Using peer-ethnography to explore the health and well-being of college students affected by COVID-19.

PURPOSE: COVID-19 continues to infect and affect college-aged youth. We lack information about how students experienced the pandemic day-to-day and what they need for recovery, from their own perspectives. This study employed peer ethnography to explore student's insights for current and future prevention and care. METHODS: A team of eight students were trained as peer ethnographers to observe and record conversations with their peers in 15-minute increments during the COVID-19 pandemic. Transcripts of 200 conversations were collated and analysed via theme analysis to identify patterns. RESULTS: Student conversations revealed dichotomous perspectives about COVID-19. Some students prioritized safety, captured via three themes-caution, rethinking routines, and protecting others. Other students struggled to follow prevention guidelines and took risks, also captured by three themes-parties, denial, and misinformation. A third category of themes captured the results of this dichotomy-tense campus relationships and a health leadership vacuum. CONCLUSIONS: Our findings identify specific locations for intervention (e.g., off campus parties) and needed community collaborations (e.g., bars and universities) for COVID-19 and future pandemics. Our findings suggest that overarching approaches, like harm reduction or affirmation (versus shame), are helpful intervention frameworks. Findings also celebrate the value of peer-ethnography, to learn about pandemics and solutions from the ground up.

How Midwestern College students protected their families in the first year of COVID-19.

Introduction: College students routinely visit their families due to geographic proximity and their financial dependence. Consequently, the potential of transmitting COVID-19 from campus to their families' homes is consequential. Family members are key sources of support for one another in nearly all matters but there is little research uncovering the mechanisms by which families have protected each other in the pandemic. Methods: Through an exploratory qualitative study, we examined the perspectives of a diverse, randomly sampled, group of students from a Midwestern University (pseudonym), in a college town, to identify COVID-19 prevention practices with their family members. We interviewed 33 students between the end of December 2020 and mid-April 2021 and conducted a thematic analysis through an iterative process. Results: Students navigated major differences in opinions and undertook significant actions in attempts to protect their family members from COVID-19 exposure. Students' actions were rooted in the greater good of public health; prosocial behavior was on display. Discussion: Larger public health initiatives could target the broader population by involving students as messengers.

"Each Day We Lose a Little More": Visual Depictions of Family Caregiving for Persons with Dementia.

More than 11 million Americans provide unpaid care for people with dementia (PWD) and need emotional, financial, and physical support. This study explored how participants in Caregiver Speaks, a social networking and image-based storytelling intervention designed to help caregivers make meaning of caregiving, described their caregiving experiences and needs. Strategies of thematic analysis were used to identify patterns in 28 different caregivers' images (N = 59) and text interactions on social media. Caregivers identified as white (71.4%), as women (92.9%), and as an adult child or child-in-law of the PWD (85.7%). Through images and text, caregivers explained interrelated changes in their behaviors (e.g., managing dual roles), thoughts (e.g., realizing severity of illness), and feelings (e.g., trapped) throughout the caregiving process. Findings reiterate that caregiving changes significantly over time, that visual storytelling helps to concretely capture those changes, and that interventions are needed to respond to caregivers' hardships across the caregiving time span.

Similarities in COVID-19 Mortality Between Canadian Provinces and American States Before Vaccines Were Available.

Canada and the USA are often compared for their markedly different approaches to health care despite cultural similarities and sharing the world's longest international boundary. The period between the onset of the COVID-19 pandemic in January 2020 and the availability of a vaccine in December 2020 offers an ideal opportunity to compare subnational Canadian and American pandemic mortality. Preventing the spread of COVID-19 was through compliance with health orders and best practices; treatment was only available to those admitted to hospitals and whose lives were at risk. Using publicly available data from the Johns Hopkins University 2019 Novel Coronavirus Visual Dashboard, we seek to uncover if there were any similarities in Canadian provinces' and American states' monthly COVID-19 mortality per 100,000 people, building on a broader scientific push towards understanding the successes and failures of different health systems in the pandemic. The similar province and state cumulative COVID-19 mortality rate trajectories identified in our analyses do not amount to intuitive comparative jurisdictions which suggests the importance of identifying localized pandemic responses.

En dépit de leur proximité culturelle et de leur frontière commune, la plus longue au monde, les États-Unis et le Canada font souvent l'objet de comparaisons quant à leurs approches très différentes en matière de soins de santé. La période comprise entre le début de la pandémie de COVID-19 en janvier 2020 et la disponibilité d'un vaccin en décembre de la même année nous offre une occasion idéale de comparer la mortalité pandémique à l'échelle infranationale dans les deux pays. Au cours de cette période, la lutte contre la propagation de la COVID-19 s'est articulée autour du respect des ordonnances de santé et des pratiques exemplaires, les traitements n'étant réservés qu'aux personnes admises dans les hôpitaux dans un état critique. En utilisant les données du tableau de bord de la COVID-19 proposé par l'université John Hopkins, et en nous fondant sur une tendance scientifique plus large visant à comprendre les réussites et les échecs des différents systèmes de santé au cours de la pandémie, nous avons tenté de déceler des similitudes entre les provinces canadiennes et les états américains relativement au nombre de décès mensuel de la COVID-19 pour 100 000 habitants. Les trajectoires similaires des taux de mortalité cumulés liés à la COVID-19 dans les provinces et les états, observées dans nos analyses, ne constituent en aucun cas une comparaison intuitive entre les deux pays, ce qui souligne l'importance d'identifier les réponses locales à la pandémie.

Sharing Lived Experiences of HIV Stigmatization: Process of Disseminating a Traveling Photovoice Exhibit.

A Memphis-based, community-academic partnership created Snap Out Stigma, a photovoice project, to understand lived experiences of HIV stigma among people with HIV. This report describes traveling photovoice exhibit dissemination strategies, lessons learned, and goals for the future of photovoice dissemination activities and community engagement in Memphis.

Engaging Black men who have sex with men (MSM) in the South in identifying strategies to increase PrEP uptake.

BACKGROUND: Promotion, uptake, and adherence of pre-exposure prophylaxis (PrEP) is paramount to ending the HIV epidemic among young Black men who have sex with men in the South. The purpose of this study was to explore strategies needed for and barriers to PrEP uptake needed to achieve HIV prevention goals identified in the U.S. Department of Health & Human Services initiative to reduce new HIV infections in the United States by 90 percent by 2030. METHOD: Young adults (n = 25) between the ages of 15-34 were recruited from community-based organizations in Memphis to participate in four focus group discussions. Discussion topics included motivations, barriers, and facilitators to PrEP use. Data were analyzed using thematic analysis. RESULTS: All (100%) of participants self-identified as HIV-negative, Black (96%), men who have sex with men (96%), and currently prescribed PrEP/Truvada (60%). Themes identified for increasing uptake included 1) trusted peers, 2) relatable healthcare provider (e.g., Historically Black College and University (HBCU) trained, LGBTQ), and 3) use of social media. Mislabeling of PrEP as promiscuity promoting and limitations with PrEP marketing (e.g., solely LGBTQ) were recognized as barriers that perpetuated stigma. CONCLUSION: Findings suggest the importance of increasing awareness among health professions students matriculating at HBCUs of their perceived role as relatable healthcare providers by Black MSM; working closely with couples; and crafting of PrEP messaging that is non-stigmatizing. Findings will inform public health interventions for young Black MSM and facilitate HIV prevention efforts with other groups disproportionally affected by HIV in the South.

"COVID Is Another Layer of Problematic Things": Change, Vulnerability, and COVID-19 among University Students.

The COVID-19 pandemic not only had detrimental effects on physical health but also had adverse effects on college students' mental health. This paper begins to fill a gap in knowledge related to the contextual factors that impacted college students' mental health during COVID. Using in-depth interviews with a diverse sample of 33 college students at a Midwestern university, during Spring 2021, we highlight the pandemic's role in shaping college students' mental health and their outlook of the future. Thematic analysis revealed student reports of mental health decline during the pandemic attributed to campus closures and social distancing policies implemented by the institution to reduce the spread of COVID-19. Students shared that the pandemic created uncertainties about their future opportunities for education, career fulfillment, and employment. However, the interviews also suggested a general sense of adaptation to the pandemic's impact which was students achieved via a combination of active and passive coping strategies. Expanding institution-based mental health services to include a variety of modalities and off-line toolkits for students can help students cope with mental health challenges, whether in 'normal times' or during national crises. Future research should focus on identifying strategies for promoting mental wellness among college students and exploring post-pandemic mental health wellbeing.

Undergraduate Vaccine Hesitancy and the Influence of "Home" Locales.

PURPOSE: In the US, the COVID-19 pandemic has exposed deeply rooted resistance to public health. This has important consequences for SARS-CoV-2 variant spread and for future uptake of influenza and other vaccines. We examine these phenomena in Missouri, where its low vaccination rates, high levels of uninsured residents, predominance of conservative values, and stark rural-urban divides are intricately connected to public health resistance. The Socio-Ecological model guides our approach. METHODS: We use data from the Fall 2020 Midwestern University (MWU-a pseudonym) Study of Seropositivity and Risk for SARS-CoV-2 and COVID-19 which are harmonized with the American Community Survey, Missouri County-Level Study, and the USDA Rural-Urban Continuum Codes to estimate multi-level regression models on the relationship between undergraduate students' "home" locales and their own COVID-19 and influenza vaccine hesitancy. FINDINGS: The availability of primary care physicians, the prevalence of influenza vaccinations, and location type at the county level, as well as the percentage of residents without health insurance at the zip code level differentially predict COVID-19 and influenza vaccine hesitancy. CONCLUSIONS: There is a link between county-level health and geographic characteristics, and individuals'-who were influenced by those counties because that is where their parents live-hesitancy towards vaccines. Identifying feasible, precise, local solutions to reducing vaccine hesitancy could take place if community members and other stakeholders would be open to changes in local-level health policy or practice.

Snap out stigma photovoice project in the U.S. South.

BACKGROUND: The purpose of SNAP Out Stigma (SOS) was to design and implement a community-based intervention to reduce HIV-related stigma for people living with HIV (PLWH) in the Deep South. This region is a subset of 9 states including Memphis, Tennessee (project site) driving the epidemic in the United States. The purpose of this paper is to explain how PLWH in the U.S. South used Photovoice to communicate stigmatizing lived experiences and contextualize their intersection with multi-level sources of support. METHODS: PLWH attended one-on-one and/or group sessions with other PLWH. In Session 1, PLWH received a project overview, met other participants, received a camera and camera training, completed a standardized internalized stigma scale, discussed experiences of internalized stigma, and were instructed to take 3-10 pictures that captured stigma. In Session 2, PLWH discussed the pictures and their meaning. In Session 3, PLWH expanded on what they shared in previous sessions in a one-on-one interview. Thematic analysis captured key patterns of how PLWH experienced stigma. RESULTS: Forty-seven PLWH attended Session 1 and were issued a camera. Of those, 35 completed sessions 2 and 3. Participants self-identified as cis man who has sex with men (n = 18), ciswoman (n = 5), transwoman (n = 10), and non-binary (n = 2). Four emergent themes intersecting with internalizations of stigma were identified including: medical, social support, church, and self. CONCLUSIONS: The SOS intervention created a safe space for PLWH to share lived experiences of stigmatization. Photovoice facilitated discussion topics ranging from healing and recovery to overcoming factors of social determinants of HIV. We identified trauma-informed growth as an area of future programs for PLWH.

Comprehensive Process Mapping and Qualitative Interviews to Inform Implementation of Rapid Linkage to HIV Care Programs in a Mid-Sized Urban Setting in the Southern United States.

BACKGROUND: Rapid antiretroviral therapy (ART) initiation, in which people living with HIV start ART within days of diagnosis, is a key component of the US Ending the HIV Epidemic initiative. SETTING: The Memphis Metropolitan Statistical Area ranked fourth in the United States for the highest HIV incidence per 100,000 population in 2018. Rapid ART programs are limited in the Memphis Metropolitan Statistical Area, and our objective was to identify local implementation barriers. METHODS: We conducted participatory process mapping and in-depth interviews to detail steps between HIV testing at the municipal health department's Sexually Transmitted Infections Clinic and ART prescription from a nearby high-volume Ryan White-funded HIV Clinic. RESULTS: Process mapping identified 4 modifiable, rate-limiting rapid ART barriers: (1) requiring laboratory-based confirmatory HIV results, (2) eligibility documentation requirements for Ryan White-funded services, (3) insufficient HIV Clinic medical provider availability, and (4) variability in ART initiation timing among HIV Clinic providers. Staff at both sites highlighted suboptimal communication and sense of shared management between facilities, limited resources to address important social determinants of health, and lack of Medicaid expansion in Tennessee as key barriers. In-depth interview themes negatively affecting rapid ART initiation included clinic burden; provider knowledge, attitudes, and beliefs; and client psychosocial needs. CONCLUSIONS: Our preimplementation work identified modifiable and systemic barriers to systems flow and patient-level outcomes. This work will inform the design and implementation of a locally relevant rapid ART program in Memphis, a community disproportionately affected by the HIV epidemic.

Barriers and Facilitators to HIV Pre-Exposure Prophylaxis Uptake, Adherence, and Persistence Among Transgender Populations in the United States: A Systematic Review.

HIV pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV; however, PrEP use among transgender individuals remains low. We conducted a systematic review to identify barriers and facilitators to PrEP uptake, adherence, and persistence among transgender individuals in the United States. We conducted a literature search in PubMed and CINAHL databases in March 2021 and followed PRISMA guidelines. Studies were eligible if they were published in a peer-reviewed journal and reported interest, uptake, adherence, and/or persistence of PrEP use among transgender individuals. Articles that did not disaggregate results for transgender participants were excluded. Data from included articles were coded using content analysis and narratively synthesized using a framework matrix. We screened 254 unique articles published after US Food and Drug Administration approval of PrEP, and 33 articles were included in the review. Five themes were identified in the literature, including (1) PrEP concentrations were lower among individuals taking feminizing hormones, but the difference did not appear clinically significant; (2) concerns regarding interactions between gender-affirming hormone therapy and PrEP remain a large barrier; (3) PrEP initiation may facilitate increased self-advocacy and self-acceptance; (4) lack of trust in medical institutions impacts PrEP uptake; and (5) social networks have a significant influence on PrEP knowledge, interest, and adherence. Additional research is needed involving transgender men and nonbinary persons, and efforts to improve PrEP persistence among the transgender community are needed. Training health care providers to provide inclusive and affirming care is perhaps one of the strongest areas for intervention to increase PrEP uptake and persistence.

Image to Action: Past Success, Ongoing Questions, and New Horizons for Photovoice Exhibits.

When participants define and share their lives through photovoice, they can potentially become empowered as experts in their health needs. Images from photovoice exhibits confront gaps between what researchers and policy makers assume people need and what people show that they need. The exhibit is bridge to action across the socioecological spectrum and a way that photovoice studies have helped affect change at individual, interpersonal, community, institutional, and policy levels. However, for this nontraditional modality of research to be most effective in achieving its goals, substantial buy-in from participants, researchers, and policy makers is necessary. Despite the great potential of photovoice exhibits, difficulties in translating findings to social action, ethical quandaries related to participant privacy and representation, and not knowing the overall impact of exhibits on viewers can severely inhibit success. Consequently, we recommend four areas to consider for the future of exhibits: (1) understanding and measuring empowerment and change that happens for participants via photovoice exhibits, (2) considering innovative and new forms of exhibits and sharing information with the public, (3) documenting exhibit processes to produce lessons learned and guides for others, and (4) exploring the ethics and impact of exhibits on photovoice audiences.

Sustaining an HIV Prevention and Wellness Program for Sexual Gender Minorities during the COVID-19 Pandemic.

Improving mental health, body image, and financial stability is paramount to achieving viral suppression and maintaining HIV-negative status for minoritized communities. The purpose of this paper is to describe the lessons learned from maintenance of an HIV prevention and wellness program during the COVID-19 pandemic. A three-session program was implemented in a hybrid format to account for county-wide restrictions and reopening processes. Lessons learned include the utility of a hybrid format, importance of CBPR partnership, innovation in virtual platform, value of social media presence and upkeep, and use of multiple methods to ascertain evaluative data. Sustaining an HIV prevention and wellness program requires strong research collaborations and ongoing engagement with priority populations and the flexibility to pivot as needed.

"When Her Visa Expired, the Family Refused to Renew It," Intersections of Human Trafficking and Domestic Violence: Qualitative Document Analysis of Case Examples from a Major Midwest City.

This study aimed to further understand typologies of trafficking that occur in the home, by an individual's intimate partner (IP) or family members and this overlap with extant knowledge on perpetrator manipulation via the Power and Control Wheel. Inductive and deductive techniques were used to analyze secondary data from a federally funded anti-trafficking program in a Midwest metropolitan area recorded between 2008 and 2017. Cases were included if there was indication of sex or labor exploitation initiated by an IP, family member, or other in the domestic setting via elements of abuse; 59 cases of 213 met this criteria. Most cases included the IP as the trafficker, followed by family members, then others in the domestic setting. Abuse was more commonly used than the threat of abuse. From the Power and Control Wheel, the most frequent types of abuse were using privilege, physical abuse, economic abuse, isolation, and sexual abuse. Case typologies included: those with elements of sex trafficking, specifically forced commercial sex by an IP or family member; those with elements of labor trafficking such as domestic servitude (with or without childcare provision abuse), exploitation in a family business by an IP or family member, or work environments by family and non-family; those with elements of sex and labor trafficking included servile partnerships and forced marriage. Trafficking exploitation by an IP, family member, or in the domestic setting is not uncommon. Intimate relationships with a trafficker, psychological coercion, and threats may reduce reporting of abuse, subsequent provision of services, and result in misclassification as victims of IP violence. This study sheds light on various typologies of trafficking and exploitation in the domestic setting, further expanding the anti-trafficking movement's evidence base for intervention and prevention and adding complexity and nuance to the pathways to trafficking exploitation.

'PrEP'ing Memphis: A qualitative process evaluation of peer navigation support.

BACKGROUND: HIV PrEP (pre-exposure prophylaxis) navigation comprises intervention strategies used to improve PrEP uptake via education, linkage, and follow-up/ongoing engagement. During 2016-2019, the Tennessee Department of Health (TDH) implemented a CDC-funded demonstration project ("Project PrIDE") focused on PrEP navigation in Memphis community-based organizations (CBOs) and the Shelby County Health Department (HD). A process evaluation was conducted to determine facilitators and barriers to the implementation of the Memphis-based Project PrIDE PrEP navigation activities. METHODS: A total of fourteen in-depth qualitative interviews were conducted, with nine PrEP navigators in evaluation year 1 (2018) and five of the original navigators in evaluation year 2 (2019), to understand the navigation processes using thematic analysis. RESULTS: Facilitators of PrEP navigation included accessing clients at testing events, accompanying clients to first appointments, rapport building with patient and clinic staff, and maintaining consistent engagement with clients. Factors impeding PrEP navigation included difficulties assessing client readiness, tracking client navigation status, and stigmatizing clinic and social experiences for clients. CONCLUSIONS AND LESSONS LEARNED: Findings have informed the scale-up of PrEP navigation implementation statewide, along with priority setting and resource allocation for the local Ending the HIV Epidemic (EHE) initiative in Memphis.

Strengths despite stress: Social-structural stressors and psychosocial buffers of depressive symptoms among U.S. Black men.

We examined the association between social-structural stressors-racial discrimination, incarceration, and unemployment-and depressive symptoms among 578 predominantly low-income urban Black men, ages 18-45. We also examined the extent to which two protective factors-social support and problem-solving coping-moderated the relationship between social-structural stressors and depressive symptoms. Results showed that more everyday racial discrimination and incarceration, but not unemployment, significantly predicted more depressive symptoms. The links between discrimination, incarceration, and depressive symptoms were stronger for men who reported lower levels of problem-solving coping and social support than those with higher levels. Our study suggests that interventions emphasizing protective factors may help Black men cope with some of the deleterious effects of racial discrimination and incarceration. It also underscores a need for structural interventions that reduce racial discrimination and incarceration. Depression among Black men is not simply a biomedical or psychological condition, but also a critical health equity issue. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A Photovoice Exploration of the Lived Experience of Intersectional Stigma among People Living with HIV.

Stigma research among people living with HIV (PLWH) has been increasingly interpreted through the framework of intersectionality, which comprehends the interwovenness of vulnerable individuals' identities. However, community-based participatory methods have not been widely employed to better understand these forms of stigma through an intersectional lens, despite such methods offering the opportunity for participants to define issues and solutions from their lived experiences. To advance this research, we employed photovoice to elicit grounded, visceral definitions of stigma for PLWH. Participants took pictures representing their identities and experiences with HIV and other stigmas and discussed them in groups and individual interviews, ultimately creating a virtual exhibit to educate and inspire others. Theme and narrative analysis uncovered patterns in the visual and textual data, revealing participants' experiences of HIV stigma based on their intersections of sexuality, race/ethnicity, illness, and roles and expectations in specific scenarios. Stigma also fostered the development of participants' strengths, such as resiliency, and new identities, such as educators. Participatory methods like photovoice, where participants can define intersectionality on their own terms, can help direct interventions to limit the PLWH's lived stigmas and increase effective coping.

Listening to Transgender Patients and Their Providers in Non-Metropolitan Spaces: Needs, Gaps, and Patient-Provider Discrepancies.

Trans and gender non-conforming (TGNC) patients need better care; providers need TGNC focused medical trainings. TGNC health conferences can help, yet these events occur mostly in urban centers. Meanwhile, patients in non-metropolitan areas often face significant discrimination and notably poor access to TGNC care. This study explores the ongoing needs of TGNC patients and their providers following a one-day TGNC health conference in a small town in the American Midwest. Exploratory semi-structured interviews were used to gather in-depth information from TGNC conference attendees (N = 25). Theme analysis methods were used to identify areas of need for future trainings. Providers reported that they needed more exposure to TGNC patients, judgement-free opportunities to learn the basics about TGNC care, and ongoing trainings integrated into their medical school and ongoing education credits. Patients needed better access to care, more informed providers, and safer clinics. They cited lack of specialty care (e.g., mental health, surgery) as particularly problematic in a non-metropolitan setting. TGNC patients, and their providers in non-metropolitan areas, urgently need support. Patients lack specialized care and often possess greater knowledge than their health care teams; providers, in these areas, lack opportunities to work with patients and stay up to date on treatments.

Digital storytelling: Narrating meaning in bereavement.

Individuals who cannot make sense of a significant death are more likely to experience bereavement complications than those who are able to reconcile their loss with existing or newly-developed ways of understanding the world. Digital Storytelling, a multi-media narrative technique, has been identified as a potential facilitator of meaning-making processes. In this secondary qualitative analysis, researchers described the meaning-making processes evident in bereaved individuals' (N = 14) personally-created digital stories, identifying sense making, benefit finding, continuing bonds, shifting identity, and addressing unfinished business. Findings support prior research and enrich emerging understandings of arts-based interventions as tools to facilitate and communicate meaning-making processes.