"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.

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.

The Use and Effectiveness of the Whole School Approach in School-Based Interventions Addressing Gender-Based Violence in Sub-Saharan Africa: A Systematic Review

Adolescents and young people in sub-Saharan Africa (SSA) experience high rates of gender-based violence (GBV). The whole school approach (WSA) is an established benchmark of effective school-based interventions to address this issue. We conducted a systematic review of peer-reviewed literature using PubMed/Medline, EMBASE, Scopus, Web of Science, Cochrane Library, Clinicaltrials.gov, and Google Scholar (1) to determine the characteristics, measured outcomes, and effectiveness of school-based GBV interventions and (2) to examine each papers' alignment with WSA and methodological quality. We developed a comprehensive intervention characteristics form for data extraction and analyzed the selected studies' quality using the modified Methodological Quality Rating Scale. To measure alignment with WSA implementation standards, we expanded the application of the WSA by creating the Whole School Approach Rating Scale (WSARS) for assessing school-based GBV interventions. Most interventions (n = 14/16) we reviewed effectively addressed at least one of the three outcomes of interest (i.e., sexual violence, physical violence, and GBV-related knowledge/attitudes). Over half (n = 9/16) of the studies were rated high on the WSARS. However, we observed no significant differences in effectiveness between studies rated high and those rated low on the WSARS. Our results indicate that school-based GBV interventions could be an effective and sustainable strategy for addressing GBV in and around schools.

Perceived barriers and facilitators to the adoption of telemedicine infectious diseases consultations in southeastern Missouri hospitals

INTRODUCTION

Telemedicine infectious diseases consultations (tele-ID consults) improves access to healthcare for underserved/resource-limited communities. However, factors promoting or hindering implementation of tele-ID consults in low-resource settings are understudied. This study sought to fill this gap by describing perceived barriers and facilitators tele-ID consults at three rural hospitals in southeastern Missouri.

METHODS

Twelve in-depth, semi-structured interviews were conducted with a purposively sampled group of information-rich hospital stakeholders from three rural, southeastern Missouri hospitals with partial or no on-site availability of ID physicians. Our literature-informed interview guide elicited participants' knowledge and experience with tele-ID consults, perceptions on ID consultation needs, and perceived barriers to and facilitators of tele-ID consults. Interview transcripts were coded using an iterative process of inductive analysis to identify core themes related to barriers and facilitators.

RESULTS

Perceived barriers to adopting and implementing tele-ID consults included logistical challenges, technology and devices, negative emotional responses, patient-related factors, concerns about reduced quality of care when using telemedicine, lack of acceptance or buy-in from physicians or staff, and legal concerns. Key facilitators included perceived need, perceived benefits to patients and physicians, flexibility and openness to change among staff members and patients, telemedicine champions, prior experiences, and enthusiasm.

DISCUSSION

Our findings demonstrate that rural hospitals need tele-ID consults and have the capacity to implement tele-ID consults, but operational and technical feasibility challenges remain. Adoption and implementation of tele-ID consults may reduce ID-physician shortage-related service gaps by permitting ID physician's greater geographic reach.

Socioeconomic Factors and Patterns of Intimate Partner Violence among Ever-Married Women in Uganda: Pathways and Actions for Multicomponent Violence Prevention Strategies

Intimate partner violence (IPV) is a severe public health problem in sub-Saharan Africa (SSA) with harmful effects on the physical, psychological, and socioeconomic wellbeing of survivors and their families. In SSA, IPV is associated with mental health disorders, high-risk behaviors, and HIV vulnerability, especially among women. In Uganda, poor socioeconomic status increases women's vulnerability to IPV. Yet there is limited evidence on the association between socioeconomic factors and IPV severity in Uganda. Our study used population-based data to (a) establish different patterns describing the severity of IPV experiences, (b) explore associations between socioeconomic factors and severity of IPV experiences among Ugandan ever-married women, and (c) examine direct and indirect pathways from socioeconomic factors to severity of IPV experiences. Data were drawn from the 2016 Uganda Demographic and Health Survey's sample of 7,536 ever-married women aged 15-49 years. A latent class analysis examined distinct patterns of IPV severity among this sample, yielding a four-class solution: low violence (n = 5,059; 67.1%); high physical violence, low sexual violence (n = 1,501; 19.9%); high sexual violence, moderate physical violence (n = 535; 7.1%); and high sexual and severe physical violence (n = 441; 5.9%). Using the low violence group as the reference category, we conducted a multinomial logistic regression that found significant associations between secondary education (aOR 2.35, 95% CI: [1.06, 5.24]), poorest on the wealth index (aOR 2.00, 95% CI: [1.13, 3.54]), and severe IPV experiences. Decision-making (aOR 0.81, 95% CI: [0.68, 0.96]) played a protective role against membership in the high sexual and physical violence class compared to the reference category. Using path analysis, we found that labor force participation partially mediated the path from wealth index and education to IPV severity. Findings indicate the need for interventions that aim to keep girls in school and target schools, communities, and media platforms to address gender norms, economic vulnerability, and comprehensive screening for multiple forms of violence.

Alleviating psychological distress and promoting mental wellbeing among adolescents living with HIV in sub-Saharan Africa, during and after COVID-19

COVID-19 social control measures (e.g. physical distancing and lockdowns) can have both immediate (social isolation, loneliness, anxiety, stress) and long-term effects (depression, post-traumatic stress disorder) on individuals' mental health. This may be particularly true of adolescents living with HIV (ALHIV) and their caregivers - populations already overburdened by intersecting stressors (e.g. psychosocial, biomedical, familial, economic, social, or environmental). Addressing the adverse mental health sequelae of COVID-19 among ALHIV requires a multi-dimensional approach that at once (a) economically empowers ALHIV and their households and (b) trains, mentors, and supervises community members as lay mental health services providers. Mental health literacy programming can also be implemented to increase mental health knowledge, reduce stigma, and improve service use among ALHIV. Schools and HIV care clinics offer ideal environments for increasing mental health literacy and improving access to mental health services.

From "4Rs and 2Ss" to "Amaka Amasanyufu" (Happy Families): Adapting a U.S.-based Evidence-Based Intervention to the Uganda Context

In Uganda, one in five children presents mental health challenges, including disruptive behavior disorders (DBDs). DBDs can persist through adulthood and result in negative outcomes. Effective interventions for DBDs have been developed and tested in high-poverty communities in developed countries. Yet, most African countries, such as Uganda, lack such interventions. This paper describes the adaptation process of an evidence-based intervention of U.S. origin to optimize fit to context with intervention fidelity, as part of a randomized trial conducted with youth that exhibit behavioral challenges and their caregivers in 30 schools in Uganda. The process involved: initial meetings with headteachers and teachers to introduce the study and the main concepts of the intervention; initial manual review focusing on 4Rs and 2Ss content by the Uganda team; engagement of community stakeholders for additional feedback on content and cultural relevance; final revision of the manual; and collection of children's drawings for the illustration of the manual. This paper describes both similarities and differences between the original and adapted intervention content and methods of delivery. The findings also highlight the importance of involving community stakeholders in the adaptation process.

The effectiveness of treatment supporter interventions in antiretroviral treatment adherence in sub-Saharan Africa: a systematic review and meta-Analysis

This systematic review and meta-analysis evaluated the effectiveness of treatment supporter interventions (TSI) in improving ART adherence and viral suppression among adults living with HIV (PLWH) in sub-Saharan Africa. This review included ten randomized controlled trials (RCT) and six cohort studies comparing treatment support interventions to the standard of care (SOC). Primary outcomes include pill count ART adherence and viral load suppression (VLS). Pooled relative risk ratios (PRR) with 95% confidence intervals were generated using random-effects models. Stratified analyses and meta-regressions were conducted to determine the effect of study type, follow-upperiod, and patient treatment supporters on ART adherence. Treatment supporters included partners, friends, family members, trained community health workers, and HIV positive peers. TSIs were associated with a 7.6% higher ART adherence compared to the SOC group (PRR = 1.076, [95% CI = 1.005, 1.151]). VLS was 5% higher in the treatment group compared to the SOC group (PRR = 1.05, [95% CI = 1.061, 1.207]). There was a significant, positive association between TSIs and VLS in community-based delivery settings but not in facility-based settings. TSIs were statistically significant for VLS in cohort study designs (RR = 1.073, [95% CI = 1.028, 1.121]) but not in RCTs. Findings suggest that TSIs critical in facilitating optimal ART adherence and VLS among PLWHs.

2513. The Effect of Treatment Supporter Interventions on ART Adherence in Eastern and Southern Africa: a systematic review and meta-analysis

Background

Access to ART has significantly reduced morbidity and mortality and improved quality of life in people living with HIV (PLWH). Treatment supporter interventions (TSIs) utilize patient or facility selected individuals to increase optimal ART adherence through home visits, peer support and medication management. This aim of this meta-analysis is to evaluate the effectiveness of TSIs in improving optimal ART adherence among PLWH in SSA using process- and outcome-oriented measures.

Methods

We searched PubMed, EMBASE, SCOPUS, Web of Science (WOS), Cochrane Library, and ClinicalTrials.gov for randomized controlled trials or cohort studies comparing treatment supporter interventions to the standard of care conducted in Eastern and Southern Africa. The primary outcomes were ART adherence measured by pill counts and virologic suppression. Pooled risk ratios with 95% confidence intervals were calculated using random-effects models. Stratified analyses and meta-regression were conducted to determine the effect of study type and patient nomination of treatment supporters on ART adherence.

Results

Sixteen studies, 10 RCTs and 6 cohort studies, were selected for inclusion. Virologic suppression was reported in 14 studies with 12,457 individuals in TSIs and 23,592 receiving the standard of care. Optimal ART adherence was reported in 7 RCTs only (2,185 individuals in TSI and 1,545 receiving SOC). Optimal ART adherence was 7.6% higher in TSIs compared with SOC (pooled RR 1.076, 95% CI 1.005–1.151, p = 0.035). Heterogeneity of these studies was high (I² = 91.1%). Virologic suppression was 5% higher in TSIs compared with the standard of care (pooled RR 1.05, 95% CI 1.019–1.081, P = 0.001). Meta-regression demonstrated that virologic suppression did not significantly vary by study type (b = −0.042, 95% CI −0.09–0.001, P = 0.057) and patient selection of the treatment supporter (b = 0.026, 95% CI −0.07–0.12, P = 0.554).

Conclusion

Optimal ART adherence is marginally higher in treatment supporter interventions compared with the standard of care. Patient-nominated supporters achieve similar rates of virologic suppression to facility-selected supporters, and could play a critical role in addressing disparities in health outcomes among PLWH.

Disclosures

All authors: No reported disclosures.

Perceived social support and psychological wellbeing of children orphaned by HIV/AIDS in Southwestern Uganda

Evidence points to a correlation between perceived social support and children's psychological well-being globally. However, only a few studies have examined the relationship between perceived social support (PSS) from multiple sources and children's psychological outcomes. Even fewer studies have examined the relationship between perceived social support from multiple sources and the psychological outcomes of children orphaned by HIV/AIDS in Sub-Saharan Africa (SSA). This study examines whether PSS from multiple sources (parents/caregivers, teachers, friends and classmates) and family cohesion are independently and collectively associated with the psychological well-being of children orphaned by HIV/AIDS in Uganda. This study used baseline data from a National Institute of Health (NIH)-funded Suubi-Maka (Hope for families) study, conducted in Southwestern Uganda. A total of 346 child-caregiver dyads from 10 comparable primary schools participated in the study. Multivariate and multivariable regression analyses were conducted to examine: (1) variations in PSS from multiple sources and family cohesion, and (2) the relationship between PSS, family cohesion and children's psychological outcomes, measured by depression, hopelessness, and self-concept. Controlling for participants' demographic and household characteristics, the combined measure of PSS from multiple sources was positively associated with self-concept (b = .32, 95% CI = .23, .41, p ≤ .001) and negatively associated with hopelessness (b = -.19, 95% CI = -.29, -.09, p ≤ .001) and depressive symptoms (b = -.13, 95% CI = -.23, -.03, p ≤ .01). PSS from parents/guardians and teachers was a significant predictor. In addition, family cohesion was positively associated with self-concept (b = .37, 95% CI = .15, .58, p ≤ .001) and negatively associated with depressive symptoms (b = -.36, 95%CI = -.59, -.13, p≤ = .01). Findings indicate that family cohesion and perceived social support, especially from parent/caregivers and teachers were associated with better children's psychological outcomes. In HIV-impacted communities, interventions designed to strengthen family relationships and social support are essential to offset children's psychological well-being.