Identifying social determinants of health in populations exposed to structural inequities: a qualitative study of the COVID-19 pandemic experiences of Black and Latinx people living with HIV and cardiovascular risks.

Introduction: Black and Latinx communities experience inequities in the social determinants of health (SDOH) and high rates of chronic illnesses [e.g., cardiovascular disease (CVD), HIV]. The COVID-19 pandemic amplified these long-standing SDOH disparities. However, scant attention has been paid to the pandemic-related experiences of populations exposed to structural inequities. Methods: Using a semi-structured interview guide, 60 in-depth telephone interviews were conducted with Black and Latinx people living with HIV (PLWH) and CVD risks to assess: (1) perceived personal and community risk for COVID-19; (2) knowledge of and access to COVID-19 public health information; (3) barriers to COVID-19 public health recommendations and vaccine uptake; and (4) perceptions of HIV, CVD, and COVID-19. Interviews were professionally transcribed into either English or Spanish. Spanish transcripts were translated into English. Rapid qualitative analysis was used to summarize each transcript into a structured templaicte corresponding to interview guide domains. Summaries were combined into matrices for identification and comparison of themes across domains. Results: Participants reported risks for COVID-19 due to being immunocompromised and SDOH, including transportation, exposure to risks conferred by others, living in under-resourced neighborhoods, and housing insecurity. Participants engaged in protective countermeasures by adhering to public health mandates. Relationships with providers, participating in community support groups, and digital inclusion and literacy were salient with respect to dissemination of COVID-19 information and vaccine uptake. Experiences with managing a chronic illness facilitated vaccine acceptance. Participants described language barriers, experiences of discrimination, and a historical lack of trust in medical systems and vaccines. Discussion: This study provides a real-time narrative from PLWH and CVD risks who were vulnerable during the height of the COVID-19 pandemic. Implications include the need for continuity with providers and established community networks, increasing internet access and digital health literacy, and addressing historical trauma incurred in medical settings. It is critical to understand the impact of traditional SDOH on those living with chronic illness as well as other social determinants that shed light on access to public health information, adherence to public health recommendations, and vaccine uptake among populations exposed to structural inequities.

Multilevel perceptions of the virtual delivery of the University of California Diabetes Prevention Program on RE-AIM domains due to COVID-19 mandates.

Background: The University of California's Diabetes Prevention Program (UC DPP) Initiative was implemented across all 10 UC campuses in 2018. The COVID-19 pandemic and accompanying mandates required swift changes to program delivery, including pivoting from in-person to virtual delivery (i.e., Zoom). Our goal was to assess multilevel constituent perceptions of the use of a virtual platform to deliver UC DPP due to COVID-19 mandates. Methods: We conducted qualitative interviews with 68 UC DPP participants, coordinators, and leaders to examine the use of virtual platform delivery on the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) of UC DPP. Transcripts were analyzed using rapid qualitative analysis and emergent themes were categorized using domains corresponding to RE-AIM framework. Results: Among UC DPP participants (n = 42), virtual delivery primarily impacted perceptions of UC DPP effectiveness and implementation. Some participants perceived program effectiveness to be negatively impacted, given their preference for in-person sessions, which they felt provided more engagement, peer support, and accountability. Implementation challenges included problems with virtual format (e.g., "Zoom fatigue"); however, several benefits were also noted (e.g., increased flexibility, maintenance of DPP connections during campus closures). UC DPP coordinators (n = 18) perceived virtual delivery as positively impacting UC DPP reach, since virtual platforms provided access for some who could not participate in-person, and negatively impacting effectiveness due to reduced engagement and lower peer support. UC leaders (n = 8) perceived that use of the virtual format had a positive impact on reach (e.g., increased availability, accessibility) and negatively impacted effectiveness (e.g., less intensive interactions on a virtual platform). Across constituent levels, the use of a virtual platform had little to no impact on perceptions of adoption and maintenance of UC DPP. Conclusion: Perceptions of the reach, effectiveness, and implementation of UC DPP using a virtual platform varied across constituents, although all groups noted a potential negative impact on overall program effectiveness. Unanticipated program adaptations, including virtual delivery, present potential benefits as well as perceived drawbacks, primarily across the effectiveness domain. Understanding differential constituent perceptions of the impact of virtual delivery can help maximize RE-AIM and inform future UC DPP delivery strategies.

Need for Sexual, Reproductive, and Mental Health Promotion Among Diverse College Students in a COVID-19 Era.

In 2020, the COVID-19 pandemic forced unprecedented disruptions in higher education operations. While the adverse mental health effects experienced by college students due to these changes are well documented, less is known about the impact on their sexual and reproductive health (SRH), and the reciprocal relationships between SRH and mental health among adolescents and emerging adults. This position paper reviews existing literature on the effects of the COVID-19 pandemic on SRH, sexual violence, unintended pregnancy, sexually transmitted illness and human immunodeficiency virus rates and highlights issues specific to college-aged males, females, racial/ethnic and sexual minorities, and individuals with disabilities. The need to conceptualize SRH as an integral component of normal development, overall health, and well-being in the context of COVID-19 is discussed. The need to prioritize the design and implementation of developmentally appropriate, evidence-based SRH interventions specifically targeting college students is identified. Furthermore, an intergenerational approach to SRH that includes parents/caregivers and/or college faculty and staff (e.g., coaches, trainers) could facilitate comprehensive SRH prevention programming that enhances sexual violence prevention training programs currently mandated by many colleges. Policies and programs designed to mitigate adverse pandemic-related exacerbations in negative SRH outcomes are urgently needed and should be included in mainstream clinical psychology, not only focused on preventing unwanted outcomes but also in promoting rewarding interpersonal relationships and overall well-being. Recommendations for clinical psychologists and mental health researchers are made.

Novel methodologies using history to document the effects of African American sexual trauma: Perspectives of Gail E. Wyatt, PhD.

This article describes the nearly half a century career of Dr. Gail E. Wyatt, PhD, and her development of novel methodologies and measures of sexual trauma, specifically the Wyatt Sex History Questionnaire and the University of California, Los Angeles, Life Adversities Screener. These approaches broke the silence around experiences of sexual violence, particularly among African Americans, identifying their effects on sexual functioning and mental health. These novel methods are designed without assuming sexual literacy of respondents, knowledge of anatomy, or that discussing sex is easy or common; they include topics that are considered private and may evoke emotions. Trained professionals administering face-to-face interviews can serve to establish rapport and educate the participant or client while minimizing possible discomfort and shame around the disclosure of sexual practices. In this article, four topics are discussed focusing on African Americans, but they may also be relevant to other racial/ethnic groups: (a) breaking the silence about sex, (b) sexual harassment: its disclosure and effects in the workplace, (c) racial discrimination: identifying its effects as a form of trauma, and (d) the cultural relevance of promoting sexual health. Historical patterns of abuse and trauma can no longer be ignored but need to be better understood by psychologists and used to improve policy and treatment standards. Recommendations for advancing the field using novel methods are provided. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

How Mental Health Professionals Can Address Disparities in the Context of the COVID-19 Pandemic.

The Coronavirus 2019 (COVID-19) pandemic is an unparalleled crisis, yet also a unique opportunity for mental health professionals to address and prioritize mental and physical health disparities that disproportionately impact marginalized populations. Black, Indigenous, and People of Color (BIPOC) have long experienced structural racism and oppression, resulting in disproportionately high rates of trauma, poverty, and chronic diseases that span generations and are associated with increased COVID-19 morbidity and mortality rates. The current pandemic, with the potential of conferring new trauma exposure, interacts with and exacerbates existing disparities. To assist mental health professionals in offering more comprehensive services and programs for those who have minimal resources and the most profound barriers to care, four critical areas are highlighted as being historically problematic and essential to address: (a) recognizing psychology's role in institutionalizing disparities; (b) examining race/ethnicity as a critical variable; (c) proactively tackling growing mental health problems amidst the COVID-19 crisis; and (d) understanding the importance of incorporating historical trauma and discrimination in research and practice. Recommendations are provided to promote equity at the structural (e.g., nationwide, federal), professional (e.g., the mental health professions), and individual (e.g., practitioners, researchers) levels.

A hybrid effectiveness/implementation trial of an evidence-based intervention for HIV-serodiscordant African American couples.

Couples-based behavioral HIV prevention interventions have demonstrated efficacy, but few are routinely available in community-based settings in the United States. The Eban intervention, designed for heterosexual African American serodiscordant couples and proven efficacious in a cluster randomized trial, was implemented in community-based HIV service organizations in two cities disproportionately affected by the HIV epidemic. This article reports primarily on the effectiveness results related to condom use and results related to retention challenges within a Hybrid Type 2 implementation/effectiveness trial. Ninety-one individuals enrolled at baseline; 39 completed the posttest, and 30 completed the 3-month follow-up. Although condom use did not monotonically increase from baseline to posttest and 3-month follow-up, it did increase from baseline (44%) to posttest (73%), and from baseline to 3-month follow-up with an overall positive slope of Time 0.13 to 0.14 (p < .001). There was a significant increase in the number of people who used condoms 100% of the time from baseline (36.3%) to posttest (56.4%; p = .04) but not from baseline to 3-month follow-up (46.7%; p = .2907). Challenges with resources as basic as housing, food, and transportation complicated participation (and therefore implementation) and may have impeded couples' maintenance of risk reduction strategies beyond the intervention. In light of couples' numerous observed vulnerabilities, we constructed a composite score of "critical vulnerability" and found that depression was persistently related to critical vulnerability and that retention was higher among those with less vulnerability. These findings highlight the important yet underaddressed role of patient-level factors in the process and outcomes of hybrid implementation/effectiveness research. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Predictors of somatic symptom severity: The role of cumulative history of trauma and adversity in a diverse community sample.

OBJECTIVE: Somatic symptoms are often reported among victims of trauma, and place a significant burden on primary care health providers. We examined the relationship between lifetime histories of trauma and adversity, including aspects not previously studied (i.e., perceived discrimination), and somatic symptoms, as well as the mediating role of posttraumatic stress symptoms (PTSS) and depressive symptoms. METHOD: A multiethnic community sample of 500 male and female participants (230 African American and 270 Latino) completed measures of demographic characteristics, the University of California, Los Angeles Lifetime Adversities Screener (LADS), depressive symptoms, PTSS, and somatic symptoms. RESULTS: An ordinary least-squares regression analysis controlling for age, gender, and race/ethnicity indicated that higher levels of lifetime adversity and trauma were significantly associated with more severe somatic symptoms (b = 6.95, p < .0001). Formal mediation tests indicated that there was a significant indirect effect of LADS on somatic symptoms via PTSS and depressive symptoms, indirect effect = 2.64 (95% confidence interval [CI] [1.2, 4.1]) and 2.19 (95% CI [1.3, 3.3]), respectively. Even after PTSS and depressive symptoms were taken into account, the LADS remained significantly associated with somatic symptoms (b = 2.13, p < .05), suggesting partial mediation. CONCLUSION: Exposure to traumatic and adverse events (the LADS) was associated with somatic symptom severity. Furthermore, although PTSS and depressive symptoms partially accounted for the association between the LADS and somatic symptoms, the LADS remained significant, suggesting that both exposure to trauma and adversity and the resultant development of PTSS and depressive symptoms influence the development of somatic symptoms. (PsycINFO Database Record

Associations between intimate partner violence and posttraumatic stress symptom severity in a multiethnic sample of men with histories of childhood sexual abuse.

OBJECTIVE: Little research exists identifying risk factors for posttraumatic stress symptoms (PTSS) among men with histories of childhood sexual abuse (CSA) who have been exposed to intimate partner violence (IPV). METHODS: One hundred and fifty African American, Latino and non-Latino White men with histories of CSA participated in this study. RESULTS: An ordinary least squares regression model with race/ethnicity, HIV serostatus, and CSA severity treated as cofounders and with IPV as the predictor was fitted to predict level of PTSS. Higher levels of IPV were significantly associated with higher PTSS, as were higher levels of chronic stress, and being African American. CONCLUSIONS: Mental health service providers should routinely screen for IPV in men who report histories of CSA and PTSS.

Childhood sexual abuse severity and disclosure predict posttraumatic stress symptoms and biomarkers in ethnic minority women.

OBJECTIVE: Adult posttraumatic stress symptoms and a biomarker index of current health risk in childhood sexual abuse (CSA) survivors were investigated in relation to CSA severity, disclosure, and other peri- and post-trauma factors. METHOD: A community sample of 94 African American and Latina female CSA survivors was assessed. RESULTS: Severe CSA predicted posttraumatic stress symptoms overall, avoidance/numbing symptoms, and greater biomarker risk and was not mediated by post-trauma variables. Moderate CSA severity was mediated by post-trauma disclosure, predicted reexperiencing symptoms, but was unrelated to biomarker risk. No overall ethnic differences were found. CONCLUSION: Results suggest targets for interventions to improve the well-being of minority women CSA survivors.

Severity of child sexual abuse, post- traumatic stress and risky sexual behaviors among HIV-positive women.

Child sexual abuse (CSA) has been shown to enhance risk for HIV infection and other adverse outcomes. However, most studies examine the effects of a single incident of CSA rather than the full burden of abuse over the life span in predicting these adverse outcomes. A multi-dimensional approach was used in this study to examine the severity of abuse as a predictor of post-traumatic stress, depression, sexual symptoms, and risky sexual behaviors in a multi-ethnic sample of 147 HIV-positive women. Multivariate models indicated that experiencing both intrafamilial and extrafamilial CSA, adult sexual abuse (ASA) and Latina ethnicity predicted PTSD symptoms. ASA also predicted sexual trauma symptoms. Also, CSA and adult re-victimization contributed independently to risk for PTSD and sexual trauma symptoms, but not for risky sexual behaviors. The results support the need for interventions for HIV-positive women that address the full burden of abuse experienced and its sequelae.

HIV-positive black women with histories of childhood sexual abuse: patterns of substance use and barriers to health care.

A constellation of factors contributes to Black women's health including stressors and traumatic experiences. Their psychological adjustment and substance use can further affect their health status. The purpose of this study was to examine patterns of substance abuse and barriers to health care among HIV-positive Black women with histories of childhood sexual abuse (CSA). Baseline data on a community sample of 75 Black HIV-positive women were analyzed to assess and identify drug use, alcohol use, participation in an alcohol or drug treatment program, and communication skills with providers, all of which may act as barriers to health care. Findings indicate that substance use is a significant health problem, with 83% of the participants having used at least one substance regularly and 28% having engaged in regular injection drug use. Barriers to health care included confidentiality issues, poor financial resources, difficulty getting an appointment, excessive waiting to see a health care provider and obligation to care for others. Contrary to past research, poor communication between the participants and the providers did not seem to be a barrier to health care utilization for these women. Early traumatic experiences, including CSA, regardless of whether incidents involved penetration, may exacerbate the problems faced by HIV-positive Black women. Implications for future research and culturally relevant prevention and intervention programs are discussed.

Does a history of childhood sexual abuse affect sexual outcomes in breast cancer survivors?

PURPOSE: Little is known about a history of childhood sexual abuse (CSA) in breast cancer survivors and its relationship to sexual functioning after cancer. As part of a larger survey study examining sexuality and intimacy in breast cancer survivors, we conducted in-person interviews with a subsample of participants. METHODS: A total of 147 women in Los Angeles, CA, and Washington, DC, completed a structured interview that addressed sexual socialization and a history of sexual abuse. Trained female interviewers conducted the interviews. Descriptive statistics and regression analyses were used to examine the prevalence of CSA, and its potential impact on sexual health and functioning. RESULTS: One in three women reported at least one CSA incident. Among women who had experienced CSA, 71% reported a single incident, and 22% reported a penetrative form of sexual contact. In multivariate regression analyses examining physical and psychological aspects of sexuality and body image, CSA was not a significant predictor of physical discomfort. However, a history of penetrative CSA was a significant predictor of psychological discomfort (P = .02). CONCLUSION: The prevalence of CSA in this sample was similar to the general population literature on this topic. In this small sample, a past history of CSA did not contribute significantly to the physical discomforts associated with sexual intimacy after breast cancer; however, our findings suggest that a past history of penetrative CSA is associated with increased psychological discomfort, and may warrant additional examination in future research.

The efficacy of an integrated risk reduction intervention for HIV-positive women with child sexual abuse histories.

Child sexual abuse (CSA) is associated with HIV risk behaviors [Bensley, L., Van Eenwyk, J., and Simmons, K. W., 2003.] and more prevalent among women living with HIV than in the general population [Koenig, L. J., and Clark, H., 2004]. This randomized Phase~I clinical trial tested the impact of a culturally congruent psychoeducational intervention designed to reduce sexual risks and increase HIV medication adherence for HIV-positive women with CSA histories. An ethnically diverse sample of 147 women were randomized to two conditions: an 11-session Enhanced Sexual Health Intervention (ESHI) or an attention control. Results based on "intent to treat'' analyses of pre-post changes are reported here. Additional analyses explored whether the observed effects might depend on "intervention dose,'' i.e., number of sessions attended. Women in the ESHI condition reported greater sexual risk reduction than women in the control condition. Although there were no differences between women in the ESHI and control groups on medication adherence, women in the ESHI condition who attended 8 or more sessions reported greater medication adherence at posttest than control women. The findings provide initial support for this culturally and gender-congruent psychoeducational intervention for HIV-positive women with CSA, and highlight the importance of addressing the effects of CSA on sexual risk reduction and medication adherence in preventive interventions for women.

Child sexual abuse: associations with the sexual functioning of adolescents and adults.

As we move into the 21st century, information about sex is widespread and more accessible to the general public than ever before. This interest in sex also increases the focus on symptoms and patterns associated with sexual problems. However, the etiology of sexual dysfunction is multifaceted and poorly understood. One factor that has received growing attention is the role that early sexual abuse plays in sexual development and later sexual functioning, and how these associations differ between males and females. Despite high prevalence rates of child sexual abuse (CSA), which occurs to approximately 1 in 3 females and 1 in 10 males under the age of 18, we do not completely understand the complexities of how and to what extent CSA affects sexual functioning. Nonetheless, the research highlights the need to recognize the potentially powerful influence that abusive childhood experiences contribute to sexual health, performance, and satisfaction. We review research on the relationship between CSA and adolescent and adult sexual functioning. We use a developmental framework to guide our understanding of the effects of CSA, as well as gender and ethnic differences, on the sexual functioning of male and female survivors.