Intersectional Disparities in Youth Tobacco Use by Sexual and/or Gender Minority Status and Race and/or Ethnicity.

INTRODUCTION: The current study applied an intersectional lens to examine societal factors, individual psychological outcomes, and youth combustible tobacco and vape use at the intersection of sexual and/or gender minority (SGM) status and race and/or ethnicity. AIMS AND METHODS: Data were drawn from 133 969 youth respondents surveyed in the 2019-2020 California Student Tobacco Survey, a representative school-based survey of 8th and 10th-grade public school students throughout California. The impact of multiple marginalized group membership using four mutually exclusive intersectional positions (non-SGM white, SGM white, racial minority only, and both SGM and racial minority), in addition to specific differences across ten SGM by race and/or ethnicity groups (e.g. non-SGM black or African American, SGM black or African American, etc.) were assessed. RESULTS: Compared to heterosexual and cisgender white youth, SGM and racial minority adolescents were shown to experience poorer school tobacco education quality and cessation support, lower school and family connectedness, and higher anxiety and depression symptoms. SGM and racial minority youth had a higher prevalence of ever-combustible tobacco use but were less likely to be current vape users compared to non-SGM white respondents. In examining specific group differences, results revealed that SGM teens had the highest risk of ever combustible tobacco use. This disparity was amplified for those belonging to multiple marginalized groups, with black or AA SGM teens evidenced to be at the highest risk of current combustible tobacco. CONCLUSIONS: Information from this study has useful implications for SGM measurement in surveillance systems and highlights the usefulness of adopting an intersectional approach to inform equity-driven public health policy and intervention. IMPLICATIONS: This representative study of California youth supports that identifying as a sexual and/or gender minority (SGM) is an important risk factor for combustible tobacco use. Particularly, observed SGM disparities were magnified for the youth belonging to marginalized groups, as black or African American SGM teens were shown to be at the highest risk of current combustible tobacco use. Findings support that Intersectionality Theory represents a useful framework for examining tobacco-related disparities and underscores the importance of assessing how the intersection of multiple social categories impacts youth tobacco use.

"I think we can do without [tobacco]": support for policies to end the tobacco epidemic among California adolescents.

INTRODUCTION: The tobacco endgame, policies aiming to end the commercial tobacco epidemic, requires sustained public support, including among youth. We assessed endgame support among California (USA) adolescents, including their reasons and associated participant and policy-specific factors. METHODS: Teens, Nicotine and Tobacco Project online surveys (n=4827) and focus groups were conducted in 2021 and 2022 among California residents aged 12-17 years. Cross-sectional survey participants were asked their agreement level with eight policy statements related to tobacco and/or cannabis sales restrictions, use in public places and use in multiunit housing. Ordered logistic regression modelled level of agreement according to respondent characteristics, behaviours and statement content. Qualitative data were collected through focus groups (n=51 participants), which were analysed to provide insight into support for different policies. RESULTS: Most survey participants agreed or strongly agreed with tobacco product sales restrictions (72%-75%, depending on the policy), bans on use in public spaces (76%-82%) and smoke-free (79%) and vape-free (74%) apartment buildings. Support was stronger among younger, female, Asian and tobacco non-using participants and for policies directed at 'tobacco' (vs 'vapes' or cannabis), at flavoured tobacco (compared with all tobacco), and when statements featured 'should end' (vs 'not allowed'). Focus group participants who were supportive viewed policies as protecting children from harmful products, while those less supportive cited concerns about limiting adults' freedoms and unintended consequences. CONCLUSIONS: Most participants supported strong tobacco control policies. Public communication that promotes broader endgame benefits besides protecting youth and accelerates industry denormalisation may counter youth concerns and further bolster their support.

Self-Measured Blood Pressure Monitoring: Program Planning, Implementation, and Lessons Learned From 5 Federally Qualified Health Centers in Hawai'i.

Self-measured blood pressure monitoring programs (BPMPs) are effective at controlling hypertension. We examined implementation of self-measured BPMPs at 5 Hawai'i-based Federally Qualified Health Centers (FQHCs). In a process evaluation of these programs, we found that FQHCs developed protocols for self-measured BPMP recruitment and enrollment and provided additional supports to account for their patients' psychosocial needs to achieve blood pressure control, such as lifestyle change education and opportunities through referrals either to on-site or other programs (eg, on-site gym, tobacco cessation program). Common barriers across sites included insufficient material support for blood pressure monitors and data collection; funding, which affects program sustainability; and the lack of an "off-the-shelf" self-measured BPMP intervention. Policy makers and funding organizations should address these issues related to self-measured BPMPs to ensure implementation success.

Housing and Food Insecurity and Chronic Disease Among Three Racial Groups in Hawai'i.

INTRODUCTION: Food and housing insecurity are social determinants of health related to chronic disease, including diabetes, cardiovascular disease (CVD), and asthma. How these insecurities affect chronic disease among the 3 largest racial groups in Hawai'i is unknown. The purpose of this study was to examine chronic disease by housing and food insecurity among whites, Asians, and Native Hawaiian/other Pacific Islanders (NHOPIs) in Hawai'i. METHODS: We pooled data on 9,907 respondents from the 2009 and 2012 Behavioral Risk Factor Surveillance System. Dependent variables were diabetes, CVD, and asthma. Independent variables were housing and food insecurity. Logistic regression models were stratified by race to examine within-group differences by severity of insecurity. RESULTS: Compared with housing secure respondents, housing insecure NHOPIs had higher adjusted odds of diabetes (odds ratio [OR] = 1.85; 95% confidence interval [CI], 1.13-3.01) and CVD (OR = 1.85; 95% CI, 1.04-3.28), and housing insecure whites (OR = 1.52; 95% CI, 1.12-2.04) and Asians (OR = 1.93; 95% CI, 1.29-2.88) had higher adjusted odds of asthma. Compared with food secure participants, food insecure NHOPIs had higher adjusted odds of diabetes (OR = 2.17; 95% CI, 1.28-3.68); food insecure whites (OR = 1.88; 95% CI, 1.16-3.05) and NHOPIs (OR = 2.04; 95% CI, 1.10-3.78) had higher adjusted odds of CVD, and food insecure whites (OR = 1.53; 95% CI, 1.06-2.22) and Asians (OR = 1.79; 95% CI, 1.05-3.06) had higher adjusted odds of asthma. CONCLUSION: Housing and food insecurity are associated with higher rates of chronic diseases among some races in Hawai'i. Policy makers should work to increase affordable housing and improve policies to increase food affordability.

Perceived discrimination and youth vaping: The role of intersectional identities.

INTRODUCTION: Electronic cigarettes (also termed e-cigarette or vapes) often contain nicotine, an addictive psychoactive substance, which can have harmful effects during adolescence. Frequent experiences of discrimination are one risk factor shown to increase susceptibility to tobacco use, especially for individuals that identify as a social minority. Applying Intersectionality Theory, this research examined the relationship between youth experiences of discrimination and vape use at the intersection of race/ethnicity and sexual orientation. METHOD: Cross-sectional survey data from 4747 youth (ages 12-17) that participated in the 2022 Teens, Nicotine, and Tobacco Project (TNT) online survey were used to evaluate the impact of discrimination on vape use for lesbian, gay, bisexual, and/or queer/questioning (LGBQ+) youth of color. RESULTS: Multivariable regression analyses showed that identifying as both a sexual and racial/ethnic minority was a risk factor for experiencing discrimination. Frequent discrimination and reporting discrimination due to sexual orientation was associated with a greater likelihood of ever and current vaping. Path models supported that discrimination mediated the relationship between intersectional identity and vape use. LGBQ+ youth of color reported more frequent discrimination, which was associated with a greater likelihood of ever/current vape use. CONCLUSIONS: Intersectionality Theory aids in understanding how discrimination can exacerbate tobacco-related disparities for youth with multiple minority identities. Findings corroborate the importance of measuring discrimination in public health surveys. Effective tobacco interventions could incorporate strategies to cope with discrimination-related stress.

Examining Mental Health and Economic Consequences During the COVID-19 Pandemic Among Filipino Residents in Hawai'i: May - Oct 2020.

The coronavirus disease 2019 (COVID-19) pandemic has resulted in rapid and drastic changes to daily lives, posing a threat to residents' mental health and well-being. Filipinos are disproportionately impacted by COVID-19 and have one of the highest COVID-19 prevalence in Hawai'i. The COVID-19 pandemic has been associated with a rise in mental health concerns, yet little is known about the impact on the mental health of Filipinos in Hawai'i. Using publicly available polling data from the SMS Community Pulse Survey, this study sought to describe the mental distress experienced by Filipino residents during the COVID-19 pandemic. Data were collected from an online panel of Hawai'i residents over 4 timepoints (May 5-10; June 11-17; July 31-August 8; October 19-31, 2020). Compared to non-Filipinos, a higher proportion of Filipinos reported feeling stress and sadness during 3 of the 4 timepoints. Across all timepoints, Filipinos were more likely to respond affirmatively to mental health indicators (62.5%). Similarly, Filipinos reported food insecurity in higher proportions relative to non-Filipinos in most timepoints, particularly notable in Timepoint 4 where 33.0% of Filipino respondents reported food insecurity. These findings suggest that Filipinos would benefit from social policy and community-supported initiatives to address social determinants of health, reduce chronic stress, and prevent further mental health disparities.

Nicotine vaping for relaxation and coping: Race/ethnicity differences and social connectedness mechanisms.

The current study examined race- and ethnicity-based differences in the reasons that youth report for vaping, with an emphasis on understanding the relationship between race/ethnicity and vaping for relaxation and stress/anxiety coping. This work also sought to go beyond examining race-based differences as a cause of tobacco-use disparities by assessing social connectedness factors that mediate relationships between race/ethnicity and vaping for relaxation and coping. Research questions were tested using data from the 2019-2020 California Student Tobacco Survey, a representative school-based survey of 10th and 12th grade public school students throughout schools in California. Overall, 7.78% of the sample reported using nicotine vapes in the past 30 days. The final sample included 11,112 high school student current vape users. The most important reason that youth vaped was for relaxation and stress/anxiety coping, with racial and ethnic minorities most likely to report this vaping motivation. Analyses of the structural mechanisms underlying the relationship between race/ethnicity and vaping reasons showed that minority youth reported lower school, peer, and family connectedness when compared to White youth. Lower school and family connectedness were in turn correlated with being motivated to vape to relax or relieve stress and anxiety, and lower overall mental health. Findings imply that future intervention efforts might profitably focus on reducing stressors associated with relaxation and stress/anxiety coping motivations and highlight the importance of connectedness for indirectly decreasing vape use risk by improving negative mood and mental health.

Adaptions to the National Diabetes Prevention Programme lifestyle change curriculum by Hawai'i Federally Qualified Health Centers: a qualitative descriptive study.

OBJECTIVE: The objective of this qualitative study was to describe the community-appropriate and culturally appropriate adaptations made by lifestyle change programme (LCP) coaches to the National Diabetes Prevention Programme curriculum for Federally Qualified Health Center (FQHC) patients in Hawai'i, an ethnically diverse state with a high proportion of Native Hawaiians and Pacific Islanders (NHPI). RESEARCH DESIGN AND METHODS: We used a qualitative descriptive approach. First, we conducted a document review of existing programmatic notes and materials followed by video interview calls with 13 lifestyle coaches at 7 FQHCs implementing in-person LCPs. Lifestyle coaches catalogued, described and explained the rationale for adaptations. The research team counted adaptations if they met a specific adaptation definition derived from several sources. Community and cultural relevancy of adaptations were analysed using an existing framework for weight loss and diabetes prevention for NHPIs. RESULTS: The average number of adaptations per FQHC was 8.61 (range: 4-16). Adaptations fell into 11 broad categories such as off-site community field trips, food-related and nutrition-related activities, and physical activity opportunities. Novel adaptations included goal setting with motivational interviewing and dyadic recruitment. Field trips and in-class food demonstrations addressed the most constructs related to weight loss and diabetes prevention for NHPI, including social and community barriers, familial barriers and barriers to self-efficacy. CONCLUSIONS: Lifestyle coaches were culturally attuned to the needs of LCP participants, particularly from NHPI communities. Policy-makers should recognise the extra work that LCP coaches do in order to increase enrollment and retention in these types of programmes.

Community Health Workers in Hawai'i: A Scoping Review and Framework Analysis of Existing Evidence.

Introduction: Community health workers (CHWs) play a vital role in health across Hawai'i, but the scope of this work is not comprehensively collated. This scoping review describes the existing evidence of the roles and responsibilities of CHWs in Hawai'i. Methods: Between May and October 2018, researchers gathered documents (eg, reports, journal articles) relevant to Hawai'i CHWs from health organizations, government entities, colleges/universities, and CHWs. Documents were reviewed for overall focus and content, then analyzed using the Centers for Disease Control and Prevention's 10 Essential Public Health Services as well as the Community Health Worker Core Consensus Project roles to identify workplace roles and gaps. Results: Of 92 documents received, 68 were included for review. The oldest document dated to 1995. Document types included curricula outlines, unpublished reports, and peer-reviewed articles. Documents discussed trainings, certification programs, CHWs' roles in interventions, and community-, clinical-, and/or patient-level outcomes. Cultural concordance parity between CHWs and patients, cost savings, and barriers to CHW work were noted. Most roles named by the Community Health Worker Core Consensus Project were mentioned in documents, but few were related to the roles of "community/policy advocacy" and "participation in research and evaluation." Workplace roles, as determined using the 10 Essential Public Health Services, focused more on "assuring workforce competency" and "evaluation," and less on "policy development," and "enforcing laws." Discussion: CHWs are an important part of Hawaii's health system and engage in many public health functions. Although CHW roles in Hawai'i mirrored those identified by the CHW Core Consensus Project and 10 Essential Public Health Services frameworks, there is a noticeable gap in Hawai'i CHW professional participation in research, evaluation, and community advocacy.

Legislative Definitions of Community Health Workers: Examples from Other States to Inform Hawai'i.

Community health workers (CHWs) have been important contributors to the health and wellness of disenfranchised and minority communities for more than 50 years in the United States. Recently the Centers for Disease Control and Prevention (CDC) recommended several policy initiatives to support and advance the CHW workforce, including formalizing a state-level definition for CHWs. Such state-wide standards can lay the groundwork for health insurance reimbursement for CHW services, help establish a professional identity, and generate cohesion among CHWs. Some states have already adopted a formal definition of CHWs. Hawai'i has had grassroots and political movement in this direction, although no widespread, formal consensus has been reached. This paper reviews decisions in other states in formally defining CHWs in order to inform efforts in Hawai'i. As of February 2019, data has been collected on states which have formally defined CHWs. Two independent reviewers compared the definitions used in 15 states with formalized definitions using the American Public Health Association (APHA) CHW Section definition. We found that most states built upon the APHA definition to create working definitions that were codified into law, sometimes with minor modifications for relevance to their communities. Given the widespread use of the APHA definition, Hawai'i may also find benefit from using the APHA definition as a backbone for a state-level definition. Critically, following best practices, it will be important to take steps to ensure CHW self-determination in all aspects of the processes towards a state-level definition of and scope of care for CHWs.

Differential Influence of Weight Status on Chronic Diseases by Reported Sexual Orientation Identity in Men.

PURPOSE: This study examined whether the association between weight status and four chronic diseases (heart disease, hypertension, lifetime asthma, and type 2 diabetes) varied according to sexual orientation identity among adult men, controlling for demographic, socioeconomic, and other factors. METHODS: Pooled data from male adult participants (n = 72,214) in the 2003-2012 California Health Interview Survey were used along with logistic regression models to estimate whether the associations between weight status and chronic diseases varied by sexual orientation identity. RESULTS: Weight status was positively associated with each of the chronic diseases (hypertension, heart disease, asthma, and diabetes) among both gay and bisexual men and heterosexual men; however, the associations varied significantly by sexual orientation identity. Among gay and bisexual men, the associations were stronger and statistically significant-with the exception of lifetime asthma-particularly for men in the obese classifications, before and after controlling for age, marital status, race/ethnicity, education, income, health insurance status, food security level, smoking, and nativity. CONCLUSIONS: Weight status had stronger detrimental associations with chronic disease among gay and bisexual men despite these men having greater socioeconomic advantage and lower body mass index than heterosexual men. Future research should examine mechanisms, including stress related to minority status, which may lead to greater risks for chronic diseases among sexual minority men.

Greater Community-Clinical Linkages and Attention to Patient Life Stage: Recommendations to Improve Diabetes Self-Management Education in Hawai'i.

Patients with diabetes regularly carry out multiple disease-management behaviors-taking prescribed medications, following diet and exercise regimens, self-monitoring their blood glucose concentrations, and coping emotionally with the condition-that may require ongoing support from community and clinical resources. Diabetes self-management education (DSME) is an ongoing, patient-centered process that helps provide the knowledge, skills, and ability for self-care. Evidence suggests that DSME is most effective when reinforced by community resources, through what are called community-clinical resources. We conducted a series of qualitative key-informant interviews with DSME coordinators/managers from all counties in Hawai'i to document the landscape of DSME services in the state, focusing specifically on challenges and recommendations. We analysed the results using the socioecological model in order to chart these factors by levels of influence on health care providers, in terms of service provision, and on patients, in terms of DSME utilization. Many interviewees highlighted concerns about low utilization of DSME services, as well as practical implementation challenges (eg, group versus 1-on-1 sessions). Nonetheless, DSME coordinators/managers offered numerous recommendations to improve DSME across Hawai'i, highlighting opportunities for improved community-clinical linkages. Finally, emergent from the interviews were anxieties about increasing numbers of youth with diabetes and insufficient resources for them in DSME or other community-clinical resources. This paper offers suggestions to expand community-clinical linkages and to adapt services provided by DSME to meet patient and community needs. It is particularly timely as Hawai'i is rapidly increasing the number and diversity of DSME programs available.

Community Health Workers in Action: Community-Clinical Linkages for Diabetes Prevention and Hypertension Management at 3 Community Health Centers.

In 2014, the Hawai'i State Department of Health (HDOH) received funding from the Centers for Disease Control and Prevention (CDC), via the 1422 Cooperative Agreement, to conduct diabetes prevention and hypertension management. To implement one grant-required strategy-the engagement of community health workers (CHWs) to promote community-clinical linkages-the HDOH partnered with the Hawai'i Primary Care Association and 9 federally qualified health centers (FQHCs). This qualitative evaluation case study sought to understand how 3 of the funded FQHCs engaged CHWs, the types of community-clinical linkages the CHWs promoted, and the facilitators of and barriers to those linkages. Evaluators conducted 2 semi-structured group interviews with 6 administrators/clinicians and 7 CHWs in April 2018. The transcribed interviews were deductively and inductively analyzed to identify major themes. First, CHWs made multiple internal and external linkages using resources provided by the grant as well as other resources. Second, CHWs faced barriers in making community-clinical linkages due to individual patient, geographic, and economic constraints. Third, CHWs have unmet professional needs related to building community-clinical linkages including professional development, networking, and burnout. Reimbursement and payment mechanisms are an all-encompassing challenge to the sustainability of CHW positions, as disease-specific funding and a complete lack of reimbursement structures make CHW positions unstable. Thus, CHWs fulfill a number of grant-specific roles at FQHCs due to this patchwork of funding sources, and this relates to CHWs' experiences of burnout. Policy implications of this study include funding and reimbursement stabilization so FQHCs may consistently engage and support the CHW workforce to meet their patients' complex, diverse needs. More professional development opportunities for CHWs are necessary to build sustainable networks of resources.

People who inject drugs and HIV crisis in Pence's Indiana: A media analysis using two policymaking theories.

BACKGROUND: In 2015, Scott County, Indiana was the center of an HIV outbreak related to injection drug use. Critiques of the government response exist; however, none examine the response through policymaking theories. This paper examines policy changes affecting people who use drugs (PWID) in Indiana through two theories: the social construction of target populations and punctuated equilibrium. METHODS: A media analysis was performed to examine the prevailing image of PWID in Indiana ten years prior to the outbreak and two years after the crisis emerged. Article tone was assessed to examine the social construction of PWID, and how this construction related to incremental, then punctuated policy making. RESULTS: A total of 372 news articles were examined. Media tone towards PWID was significantly more negative in the 10 years before the outbreak. Most articles regarding PWID pre-outbreak were crime-related, while during crisis, articles types varied and reframed PWID. CONCLUSION: News article tone changed significantly, allowing new approaches to health related to PWID to be considered. This paper demonstrates the utility of these policy frameworks and analysis of target populations through media depictions. Implications for public health practitioners are discussed.

Relationships between Sexual Orientation, Weight, and Health in a Population-Based Sample of California Women.

BACKGROUND: Most biomedical research has reported associations between weight and physical health problems; little is known about whether those associations vary by sexual identity. METHODS: Pooled data from the 2003 through 2013 waves of the California Health Interview Survey was used to construct logistic regression models to examine whether the associations between weight and four chronic conditions (type 2 diabetes, hypertension, heart disease, and asthma) varied by sexual identity. RESULTS: A total of 97,720 heterosexual and 2,822 lesbian/bisexual women comprised the analytic sample. There was a significant interaction between weight status and sexual identity (p < .001) for all four chronic diseases. Among lesbian/bisexual women, weight status was positively associated with heart disease, hypertension, asthma, and diabetes, although the associations between any weight status and heart disease, and between overweight and asthma, were not statistically significant. Among heterosexual women, weight status was positively and significantly associated with heart disease, hypertension, asthma, and diabetes. Except for overweight and heart disease, these associations remained significant after adjustment for covariates. CONCLUSION: This study underscores the importance of disaggregating analyses by sexual identity in studies that examine weight-chronic disease associations.