Disparities in COVID-19-Related Psychological Distress Among Recipients of a State's Public Mental Health Services.

OBJECTIVE: The authors examined changes in perceived anxiety, stress, and mental health symptoms (i.e., psychological distress) reported by recipients of New York State public mental health services during the early months of the COVID-19 pandemic, as well as whether these changes varied by demographic characteristics or pandemic-related socioeconomic challenges. METHODS: A statewide survey of service recipients (N=3,483) was conducted (May 8-June 22, 2020). Descriptive analyses were summarized, and logistic regression was used to evaluate associations between increases in reported psychological distress and age, gender, region of residence, race and ethnicity, socioeconomic challenges, and alcohol or drug use. RESULTS: Fifty-five percent of respondents (N=1,933) reported a slight or moderate increase in COVID-19-related psychological distress, and 15% (N=520) reported a substantial increase. In adjusted models, substantial elevations in psychological distress were associated with identifying as female (AOR=1.83, 95% CI=1.50-2.25), experiencing three or more pandemic-related socioeconomic challenges (AOR=2.41, 95% CI=1.91-3.03), and reporting increased use of alcohol or drugs (AOR=1.81, 95% CI=1.34-2.44). Compared with non-Hispanic/Latinx White service recipients, non-Hispanic/Latinx Black individuals had lower odds of reporting substantially increased psychological distress (AOR=0.59, 95% CI=0.45-0.76), as did non-Hispanic/Latinx Asian-descent individuals (AOR=0.28, 95% CI=0.12-0.64). CONCLUSIONS: In this large sample of recipients of New York State public mental health services, the COVID-19 pandemic's impact on psychological well-being was widespread and varied by gender, race and ethnicity, and socioeconomic vulnerability. These relationships must be considered in ongoing efforts to provide optimal care for this population.

Exploring the intersections of structural inequities and health disparities: the challenge and opportunity of recognizing racism as a public health crisis.

Although increasingly being recognized as a driver of poor health and health inequities, there is limited research on the pervasive effects of racism on population health. In this editorial, we set the context and invite contributions for a BMC Public Health Collection of articles titled, "Racism as Public Health Crisis."

The Color of Autonomy: Examining Racial Inequity in Coercive Institutional Practices.

Two articles recently published in this journal identified racial inequities in routine psychiatric practice. This Open Forum discusses the need for a paradigm shift in inequities research. The two articles reviewed here, one by Shea and colleagues on racial-ethnic inequities in inpatient psychiatric civil commitment and one by Garrett and colleagues on racial-ethnic disparities in psychiatric decisional capacity consultations, are examples of the new research gaze. Four topics are identified for enhancing understanding of racism and other forms of structural exclusion in psychiatric practice: medical authority and power imbalance between providers and patients, involuntary psychiatric commitment and requests for decisional capacity consultations as strategic research events, limited use of theory, and limitations of the literature on psychiatric inequities.

A longitudinal pathway from ethnic-racial discrimination to sexual risk behaviors among Black women and Latinas: Ethnic-racial identity exploration as a protective factor.

BACKGROUND: Black women and Latinas in their thirties continue to be at risk for HIV transmission via heterosexual intercourse. METHODS: Informed by the Theory of Gender and Power, this study investigated a longitudinal path model linking experiences of ethnic-racial discrimination in late adolescence to sexual risk behaviors in adulthood among 492 Black women and Latinas. We also tested whether ethnic-racial identity exploration served as a resilience asset protecting women against the psychological impact of ethnic-racial discrimination. Survey data from female participants in the Harlem Longitudinal Development Study, which has followed a cohort of New York City Black and Latinx youth since 1990, were analyzed. Data for this analysis were collected at four time points when participants were on average 19, 24, 29, and 32 years of age. Structural equation modeling was used to examine a hypothesized pathway from earlier ethnic-racial discrimination to later sexual risk behaviors and the protective role of ethnic-racial identity exploration. RESULTS: Results confirmed that ethnic-racial discrimination in late adolescence was linked with sexual risk behaviors in the early thirties via increased levels of affective distress in emerging adulthood, experiences of victimization in young adulthood, and substance use in the early thirties among women low in ethnic-racial identity exploration. We also found that ethnic-racial identity served as a resilience asset, as the association between discrimination in late adolescence and affective distress in emerging adulthood was not significant among women with higher levels of ethnic-racial identity exploration. CONCLUSIONS: The results provide important preliminary evidence that ethnic-racial identity exploration may serve as a resilience asset among Black women and Latinas confronting racial discrimination. Further, we suggest that ethnic-racial identity exploration may constitute an important facet of critical consciousness.

Anti-Asian Attitudes in the Context of the COVID-19 Pandemic: an Exploratory Study.

OBJECTIVE: The purpose of this paper was to measure if people with greater "structural literacy," as indicated by greater awareness of racial and socioeconomic disparities in COVID-19 impact, would hold fewer negative attitudes against those perceived to be Asian in the context of the COVID-19 pandemic. METHODS: A survey was administered between April and August 2020 to participants from two longitudinal cohorts in New York State. The survey assessed anti-Asian attitudes relating to COVID-19, awareness of racial and socioeconomic disparities in COVID-19, residential location, socioeconomic status, and other demographic information. The sample included 233 Black, Latinx, and White midlife adults from urban, suburban, and rural New York neighborhoods. Multivariable regression modeling was used to assess associations between COVID-19 disparities awareness, an indicator of structural literacy, and anti-Asian attitudes, adjusting for gender, race/ethnicity, residential location, and socioeconomic disadvantage. RESULTS: Greater awareness of disparities in COVID-19 was associated with lower levels of anti-Asian attitudes after adjustment (adj-slope = - 0.358, p < 0.001). CONCLUSION: Greater structural literacy, as measured by awareness of socioeconomic and racial disparities in COVID-19 impact, was associated with fewer anti-Asian attitudes among Black, Latinx, and White adults. IMPLICATIONS: Increasing structural literacy may reduce anti-Asian attitudes that motivate harmful acts against oppressed groups.

Challenges and opportunities of telehealth digital equity to manage HIV and comorbidities for older persons living with HIV in New York State.

BACKGROUND: Older persons living with HIV (PLWH) need routine healthcare to manage HIV and other comorbidities. This mixed methods study investigated digital equity, constituted as access, use and quality, of HIV and specialty telehealth services for PLWH > 50 years during the initial wave of the COVID-19 pandemic when services transitioned to remote care. METHODS: A survey of closed and open-ended questions was administered to 80 English (N = 63) and Spanish (N = 17) speaking PLWH receiving HIV care at an Academic Medical Center (N = 50) or a Federally Qualified Health Center (N = 30) in New York State. Quantitative analyses examined characteristics predicting telehealth use and visit quality. Qualitative analyses utilized thematic coding to reveal common experiences. Results were integrated to deepen the interpretation. RESULTS: Telehealth access and use were shaped by multiple related and unstable factors including devices and connectivity, technology literacy, and comfort including privacy concerns. Participants demonstrated their substantial effort to achieve the visit. The majority of patients with a telehealth visit perceived it as worse than an in-person visit by describing it as less interpersonal, and resulting in poorer outcomes, particularly participants with less formal education. Technology was not only a barrier to access, but also influenced perceptions of quality. CONCLUSIONS: In the COVID-19 pandemic initial wave, barriers to using telehealth were unequally distributed to those with more significant access and use challenges. Beyond these barriers, examining the components of equity indicate further challenges replicating in-person care using telehealth formats for older PLWH. Work remains to establish telehealth as both equitable and desirable for this population.

Internet use and uptake of a web-based prevention and risk reduction intervention for persons who use drugs in New York City - WebHealth4Us study (2013-2016).

Background: Data on Internet utilization is needed, particularly during a time when in-person services are limited or only available virtually. The purpose of this study was to identify characteristics of Internet use among persons who use drugs and assess adoption of an interactive, risk reduction informational website - WebHealth4Us. Methods: Participant recruitment occurred in pharmacies participating in the New York State pharmacy syringe access program (n = 209). ACASI surveys were conducted on-site to ascertain Internet use and related sociodemographics and risk behaviors. Internet users (use ≥ once/month) were shown a website WebHealth4Us highlighting social services and risk reduction information on four topic areas: mental health, HIV, HCV, and other STI; users could also sign-up for weekly text messages for any topic area. Follow-up ACASI occurred at four weeks to assess user experiences and website adoption. Results: Study sample (n = 196) was mostly male (60%), average age 46, black/Latinx (76%), had a history of incarceration (79%), and reported past/current injection (53%) or non-injection (51%) drug use. Internet use was high (79%), accessed >4 times/week (60%) most commonly for: housing (61%), health issues (54%), and drug treatment (45%). Over one-third accessed WebHealth4Us during follow-up, and 35% of those opted for weekly text messages (mental health most common topic selected). After adjustment, younger age (AOR = 0.96) and alcohol use (AOR = 2.26) predicted WebHealth4Us access. Conclusion: Internet use was high with considerable WebHealth4Us access, and specifically for mental health needs. Web-based interventions warrant large-scale investigation in high-risk communities, prioritizing social determinants and behavioral health.

Crisis Intervention Team (CIT) training and impact on mental illness and substance use-related stigma among law enforcement.

Limited empirical data and research exists about stigmatizing attitudes and perceptions held by law enforcement officers towards persons with mental illness and substance use issues. Pre- and post-training survey data from 92 law enforcement personnel who attended a 40-hour Crisis Intervention Team (CIT) training was used to investigate training-related changes in mental illness stigma and substance use stigma. Training participant's mean age was 38.35 ± 9.50 years, majority white non-Hispanic race/ethnicity (84.2%), male gender (65.2%), and reported job category as road patrol (86.9%). Pre-training, 76.1% endorsed at least one stigmatizing attitude towards people with mental illness, and 83.7% held a stigmatizing attitude towards those with substance use problems. Poisson regression revealed that working road patrol (RR=0.49, p<0.05), awareness of community resources (RR=0.66, p<0.05), and higher levels of self-efficacy (RR=0.92, p<0.05) were associated with lower mental illness stigma pre-training. Knowledge of communication strategies (RR=0.65, p<0.05) was associated with lower pre-training substance use stigma. Post-training, improvement in knowledge of community resources and increases in self-efficacy were significantly associated with decreases in both mental illness and substance use stigma. These findings highlight the existence of stigma related to both mental illness and substance use pre-training suggesting the need for implicit and explicit bias training prior to the start of active law enforcement duty. These data are consistent with prior reports indicating CIT trainings as a path to address mental illness and substance use stigma. Further research on effects of stigmatizing attitudes and additional stigma-specific training content is warranted.

The Impacts of COVID-19 on a Statewide Population With Mental Illness.

OBJECTIVE: This survey examined the experiences of individuals receiving treatment in a large public mental health system during the early months of the COVID-19 pandemic. METHODS: The survey, conducted between May and June 2020, assessed four domains: impacts on mental health, experiences with telehealth, access to care and resources, and sources and adequacy of support. Descriptive analyses were conducted. RESULTS: Of 4,046 respondents, 70% reported increases in their anxiety and stress because of the pandemic. A majority (55%) reported experiencing challenges related to the social determinants of health and functional needs. Most respondents reported that their care went undisrupted, with 92% using telehealth and 90% reporting feeling adequately supported. CONCLUSIONS: The pandemic substantially affected individuals with mental illness, particularly with regard to mental health related to the social determinants of health and functional needs. However, respondents felt that their mental health care was maintained and that they were adequately supported.

Should a Healthcare System Facilitate Racially Concordant Care for Black Patients?

Addressing racial disparities in health outcomes is an urgent priority for many health care organizations, leading health care managers to explore the potential for organization-level interventions to yield substantive health gains. In recent literature, it is suggested that Black patients who are treated by Black physicians may achieve superior health outcomes in some settings. In this case discussion, we consider a case in which a medical director considers implementing a voluntary program to promote racially concordant care for Black patients. Commentators consider the precedent for such a program, both in current informal care networks and 20th century medical history, as well as the burden such a program may place on Black physicians and the risks of reducing patients' intersectional identities to be solely about race. A subset of commentators suggest that these risks are mitigated by the voluntary nature of the program, whereas others offer caution about relying solely on Black physicians to remedy health disparities. Others view multiple paths as morally defensible but emphasize the need for managers to take proactive steps to communicate and evaluate their choices in the face of such a complex social challenge.

Rural and small metro area naloxone-dispensing pharmacists' attitudes, experiences, and support for a frontline public health pharmacy role to increase naloxone uptake in New York State, 2019.

INTRODUCTION: The purpose of this study is to assess community pharmacists' attitudes and experiences related to naloxone dispensation and counseling in non-urban areas in New York State to better understand individual and structural factors that influence pharmacy provision of naloxone. MATERIALS AND METHODS: The study conducted interviewer-administered semistructured surveys among community pharmacists in retail, independent, and supermarket pharmacies between October 2019 and December 2019. The 29-item survey ascertained pharmacists' demographic and practice characteristics; experiences and beliefs related to naloxone dispensation; and attitudes toward expansion of pharmacy services to include on-site public health services for persons who use opioids. The study used Chi square tests to determine associations between each characteristic and self-reported naloxone dispensation (any vs. none). RESULTS: A total of 60 of the 80 community pharmacists that the study team had approached agreed to participate. A majority were supportive of expanding pharmacy-based access to vaccinations (93.3%), on-site HIV testing, or referrals (75% and 96.7%, respectively), providing information on safe syringe use (93.3%) and disposal (98.3%), and referrals to medical/social services (88.3%), specifically substance use treatment (90%). A majority of pharmacist respondents denied negative impacts on business with over half reporting active naloxone dispensation (58.3%). Pharmacists dispensing naloxone were more likely to be multilingual (p < 0.03), and to specifically support on-site HIV testing (p < 0.02) than those who were not dispensing naloxone. DISCUSSION: Community pharmacists were highly favorable of naloxone dispensation in rural and small metro area pharmacies in NY, and those fluent in additional language(s) and supportive of on-site HIV testing were associated with active naloxone dispensation. While active naloxone dispensation was low, pharmacists appear supportive of a "frontline public health provider" model, which could facilitate naloxone uptake and warrants large-scale investigation. CONCLUSION: Rural and small metro area pharmacists are generally favorable of naloxone dispensation.

Single Room Occupancy Residence: Processes Linking Housing to Not Engaging in HIV Outpatient Care.

Homelessness and housing instability undermine engagement in medical care, adherence to treatment and health among persons with HIV/AIDS. However, the processes by which unstable and unsafe housing result in adverse health outcomes remain understudied and are the focus of this manuscript. From 2012 to 2014, we conducted qualitative interviews among inpatients with HIV disengaged from outpatient care (n = 120). We analyzed the content of the interviews with participants who reported a single room occupancy (SRO) residence (n = 44), guided by the Health Lifestyle Theory. Although SROs emerged as residences that were unhygienic and conducive to drug use and violence, participants remained in the SRO system for long periods of time. This generated experiences of living instability, insecurity and lack of control that reinforced a set of tendencies (habitus) and behaviors antithetical to adhering to medical care. We called for research and interventions to transform SROs into housing protective of its residents' health and wellbeing.

RESUMEN: La indigencia y la inestabilidad de vivienda reducen la participación en la atención médica, la adherencia al tratamiento y la salud de las personas viviendo con VIH/SIDA. Sin embargo, los procesos mediante los cuales la vivienda inestable e insegura conllevan a resultados adversos de salud permanecen poco estudiados y son el enfoque de este manuscrito. En el 2012­2014, llevamos a cabo entrevistas cualitativas con pacientes hospitalizados con VIH desconectados de servicios de atención ambulatoria (n = 120). Analizamos el contenido de las entrevistas (n = 44) con participantes que residían en un programa de ocupación de habitación individual (SRO, por sus siglas en inglés), guiados por la Teoría del Estilo de Vida Saludable. Aunque el programa de ocupación de habitación individual surgió en las entrevistas como residencias antihigiénicas y propicias para el uso de drogas y la violencia, los participantes se mantuvieron en el programa de ocupación de habitación individual por largo tiempo. Esto generó experiencias de inestabilidad en la vivienda, inseguridad y falta de control que reforzó tendencias (habitus) y comportamientos antitéticos a adherirse a la atención médica. Pedimos investigaciones e intervenciones para transformar los programas de ocupación de habitación individual en viviendas que protejan la salud y el bienestar de sus residentes.

Longitudinal predictors of male sexual partner risk among Black and Latina women in their late thirties: ethnic/racial identity commitment as a protective factor.

This study aimed to investigate predictors of male sexual partner risk among Latinas and Black women in their late thirties. We used multiple regression analysis to examine factors associated with male sexual partner risk among 296 women who participated in two waves of the Harlem Longitudinal Development Study (New York, 2011-2013 and 2014-2016). Women who experienced childhood sexual abuse had higher risk partners than those who did not [b = 0.16, 95% confidence interval (CI) = 0.06, 0.28]. Earlier marijuana use was a risk factor for partner risk in the late thirties (b = 0.12, 95% CI = 0.04, 0.27). Higher levels of ethnic/racial identity commitment mitigated this risk (b = - 0.15, 95% CI = - 0.26, - 0.04). Ethnic/racial identity commitment can be protective against male sexual partner risk among Latina and Black women who use marijuana. Further research should explore the protective role of different dimensions of ethnic/racial identity against sexually transmitted infections, including HIV.

Pharmacy PEP Access Intervention Among Persons Who Use Drugs in New York City: iPEPcare Study-Rethinking Biomedical HIV Prevention Strategies.

Biomedical HIV prevention uptake has not taken hold among Black and Latinx populations who use street-marketed drugs. A pilot intervention providing a PEP informational video and direct pharmacy access to a PEP starter dose was conducted among this population. Four study pharmacies were selected to help facilitate syringe customer recruitment (2012-2016). Baseline, post-video, and 3-month ACASI captured demographic, risk behavior, and psychosocial factors associated with PEP willingness, and willingness to access PEP in a pharmacy. A non-experimental study design revealed baseline PEP willingness to be associated with PEP awareness, health insurance, being female, and having a high-risk partner (n = 454). Three-month PEP willingness was associated with lower HIV stigma (APR = 0.95). Using a pre-post approach, PEP knowledge (p < 0.001) and willingness (p < 0.001) increased overtime; however, only three participants requested PEP during the study. In-depth interviews (n = 15) identified lack of a deeper understanding of PEP, and contextualized perceptions of HIV risk as PEP access barriers. Pharmacy PEP access shows promise but further research on perceived risk and HIV stigma is warranted.

Rethinking Cultural Competence: Shifting to Cultural Humility.

Healthcare and social services providers are deemed culturally competent when they offer culturally appropriate care to the populations they serve. While a review of the literature highlights the limited effectiveness of cultural competence training, its value remains largely unchallenged and it is institutionally mandated as a means of decreasing health disparities and improving quality of care. A plethora of trainings are designed to expose providers to different cultures and expand their understanding of the beliefs, values and behavior thus, achieving competence. Although this intention is commendable, training providers in becoming competent in various cultures presents the risk of stereotyping, stigmatizing, and othering patients and can foster implicit racist attitudes and behaviors. Further, by disregarding intersectionality, cultural competence trainings tend to undermine provider recognition that patients inhabit multiple social statuses that potentially shape their beliefs, values and behavior. To address these risks, we propose training providers in cultural humility, that is, an orientation to care that is based on self-reflexivity, appreciation of patients' lay expertise, openness to sharing power with patients, and to continue learning from one's patients. We also briefly discuss our own cultural humility training. Training providers in cultural humility and abandoning the term cultural competence is a long-awaited paradigm shift that must be advanced.

Sexual Risk Behaviors Among Black and Puerto Rican Women in Their Late Thirties: A Brief Report.

In New York City, over 90% of women newly diagnosed with human immunodeficiency virus (HIV) are Black and Latina; a quarter of these infections occur among 30-39 year-olds. A survey was administered to 343 Black and Puerto Rican women (2014-2016) to examine two HIV infection risk factors: relationship exclusivity and having experienced childhood sexual abuse (CSA). A majority of male partners (69.7%) had at least one risk for HIV transmission. Women in non-exclusive sexual relationships (nESRs) had higher-risk partners, but engaged in safer sex practices than those in ESRs. Two-thirds of women in ESRs (64.8%) reported unprotected vaginal intercourse, although 33.5% had partners with a history of concurrent relationships. Among women in nESRs, having experienced CSA was a strong risk factor for HIV infection. Black and Latina women's vulnerability to HIV infection is significant, even when in exclusive relationships. Safer sex counseling should be integrated in primary care.

A Polydrug and Psychosocial Profile of Synthetic Cannabinoid Use in a New York City Community Sample, 2016-2017.

BACKGROUND: Epidemiologic reports available on synthetic cannabinoids (SCs) have focused on sociodemographics, indicating high prevalence of SC use predominantly among white, relatively affluent, males. However, there is emerging evidence suggesting high SC prevalence among socioeconomically disadvantaged, racial/ethnic minority males. OBJECTIVES: The purpose of this study is to investigate the risk correlates of SC use among psychosocial vulnerable communities. METHOD: The sample of 100 participants was recruited from two harm reduction-focused, community-based organizations in the South Bronx and East Harlem neighborhoods in New York City. Consented individuals 18 years and older underwent a 30- minute survey ascertaining sociodemographics, psychosocial characteristics, SC and polydrug use characteristics, and mental health history. RESULTS: The study population was majority male (61%), Latino (56%), commonly diagnosed with psychiatric illness (67%), and with a mean age of 45.4. Those reporting SC use (74%) were more likely to be male, homeless, and report polydrug use. After adjustment, being male (AOR = 5.64), homelessness (AOR = 4.88) along with cocaine (AOR = 5.63) and opiate use (AOR = 31.1) were independently associated with SC use. The most common reasons for using SC were affordability, inability to detect SC in drug tests, and perceived physical and emotional benefits. Conclusion/importance: This work is significant in expanding the populations thought to be impacted by and understanding social disparities related to SC use. Further investigation is needed to assess the relationship between concomitant use of SC and other drug, particularly opiates. This may suggest that the sequelae of one drug may enhance or alleviate the effects of the other.

HIV-related 'conspiracy beliefs': lived experiences of racism and socio-economic exclusion among people living with HIV in New York City.

HIV-related 'conspiracy beliefs' include ideas about the genocidal origin of HIV and the nature and purpose of HIV-related medications. These ideas have been widely documented as affecting myriad health behaviours and outcomes, including birth control use and HIV testing. Most HIV-related research has quantitatively explored this phenomenon, and further qualitative research is necessary to better understand the complexity of these beliefs as articulated by those who endorse them. Moreover, public health in general has over-emphasised the role of the Tuskegee Syphilis Study in explaining mistrust, rather than focus on ongoing social inequalities. Twenty-seven semi-structured interviews were conducted with low-income Black and Latinx people living with HIV who were currently, or had been recently, disengaged from HIV medical care. Beliefs about the role and intentions of the government and pharmaceutical industry in the epidemic highlighted the racism and classism experienced by participants. Notably, however, HIV care providers were not perceived as part of the government-pharmaceutical collusion. Interventions should focus on fostering positive beliefs about HIV medication and building trust between HIV care providers and populations that have experienced ongoing social and economic exclusion. Replacing the phrase 'conspiracy beliefs' with more descriptive terms, such as HIV-related beliefs, could avoid discrediting people's lived experiences.