COVID-19 Vaccination Coverage and Vaccine Confidence by Sexual Orientation and Gender Identity - United States, August 29-October 30, 2021.

Lesbian, gay, bisexual, and transgender (LGBT) populations have higher prevalences of health conditions associated with severe COVID-19 illness compared with non-LGBT populations (1). The potential for low vaccine confidence and coverage among LGBT populations is of concern because these persons historically experience challenges accessing, trusting, and receiving health care services (2). Data on COVID-19 vaccination among LGBT persons are limited, in part because of the lack of routine data collection on sexual orientation and gender identity at the national and state levels. During August 29-October 30, 2021, data from the National Immunization Survey Adult COVID Module (NIS-ACM) were analyzed to assess COVID-19 vaccination coverage and confidence in COVID-19 vaccines among LGBT adults aged ≥18 years. By sexual orientation, gay or lesbian adults reported higher vaccination coverage overall (85.4%) than did heterosexual adults (76.3%). By race/ethnicity, adult gay or lesbian non-Hispanic White men (94.1%) and women (88.5%), and Hispanic men (82.5%) reported higher vaccination coverage than that reported by non-Hispanic White heterosexual men (74.2%) and women (78. 6%). Among non-Hispanic Black adults, vaccination coverage was lower among gay or lesbian women (57.9%) and bisexual women (62.1%) than among heterosexual women (75.6%). Vaccination coverage was lowest among non-Hispanic Black LGBT persons across all categories of sexual orientation and gender identity. Among gay or lesbian adults and bisexual adults, vaccination coverage was lower among women (80.5% and 74.2%, respectively) than among men (88.9% and 81.7%, respectively). By gender identity, similar percentages of adults who identified as transgender or nonbinary and those who did not identify as transgender or nonbinary were vaccinated. Gay or lesbian adults and bisexual adults were more confident than were heterosexual adults in COVID-19 vaccine safety and protection; transgender or nonbinary adults were more confident in COVID-19 vaccine protection, but not safety, than were adults who did not identify as transgender or nonbinary. To prevent serious illness and death, it is important that all persons in the United States, including those in the LGBT community, stay up to date with recommended COVID-19 vaccinations.

Selecting Evidence-Based HIV Prevention Behavioral Interventions for HIV-Negative Persons for National Dissemination.

This paper describes the development of a formula to determine which evidence-based behavioral interventions (EBIs) targeting HIV-negative persons would be cost-saving in comparison to the lifetime cost of HIV treatment and the process by which this formula was used to prioritize those with greatest potential impact for continued dissemination. We developed a prevention benefit index (PBI) to rank risk-reduction EBIs for HIV-negative persons based on their estimated cost for achieving the behavior change per one would-be incident infection of HIV. Inputs for calculating the PBI included the mean estimated cost-per-client served, EBI effect size for the behavior change, and the HIV incidence per 100,000 persons in the target population. EBIs for which the PBI was ≤ $402,000, the estimated lifetime cost of HIV care, were considered cost-saving. We were able to calculate a PBI for 35 EBI and target population combinations. Ten EBIs were cost-saving having a PBI below $402,000. One EBI did not move forward for dissemination due to high start-up dissemination costs. DHAP now supports the dissemination of 9 unique EBIs targeting 13 populations of HIV-negative persons. The application of a process, such as the PBI, may assist other health-field policymakers when making decisions about how to select and fund implementation of EBIs.

Refugee children's sandplay narratives in immigration detention in Canada.

Asylum seeking children arriving in Canada regularly face incarceration in medium-security-style immigration detention centres. Research demonstrates the human cost of detaining migrant children and families and the psychiatric burden linked with such imprisonment. This study aims to understand the lived experiences of children aged 3-13 held in detention. Informed by a qualitative methodology of narrative inquiry, child participants created worlds in the sand and generated stories to express their subjective experience. Results suggest that children's sandplay confirms the traumatic nature of immigration detention while also revealing children's sometimes conflicting understanding of the meaning of detention and their own migration. The results are contextualized by a description of detention conditions and the psychiatric symptoms associated with immigration incarceration. The study highlights the need for more research examining the impact of immigration detention on children's mental health, while also underlining how refugee children's voices provide important direction for policy change.

A Latent Class Analysis of Attitudes Towards Asylum Seeker Access to Health Care.

In the past decade there has been an increase in focus on the concept of deservingness and how it plays out in debates around health care for migrant populations with precarious legal status. This study uses latent class analysis to identify subtypes of attitudes regarding asylum seeker access to health care and endorsement of support for asylum seeker access to care among 4066 employees of health care institutions in Montreal and Toronto, Canada. Authors identified four classes of attitudes towards asylum seeker access to care named 'Favorable,' 'Opposed,' 'Ambivalent/Reactive,' and 'Unconcerned/Status quo'. The odds of endorsing access to health care depended on the individual's class membership of asylum seeker attitude. Although there are segments of the population that overwhelmingly endorse, or reject, asylum seeker access to care, there are important variants in opinions and beliefs. Interventions are needed to engage professionals more ambivalent or opposed to asylum seeker access to care.

Interventions facilitating access to perinatal care for migrant women without medical insurance: A scoping review protocol.

INTRODUCTION: Inadequate pregnancy monitoring for pregnant migrant women without medical insurance (PMWMI) exposes them to severe complications during childbirth and consequences for the health of their child (e.g. preterm delivery, low birth weight, etc.). This scoping review aims to identify existing interventions globally to improve access to perinatal care for PMWMI. It will also highlight the strengths, weaknesses as well as the costs of these interventions. MATERIALS AND METHODS: The methodological framework developed by Arksey & O'Malley (2005) will be used. An electronic search of studies from 2000 to 2021, published in French or English, will be conducted in 12 databases. Publication in Websites of non-governmental organizations working on migrant women without medical insurance issues will be also searched. All articles related to perinatal follow-up and care of PMWMIs, regardless of design, will be included. Editorial comments will be excluded. Outcomes of interest will focus on the impacts, strengths, weaknesses, and cost of interventions. Selection of articles and data extraction will be done by two independent researchers following the Tricco et al. (2018) reporting guide. Finally, a deliberative workshop with experts will allow to identify the most promising and appropriate interventions that can facilitate access to perinatal services by PMWMIs in the Quebec province of Canada.

Canadian Health Personnel Attitudes Toward Refugee Claimants' Entitlement to Health Care.

Health care personnel attitudes toward refugee claimant entitlement to health care are influenced by multilevel factors including institutional and societal culture. Although individual attitudes may be modified through training, macro- and meso-issues require system-level interventions. This paper analyzes the role of individual-, institutional-, and city-level factors in shaping attitudes toward refugee claimants' access to health care among Canadian health care personnel. A total of 4207 health care personnel in 16 institutions located in Montreal and Toronto completed an online survey on attitudes regarding health care access for refugee claimants. We used multilevel logistic regression analysis to identify individual-, institutional-, and city-level predictors of endorsing access to care. Participants who had prior contact with refugee claimants had greater odds of endorsing access to care than those who did not (OR 1.13; 95% CI 1.05, 1.21). Attitudes varied with occupation: social workers had the highest probability of endorsing equal access to health care (.83; 95% CI .77, .89) followed by physicians (.77; 95% CI .71, .82). An estimated 7.97% of the individual variation in endorsement of equal access to health care was attributable to differences between institutions, but this association was no longer statistically significant after adjusting for city residence. Results indicate that the contexts in which health care professionals live and work are important when understanding opinions on access to health care for vulnerable populations. They suggest that institutional interventions promoting a collective mission to care for vulnerable populations may improve access to health care for precarious status migrants.

A review of the Centers for Disease Control and Prevention's response to the HIV/AIDS crisis among Blacks in the United States, 1981-2009.

Among US racial/ethnic groups, Blacks are at the highest risk of acquiring HIV/AIDS. In response, the Centers for Disease Control and Prevention (CDC) has launched the Heightened National Response to Address the HIV/AIDS Crisis Among African Americans, which seeks to engage public and nonpublic partners in a synergistic effort to prevent HIV among Blacks. The CDC also recently launched Act Against AIDS, a campaign to refocus attention on the domestic HIV/AIDS crisis. Although the CDC's efforts to combat HIV/AIDS among Blacks have achieved some success, more must be done to address this crisis. New initiatives include President Obama's goal of developing a National HIV/AIDS Strategy to reduce HIV incidence, decrease HIV-related health disparities, and increase access to care, especially among Blacks and other disproportionately affected populations.

Impact of the Charter of Quebec Values on psychological well-being of francophone university students.

This paper discusses results from a pilot study conducted in the spring of 2014 among young adults living in Montreal. The main objective of this study was to assess the relation between perception of the Charter of Quebec Values, 1 self-identification, perception of intercommunity relations, perceived discrimination, and psychological well-being in young students enrolled in undergraduate or graduate programs of a francophone university in Montreal. A total of 441 students (30.5% male, 69.5% female) took part in a web survey designed by the research team. The data analyses and results suggest that the debate around the Charter of Quebec values was associated with a shift from a predominantly positive perception of intercommunity relations to a predominantly negative one, particularly among women, immigrants, and those who self-identified as cultural or religious minorities. In addition, more than 30% of participants reported having experienced some form of ethnic or religious discrimination since the Charter was released (personally or as a witness). This was particularly the case among immigrants, as well as those who self-identified as bicultural or from cultural or religious minority groups. This study's results thus highlight the exacerbation of intercommunity tensions linked to the public debate around identity and intercommunity relations in Quebec.

An HIV/AIDS crisis among African American women: a summary for prevention and care in the 21st century.

The meeting, HIV/AIDS and African American Women: A Consultation Supporting CDC's Heightened National Response to the HIV/AIDS Crisis among African Americans, provided a forum to address gaps in prevention and HIV/AIDS infection for African American women. Health researchers, community-based organization leaders, and representatives from both healthcare and non-healthcare sectors took this opportunity to discuss and develop a variety of priorities and suggestions for HIV/AIDS prevention. Four focus areas were provided for meeting attendees to promote discussion and strategy development. The resulting list of priorities and suggestions for HIV/AIDS prevention may provide future steps for researchers, communities, and physicians to increase prevention and decrease infection rates. Novel, innovative, and participatory approaches are needed within and outside the public arena to decrease the gaps in HIV/AIDS prevention for African American women.

Symbolic violence and disempowerment as factors in the adverse impact of immigration detention on adult asylum seekers' mental health.

OBJECTIVES: The first objective of this qualitative component of a mixed-methods study is to provide a descriptive account of adult asylum seekers' experience of detention in Canadian immigration detention centers. The second objective is to identify the main underlying factors accounting for their reported feelings of distress. METHODS: Researchers interviewed 81 adult asylum seekers held in two Canadian immigration detention centers concerning their experience of detention. Participants were drawn from a sample of 122 detained asylum seekers who had completed structured questionnaires about mental health and detention conditions. RESULTS: Asylum seekers expressed shock and humiliation at being "treated like criminals." Detainees felt disempowered by the experience of waiting for an indeterminate period for the outcome of a discretionary decision over which they have little control, but which will determine their freedom and their future. For trauma survivors, detention sometimes triggered retraumatization. CONCLUSIONS: Detention, even for brief periods in relatively adequate conditions, was found to be detrimental to asylum seekers' mental health. This adverse impact appears to be largely attributable to the combined effect of two factors: symbolic violence and disempowerment.

Using HIV Surveillance Data to Link People to HIV Medical Care, 5 US States, 2012-2015.

INTRODUCTION: From 2012 through 2015, the Centers for Disease Control and Prevention (CDC) provided funding to 5 health departments for demonstration projects using HIV surveillance data to link people with newly diagnosed HIV to care. We assessed how well these health departments established linkage to care, how the demonstration projects helped them with this work, and if they sustained these activities after CDC funding ended. MATERIALS AND METHODS: We obtained quantitative and qualitative data on linkage-to-care activities from health department communications and progress reports submitted to CDC. We calculated and combined linkage-to-care results for the 5 health departments, and we compared these results with the combined linkage-to-care results for 61 health departments that received CDC funding for routine HIV prevention activities (eg, HIV testing, linkage to and reengagement in HIV care, HIV partner services) and for the same 5 health departments when they used only routine HIV prevention activities for linkage to care. RESULTS: Of 1269 people with a new HIV diagnosis at the 5 health departments, 1124 (89%) were linked to care, a result that exceeded the 2010-2015 National HIV/AIDS Strategy goal (85%), the CDC Funding Opportunity Announcement performance standard (80%), and combined results for the 61 health departments (63%) and the same 5 health departments (66%) using routine HIV prevention activities. Benefits of the projects were improved collaboration and coordination and more accurate, up-to-date surveillance data. All health departments continued linkage-to-care activities after funding ended. PRACTICE IMPLICATIONS: Using HIV surveillance data to link people with HIV to care resulted in substantial clinical and public health benefits. Our observations underscore the importance of collaboration among medical providers, public health staff members, community-based organizations, and people with HIV to ensure the best possible clinical and public health outcomes.

The gap between entitlement and access to healthcare: An analysis of "candidacy" in the help-seeking trajectories of asylum seekers in Montreal.

In 2012 the Canadian government made significant cuts to its historically strong federal refugee health coverage plan. While this policy had negligible effects on the level of coverage provided to asylum seekers in Quebec, there is evidence that this group nonetheless experienced reduced healthcare access during the period of polarized national debate that ensued. This study engaged the "candidacy" model of healthcare access to illuminate factors contributing to the observed gap between entitlement and access. Twenty-five semi-structured interviews were conducted with asylum seekers in Montreal to elicit narrative accounts of difficulties encountered in the pursuit of healthcare. Thematic content analysis in conjunction with a holistic examination of help-seeking trajectories revealed several important barriers to obtaining care, including widespread confusion and misinformation about refugee health coverage, cumbersome administrative procedures specific to asylum seekers, and long wait times. Feelings of marginalization and insecurity associated with precarious migratory status appeared to amplify the effects of these barriers to care such that even a minor access difficulty could have dramatic effects on future help-seeking and access outcomes. Demonstrating awareness of public discourses interrogating their deservingness of health coverage, participants often interpreted access difficulties as evidence of health professionals' unwillingness to serve them. Such interpretations conspired with fears associated with the asylum claim process to suppress self-advocacy, further help-seeking, and at times even information-seeking. This finding is particularly significant in that it suggests a mechanism through which hostile public representations of forced migrants-increasingly prevalent in Western host countries-can themselves endanger the physical, psychological, and social health of highly disadvantaged populations, even in the presence of strong entitlement policies. We close with reflections on how theoretical models of healthcare access might be adjusted to better accommodate the unique experiences of precarious status migrants.

Encouraging understanding or increasing prejudices: A cross-sectional survey of institutional influence on health personnel attitudes about refugee claimants' access to health care.

BACKGROUND: This paper investigates the personal, professional and institutional predictors of health institution personnel's attitudes regarding access to healthcare for refugee claimants in Canada. METHODS: In Montreal, the staff of five hospitals and two primary care centres (n = 1772) completed an online questionnaire documenting demographics, occupation, exposure to refugee claimant patients, and attitudes regarding healthcare access for refugee claimants. We used structural equations modeling to investigate the associations between professional and institutional factors with latent functions of positive and negative attitudes toward refugee's access to healthcare. RESULTS: Younger participants, social workers, participants from primary care centres, and from 1st migrant generation had the lowest scores of negative attitudes. Respondents who experienced contact with refugees had lower scores of negative attitudes (B = -14% standard deviation [SD]; 95% CI: -24, -4%). However, direct contact with refugees increased scores of negative attitudes in the institution with the most negative attitudes by 36% SD (95% CI: 1, 71%). INTERPRETATION: Findings suggest that institutions influence individuals' attitudes about refugee claimants' access to health care and that, in an institutional context of negative attitudes, contact with refugees may further confirm negative perceptions about this vulnerable group.

Knowledge of Healthcare Coverage for Refugee Claimants: Results from a Survey of Health Service Providers in Montreal.

Following changes to the Interim Federal Health (IFH) program in Canada in 2012, this study investigates health service providers' knowledge of the healthcare coverage for refugee claimants living in Quebec. An online questionnaire was completed by 1,772 staff and physicians from five hospitals and two primary care centres in Montreal. Low levels of knowledge and significant associations between knowledge and occupational group, age, and contact with refugees were documented. Social workers, respondents aged 40-49 years, and those who reported previous contact with refugee claimants seeking healthcare were significantly more likely to have 2 or more correct responses. Rapid and multiple changes to the complex IFH policy have generated a high level of confusion among healthcare providers. Simplification of the system and a knowledge transfer strategy aimed at improving healthcare delivery for IFH patients are urgently needed, proposing easy avenues to access rapidly updated information and emphasizing ethical and clinical issues.

Asylum-seeking children's experiences of detention in Canada: A qualitative study.

Children and parents seeking asylum are regularly detained in Canada, however little is known about the experiences of detained families. International literature suggests that the detention of children is associated with significant morbidity. Our study aims to understand the experiences of detained children and families who have sought asylum in Canada by using a qualitative methodology that includes semistructured interviews and ethnographic participant observation. Detention appears to be a frightening experience of deprivation that leaves children feeling criminalized and helpless. Family separation further shatters children's sense of well-being. Children's emotional and behavioral responses to separation and to detention suggest that the experience is acutely stressful and, in some cases, traumatic--even when detention is brief. Distress and impairment may persist months after release. Given the burden of psychological suffering and the harmful consequences of separating families, children should not be detained for immigration reasons and parents should not be detained without children.

Psychiatric symptoms associated with brief detention of adult asylum seekers in Canada.

OBJECTIVES: To examine the association between brief detention and psychiatric symptom levels among adult asylum seekers. METHOD: The Harvard Trauma Questionnaire and the Hopkins Symptoms Checklist-25 were used to assess psychiatric symptoms and premigration trauma exposure in 122 detained and 66 nondetained adult asylum seekers in Montreal and Toronto. RESULTS: After a mean detention of 31 days, the proportion of asylum seekers scoring above clinical cutpoints was significantly higher in the detained than the nondetained group for posttraumatic stress (χ² = 4.117, df = 1, P = 0.04), depression (χ² = 13.813, df = 1, P < 0.001), and anxiety (χ² = 4.567, df = 1, P = 0.03) symptoms. Hierarchical multiple regression models showed that posttraumatic stress, depression, and anxiety symptom levels were significantly higher among detained asylum seekers than among the nondetained comparison group, taking into account previous trauma and demographics. Incremental F was significant for the addition of detention status for all 3 models, indicating that detention contributed to increased symptom levels. CONCLUSIONS: For asylum seekers, even brief detention is associated with increased psychiatric symptoms. Governments should consider the many viable alternatives to incarceration of asylum seekers, such as temporary placement in a supervised residential facility, to minimize the risks of psychological harm to this vulnerable population.

Objectifs :Examiner l'association entre la brève détention et les taux de symptômes psychiatriques chez les demandeurs d'asile adultes. Méthode : Le questionnaire de Harvard sur les traumatismes et la liste de symptômes-25 de Hopkins ont servi à évaluer les symptômes psychiatriques et l'exposition à des traumatismes pré-migration chez 122 demandeurs d'asile adultes détenus et 66 non détenus à Montréal et Toronto. Résultats : Après une détention moyenne de 31 jours, la proportion de demandeurs d'asile dont les scores étaient au-dessus des seuils cliniques d'inclusion était significativement plus élevée chez les détenus que dans le groupe des non détenus pour des symptômes de stress post-traumatique (χ2 = 4,117, dl = 1, P = 0,04), de dépression (χ2 = 13,813, dl = 1, P < 0,001), et d'anxiété (χ2 = 4,567, dl = 1, P = 0,03). Les modèles hiérarchiques de régression multiple indiquaient que les taux de symptômes de stress post-traumatique, de dépression, et d'anxiété étaient significativement plus élevés chez les demandeurs d'asile détenus que dans le groupe de non détenus, en prenant en compte les traumatismes antérieurs et les données démographiques. Le test F incrémental était significatif pour l'addition du statut de détention dans les 3 modèles, indiquant que la détention contribuait aux taux de symptômes plus élevés. Conclusions : Pour les demandeurs d'asile, une détention, même brève, est associée à des symptômes psychiatriques accrus. Les gouvernements devraient envisager les nombreuses solutions de rechange viables à l'incarcération des demandeurs d'asile, comme par exemple le placement temporaire dans une résidence supervisée, afin de minimiser les risques de dommages psychologiques pour cette population vulnérable.