Gender Diversity, Disability, and Well-Being: Impact of Delayed and Foregone Care Because of COVID-19

Purpose: This study explored the impact of delayed and foregone care due to COVID-19 on well-being among disabled and gender diverse adults. Methods: Using data from the 2021 National Survey on Health and Disability and logistic regression modeling we assessed the impact of delayed or foregone care due to COVID-19 on well-being among disabled people (n = 1638), with comparisons between cisgender (n = 1538) and gender diverse (n = 100) people with disabilities. We report odds ratios (OR) and confidence intervals (CI). Results: Disabled people reported high rates of delayed (79.36%) and foregone (67.83%) care and subsequent negative effects on well-being (72.07%). Gender diverse disabled people were over four times more likely to have delayed any care (OR 4.45, 95% CI 1.86-10.77) and three times more likely to have foregone any care (OR 3.14, 95% CI 1.71-5.79) due to COVID-19 compared to cisgender disabled people. They were three times more likely to report any negative impact on their health and well-being because of delayed and foregone care (OR 2.78, 95% CI 1.43-5.39). Conclusion: The COVID-19 pandemic affected the health care utilization of disabled people, resulting in high rates of delayed care, foregone care, and negative impacts on well-being. These effects were intensified at the intersection of disability and marginalized gender identity, with gender diverse disabled people having higher odds of delayed and foregone care and negative effects on well-being, including physical health, mental health, pain levels, and overall level of functioning.

Meaningful Social Inclusion and Mental Well-Being Among Autistic Adolescents and Emerging Adults: Protocol for a Community-Based Mixed Methods Study

BACKGROUND

In the United States, autistic people face high rates of co-occurring mental illnesses and premature death due to self-harm, which are indicators of threats to mental well-being. Social inclusion may enhance mental well-being and resilience among autistic people. According to Simplican and colleague's (2015) model of social inclusion for people with intellectual and developmental disabilities, social inclusion is an interaction between community participation and interpersonal relationships. There is limited research on social inclusion that includes the integration of interpersonal relationships and community participation among autistic people or the impact of social inclusion on the well-being of autistic people. Additionally, little evidence exists regarding how autistic people prefer to be included in the community or form interpersonal relationships.

OBJECTIVE

The long-term objective of this project is to improve social inclusion factors to support the mental well-being of autistic people. This protocol describes a community-based, mixed methods pilot study to develop a definition of meaningful social inclusion for autistic people and to understand the relationship between meaningful social inclusion and mental well-being among autistic adolescents and emerging adults.

METHODS

The project uses a community-based, sequential mixed methods design with a formative phase (Phase 1) that informs a survey phase (Phase 2) and concludes with a process evaluation of the community engagement process (Phase 3). During Phase 1, we will recruit 10 community partners (autistic adults and stakeholders) and conduct sharing sessions to cocreate a definition of meaningful social inclusion and a survey of meaningful social inclusion and well-being. During Phase 2, we will recruit 200 participants (100 autistic adolescents and emerging adults and 100 caregivers) to complete the survey. We will examine whether meaningful social inclusion predicts well-being given sociodemographic factors using ordered logistic regression, with well-being categorized as low, medium, and high. During Phase 3, the community partners from Phase 1 will complete a survey on their experiences with the project.

RESULTS

Ethics approval was obtained for this project in March 2023. We have recruited community partners and started the Phase 1 focus groups as of September 2023. Phase 2 and Phase 3 have not yet started. We expect to complete this study by March 2025.

CONCLUSIONS

Using a community-based, mixed methods approach, we intended to develop a definition of meaningful social inclusion for autistic people and understand the role meaningful social inclusion plays in the well-being of autistic people.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52658.

Advancing Equity Through Centering Societal Values to Operationalize Racism as a Public Health Crisis: The KKey Values Inequities Model

Background

The past two decades have been marked by increased efforts to advance equity in various disciplines, including social sciences, public health, environmental health, and medicine. In 2020, a national movement of municipalities declared racism a public health crisis. These efforts have coincided and likely shaped a growing sphere of federal and philanthropic funding for health equity, which frequently calls for practical interventions toward reducing and ultimately eliminating disparities. Disparities in health such as maternal mortality, infant mortality, diabetes, cancer, and stroke have been linked to root causes such as racism. Often, root causes are also linked to disparities in other sectors (i.e., finance/wealth attainment, educational attainment, career attainment, and home ownership). In 2021, in a study published in the New England Journal of Medicine, suggested that racist policies were root causes of U.S. racial health inequities. While racism, sexism, and classism, etc., are characterized as root causes, we posit that there is a deeper driver that has yet to be advanced. This presents a disparity-inequity model that maps disparities and inequities to the societal value system, not root causes.

Methods

The KKey Values Inequities Disparities Model described in this article combines a case study of the Flint Water Crisis to explore the historic impact of human devaluation and its role in systemic racism and classism, which ultimately creates and exacerbates inequities that produce disparities in communities. The model integrates the value system and its contribution to societal causes (formerly known as root causes).

Conclusions

A broadly defined values-inequities-disparities model will allow researchers, practitioners, decision makers, lawmakers, and community members to (1) assess the core root of inequities and disparities; (2) identify solutions in the human value domain; (3) design appropriate course corrective programming, interventions, processes, and procedures; and (4) create actions to integrate new systemic procedures and practices in our laws and governance to advance equity.

Trust in and Use of COVID-19 Information Sources Differs by Health Literacy among College Students

People’s health information-seeking behaviors differ by their health literacy levels. This study assessed the relationship between health literacy and college students’ levels of trust in and use of a range of health information sources of COVID-19. We collected data from August to December 2020 among college students (n = 763) through an online survey. We used a health literacy measure containing three self-reported survey questions, developed by the CDC. We assessed the extent to which participants trusted and used any of the sixteen different sources of information about COVID-19. Respondents reported high levels of trusting and using COVID-19 information from the CDC, health care providers, the WHO, state/county/city health departments, and official government websites when compared to other sources. After controlling for demographic characteristics (i.e., gender, age, race, ethnicity, and income), those who reported having lower health literacy were significantly less likely to trust and use COVID-19 information from these health authorities when compared to participants who reported having higher health literacy. Students with lower self-reported health literacy indicated not trusting or using official health authority sources for COVID-19 information. Relying on low-quality information sources could create and reinforce people’s misperceptions regarding the virus, leading to low compliance with COVID-19-related public health measures and poor health outcomes.

COVID-19 information-seeking behaviors and preventive behaviors among college students in Oklahoma

Objective: To explore experiences, beliefs, and information-seeking behavior around COVID-19 among college students in Oklahoma. Participants: Fifteen college students participated during the pandemic period from April to July 2020. Methods: An exploratory, qualitative research approach method was used to discover students' experiences, beliefs, and information-seeking behaviors around COVID-19. Exploration of beliefs was guided by the Health Belief Model. Results: Students engaged in COVID-19 information-seeking behaviors predominantly through Internet sites, broadcast news, health professionals, and governmental sources. Students experienced emotional burden as a result of COVID-19 misinformation in these sources. While most students perceived a low chance of acquiring the virus due to their lack of underlying medical conditions, they were still concerned about the consequences of becoming infected. Students noted the difficulty of physical distancing while on campus. Conclusions: Colleges/universities should maximize the dissemination of timely, valid health information for the safety of their students and the broader community.

Gender Identity, Disability, and Unmet Healthcare Needs among Disabled People Living in the Community in the United States

Disabled adults and transgender people in the United States face multiple compounding and marginalizing forces that result in unmet healthcare needs. Yet, gender identity among disabled people has not been explored, especially beyond binary categories of gender. Using cross-sectional survey data, we explored the rates of disability types and the odds of unmet healthcare needs among transgender people with disabilities compared to cisgender people with disabilities. The rates of disability type were similar between transgender and cisgender participants with two significant differences. Fewer transgender participants identified physical or mobility disability as their main disability compared to cisgender participants (12.31%/8 vs. 27.68/581, p < 0.01), and more transgender participants selected developmental disability as their main disability compared to cisgender participants (13.85%/9 vs. 3.67%/77, p < 0.001). After adjusting for sociodemographic characteristics, the odds of disabled transgender participants reporting an unmet need were higher for every unmet need except for preventative services.

COVID-19 Related Experiences Among College Students With and Without Disabilities: Psychosocial Impacts, Supports, and Virtual Learning Environments

This cross-sectional analysis estimated differences, based on disability status, in college students' (n = 777) experiences during the COVID-19 pandemic. Data were modeled using t-tests and logistic regression. Most participants were white (86.2%), and women (66.4%). The mode age was 23. A third (35.6%) had at least one disability. Students reported high rates of psychosocial distress, like fear of contracting (59.7%) and spreading (74.3%) COVID-19, worry about friends and family (83.7%), and increased anxiety (72.5%), depression (59.9%), and substance use (24.7%). Forty-two percent (42.2%) were scared they would miss out on their education through virtual classes. About a third feared forgetting assignments (34.1%) and making mistakes (33.9%). Fewer students expressed apprehension about (27.9%) and intimidation by (26.3%) virtual learning. Only 17.2% would continue taking virtual classes after the pandemic. Students with disabilities (M = 12.4, SD = 4.1) experienced more psychosocial stressors compared to students without disabilities (M = 9.9, SD = 4.2), [t₍₇₇₅₎ = 7.86, p < 0.001]. In adjusted models, disabled students were more than twice as likely to experience worry about medical bills (OR = 2.29), loneliness (OR = 2.09), and increased anxiety (OR = 2.31). They were also more than three times as likely to report increased depression (OR = 3.51) and changes in sexual activity (OR = 3.12). However, students with disabilities (M = 1.5, SD = 1.1) also reported receiving more support compared to their non-disabled classmates (M = 1.1, SD = 1.1), [t₍₇₇₅₎ = 6.06, p < 0.001]. Disabled students were more likely to feel a sense of contributing to society by following precautions (OR = 1.80) and receive support from family and others (emotional support: OR = 2.01, financial support: OR = 2.04). Interestingly, no significant differences were found in students' feelings associated with online or virtual learning [t_(526.08) = 0.42, p = 0.68]. Students with disabilities, though, trended toward reporting negative experiences with virtual learning. In conclusion, students with disabilities were disproportionately affected by COVID-19 stressors, but also expressed more support and a sense of contributing to the common good.

Framing the front door: co-creating a home health care assessment of service need for children with disabilities

This paper details the co-creation of a home health assessment tool for children with disabilities in the context of state-level systems change from traditional Medicaid to Medicaid managed care. A community based, sequential, mixed methods design was used to co-develop the assessment. A process evaluation highlighted community members' experiences with Medicaid managed care. Community members identified issues related to appropriateness of items and loss of services and recommended a dual assessment process to address concerns. Results indicated that 72% of items functioned well. Community members felt that organizational policies and the accuracy of clinical information obtained during assessment processes led directly to loss of services. Co-creating the assessment with caregivers of children with disabilities led to a comprehensive, person-centered, and holistic tool. The process buttressed several concrete systems and policy actions to improve home health care for children with disabilities in Medicaid managed care.

A Provider-Facing eHealth Tool for Transitioning Youth With Special Health Care Needs From Pediatric to Adult Care: Mixed Methods, User-Engaged Usability Study

BACKGROUND

There is a need for medical education on health care transitions for youth with special health care needs. The Texas Transition Toolkit (the tool) supports providers through a one-stop shop for researching literature on care transitions, a catalog of care transition tools, and guides for developing care transition programs.

OBJECTIVE

This study aims to assess the functionality and usability of the tool with providers working with transition-aged children and youth with special health care needs (representative users).

METHODS

The tool was evaluated using a triangulated mixed methods case study approach consisting of a concurrent think-aloud phase, a satisfaction survey, and a survey of problem relevance and task performance to operationalize and capture functionality and usability. Our mixed methods deep dive into the functionality and usability of the tool focused on 10 representative users from one medical home in Texas and 5 website design experts.

RESULTS

Representative users found the tool to be highly relevant, as demonstrated by the satisfaction score for relevance (138/150, 92%). According to the users, the tool provided comprehensive information related to health care transitions for youth with special health care needs, with a satisfaction score of 87.3% (131/150) for comprehensive. Overall satisfaction with the tool was high at 81.92% (1065/1300) with a cutoff score of 73.33% (953.4/1300) indicating high satisfaction, but users reported relatively lower satisfaction with search (114/150, 76%) and navigation (ease of use: 114/150, 76%; hyperlinks: 163/200, 81.5%; structure: 159/200, 79.5%). They experienced search- and navigation-related problems (total problems detected: 21/31, 68%) and, based on quality checks, had a relatively low task completion rate for tasks involving finding information (60/80, 75%), which required searching and navigation. The problems identified around search and navigation functionality were relevant (relevance scores ranging from 14.5 to 22, with a cutoff score of 11.7 indicating relevance).

CONCLUSIONS

The tool may help bridge the gaps in training on health care transitions for youth with special health care needs in US medical education. The tool can be used to create structured protocols to help improve provider knowledge, collaboration across pediatric and adult care providers, and the continuity of care as youth with special health care needs transition from pediatric to adult care. The results provided a road map for optimizing the tool and highlighted the importance of evaluating eHealth technologies with representative users.

Socioeconomic Status and Access to Healthcare: Interrelated Drivers for Healthy Aging

The rapid growth of the global aging population has raised attention to the health and healthcare needs of older adults. The purpose of this mini-review is to: (1) elucidate the complex factors affecting the relationship between chronological age, socio-economic status (SES), access to care, and healthy aging using a SES-focused framework; (2) present examples of interventions from across the globe; and (3) offer recommendations for research-guided action to remediate the trend of older age being associated with lower SES, lack of access to care, and poorer health outcomes. Evidence supports a relationship between SES and healthcare access as well as healthcare access and health outcomes for older adults. Because financial resources are proportional to health status, efforts are needed to support older adults and the burdened healthcare system with financial resources. This can be most effective with grassroots approaches and interventions to improve SES among older adults and through data-driven policy and systems change.