Gender Discrimination and Mental Health Among Health Care Workers: Findings from a Mixed Methods Study.

Background: Gender discrimination among healthcare workers (HCWs) negatively impacts their mental health and career development; however, few studies have explored how experiences of gender discrimination change during times of health system strain. Methods: This survey-based study assesses the associations between gender discrimination and four stress-related mental health outcomes (posttraumatic stress, depression, anxiety, and burnout), as well as the qualitative experiences of gender discrimination in healthcare during the COVID-19 pandemic. Results: Among women, increased gender discrimination was associated with heightened symptoms of posttraumatic stress, depression, anxiety, and burnout after adjusting for demographics and pandemic-related stressors; however, among men, increased gender discrimination was only associated with heightened symptoms of depression. Using thematic analysis, we identified five themes that describe experiences of gender discrimination faced by women in healthcare, including differential valuing of work and contributions, gendered roles and assumptions about roles, maternal discrimination, objectification, and "old boys club." We also identified two themes describing how men perceived gender discrimination, including instances of symbolic discrimination and woman provider preference. Conclusion: These findings suggest that experiences of gender discrimination persist during times of health system strain and negatively impact women HCWs' mental health.

Pre- and peri-traumatic event stressors drive gender differences in chronic stress-related psychological sequelae: A prospective cohort study of COVID-19 frontline healthcare providers.

Women are at heightened risk for chronic stress-related psychological sequelae (SRPS), including major depressive disorder (MDD), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD) in response to potentially traumatic events, including the COVID-19 pandemic. However, few studies have examined pre- and peri-event stressors that could account for gender differences in chronic SRPS. To address this gap, we conducted a prospective cohort study of healthcare providers (HCPs) caring for patients with COVID-19 at a large tertiary care hospital in New York City, and measured mental health risk factors and symptoms of MDD, GAD, and PTSD at baseline (April 2020) and at a 7-month follow-up (December 2020). We defined chronic SRPS as the presence of probable MDD, GAD, and/or PTSD at both timepoints. We conducted a mediation analysis to evaluate whether pre- and peri-event stressors explained women's increased risk for chronic SRPS. Among our sample of 786 HCPs, 571 (72.6%) were women. Compared with men, women were twice as likely to have chronic SRPS (18.7% vs. 8.8%, χ2[1] = 11.38, p < 0.001). However, after accounting for pre- and peri-event stressors, being a woman was no longer associated with chronic SRPS (p = 0.58). The pre- and peri-event stressors that accounted for this heightened risk among women included being in a woman-prevalent profession (specifically nursing; estimate = 0.08, SE = 0.04, p = 0.05), pre-pandemic burnout (estimate = 0.11, SE = 0.05, p = 0.04), greater family-related (estimate = 0.09, SE = 0.03, p = 0.004), infection-related (estimate = 0.06, SE = 0.02, p = 0.007), and work-related concerns (estimate = 0.11, SE = 0.03, p < 0.001), and lower leadership support (estimate = 0.07, SE = 0.03, p = 0.005). These findings can inform institutional interventions to mitigate the risk of chronic SRPS among women HCPs.

Gender discrimination among women healthcare workers during the COVID-19 pandemic: Findings from a mixed methods study.

BACKGROUND: Gender discrimination among women healthcare workers (HCWs) negatively impacts job satisfaction, mental health, and career development; however, few studies have explored how experiences of gender discrimination change during times of health system strain. Thus, we conducted a survey study to characterize gender discrimination during a time of significant health system strain, i.e., the COVID-19 pandemic. METHODS: We used a convenience sampling approach by inviting department chairs of academic medical centers in the United States to forward our online survey to their staff in January 2021. The survey included one item assessing frequency of gender discrimination, and an open-ended question asking respondents to detail experiences of discrimination. The survey also included questions about social and work stressors, such as needing additional childcare support. We used ordinal logistic regression models to identify predictors of gender discrimination, and grounded theory to characterize themes that emerged from open-ended responses. RESULTS: Among our sample of 716 women (mean age = 37.63 years, SD = 10.97), 521 (72.80%) were White, 102 (14.20%) Asian, 69 (9.60%) Black, 53 (7.4%) Latina, and 11 (1.50%) identified as another race. In an adjusted model that included demographic characteristics and social and work stressors as covariates, significant predictors of higher gender discrimination included younger age (OR = 0.98, 95%CI = 0.96, 0.99); greater support needs (OR = 1.26, 95%CI = 1.09,1.47); lower team cohesion (OR = 0.94, 95%CI = 0.91, 0.97); greater racial discrimination (OR = 1.07, 95%CI = 1.05,1.09); identifying as a physician (OR = 6.59, 95%CI = 3.95, 11.01), physician-in-training (i.e., residents and fellows; OR = 3.85, 95%CI = 2.27,6.52), or non-clinical worker (e.g., administrative assistants; OR = 3.08, 95%CI = 1.60,5.90), compared with nurses; and reporting the need for a lot more childcare support (OR = 1.84, 95%CI = 1.15, 2.97), compared with reporting no childcare support need. In their open-ended responses, women HCWs described seven themes: 1) belittlement by colleagues, 2) gendered workload distributions, 3) unequal opportunities for professional advancement, 4) expectations for communication, 5) objectification, 6) expectations of motherhood, and 7) mistreatment by patients. CONCLUSIONS: Our study underscores the severity of gender discrimination among women HCWs. Hospital systems should prioritize gender equity programs that improve workplace climate during and outside of times of health system strain.

"I can't do it": A qualitative study exploring case and contact experiences with COVID-19 contact tracing.

BACKGROUND: Low engagement in contact tracing for COVID-19 dramatically reduces its impact, but little is known about how experiences, environments and characteristics of cases and contacts influence engagement. METHODS: We recruited a convenience sample of COVID-19 cases and contacts from the New Haven Health Department's contact tracing program for interviews about their contact tracing experiences. We analyzed transcripts thematically, organized themes using the Capability, Opportunity, Motivation, Behavior (COM-B) model, and identified candidate interventions using the linked Behavior Change Wheel Framework. RESULTS: We interviewed 21 cases and 12 contacts. Many felt physically or psychologically incapable of contact tracing participation due to symptoms or uncertainty about protocols. Environmental factors and social contacts also influenced engagement. Finally, physical symptoms, emotions and low trust in and expectations of public health authorities influenced motivation to participate. CONCLUSION: To improve contact tracing uptake, programs should respond to clients' physical and emotional needs; increase clarity of public communications; address structural and social factors that shape behaviors and opportunities; and establish and maintain trust. We identify multiple potential interventions that may help achieve these goals.

Narrative identity among people with disabilities in the United States during the Covid-19 pandemic: The interdependent self.

This study examines narrative identity among a large, diverse sample of people with disabilities (PWDs) in the United States during the "second wave" of the Covid-19 pandemic (October-December 2020). The study relied on abductive analyses, combining a purely inductive phase of inquiry followed by two rounds of investigation that filtered inductive insights through three theoretical lenses: social-ecological theory, the theory of narrative identity, and perspectives from the interdisciplinary field of disability studies. The central result was the identification of a particular configuration of self, one that was demonstrably interdependent with both immediate interpersonal contexts and with broader cultural contexts. This interdependent self was interpreted in both positive and negative ways by PWDs. These findings invite future inquiry into commonplace conceptualizations of an independent self at the center of personality research and suggest that dominant conceptualizations of "the good life" may overly emphasize independence.

Centering Health Equity Within COVID-19 Contact Tracing: Connecticut's Community Outreach Specialist Program.

CONTEXT: The COVID-19 pandemic has disproportionately impacted vulnerable populations, including those who are non-English-speaking and those with lower socioeconomic status; yet, participation of these groups in contact tracing was initially low. Distrust of government agencies, anticipated COVID-19-related stigma, and language and cultural barriers between contact tracers and communities are common challenges. PROGRAM: The Community Outreach Specialist (COS) program was established within the Connecticut Department of Public Health (DPH) COVID-19 contact tracing program to encourage participation in contact tracing and address a need for culturally competent care and social and material support among socially vulnerable and non-English-speaking populations in 11 high-burden jurisdictions in Connecticut. IMPLEMENTATION: In partnership with state and local health departments, we recruited 25 COS workers with relevant language skills from target communities and trained them to deliver contact tracing services to vulnerable and non-English speaking populations. EVALUATION: We conducted a cross-sectional analysis using data from ContaCT, DPH's enterprise contact tracing system. Overall, the COS program enrolled 1938 cases and 492 contacts. The proportion of residents reached (ie, called and interviewed) in the COS program was higher than that in the regular contact tracing program for both cases (70% vs 57%, P < .001) and contacts (84% vs 64%, P < .001). After adjusting for client age, sex, race and ethnicity, language, and jurisdiction, we found that the COS program was associated with increased reach for contacts (odds ratio [OR] = 1.52; 95% confidence interval [95% CI], 1.17-1.99) but not for cases (OR = 0.78; 95% CI, 0.70-0.88). Rapid qualitative analysis of programmatic field notes and meeting reports provided evidence that the COS program was feasible and acceptable to clients and contributed to COVID-19 education and communication efforts. CONCLUSION: A COS program employing a client-centered, community-engaged strategy for reaching vulnerable and non-English-speaking populations was feasible and more effective at reaching contacts than standard COVID-19 contact tracing.

Narrative identity among people with disabilities during the Covid-19 pandemic: The interdependent self

This study examines narrative identity among a large, diverse American sample of people with disabilities (PWDs) during the “second wave” of the Covid-19 pandemic (October-December, 2020). The study relied on abductive analyses, combining a purely inductive phase of inquiry followed by two rounds of investigation that filtered inductive insights through three theoretical lenses: social-ecological theory, the theory of narrative identity, and perspectives from the interdisciplinary field of disability studies. The central result was the identification of a particular configuration of self, one that was demonstrably interdependent with both immediate interpersonal contexts and with broader cultural contexts. This interdependent self was interpreted in both positive and negative ways by PWDs. These findings invite future inquiry into commonplace conceptualizations of an independent self at the center of personality research and suggest that dominant conceptualizations of “the good life” may overly emphasize independence.

Lessons Learned From COVID-19 Contact Tracing During a Public Health Emergency: A Prospective Implementation Study.

Background: Contact tracing is a core element of the public health response to emerging infectious diseases including COVID-19. Better understanding the implementation context of contact tracing for pandemics, including individual- and systems-level predictors of success, is critical to preparing for future epidemics. Methods: We carried out a prospective implementation study of an emergency volunteer contact tracing program established in New Haven, Connecticut between April 4 and May 19, 2020. We assessed the yield and timeliness of case and contact outreach in reference to CDC benchmarks, and identified individual and programmatic predictors of successful implementation using multivariable regression models. We synthesized our findings using the RE-AIM implementation framework. Results: Case investigators interviewed only 826 (48%) of 1,705 cases and were unable to reach 545 (32%) because of incomplete information and 334 (20%) who missed or declined repeated outreach calls. Contact notifiers reached just 687 (28%) of 2,437 reported contacts, and were unable to reach 1,597 (66%) with incomplete information and 153 (6%) who missed or declined repeated outreach calls. The median time-to-case-interview was 5 days and time-to-contact-notification 8 days. However, among notified contacts with complete time data, 457 (71%) were reached within 6 days of exposure. The least likely groups to be interviewed were elderly (adjusted relative risk, aRR 0.74, 95% CI 0.61-0.89, p = 0.012, vs. young adult) and Black/African-American cases (aRR 0.88, 95% CI 0.80-0.97, pairwise p = 0.01, vs. Hispanic/Latinx). However, ties between cases and their contacts strongly influenced contact notification success (Intraclass Correlation Coefficient (ICC) 0.60). Surging caseloads and high volunteer turnover (case investigator n = 144, median time from sign-up to retirement from program was 4 weeks) required the program to supplement the volunteer workforce with paid public health nurses. Conclusions: An emergency volunteer-run contact tracing program fell short of CDC benchmarks for time and yield, largely due to difficulty collecting the information required for outreach to cases and contacts. To improve uptake, contact tracing programs must professionalize the workforce; better integrate testing and tracing services; capitalize on positive social influences between cases and contacts; and address racial and age-related disparities through enhanced community engagement.

Racial and Gender Discrimination Predict Mental Health Outcomes among Healthcare Workers Beyond Pandemic-Related Stressors: Findings from a Cross-Sectional Survey.

Racial and gender discrimination are risk factors for adverse mental health outcomes in the general population; however, the effects of discrimination on the mental health of healthcare workers needs to be further explored, especially in relation to competing stressors. Thus, we administered a survey to healthcare workers to investigate the associations between perceived racial and gender discrimination and symptoms of depression, anxiety, posttraumatic stress, and burnout during a period of substantial stressors related to the COVID-19 pandemic and a national racial reckoning. We used multivariable linear regression models, which controlled for demographics and pandemic-related stressors. Of the 997 participants (Mean Age = 38.22 years, SD = 11.77), 688 (69.01%) were White, 148 (14.84%) Asian, 86 (8.63%) Black, 73 (7.32%) Latinx, and 21 (2.11%) identified as another race. In multivariable models, racial discrimination predicted symptoms of depression (B = 0.04; SE: 0.02; p = .009), anxiety (B = 0.05; SE: 0.02; p = .004), and posttraumatic stress (B = 0.01; SE: 0.01; p = .006) and gender discrimination predicted posttraumatic stress (B = 0.11; SE: 0.05; p = .013) and burnout (B = 0.24; SE: 0.07; p = .001). Discrimination had indirect effects on mental health outcomes via inadequate social support. Hospital-wide diversity and inclusion initiatives are warranted to mitigate the adverse mental health effects of discrimination.

Implementation of a volunteer contact tracing program for COVID-19 in the United States: A qualitative focus group study.

BACKGROUND: Contact tracing is an important tool for suppressing COVID-19 but has been difficult to adapt to the conditions of a public health emergency. This study explored the experiences and perspectives of volunteer contact tracers in order to identify facilitators, challenges, and novel solutions for implementing COVID-19 contact tracing. METHODS: As part of a study to evaluate an emergently established volunteer contact tracing program for COVID-19 in New Haven, Connecticut, April-June 2020, we conducted focus groups with 36 volunteer contact tracers, thematically analyzed the data, and synthesized the findings using the RE-AIM implementation framework. RESULTS: To successfully reach cases and contacts, participants recommended identifying clients' outreach preferences, engaging clients authentically, and addressing sources of mistrust. Participants felt that the effectiveness of successful isolation and quarantine was contingent on minimizing delays in reaching clients and on systematically assessing and addressing their nutritional, financial, and housing needs. They felt that successful adoption of a volunteer-driven contact tracing model depended on the ability to recruit self-motivated contact tracers and provide rapid training and consistent, supportive supervision. Participants noted that implementation could be enhanced with better management tools, such as more engaging interview scripts, user-friendly data management software, and protocols for special situations and populations. They also emphasized the value of coordinating outreach efforts with other involved providers and agencies. Finally, they believed that long-term maintenance of a volunteer-driven program requires monetary or educational incentives to sustain participation. CONCLUSIONS: This is one of the first studies to qualitatively examine implementation of a volunteer-run COVID-19 contact tracing program. Participants identified facilitators, barriers, and potential solutions for improving implementation of COVID-19 contact tracing in this context. These included standardized communication skills training, supportive supervision, and peer networking to improve implementation, as well as greater cooperation with outside agencies, flexible scheduling, and volunteer incentives to promote sustainability.

Socio-ecological predictors of mental health outcomes among healthcare workers during the COVID-19 pandemic in the United States.

BACKGROUND: Healthcare workers are at increased risk of adverse mental health outcomes during the COVID-19 pandemic. Studies are warranted that examine socio-ecological factors associated with these outcomes to inform interventions that support healthcare workers during future disease outbreaks. METHODS: We conducted an online cross-sectional study of healthcare workers during May 2020 to assess the socio-ecological predictors of mental health outcomes during the COVID-19 pandemic. We assessed factors at four socio-ecological levels: individual (e.g., gender), interpersonal (e.g., social support), institutional (e.g., personal protective equipment availability), and community (e.g., healthcare worker stigma). The Personal Health Questionnaire-9, Generalized Anxiety Disorder-7, Primary Care Post-Traumatic Stress Disorder, and Alcohol Use Disorders Identification Test-Concise scales assessed probable major depression (MD), generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and alcohol use disorder (AUD), respectively. Multivariable logistic regression models were used to assess unadjusted and adjusted associations between socio-ecological factors and mental health outcomes. RESULTS: Of the 1,092 participants, 72.0% were female, 51.9% were frontline workers, and the mean age was 40.4 years (standard deviation = 11.5). Based on cut-off scores, 13.9%, 15.6%, 22.8%, and 42.8% had probable MD, GAD, PTSD, and AUD, respectively. In the multivariable adjusted models, needing more social support was associated with significantly higher odds of probable MD, GAD, PTSD, and AUD. The significance of other factors varied across the outcomes. For example, at the individual level, female gender was associated with probable PTSD. At the institutional level, lower team cohesion was associated with probable PTSD, and difficulty following hospital policies with probable MD. At the community level, higher healthcare worker stigma was associated with probable PTSD and AUD, decreased satisfaction with the national government response with probable GAD, and higher media exposure with probable GAD and PTSD. CONCLUSIONS: These findings can inform targeted interventions that promote healthcare workers' psychological resilience during disease outbreaks.

Community Trace: Rapid Establishment of a Volunteer Contact Tracing Program for COVID-19.

Contact tracing was one of the core public health strategies implemented during the first months of the COVID-19 pandemic. In this essay, we describe the rapid establishment of a volunteer contact tracing program in New Haven, Connecticut. We describe successes of the program and challenges that were faced. Going forward, contact tracing efforts can best be supported by increased funding to state and local health departments for a stable workforce and use of evidence-based technological innovations.

A hybrid inductive-abductive analysis of health workers' experiences and wellbeing during the COVID-19 pandemic in the United States.

The COVID-19 pandemic puts health workers at increased risk of adverse mental health outcomes. However, no studies have assessed health workers' experiences using qualitative methods during the COVID-19 outbreak in the United States to identify novel factors that could relate to their mental health. In May 2020, we distributed an online survey to health workers across 25 medical centers throughout the United States. The Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Primary Care-Post-Traumatic Stress Disorder, and Alcohol Use Disorders Identification Test-Concise and associated cutoff values were used to assess rates of probable major depression, generalized anxiety disorder, post-traumatic stress disorder, and alcohol use disorder, respectively. To provide insight into the factors shaping these and other mental health conditions, we included two open-ended questions asking respondents to recount their most upsetting and hopeful experiences during the COVID-19 pandemic and how it made them feel. Using a hybrid inductive-abductive approach and thematic content analysis, we created a Social Ecological Model to represent themes among health workers' experiences within five ecological levels: individual, interpersonal, organization, community, and public policy. Of the 1,132 participants who completed the survey, 14.0% had probable major depression, 15.8% probable generalized anxiety disorder, 23.1% probable post-traumatic stress disorder, and 42.6% probable alcohol use disorder. Individual level themes included participants' personal health and self-care behaviors. Interpersonal level themes included the health of their social circle, family functioning, and social support. Organization level themes included their hospital's management, resources, patient care, routine, and teams. Themes in the community level included the media, scientific knowledge about COVID-19, morale, behavior, and support of health workers. Lastly, government and health system leadership and shelter-in-place policy were themes within the public policy level. Our findings provide insights into novel factors that have impacted health workers' wellbeing during the COVID-19 pandemic. These factors should be further explored to inform interventions and public policy that mitigate mental health morbidities among health workers during this and future outbreaks.