Housing and food stress among transgender adults in the United States.

PURPOSE: The purpose of the study was to assess housing and food-related stress in transgender and cisgender adults in the United States. METHODS: Data from the 2014 and 2015 Behavioral Risk Factor Surveillance System were analyzed for 53,060 adults who responded to the Sexual Orientation and Gender Identity module and the Social Context module. We used multiple logistic regression to assess the association of gender identity with housing and food-related stress. RESULTS: There were no significant differences by gender identity in the odds of experiencing housing or food-related stress. A sensitivity analysis revealed that with a broader definition of food-related stress, transgender individuals had higher odds of experiencing food-related stress compared with cisgender individuals. The sample of transgender individuals who experienced food-related stress were young, single, racially diverse, sexual minorities, and the majority had a high school degree or less. Similarly, most transgender individuals who experienced housing-related stress were single, sexual minorities, and had a high school degree or less. CONCLUSIONS: More precise assessments of housing and food insecurity among probability-based samples of transgender individuals are needed to fully understand housing and food-related instability and the stress associated with these experiences.

Food Insecurity Among Transgender and Gender Nonconforming Individuals in the Southeast United States: A Qualitative Study.

Purpose: Transgender and gender nonconforming (TGNC) people experience high rates of poverty, joblessness, and homelessness, which drive risk for food insecurity. TGNC people also face discrimination due to transphobia and cissexism, which may contribute to these drivers. Minimal empirical evidence describes experiences with food insecurity among TGNC people. This project investigated food insecurity among TGNC people and how these experiences relate to their physical and mental health. Methods: Semistructured telephone interviews were conducted with 20 TGNC people residing in the Southeast United States (U.S.), recruited through social media. Interviews were transcribed and qualitatively coded. Results: TGNC people reported living in extreme poverty. They described how the conservative sociopolitical climate of the Southeast United States made it difficult to find and maintain employment, which was a primary driver of food insecurity. Participants experienced discomfort seeking food assistance due to discrimination and concern for reducing emergency food availability for people in greater need. Stress from unemployment and underemployment, inadequate food supplies, and discrimination was reported as a contributor to poor physical and mental health, and weakened support systems. Conclusion: Poverty and food insecurity erode TGNC people's physical and mental health and support systems. TGNC people faced substantial barriers-including unemployment and underemployment and multilevel discrimination-which prevented them from affording adequate food. Public health solutions include implementing employment nondiscrimination policy to protect TGNC people in the workplace and building relationships between local food pantries and LGBT organizations to create safer environments for all persons in need of food assistance.

Comparing provider and patient views of issues for low-resourced breast cancer patients.

OBJECTIVE: The purpose of this study was to compare provider and patient views from the same clinical settings on issues raised by low-socioeconomic status (SES) breast cancer survivors. METHODS: We conducted qualitative interviews among two groups: low-SES breast cancer survivors (n = 37) and medical personnel (ie, physicians, nurses, and navigators; n = 8) who interact and serve with these patients from two geographically distinct low-resourced clinical settings. These semistructured qualitative interviews used grounded theory to identify several potential themes, such as finances, resources, and medical care. Transcripts were coded and summarized into themes. RESULTS: We analyzed each type of interview data separately then compared patient and provider perspectives. From these qualitative interviews, we discovered that low-SES breast cancer survivors reported many unmet needs, including transportation, housing, health literacy, and language, among others. Providers reported that many of these needs are served by the extensive network of supports surrounding these patients. CONCLUSIONS: These results illustrate that low-SES breast cancer survivors have unique needs that differ from other breast cancer survivors. Many providers feel that these needs are being met, but patients have more diverse experiences. By better addressing the links between resource needs and low-SES breast cancer survivors, quality of life can be improved.

Expanding Contraceptive Access for Women With Substance Use Disorders: Partnerships Between Public Health Departments and County Jails.

CONTEXT: Law enforcement has been the primary strategy for addressing the opioid epidemic. As a result, the incarceration rate for women in county jails has increased more than 800% since 1980, and most women inmates struggle with substance use disorders. There is a large unmet need for contraception among women in county jails. PROGRAM: The East Region of the Tennessee Department of Health partnered with county correctional facilities to provide comprehensive family planning education and voluntary long-acting reversible contraception (LARC) to women in 15 jails. IMPLEMENTATION: Incarcerated women were invited to attend a comprehensive family planning education session conducted in the jail by health department nurses. The sessions included information on neonatal abstinence syndrome. The nurses explained that the women could receive intrauterine devices, implants, and injectable progesterone while incarcerated and come to the health department for all contraceptive methods upon release. Between January 2014 and June 2017, nurses conducted 182 education sessions, and 794 women received a LARC. Method placement occurred in the jails or at the local health department. No adverse effects were known to have occurred. EVALUATION: We collected pilot data to explore the accuracy and the comprehensiveness of the family planning education session and whether the incarcerated women experienced the program as voluntary. All 18 women inmates interviewed reported experiencing the program as voluntary. Using published and administrative data, we roughly estimated that the program prevented between 270 and 460 unintended pregnancies and between 40 and 52 cases of neonatal abstinence syndrome in the first year after the women received a method. This represents a cost savings to Medicaid of $1.4 million. DISCUSSION: The partnership demonstrated the feasibility of providing voluntary comprehensive family planning education and access to highly effective contraception for women inmates who, as a group, face a host of political, socioeconomic, and personal barriers to reproductive health care.

Environmental and Individual Predictors of Healthy Dietary Behaviors in a Sample of Middle Aged Hispanic and Caucasian Women.

The objective of this effort is to gather data to tailor interventions appropriately. Greater understanding of the correlates of socioeconomic status and obesogenic dietary behaviors was the focus of this manuscript. Using multistage sampling, women with varied education levels completed a baseline assessment in a longitudinal study of women aged 30 to 50 years. This study was conducted in low-SES areas of South King County, Washington State. This study included 530 Caucasian and 510 Hispanic women. Fruit and vegetable consumption was positively associated and soft drink consumption inversely associated with the level of education in Caucasian women. In contrast, percentage calories from fat was positively associated with the level of education in Hispanic women. In Hispanic women, level of education interacted significantly with food security in relation to percentage calories from fat, and with eating norms in relation to soft drink consumption. Neighborhood presence of ethnic food stores was associated with outcomes for Hispanic women, but for Caucasians, presence of fast food restaurants was important. Education was consistently associated with two of the three obesogenic dietary behaviors studied among Caucasian women. Education played a moderating role in the associations of food security and eating norms, independent of area level food availability, in two of three obesogenic dietary behaviors studied. However, these patterns differed for Hispanic women, indicating the need for more research into important variables to support change in Hispanic women. Women of differing ethnic groups did not respond similarly to environmental conditions and policy-relevant surroundings. These data have meaning for considering urban policy that impacts obesity levels in the population.

Sexual orientation measurement and chronic disease disparities: National Health and Nutrition Examination Survey, 2009-2014.

PURPOSE: To examine chronic disease disparities by sexual orientation measurement among sexual minorities. METHODS: We pooled data from the 2009-2014 National Health and Nutrition Examination Survey to examine differences in chronic disease prevalence between heterosexual and sexual minority people as defined by sexual identity, lifetime sexual behavior, 12-month sexual behavior, and concordance of lifetime sexual behavior and sexual identity. RESULTS: Self-identified lesbian women reported greater odds of asthma (adjusted odds ratio [aOR], 3.19; 95% confidence intervals [CI], 1.37-7.47) and chronic bronchitis (aOR, 2.64; 95% CI, 1.21-5.72) than self-identified heterosexual women. Self-identified sexual minority women with a history of same-sex sexual behavior reported greater odds of arthritis (aOR, 1.67; 95% CI, 1.02-2.74). Compared with heterosexual men, gay men reported greater odds of chronic bronchitis when sexual orientation was defined by sexual identity (aOR, 4.68; 95% CI, 1.90-11.56) or 12-month sexual behavior (aOR, 3.22; 95% CI, 1.27-8.20), as did bisexual men defined by lifetime sexual behavior (aOR, 2.36; 95% CI, 1.14-4.89). Bisexual men reported greater odds of asthma when measured by lifetime sexual behavior (aOR, 1.90; 95% CI, 1.12-3.19), as did self-identified heterosexual men with a history of same-sex sexual behavior (aOR, 2.21; 95% CI, 1.10-4.46). CONCLUSIONS: How we define sexual orientation influences our understanding of chronic disease prevalence. Capturing subgroups of sexual minority people in health surveillance is essential for identifying groups most at risk and developing targeted interventions to reduce chronic disease disparities.

Understanding Health Information Seeking on the Internet Among Sexual Minority People: Cross-Sectional Analysis From the Health Information National Trends Survey.

BACKGROUND: Individuals who face barriers to health care are more likely to access the Internet to seek health information. Pervasive stigma and heterosexism in the health care setting are barriers to health care for sexual minority people (SMP, ie, lesbian, gay, and bisexual people); therefore, SMP may be more likely to use the Internet as a source of health information compared to heterosexual people. OBJECTIVE: Currently, there is a dearth of published empirical evidence concerning health information seeking on the Internet among SMP; the current project addresses this gap. METHODS: Data from the 2015 Health Information National Trends Survey Food and Drug Administration Cycle were used to describe and summarize health information seeking among SMP (n=105) and heterosexual people (n=3405). RESULTS: Almost all of the SMP in this sample reported having access to the Internet (92.4%, 97/105). SMP were equally as likely as heterosexual people to seek health information on the Internet (adjusted odds ratio [aOR] 0.94, 95% CI 0.56-1.66) and to report incidental exposure to health information online (aOR 1.02, 95% CI 0.66-1.60). SMP were 58% more likely to watch a health-related video on YouTube than heterosexual people (aOR 1.58, 95% CI 1.00-2.47). Incidental exposure to health information was associated with seeking health information for oneself (aOR 3.87, 95% CI 1.16-14.13) and for someone else (aOR 6.30, 95% CI 2.40-17.82) among SMP. CONCLUSIONS: SMP access the Internet at high rates and seek out health information online. Their incidental exposure could be associated with seeking information for self or others. This suggests that online interventions could be valuable for delivering or promoting health information for SMP.

Measuring Sexual and Gender Minority Populations in Health Surveillance.

PURPOSE: Sexual and gender minorities (SGMs) are underrepresented and information about SGMs is difficult to locate in national health surveillance data, and this limits identification and resolution of SGM health disparities. It is also not known how measures of sexual orientation and transgender-inclusive gender identity in health surveillance compare with best practice recommendations. This article reviews and summarizes the publicly available, English language, large-scale, rigorously sampled, national, international, and regional data sources that include sexual orientation or transgender-inclusive gender identity and compares measures with best practice guidelines. METHODS: A systematic review was undertaken of national, international, state, and regional health surveillance data sources. Data sources that measured sexual orientation or transgender-inclusive gender identity and met seven inclusion criteria were included. RESULTS: Forty-three publicly accessible national, international, and regional data sources included measures of sexual orientation and transgender-inclusive gender identity and health. For each data source, sampling design, sample characteristics, study years, survey questions, contact persons, and data access links are provided. Few data sources met best practice recommendations for SGM measurement: 14% measured all three dimensions of sexual orientation (identity, behavior, attraction) as recommended by the Sexual Minority Assessment Research Team. No data sources measured transgender-inclusive gender identity according to the Gender Identity in U.S. Surveillance-recommended two-step method of measuring sex assigned at birth and current gender identity. CONCLUSIONS: This article provides a much needed detailed summary of extant health surveillance data sources that can be used to inform research about health risks and disparities among SGM populations. Future recommendations are for more rigorous measurement and oversampling to advance what is known about SGM health disparities and guide development of interventions to reduce disparities.

Minority stress, psychosocial resources, and psychological distress among sexual minority breast cancer survivors.

OBJECTIVE: Few studies have examined unique factors predicting psychological distress among sexual minority (i.e., lesbian and bisexual) women postbreast cancer diagnosis. The present study assessed the association of minority stress and psychosocial resource factors with depression and anxiety symptoms among sexual minority breast cancer survivors. METHOD: Two hundred one sexual minority women who had ductal carcinoma in situ or Stage I-IV breast cancer participated in this study through the Love/Avon Army of Women. Self-report questionnaires were used to assess demographic and clinical factors, minority stress factors (discrimination, minority identity development, outness), psychosocial resources (resilience, social support), and psychological distress (anxiety and depression). These factors were included in a structural equation model, testing psychosocial resources as mediators between minority stress and psychological distress. RESULTS: There were no significant differences noted between lesbian and bisexual women. The final structural equation model demonstrated acceptable fit across all sexual minority women, χ2 = 27.83, p > .05; confirmatory fit index = 0.97, root-mean-square error of approximation = 0.04, Tucker-Lewis index = 0.93. The model accounted for significant variance in psychological distress (56%). Examination of indirect effects confirmed that exposure to discrimination was associated with distress via association with resilience. CONCLUSIONS: Factors unique to sexual minority populations, such as minority stress, may be associated with higher rates of psychological distress among sexual minority breast cancer survivors. However, presence of psychosocial resources may mediate relationships with distress in this population; enhancement of resilience, in particular, could be an aim of psychological intervention. (PsycINFO Database Record

Psychosocial Clusters and their Associations with Well-Being and Health: An Empirical Strategy for Identifying Psychosocial Predictors Most Relevant to Racially/Ethnically Diverse Women's Health.

BACKGROUND: Strategies for identifying the most relevant psychosocial predictors in studies of racial/ethnic minority women's health are limited because they largely exclude cultural influences and they assume that psychosocial predictors are independent. This paper proposes and tests an empirical solution. METHODS: Hierarchical cluster analysis, conducted with data from 140,652 Women's Health Initiative participants, identified clusters among individual psychosocial predictors. Multivariable analyses tested associations between clusters and health outcomes. RESULTS: A Social Cluster and a Stress Cluster were identified. The Social Cluster was positively associated with well-being and inversely associated with chronic disease index, and the Stress Cluster was inversely associated with well-being and positively associated with chronic disease index. As hypothesized, the magnitude of association between clusters and outcomes differed by race/ethnicity. CONCLUSIONS: By identifying psychosocial clusters and their associations with health, we have taken an important step toward understanding how individual psychosocial predictors interrelate and how empirically formed Stress and Social clusters relate to health outcomes. This study has also demonstrated important insight about differences in associations between these psychosocial clusters and health among racial/ethnic minorities. These differences could signal the best pathways for intervention modification and tailoring.

Farmers' markets' uptake of food assistance programmes in East Tennessee, USA.

OBJECTIVE: Limited acceptance of government food assistance programmes such as the US Department of Agriculture's (USDA) Supplemental Nutrition Assistance Program (SNAP) is a barrier that produces unequal access to market products for SNAP beneficiaries. There is a dearth of published evidence to explain the limited SNAP acceptance at farmers' markets. The current project aimed to fill this gap; to identify and describe the barriers to markets' acceptance of SNAP. DESIGN: Cross-sectional, semi-structured interviews were conducted. SETTING: All interviews were conducted via telephone. SUBJECTS: Twelve East Tennessee area market managers, vendors and other key stakeholders. RESULTS: Multiple barriers exist for SNAP implementation at markets including administrative and time limitations, prejudice from market vendors against SNAP beneficiaries, and resistance to invasive and burdensome requirements of the USDA SNAP application required for farmers' markets. CONCLUSIONS: SNAP acceptance at farmers' markets is a complex issue, especially for small, rural markets. If farmers' markets are to serve as sustainable resources to increase food access, these issues must be addressed so that SNAP can be accepted. Successful implementation of SNAP at rural markets requires increased administrative support and vendor education about SNAP and its beneficiaries. A revised USDA SNAP application process for farmers' markets should also be considered.

Associations between non-discrimination and training policies and physicians' attitudes and knowledge about sexual and gender minority patients: a comparison of physicians from two hospitals.

BACKGROUND: Some physicians lack knowledge and awareness about health issues specific to sexual and gender minority (SGM) individuals. To help improve this, hospitals have implemented policies that mandate non-discrimination and training to promote sexual and gender minority health. There is limited evidence about how such policies relate to physicians' knowledge, attitudes, and gender and sexual minority affirmative practices. METHOD: A random sample of 1000 physicians was recruited from a complete list of physicians affiliated with one of two university Hospitals located in Tennessee and 180 physicians completed the survey concerning attitudes and knowledge about SGM individuals. Physicians were affiliated with either Hospital A that had not implemented policies for non-discrimination and training, or Hospital B that did. RESULTS: Physicians held different attitudes about SGM patients than non-patients. Physicians affiliated with Hospital A held more negative attitudes about SGM individuals who were non-patients than physicians affiliated with Hospital B. There were no differences between the two hospitals in physicians' attitudes and knowledge about SGM patients. CONCLUSION: Policies that mandate non-discrimination and training as they currently exist may not improve physicians' attitudes and knowledge about SGM individuals. Additional research is needed to understand how these policies and trainings relate to physicians' SGM affirmative practices.

Gay Acres: Sexual Orientation Differences in Health Indicators Among Rural and Nonrural Individuals.

PURPOSE: Geographic location is a significant factor that influences health status and health disparities. Yet, little is known about the relationship between geographic location and health and health disparities among lesbian, gay, and bisexual (LGB) persons. This study used a US population-based sample to evaluate the associations of sexual orientation with health indicators by rural/nonrural residence. METHODS: Data were pooled from the 10 states that collected sexual orientation in the 2010 Behavioral Risk Factor Surveillance System surveys. Rural status was defined using metropolitan statistical area, and group differences by sexual orientation were stratified by gender and rural/nonrural status. Chi-square tests for categorical variables were used to assess bivariate relationships. Multivariable logistic regression models stratified by gender and rural/nonrural status were used to assess the association of sexual orientation to health indicators, while adjusting for age, race/ethnicity, education, and partnership status. All analyses were weighted to adjust for the complex sampling design. FINDINGS: Significant differences between LGB and heterosexual participants emerged for several health indicators, with bisexuals having a greater number of differences than gay men/lesbians. There were fewer differences in health indicators for rural LGB participants compared to heterosexuals than nonrural participants. CONCLUSIONS: Rural residence appears to influence the pattern of LGB health disparities. Future work is needed to confirm and identify the exact etiology or rural/nonrural differences in LGB health.

Sexual minority cancer survivors' satisfaction with care.

Satisfaction with care is important to cancer survivors' health outcomes. Satisfaction with care is not equal for all cancer survivors, and sexual minority (i.e., lesbian, gay, and bisexual) cancer survivors may experience poor satisfaction with care. Data were drawn from the 2010 LIVESTRONG national survey. The final sample included 207 sexual minority cancer survivors and 4,899 heterosexual cancer survivors. Satisfaction with care was compared by sexual orientation, and a Poisson regression model was computed to test the associations between sexual orientation and satisfaction with care, controlling for other relevant variables. Sexual minority cancer survivors had lower satisfaction with care than did heterosexual cancer survivors (B = -0.12, SE = 0.04, Wald χ(2) = 9.25, p< .002), even controlling for demographic and clinical variables associated with care. Sexual minorities experience poorer satisfaction with care compared to heterosexual cancer survivors. Satisfaction with care is especially relevant to cancer survivorship in light of the cancer-related health disparities reported among sexual minority cancer survivors.

Treatment summaries, follow-up care instructions, and patient navigation: could they be combined to improve cancer survivor's receipt of follow-up care?

PURPOSE: Cancer survivors require follow-up care to ensure early detection of recurrence, management of late/long term effects, preventive screening for early detection of second primary malignancies, as well as other forms of preventive care. But not all survivors receive necessary follow-up care. Combining survivorship care plans and patient navigation may be a successful strategy to improve survivor's receipt of necessary follow-up care. METHODS: Using data from the 2010 LIVESTRONG online survey of cancer survivors (N = 3854), this study tested associations between receipt of follow-up care instructions (FCI) and treatment summaries (TS) paired with patient navigation (PN), and survivor's receipt of cancer surveillance, preventive cancer screening, and attendance at regular medical appointments. RESULTS: Survivors who received FCI, TS, and patient navigation were the most likely to report attendance at all medical appointments (aOR 4.17, 95% CI 2.30, 7.57, p ≤ .001) and receipt of preventive cancer screening (aOR 3.56, 95% CI 2.28, 5.55, p ≤ .001). CONCLUSIONS: Likelihood of receiving follow-up care was greatest when survivors received FCI, TS, and PN. This pairing appeared to be most beneficial for survivor's attendance at medical appointments and receipt of preventive cancer screening. IMPLICATIONS FOR CANCER SURVIVORS: By improving attendance at medical appointments and prevention cancer screening, pairing SCP and PN could benefit survivors through reduced recurrence, earlier recurrence detection, and prevention of second primaries.

Follow-up care instructions, treatment summaries, and cancer survivors' receipt of follow-up health care and late/long term effects.

PURPOSE: Cancer survivors need follow-up care. Survivorship care plans (SCP), including follow-up care instructions (FCI) and treatment summaries (TS), were designed to improve cancer survivors' receipt of follow-up care after cancer treatment. However, there is a paucity of evidence regarding the relationship between survivors' receipt of FCI and TS and their receipt of follow-up care and late/long term effects. METHODS: This study used data from the 2010 LIVESTRONG online survey of people affected by cancer, including 3541 cancer survivors who had completed treatment. RESULTS: Receipt of FCI was associated with greater likelihood of attendance at all regular medical appointments (aOR 2.28, 95% CI 1.60-3.23), receipt of cancer surveillance (aOR 1.64, 95% CI 1.28-2.09), being up to date on preventive cancer screening (aOR 2.63, 95% CI 2.00-3.47), and with fewer late/long term effects (IRR 0.77, 95% CI 0.69-0.85). Receipt of TS was associated with greater likelihood of attendance at all regular medical appointments (aOR 1.79, 95% CI 1.31-2.44) and being up to date on preventive cancer screening (aOR 1.43, 95% CI 1.14-1.78), but not cancer surveillance or late/long term effects. CONCLUSIONS: This study is among the first to document the associations between SCP and survivors' attendance at regular medical appointments, cancer surveillance, preventive cancer screenings, and late/long term effects. The findings suggest that SCP may facilitate follow-up care needed by cancer survivors after cancer treatment is completed.

Health Behaviors and Self-Reported Health Among Cancer Survivors by Sexual Orientation.

PURPOSE: Health behaviors and self-reported health are important for understanding cancer survivor health. However, there is a paucity of published research about how cancer survivors' health behaviors and self-rated health vary by sexual orientation. This study examined cancer survivors' health behaviors and self-reported health by sexual orientation. METHODS: This study used data from the National Health and Nutrition Examination Survey (NHANES) from 2001-2010. Self-reported health and cancer-related health behaviors were compared by sexual orientation. Propensity score adjustment was used to account for differences in age, race, education, gender and health insurance status. RESULTS: Of the 602 survivors eligible for the study, 4.3% identified as sexual minorities. Sexual minorities were 2.6 times more likely to report a history of illicit drug use (adjusted odds ratio [aOR]=2.4, 95% confidence interval [CI]: 1.04, 5.35), and 60% less likely to report their current health status as good (aOR=0.40, 95% CI: 0.18, 0.89), compared to heterosexual cancer survivors. These disparities persisted even after adjustment for socio-demographic characteristics. CONCLUSION: Our findings suggest that sexual minority cancer survivors may be at greater risk for poorer outcomes after cancer than other survivors. A possible explanation for the observed differences involves minority stress. Future research should test stress as an explanation for these differences. However, using population-methods to achieve this goal requires larger samples of lesbian, gay, and bisexual (LGB) cancer survivors.

How do follow-up care instructions and treatment summaries relate to cancer survivors' cancer-related pain?

CONTEXT: Cancer-related pain is a problem for many cancer survivors. Treatment summaries (TS) and follow-up care instructions (FCI) provided after cancer treatment could reduce pain for cancer survivors. OBJECTIVES: This study sought to determine how TS and FCI received by cancer survivors relate to cancer survivors' cancer-related pain after treatment completion. METHODS: Data were from 2010, Behavioral Risk Factor Surveillance System, Cancer Survivorship module, completed by 10 U.S. states and entities. RESULTS: Pain was reported by 9% of survivors. TS (P = 0.02) and FCI (P < 0.001) were associated with pain. Compared with cancer survivors who had not received TS or FCI, those who received TS had greater odds of pain (odds ratio, 1.57; 95% confidence interval, 1.08-2.28) and those who received FCI had more than twice the odds of pain (odds ratio, 2.36; 95% confidence interval, 1.52-3.67). CONCLUSION: FCI and TS were related to pain but in the opposite direction than predicted. Those who received TS and FCI were more likely to report pain than those who did not receive FCI and TS. This may be explained by the severity of cancer treatment. It is possible that those who undergo more severe cancer treatments are more likely to receive FCI and TS. Testing this relationship is a logical next step.