An eHealth Intervention for Promoting COVID-19 Knowledge and Protective Behaviors and Reducing Pandemic Distress Among Sexual and Gender Minorities: Protocol for a Randomized Controlled Trial (#SafeHandsSafeHearts)

Covid-19 Vaccine Hesitancy and Under-Vaccination among Marginalized Populations in the United States and Canada: A Scoping Review

BACKGROUND

Amid persistent disparities in Covid-19 vaccination and burgeoning research on vaccine hesitancy (VH), we conducted a scoping review to identify multilevel determinants of Covid-19 VH and under-vaccination among marginalized populations in the U.S. and Canada.

METHODS

Using the scoping review methodology developed by the Joanna Briggs Institute, we designed a search string and explored 7 databases to identify peer-reviewed articles published from January 1, 2020-October 25, 2022. We combine frequency analysis and narrative synthesis to describe factors influencing Covid-19 VH and under-vaccination among marginalized populations.

RESULTS

The search captured 11,374 non-duplicated records, scoped to 103 peer-reviewed articles. Among 14 marginalized populations identified, African American/Black, Latinx, LGBTQ+, American Indian/Indigenous, people with disabilities, and justice-involved people were the predominant focus. Thirty-two factors emerged as influencing Covid-19 VH, with structural racism/stigma and institutional mistrust (structural)(n = 71) most prevalent, followed by vaccine safety (vaccine-specific)(n = 62), side effects (vaccine-specific)(n = 50), trust in individual healthcare provider (social/community)(n = 38), and perceived risk of infection (individual)(n = 33). Structural factors predominated across populations, including structural racism/stigma and institutional mistrust, barriers to Covid-19 vaccine access due to limited supply/availability, distance/lack of transportation, no/low paid sick days, low internet/digital technology access, and lack of culturally- and linguistically-appropriate information.

DISCUSSION

We identified multilevel and complex drivers of Covid-19 under-vaccination among marginalized populations. Distinguishing vaccine-specific, individual, and social/community factors that may fuel decisional ambivalence, more appropriately defined as VH, from structural racism/structural stigma and systemic/institutional barriers to vaccination access may better support evidence-informed interventions to promote equity in access to vaccines and informed decision-making among marginalized populations.

"Going vaccine hunting": Multilevel influences on COVID-19 vaccination among racialized sexual and gender minority adults-a qualitative study

High levels of COVID-19 vaccine hesitancy have been reported among Black and Latinx populations, with lower vaccination coverage among racialized versus White sexual and gender minorities. We examined multilevel contexts that influence COVID-19 vaccine uptake, barriers to vaccination, and vaccine hesitancy among predominantly racialized sexual and gender minority individuals. Semi-structured online interviews explored perspectives and experiences around COVID-19 vaccination. Interviews were recorded, transcribed, uploaded into ATLAS.ti, and reviewed using thematic analysis. Among 40 participants (mean age, 29.0 years [SD, 9.6]), all identified as sexual and/or gender minority, 82.5% of whom were racialized. COVID-19 vaccination experiences were dominated by structural barriers: systemic racism, transphobia and homophobia in healthcare and government/public health institutions; limited availability of vaccination/appointments in vulnerable neighborhoods; absence of culturally-tailored and multi-language information; lack of digital/internet access; and prohibitive indirect costs of vaccination. Vaccine hesitancy reflected in uncertainties about a novel vaccine amid conflicting information and institutional mistrust was integrally linked to structural factors. Findings suggest that the uncritical application of "vaccine hesitancy" to unilaterally explain undervaccination among marginalized populations risks conflating structural and institutional barriers with individual-level psychological factors, in effect placing the onus on those most disenfranchised to overcome societal and institutional processes of marginalization. Rather, disaggregating structural determinants of vaccination availability, access, and institutional stigma and mistrust from individual attitudes and decision-making that reflect vaccine hesitancy, may support 1) evidence-informed interventions to mitigate structural barriers in access to vaccination, and 2) culturally-informed approaches to address decisional ambivalence in the context of structural homophobia, transphobia, and racism.

Beyond the bench: LGBTQ+ health equity after India's "no same-sex marriage" verdict

LGBTQ+ people (e.g., lesbian, gay, bisexual, transgender, and queer or questioning people) experience systemic marginalisation and discrimination globally and throughout India. In October 2023, the Indian Supreme Court rejected the legal recognition of same-sex marriage, blocking marriage equality for LGBTQ+ people and contending that the right to marry neither qualifies as a fundamental right accorded by the Indian Constitution nor falls under the Supreme Court's purview. Although the Supreme Court declared opposition to discrimination based on sexual orientation, its failure to recognise same-sex marriage legally is a substantial obstruction to full LGBTQ+ equality. We propose that the refusal of the Indian legal system to honour same-sex marriage while calling for an end to societal violence and discriminatory behaviour against the LGBTQ+ community is inherently flawed and counterintuitive. Informed by our team's multidisciplinary orientation as healthcare professionals, researchers, and advocates, we delineate explicit challenges that LGBTQ+ people in India may encounter due to the Supreme Court's recent ruling. We subsequently put forth a series of interprofessional and intersectoral recommendations to mitigate this decision's immediate and long-term consequences, providing an actionable path toward LGBTQ+ inclusion, justice, and equity in India.

Psychological Distress Among High School Students in Bangkok Thailand

Introduction

This study investigated psychological distress among high school students in Thailand.A sample of 8,345 students from thirty-five Bangkok schools voluntarily participated, responding to a questionnaire and undergoing stress assessments. Socio-demographic factors including grade level, school scale, hometown, parental marital status, presence of siblings, gender, health conditions, online classes, and family monthly income were analyzed.

Results

Of the participants, 1,087 (13.02%) experienced psychological distress. Grade level, school scale, hometown, parental marital status, and siblings' presence showed no significant associations with distress. However, being female or transgender correlated with higher distress levels. Students with health issues and those in online classes also experienced elevated distress. Additionally, a family monthly income below 10,000 Thai Baht was associated with distress.

Conclusion

This study sheds light on factors contributing to psychological distress in high school students. It highlights the need for tailored support for vulnerable groups within the student population, emphasizing the role of educators, policymakers, and mental health professionals in addressing these challenges.

Effectiveness of an eHealth intervention for reducing psychological distress and increasing COVID-19 knowledge and protective behaviors among racialized sexual and gender minority adults: A quasi-experimental study (#SafeHandsSafeHearts)

PURPOSE

Sexual and gender minority and racialized populations experienced heightened vulnerability during the Covid-19 pandemic. Marginalization due to structural homophobia, transphobia and racism, and resulting adverse social determinants of health that contribute to health disparities among these populations, were exacerbated by the Covid-19 pandemic and public health measures to control it. We developed and tested a tailored online intervention (#SafeHandsSafeHearts) to support racialized lesbian, gay, bisexual, transgender, queer, and other persons outside of heteronormative and cisgender identities (LGBTQ+) in Toronto, Canada during the pandemic.

METHODS

We used a quasi-experimental pre-test post-test design to evaluate the effectiveness of a 3-session, peer-delivered eHealth intervention in reducing psychological distress and increasing Covid-19 knowledge and protective behaviors. Individuals ≥18-years-old, resident in Toronto, and self-identified as sexual or gender minority were recruited online. Depressive and anxiety symptoms, and Covid-19 knowledge and protective behaviors were assessed at baseline, 2-weeks postintervention, and 2-months follow-up. We used generalized estimating equations and zero-truncated Poisson models to evaluate the effectiveness of the intervention on the four primary outcomes.

RESULTS

From March to November 2021, 202 participants (median age, 27 years [Interquartile range: 23-32]) were enrolled in #SafeHandsSafeHearts. Over half (54.5%, n = 110) identified as cisgender lesbian or bisexual women or women who have sex with women, 26.2% (n = 53) cisgender gay or bisexual men or men who have sex with men, and 19.3% (n = 39) transgender or nonbinary individuals. The majority (75.7%, n = 143) were Black and other racialized individuals. The intervention led to statistically significant reductions in the prevalence of clinically significant depressive (25.4% reduction, p < .01) and anxiety symptoms (16.6% reduction, p < .05), and increases in Covid-19 protective behaviors (4.9% increase, p < .05), from baseline to postintervention.

CONCLUSION

We demonstrated the effectiveness of a brief, peer-delivered eHealth intervention for racialized LGBTQ+ communities in reducing psychological distress and increasing protective behaviors amid the Covid-19 pandemic. Implementation through community-based organizations by trained peer counselors supports feasibility, acceptability, and the importance of engaging racialized LGBTQ+ communities in pandemic response preparedness. This trial is registered with ClinicalTrials.gov, number NCT04870723.

Associations between water insecurity and mental health outcomes among lesbian, gay, bisexual, transgender and queer persons in Bangkok, Thailand and Mumbai, India: Cross-sectional survey findings

Background

Water insecurity disproportionally affects socially marginalized populations and may harm mental health. Lesbian, gay, bisexual, transgender and queer (LGBTQ) persons are at the nexus of social marginalization and mental health disparities; however, they are understudied in water insecurity research. Yet LGBTQ persons likely have distinct water needs. We explored associations between water insecurity and mental health outcomes among LGBTQ adults in Mumbai, India and Bangkok, Thailand.

Methods

This cross-sectional survey with a sample of LGBTQ adults in Mumbai and Bangkok assessed associations between water insecurity and mental health outcomes, including anxiety symptoms, depression symptoms, loneliness, alcohol misuse, COVID-19 stress and resilience. We conducted multivariable logistic and linear regression analyses to examine associations between water insecurity and mental health outcomes.

Results

Water insecurity prevalence was 28.9% in Mumbai and 18.6% in Bangkok samples. In adjusted analyses, in both sites, water insecurity was associated with higher likelihood of depression symptoms, anxiety symptoms, COVID-19 stress, alcohol misuse and loneliness. In Mumbai, water insecurity was also associated with reduced resilience.

Conclusion

Water insecurity was common among LGBTQ participants in Bangkok and Mumbai and associated with poorer well-being. Findings signal the importance of assessing water security as a stressor harmful to LGBTQ mental health.

A Feasibility Study of the SAFE Pilot Program: A University-School Board Partnership in Ontario

The Support and Aid to Families Electronically (SAFE) pilot program was developed through a community-university partnership to support parents of elementary students in Ontario, while providing stable practicums for social work students in the midst of COVID-19 restrictions. Purpose: The aim of the current study was to examine the feasibility of the SAFE pilot program as a mental health support to families by examining three feasibility objectives: demand, acceptably, and implementation. Method: Qualitative data from interviews, focus groups, and qualitative surveys involving service users, social work students, referring school board and university professionals (n = 37) were examined. Results: Demand for SAFE extended beyond the pandemic. A high-level of acceptance of SAFE was identified. Areas of success and considerations for implementation are outlined. Discussion: This study provides practice guidance on implementing this unique program, with potential to address gaps in service provision and the ongoing crisis in field education.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Impact of COVID-19 on Sexual and Gender Minority Communities: Focus Group Discussions

BACKGROUND

People who identify as sexual and gender minorities (SGM) experienced disproportionate economic and mental health issues related to COVID-19 when compared to the general population. The purpose of this study was to better understand how COVID-19 has impacted the SGM community and ways to address vaccine hesitancy.

METHODS

Three focus groups were conducted with 21 members of the SGM community between 5 November and 10 December 2020. A thematic analysis using the reflexive approach was applied to the transcripts of the focus groups.

RESULTS

Four themes emerged: (1) Impact of COVID-19 on the Community, (2) Perceptions of Contact Tracing and Testing, (3) Perceptions of a Potential COVID-19 Vaccine, and (4) Decreasing Vaccine Hesitancy. The most relevant subthemes were that social isolation led to anxiety, stress, and fear in the SGM community during COVID-19; resilience and adaptation were positive outcomes of the pandemic; histories of medical racism contributed to hesitancy to get tested; and specific messaging from trusted messengers may be needed to encourage SGM communities to get vaccinated. These findings support other COVID-19 research on the SGM community during the start of the pandemic.

CONCLUSIONS

This study provides insight into the impact of the early stages of COVID-19 on the SGM community, highlighting the unique hurdles faced by SGM individuals with regard to contact tracing and vaccine hesitancy.

Mental health, economic well-being and health care access amid the COVID-19 pandemic: a mixed methods study among urban men who have sex with men in India

Scant empirical research from Asia has addressed the impact of COVID-19 on sexual minority health. We aimed to explore and understand the impact of COVID-19 on income security, mental health, HIV risk and access to health services among men who have sex with men (MSM) in India. We conducted a concurrent mixed methods study from April to June 2020, including a cross-sectional survey and in-depth semi-structured interviews with MSM recruited from three non-governmental organisations providing HIV prevention services in Chandigarh, India. We examined the associations of sexual minority stressors (sexual stigma, internalised homonegativity), economic stressors, and stress due to social distancing, with depression and anxiety, HIV risk, and access to health services. Survey findings (n = 132) indicated that internalised homonegativity and stress related to social distancing were significantly associated with depressive and anxiety symptoms. Results also showed reduced access to condoms, HIV testing and counselling services. Qualitative findings (n = 10) highlighted adverse economic impacts of COVID-19, including loss of employment/wages and engaging in survival sex work, which contributed to psychological distress and HIV risk. The COVID-19 pandemic has resulted in considerable psychological and financial distress among low socioeconomic status MSM in India, including those involved in sex work - communities already marginalised in economic, family and healthcare sectors. Structural interventions to improve access to mental health and HIV services and decrease financial burden are critical to mitigate the impact of COVID-19.

Information and communication technology-based health interventions for transgender people: A scoping review

In the recent past, there has been a strong interest in the use of information and communication technology (ICT) to deliver healthcare to 'hard-to-reach' populations. This scoping review aims to explore the types of ICT-based health interventions for transgender people, and the concerns on using these interventions and ways to address these concerns. Guided by the scoping review frameworks offered by Arksey & O'Malley and the PRISMA-ScR checklist, literature search was conducted in May 2021 and January 2022 in three databases (PubMed, CINAHL and Scopus). The two searches yielded a total of 889 non-duplicated articles, with 47 of them meeting the inclusion criteria. The 47 articles described 39 unique health projects/programs, covering 8 types of ICT-based interventions: videoconferencing, smartphone applications, messaging, e-coaching, self-learning platforms, telephone, social media, and e-consultation platforms. Over 80% of the health projects identified were conducted in North America, and 62% focused on HIV/sexual health. The findings of this review suggest that transgender people had often been regarded as a small subsample in ICT-based health projects that target other population groups (such as 'men who have sex with men' or 'sexual minority'). Many projects did not indicate whether transgender people were included in the development or evaluation of the project. Relatively little is known about the implementation of ICT-based trans health interventions outside the context of HIV/sexual health, in resource limiting settings, and among transgender people of Asian, Indigenous or other non-White/Black/Hispanic backgrounds. While the range of interventions identified demonstrate the huge potentials of ICT to improve healthcare access for transgender people, the current body of literature is still far from adequate for making comprehensive recommendations on the best practice of ICT-based interventions for transgender people. Future ICT-based interventions need to be more inclusive and specified, in order to ensure the interventions are safe, accessible and effective for transgender people.

COVID-19 vaccine hesitancy among marginalized populations in the U.S. and Canada: Protocol for a scoping review

INTRODUCTION

Despite the development of safe and highly efficacious COVID-19 vaccines, extensive barriers to vaccine deployment and uptake threaten the effectiveness of vaccines in controlling the pandemic. Notably, marginalization produces structural and social inequalities that render certain populations disproportionately vulnerable to COVID-19 incidence, morbidity, and mortality, and less likely to be vaccinated. The purpose of this scoping review is to provide a comprehensive overview of definitions/conceptualizations, elements, and determinants of COVID-19 vaccine hesitancy among marginalized populations in the U.S. and Canada.

MATERIALS AND METHODS

The proposed scoping review follows the framework outlined by Arksey and O'Malley, and further developed by the Joanna Briggs Institute. It will comply with reporting guidelines from the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The overall research question is: What are the definitions/conceptualizations and factors associated with vaccine hesitancy in the context of COVID-19 vaccines among adults from marginalized populations in the U.S. and Canada. Search strategies will be developed using controlled vocabulary and selected keywords, and customized for relevant databases, in collaboration with a research librarian. The results will be analyzed and synthesized quantitatively (i.e., frequencies) and qualitatively (i.e., thematic analysis) in relation to the research questions, guided by a revised WHO Vaccine Hesitancy Matrix.

DISCUSSION

This scoping review will contribute to honing and advancing the conceptualization of COVID-19 vaccine hesitancy and broader elements and determinants of underutilization of COVID-19 vaccination among marginalized populations, identify evidence gaps, and support recommendations for research and practice moving forward.