Collection of social determinant of health measures in U.S. national surveillance systems for HIV, viral hepatitis, STDs, and TB

Construction of a Theoretical Model of Chronic Disease Self-Management: Self-Management Within a Syndemic

The purpose of this article is to describe a model of chronic disease self-management that incorporates the complexity of social and environmental interactions experienced by people who self-manage chronic conditions. This study combines quantitative data from a large national research cohort and qualitative interviews to test and refine a self-management model. The self-management within a syndemic model depicts the contextual, psychological, and social factors that predict self-management behaviors and clinical and long-term outcomes.

An Evaluation of TransLife Care: A Locally Developed Structural HIV Prevention Intervention for Transgender Women in Chicago, Illinois

Transgender women are disproportionately impacted by HIV infection. We report herein the findings of a pre-post evaluation of the TransLife Care (TLC) project in Chicago, Illinois, on behaviors associated with HIV transmission among transgender women. Participants who received any TLC component versus those who did not were compared using mixed-effects logistic regression with random intercepts across follow-up time points. Ninety-seven participants aged 18 to 59 (median age 24) enrolled; 76.3% were transgender women of color. There was a decrease in condomless sex without consistent PrEP use at 8 months, which was not significantly different between those who did and did not receive the TLC intervention, controlling for calendar time. Evidence does not indicate that the TLC reduces condomless sex without PrEP protection among urban transgender women. However, given the preponderance of evidence of the influence of structural barriers on condomless sex, future research should continue to test the efficacy of structural interventions.

The HealthStreet Cancer Survivor Cohort: a Community Registry for Cancer Research

PURPOSE

This report describes a cancer survivor cohort from a community engagement program and compares characteristics and willingness to participate in health research between the cancer survivors and non-cancer community members.

METHODS

Among 11,857 members enrolled in HealthStreet at the University of Florida (10/2011-03/2020), 991 cancer survivors were identified and 1:1 matched to control members without cancer on sex, age, and zip code. Demographics, body weight, height, social determinants of health, history of cancer, and willingness to participate in research were recorded by Community Health Workers as a part of the baseline Health Needs Assessment.

RESULTS

Among the cancer survivors, 71.6% were female and 19.2% lived in rural areas with a mean age of 56.7 years in females and 60.8 years in males. At baseline, 44.7% received a cancer diagnosis within 5 years, while 15.8%, more than 20 years. Cancer survivors (vs. matched non-cancer controls) were less likely to be Black (31.1% vs. 63.6%) but more likely to be divorced, separated, or widowed (49.5% vs. 41.2%), be normal/underweight (34.0% vs. 25.6%) and have health insurance (80.0% vs. 68.6%; all p < 0.05). Cancer survivors versus matched controls reported higher rates of ever being in a health research study (32.4% vs. 24.9%) and interest in participating in studies ranging from minimal risk to greater-than-minimal risk.

CONCLUSIONS

Cancer survivors from this community engagement program agnostic to cancer types and treatment are diverse in geography, race, and social determinants of health and can be a valuable resource for observational, interventional, and biospecimen research in cancer survivorship.

Lower PrEP Retention among Young and Black Clients Accessing PrEP at a Cluster of Safety Net Clinics for Gay and Bisexual Men

Young men of color who have sex with men are vulnerable to HIV and experience poor PrEP uptake and retention. We conducted a secondary data analysis and calculated adjusted Prevalence Odds Ratios (aPORs) for PrEP retention along with 95% CIs at 90, 180, and 360 days at an organization running safety net clinics in Texas for gay and bisexual men. We found statistically significant association with age, race, in-clinic versus telehealth appointments, and having healthcare insurance. White clients had an aPOR of 1.29 [1.00, 1.67] as compared to Black clients at 90 days. Age group of 18-24 had a lower aPOR than all other age groups except 55 or older at all three time periods. Clients who met providers in person had an aPOR of 2.6 [2.14, 3.19] at 90, 2.6 [2.2, 3.30] at 180 days and 2.84 [2.27, 3.54] at 360 days. Our findings highlight the need for population-specific targeted interventions.

Importance of social vulnerability on long-term outcomes after heart transplantation

The relationship between social determinants of health and outcomes after heart transplantation has not been examined. The social vulnerability index (SVI) uses United States census data to determine the social vulnerability of every census tract based on 15 factors. This retrospective study seeks to examine the impact of SVI on outcomes after heart transplantation. Adult heart recipients who received a graft between 2012 and 2021 were stratified into SVI percentiles of <75% and SVI of ≥75%. The primary endpoint was survival. The median SVI was 48% (interquartile range: 30%-67%) among 23 700 recipients. One-year survival was similar between groups (91.4 vs 90.7%, log-rank P = .169); however, 5-year survival was lower among individuals living in vulnerable communities (74.8% vs 80.0%, P < .001). This finding persisted despite risk adjustment for other factors associated with mortality (survival time ratio 0.819, 95% confidence interval: 0.755-0.890, P < .001). The incidences of 5-year hospital readmission (81.4% vs 75.4%, P < .001) and graft rejection (40.3% vs 35.7%, P = .004) were higher among individuals living in vulnerable communities. Individuals living in vulnerable communities may be at increased risk of mortality after heart transplantation. These findings suggest there is an opportunity to focus on these recipients undergoing heart transplantation to improve survival.

A Scoping Review of Approaches to Improving Quality of Data Relating to Health Inequalities

Identifying and monitoring of health inequalities requires good-quality data. The aim of this work is to systematically review the evidence base on approaches taken within the healthcare context to improve the quality of data for the identification and monitoring of health inequalities and describe the evidence base on the effectiveness of such approaches or recommendations. Peer-reviewed scientific journal publications, as well as grey literature, were included in this review if they described approaches and/or made recommendations to improve data quality relating to the identification and monitoring of health inequalities. A thematic analysis was undertaken of included papers to identify themes, and a narrative synthesis approach was used to summarise findings. Fifty-seven papers were included describing a variety of approaches. These approaches were grouped under four themes: policy and legislation, wider actions that enable implementation of policies, data collection instruments and systems, and methodological approaches. Our findings indicate that a variety of mechanisms can be used to improve the quality of data on health inequalities at different stages (prior to, during, and after data collection). These findings can inform us of actions that can be taken by those working in local health and care services on approaches to improving the quality of data on health inequalities.

Association of Area-Based Socioeconomic Measures with Tuberculosis Incidence in California

We assessed the association of area-based socio-economic status (SES) measures with tuberculosis (TB) incidence in California. We used TB disease data for 2012-2016 (n = 9901), population estimates, and SES measures to calculate incidence rates, rate ratios, and 95% confidence intervals (95% CI) by SES and birth country. SES was measured by census tract and was categorized by quartiles for education, crowding, and the California Healthy Places Index (HPI)and by specific cutoffs for poverty. The lowest SES areas defined by education, crowding, poverty, and HPI had 39%, 40%, 41%, and 33% of TB cases respectively. SES level was inversely associated with TB incidence across all SES measures and birth countries. TB rates were 3.2 (95% CI 3.0-3.4), 2.1 (95% CI 1.9-2.2), 3.6 (95% CI 3.3-3.8), and 2.0 (95% CI 1.9-2.1) times higher in lowest SES areas vs. highest SES areas as defined by education, crowding, poverty and HPI respectively. Area-based SES measures are associated with TB incidence in California. This information could inform TB prevention efforts in terms of materials, partnerships, and prioritization.

Evaluating Locally Developed Interventions to Promote PrEP Among Racially/Ethnically Diverse Transgender Women in the United States: A Unique CDC Initiative

In the United States, transgender women are disproportionately affected by HIV. However, few evidence-based prevention interventions exist for this key population. We describe two promising, locally developed interventions that are currently being implemented and evaluated through the Centers for Disease Control and Prevention Combination HIV Prevention for Transgender Women Project: (a) ChiCAS, designed to promote the uptake of pre-exposure prophylaxis (PrEP), condom use, and medically supervised hormone therapy among Spanish-speaking transgender Latinas, and (b) TransLife Care, designed to address the structural drivers of HIV risk through access to housing, employment, legal services, and medical services, including HIV preventive care (e.g., PrEP use) among racially/ethnically diverse urban transgender women. If the evaluation trials determine that these interventions are effective, they will be among the first such interventions for use with transgender women incorporating PrEP, thereby contributing to the evidence-based resources that may be used to reduce HIV risk among this population.

Evaluating Locally Developed Interventions to Promote PrEP Among Racially/Ethnically Diverse Transgender Women in the United States: A Unique CDC Initiative

In the United States, transgender women are disproportionately affected by HIV. However, few evidence-based prevention interventions exist for this key population. We describe two promising, locally developed interventions that are currently being implemented and evaluated through the Centers for Disease Control and Prevention Combination HIV Prevention for Transgender Women Project: (a) ChiCAS, designed to promote the uptake of pre-exposure prophylaxis (PrEP), condom use, and medically supervised hormone therapy among Spanish-speaking transgender Latinas, and (b) TransLife Care, designed to address the structural drivers of HIV risk through access to housing, employment, legal services, and medical services, including HIV preventive care (e.g., PrEP use) among racially/ethnically diverse urban transgender women. If the evaluation trials determine that these interventions are effective, they will be among the first such interventions for use with transgender women incorporating PrEP, thereby contributing to the evidence-based resources that may be used to reduce HIV risk among this population.

Evaluation of Translife Care: An Intervention to Address Social Determinants of Engagement in HIV Care Among Transgender Women of Color

The TransLife Care (TLC) project was developed to address the structural factors that act as barriers to HIV care among transgender women of color. The purpose of this study was to evaluate the feasibility and initial efficacy of the TLC project; primary HIV care outcomes included linkage to HIV care, engagement in care, retention in care, use of ART and viral suppression among N = 120 participants. In multivariable analysis, receipt of the intervention (versus none), was associated with any HIV care visit (aOR 2.05; 95% CI 1.25-3.37; p = 0.005), more total HIV care visits (aRR 1.45; 95% CI 1.09-1.94; p = 0.011), being retained in care (aOR 1.58; 95% CI 1.03-2.44; p = 0.038), and having a viral load test done (aOR 1.95; 95% CI 1.23-3.09; p = 0.004). We conclude that a structural intervention, designed and delivered by the focus population, that directly addresses social determinants, is feasible and efficacious to promote HIV care engagement among transgender women of color.

Measuring and explaining inequality of continuous care for people living with HIV receiving antiretroviral therapy in Kunming, China

Background

In the context of scaling up free antiretroviral therapy (ART), healthcare equality is essential for people living with HIV. We aimed to assess socioeconomic-related inequalities in uptake of continuous care for people living with HIV receiving ART, including retention in care in the last six months, routine toxicity monitoring, adequate immunological and virological monitoring, and uptake of mental health assessment in the last 12 months. We also determined the contributions of socioeconomic factors to the degree of inequalities.

Methods

A hospital-based cross-sectional survey was conducted among consecutive clients visiting an HIV treatment center in Kunming, China in 2019. Participants were 702 people living with HIV aged ≥18 years (median age: 41.0 years, 69.4% male) who had been on ART for 1–5 years. Socioeconomic-related inequality and its contributing factors were assessed by a normalized concentration index (CI_n) with a decomposition approach.

Results

The uptake of mental health assessment was low (15%) but significantly higher among the rich (CI_n 0.1337, 95% CI: 0.0140, 0.2534). Retention in care, toxicity, and immunological monitoring were over 80% but non-significant in favor of the rich (CI_n: 0.0117, 0.0315, 0.0736, respectively). The uptake of adequate virological monitoring was 15% and higher among the poor (CI_n = -0.0308). Socioeconomic status positively contributed to inequalities of all care indicators, with the highest contribution for mental health assessment (124.9%) and lowest for virological monitoring (2.7%).

Conclusions

These findings suggest virological monitoring and mental health assessment be given more attention in long-term HIV care. Policies allocating need-oriented resources geared toward improving equality of continuous care should be developed.

Assessment of socioeconomic inequality based on virus-contaminated water usage in developing countries: A review

Water is an essential resource required for various human activities such as drinking, cooking, and other recreational activities. While developed nations have made significant improvement in providing adequate quality water and sanitation devoid of virus contaminations to a significant percentage of the residences, many of the developing countries are still lacking in these regards, leading to many death cases among the vulnerable due to ingestion of virus-contaminated water and other waterborne pathogens. However, the recent global pandemic of COVID-19 seems to have changed the paradigm by reawakening the importance of water quality and sanitation, and focusing more attention on the pervasive effect of the use of virus-contaminated water as it can be a potential driver for the spread of the virus and other waterborne diseases, especially in developing nations that are characterized by low socioeconomic development. Therefore, this review assessed the socioeconomic inequalities related to the usage of virus-contaminated water and other waterborne pathogens in developing countries. The socioeconomic factors attributed to the various waterborne diseases due to the use of virus-contaminated water in many developing countries are poverty, the standard of living, access to health care facilities, age, gender, and level of education. Some mitigation strategies to address the viral contamination of water sources are therefore proposed, while future scope and recommendations on tackling the essential issues related to socioeconomic inequality in developing nations are highlighted.

Assessment of socioeconomic inequality based on virus-contaminated water usage in developing countries: A review

Water is an essential resource required for various human activities such as drinking, cooking, and other recreational activities. While developed nations have made significant improvement in providing adequate quality water and sanitation devoid of virus contaminations to a significant percentage of the residences, many of the developing countries are still lacking in these regards, leading to many death cases among the vulnerable due to ingestion of virus-contaminated water and other waterborne pathogens. However, the recent global pandemic of COVID-19 seems to have changed the paradigm by reawakening the importance of water quality and sanitation, and focusing more attention on the pervasive effect of the use of virus-contaminated water as it can be a potential driver for the spread of the virus and other waterborne diseases, especially in developing nations that are characterized by low socioeconomic development. Therefore, this review assessed the socioeconomic inequalities related to the usage of virus-contaminated water and other waterborne pathogens in developing countries. The socioeconomic factors attributed to the various waterborne diseases due to the use of virus-contaminated water in many developing countries are poverty, the standard of living, access to health care facilities, age, gender, and level of education. Some mitigation strategies to address the viral contamination of water sources are therefore proposed, while future scope and recommendations on tackling the essential issues related to socioeconomic inequality in developing nations are highlighted.

Physical activity, social support and socio-economic status amongst persons living with HIV and AIDS: a review

Physical activity can be used for the effective and comprehensive management of HIV and AIDS. Social support and socio-economic status (SES) are two factors that shape physical activity behaviours. Individuals of low SES carry a disproportionate burden of the HIV and AIDS epidemic. In addition, limited resources constitute socio-ecological barriers predisposing such individuals to physical inactivity. The purpose of this narrative review is to examine the available literature on physical activity, social support and SES and to generate recommendations for designing and implementing physical activity interventions targeting people living with HIV and AIDS (PLWHA) of low SES. The review used literature from Google, Google Scholar and PubMed on physical activity of PLWHA, social support for physical activity, and SES and physical activity. Qualitative and quantitative studies in English were included from 1970 to 2016. The results show that social support plays a major role in promoting physical activity and counteracting the barriers to PA in PLWHA of low SES. The results on the role of social support and the influence of SES are integrated to help design appropriate physical activity interventions for PLWHA of low SES. Well-designed interventions should utilise social support and be contextualised for PLWHA of low SES, whose living conditions present multiple barriers to physical activity.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Socio-economic status influences access to second-line disease modifying treatment in Relapsing Remitting Multiple Sclerosis patients

Objective

In MS, Socio-Economic status (SES) may influence healthcare and access to disease-modifying treatments (DMTs). Optimising delays to switch patients to a second-line DMT may hamper disease progression most effectively and achieve long term disease control. The objective of this study is to identify the influence of SES on the delay between first and second line DMT in RRMS patients, in Western-Normandy, France.

Methods

The association between SES and the delay to access a second-line DMT were studied using data from the MS registry of Western-Normandy including 733 patients with a diagnosis of RRMS during the period in question [1982–2011]. We used the European Deprivation Index (EDI), a score with a rank level inversely related to SES. We performed multivariate adjusted Cox models for studying EDI effect on the delay between first and second line DMT.

Results

No significant influence of SES was observed on delay to access a second-line DMT if first-line DMT exposure time was less than 5 years. After 5 years from initiation of first-line treatment the risk of accessing a second-line DMT is 3 times higher for patients with lower deprivation indices (1^st quintile of EDI) ([HR] 3.14 95%CI [1.72–5.72], p-value<0.001) compared to patients with higher values (EDI quintiles 2 to 5).

Interpretation

In RRMS, a high SES may facilitate access to a second-line DMT a few years after first-line DMT exposure. Greater consideration should also be given to the SES of MS patients as a risk factor in therapeutic healthcare issues throughout medical follow-up.

Collection of Data on Race, Ethnicity, Language, and Nativity by US Public Health Surveillance and Monitoring Systems: Gaps and Opportunities

OBJECTIVE

Despite increasing diversity in the US population, substantial gaps in collecting data on race, ethnicity, primary language, and nativity indicators persist in public health surveillance and monitoring systems. In addition, few systems provide questionnaires in foreign languages for inclusion of non-English speakers. We assessed (1) the extent of data collected on race, ethnicity, primary language, and nativity indicators (ie, place of birth, immigration status, and years in the United States) and (2) the use of data-collection instruments in non-English languages among Centers for Disease Control and Prevention (CDC)-supported public health surveillance and monitoring systems in the United States.

METHODS

We identified CDC-supported surveillance and health monitoring systems in place from 2010 through 2013 by searching CDC websites and other federal websites. For each system, we assessed its website, documentation, and publications for evidence of the variables of interest and use of data-collection instruments in non-English languages. We requested missing information from CDC program officials, as needed.

RESULTS

Of 125 data systems, 100 (80%) collected data on race and ethnicity, 2 more collected data on ethnicity but not race, 26 (21%) collected data on racial/ethnic subcategories, 40 (32%) collected data on place of birth, 21 (17%) collected data on years in the United States, 14 (11%) collected data on immigration status, 13 (10%) collected data on primary language, and 29 (23%) used non-English data-collection instruments. Population-based surveys and disease registries more often collected data on detailed variables than did case-based, administrative, and multiple-source systems.

CONCLUSIONS

More complete and accurate data on race, ethnicity, primary language, and nativity can improve the quality, representativeness, and usefulness of public health surveillance and monitoring systems to plan and evaluate targeted public health interventions to eliminate health disparities.

Capturing the Social Location of African American Mothers Living With HIV: An Inquiry Into How Social Determinants of Health Are Framed

BACKGROUND

The disparate health outcomes of African American mothers living with HIV are considerable. Multidimensional approaches are needed to address the complex social and economic conditions of their lives, collectively known as the social determinants of health.

OBJECTIVES

The purpose of this study was to explore the social determinants of health for African American mothers living with HIV by examining how mothers describe their social location at the intersection of gender, race, and class inequality; HIV-related stigma; and motherhood. How they frame the impact of their social location on their health experiences is explored.

METHODS

This exploratory study included in-depth, semistructured interviews with 18 African American mothers living with HIV at three time points. We used an intersectional framework and frame analysis to explore the meaning of these constructs for participants.

RESULTS

Findings from 48 interviews include a description of the intersecting social determinants functioning as systems of inequality and the heterogeneous social locations. Three frames of social location were used to organize and explain how African American mothers living with HIV may understand their social determinants of health: (a) an emancipatory frame, marked by attempts to transcend the negative social connotations associated with HIV and socially constructed identities of race, gender, and class; (b) a maternal frame, marked by a desire to maintain a positive maternal identity and maternal-child relations; and (c) an internalized frame, marked by an emphasis on the deleterious and stigmatizing effects of HIV, racial, gender, and class inequality.

DISCUSSION

The findings offer knowledge about the heterogeneity in how demographically similar individuals frame their social location as well as how the intersections of social determinants influence participant's health experiences. Potential health implications and interventions are suggested for the three frames of social location used to describe intersecting social determinants of health. The study offers an analytic approach for capturing the complexity inherent in intersectional methodologies examining the role of social determinants in producing health inequities.

Assessment of Macro-Level Socioeconomic Factors That Impact Waterborne Diseases: The Case of Jordan

The Hashemite Kingdom of Jordan is an example of a country that suffers from high water scarcity. Additionally, due to the economic drivers in the country, such as phosphate and potash extraction and pharmaceutical production, the little fresh water that remains is generally polluted. The infrastructure, often antiquated in urban areas and non-existent in rural areas, also contributes to poor water conditions and to the spread of waterborne diseases. This paper examines the socioeconomic factors that contribute to diarrhea and hepatitis A on a macro level in Jordan and discusses the public-policies that government officials could use to abate those problems. Ordinary least squares time series models are used to understand the macro-level variables that impact the incidence of these diseases in Jordan. Public health expenditure has a significant impact on reducing their incidence. Furthermore, investment in sanitation facilities in rural regions is likely to reduce the number of cases of hepatitis A. Perhaps the most surprising outcome is that importation of goods and services likely results in a decrease in cases of hepatitis A. However, income has little impact on the incidence of diarrhea and hepatitis A.

Getting Data Right - and Righteous to Improve Hispanic or Latino Health

Hispanics or Latinos constitute the largest racial/ethnic minority in the United States. They are also a very diverse population. Latino/Hispanic's health varies significantly for subgroups defined by national origin, race, primary language, and migration-related factors (place of birth, immigration status, years of residence in the United States). Most Hispanics speak Spanish at home, and one-third have limited English proficiency (LEP). There is growing awareness on the importance for population health monitoring programs to collect those data elements (Hispanic subgroup, primary language, and migration-related factors) that better capture Hispanics' diversity, and to provide language assistance (translation of data collection forms, interpreters) to ensure meaningful inclusion of all Latinos/Hispanics in national health monitoring. There are strong ethical and scientific reasons for such expansion of data collection by public health entities. First, expand data elements can help identify otherwise hidden Hispanic subpopulations' health disparities. This may promote a more just and equitable distribution of health resources to underserved populations. Second, language access is needed to ensure fair and legal treatment of LEP individuals in federally supported data collection activities. Finally, these strategies are likely to improve the quality and representativeness of data needed to monitor and address the health of all Latino/Hispanic populations in the United States.

Condom deserts: geographical disparities in condom availability and their relationship with rates of sexually transmitted infections

BACKGROUND

Identifying predictors that contribute to geographical disparities in sexually transmitted infections (STIs) is necessary. This study assesses the spatial relationship between condom availability to locations of STIs in order to better understand these geographical disparities.

OBJECTIVES

We conducted a condom availability audit among potential condom-selling establishments. New gonorrhoea and chlamydia cases in 2011 (n=6034) and HIV infection cases from 2006 to 2011 (n=565) were collected by census tract in St Louis, Missouri. 829 potential condom-selling establishments participated in the condom availability audit in St Louis City; 242 of which sold condoms.

RESULTS

A negative linear relationship exists between condom vendors and cases of gonorrhoea and chlamydia, after adjusting for concentrated disadvantage and free condom locations. Higher concentrated disadvantage, higher proportions of convenience vendors and free locations were associated with higher rates of HIV.

CONCLUSIONS

This study was conducted to provide evidence that lack of condom availability is associated with STI rates, and likely is an integral component to influencing the subjective norms surrounding condom use and STI rates. Condom distribution interventions may be addressing availability needs and social norms, yet are more likely to be effective when placed in locations with the highest STI rates.

[Sexually transmitted diseases: the impact of stigma and taboo on current medical care]

Sexually transmitted diseases (STD) are probably the most tabooed diseases we know. The many taboos and the related stigmata shape patients' lives and significantly influence health care policies, medical research, and current problems in medical ethics. To better understand these complex influences, the still powerful taboos and related metaphors associated with illness and disease are analyzed within their cultural and historical background and concerning the actual impact on patient care and research. It becomes obvious that research and health care policies cannot be satisfyingly successful in helping people affected by STDs as long as these "nonscientific" factors are not taken into account.

Sex and gender in the US health surveillance system: a call to action

Youth Risk Behavior Survey (YRBS) data have exposed significant sexual orientation disparities in health. Interest in examining the health of transgender youths, whose gender identities or expressions are not fully congruent with their assigned sex at birth, highlights limitations of the YRBS and the broader US health surveillance system. In 2009, we conducted the mixed-methods Massachusetts Gender Measures Project to develop and cognitively test measures for adolescent health surveillance surveys. A promising measure of transgender status emerged through this work. Further research is needed to produce accurate measures of assigned sex at birth and several dimensions of gender to further our understanding of determinants of gender disparities in health and enable strategic responses to address them.

Immigrant health inequalities in the United States: use of eight major national data systems

Eight major federal data systems, including the National Vital Statistics System (NVSS), National Health Interview Survey (NHIS), National Survey of Children's Health, National Longitudinal Mortality Study, and American Community Survey, were used to examine health differentials between immigrants and the US-born across the life course. Survival and logistic regression, prevalence, and age-adjusted death rates were used to examine differentials. Although these data systems vary considerably in their coverage of health and behavioral characteristics, ethnic-immigrant groups, and time periods, they all serve as important research databases for understanding the health of US immigrants. The NVSS and NHIS, the two most important data systems, include a wide range of health variables and many racial/ethnic and immigrant groups. Immigrants live 3.4 years longer than the US-born, with a life expectancy ranging from 83.0 years for Asian/Pacific Islander immigrants to 69.2 years for US-born blacks. Overall, immigrants have better infant, child, and adult health and lower disability and mortality rates than the US-born, with immigrant health patterns varying across racial/ethnic groups. Immigrant children and adults, however, fare substantially worse than the US-born in health insurance coverage and access to preventive health services. Suggestions and new directions are offered for improvements in health monitoring and for strengthening and developing databases for immigrant health assessment in the USA.

HIV infection and testing among Latino men who have sex with men in the United States: the role of location of birth and other social determinants

BACKGROUND

In the United States, Latino men who have sex with men (MSM) are disproportionately affected by HIV. Latino MSM are a diverse group who differ culturally based on their countries or regions of birth and their time in the United States. We assessed differences in HIV prevalence and testing among Latino MSM by location of birth, time since arrival, and other social determinants of health.

METHODS

For the 2008 National HIV Behavioral Surveillance System, a cross-sectional survey conducted in large US cities, MSM were interviewed and tested for HIV infection. We used generalized estimating equations to test associations between various factors and 1) prevalent HIV infection and 2) being tested for HIV infection in the past 12 months.

RESULTS

Among 1734 Latino MSM, HIV prevalence was 19%. In multivariable analysis, increasing age, low income, and gay identity were associated with HIV infection. Moreover, men who were U.S.-born or who arrived ≥5 years ago had significantly higher HIV prevalence than recent immigrants. Among men not reporting a previous positive HIV test, 63% had been tested for HIV infection in the past 12 months; recent testing was most strongly associated with having seen a health care provider and disclosing male-male attraction/sexual behavior to a health care provider.

CONCLUSIONS

We identified several social determinants of health associated with HIV infection and testing among Latino MSM. Lower HIV prevalence among recent immigrants contrasts with higher prevalence among established immigrants and suggests a critical window of opportunity for HIV prevention, which should prioritize those with low income, who are at particular risk for HIV infection. Expanding health care utilization and encouraging communication with health care providers about sexual orientation may increase testing.

The impact of social context on self-management in women living with HIV

HIV self-management is central to the health of people living with HIV and is comprised of the daily tasks individuals employ to manage their illness. Women living with HIV are confronted with social context vulnerabilities that impede their ability to conduct HIV self-management behaviors, including demanding social roles, poverty, homelessness, decreased social capital, and limited access to health care. We examined the relationship between these vulnerabilities and HIV self-management in a cross-sectional secondary analysis of 260 women living with HIV from two U.S. sites. All social context variables were assessed using validated self-report scales. HIV Self-Management was assessed using the HIV Self-Management Scale that measures daily health practices, HIV social support, and the chronic nature of HIV. Data were analyzed using appropriate descriptive statistics and multivariable regression. Mean age was 46 years and 65% of participants were African-American. Results indicated that social context variables, particularly social capital, significantly predicted all domains of HIV self-management including daily health practices (F = 5.40, adjusted R(2) = 0.27, p < 0.01), HIV social support (F = 4.50, adjusted R(2) = 0.22, p < 0.01), and accepting the chronic nature of HIV (F = 5.57, adjusted R(2) = 0.27, p < 0.01). We found evidence to support the influence of the traditional social roles of mother and employee on the daily health practices and the chronic nature of HIV domains of HIV self-management. Our data support the idea that women's social context influences their HIV self-management behavior. While social context has been previously identified as important, our data provide new evidence on which aspects of social context might be important targets of self-management interventions for women living with HIV. Working to improve social capital and to incorporate social roles into the daily health practices of women living with HIV may improve the health of this population.

Determinants of unequal HIV care access among people living with HIV in Peru

BACKGROUND

Equity in access to health care among people living with HIV (PLHA) has not been extensively studied in Peru despite the fact there is significant social diversity within this group. We aimed to assess the extent to which health care provision to PLHA, including ARVT, was equitable and, if appropriate, identify factors associated with lower access.

METHODS

We conducted a survey among adult PLHA in four cities in Peru, recruited through respondent-driven sampling (RDS), to collect information on socio-demographic characteristics, social network size, household welfare, economic activity, use of HIV-related services including ARV treatment, and health-related out-of-pocket expenses.

RESULTS

Between September 2008 and January 2009, 863 individuals from PLHA organizations in four cities of Peru were enrolled. Median age was 35 (IQR = 29-41), and mostly male (62%). Overall, 25% reported to be gay, 11% bisexual and 3% transgender. Most PLHA (96%) reported access to some kind of HIV-related health service, and 84% were receiving those services at a public facility. Approximately 85% of those reporting access to care were receiving antiretroviral treatment (ARV), and 17% of those not in treatment already had indication to start treatment. Among those currently on ARV, 36% percent reported out-of-pocket expenses within the last month. Transgender identity and age younger than 35 years old, were associated with lower access to health care.

CONCLUSIONS

Our findings contribute to a better social and demographic characterization of the situation of PLHAs, their access to HIV care and their source of care, and provide an assessment of equity in access. In the long term, it is expected that HIV care access, as well as its social determinants, will impact on the morbidity and mortality rates among those affected by the HIV/AIDS epidemic. HIV care providers and program managers should further characterize the barriers to healthcare access and develop strategies to resolve them by means of policy change, for the benefit of the health service users and as part of the national response to the HIV/AIDS epidemic within a human rights framework.

The Rationale, Design, and Initial Efficacy of SystemCHANGE™ -HIV: A Systems-Based Intervention to Improve Physical Activity in People Living with HIV

The purpose of this paper was to describe SystemCHANGE^™-HIV, a novel self-management intervention for people living with HIV (PLWH) and provide evidence of its initial efficacy to improve physical activity. The rationale and design of the SystemCHANGE^™-HIV intervention were reviewed. Intervention detail, including its historical use, learning exercises and content, were provided. Forty PLWH participated in this pilot study, using a randomized clinical trial design. Intervention participants increased their physical activity by 300 Metabolic Equivalent minutes per week, compared to the control condition. Additionally, 70% of intervention participants increased their physical activity, whereas 65% of control subjects either had no change or experienced a decrease in physical activity. SystemCHANGE^™-HIV is an innovative intervention for PLWH, representing a new paradigm in health behavior change. Findings support its potential to increase physical activity in PLWH. Future work should refine and rigorously test the effect of this intervention.

Sexually transmitted diseases: reflections on metaphors and ethics

Sexually transmitted diseases (STDs) are probably the most tabooed diseases we know. The taboos and the related stigmata shape patients reality and influence significantly health care policies, medical research, and actual problems in medical ethics. To better understand these complex influences of ancient but still powerful taboos, related metaphors associated with illness and disease are analyzed according to their historical development and actual impact on society. It becomes obvious that research and health care policies cannot be satisfyingly successful in helping people affected by STDs as long as they do not take the mechanisms of taboos and associated metaphors into account.

Linear and non-linear associations of gonorrhea diagnosis rates with social determinants of health

Identifying how social determinants of health (SDH) influence the burden of disease in communities and populations is critically important to determine how to target public health interventions and move toward health equity. A holistic approach to disease prevention involves understanding the combined effects of individual, social, health system, and environmental determinants on geographic area-based disease burden. Using 2006–2008 gonorrhea surveillance data from the National Notifiable Sexually Transmitted Disease Surveillance and SDH variables from the American Community Survey, we calculated the diagnosis rate for each geographic area and analyzed the associations between those rates and the SDH and demographic variables. The estimated product moment correlation (PMC) between gonorrhea rate and SDH variables ranged from 0.11 to 0.83. Proportions of the population that were black, of minority race/ethnicity, and unmarried, were each strongly correlated with gonorrhea diagnosis rates. The population density, female proportion, and proportion below the poverty level were moderately correlated with gonorrhea diagnosis rate. To better understand relationships among SDH, demographic variables, and gonorrhea diagnosis rates, more geographic area-based estimates of additional variables are required. With the availability of more SDH variables and methods that distinguish linear from non-linear associations, geographic area-based analysis of disease incidence and SDH can add value to public health prevention and control programs.

Tool, weapon, or white elephant? A realist analysis of the five phases of a twenty-year programme of occupational health information system implementation in the health sector

Background

Although information systems (IS) have been extensively applied in the health sector worldwide, few initiatives have addressed the health and safety of health workers, a group acknowledged to be at high risk of injury and illness, as well as in great shortage globally, particularly in low and middle-income countries.

Methods

Adapting a context-mechanism-outcome case study design, we analyze our team’s own experience over two decades to address this gap: in two different Canadian provinces; and two distinct South African settings. Applying a realist analysis within an adapted structuration theory framing sensitive to power relations, we explore contextual (socio-political and technological) characteristics and mechanisms affecting outcomes at micro, meso and macro levels.

Results

Technological limitations hindered IS usefulness in the initial Canadian locale, while staffing inadequacies amid pronounced power imbalances affecting governance restricted IS usefulness in the subsequent Canadian application. Implementation in South Africa highlighted the special care needed to address power dynamics regarding both worker-employer relations (relevant to all occupational health settings) and North–south imbalances (common to all international interactions). Researchers, managers and front-line workers all view IS implementation differently; relationships amongst the workplace parties and between community and academic partners have been pivotal in determining outcome in all circumstances. Capacity building and applying creative commons and open source solutions are showing promise, as is international collaboration.

Conclusions

There is worldwide consensus on the need for IS use to protect the health workforce. However, IS implementation is a resource-intensive undertaking; regardless of how carefully designed the software, contextual factors and the mechanisms adopted to address these are critical to mitigate threats and achieve outcomes of interest to all parties. Issues specific to IS development, including technological support and software licensing models, can also affect outcome and sustainability – especially in the North–south context. Careful attention must be given to power relations between the various stakeholders at macro, meso and micro levels when implementing IS. North–South-South collaborations should be encouraged. Governance as well as technological issues are crucial determinants of IS application, and ultimately whether the system is seen as a tool, weapon, or white elephant by the various involved parties.

"You may call me a fool, But was there a rule The weapon should be turned into a tool? And what do we see? The first tool I step on Turned into a weapon. - Robert Frost"

"White (albino) elephants were regarded as holy in ancient times in Thailand and other Asian countries. Keeping a white elephant was a very expensive undertaking, since the owner had to provide the elephant with special food and provide access for people who wanted to worship it. If a Thai King became dissatisfied with a subordinate, he would give him a white elephant. The gift would, in most cases, ruin the recipient. - The Phrase Finder"

Local decision makers' awareness of the social determinants of health in Turkey: a cross-sectional study

BACKGROUND

Social determinants have been described as having a greater influence than other determinants of health status. The major social determinants of health and the necessary policy objectives have been defined; it is now necessary to evaluate the effectiveness of these policies. Previous studies have shown that descriptions of the awareness level of citizens and local decision makers, practice-based research and evidence, and intersectoral studies are the best options for investigating the social determinants of health at the community level. The objective of the present study was to define local decision makers' awareness of the social determinants of health in the Aydin province of Turkey.

METHODS

A total of 53 mayors serve the Aydin city center, districts and towns. Aydin city center has 22 neighborhoods and 22 headmen responsible for them. The present study targeted all mayors and headmen in Aydin - a total of 75 possible participants. A questionnaire was used to collect the data. The questionnaire was faxed to the mayors and administered face-to-face with the headmen.

RESULTS

Headmen identified the three most important determinants of public health as environmental issues, addictions (smoking, alcohol) and malnutrition. According to the mayors, the major determinant of public health is stress, followed by malnutrition, environmental issues, an inactive lifestyle, and the social and economic conditions of the country. Both groups expressed that the Turkish Ministry of Health, municipalities and universities are the institutions responsible for developing health policy. Headmen were found to be unaware and mayors were aware of the social determinants of health as classified by the World Health Organisation. Both groups were classified as unaware with regard to their awareness of the Marmot Review policy objectives.

CONCLUSIONS

Studies such as the present study provide important additional information on the social determinants of health, and help to increase the awareness levels of both local decision-makers and the community. Such studies must be considered a vital first step in future public health research on health determinants and their impact on national and international policies.