Addressing Health Equity and Social Determinants of Health Through Healthy People 2030.

The evolution of Healthy People reflects growing awareness of health inequities over the life course. Each decade, the initiative has gained understanding of how the nation can achieve health and well-being. To inform Healthy People 2030's visionary goal of achieving health equity in the coming decade, the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 (Secretary's Advisory Committee) provided the US Department of Health and Human Services with guidance on key terms, frameworks, and measurement for health equity. Conditions in the environments in which people are born, live, learn, work, play, worship, and age influence health and well-being outcomes, functioning, and quality-of-life outcomes and risks and are mostly responsible for health inequities. No single individual, organization, community, or sector has sole ownership, accountability, or capacity to sustain the health and well-being of an entire population. The COVID-19 pandemic in the United States highlights underlying inequities and disparities in health and health care across segments of the population. Contributing factors that were known prior to the pandemic have led to major discrepancies in rates of infection and death. To reduce health disparities and advance health equity, systems approaches-designed to shift interconnected aspects of public health problems-are needed.

The Citizen Psychologist Curriculum-Preparing psychologists for public service: The 2018 American Psychological Association Presidential Initiative.

This article describes a curriculum developed as part of the American Psychological Association President Jessica Henderson Daniel's, 2018 Presidential Initiative-The Citizen Psychologist. The curriculum is designed to prepare the next generation of Citizen Psychologists to provide the broadest sense of service as leaders in their communities and in public service psychology. The curriculum prepares the learner to bring psychological knowledge, science, and expertise to bear on existing challenges to improve community well-being locally, nationally, and globally. This includes addressing the services needs of various vulnerable populations such as veterans, prisoners, the seriously mentally ill, those with substance abuse problems, children, and older adults. Competency-based curricula are presented in a series of modules, each dedicated to a level of education and training from high school through lifelong learning. Each module presents learning outcomes, activities, and resources designed to develop level-specific competencies. Steps for implementation and recommendations at the local and national level are provided. Implications of incorporating the Citizen Psychologist curriculum in education and training programs are discussed including encouraging students to explore volunteer and career opportunities in public service psychology. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

What Will It Take to End the HIV/AIDS Epidemic? Linking the Most Disenfranchised Into Care Through Outreach.

The 2015 National HIV/AIDS Strategy renewed its goal of increasing access to care for people living with HIV/AIDS (PLWHA) and called for an increased focus on linkage to care efforts. As many PLWHA face multiple barriers to care and live on the margins of society, adoption of intensive outreach activities is necessary to engage the most disenfranchised PLWHA into care and to ultimately end the HIV epidemic. The Bay Area Network for Positive Health (BANPH), comprising 12+ agencies, established a network outreach model for our linkage-to-care project to engage the hardest-to-reach populations in the San Francisco Bay Area. During the years 2010-2013, BANPH agencies conducted street outreach, analyzed internal tracking systems to identify out-of-care individuals and individuals experiencing tenuous care, and surveyed participants using Apple iPod Touch devices. During the 3-year project, BANPH agencies engaged 602 out-of-care PLWHA and linked 440 to care. On average, outreach workers made 10 contact attempts with a client to link them to care. Sixty-three percent of participants were linked to care on an average of 56 days after initial contact. Factors, including lack of case management, lack of transportation, competing concerns, substance abuse, and HIV stigma, were significantly associated with linkage-to-care outcomes. Intensive outreach efforts could help to reduce barriers to care for hard-to-reach PLWHA, but these efforts require a tremendous amount of time and resources. A network outreach model could help facilitate sharing of limited resources and increase regional outreach capacity for linkage-to-care programs.

Enabling full representation in science: the San Francisco BUILD project's agents of change affirm science skills, belonging and community.

BACKGROUND: The underrepresentation of minority students in the sciences constrains innovation and productivity in the U.S. The SF BUILD project mission is to remove barriers to diversity by taking a "fix the institution" approach rather than a "fix the student" one. SF BUILD is transforming education, research, training, and mentoring at San Francisco State University, a premiere public university that primarily serves undergraduates and ethnic minority students. It boasts a large number of faculty members from underrepresented groups (URGs), including many of the project leaders. These leaders collaborate with faculty at the University of California San Francisco (UCSF), a world-class medical research institution, to implement SF BUILD. KEY HIGHLIGHTS: Together, the campus partners are committed to creating intellectually safe and affirming environments grounded in the Signaling Affirmation for Equity (SAFE) model, which is based on robust psychosocial evidence on stereotype threat and its consequences. The SAFE model dictates a multilevel approach to increasing intent to pursue a biomedical career, persistence in STEM fields, and productivity (e.g. publications, presentations, and grants) by implementing transformative activities at the institutional, faculty, and student levels. These activities (1) increase knowledge of the stereotype threat phenomenon; (2) affirm communal and altruistic goals of students and faculty to "give back" to their communities in classrooms and research activities; and (3) establish communities of students, faculty and administrators as "agents of change." Agents of change are persons committed to establishing and maintaining SAFE environments. In this way, SF BUILD advances the national capacity to address biomedical questions relevant to communities of color by enabling full representation in science. IMPLICATIONS: This chapter describes the theoretical and historical context that drive the activities, research and evaluation of the SF BUILD project, and highlights attributes that other institutions can use for institutional change. While this paper is grounded in psychosocial theory, it also provides practical solutions for broadening participation.

Pilot Test of a Culturally Sensitive Hypertension Management Intervention Protocol for Older Chinese Immigrants: Chinese Medicine as Longevity Modality.

Hypertension control in older Chinese immigrants remains a significant health issue because of their unique cultural health practices to manage their hypertension. At present, there are limited culturally sensitive health education materials regarding hypertension management tailored for the older Chinese population available for and feasible to use. Because the San Francisco Bay Area has a large population of older Chinese immigrants, development of a culturally appropriate intervention is important to help this population achieve better blood pressure control. The focus of this study was to develop and test the feasibility of a culturally sensitive hypertension management intervention protocol, Chinese Medicine as Longevity Modality. This intervention protocol is implemented as a patient education health program delivered via video format in combination with an individual consultation provided by a nurse in the initial intervention, followed by four phone calls between the initial intervention and the second follow-up visit. The results of the study showed that the proposed intervention protocol was acceptable for the target population.

Beyond the discourse of reproductive choice: narratives of pregnancy resolution among Latina/o teenage parents.

Despite the fact that the US teenage birth rate has declined dramatically in recent years, teen births among Latinas are higher than any other racial/ethnic group. Most studies focus on the causes and consequences of early motherhood among Latina teenagers, neglecting other important dimensions of the issue. This study examines how Latina/o teenage parents living in California narrate their experiences with unintended pregnancy resolution. Qualitative analysis reveals three central themes. First, participants expressed shock upon learning they or their partner was pregnant, followed by acceptance about their impending parenthood. Second, participants' views of abortion and adoption largely foreclosed these options as pathways by which to resolve their unintended pregnancies. Third, participants recounted numerous stories of the messages they received from parents, other family members and male partners that were frequently directive regarding how to resolve their pregnancies. These findings have implications for young people's reproductive health and rights, and for reproductive justice more broadly.

The intersection of gender and ethnicity in HIV risk, interventions, and prevention: new frontiers for psychology.

This article articulates a contextualized understanding of gender and ethnicity as interacting social determinants of HIV risk and acquisition, with special focus on African Americans and Hispanics/Latinos--2 ethnic groups currently at most risk for HIV/AIDS acquisition in the United States. First, sex and gender are defined. Second, a conceptual model of gender, ethnicity, and HIV risk and resilience is presented. Third, a historical backdrop of gender and ethnic disparities is provided, with attention to key moments in history when notions of the intersections between gender, ethnicity, and HIV have taken important shifts. Finally, new frontiers in psychology are presented, with recommendations as to how psychology as a discipline can better incorporate considerations of gender and ethnicity as not only HIV risk factors but also as potential avenues of resilience in ethnic families and communities. Throughout the article, we promulgate the notion of a syndemic intersectional approach, which provides a critical framework for understanding and building the conditions that create and sustain overall community health by locating gendered lived experiences and expectations within the layered conceptual model ranging from the biological self to broader societal structures that define and constrain personal decisions, behaviors, actions, resources, and consequences. For ethnic individuals and populations, health disparities, stress and depression, substance abuse, and violence and trauma are of considerable concern, especially with regard to HIV risk, infection, and treatment. The conceptual model poses new frontiers for psychology in HIV policy, research, interventions, and training.

Agents of change: peer mentorship as HIV prevention among HIV-positive injection drug users.

This paper presents a qualitative investigation of peer mentoring among HIV seropositive injection drug users in a randomized controlled trial, the INSPIRE study. Qualitative analyses of 68 in-depth open-ended interviews conducted in 2005 in Baltimore, New York, Miami, and San Francisco revealed that these individuals conceptualized themselves as change agents through the identity of peer mentor at the three related domains of individual, interpersonal, and community-level change. Implications for program development and future research of peer mentoring as a mechanism for HIV prevention are discussed. This study was funded by the Centers for Disease Control and Prevention and Health Resources and Services Administration (HRSA).

Preventing HIV in U.S. women and girls: a call for social action.

Successes in HIV prevention efforts in the U.S. have resulted in drastic reductions in the number of new infections in the U.S. among white gay men and injection drug users, a stabilization in overall annual rates of new HIV infections, and near eradication of mother-to child transmission of HIV. Despite this remarkable progress, the proportion of AIDS cases in women has slowly, quietly, and steadily increased from 7% in 1985 to 25% in 2008. The fact the prevention efforts have not reduced HIV spread among women suggests that targeting the individual behaviors of women to prevent HIV acquisition is not a sufficiently effective public health strategy. Interventions that more broadly address the needs of women and their families, and address the contextual factors in which HIV risk occurs are more likely to lead to measurable and sustainable progress. Over the past 30 years, we have seen the U.S. HIV epidemic in women become similar to patterns of HIV risk among women in the developing world. In 2009, 85% of women who acquired HIV became infected through sex with a man and the majority (83%) of them were non-white women. Efforts to understand these immense disparities and create gender-responsive strategies must be a priority within our National HIV/AIDS Strategy.

Is injection serosorting occurring among HIV-positive injection drug users? Comparison by injection partner's HIV status.

Research needs to build evidence for the roles that HIV status of injection partners may or may not play in injection risk behaviors of injection drug users (IDUs). Using baseline data collected from a randomized controlled study (INSPIRE) conducted in four cities (Baltimore, Miami, New York, and San Francisco) from 2001 to 2005, we categorized 759 primarily heterosexual HIV-positive IDUs into four groups based on HIV serostatus of drug injection partners. Thirty-two percent of the sample injected exclusively with HIV-positive partners in the past 3 months and more than 60% had risky injection behavior with these partners. Eight percent injected exclusively with HIV-negative partners and 49% injected with any unknown status partners. The remaining 11% reported having both HIV-positive and -negative injection partners, but no partners of unknown HIV status. Riskier injection behavior was found among the group with mixed status partners. The risk among the group with any unknown status partners appeared to be driven by the greater number of injection partners. No major group differences were observed in socio-demographic and psychosocial factors. Our analysis suggests that serosorting appeared to be occurring among some, but not an overwhelming majority of HIV-positive IDUs, and knowledge of HIV status of all injection partners per se did not appear to be as important as knowledge of sexual partner's HIV status in its association with risk behavior.

Is sexual serosorting occurring among HIV-positive injection drug users? Comparison between those with HIV-positive partners only, HIV-negative partners only, and those with any partners of unknown status.

Using baseline data from a multi-site, randomized controlled study (INSPIRE), we categorized 999 HIV-positive IDUs into three groups based on serostatus of their sex partners. Our data provide some evidence for serosorting occurring in our sample; about 40% of the sample had sex exclusively with HIV-positive partners, and about half of them reported having unprotected sex with these partners. Twenty per cent had sex exclusively with HIV-negative partners; their sexual behaviors tended to be least risky with about two-thirds reporting their sex was protected. However, we also found that another 40% had at least one partner of unknown HIV status and sexual and drug risk was the highest among them. They were also least empowered, showing attributes that may undermine HIV prevention. Some of these findings are consistent with findings from MSM studies, suggesting that partner selection practices are similar between primarily heterosexual IDUs and MSM.

Beliefs that condoms reduce sexual pleasure-gender differences in correlates among heterosexual HIV-positive injection drug users (IDUs).

Studies consistently find that negative condom beliefs or attitudes are significantly associated with less condom use in various populations, including HIV-positive injection drug users (IDUs). As part of efforts to reduce sexual risk among HIV-positive IDUs, one of the goals of HIV interventions should be the promotion of positive condom beliefs. In this paper we sought to identify the correlates of negative condom beliefs and examined whether such correlates varied by gender, using a subsample (those with an opposite-sex main partner; n = 348) of baseline data collected as part of a randomized controlled study of HIV-positive IDUs. In multivariate analyses, we found more significant correlates for women than for men. With men, perception that their sex partner is not supportive of condom use (negative partner norm) was the only significant correlate (Beta = -0.30; p < 0.01; R (2) = 0.18). Among women, negative partner norm (Beta = -0.18; p < 0.05); having less knowledge about HIV, STD, and hepatitis (Beta = -0.16; p < 0.05); lower self-efficacy for using a condom (Beta = -0.40; p < 0.01); and more episodes of partner violence (Beta = 0.15; p < 0.05) were significantly associated with negative condom beliefs (R (2) = 0.36). These findings suggest important gender-specific factors to consider in interventions that seek to promote positive condom beliefs among HIV-positive IDUs.

Correlates of risk patterns and race/ethnicity among HIV-positive men who have sex with men.

Behaviors related to HIV infection vary by race, with African American and Latino men who have sex with men (MSM) more likely to report sex with women than are European-American MSM. The epidemic among African Americans, in particular, is growing rapidly among both men and women. Some have hypothesized that bisexually active men may be contributing to the epidemic among women. However, little is known about risk patterns among men of different races who are already infected. In this study of 456 HIV-seropositive MSM we found that, like HIV-negative MSM, African American MSM who are HIV-positive were less likely than European American men to identify as gay, more likely to report sex with women, and less comfortable discussing their MSM behavior with close friends and acquaintances. African American participants also exhibited higher levels of internalized homophobia, as well as lower self-efficacy for disclosing their HIV status to sex partners. Implications for interventions for this population are discussed.

Beliefs about personal and partner responsibility among HIV-seropositive men who have sex with men: measurement and association with transmission risk behavior.

Beliefs of people living with HIV about their own responsibility for preventing HIV transmission (personal responsibility) and their sex partners' responsibility for protecting themselves (partner responsibility) are poorly understood. A sample of 1163 HIV-seropositive men who have sex with men (MSM; 55% men of color) completed an A-CASI assessment of sexual behavior and psychosocial measures. A two-dimensional model that represents four orientations toward responsibility was tested: (1) self-high personal and low partner responsibility, (2) other-low personal and high partner responsibility, (3) shared-high personal and high partner responsibility, and (4) diminished-low personal and low partner responsibility. As predicted, the self-responsibility group demonstrated the lowest risk of HIV transmission; the other responsibility group had the highest risk. Intermediate risk was observed in the shared and diminished responsibility groups. Implications for future research and HIV prevention efforts are discussed.

Results from a randomized controlled trial of a peer-mentoring intervention to reduce HIV transmission and increase access to care and adherence to HIV medications among HIV-seropositive injection drug users.

BACKGROUND: There is a lack of effective behavioral interventions for HIV-positive injection drug users (IDUs). We sought to evaluate the efficacy of an intervention to reduce sexual and injection transmission risk behaviors and to increase utilization of medical care and adherence to HIV medications among this population. METHODS: HIV-positive IDUs (n=966) recruited in 4 US cities were randomly assigned to a 10-session peer mentoring intervention or to an 8-session video discussion intervention (control condition). Participants completed audio computer-assisted self-interviews and had their blood drawn to measure CD4 cell count and viral load at baseline and at 3-month (no blood), 6-month, and 12-month follow-ups. RESULTS: Overall retention rates for randomized participants were 87%, 83%, and 85% at 3, 6, and 12 months, respectively. Participants in both conditions reported significant reductions from baseline in injection and sexual transmission risk behaviors, but there were no significant differences between conditions. Participants in both conditions reported no change in medical care and adherence, and there were no significant differences between conditions. CONCLUSIONS: Both interventions led to decreases in risk behaviors but no changes in medical outcomes. The characteristics of the trial that may have contributed to these results are examined, and directions for future research are identified.

Correlates of lending needles/syringes among HIV-seropositive injection drug users.

Among HIV-positive injection drug users (IDUs), we examined the correlates of lending needles/syringes with HIV-negative and unknown status injection partners. HIV-positive IDUs (N=738) from 4 cities in the United States who reported injection drug use with other IDUs in the past 3 months participated in an audio computer-assisted self-administered interview. Eighteen percent of study participants self-reported having lent their needles to HIV-negative or unknown status injection partners. Multivariate analyses showed that 6 variables were significantly associated with this high-risk injecting practice. Older IDUs, high school graduates, and those reporting more supportive peer norms for safer drug use were less likely to lend needles/syringes. Admission to a hospital for drug treatment in the past 6 months, having injected with >1 person in the past 3 months, and having more psychiatric symptoms were all associated with more risk. These findings underscore the need for a continued prevention focus on HIV-positive IDUs that recognizes the combination of drug use, mental health factors, and social factors that might affect this high-risk injecting practice, which could be associated with HIV and hepatitis C transmission.

Sexual transmission risk behavior reported among behaviorally bisexual HIV-positive injection drug-using men.

BACKGROUND: Few research studies have examined the HIV transmission risk behaviors of HIV-positive injection drug users (IDUs) who are men who have sex with men and women (MSMW). METHODS: We compared unprotected vaginal or anal sex with an HIV-negative or unknown (UNK) status sexual partner of MSMW (n=118) with men who have sex exclusively with women (MSW; n=469) and men who have sex exclusively with men (MSM; n=90) using baseline information from the Intervention for Seropositive Injectors-Research and Evaluation (INSPIRE) study, a 4-city randomized controlled trial. RESULTS: MSMW were twice as likely to report unprotected vaginal sex (P<0.001) and 3 times as likely to report unprotected anal sex with an HIV-negative/UNK status female partner (P<0.001) as MSW. MSMW did not differ in their report of unprotected insertive anal sex and were half as likely to report unprotected receptive anal sex with HIV-negative/UNK status men (P=0.02) as MSM. MSMW were 2 times as likely to report engaging in transactional sex (buying or selling sex in exchange for money, drugs, or housing) than MSM or MSW (81%, 43%, and 36%, respectively; P<0.001). CONCLUSIONS: Further research is needed to understand the contexts of unprotected sex among HIV-positive injection drug-using MSMW. Prevention programs should target the unique prevention needs of this population, particularly their risk with female partners.

Are feelings of responsibility to limit the sexual transmission of HIV associated with safer sex among HIV-positive injection drug users?

We developed a scale among HIV-positive injection drug users (IDUs) to measure self-perceived responsibility to limit HIV transmission during sex. We describe the characteristics of HIV-positive IDUs (n=1114, 62% male, HIV-positive for 9 years on average) who felt responsible for protecting their sexual partners from HIV and evaluated whether such feelings were associated with safer sexual practices. Using this scale (Cronbach alpha=0.83) and audio computer-assisted self-interviewing technology, 75% of this sample felt responsible for protecting their sexual partners from HIV. In cross-sectional multivariate analysis, HIV-positive IDUs who felt responsible were those with greater HIV knowledge (adjusted odds ratio [95% confidence interval]: 1.74 [1.26 to 2.40]), perceived social support (1.77 [1.28 to 2.44]), self-efficacy for safely injecting (1.41 [1.02 to 1.94]), and self-efficacy for using condoms (1.92 [1.38 to 2.68]). Feeling responsible was associated with having relatively fewer sex partners (<10 vs. >or=10, 0.57 [0.34 to 0.96]) and a lower odds of unprotected sex (0.63 [0.45 to 0.89]) but was not associated with safer injection practices. Feelings of responsibility did not vary by demographic characteristics, suggesting that prevention messages that encourage HIV-positive people to play a role in curbing HIV transmission may be acceptable to many HIV-positive IDUs. Working with HIV-positive IDUs to increase or reinforce feelings of responsibility may reduce the sexual transmission of HIV.

Correlates of depression among HIV-positive women and men who inject drugs.

INTRODUCTION: Although depression is common among HIV-positive injection drug users (IDUs), little is known about differences between male and female HIV-positive IDUs. METHODS: We used baseline data for 1126 HIV-positive IDUs from a behavioral intervention trial from 2001 through 2005 in 4 US cities. Using the Brief Symptom Inventory-18, scores indicating high risk for depression were calculated separately for men and women based on raw scores of 9 for women and 7 for men. We did separate logistic regressions for men and women to evaluate correlates of depression in 4 domains: sociodemographic, psychosocial, substance use, and sexual behaviors/attitudes. RESULTS: Approximately one third of women and men met the criteria for being at high risk of depression. Women reported significantly more depressive symptoms than men. Correlates linked with depression for both genders included perceived functional limitation, greater negative feelings regarding condom use, lower social support, and lower sense of empowerment. Being physically abused as adults and being Hispanic were correlates specific to men. No unique correlate was identified for women. DISCUSSION: Because of the high prevalence of depression among HIV-positive IDUs, caregivers should screen HIV-positive IDUs for depression and consider treatment for depression. Because of the similarities in correlates of depression among men and women, case finding and interventions for depression are likely to be similar for male and female HIV-positive IDUs.

Boyfriends, girlfriends and teenagers' risk of sexual involvement.

CONTEXT: Having a boyfriend or girlfriend, especially an older one, is associated with increased sexual risk in early adolescence. The mechanisms underlying this association are unclear. METHODS: Middle school students in Northern California were surveyed annually from 1997 to 2000. For a sample of 1,214 males and 1,308 females who were sexually inexperienced in seventh grade, logistic and linear regression were used to explore associations between relationship status in seventh grade and sexual activity in ninth grade, controlling for sixth-grade and eighth-grade characteristics. RESULTS: Males who had had a girlfriend their age by seventh grade were more likely than those who had had no relationship to report sexual activity in ninth grade (odds ratio, 2.1). Similarly, for females, the odds of being sexually active in ninth grade were elevated among those who had had a boyfriend their age (2.9); however, they also were higher among those who had had an older boyfriend than among those who had had one their age (2.1). With sixth-grade risk factors controlled, relationship status in seventh grade remained significant only for females; the association was explained by early menarche and by participation in situations that could lead to sex and riskier peer norms in eighth grade. For males, eighth-grade situations that could lead to sex, Hispanic ethnicity and sixth-grade peer norms explained ninth-grade sexual behavior. CONCLUSIONS: To reduce the risk of adolescent sexual activity, parents and communities should encourage youth in middle school, especially females who experience early menarche, to delay serious romantic relationships.