more days had elapsed. Findings suggest how GSAs may cultivate hope among LGBTQ+ youth.

Using ethnographic approaches to document, evaluate, and facilitate virtual community-engaged implementation research.

BACKGROUND: Community Advisory Boards (CABs) have been frequently used to engage diverse partners to inform research projects. Yet, evaluating the quality of engagement has not been routine. We describe a multi-method ethnographic approach documenting and assessing partner engagement in two "virtual" CABs, for which we conducted all meetings remotely. METHODS: Two research projects for increasing equitable COVID-19 testing, vaccination, and clinical trial participation for underserved communities involved remote CAB meetings. Thirty-three partners representing 17 community groups participated in 15 sessions across the two CABs facilitated by a social change organization. We developed ethnographic documentation forms to assess multiple aspects of CAB member engagement (e.g., time spent speaking, modality used, types of interactions). Documenters were trained to observe CAB sub-groups via virtual sessions. Debriefing with the documentation team after CAB meetings supported quality assurance and process refinement. CAB members completed a brief validated survey after each meeting to assess the quality and frequency of engagement. Content and rapid thematic analysis were used to analyze documentation data. Quantitative data were summarized as frequencies and means. Qualitative and quantitative findings were triangulated. RESULTS: A total of 4,540 interactions were identified across 15 meetings. The most frequent interaction was providing information (44%), followed by responding (37-38%). The quality and frequency of stakeholder engagement were rated favorably (average 4.7 of 5). Most CAB members (96%) reported good/excellent engagement. Specific comments included appreciation for the diversity of perspectives represented by the CAB members and suggestions for improved live interpretation. Debriefing sessions led to several methodological refinements for the documentation process and forms. CONCLUSION: We highlight key strategies for documenting and assessing community engagement. Our methods allowed for rich ethnographic data collection that refined our work with community partners. We recommend ongoing trainings, including debriefing sessions and routinely reviewed assessment of data to strengthen meaningful community engagement.

Gender-Sexuality Alliance Advisors' Self-Efficacy to Address Transgender Issues: An Interpersonal Protective Factor for Transgender Student Depression.

Purpose: Our purpose was to assess the association between Gender-Sexuality Alliances (GSAs) advisors' self-efficacy to address transgender issues and their students' depressive symptoms, by students' gender identity (i.e., transgender vs. cisgender). We predict that higher advisor self-efficacy will be associated with decreases in student depressive symptoms for transgender students, though not necessarily for cisgender students. Methods: Data come from surveys of student members (n = 366) and advisors (n = 58) of 38 purposively sampled GSAs in Massachusetts high schools, in 2016-2017 and 2017-2018. We used a linear mixed-effects model to assess the association between advisor self-efficacy to address transgender issues and student change in Center for Epidemiological Studies Depression-10 scores between the beginning and end of the school year by gender identity, adjusting for student covariates. Results: Students were 10-20 years old (mean = 15, standard deviation [SD] = 1.4); 28% were transgender, 28% were students of color, and 86% were lesbian, gay, bisexual, or queer/questioning or other non-heterosexual identity. The GSA advisor self-efficacy scores ranged from 13 to 25 with a mean of 20.4 (SD = 3.0). Greater advisor self-efficacy to address transgender issues was associated with a decrease in depressive symptoms for transgender students (estimate = -0.47, p = 0.01), but not for cisgender students. Conclusions: GSA advisor self-efficacy to address transgender issues could be protective for transgender student depressive symptoms. Thus, increasing advisor self-efficacy to address transgender issues may help decrease depressive symptomatology for transgender youth, and intervention work in this area is needed to bolster this claim.

Wearable fitness tracker use in federally qualified health center patients: strategies to improve the health of all of us using digital health devices.

As the use of connected devices rises, an understanding of how digital health technologies can be used for equitable healthcare across diverse communities is needed. We surveyed 1007 adult patients at six Federally Qualified Health Centers regarding wearable fitness trackers. Findings indicate the majority interest in having fitness trackers. Barriers included cost and lack of information, revealing that broad digital health device adoption requires education, investment, and high-touch methods.

Co-creating a Theory of Change to advance COVID-19 testing and vaccine uptake in underserved communities.

OBJECTIVES: To describe the use of a Theory of Change to meaningfully engage community members from or support underserved communities in two National Institutes of Health-funded implementation science projects aimed at promoting equitable access to COVID-19 testing and vaccination for underserved communities. STUDY SETTING: Both projects focused on Latino, Black, and immigrant and refugee communities in South/Central San Diego and/or individuals accessing care at a federally qualified health center near the US/Mexico border during December 2020-April 2021. STUDY DESIGN: By using a participatory action research design, Community Advisory Boards (CABs) were established for each project with 11 and 22 members. CAB members included community organizers, promotores de salud (community health workers), clinic providers and administrators, and public health researchers. The CABs were guided through a seven-session Theory of Change process, focused on identifying necessary conditions that must exist to eliminate COVID-19 disparities along with specified actions to create those conditions and a blueprint for assessing the impact of those actions. DATA COLLECTION: Each session lasted 2 h hosted virtually and was augmented by interactive web-based activities. There was a live interpreter who facilitated the participation of Spanish-speaking CAB members. A Theory of Change for each project was completed in approximately 4 months. PRINCIPAL FINDINGS: Nine necessary conditions were identified related to (1) accessible and available services; (2) culturally and linguistically competent programming; (3) investment in trusted community and faith leaders; (4) social safety nets to provide ancillary services. Corresponding actions to create these conditions and measures to indicate success in creating these conditions were operationalized by the CAB. CONCLUSIONS: While resource-intensive, a CAB-led Theory of Change process yielded a rich opportunity to engage diverse groups that typically are not invited to inform these processes.

Sexuality and HIV Education in Charter Schools: An Exploratory Study With Principals in San Diego County, California.

BACKGROUND: Schools can address critical sexual and reproductive health (SRH) issues among youth. However, little is known about SRH education being implemented in charter schools. Thus, our purpose was to explore implementation of SRH education in charter schools. METHODS: Using purposive sampling, semistructured telephone interviews were conducted with 20 charter school principals in San Diego County, California. Questions were guided by the Kaiser Family Foundation National Survey of Public Secondary School Principals. Analyses followed a case-oriented approach, examining aspects within each case (ie, a principal), and then a comparative analysis of a small number of cases (ie, all principals). RESULTS: Overall, 17 principals acknowledged offering sexuality education in the previous 2 years. Over half of these schools had provided content on: sexually transmitted diseases/human immunodeficiency virus/acquired immune deficiency syndrome (STDs/HIV/AIDS), reproduction/pregnancy/birth, pregnancy prevention methods, delaying sex, and managing sexual pressure. Condom use, sexual assault, sexual orientation, talking with partners about STD/pregnancy prevention, talking with parents about relationships/sex, and using/where to get contraception were less commonly taught. Abortion was not addressed. When asked the grade they would assign to their schools' sexuality/HIV instruction, principals assigned 1 A, 7 Bs, 7 Cs, and 1 D. CONCLUSIONS: Consistency between our findings and what has been reported elsewhere varies. As charter schools often have greater curricular flexibility than traditional schools, this study provides unique preliminary data to inform future innovative, or strengthen existing, SRH programming.