Public restrooms, periods, and people experiencing homelessness: An assessment of public toilets in high needs areas of Manhattan, New York.

Access to safe, clean water and sanitation is globally recognized as essential for public health. Public toilets should be accessible to all members of a society, without social or physical barriers preventing usage. A public toilet facility's design and upkeep should offer privacy and safety, ensure cleanliness, provide required sanitation-related resources, and be gender equitable, including enabling comfortable and safe management of menstruation. Menstrual hygiene management (MHM) refers to the need to ensure that girls, women and all people who menstruate have access to clean menstrual products, privacy to change the materials as often as needed, soap and water for washing the body as required, and access to facilities to dispose of used materials. Challenges around menstruation faced by people experiencing homelessness, which tend to be greater than those facing the general population, include inadequate toilet and bathing facilities, affordability issues around menstrual products, and menstrual stigma. Public toilets are a vital resource for managing menstruation, particularly for vulnerable populations without reliable access to private, safe, and clean spaces and menstrual products. This mixed-methods study sought to: 1) understand the lived experiences of MHM among people experiencing homelessness in New York City with respect to public toilets; 2) describe general and MHM-related characteristics of public toilets in high need areas of Manhattan and analyze their interrelationships; and 3) examine the associations among neighborhood-level demographics and the public toilet characteristics in those areas. Qualitative methods included key informant interviews (n = 15) and in-depth interviews (n = 22) with people with experience living on the street or in shelters, which were analyzed using Malterud's 'systematic text condensation' for thematic cross-case analysis. Quantitative methods included audits and analyses of public toilet facilities (n = 25) using traditional statistics (e.g., Spearman's correlations) and spatial analyses (e.g., proximity buffers). Qualitative findings suggest cleanliness, access to restrooms, and availability of resources are critical issues for the participants or prospective users. Quantitative analyses revealed insufficiently provided, maintained, and resourced public toilets for managing menstruation in high-needs areas. Findings also suggest that toilets with more MHM-related resource availability, such as menstrual products and toilet stall disposal bins, were more difficult to access. Neighborhood-level characteristics showed a potential environmental injustice, as areas characterized by higher socioeconomic status are associated with more access to MHM-specific resources in public restrooms, as well as better overall quality.

Seeking menstrual products: a qualitative exploration of the unmet menstrual needs of individuals experiencing homelessness in New York City.

BACKGROUND: There has been increasing recognition that certain vulnerable populations in the United States of America struggle to meet their menstruation-related needs, including people experiencing homelessness. Media and policy attention on this subject has focused on the provision of free menstrual products to vulnerable populations, including a New York City legislative bill, which guarantees access to menstrual products for Department of Homeless Services shelter residents (Intros 1123-A). METHODS: This qualitative study explored the challenges people experiencing homelessness in New York City face in accessing menstrual products. Data collection was conducted from June to August 2019 and included: Semi-structured key informant interviews with staff from relevant government agencies and homeless service providers (n = 15), and semi-structured in-depth interviews with individuals with experience living on the street and in shelters (n = 22). Data were analysed using thematic analysis. RESULTS: Key themes that emerged included: (1) insufficient and inconsistent access to menstrual products; (2) systemic challenges to providing menstrual products; and (3) creative solutions to promote access to menstrual products. Both shelter- and street-living individuals reported significant barriers to accessing menstrual products. While both populations struggle, those in shelters were more likely to be able to purchase menstrual products or access free products at their shelter, while those living on the streets were more likely to have to resort to panhandling, theft, or using makeshift materials in place of menstrual products. Across both populations, individuals described barriers to accessing free products at shelters and service providers, primarily due to distribution systems that rely on gatekeepers to provide a few pads or tampons at a time, sometimes of inadequate quality and only upon request. Shelters and service providers also described challenges providing these products, including inconsistent supply. CONCLUSION: These findings highlight the critical importance of expanding and improving initiatives seeking to provide access to menstrual products for vulnerable populations. Despite policy level efforts to support menstrual product access, individuals experiencing homelessness in New York City, whether living in shelters or on the street, are often not able to access the menstrual products that they need to manage their monthly menstrual flow.

Merging Intentional Peer Support and Dialogic Practice: Implementation Lessons From Parachute NYC.

This ethnographically informed implementation analysis of Parachute NYC between 2012 and 2015 documents the obstacles that can impede disruptive innovations in public mental health. Parachute combined family-based dialogic practice with peer-staffed crisis respite centers and mixed teams of clinicians and peers in an ambitious effort to revamp responses to psychiatric crises. This Open Forum reviews the demands posed by formidable contextual constraints, extended trainings in novel therapeutic techniques, and the effort to ensure sustainability in a managed care environment. It cautions that requiring innovations to produce evidence under the structural constraints that Parachute endured hobbles the effort and thwarts its success. The dialogic embrace of ordinary people and the use of peer labor as active treatment agents promote a slower and more participatory approach to psychiatric crises that offers extraordinary promise. However, a better prepared and more receptive context is needed for a fair trial of the comparative effectiveness of this approach.

Signing on for dirty work: Taking stock of a public psychiatry project from the inside.

As applied anthropologists used to working at arm's length from public psychiatry, we step out of the daily grind to take stock of the challenges of taking on ethnography entrained-harnessed to the implementation of a new program. These include the loss of critical distance, the struggles to negotiate locally viable forms of authority and relevance, the necessity of sustaining a Janus-faced relation with principal players, the urgency of seeing time-sensitive information converted into corrective feedback, and the undeniable attraction of being part of "committed work" with game-changing potential. In so doing, we rework the terms of witnessing and revive an old alternative: that documentary dirty work be reclaimed as a variant of public anthropology, one that transforms the work of application from mere afterthought to integral part of the original inquiry.

Embodying recovery: a qualitative study of peer work in a consumer-run service setting.

The use of peer support for persons with mental illness has been gaining force. While research has demonstrated the benefits of peer support, few studies have investigated the qualitative characteristics of how peer support aids persons recovering from mental illness. Therefore, this study sought to clarify the characteristics that constitute peer support and its contribution to recovery. We conducted ethnographic fieldwork and semi-structured interviews with nine peer advocates at a consumer-run organization in New York City, and identified three themes that describe how peer support influences recovery: transforming experience into expertise, understanding the mechanics of peer support, and launching peers towards their own recovery. Peer support plays a critical role in helping clients move beyond their patient role to an empowered sense of personhood. Additionally, the value of peer support highlights current deficiencies within the mental health system and how a bolder shift towards recovery might repair them.

"Being responsible, respectful, trying to keep the tradition alive:" cultural resilience and growing up in an Alaska Native community.

Indigenous circumpolar youth are experiencing challenges of growing up in a context much different from that of their parents and their grandparents due to rapid and imposed social change. Our study is interested in community resilience: the meaning systems, resources, and relationships that structure how youth go about overcoming difficulties. The research reflects an understanding that social and cultural ecologies influence people's available and meaningful options. The in-depth, qualitative study of 20 youth from the same Arctic community shows Inupiat (Alaska Native) youth are navigating challenges. Findings from this research suggest that Inupiat youth reflect more flexible patterns of resilience when they are culturally grounded. This cultural foundation involves kinship networks that mediate young people's access to cultural and material assets. Our participants emphasized the importance of taking care of others and "giving back to the community." Being "in the country" linked youth to traditional ontology that profoundly shifted how youth felt in relation to themselves, to others, and the world. The vast majority of participants' "fulfillment narratives" centered on doing subsistence and/or cultural activities. In relation to this, young people were more likely to demonstrate versatility in their resilience strategies when deploying coherent self-narratives that reflected novel yet culturally resonant styles. Young women were more likely to demonstrate this by reconfiguring notions of culture and gender identity in ways that helped them meet challenges in their lives. Lastly, generational differences in understandings signal particular ways that young people's historical and political positioning influences their access to cultural resources.

Mapping resilience pathways of Indigenous youth in five circumpolar communities.

This introduction to the Special Issue Indigenous Youth Resilience in the Arctic reviews relevant resilience theory and research, with particular attention to Arctic Indigenous youth. Current perspectives on resilience, as well as the role of social determinants, and community resilience processes in understanding resilience in Indigenous circumpolar settings are reviewed. The distinctive role for qualitative inquiry in understanding these frameworks is emphasized, as is the uniquely informative lens youth narratives can offer in understanding Indigenous, cultural, and community resilience processes during times of social transition. We then describe key shared cross-site methodological elements of the Circumpolar Indigenous Pathways to Adulthood study, including sampling, research design, procedures, and analytic strategies. The site-specific papers further elaborate on methods, focusing on those elements unique to each site, and describe in considerable detail locally salient stressors and culturally patterned resilience strategies operating in each community. The concluding paper considers these across sites, exploring continuities and discontinuities, and the influence of cross-national social policies.

Central role of relatedness in Alaska native youth resilience: Preliminary themes from one site of the Circumpolar Indigenous Pathways to Adulthood (CIPA) study.

This qualitative study of youth resilience takes place in an Alaska Native community, which has undergone rapid, imposed social change over the last three generations. Elders, and successive generations have grown up in strikingly different social, economic and political contexts. Youth narratives of relationships in the context of adolescent growth and development offer insights to better understand culturally-patterned experience, continuity and change. Local youth and adults shaped the design, implementation and analysis phases of this participatory study. Multiple interviews, totaling 20 older (ages 15-18) and younger (11-14) boys and girls provide accounts of everyday lives and life histories. Although losing close relationships was the most common stressor, many of the participants' resilience strategies centered on their connections to others. Participants cultivated 'relatedness', nurturing relationships that took on kinship qualities. Within these relationships, youth participants acted more responsibly and/or developed a sense of competency and self-worth because of others' reliance on them.

The murky middle ground - when ethnographers engage public health.

This commentary revisits dilemmas of relevance that applied anthropology in the U.S. has long grappled with, no matter the rigor and depth of inquiry. Direct action, collaborative research and active public engagement offer proven alternatives for upping the participatory quotient, but they remain the exception. A third, more common, middle ground may be also discerned, sometimes involving the sort of "dirty work" that seems to lie outside of one's professional remit. Commitment to such work, it turns out, is not simply a matter of character or disciplinary ethics, but of the terms and conditions of anthropological employment. Even without the "second shift" of going public with one's findings, critically positioned research can keep problematic issues that might otherwise slip into the convenient silences of social and economic policy.

Found in translation: Decoding local understandings of genetics and heredity in a Yup'ik Eskimo community.

The Center for Alaska Native Health Research is a community-based participatory research center that conducts studies involving genetic research with Yup'ik Eskimo community members in Southwest Alaska, where Yup'ik remains the first language for most residents. Cultural equivalents are needed to communicate results of these studies among all partners and members of the participating communities, since many scientific terms have no direct translation in Yup'ik. To inform that effort, we examined local understandings of genetics and heredity in one community. Here, we report results from back-translated Yup'ik interviews, and identify working genetic concepts shared by participants from interviews and focus groups. We suggest issues involved in, and some potential steps toward, developing a concise, scientifically accurate and culturally relevant term for "genetics" and other health concepts.

Independent review of social and population variation in mental health could improve diagnosis in DSM revisions.

At stake in the May 2013 publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), are billions of dollars in insurance payments and government resources, as well as the diagnoses and treatment of millions of patients. We argue that the most recent revision process has missed social determinants of mental health disorders and their diagnosis: environmental factors triggering biological responses that manifest themselves in behavior; differing cultural perceptions about what is normal and what is abnormal behavior; and institutional pressures related to such matters as insurance reimbursements, disability benefits, and pharmaceutical marketing. In addition, the experts charged with revising the DSM lack a systematic way to take population-level variations in diagnoses into account. To address these problems, we propose the creation of an independent research review body that would monitor variations in diagnostic patterns, inform future DSM revisions, identify needed changes in mental health policy and practice, and recommend new avenues of research. Drawing on the best available knowledge, the review body would make possible more precise and equitable psychiatric diagnoses and interventions.

Immediate effects of localized vibration on hamstring and quadricep muscle performance.

PURPOSE/BACKGROUND: A reduction in the maximal force output of muscles following pre-performance stretching has been reported. Several studies have suggested that localized vibration may enhance or replace stretching for gaining flexibility. It is important to know if localized vibration may also compromise muscle output. The purpose of this investigation was to determine the immediate effects of localized hamstring vibration on hamstrings (HAM) and quadriceps (QUAD) performance. METHODS: Thirty asymptomatic participants, 19 female and 11 male, mean age 25.4 years (±SD 2.7) received either five minutes of localized vibration to the right hamstrings at 30 Hz and 6 mm amplitude, or sham. One week later, each participant received the alternate treatment. Following treatments, right (R) and left (L) isometric HAM and QUAD strength was measured twice by handheld dynamometer and maximal horizontal hop distance of each lower extremity was measured by single leg hop test (SLH). Treatment outcomes were compared using paired t-tests. Treatment order effect was measured by independent T-test. Pre-study intrarater reliability for dynamometry was established using ICC((3,2)). RESULTS: Mean (±SD) values for strength following vibration were 58.7 kg (15.7), 60.4 kg (14.0), 45.5 kg (14.2), 45.8 kg (13.2) for R QUAD, L QUAD, R HAM, L HAM respectively. SLH mean values were R SLH 153.8 cm (35 cm) and L SLH 155.4 cm (36 cm). There were no significant differences in means between vibration and sham treatment for any outcomes on either leg (p-values ranged .412-.971); p<.001 for all comparisons. Order had no significant effect (p-values .370-1.0). Intrarater ICCs were .888, .762, .884, .960 for R HAM, L HAM, R QUAD, L QUAD. CONCLUSIONS: Unilateral application of localized vibration to the hamstrings at a duration previously reported to increase flexibility did not diminish the isometric performance of the hamstrings or quadriceps of either leg. LEVEL OF EVIDENCE: 1b.

Commentary: The counter-reformation that failed? A commentary on the mixed legacy of supported housing.

The articles in this special section rejoin a conversation about the terms and conditions of social participation that was suspended some time ago. While welcoming the move, this commentary raises some questions about the vehicle. The formidable achievements of supported housing notwithstanding, it still functions as an abeyance mechanism ensuring its occupants a kind of sheltered livelihood. Arguably, then, the larger social questions gathered under the encompassing terms of social inclusion and citizenship will not be fully addressed, and may be occluded, either by declaring supported housing a forward operating base of recovery or by rewriting its original remit as an undeclared experiment in reintegration. To extend its promise will mean first confronting the purposes served by supported housing, by design or default, in its present configuration.

Partners in recovery: social support and accountability in a consumer-run mental health center.

OBJECTIVE: Consumer-run mental health programs that include advocacy, peer counseling, and mentoring are somewhat commonplace in community mental health services, yet fully peer-operated mental health centers remain novel in the public mental health landscape. This ethnographic study of a consumer-run mental health center had two major aims: to learn what is distinctive about consumer-run services-for example, how they might strengthen personal capacity for social integration-and to explore how the development of these capacities might promote recovery. METHODS: Data collection for this modified ethnographic study consisted of ten months of participant observation, coupled with semistructured interviews (N=25), a focus group (N=22), and dramatic skits (N=17), to identify and define the distinctive features of the program, both structurally and from the point of view of participants. Inquiry was framed theoretically by the capabilities approach. RESULTS: Participants in this consumer-run mental health program experienced themselves as accountable for and to their peers in what amounts to a shared project of recovery. CONCLUSIONS: As part of a capacity-building approach in consumer-run services, programs should aim to not only provide social support for participants but also foster a culture in which service users are accountable for their peers. Such reciprocity may help to strengthen socialization skills, which could better prepare consumers for participation in the community at large.

Components of cultural competence in three mental health programs.

OBJECTIVE: The aim of this study was to identify components of cultural competence in mental health programs developed for cultural groups by community and mental health professionals from these groups. METHODS: Three programs were studied: a prevention program primarily serving African-American and Afro-Caribbean youth, a Latino adult acute inpatient unit, and a Chinese day treatment program in a community-based agency. Nine study-trained field researchers used a semistructured instrument that captures program genealogy, structure, processes, and cultural infusion. Program cultural elements were identified from field notes and from individual and group interviews of consumers and staff (N=104). A research-group consensus process with feedback from program staff was used to group elements by shared characteristics into the program components of cultural competence. RESULTS: Components included communication competencies (with use of colloquialisms and accepted forms of address); staff in culturally acceptable roles; culturally framed trust building (such as pairing youths with mentors), stigma reduction, friendly milieus (such as serving culturally familiar foods and playing music popular with the culture), and services; and peer, family, and community involvement (including use of peer counselors and mentors, hosting parent weekends, and linking clients with senior center and community services). CONCLUSIONS: Incorporating these components into any program in which underserved cultural populations are seen is recommended for improving cultural competence.

The work of recovery on two assertive community treatment teams.

The compatibility of recovery work with the Assertive Community Treatment (ACT) model has been debated; and little is known about how to best measure the work of recovery. Two ACT teams with high and low recovery orientation were identified by expert consensus and compared on a number of dimensions. Using an interpretive, qualitative approach to analyze interview and observation data, teams differed in the extent to which the environment, team structure, staff attitudes, and processes of working with consumers supported principles of recovery orientation. We present a model of recovery work and discuss implications for research and practice.