Clinicians' perspectives on race-specific guidelines for hypertensive treatment.

Despite the general consensus that there is no biological basis to race, racial categorization is still used by clinicians to guide diagnosis and treatment plans for certain diseases. In medicine, race is commonly used as a rough proxy for unmeasured social, environmental, and genetic factors. The American College of Cardiology's Eighth Joint National Committee's (JNC 8) guidelines for the treatment of hypertension provide race-specific medication recommendations for Black versus non-Black patients, without strong evidence for race-specific physiological differences in drug response. Clinicians practicing family or geriatric medicine (n = 21) were shown a video of a mock hypertensive patient with genetic ancestry test results that could be viewed as discordant with their phenotype and self-identified race. After viewing the videos, we conducted in-depth interviews to examine how clinicians value and prioritize different cues about race -- namely genetic ancestry data, phenotypic appearance, and self-identified racial classifications - when making treatment decisions in the context of race-specific guidelines, particularly in situations when patients claim mixed-race or complex racial identities. Results indicate that clinicians inconsistently follow the race-specific guidelines for patients whose genetic ancestry test results do not match neatly with their self-identified race or phenotypic features. However, many clinicians also emphasized the importance of clinical experience, side effects, and other factors in their decision making. Clinicians' definitions of race, categorization of the patient's race, and prioritization of racial cues greatly varied. The existence of the race-specific guidelines clearly influences treatment decisions, even as clinicians' express uncertainty about how to incorporate consideration of a patient's genetic ancestry. In light of widespread debate about removal of race from medical diagnostics, researchers should revisit the clinical justification for maintaining these race-specific guidelines. Based on our findings and prior studies indicating a lack of convincing evidence for biological differences by race in medication response, we suggest removing race from the JNC 8 guidelines to avoid risk of perpetuating or exacerbating health disparities in hypertension.

Investing in Retail Food Safety: Assessing the NEHA-FDA Retail Flexible Funding Model Grant Program's Distribution Through an SDOH Lens.

Social Determinants of Health (SDOH) have a major impact on community health and quality of life. Healthy People 2030 has an increased focus on SDOH, given their contribution to health disparities and inequalities as a social phenomenon. Despite advances in food hygiene and sanitation, structural disparities related to SDOH leave food systems vulnerable. The Voluntary National Retail Food Regulatory Program Standards (VNRFRPS), otherwise known as the Retail Program Standards initiative is part of the Food and Drug Administration (FDA)'s strategy for prevention-based food safety to reduce foodborne illness. The National Environmental Health Association (NEHA) and the U.S. Food and Drug Administration (FDA) work in partnership to administer the NEHA-FDA Retail Flexible Funding Model (RFFM) Grant Program. The program provides funding to State, Local, Tribal, and Territorial (SLTT) retail food regulatory agencies as they achieve and advance conformance with the VNRFRPS. In its first year (Calendar Year 2022) of the 3-year cycle, the grant program awarded $6.87M in funding to over 200 jurisdictions nationwide. The research note shares preliminary findings of utilizing Geographic Information Systems (GIS) to map the first-year SLTT grant program awardees, with a selection of their jurisdiction's Social Determinants of Health (SDOH) metrics. Integration and analysis of program-specific grant funding and mapping with the relevant health determinants provide an opportunity to understand further the need for comprehensive program investments for greater impact and improvements in public health.

Barriers and facilitators to COVID-19 testing among staff and parents from San Diego schools.

COVID-19 testing is an important risk mitigation strategy for COVID-19 prevention in school settings, where the virus continues to pose a public health challenge for in-person learning. Socially vulnerable school communities with the highest proportion of low-income, minority, and non-English speaking families have the least testing access despite shouldering a disproportionate burden of COVID-19 morbidity and mortality. Through the Safer at School Early Alert (SASEA) program, we investigated community perceptions of testing in San Diego County schools, with a focus on barriers and facilitators from the perspective of socially vulnerable parents and school staff. Using a mixed-methods approach, we administered a community survey and conducted focus group discussions (FGDs) with staff and parents from SASEA-affiliated schools and childcares. We recruited 299 survey respondents and 42 FGD participants. Protecting one's family (96.6%) and protecting one's community (96.6%) were marked as key motivators to testing uptake. School staff in particular reported that the reassurance of a negative status mitigated concerns about COVID-19 infection in schools. Participants expressed that COVID-19-related stigma, loss of income as a result of isolation/quarantine requirements, and lack of multilingual materials were the most significant barriers to testing. Our findings suggest that the testing barriers faced by school community members are predominantly structural. Testing uptake efforts must provide support and resources to manage the social and financial consequences of testing while continuously communicating its benefits. There is a clear need to continue to incorporate testing as a strategy to maintain school safety and facilitate access for vulnerable community members.

Overcrowded housing reduces COVID-19 mitigation measures and lowers emotional health among San Diego refugees from September to November of 2020.

Refugee communities are vulnerable to housing insecurity, which drives numerous health disparity outcomes in a historically marginalized population. The COVID-19 pandemic has only worsened the ongoing affordable housing crisis in the United States while continuing to highlight disparities in health outcomes across populations. We conducted interviewer-administered surveys with refugee and asylum seekers in San Diego County at the height of the COVID-19 pandemic to understand the social effects and drivers of COVID-19 in one of the largest refugee communities in the United States. Staff from a community-based refugee advocacy and research organization administered the surveys from September-November 2020. 544 respondents participated in the survey, which captured the diversity of the San Diego refugee community including East African (38%), Middle Eastern (35%), Afghan (17%), and Southeast Asian (11%) participants. Nearly two-thirds of respondents (65%) reported living in overcrowded conditions (> 1 individual per room) and 30% in severely crowded conditions (> 1.5 individuals per room). For each additional person per room, self-reported poor emotional health increased. Conversely, family size was associated with a lower likelihood of reporting poor emotional health. Crowded housing was significantly associated with a lower probability of accessing a COVID-19 diagnostic test, with every additional reported person per room there was approximately an 11% increase in the probability of having never accessed a COVID-19 testing. Access to affordable housing had the largest effect size and was associated with fewer people per room. Overcrowding housing is a structural burden that reduces COVID-19 risk mitigation behaviors. Improved access to affordable housing units or receiving vouchers could reduce overcrowded housing in vulnerable refugee communities.

"A lotta people switched playing hard ball to playing Russian roulette": Experiences with rising overdose incidence caused by drug supply changes during the COVID-19 pandemic in the San Diego-Tijuana border metroplex.

Background: People who use drugs (PWUD) in the San Diego, USA and Tijuana, Mexico metroplex face high overdose risk related to historic methamphetamine use and relatively recent fentanyl introduction into local drug supplies. The personal overdose experiences of PWUD in this region are understudied, however, and may have been influenced by the COVID pandemic. Methods: From September-November 2021, we conducted 28 qualitative interviews among PWUD ≥18 years old sampled from an ongoing cohort study in the San Diego-Tijuana metroplex. Interviews explored overdose experiences and changes in the drug supply. Thematic analysis of coded interview transcripts explored overdose experiences, perspectives on drug supply changes, interactions with harm reduction services, and naloxone access. Results: Among 28 participants, 13 had experienced an overdose. Participants discussed rising levels of fentanyl in local drug supplies and increasing overdose incidents in their social networks. Participants discussed a general shift from injecting heroin to smoking fentanyl in their networks. Participants' most common concerns included having consistent access to a safe and potent drug supply and naloxone. Conclusion: Participants prioritized adapting to drug supply changes and preventing overdose compared to other health concerns, such as HIV and COVID-19. Efforts to address overdose in this region could benefit from drug checking services and expanded, equitable delivery of naloxone.

COVID-19 disproportionately impacts access to basic needs among households with disabled members.

BACKGROUND: The COVID-19 pandemic has disproportionately impacted disabled people, especially those who are members of marginalized communities that were already denied access to the resources and opportunities necessary to ensure health equity before the pandemic. OBJECTIVE: Compare COVID-19 impact on basic needs access among households with and without disabled adults. METHODS: An online survey was distributed to households with children enrolled in one of 30 socially vulnerable elementary or middle schools in San Diego County, California. We measured disability using the single-item Global Activities Limitations Indicator. We measured pandemic impacts on basic needs access using the RADx-UP common data elements toolkit. We then assessed number of impact items reported by household disability using multivariable linear regression, adjusting for household income, household size, education, parent gender, and child's ethnicity. RESULTS: Of 304 participants, 41% had at least one disabled household member. Participants reporting a disabled household member were more likely to report challenges accessing basic needs, such as food, housing, healthcare, transportation, medication, and stable income during the pandemic (all p < 0.05). Difficulty accessing basic needs was significantly associated with household income and parent gender in the final regression model. CONCLUSIONS: Households with a disabled member were significantly more likely to experience difficulty accessing basic needs during the COVID-19 pandemic. This has important implications for the disproportionate impact of COVID-19 on disabled people, especially those from low-income communities that already face barriers to accessing resources. To improve COVID-19 outcomes for disabled people, we must focus on meeting their basic needs.

"We're already doing this work": ethical research with community-based organizations.

BACKGROUND: Public health research frequently relies on collaborations with community-based organizations, and these partnerships can be essential to the success of a project. However, while public health ethics and oversight policies have historically focused on ensuring that individual subjects are protected from unethical or unfair practices, there are few guidelines to protect the organizations which facilitate relationships with - and are frequently composed of - these same vulnerable populations. As universities, governments, and donors place a renewed emphasis on the need for community engaged research to address systematic drivers of health inequity, it is vital that the ways in which research is conducted does not uphold the same intersecting systems of gender, race, and class oppression which led to the very same health inequities of interest. METHODS: To understand how traditional notions of public health research ethics might be expanded to encompass partnerships with organizations as well as individuals, we conducted qualitative interviews with 39 staff members (executive directors and frontline) at community-based organizations that primarily serve people who use drugs, Black men who have sex with men, and sex workers across the United States from January 2016 - August 2017. We also conducted 11 in-depth interviews with professional academic researchers with experience partnering with CBOs that serve similar populations. Transcripts were analyzed thematically using emergent codes and a priori codes derived from the Belmont Report. RESULTS: The concepts of respect, beneficence, and justice are a starting point for collaboration with CBOs, but participants deepened them beyond traditional regulatory concepts to consider the ethics of relationships, care, and solidarity. These concepts could and should apply to the treatment of organizations that participate in research just as they apply to individual human subjects, although their implementation will differ when applied to CBOs vs individual human subjects. CONCLUSIONS: Academic-CBO partnerships are likely to be more successful for both academics and CBOs if academic researchers work to center individual-level relationship building that is mutually respectful and grounded in cultural humility. More support from academic institutions and ethical oversight entities can enable more ethically grounded relationships between academic researchers, academic institutions, and community based organizations.

COVID-19 vaccination acceptability and experiences among people who inject drugs in San Diego County.

Background: People who inject drugs (PWID) face increased risk of SARS-CoV-2 acquisition and severe disease, yet COVID-19 vaccine uptake has been suboptimal. To inform vaccination interventions tailored for the needs of this population, we explored COVID-19 vaccination acceptability and experiences among PWID in San Diego County, USA. Methods: From September-November 2021, we conducted qualitative interviews with PWID aged ≥18 years who were participating in a prospective study of infectious disease risks in San Diego. Thematic analysis of coded interview transcripts focused on identifying barriers and facilitators to COVID-19 vaccination. Results: Of 28 participants, 15 reported having had ≥1 dose of COVID-19 vaccine, primarily received through community health centers, pharmacies, jails, and homeless shelters. We identified three key barriers to COVID-19 vaccination: (1) low perceived risk of COVID-19 (or belief in natural immunity), (2) institutional distrust (e.g., of pharmaceutical companies and government agencies that "rushed" vaccine development, approval, and distribution), and (3) conflicting information from news, social media, and peers. We also identified three key facilitators of vaccination, including (1) heightened personal and interpersonal safety concerns, (2) health service outreach efforts to make vaccines more accessible, and (3) tailored information delivered by trusted sources (e.g., outreach or community health workers). Conclusions: Tailored intervention strategies to increase acceptability and uptake of COVID-19 vaccination among PWID should involve efforts to increase vaccine literacy and motivation while decreasing institutional distrust and structural barriers to access.

Long-Acting Injectable Human Immunodeficiency Virus Pre-Exposure Prophylaxis Preferred Over Other Modalities Among People Who Inject Drugs: Findings from a Qualitative Study in California.

People who inject drugs (PWID) have extraordinarily low uptake of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) despite high levels of need. Long-acting PrEP modalities hold promise for HIV prevention among PWID, but product preferences remain poorly understood. From September to November 2021, we conducted qualitative interviews with 28 HIV-negative, adult (≥18 years) PWID in San Diego County, CA, to explore their perspectives on daily oral PrEP pills and long-acting PrEP modalities (i.e., injections, implants, intravaginal rings, and broadly neutralizing antibodies), which we explained using standard scripts. Thematic analysis identified variations in PrEP modality interest and acceptability. We identified three key factors across the 28 interviews that appeared to influence PrEP modality preferences: perceived convenience of use, invasiveness, and familiarity (based on past experience). Overall, most participants preferred injectable PrEP over other modalities because they viewed injectable medications as convenient, noninvasive, and familiar. While injectable PrEP was recently approved for use in the United States and was most the acceptable PrEP modality in this sample, our findings suggest that intervention and implementation research is urgently needed to improve our understanding of strategies that could support access, uptake, and sustained adherence to longer-acting PrEP for PWID.

Understanding the impact of the COVID-19 pandemic on refugee communities in San Diego, California: A participatory action research cross-sectional study.

Background: While the COVID-19 pandemic has impacted people worldwide, refugee communities are particularly vulnerable to the pandemic's social, economic and health impacts. This study assessed factors associated with increases in adverse community effects of COVID-19 in a refugee community in California. Methods: This study uses data from a cross-sectional survey developed and administered as part of a participatory action research project by a refugee community organization in San Diego, California. Data was collected between September and November 2020 in a sample of refugee community members (n = 517). Multivariable Poisson regression models measured associations between sociodemographic and acculturation measures with seven adverse community effects overall and stratified by duration of residence in the United States. Adverse community effects included job/wage loss, bank/cash access barriers, food insecurity, school interruptions, household violence, substance misuse and poor mental health. Results: Refugee community members reported an average of 2.1 adverse community effects that worsened during the COVID-19 pandemic, with job/wage loss and poor mental health the most prevalent (84% and 49%). Characteristics associated with reporting increased numbers of adverse community effects included being younger, female, childless, not actively seeking employment, living in the US for six or more years and speaking English at home. Stratified analyses show that these associations were concentrated in refugees who had lived in the US for at least six years. Conclusion: Refugee communities have experienced pervasive job losses and worsening mental health during the COVID-19 pandemic, and these effects are concentrated in respondents who have lived in the US for six or more years. Additional targeted support is needed to ensure that refugees who have lived in the US for longer durations have the financial and social support needed to cope with the unprecedented challenges brought on by the COVID-19 pandemic.

Shifting Priorities and Neoliberal Ideologies in Refugee Health Intervention Design in the US.

We discuss the design of a technology-based vaccine education intervention for Somali refugees in the US. Originally conceived of as a culturally and linguistically appropriate project to be co-designed by refugees, funder demands for a "social enterprise" led to future iterations being developed for a "generic" audience. We explore epistemological negotiations and shifting priorities that shaped intervention design, highlighting how nonprofits engage neoliberal ideologies such as "social enterprise" and "design thinking" while attempting to meet community needs. We argue that social enterprises and design thinking can suffuse neoliberal ideologies into nonprofits to the detriment of community-engaged solutions.

Development of a culturally and linguistically sensitive virtual reality educational platform to improve vaccine acceptance within a refugee population: the SHIFA community engagement-public health innovation programme.

OBJECTIVES: To combat misinformation, engender trust and increase health literacy, we developed a culturally and linguistically appropriate virtual reality (VR) vaccination education platform using community-engaged approaches within a Somali refugee community. DESIGN: Community-based participatory research (CBPR) methods including focus group discussions, interviews, and surveys were conducted with Somali community members and expert advisors to design the educational content. Co-design approaches with community input were employed in a phased approach to develop the VR storyline. PARTICIPANTS: 60 adult Somali refugees and seven expert advisors who specialise in healthcare, autism research, technology development and community engagement. SETTING: Somali refugees participated at the offices of a community-based organisation, Somali Family Service, in San Diego, California and online. Expert advisors responded to surveys virtually. RESULTS: We find that a CBPR approach can be effectively used for the co-design of a VR educational programme. Additionally, cultural and linguistic sensitivities can be incorporated within a VR educational programme and are essential factors for effective community engagement. Finally, effective VR utilisation requires flexibility so that it can be used among community members with varying levels of health and technology literacy. CONCLUSION: We describe using community co-design to create a culturally and linguistically sensitive VR experience promoting vaccination within a refugee community. Our approach to VR development incorporated community members at each step of the process. Our methodology is potentially applicable to other populations where cultural sensitivities and language are common health education barriers.