Whither syndemics?: Trends in syndemics research, a review 2015-2019

From conceptualising to modelling structural determinants and interventions in HIV transmission dynamics models: a scoping review and methodological framework for evidence-based analyses

BACKGROUND

Including structural determinants (e.g. criminalisation, stigma, inequitable gender norms) in dynamic HIV transmission models is important to help quantify their population-level impacts and guide implementation of effective interventions that reduce the burden of HIV and inequalities thereof. However, evidence-based modelling of structural determinants is challenging partly due to a limited understanding of their causal pathways and few empirical estimates of their effects on HIV acquisition and transmission.

METHODS

We conducted a scoping review of dynamic HIV transmission modelling studies that evaluated the impacts of structural determinants, published up to August 28, 2023, using Ovid Embase and Medline online databases. We appraised studies on how models represented exposure to structural determinants and causal pathways. Building on this, we developed a new methodological framework and recommendations to support the incorporation of structural determinants in transmission dynamics models and their analyses. We discuss the data and analyses that could strengthen the evidence used to inform these models.

RESULTS

We identified 17 HIV modelling studies that represented structural determinants and/or interventions, including incarceration of people who inject drugs (number of studies [n] = 5), violence against women (n = 3), HIV stigma (n = 1), and housing instability (n = 1), among others (n = 7). Most studies (n = 10) modelled exposures dynamically. Almost half (8/17 studies) represented multiple exposure histories (e.g. current, recent, non-recent exposure). Structural determinants were often assumed to influence HIV indirectly by influencing mediators such as contact patterns, condom use, and antiretroviral therapy use. However, causal pathways' assumptions were sometimes simple, with few mediators explicitly represented in the model, and largely based on cross-sectional associations. Although most studies calibrated models using HIV epidemiological data, less than half (7/17) also fitted or cross-validated to data on the prevalence, frequency, or effects of exposure to structural determinants.

CONCLUSIONS

Mathematical models can play a crucial role in elucidating the population-level impacts of structural determinants and interventions on HIV. We recommend the next generation of models reflect exposure to structural determinants dynamically and mechanistically, and reproduce the key causal pathways, based on longitudinal evidence of links between structural determinants, mediators, and HIV. This would improve the validity and usefulness of predictions of the impacts of structural determinants and interventions.

Co-occurring Intimate Partner Violence, Mental Health, Human Immunodeficiency Virus, and Parenting Among Women: A Scoping Review

Little research exists on the human immunodeficiency virus (HIV)-intimate partner violence (IPV)-mental health (MH) syndemic impact on parenting. The objective of this scoping review is to identify and summarize the available evidence regarding the syndemic relationship between HIV or Acquired Immune Deficiency Syndrome (AIDS), IPV, and poor MH among mothers and caregivers who identify as women. We conducted the review according to the Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and meta-analyses extension for scoping reviews guidelines, a comprehensive search was conducted from 2001 to September 2023. The inclusion criteria targeted studies examining at least two of the HIV, IPV, or MH epidemics among participants and their syndemic impact on parenting. Both qualitative and quantitative studies were included. Covidence software was used to screen and extract data. Twenty-three studies were included in the analysis. Most of the studies were conducted in the United States. Furthermore, all the studies used quantitative research designs, with most being longitudinal. Most of the research was concentrated on the IPV-MH syndemic with no research found on the HIV-IPV syndemic impact on parenting. Research on the HIV-IPV-MH syndemic found that an HIV diagnosis exacerbated the negative impacts of IPV-MH on parenting. Research on IPV-MH showed that this syndemic significantly influences parenting, leading to less nurturing and more punitive behaviors. Studies did not find a direct association between IPV and harsh parenting practices, the relationship was mediated by poor MH. Studies examining the HIV-MH syndemic found that anxiety and maternal depression were the most frequent MH disorders. The review revealed that living with the different syndemics, (IPV-MH-HIV, HIV-MH, and IPV-MH) adversely affects parenting practices, resulting in harsher parenting.

Psychosocial Syndemic Burden, Sexual Behaviors, and Engagement in HIV Prevention Care Among Sexual and Gender Minority Youths: United States, 2022

Objectives. To examine linear and nonlinear associations between psychosocial syndemic factors and HIV risk and engagement in HIV prevention care among sexual and gender minority (SGM) youths. Methods. Between February and October 2022, we recruited 17 578 SGM youths aged 13 to 18 years in the United States for an online survey. We examined the relationship of syndemics (i.e., binge drinking, drug use, sexual victimization, and anti-lesbian, gay, bisexual, and transgender discrimination) with sexual behaviors (i.e., sexual initiation, condomless anal or vaginal sex, and number of sexual partners) and HIV prevention care (i.e., HIV testing, preexposure prophylaxis awareness and utilization) using regression. Results. Psychosocial syndemic burden (number of syndemic factors reported) was linearly and cubically associated with engagement in sexual behaviors. Psychosocial syndemic burden was linearly associated with higher HIV testing and preexposure prophylaxis awareness and cubically associated with higher preexposure prophylaxis utilization. Conclusions. Our findings are evidence of synergism across psychosocial syndemic factors regarding HIV risk and engagement in HIV prevention care among SGM youths in the United States. Public Health Implications. Multicomponent interventions may help reduce HIV risk and promote access to HIV prevention services among SGM individuals aged 13 to 18 years. (Am J Public Health. 2024;114(9):892-902. https://doi.org/10.2105/AJPH.2024.307753).

Convergence between Cardiometabolic and Infectious Diseases in Adults from a Syndemic Perspective: A Scoping Review

Objective. Synthesize the approaches used to study the convergence between cardiometabolic and infectious diseases in adults from a syndemic perspective based on the scientific evidence available to date worldwide. Methods. Scoping review that follows the recommendations of the PRISMA statement. The protocol was registered in INPLASY202150048. The search for studies was carried out in MEDLINE, LILACS, Web of Science and Scopus. Results. Since the COVID-19 pandemic, there has been an increase in studies in the field of convergence between cardiometabolic and infectious diseases from a syndemic perspective, but only three studies were classified as true syndemics. There are weaknesses in the adherence to the elements of the syndemic theory, given a low incorporation of population measurements, and until now it has not been possible to find convincing empirical evidence that supports the bio-bio interface. Quantitative methods predominated through models focused on "sum scores". Conclusions. Future studies should comprehensively address the elements of syndemics, review discrepancies between additive analyses versus other modeling, and incorporate the influence of large-scale social forces. The lack of these aspects distances studies from the notion of syndemic, bringing them closer to comorbidity or multimorbidity approaches.

Using a Syndemics Perspective to (Re)Conceptualize Vulnerability during the COVID-19 Pandemic: A Scoping Review

Syndemics theory has been applied to study interactions between biomedical and social factors leading to the clustering of diseases. Because syndemics theory focuses on interactions that enhance risk, the concept of vulnerability is central to this approach. We conducted a scoping review to better understand how this theoretical framework helped to define, operationalize, and tackle issues of vulnerability during the COVID-19 pandemic. Original research, reviews, and opinion pieces elaborating on syndemics, vulnerability, and COVID-19, published between December 2019 and October 2022 and available from PubMed, were eligible. We analyzed 40 records and identified three framings of syndemics operating during this period: (1) interactions between COVID-19, diseases/health conditions, and specific social factors; (2) interactions between COVID-19 and social determinants of health; and (3) impacts of COVID-19 on specific populations. Emerging conceptualizations described vulnerability to COVID-19 as a systemic issue, explained the impact of COVID-19 control measures on increased vulnerability, and presented COVID-19 as a syndemic on its own. However, this theory's potential for deepening our understanding of vulnerability during this pandemic was constrained by superficial explorations of the interactions between biomedical and social spheres, and insufficient theoretical and methodological support from the social sciences.

Syndemic Theory and Its Use in Developing Health Interventions and Programming: A Scoping Review

PURPOSE OF REVIEW

The central tenet of syndemics theory is that disease interactions are driven by social factors, and that these factors have to be understood in order to reduce the health burdens of local populations. Without an understanding of the theory and how it is being put into practice, there is a strong possibility of losing the potential for syndemic theory to positively impact change at community and individual level.

METHODS

Following an initial database search that produced 921 articles, we developed a multi-stage scoping review process identifying invention studies that employ syndemic theory. Inclusion was defined as the presence of healthcare interventions examining multiple social-biological outcomes, refering to a specific (local) at risk population, developing or attempting to develop interventions impacting upon multiple health and/or social targets, and explicit employment of syndemic theory in developing the intervention.

RESULTS

A total of 45 articles contained a substantial engagement with syndemic theory and an original healthcare intervention. However, only eleven studies out of all 921 articles met the inclusion criteria.

DISCUSSION/CONCLUSION

It is strongly suggested that when employing syndemic theory researchers focus close attention to demonstrating disease interactions, providing evidence of the social drivers of these disease interactions, and constructing interventions grounded in these analytical findings. We conclude that although frequently referred to, syndemic theory is rarely employed in its entirety and recommend that interventions be developed using a more thorough grounding in this important and powerful theory.

The impact of social isolation policies during COVID-19 on suburban mothers and pregnant women with opioid use disorder

The aim of this qualitative research paper was to identify how social isolation policies implemented during the COVID-19 pandemic impacted the lives of pregnant women and mothers with opioid use disorder. Between 2020 and 2022, in-depth interviews were conducted with 37 mothers and pregnant women living in the suburbs of Newark, NJ, and New Haven, CT. Participants had to be at least 18 years old, misused or abused opioids in the last 12 months while residing in a suburban location, and pregnant or caring for children aged 12 and younger. We used syndemics theory to guide our grounded theory analysis to identify relationships between social situations, health conditions, and opioid use disorder. Five major themes emerged that were either directly or indirectly impacted by social isolation caused by policies implemented during the COVID-19 pandemic: Relationships, Environment, Services, Drug Use, and Health. Findings from this study reveal new insights into how mothers and their health were impacted by prolonged social isolation policies and offer suggestions for policymakers and service providers to better address future crisis.

On the issue of treating HIV in people with syndemic mental-health and substance-use disorders

People with HIV and comorbid substance use problems may be among those who benefit most from long-acting HIV antiretroviral treatment, but they are routinely excluded from Phase 3 clinical trials. Their inclusion would permit an examination of the clinical value of long-acting therapies for people with adherence problems and an exploration of syndemic interactions between HIV, mental health conditions, and substance use problems, which compound into a major challenge in the efforts to end the HIV epidemic.

Preventing Health Disparities during COVID through Perinatal Home Screening as Black Authoritative Knowledge

During COVID-19 epidemic, health protocols limited face-to-face perinatal visits and increased reliance on telehealth. To prevent increased health disparities among BIPOC pregnant patients in health-underserved areas, we used a pre-post survey design to pilot a study assessing (1) feasibility of transferring technology including a blood pressure (BP) cuff (BPC) and a home screening tool, (2) providers' and patients' acceptance and use of technology, and (3) benefits and challenges of using the technology. Specific objectives included (1) increasing contact points between patients and perinatal providers; (2) decreasing barriers to reporting and treating maternal hypertension, stress/depression, and intimate partner violence (IPV)/domestic violence (DV); and (3) bundling to normalize and facilitate mental, emotional, and social health monitoring alongside BP screening. Findings confirm this model is feasible. Patients and providers used this bundling model to improve antenatal screening under COVID quarantine restrictions. More broadly, home-monitoring improved antenatal telehealth communication, provider diagnostics, referral and treatment, and bolstered patient autonomy through authoritative knowledge. Implementation challenges included provider resistance, disagreement with lower than ACOG BP values to initiate clinical contact and fear of service over-utilization, and patient and provider confusion about tool symbols due to limited training. We hypothesize that routinized pathologization and projection of crisis onto BIPOC people, bodies, and communities, especially around reproduction and continuity, may contribute to persistent racial/ethnic health disparities. Further research is needed to examine whether authoritative knowledge increases use of critical and timely perinatal services by strengthening embodied knowledge of marginalized patients and, thus, their autonomy and self-efficacy to enact self-care and self-advocacy.

Do syndemic conditions predict HIV medication adherence among urban African American men?

Much progress has been made in advancing antiretroviral (ART) adherence, yet disparities remain. To explore relationships of syndemic conditions - co-occurring health conditions caused by combinations of biological, social, and structural factors - to ART adherence among African American men, we used data from longitudinal assessments of 302 African American men enrolled in a study designed to increase physical activity and healthy eating. Syndemic conditions included alcohol dependency, drug dependency, depression, post-traumatic stress disorder, and unstable housing. A syndemic conditions variable was operationalized to indicate the presence of 0-5 conditions. About 55% of participants had 1 or more syndemic conditions. Age and marriage were positively associated with ART adherence, whereas number of syndemic conditions was negatively associated with adherence during the 12-month period. The interaction of being married and the syndemic conditions variable significantly predicted greater adherence. Similarly, the interaction of more education and the syndemic conditions variable predicted greater adherence. In multiple regression models, the syndemic conditions variable remained significant (-0.018) in predicting adherence; however, there was no significant interaction among the 5 conditions. This study lends evidence to syndemics literature indicating deleterious consequences of negative life experiences on health outcomes.

Transactional sex among adults accessing sexual health services in Alabama, 2008-2022: Prevalence, associated risk factors, and associations with HIV, HCV, and STI diagnosis

BACKGROUND

The U.S. Deep South bears a disproportionate burden of HIV and other STIs. Transactional sex may influence these epidemics, but few studies have estimated its prevalence or correlates in the Deep South.

METHODS

We estimated the history of transactional sex among adults accessing an Alabama AIDS Service Organization from 2008-2022, using chi-square tests to examine its sociodemographic and behavioral correlates. We used modified Poisson regression with cluster-robust standard errors to estimate adjusted prevalence ratios (aPR) and 95 % confidence intervals (CI) for the associations between transactional sex and new HIV, hepatitis C (HCV), and STI diagnoses.

RESULTS

Transactional sex was reported at 944/20,013 visits (4.7 %) and associated with older age, being a cisgender woman or gender minority, identifying as white, diverse drug use, and sharing of drug equipment. Compared to others, clients reporting transactional sex had increased prevalence of syphilis (apR 3.60, 95 % CI 1.16-11.19) and HCV (aPR 1.53, 95 % CI 1.24-1.88).

CONCLUSION

Using 14 years of community-based data, this study is the first to estimate the relationship between transactional sex and HIV, HCV, and STIs in Alabama and highlights the need address STI burden and diverse drug use among people who transact sex in the Deep South.

"Gender-Based Water Violence": Cross-Cultural Evidence for Severe Harm Associated With Water Insecurity for Women and Girls

We examined how study participants in Indonesia and Peru viewed the relationship between water insecurity and women's health via thematic analysis of interviews and focus groups. Participants reported that water insecurity led to vaginal infections, miscarriage, premature births, uterine prolapse, poor nutrition, restricted economic opportunities, and intergenerational cycles of poverty. Participants in both countries stated that extreme burdens associated with water insecurity should be categorized as violence. Based on these findings, we developed the concept of "gender-based water violence," defined as the spectrum of stressors associated with water insecurity that are so severe as to threaten human health and well-being, particularly that of women and girls.

Intersectional Microaggressions and Implications for Health Inequities and HIV Among Latino/x Sexual Minority Males in Puerto Rico

Latino/x sexual minority males (SMM) continue to be disproportionately impacted by health inequities. This study aims to understand the lived experience of Puerto Rican (PR) SMM related to how intersectional microaggressions influence health-related risk and protective factors. Young adult (ages 21-30) PR SMM from San Juan, Puerto Rico, completed a bilingual in-depth individual interview (14 in Spanish and 1 in English). A thematic analysis based on the original language of the interviews was conducted using NVivo. Six prominent themes were identified through the data analysis: (1) religious microaggressions, being gay is bad because God doesn't like it; (2) gender microaggressions, gay is not good because it's not for men; (3) sexuality microaggressions, this one is a homosexual, coming out as a sexual minority; (4) trans microaggressions, drag queens create an illusion; (5) internalized microaggressions, battling with internalized homophobia; and (6) mitigating microaggressions, establishing a supportive community. Findings suggest that multiple forms of microaggressions based on the intersectionality of sexuality and gender manifest from straight as well as gay communities. PR SMM demonstrated their resiliency by assessing interactions with others to mitigate risks and enhance supportive networks.

Conceptualizing COVID-19 syndemics: A scoping review

Background

COVID-19's heavy toll on human health, and its concentration within specific at-risk groups including the socially vulnerable and individuals with comorbidities, has made it the focus of much syndemic discourse. Syndemic theory recognizes that social factors create the conditions that support the clustering of diseases and that these diseases interact in a manner that worsens health outcomes. Syndemics theory has helped to facilitate systems-level approaches to disease as a biosocial phenomenon and guide prevention and treatment efforts. Despite its recognized value, reviews of syndemics literature have noted frequent misuse of the concept limiting its potential in guiding appropriate interventions.

Objective

To review how the term 'syndemic' is defined and applied within peer-reviewed literature in relation to COVID-19.

Design

A scoping review of definitions within COVID-19 literature published between January 1, 2020 to May 15, 2023 was conducted. Searches took place across six databases: Academic Search Premier, CINAHL, JSTOR, MEDLINE/Pubmed, PsycINFO and Scopus. PRISMA-ScR guidelines were followed.

Results

Content analysis revealed that COVID-19 has varied clustered configurations of communicable-non-communicable diseases and novel communicable disease interactions. Spatial analysis was presented as a new strategy to evidence syndemic arrangements. However, syndemics continue to be regarded as universal, with continued misunderstanding and misapplication of the concept.

Conclusion

This review found that current applications of syndemics remain problematic. Recommendations are made on the design of syndemic studies. A syndemic framework offers an opportunity for systems-level thinking that considers the full complexity of human-disease interactions and is useful to inform future pandemic preparations and responses.

Spanish residents' experiences of care during the first wave of the COVID-19 syndemic: a photo-elicitation study

PURPOSE

The main aim of this research was to explore experiences of care during the lockdown of the first wave of COVID-19 syndemic in Spain.

METHODS

This is a qualitative and explorative study using self-photo-elicitation as a data collection method. Fifteen participants (Twelve women and three men) shared 25 photographs and one video between the June 18 and August, 2020. Participants' photographs and texts were collected online. Data were analysed based on Thematic Analysis.

RESULTS

Three emerging categories were constructed: 1) the deconstruction of care: self-care and collective care 2) the crisis of care and gendered care, 2) beyond anthropocentrism: animalism and ecology. Findings indicate the need to understand "care" in terms of social reproduction, including self-care, care towards other humans and non-human animals, and collective care. Also, the need to care for planetary health and to be in contact with nature as a form of self-care and social care.

CONCLUSIONS

Care in a period of social and health crisis puts human relationships and also non-human life at the centre. Care requires adopting taking an ecological one-health perspective.

Syndemic Conditions and Their Association with HIV/STI Sexual Risk Behaviors Among Transgender Women and Cisgender Men Sex Workers in Catalonia: The SexCohort Project

BACKGROUND

Transgender women and cisgender men sex workers are vulnerable to HIV and sexually transmitted infections (STIs). This study aimed to explore in depth the prevalence of syndemic conditions and their association with the sexual risk behaviors for HIV/STI acquisition in cis men and trans women sex workers in Barcelona (Catalonia, Spain).

METHOD

We conducted a study between 2014 and 2018 to determine whether syndemic conditions (frequent alcohol consumption and polydrug use (> 2) during sex with clients; experience of violence; and lack of healthcare access) are associated with HIV/STI sexual risk behaviors. A "syndemic index" was calculated based on the cumulative number of syndemic conditions (0 to 4).

RESULTS

In the last year (2018), 78.8% of cisgender men and 68.1% of transgender women reported at least one syndemic condition. The most prevalent syndemic factor in both cisgender men and transgender women was violence (38.8% and 43.6% respectively). In multivariable analysis, an association was found between condomless anal sex and violence (aOR = 1.81), and frequent alcohol consumption and violence with reporting > 10 clients/week (aOR = 2.73 and 1.88, respectively). The higher the number of syndemic factors, the greater probability of having > 10 clients/week and reporting condomless anal sex with clients.

CONCLUSION

Psychosocial conditions have a syndemic effect on risky sexual behaviors highlighting the need for a more holistic approach to HIV/STI prevention targeting these populations.

The application of clique percolation method in health disparities research

AIMS

Clique percolation, one of the joint community detection algorithms in network science, is a novel and efficient approach to detecting overlapping communities in real networks. The current study illustrated how clique percolation can help to identify overlapping communities within the complex networks underlying health disparities, particularly highlighting nodes with strong associations with more than one community.

DESIGN

A cross-sectional study.

METHODS

The study used a dataset on Latinx populations (N = 1654; mean age = 43.3 years; 53.1% women) as an example to demonstrate the role of such overlapping nodes in the network of syndemic conditions and their common risk factors. Syndemic conditions in the network included HIV risk, substance abuse (smoking, heavy alcohol consumption and marijuana use) and poor mental health. Moreover, the risk factors encompassed individual (education and income) and sociostructural (adverse childhood experiences [ACEs] and access to services) factors. The network was estimated using the R-package bootnet. Clique percolation was conducted on the estimated network using the R-package CliquePercolation.

RESULTS

A total of three communities were detected, with HIV risk and poor mental health not being assigned to any community. In general, Community 1 was comprised of ACE categories, Community 2 included education, income and access to services and Community 3 included other syndemic conditions. Of note, two nodes were assigned to two communities: 'household dysfunction' to Communities 1 and 2 and 'smoking' to Communities 2 and 3.

CONCLUSION

Household dysfunction might be the key connector, among other ACEs, to individual and structural barriers. Such barriers further exposed Latinx individuals to risky behaviours, especially smoking, which further linked to marijuana use and heavy alcohol consumption.

IMPACT

Clique percolation facilitated our understanding of the complex systems of factors shaping health disparities. The overlapping nodes are promising intervention targets for reducing health disparities in this historically marginalized population.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

A review of place-related contextual factors in syndemics research

This review investigates the extent to which a place-based approach has been used to conceptualize context, as well as the place-related contextual factors explored in studies that explicitly invoked a syndemic framework. The literature search focused on 29 peer-reviewed empirical syndemic studies. Only 11 studies used a place-based approach to define and measure contextual factors and the spatial context was denoted using administrative boundaries such as census tracts, counties, and countries. A narrow range of place-related contextual factors were explored and most of them were related to social and economic factors that were used to define a place. Methodological gaps like a paucity of multilevel studies and studies using a place-based approach to measure context were identified. Future syndemics research should leverage multidimensional geospatial approaches to decipher the role of place-related contextual factors in syndemic dynamics.

A syndemic of inequitable gender norms and intersecting stigmas on condom self-efficacy and practices among displaced youth living in urban slums in Uganda: a community-based cross-sectional study

BACKGROUND

Adverse socio-cultural factors compromise the implementation of HIV prevention strategies among displaced youth. While condoms are an affordable and effective HIV prevention strategy for youth, stigma and inequitable gender norms may constrain condom self-efficacy (i.e., knowledge, intentions, and relationship dynamics that facilitate condom negotiation) and use. Further, knowledge of contextually appropriate HIV prevention approaches are constrained by limited understanding of the socio-cultural conditions that affect condom self-efficacy and use among displaced youth. Guided by syndemics theory, we examine independent and joint effects of adverse socio-cultural factors associated with condom self-efficacy and use among displaced youth living in urban slums in Kampala, Uganda.

METHODS

We conducted a community-based cross-sectional survey of displaced youth aged 16-24 years living in five slums in Kampala. We used multivariable logistic regression and multivariate linear regression to assess independent and two-way interactions among adverse socio-cultural factors (adolescent sexual and reproductive health-related stigma [A-SRH stigma], perceived HIV-related stigma, and beliefs in harmful inequitable gender norms) on condom self-efficacy and recent consistent condom use. We calculated the prevalence and co-occurrence of adverse socio-cultural factors; conducted regression analyses to create unique profiles of adverse socio-cultural factors; and then assessed joint effects of adverse socio-cultural factors on condom self-efficacy and practices.

RESULTS

Among participants (mean age: 19.59 years; SD: 2.59; women: n = 333, men: n = 112), 62.5% were sexually active. Of these, only 53.3% reported recent consistent condom use. Overall, 42.73% of participants reported two co-occurring adverse socio-cultural factors, and 16.63% reported three co-occurring exposures. We found a joint effect of beliefs in harmful inequitable gender norms with high A-SRH stigma (β = - 0.20; p < 0.05) and high A-SRH stigma with high perceived HIV stigma (β = - 0.31; p < 0.001) on reduced condom self-efficacy. We found a multiplicative interaction between high A-SRH stigma with high perceived HIV stigma (aOR = 0.52; 95% CI 0.28, 0.96) on recent consistent condom use. Additionally, we found that condom self-efficacy (aOR = 1.01; 95% CI 1.05, 1.16) and safer sexual communication (aOR = 2.12; 95% CI 1.54, 2.91) acted as protective factors on inconsistent condom use.

CONCLUSIONS

Displaced youth living in urban slums exhibited low consistent condom use. Intersecting stigmas were associated with lower condom self-efficacy-a protective factor linked with increased consistent condom use. Findings highlight the importance of gender transformative and intersectional stigma reduction approaches to increase sexual agency and safer sex practices among Kampala's slum-dwelling displaced youth.

High-risk polysubstance use among LGBTQ+ people who use drugs in the United States: An application of syndemic theory

BACKGROUND

Compared to heterosexual and cisgender people, lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) people are more likely to develop problems with high-risk polysubstance use. According to syndemic theory, this disparity in high-risk polysubstance use is produced by the LGBTQ+ community's increased vulnerability to experiencing psychosocial (e.g., discrimination, unwanted sex) and structural (e.g., food insecurity, homelessness) conditions, greater likelihood of coping with concurrent health problems (e.g., human immunodeficiency virus [HIV]), and decreased opportunities to develop protective factors (e.g., social support, resilience).

METHODS

Data from 306 LGBTQ+ participants living in the United States (U.S.) with a lifetime history of alcohol and drug use were analyzed; 21.2% reported lifetime problems with 10 different drugs. Bootstrapped hierarchical multiple regression was used to test demographic correlates and syndemic predictors of high-risk polysubstance use. One-way ANOVA and post-hoc comparison tests were used to test subgroup differences by gender.

RESULTS

Results indicated that income, food insecurity, sexual orientation-based discrimination, and social support were associated with high-risk polysubstance use, explaining 43.9% of the variance of high-risk polysubstance use. Age, race, unwanted sex, gender identity-based discrimination, and resilience were not significant. Group comparison tests revealed that, compared to nonbinary people and cisgender sexual minority men and women, transgender individuals experienced significantly higher levels of high-risk polysubstance use and sexual orientation-based discrimination but significantly lower levels of homelessness and social support.

CONCLUSION

This study provided further evidence for conceptualizing polysubstance use as an adverse outcome of syndemic conditions. Harm reduction strategies, anti-discrimination laws, and gender-affirming residential treatment options should be considered in U.S. drug policy. Clinical implications include targeting syndemic conditions to reduce high-risk polysubstance use among LGBTQ+ people who use drugs.

Syndemic conditions and quality of life in the PISCIS Cohort of people living with HIV in Catalonia and the Balearic Islands: a cross sectional study

BACKGROUND

People living with HIV (PLWH) face structural and psychosocial factors that affect health-related quality of life (HRQoL). We aimed to evaluate how syndemic conditions affected HRQoL in PLWH.

METHODS

A cross-sectional survey was conducted among 861 PLWH, to determine whether syndemic conditions (monthly income; sexual satisfaction; depressive symptoms; social role satisfaction; social isolation; cognitive function; nicotine dependence; perception of stigma) have an effect on HRQoL. A linear regression model and measures of Additive Interaction (AI) were used to determine the effects of syndemic conditions on HRQoL, controlling for other risk factors.

RESULTS

Overall, the most frequently observed were stigma perception (56.9%), poor cognitive function (50.6%) and the perception of social isolation (51.6%). The presence of depressive symptoms was the risk factor most associated with worse Physical Health (PH) (B 3.93, 2.71-5.15) and Mental Health (MH) (B 5.08, 3.81-6.34) in linear regression model. Specifically, an interaction was observed between poor cognitive function and poor satisfaction with social role on worse PH and MH (AI 2.08, 0.14-4.02; AI 2.69, 0.15-5.22, respectively); and low income and perception of stigma (AI 2.98, 0.26-5.71), low income and perception of social isolation (AI 2.79, 0.27-5.32), and low income and poor satisfaction with social role (AI 3.45, 0.99-5.91) on MH.

CONCLUSION

These findings provide evidence that syndemic factors impact HRQoL. HIV prevention programs should screen and address co-occurring health problems to improve patient-centered health care and outcomes.

Syndemic Profiles and Sexual Health Risks Among Sexually Exploited Adolescent Girls in Taiwan: A Latent Class Analysis

Sexually exploited adolescent girls are disproportionately affected by adverse psychosocial conditions, such as intra-familial child physical and sexual abuse, extra-familial violence and sexual assault, alcohol and drug use, and suicide. Syndemic theory suggests that these adverse psychosocial or syndemic conditions are concentrated and co-occurring in socially marginalized populations, including sexually exploited adolescents, and increase their sexual health risks, including pregnancy, abortion, and the acquisition of sexually transmitted diseases (STDs). To examine clusters of syndemic conditions, latent class analysis (LCA) was conducted to classify 335 sexually exploited girls in Taiwan into subgroups based on their probability of experiencing each syndemic condition. We used syndemic class membership to predict their sexual health outcomes, specifically pregnancy, abortion, and the acquisition of STDs. The results of LCA revealed three classes, which were "low-risk syndemic," "moderate-risk syndemic," and "high-risk syndemic." The risk of acquisition of STDs among sexually exploited girls in the "high-risk syndemic class" and "moderate-risk syndemic class" was 239% and 135% higher, respectively, than the risk of acquisition of STDs among sexually exploited girls in the "low-risk syndemic class." Differences between these three classes in pregnancy and abortion were not significant. Our findings support the syndemic theory that a pattern of syndemic conditions is associated with an increased risk of acquiring STDs. Interventions aimed at reducing the acquisition of STDs among sexually exploited girls in Taiwan should adopt a comprehensive approach to address co-occurring conditions.

Health inequalities and social determinants of health: The role of syndemics in rheumatic disease

A syndemic is the co-existence of two or more health problems (including both social and biological features) that adversely influence each other with negative consequences on disease outcomes and perpetuation of inequalities. The syndemic approach can be applied to better understand the course of rheumatic musculoskeletal diseases (RMD) involving the study of adverse biological pathways and social determinants of health (SDH) all under the same framework. Identifying if a syndemic exists within RMDs may include investigating the synergic interactions between comorbidity (e.g., diabetes, obesity, chronic kidney diseases) and the concomitant of other adverse conditions (e.g., drug non-adherence, substance abuse), along with SDHs such as low household income, unemployment, low education, limited access to health care, as well as racial/ethnic discrimination. For decades, the understanding of RMDs progression has been based on causality, rather than investigating the kaleidoscopic web of connections that can potentially influence a disease course. The co-existence of health burdens in vulnerable populations, including those with RMD, specifically in certain socioeconomic groups, calls for new ways and strategies of thinking to improve our understanding of risk factors and co-morbidities to offer tailored interventions for clinical medicine and public health policy.

Syndemic of factors that shape the early lives of women who enter into sex work: a qualitative methods study from Nairobi, Kenya

OBJECTIVE

To explore the structural and social co-factors that shape the early lives of women who enter sex work in Nairobi, Kenya.

DESIGN

Thematic analysis of qualitative data collected as part of the Maisha Fiti study among female sex workers (FSWs) in Nairobi.

PARTICIPANTS AND MEASURES

FSWs aged 18-45 years were randomly selected from seven Sex Workers Outreach Programme clinics in Nairobi and participated in baseline behavioural-biological surveys. Participants in this qualitative study were randomly selected from the Maisha Fiti study cohort and were interviewed between October 2019 and July 2020. Women described their lives from childhood, covering topics including sex work, violence and financial management.

RESULTS

48 out of 1003 Maisha Fiti participants participated in the in-depth qualitative interviews. FSWs described how physical and sexual violence, poverty and incomplete education in their childhood and adolescence intertwined with early pregnancy, marriage, intimate partner violence and relationship breakdown in their adolescence and early adulthood. The data analysis found clear syndemic relationships between these risk factors, particularly childhood violence, poverty and incomplete education and highlighted pathways leading to financial desperation and caring for dependents, and subsequent entry into sex work. Women perceived sex work as risky and most would prefer alternative work if possible, but it provided them with some financial independence and agency.

CONCLUSIONS

This is the first study in Kenya to qualitatively explore the early lives of sex workers from a syndemic perspective. This method identified the pivotal points of (1) leaving school early due to poverty or pregnancy, (2) breakdown of early intimate relationships and (3) women caring for dependents on their own. Complex, multi-component structural interventions before these points could help increase school retention, reduce teenage pregnancy, tackle violence, support young mothers and reduce entry into sex work and the risk that it entails by expanding livelihood options.

Downing the Master's Tools? New Research Strategies to Address Social Determinants of Health Inequalities

A dramatic increase in the volume of research literature referencing social determinants of health (SDH) since the report of the World Health Organization Commission on the topic in 2008 has not been matched by expansion of policies and interventions to reduce health inequalities by way of SDH. This article argues that familiar hierarchies of evidence that privilege clinical epidemiology as used in evidence-based medicine are inappropriate to address SDH. They misunderstand both the range of relevant evidence and the value-based nature of standards of proof. A richer conceptual armamentarium is available; it includes several applications of the concepts of epidemiological worlds and the lifecourse, which are explained in the article. A more appropriate evidentiary approach to SDH and health inequalities requires "downing the master's tools," to adapt Audre Lorde's phrase, and instead applying a multidisciplinary approach to assessing the evidence that adequately reflects the complexity of the relevant causal pathways. Doing so is made more difficult by the power structures that shape research priorities, yet it is essential.

A Mixed-Methods Systematic Review on Syndemics in Rheumatology

OBJECTIVE

We aimed to assess the use of framework and corresponding methodology to document syndemics and its impact in rheumatic and musculoskeletal diseases (RMDs).

METHODS

Using a mixed-methods systematic review, studies using the syndemic framework approach for RMDs were identified and published from January 2003 to January 2021. The Joanna Briggs Institute, Cochrane Collaboration, and PRISMA guidelines were followed to search, retrieve, revise, and analyze.

RESULTS

A total of 658 potential articles were identified, but only 10 were initially eligible. After a full-text review, 4 were included. Following a full-text review, 2 quantitative, 1 qualitative, and 1 mixed-methods study were included. In the first, network analysis found that RMDs were associated with comorbidities, unhealthy habits, low educational level, living in rural areas, socioeconomic conditions, and health inequality in indigenous communities. In the second, SSEM and cluster analysis demonstrated an association between low back pain and factors, such as comorbidities and indigenous status, among others, in urban/rural communities. The qualitative study examined 3 fishing family generations and reported less syndemic vulnerability. The mixed-methods study focused on osteoarthritis with multimorbidities in African American population, where lack of education added to worsening outcomes.

CONCLUSIONS

Even though the insights syndemic studies have given to other areas, its use in rheumatology is scarce. The complexity of the clinical and social determinants related to RMDs makes it necessary to conduct further studies from a syndemic perspective.

COVID-19, Mental Health, and Chronic Illnesses: A Syndemic Perspective

BACKGROUND

The COVID-19 pandemic is an epidemiological and psychological crisis; what it does to the body is quite well known by now, and more research is underway, but the syndemic impact of COVID-19 and mental health on underlying chronic illnesses among the general population is not completely understood.

METHODS

We carried out a literature review to identify the potential impact of COVID-19 and related mental health issues on underlying comorbidities that could affect the overall health of the population.

RESULTS

Many available studies have highlighted the impact of COVID-19 on mental health only, but how complex their interaction is in patients with comorbidities and COVID-19, the absolute risks, and how they connect with the interrelated risks in the general population, remain unknown. The COVID-19 pandemic can be recognized as a syndemic due to; synergistic interactions among different diseases and other health conditions, increasing overall illness burden, emergence, spread, and interactions between infectious zoonotic diseases leading to new infectious zoonotic diseases; this is together with social and health interactions leading to increased risks in vulnerable populations and exacerbating clustering of multiple diseases.

CONCLUSION

There is a need to develop evidence to support appropriate and effective interventions for the overall improvement of health and psychosocial wellbeing of at-risk populations during this pandemic. The syndemic framework is an important framework that can be used to investigate and examine the potential benefits and impact of codesigning COVID-19/non-communicable diseases (NCDs)/mental health programming services which can tackle these epidemics concurrently.

Intervening on the Intersecting Issues of Intimate Partner Violence, Substance Use, and HIV: A Review of Social Intervention Group's (SIG) Syndemic-Focused Interventions for Women

Intimate partner violence (IPV), HIV, and substance use are serious intersecting public health issues. This paper aims to describe the Social Intervention Group (SIG)'s syndemic-focused interventions for women that address the co-occurrence of IPV, HIV, and substance use, referred to as the SAVA syndemic. We reviewed SIG intervention studies from 2000 to 2020 that evaluated the effectiveness of syndemic-focused interventions which addressed two or more outcomes related to reducing IPV, HIV, and substance use among different populations of women who use drugs. This review identified five interventions that co-targeted SAVA outcomes. Of the five interventions, four showed a significant reduction in risks for two or more outcomes related to IPV, substance use, and HIV. The significant effects of SIG's interventions on IPV, substance use, and HIV outcomes among different populations of women demonstrate the potential of using syndemic theory and methods in guiding effective SAVA-focused interventions.

Sexual health indicators for the United States: Measuring progress and documenting public health needs

Introduction

Today, we are facing increased and continued adverse sexual health outcomes in the United States, including high post-COVID-19 pandemic rates of sexually transmitted infections (STIs). For the past 20 years, there have been calls for a national health strategy and a more comprehensive sexual health approach to address the myriad of persistent sexual health problems in this country. Employing a sexual health approach requires shifting from a longstanding, stigmatizing focus on morbidity toward a holistic and integrated focus on health rather than disease. While strategies are being implemented by multisectoral stakeholders, it is also important to establish a core set of indicators that broadly describe the state of sexual health in the U.S. and allow for measurement across time. The development of a comprehensive scorecard with key sexual health indicators has been proposed by other entities (e.g., Public Health England, World Health Organization), but such an attempt has not been made in the U.S.

Methods

A review of national U.S. surveys and surveillance systems with items related to sexual health was conducted for years 2010-2022 to develop an inventory of existing data that yield national estimates for potential indicators of sexual health.

Results

We selected 23 sexual health indicators in four broad domains including: (1) knowledge; communication and attitudes (five indicators); (2) behaviors and relationships (four indicators); (3) service access and utilization (seven indicators); and (4) adverse health outcomes (seven indicators). Recent data for each indicator are provided.

Discussion

A growing body of evidence shows the positive effects of moving away from a morbidity focus toward an integrated, health-promoting approach to sexual health. Yet, not much has been done in terms of how we implement this national shift. We argue that measurement and monitoring are key to future change. We envision these core sexual health indicators would be published in the form of an index that is publicly available and updated frequently. These sexual health indicators could be used for ongoing monitoring, and to guide related research, programming, and policy development to help promote sexual health in coming years.

L’approche syndémique appliquée à la santé des minorités sexuelles et de genre : étude de la portée

INTRODUCTION

Sexual and gender minorities (SGM) represent a vulnerable population, disproportionately affected by mental health issues, a higher exposure to violence and a higher prevalence of sexually transmitted infections, including HIV, for some subgroups. Derived from medical anthropology, the concept of a syndemic consists in the clustering and interaction between multiple health conditions through adverse social conditions such as discrimination or precarity. Confronted to the multitude of adverse conditions affecting SGM, this framework is pertinent to study their health and to propose interventions.

PURPOSE OF RESEARCH

The purpose of this scoping review is to synthetize the knowledge regarding syndemic theory applied to sexual and gender minorities in order to propose concrete suggestions for scholarly research and field intervention.

RESULTS

126 papers were included. European data as well as data concerning sexual minority women and transgender men are scarce. A co-occurrence of psychosocial conditions fostered by stigmatization is well-established. Furthermore, the presence of a syndemic was associated to sexual higher odds of acquiring HIV, suicidal behavior and healthcare utilization.

CONCLUSIONS

The syndemic framework is important to the health of SGM, both for academic and interventional purposes. Current priorities should be to act against structural disadvantages leading to a syndemic, to improve our knowledge on SGM health in European context and to develop local programs based on peer-support.

Compounding vulnerabilities: Syndemics and the social determinants of disease in the past

OBJECTIVE

This article explores the theory and utility of a syndemic approach for the study of disease in the past. Syndemic principles are examined alongside other theoretical developments within bioarchaeology. Two case studies are provided to illustrate the efficacy of this approach: Tuberculosis and vitamin D deficiency in 18th and 19th century England, and malaria and helminth infections in Early Medieval England.

MATERIALS

Public health studies of present syndemics, in addition to published bioarchaeological, clinical and social information relating to the chosen case studies.

METHODS

The data from these two historical examples are revisited within a syndemic framework to draw deeper conclusions about disease clustering and heterogeneity in the past.

RESULTS

A syndemic framework can be applied to past contexts using clinical studies of diseases in a modern context and relevant paleopathological, archaeological, and historical data.

CONCLUSIONS

This approach provides a means for providing a deeper, contextualised understanding ancient diseases, and integrates well with extant theoretical tools in bioarchaeology SIGNIFICANCE: Syndemics provides scholars a deep-time perspective on diseases that still impact modern populations.

LIMITATIONS

Many of the variables essential for a truly syndemic approach cannot be obtained from current archaeological, bioarchaeological, or historical methods.

SUGGESTIONS FOR FURTHER RESEARCH

More detailed and in-depth analysis of specific disease clusters within the past and the present, which draws on a comprehensive analysis of the social determinants of health.

Biocultural perspectives of infectious diseases and demographic evolution: Tuberculosis and its comorbidities through history

Anthropologists recognize the importance of conceptualizing health in the context of the mutually evolving nature of biology and culture through the biocultural approach, but biocultural anthropological perspectives of infectious diseases and their impacts on humans (and vice versa) through time are relatively underrepresented. Tuberculosis (TB) has been a constant companion of humans for thousands of years and has heavily influenced population health in almost every phase of cultural and demographic evolution. TB in human populations has been dramatically influenced by behavior, demographic and epidemiological shifts, and other comorbidities through history. This paper critically discusses TB and some of its major comorbidities through history within a biocultural framework to show how transitions in human demography and culture affected the disease-scape of TB. In doing so, I address the potential synthesis of biocultural and epidemiological transition theory to better comprehend the mutual evolution of infectious diseases and humans.

Type 2 diabetes and depressive symptoms in the adult population in Mexico: a syndemic approach based on National Health and Nutrition Survey

BACKGROUND

The syndemic approach allows the analysis of clusters of diseases that affect a population in contexts of geographic, social and economic inequalities at the same moment and time. This study aims to analyze, from a syndemic perspective, the relationship between type 2 diabetes (T2D) and depressive symptoms in Mexican adults and its association with individual, contextual and structural factors.

METHODS

Observational, cross-sectional study based on secondary data from Mexico's National Health and Nutrition Survey 2018-19. The sample of this study consisted of 16 835 adults, which represented a total of 78 463 734 persons aged ≥ 20 years. Bivariate descriptive analyses were performed and logistic regression models were estimated to analyze the association between T2D and depressive symptoms with various co-variables. In addition, interactions between T2D and depressive symptoms with obesity, educational level, and socioeconomic status were tested.

RESULTS

In the study population, 12.2% of adults aged 20 years and older self-reported having T2D, 14.7% had depressive symptoms and 2.8% had both diseases. There was a statistically significant relationship between T2D and depressive symptoms. The prevalence of T2D and depressive symptoms was higher compared to people who did not have these two conditions. Obesity increased the probability of having T2D, while violence was statistically associated with people having depressive symptoms. A low level of education increased the odds ratio of having T2D and depressive symptoms.

CONCLUSION

The availability of analytical frameworks such as the syndemic perspective could help to identify areas of opportunity for decision making and actions for population groups that-because of their individual, contextual and structural disadvantages-are at greater risk of experiencing poorer health outcomes due to the presence of T2D and depressive symptoms.

A Framework for Interfacing and Partnering with Environmental Justice Communities as a Prelude to Human Health and Hazard Identification in the Vulnerable Census Tracts of Columbus, Ohio

Columbus, Ohio is one of the more prosperous, well-educated, and progressive cities in the United States. However, it ranks as the second worst life expectancy at birth, has a census tract wealth gap (27-year disparity), and one of the higher infant mortality rates in the country. These data suggest that there are likely several high-risk, vulnerable neighborhoods in Columbus with residents experiencing disparate and adverse outcomes. Illustrative of this fact are studies that have examined the social processes and mechanisms through which neighborhood contexts are at the forefront, including exposures to chemical stressors such as particulate matter (PM_2.5) as well as non-chemical stressors including violence, social determinants of health, zoning, and land use policies. It is documented that disparate and adverse outcomes are magnified in the vulnerable neighborhoods on the Near East Side as compared to Columbus city proper, Franklin County and/or the state of Ohio. As such, we developed a nuanced community engagement framework to identify potential environmental hazards associated with adverse pregnancy outcomes in those census tracts. The refined framework uses a blended version of traditional community-based participatory research (CBPR) models and is referred to as E⁶, Enhancing Environmental Endeavors via e-Equity, Education, and Empowerment.

Pandemics, past and present: The role of biological anthropology in interdisciplinary pandemic studies

Biological anthropologists are ideally suited for the study of pandemics given their strengths in human biology, health, culture, and behavior, yet pandemics have historically not been a major focus of research. The COVID‐19 pandemic has reinforced the need to understand pandemic causes and unequal consequences at multiple levels. Insights from past pandemics can strengthen the knowledge base and inform the study of current and future pandemics through an anthropological lens. In this paper, we discuss the distinctive social and epidemiological features of pandemics, as well as the ways in which biological anthropologists have previously studied infectious diseases, epidemics, and pandemics. We then review interdisciplinary research on three pandemics–1918 influenza, 2009 influenza, and COVID‐19–focusing on persistent social inequalities in morbidity and mortality related to sex and gender; race, ethnicity, and Indigeneity; and pre‐existing health and disability. Following this review of the current state of pandemic research on these topics, we conclude with a discussion of ways biological anthropologists can contribute to this field moving forward. Biological anthropologists can add rich historical and cross‐cultural depth to the study of pandemics, provide insights into the biosocial complexities of pandemics using the theory of syndemics, investigate the social and health impacts of stress and stigma, and address important methodological and ethical issues. As COVID‐19 is unlikely to be the last global pandemic, stronger involvement of biological anthropology in pandemic studies and public health policy and research is vital.

Hepatitis C and HIV Screening, Testing, and Risk Perceptions among South-Central Appalachian County Health Department Staff

OBJECTIVES

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are significant public health concerns, especially given the risks for disease interactions. Rates of HCV and HIV are increasing, especially in rural areas. Local health departments (LHDs) play an important role in rural health care, offering screening, testing, and treatment for HCV and HIV. Gaps persist in LHD resources for meeting these demands, especially in Appalachia and the US South.

METHODS

To explore HCV/HIV screening, testing, and treatment approaches and perspectives in south-central Appalachian North Carolina, structured telephone questionnaires were administered to communicable disease nurses and other health department staff directly involved in screening and testing. Mixed-methods data analyses were conducted and triangulated with stakeholders.

RESULTS

Eighteen participants representing 19 counties completed the questionnaire, achieving a saturation sample. Participants reported barriers to screening and testing, including housing insecurity, lack of transportation and insurance, unemployment, and the isolation of living in a rural area. Divergence in perceptions of barriers between public health regions emerged, as did perceptions of who is at risk and use of stigmatizing language about people at risk for HCV/HIV.

CONCLUSIONS

This study highlights the impact of LHD behaviors and perceptions on screening and testing, and offers recommendations to improve HCV/HIV screening and testing accessibility in south-central Appalachia, a high-risk region.

Self-Reported Menstrual Alterations During the COVID-19 Syndemic in Spain: A Cross-Sectional Study

Introduction

Available evidence suggests that there might be an association between the stressors experienced during the COVID-19 syndemic and changes in menstrual patterns. The aim of this study was to assess self-reported menstrual alterations during the COVID-19 syndemic among women and people who menstruate aged 18-55 in Spain.

Materials and Methods

A cross-sectional online survey-based study was conducted (March-July 2021). Descriptive statistics were calculated and multivariate logistic regression models were constructed. This study was conducted as part of the "Equity and Menstrual Health in Spain" research project.

Results

Among participants (N=17,455), 39.4% reported menstrual alterations since the start of the syndemic. Participants self-reporting long COVID-19 presented higher odds of menstrual alterations (aOR: 1.34, 95% CI, 1.15-1.57). In participants with no history of COVID-19, the risk for self-reported menstrual alterations was significantly higher based on employment situation, among participants experiencing financial issues (eg, financial issues always/many times <12 months: aOR: 1.68, 95% CI, 1.48-1.90), poorer self-perceived health (eg, poor: aOR: 2.00, 95% CI, 1.31-3.07), and those diagnosed with polycystic ovary syndrome (aOR: 1.13, 95% CI, 1.02-1.26). Among participants with a self-reported COVID-19 diagnosis, factors that significantly increased the odds for menstrual alterations were experiencing financial strains (eg, financial issues always/many times <12 months: aOR: 1.53, 95% CI, 1.09-2.14), poorer self-perceived health (eg, poor: aOR: 3.09, 95% CI, 1.01-9.52). Overall, factors that decreased the odds of reporting menstrual alterations included age >25, being a carer, not having a gynecological condition and using hormonal contraception.

Discussion and conclusions

Findings suggest an impact of the COVID-19 syndemic on menstrual patterns. Social inequities in reporting menstrual alterations were identified. While the risk of reporting menstrual alterations was higher among participants with long COVID-19, evidence is not conclusive. Further research on menstrual health in the context of COVID-19 is needed, also to inform policy and practice.

The syndemic effects of adverse mental health conditions and polysubstance use on being at risk of clinical depression among marginally housed and homeless transitional age youth living in San Francisco, California

The objective of this study was to identify the correlates of being at risk of clinical depression and examine the role of syndemic factors among marginally housed and homeless transitional age youth (TAY). From 2017-2018, 100 TAY between the ages of 18 and 24 in San Francisco were recruited from Larkin Street Youth Services into a cross-sectional study. Participants completed surveys on mental health, substance use, and HIV risk behaviors. A syndemic score ranging from 0-3 was calculated by summing dichotomous measures of moderate or severe anxiety in the past two weeks, PTSD symptoms in the past month and polysubstance use in the past three months. We used modified Poisson regression with robust error variances to identify the correlates of being at risk of clinical depression in the past week, all primary effects measures were modeled separately. Among 100 participants, the average age was 21 (SD = 1.7), 67% were male, 38% were Multiracial, 54% identified as gay, lesbian, bisexual or pansexual, 13% were unstably housed, 50% were homeless and 23% were living with HIV. The majority (74%) were at risk of clinical depression, 51% had symptoms of moderate or severe anxiety, 80% exhibited symptoms of PTSD and 33% reported polysubstance use. After controlling for age in years, gender, race/ethnicity and sexual orientation, factors independently associated with being at risk of clinical depression were; symptoms of moderate or severe anxiety (adjusted risk ratio [aRR] = 1.62, 95% confidence interval [CI] = 1.23-2.12, P<0.001), symptoms of PTSD (aRR = 3.78, 95% CI = 1.58-9.04, P = 0.003), polysubstance use (aRR = 1.33, 95% CI = 1.06-1.68), P = 0.012), an increasing syndemic score (aRR = 1.40, 95% CI = 1.21-1.62), P<0.001), and having one, two or three syndemic factors (compared to none); (aRR = 2.68, 95% CI = 1.08-6.65, P = 0.032), (aRR = 3.24, 95% CI = 1.24-7.83, P = 0.003) and (aRR = 3.97, 95% CI = 1.65-9.52, P = 0.002), respectively. Integrated behavioral health models that treat co-occurring disorders simultaneously are needed to reduce syndemic risk among marginally housed and homeless TAY.

Global research on syndemics: a meta-knowledge analysis (2001-2020)

BACKGROUND

Syndemics or synergies of cooccurring epidemics are widely studied across health and social sciences in recent years.

METHODS

We conducted a meta-knowledge analysis of articles published between 2001 to 2020 in this growing field of academic scholarship.

RESULTS

We found a total of 830 articles authored by 3025 authors, mostly from high-income countries. Publications on syndemics are gradually increasing since 2003, with rapid development in 2013. Each article was cited more than 15 times on average, and most (n = 604) articles were original studies. Syndemics research focused on several areas, including HIV/AIDS, substance abuse, mental health, gender minority stressors, racism, violence, chronic physical and mental disorders, food insecurity, social determinants of health, and coronavirus disease 2019. Moreover, biopsychosocial interactions between multiple health problems were studied across medical, anthropological, public health, and other disciplines of science.

CONCLUSIONS

The limited yet rapidly evolving literature on syndemics informs transdisciplinary interests to understand complex coexisting health challenges in the context of systematic exclusion and structural violence in vulnerable populations. The findings also suggest applications of syndemic theory to evaluate clinical and public health problems, examine the socioecological dynamics of factors influencing health and wellbeing, and use the insights to alleviate health inequities in the intersections of synergistic epidemics and persistent contextual challenges for population health.

Global research on syndemics: a meta-knowledge analysis (2001-2020)

BACKGROUND

Syndemics or synergies of cooccurring epidemics are widely studied across health and social sciences in recent years.

METHODS

We conducted a meta-knowledge analysis of articles published between 2001 to 2020 in this growing field of academic scholarship.

RESULTS

We found a total of 830 articles authored by 3025 authors, mostly from high-income countries. Publications on syndemics are gradually increasing since 2003, with rapid development in 2013. Each article was cited more than 15 times on average, and most (n = 604) articles were original studies. Syndemics research focused on several areas, including HIV/AIDS, substance abuse, mental health, gender minority stressors, racism, violence, chronic physical and mental disorders, food insecurity, social determinants of health, and coronavirus disease 2019. Moreover, biopsychosocial interactions between multiple health problems were studied across medical, anthropological, public health, and other disciplines of science.

CONCLUSIONS

The limited yet rapidly evolving literature on syndemics informs transdisciplinary interests to understand complex coexisting health challenges in the context of systematic exclusion and structural violence in vulnerable populations. The findings also suggest applications of syndemic theory to evaluate clinical and public health problems, examine the socioecological dynamics of factors influencing health and wellbeing, and use the insights to alleviate health inequities in the intersections of synergistic epidemics and persistent contextual challenges for population health.

Context, COVID-19 and comorbidities: exploring emergent directions in syndemics and HIV research

PURPOSE OF REVIEW

The purpose of this review is to identify themes across articles that aimed to explore HIV-related syndemics in 2020 and 2021 and to discuss their implications for research on syndemics.

RECENT FINDINGS

We identified 189 articles on syndemics between 2020 and 2021. Key themes across studies included COVID-19; mental health and psychosocial challenges; substance use; socio-structural factors; protective factors; and methodological approaches. COVID-19's implications for HIV syndemic research were discussed. Mental health and substance use research largely examined linkages with sexual practices or reduced HIV care retention. Researchers examined associations between socio-structural variables (e.g. poverty) and elevated HIV exposure, reduced HIV testing and poorer health. Concepts of water insecurity and 'ecosyndemics' were also raised, as was the importance of attending to noncommunicable diseases and comorbidities. Most studies did not assess interactions between health conditions, signalling the need for methodological grounding in the foundational concepts of syndemic theory.

SUMMARY

Most studies recommended that HIV prevention and care research attend to the interplay between poor mental health, substance use and multidimensional violence. Increased attention to structural factors, particularly exacerbated poverty in the COVID-19 pandemic, is required. Research can identify protective factors to harness to advance HIV prevention and care.

This Is America: Systemic Racism and Health Inequities Amidst the COVID-19 Pandemic

The Coronavirus 2019 (COVID-19) continues to devastate the world and the United States remains number one of reported COVID-19 cases and deaths. Research demonstrates that Blacks and Hispanics in the United States are disproportionately impacted by COVID-19, especially among highly marginalized people at the intersection of immigration and incarceration. Social distancing is a privilege and contact tracing is a deterrent for historically oppressed populations. Public health professionals have attempted a multicausal approach to prevent the spread of infectious diseases, but they have been unsuccessful in addressing the biological-social impact of highly vulnerable populations. An emphasis is placed on syndemics and social determinants of health to address health inequities associated with COVID-19 due to systemic racism. Implications for social work will reinforce the profession's obligation to address public emergencies through social and political action. Recommendations will be made for social workers to support local, state, and federal level responses of COVID-19.

Weight loss interventions and nonalcoholic fatty liver disease: Optimizing liver outcomes

The growth in prevalence of obesity, type 2 diabetes and nonalcoholic fatty liver disease (NAFLD) has become one of the most important global health challenges. The three chronic diseases are closely linked in their epidemiology and pathophysiology. Currently, weight loss is the most effective treatment for NAFLD (even in the minority of patients with NAFLD who do not have obesity) and is recommended in all national and international guidelines. Accumulating evidence has shown that weight loss, whether achieved by diet and lifestyle interventions, bariatric surgery or pharmacotherapy, can improve biomarkers of NAFLD, as well as prevent progression and, in some cases, reverse fibrosis. There is a dose dependency of weight loss with NAFLD improvement. Pharmacotherapy with antiobesity medications, alone or in combination with intensive lifestyle interventions or other weight-loss drugs, is closing the efficacy gap between diet and exercise and weight-loss surgery in efficacy at reversing obesity. Given the importance of providing effective weight-loss treatment to patients with NAFLD, weight management services need to be made increasingly available and embedded within hepatology services. This narrative review addresses the evidence that weight loss optimizes liver outcomes in people with NAFLD.

Are There Global Syndemics?

In this article, we address the nature of syndemics and whether, as some have asserted, these epidemiological phenomena are global configurations. Our argument that syndemics are not global rests on recognition that they are composed of social/environment contexts, disease clusters, demographics, and biologies that vary across locations. These points are illustrated with the cases of syndemics involving COVID-19, diabetes mellitus, and HIV/AIDS. We draw on theoretical discourse from epidemiology, biology, and anthropology to present what we believe is a more accurate framework for thinking about syndemics with shared elements.

Syndemics: A Cross-Disciplinary Approach to Complex Epidemic Events Like COVID-19

In this review, we trace the origins and dissemination of syndemics, a concept developed within critical medical anthropology that rapidly diffused to other fields. The goal is to provide a review of the literature, with a focus on key debates. After a brief discussion of the nature and significance of syndemic theory and its applications, we trace the history and development of the syndemic framework within anthropology and the contributions of anthropologists who use it. We also look beyond anthropology to the adoption and use of syndemics in other health-related disciplines, including biomedicine, nursing, public health, and psychology, and discuss controversies in syndemics, particularly the perception that existing syndemics research focuses on methodologies at the individual level rather than at the population level and fails to provide evidence of synergistic interactions. Finally, we discuss emerging syndemics research on COVID-19 and provide an overview of the application of syndemics research.