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Now, more than ever, broadband Internet access (BIA) must be recognized as a social determinant of health. Disparities in access should be treated as a public health issue because they affect \"the health of people and communities where they live, learn, work and play.\" The COVID-19 pandemic demonstrates that lack of BIA influences each of the six social determinant of health domains defined by the American Medical Association.2 It also affects an additional domain, which is particularly pertinent during a pandemic-access to credible information (Figure 1). Reduced BIA, particularly during this pandemic, has the potential to exacerbate this country's existing health disparities because it disproportionately affects those who are already vulnerable. Indeed, those who are older, are racial/ ethnic minorities, have lower incomes, are less educated, or live in rural areas may experience worse health outcomes under normal circumstances and are even less able to access healthenhancing resources during social-distancing orders.

Background Stigmatization may prompt gay, bisexual, queer and other men who have sex with men (GBQMSM) to avoid or delay HIV testing. There has been little attention to GBQMSMs’ perspectives about how stigma may influence their decisions about whether, where, and how often to get tested for HIV. Methods We conducted nine focus groups with 64 adult GBQMSM in Metropolitan Detroit, including HIV-negative men and people living with HIV (PLWH). Data were thematically analyzed deductively and inductively in three rounds. Results Three themes emerged regarding whether to get tested : (1) Perceived promiscuity, risk perceptions and HIV testing; (2) Fearing sexual rejection; and (3) Fearing friend and family member distancing and rejection. Themes concerning where to get tested included: (4) Conflating HIV testing and diagnosis; and (5) Seeking privacy and safety at specialized services. As for how often to get tested , themes included: (6) Reducing contact with healthcare providers due to intersectional stigma; (7) Responsibility and regular testing; and (8) HIV stigma and testing as routine care. Black participants articulated themes (3), (4), and (6) with greater frequency than other participants. Framing HIV testing as a personal responsibility may have created a “new stigma,” with unintended consequences not observed with “routine healthcare” messaging. Conclusions GBQMSMs’ perspectives indicate the potential for new foci for HIV testing promotion interventions based on stigma-related issues that they deem important. There is a need for interventions to challenge the “promiscuity” stereotype, and to reduce the sexual stigmatization of GBQMSM living with HIV/AIDS—especially online. Provider stigma requires both intervention and continued availability of specialized services. Future stigma-reduction interventions for Black GBQMSM could focus on building family support/acceptance, awareness of multiple testing options, and integrating LGBTQ-related issues into initiatives for racial justice in health care.

The task complexity involved in connecting to telehealth video visits may disproportionately impact health care access in populations already experiencing inequities. Human intermediaries can be a strategy for addressing health care access disparities by acting as technology helpers to reduce the cognitive load demands required to learn and use patient-facing telehealth technologies. We conducted a cognitive load theory-informed pilot intervention involving warm accompaniment telehealth helping sessions with patients at a Federally Qualified Health Center (FQHC). We demonstrate how to design and report recruitment methods, reach, delivery process, and the preliminary impact of a novel equity-focused intervention. Early into the COVID-19 pandemic a telehealth helping session was offered to patients at FQHC via phone. Graduate students led the sessions on conducting a telehealth video test run or helping with patient portal log-in. They systematically recorded their recruitment efforts, intervention observations, and daily reflection notes. Following the intervention, we asked the intervention participants to participate in an interview and all patients who had telehealth visits during and 4 weeks before and after the intervention period to complete a survey. Electronic health records were reviewed to assess telehealth visit format changes. Descriptive and inferential statistical analyses of the recruitment records, electronic health record data, and surveys were performed. Through integrative analysis, we developed process-related themes and recommendations for future equity-focused telehealth interventions. Of the 239 eligible patients, 34 (14.2%) completed the intervention and 3 (1.2%) completed subsequent interviews. The intervention participants who completed the survey (n=15) had lower education and less technological experience than the nonintervention survey participants (n=113). We identified 3 helping strategies for cognitive load reduction: providing step-by-step guidance for configuring and learning, building rapport to create confidence while problem-solving, and being on the same page to counter informational distractions. Intervention participants reported increased understanding but found that learning the video visit software was more difficult than nonintervention participants. A comparison of visit experiences did not find differences in difficulty (cognitive load measure) using telehealth-related technologies, changes to visit modality, or reported technical problems during the visit. However, the intervention participants were significantly less satisfied with the video visits. Although a limited number of people participated in the intervention, it may have reached individuals more likely to need technology assistance. We postulate that significant differences between intervention and nonintervention participants were rooted in baseline differences between the groups' education level, technology experience, and technology use frequency; however, small sample sizes limit conclusions. The barriers encountered during the intervention suggest that patients at FQHC may require both improved access to web-based technologies and human intermediary support to make telehealth video visits feasible. Future large, randomized, equity-focused studies should investigate blended strategies to facilitate video visit access.

Veinot et al discuss the potential of upstream health informatics interventions to enhance health equity. It is by now well-established that both health and health disparities are profoundly social phenomena. However, the majority of consumer health informatics interventions to date have focused solely on individuals, with particular attention accorded to influencing individual-level psychosocial characteristics and health behaviors. Despite the potential advantages of upstream interventions, their broad nature means that there are conceptual difficulties in applying this approach in health informatics. The authors introduce a model of health disparities that identifies potential targets for intervention at different levels of social organization. They also discuss types of noninformatics interventions that have addressed these targets.

The COVID-19 pandemic resulted in rapid changes in how patient care was provided, particularly through the expansion of telehealth and audio-only phone-based care. The goal of this study was to evaluate inequities in video and audio-only care during various time points including the initial wave of the COVID-19 pandemic, later stages of the pandemic, and a historical control. We sought to understand the characteristics of care during this time for a variety of different groups of patients that may experience health care inequities. We conducted a retrospective analysis of electronic health record (EHR) data from encounters from 34 family medicine and internal medicine primary care clinics in a large, Midwestern health system, using a repeated cross-sectional, observational study design. These data included patient demographic data, as well as encounter, diagnosis, and procedure records. Data were obtained for all in-person and telehealth encounters (including audio-only phone-based care) that occurred during 3 separate time periods: an initial COVID-19 period (T2: March 16, 2020, to May 3, 2020), a later COVID-19 period (T3: May 4, 2020, to September 30, 2020), and a historical control period from the previous year (T1: March 16, 2019, to September 30, 2019). Primary analysis focused on the status of each encounter in terms of whether it was completed as scheduled, it was canceled, or the patient missed the appointment. A secondary analysis was performed to evaluate the likelihood of an encounter being completed based on visit modality (phone, video, in-person). In total, there were 938,040 scheduled encounters during the 3 time periods, with 178,747 unique patients, that were included for analysis. Patients with completed encounters were more likely to be younger than 65 years old (71.8%-74.1%), be female (58.8%-61.8%), be White (75.6%-76.7%), and have no significant comorbidities (63.2%-66.8%) or disabilities (53.2%-61.1%) in all time periods than those who had only canceled or missed encounters. Effects on different subpopulations are discussed herein. Findings from this study demonstrate that primary care utilization across delivery modalities (in person, video, and phone) was not equivalent across all groups before and during the COVID-19 pandemic and different groups were differentially impacted at different points. Understanding how different groups of patients responded to these rapid changes and how health care inequities may have been affected is an important step in better understanding implementation strategies for digital solutions in the future.

Purpose: Gender transition is a complex life change, and transgender identity disclosures are pivotal moments that delineate the gender transition process. The purpose of this study was to quantify the average sequence in which transgender people disclose their transgender identity to different people in their lives, such as medical professionals, family members, and online networks, and to understand the emotional implications of these disclosures. Methods: We used mixed methods to identify 362 transgender identity disclosure social media posts within 41,066 total posts from 240 Tumblr transition blogs (online spaces in which transgender people document gender transitions). We manually assigned each disclosure post an audience category, and then calculated the average sequence in which people in this sample disclosed their transgender identity to different audiences. Results: Health professionals, such as physicians and therapists, were on average some of the very first people to whom transgender Tumblr bloggers disclosed their transgender identity. Such disclosures were often anxiety provoking and emotionally difficult, whether intentional or involuntary. Next, they often disclosed to friends, followed by close family (e.g., parents and siblings) and then extended family (e.g., grandparents). Mass disclosures to large portions of a person's network, such as on one's Facebook profile, usually came late in the disclosure process. Conclusion: Gender transition is a staged process that includes a series of disclosures to different audiences that follows an average sequence. Because health care providers (e.g., physicians and therapists) who work with transgender patients are often some of the very first people to whom transgender people in our sample disclosed, providers must practice extra sensitivity when responding to such disclosures.

HIV testing promotion is a critical HIV prevention strategy, especially among at-risk groups such as young men who have sex with men (YMSM). Based on a web survey of 194 YMSM (18–24), we examine the association of social network characteristics and functions, and of individual-level characteristics, with three HIV testing behaviors (ever, repeat, and recent testing). Network homophily was associated with recent testing in multivariable models. The network function of information acquisition was associated with ever testing and repeat testing. Perceived stigma regarding HIV-related help-seeking was negatively related to recent testing. Individual characteristics were associated with testing outcomes in all models; age, perceived behavioral control, and positive attitudes had the greatest influence. Individual characteristics had a stronger association with ever testing and repeat testing than network characteristics and functions; however, this relationship was reversed for recent testing. Findings support the value of multi-level and network-focused interventions for promoting HIV testing among YMSM.

HIV/AIDS-related research requires recruitment of representative samples of MSM; yet, we know little about the comparative yield, diversity and cost–benefit tradeoffs between different recruitment venues. We compared 11 recruitment venues used for nine HIV prevention-related focus groups with MSM in Metropolitan Detroit. Of the 64 participants, 24 were clients recruited via an HIV/AIDS-focused nonprofit, 20 from Grindr advertisements, 6 from university-student email lists, and 5 from flyers/palmcards. Significantly more African–American, low-income and HIV-positive participants were recruited via the nonprofit. The best cost–benefit tradeoffs were for organizational Facebook posts, email groups, personal networking, and nonprofit recruitment. Grindr increased the size of the sample, though at greater expense. Facebook and Scruff advertisements and gay bar outreach represented greater costs than benefits. Only 11.6% of Grindr respondents attended the focus groups. A mix of online and offline recruitment venues can generate a large and diverse sample of MSM, but venue performance is uneven.

Health information is a critical resource for individuals with health concerns and conditions, such as hypertension. Enhancing health information behaviors may help individuals to better manage chronic illness. The Modes of Health Information Acquisition, Sharing, and Use (MHIASU) is a 23-item questionnaire that measures how individuals with health risks or chronic illness acquire, share, and use health information. Yet this measure has not been psychometrically evaluated in a large national sample. The objective of this study was to evaluate the psychometric properties of the self-administered MHIASU in a large, diverse cohort of individuals living with a chronic illness. Sharing Information, a prospective, observational study, was launched in August 2018 and used social media campaigns to advertise to Black women. Individuals who were interested in participating clicked on the advertisements and were redirected to a Qualtrics eligibility screener. To meet eligibility criteria individuals had to self-identify as a Black woman, be diagnosed with hypertension by a health care provider, and live in the United States. A total of 320 Black women with hypertension successfully completed the eligibility screener and then completed a web-based version of the MHIASU questionnaire. We conducted a psychometric evaluation of the MHIASU using exploratory factor analysis. The evaluation included item review, construct validity, and reliability. Construct validity was established using exploratory factor analysis with principal axis factoring. The analysis was constricted to the expected domains. Interitem correlations were examined for possible item extraction. There were no improvements in factor structure with the removal of items with high interitem correlation (n=3), so all items of the MHIASU were retained. As anticipated, the instrument was found to have 3 subscales: acquisition, sharing, and use. Reliability was high for all 3 subscales, as evidenced by Cronbach α scores of .81 (acquisition), .81 (sharing), and .93 (use). Factor 3 (use of health information) explained the maximum variance (74%). Construct validity and reliability of the web-based, self-administered MHIASU was demonstrated in a large national cohort of Black women with hypertension. Although this sample was highly educated and may have had higher digital literacy compared to other samples not recruited via social media, the population captured (Black women living with hypertension) are often underrepresented in research and are particularly vulnerable to this chronic condition. Future studies can use the MHIASU to examine health information behavior in other diverse populations managing health concerns and conditions.

Background Hemodialysis sessions frequently become unstable from complications such as intradialytic hypotension and untoward symptoms. Previous patient safety initiatives promote prevention of treatment complications; yet, they have placed little specific focus on avoidable session instability. A patient-centered definition of session instability grounded in patient experiences, and an understanding of patient perceptions of causes and solutions to instability, may enable such efforts. Methods Twenty-five participants participated in three focus groups and/or a survey. They were purposively sampled for variation in region of residence, and sensitivity to patient well-being. Focus group recordings were analyzed using descriptive coding, in vivo coding, and thematic analysis. Results Patients define unstable sessions (“bad runs”) as those in which they experience severe discomfort or unanticipated events that interfere with their ability to receive therapy. Bad runs were characterized primarily by cramping, low blood pressure (“crashing”), cannulation-related difficulties (“bad sticks”), and clotting of the dialysis circuit or vascular access. Patients believed that cramping and crashing could be explained by both patient and clinician behavior: patient fluid consumption and providers’ fluid removal goals. Patients felt that the responsibility for cannulation-related problems lay with dialysis staff, and they asked for different staff or self-cannulated as solutions. Clotting was viewed as an idiosyncratic issue with one’s body, and perceived solutions were clinician-driven. Patients expressed concern about “bad runs” on their ability to achieve fluid balance. Conclusions Findings point to novel priorities for efforts to enhance hemodialysis session stability, and areas in which patients can be supported to become involved in such efforts.