UNDERSTANDING HEALTH DISPARITIES AND BARRIERS TO HEALTHCARE UTILIZATION AMONG SEXUAL MINORITY WOMEN VETERANS WITH HAZARDOUS DRINKING AND MENTAL HEALTH COMORBIDITY
PI: Jillian R Scheer, PhD; Co-Is: Kyle Possemato, PhD; Katherine Buckheit, PhD; Nicholas Livingston, PhD
Funding: NY/NJ VA Health Care Network Center for Integrated Healthcare (CIH) Research Pilot Grant Program
Total Costs: $3,569.25
Project Period: 2023-2024
Project Summary: Sexual minority women (SMW; e.g., lesbian, bisexual) Veterans report elevated rates of violence, hazardous drinking (HD) and alcohol-related harm, such as mortality, and mental health comorbidities (e.g., PTSD, depression) compared to heterosexual women Veterans. Primary care represents a promising setting for facilitating universal screening, early and brief intervention, and timely referrals to specialized behavioral treatment (SBIRT)for HD and co-occurring mental health issues. Despite Veterans Health Administration’s (VHA’s) current initiative to create open-access healthcare and improve Veteran-centered care, SMW Veterans face several barriers to entry and engagement in VHA healthcare services (e.g., anticipated stigma, anxiety about disclosing sexual and gender identity and medically relevant information, providers’ lack of knowledge about SMW’s unique issues). These barriers promote treatment dropout and compound symptom burden. Yet, research has not examined whether SMW Veterans access VHA primary care less frequently than heterosexual women Veterans and “patient-level” barriers and facilitators to accessing SBIRT services in VHA primary care for SMW Veterans. While unknown, concerning rates of HD, alcohol-attributable death, and years of potential life lost caused by preventable alcohol-attributable medical conditions (e.g., liver disease) among SMW Veterans suggest significant unmet need that could be addressed through primary care screening, intervention, and triage. Broadening the scope of disparities research, in this formative mixed methods study, we will use implementation science methods to comprehensively (1) assess whether there are disparities in frequency of VHA primary care utilization among women Veterans based on sexual identity, (2) characterize SMW Veterans who use VHA primary care, (3) identify the continuum of care among SMW Veterans during and following primary care visits, and (4) describe patient-level barriers and facilitators to implementing SBIRT programs for SMW Veterans with HD and mental health comorbidities in VHA primary care settings. This pilot study will be the first to integrate the Consolidated Framework for Implementation Research (CFIR) and the Health Equity Implementation Framework and to use medical informatics and rapid qualitative analysis to guide the implementation of accessible, acceptable, and effective SBIRT programs for SMW Veterans in VHA primary care.
A unified protocol to address sexual minority women’s minority stress, mental health, and hazardous drinking
MPI: John Pachankis, PhD and Tonda L. Hughes, PhD, RN, FAAN; Co-Is: Jillian R. Scheer, PhD; Jeremy Kidd, MD, MPH; Steve Martino, PhD; Laurie Drabble, PhD, Katie Witkiewitz, PhD
Funding: NIH/NIAAA R01AA029088-01A1
Total Costs: $794,938
Project Period: 2022-2027
Project Summary: Background. Sexual minority women (SMW) represent one of the highest-risk groups for hazardous drinking (HD) and comorbid mental health problems (e.g., depression, anxiety) because of their exposure to minority stressors (i.e., stigma-related burdens) and associated stress reactions, like drinking to cope. Research has identified cognitive (e.g., expectations of rejection), affective (e.g., shame), and behavioral (e.g., avoidant coping) pathways through which minority stress places SMW at disproportionate risk of HD and comorbid depression/anxiety. Yet no interventions address these pathways. In fact, no HD intervention has ever been tested for efficacy with SMW. Preliminary Studies. With deep stakeholder input and NIH (R01MH109413- 02S1) and foundation (Lesbian Health Fund) support, we created EQuIP (Empowering Queer Identities in Psychotherapy). EQuIP is a 10-session cognitive-behavioral intervention focused on improving SMW’s minority stress reactions by raising awareness of the harms of minority stress, building self-affirming cognitive styles, and reducing avoidant coping. In a waitlist-controlled pilot trial (n=60), EQuIP showed strong promise for reducing HD and depression/anxiety by building adaptive responses to minority stress, making it the first intervention with preliminary efficacy for improving this population’s co-occurring behavioral and mental health challenges. Methods. We now seek to test EQuIP’s efficacy and identify facilitators of scale-up of this promising intervention. Aim 1: In a 2-arm randomized controlled trial (RCT) with SMW who experience HD and comorbid depression and/or anxiety, we will test the efficacy of EQuIP (n=225) against treatment-as-usual (i.e., supportive counseling) (n=225). Our primary outcome is proportion of heavy drinking days (≥4 drinks) on 30- day timeline followback. Secondary outcomes include reduction in WHO alcohol risk level and depression and anxiety. Because remote intervention delivery has quickly become normative, both EQuIP and treatment-as- usual will be delivered via telehealth (Zoom). In fact, our second pilot of EQuIP found strong feasibility and acceptability of telehealth delivery. Aim 2: Assessments at baseline, 4, 8, and 12 months will determine if reductions in EQuIP’s intended psychosocial mechanisms (e.g., internalized stigma, rejection sensitivity, emotion dysregulation) mediate heavy drinking reductions. To advance personalized medicine, we will also examine whether EQuIP is differentially efficacious across key demographic factors and stigma moderators. Aim 3: To prepare for implementation in frontline settings, we will conduct semi-structured interviews with directors (n=20), providers (n=20), and service users (n=20) from a network of 250 US LGBTQ community clinics. Applying the i-PARIHS framework will help identify facilitators that can support EQuIP implementation at these centers. Summary. As the first trial of an intervention for SMW’s HD and co-occurring mental health, this study responds to NIAAA’s call for trials of “interventions that address AUDs and related problems and that are appropriate to the needs of sexual and gender minority populations.”
Expressive writing therapy to reduce PTSD symptoms and hazardous drinking among trauma-exposed sexual minority women and gender diverse individuals: A randomized controlled trial
PI: Jillian R. Scheer, PhD; Co-Is: Abigail Batchelder, PhD, MPH; Skyler Jackson, PhD; Tami P. Sullivan, PhD
Funding: APF Walter Katkovsky Research Grants; ORAU Ralph E. Powe Junior Faculty Enhancement Award – Health Disparities/Equity
Total Costs: $20,000
Project Period: 2022-2023
Project Summary: This proposed study will assess the impact of the first tailored online expressive writing intervention to reduce PTSD symptoms and hazardous drinking among sexual minority women (SMW; e.g., lesbian, bisexual, or queer) and gender diverse individuals who have experienced trauma. We will accomplish this goal by drawing upon NIH’s Stage Model for Intervention Development to develop (Stage IA) and test (Stage IB) a randomized controlled trial (RCT) to compare an expressive writing treatment condition to an active control condition among a national sample of 105 racially diverse trauma-exposed SMW gender diverse individuals at risk of PTSD and hazardous drinking. We will also examine (Stage II) expressive writing treatments’ mechanisms of action in reducing PTSD symptoms and hazardous drinking compared to an attention control. This pilot study directly responds to the National Institute on Alcohol Abuse and Alcoholism’s (NIAAA’s) research priorities for evidence-based treatments to address alcohol use and related problems for SMW and gender diverse individuals. Findings from this award will increase the clinical relevance of personalized technology-delivered treatments and inform studies using computational text analysis to guide low-threshold treatments for trauma-exposed SMW and gender diverse individuals.
A Socioecological Approach to Understanding Formal Help-Seeking Barriers and Facilitators among Victimized Sexual and Gender Minority People
PI: Jillian R. Scheer, PhD; Co-Is: Katie Edwards, PhD; Adam Messinger, PhD
Funding: Syracuse University Collaboration for Unprecedented Success and Excellence (CUSE) Grant Program SD-6-2021; Adams-Cahill Graduate Research Award (PI: Cascalheira)
Total Costs: $5,000
Project Period: 2021-2024
Project Summary: Reducing social-structural drivers (e.g., poverty, stigma) of domestic violence and sexual assault (DV/SA) among diverse sexual and gender minority (SGM) individuals represents a public health priority. A comprehensive examination of drivers of DV/SA-exposed SGM people’s barriers and facilitators to accessing formal services is needed to inform the development of client-centered, affirming intervention efforts to address barriers to SGM people’s help-seeking behavior. This study aims to 1) determine SGM people’s help-seeking barriers and facilitators across multiple ecological levels and 2) identify contextual factors that contribute to whether and how victimized SGM people make use of local DV/SA-related programming and shape SGM clients’ response to DV/SA-related services. To address these aims, we will conduct a quantitative needs assessment of 350 racially and ethnically diverse DV/SA-exposed SGM living in Central New York (CNY) and conduct semi-structured interviews with Vera House (a multi-faceted, CNY-based DV/SA organization) providers (n=10) and SGM service users (n=20). This mixed-methods study is highly significant and innovative as it 1) targets SGM people living in low-resource areas (i.e., CNY); 2) assesses predictors of SGM people’s help-seeking behavior across ecological levels; and 3) synthesizes SGM clients’ and providers’ perspectives of DV/SA outreach and programming effectiveness. Documenting such barriers and facilitators directly responds to calls for research that aims to improve social-structural drivers of SGM people’s violence-related morbidity. Our findings will inform an NIH/NIMHD R01 proposal to create a) targeted linkage-to-care efforts for DV/SA-exposed SGM individuals and b) strategies that enhance protective factors to improve this vulnerable population’s service uptake and retention.
Examining sexual minority engagement in recovery community centers
PI: Abigail Batchelder, PhD, MPH; Co-Is: Jillian R. Scheer, PhD; John F. Kelly, PhD, ABPP; Bettina Hoeppner, PhD
Funding: NIH/NIDA R24DA051988, Recovery Research Institute Pilot Award
Total Costs: $29,993
Project Period: 2021 – 2023
Project Summary: In this proposed pilot study, we have two aims. For aim 1, we will conduct secondary data analyses to characterize the utilization of recovery community centers (RCCs) by sexual minority individuals, disaggregating gay, lesbian, and bisexual individuals. We will also examine utilization of RCCs by sexual minority individuals in relation to demographic variables (e.g., race, gender, ethnicity, education, income), recovery status (in versus seeking recovery), type(s) of substance use, recovery capital (e.g., employment, housing), and service utilization outside of RCCs (e.g., clinically-oriented alcohol and other substance use disorder [AOD] treatment). For aim 2, we will conduct ≥30 (or until saturation is reached) semi-structured qualitative interviews with sexual minority individuals who report utilizing RCCs in the northeast, selectively sampling to include gay, lesbian, and bisexual-identified individuals with a range of reported primary substances used. These qualitative interviews will assess sexual minority individuals’ perceived facilitators (e.g., recovery capital, self-efficacy, sense of empowerment, location of care) and barriers (e.g., stigma-related concerns about treatment, concerns about the treatment process, problem identification, and logistical barriers) to engagement in and satisfaction with RCCs and other forms of AOD treatment. Together, findings from this project will characterize the gay, lesbian, and bisexual identified individuals utilizing RCCs, and identify perceived facilitators, barriers, and satisfaction with RCC utilization as well as to other forms of AOD treatment among sexual minorities. Results from this study will increase our understanding of the utilization of RCCs by sexual minorities and the features of RCCs that are perceived as accessible and beneficial to sexual minority individuals. Given the underutilization of AOD treatment by sexual minority individuals, this information may also inform future tailored prevention and intervention strategies to better meet the needs of
this underserved patient population – a public health and federal funding priority (NOSI-MD-19-001).
Testing a biopsychosocial model of violence exposure, minority stressors, and hazardous drinking among sexual minority women
PI: Jillian R. Scheer, PhD
Funding: NIH/NIAAA K01 AA02823901A1
Total Costs: $864,111 (approx.)
Project Period: 2021 – 2026
Project Summary: Women disproportionately experience violence compared to men; however, violence against women is not distributed randomly. Due, in part, to their stigmatized identity, sexual minority women (SMW) are 2-3 times more likely to face violence than heterosexual women. Many women use alcohol to cope with the negative sequelae of violence (e.g., PTSD). This comorbidity may be exacerbated among SMW given their experiences of psychosocial stressors (i.e., violence and minority stressors such as discrimination). Despite the public health necessity of developing targeted alcohol treatment approaches for victimized SMW, current alcohol treatment models do not specify unique stressors and clinical needs of this population. Consistent with the NIAAA’s research priorities, the K01 will provide major advances in understanding biopsychosocial mechanisms (e.g., minority stressors, physiological reactivity, PTSD) and moderators (e.g., race/ethnicity) influencing the heterogeneity in hazardous drinking among SMW as well as the role that these core factors play in SMW’s differential need for and response to treatment. The project will include: 1) an epidemiologic assessment that uncovers distinct combinations of psychosocial stressors among SMW, identifies racial/ethnic differences in classes of psychosocial stressors, and determines how these patterns of psychosocial stressors predict comorbid PTSD and hazardous drinking over 11 years (n = 450-600); 2) a lab-based study that advances knowledge of the influence of minority stressors on allostatic load (e.g., salivary cortisol, heart rate, heart rate variability, and skin conductance) among victimized SMW (n = 125); and, 3) a once-daily ecological momentary assessment (EMA) approach over 21 days that determines the role of minority stressors as antecedents to daily fluctuations in PTSD and hazardous drinking using the same sample of SMW from the lab-based study. The proposed training plan in this K01 application will provide essential knowledge and skills that the principal investigator, Jillian R. Scheer, PhD, needs to become an independent, interdisciplinary alcohol scientist. The advanced training acquired by Dr. Scheer via this timely and innovative project will target 3 objectives: (1) rigorous alcohol research methodology and its application to studying determinants of hazardous drinking patterns; (2) physiological measurement of stress reactivity as a tool to assess biological mechanisms underlying the influence of minority stressors on comorbid PTSD and hazardous drinking; and, (3) EMA approaches to assess the proximal effects of minority stressors on daily comorbid PTSD and hazardous drinking among racially diverse SMW. Dr. Scheer will be primarily mentored by John Pachankis, PhD, at Yale University, with additional mentoring from Tonda Hughes, PhD (Columbia University), Rajita Sinha, PhD (Yale University), Tami Sullivan, PhD (Yale University), Joshua Warren, PhD (Yale University), and Robert Pietrzak, PhD, MPH (Yale University). Dr. Scheer’s training through the K01 award will ensure her success as an independent scientist whose work informs public health and clinical efforts to reduce alcohol use among SMW.
Identity denied: Border identity stress, identity invalidation, and psychosocial well-being among bisexual and transgender populations
PI: Skyler Jackson, PhD; Co-I: Jillian R. Scheer, PhD
Funding: Yale Fund for Lesbian and Gay Studies Research Award
Total Costs: $3,800
Project Period: 2018 – 2023
We are a team of researchers at Yale University who are interested in the experiences of individuals who identify as Biracial and Multiracial. Such individuals face unique challenges and the current research in this area is limited and needs greater representation.
We are currently conducting a two-part online study that addresses an important but little-explored question: What are the unique experiences of Biracial and Multiracial individuals? If you choose to participate, your responses to this survey will contribute to knowledge about this underdeveloped area of research.
To participate in this study, you must (a) be 18 years of age or older, (b) reside within the United States, and (c) identify as Biracial or Multiracial.
Participants are expected to complete two study phases.
- Phase 1 is a single online survey, which takes most people between 30-60 minutes to complete. At the end of this survey, you can choose to either (a) receive $10 for your participation or (b) enter a $100 (USD) raffle.
- Phase 2 involves completing a short 10-minute study every evening for one week. You will earn up to $15 for completing this weeklong study component ($1 per survey for surveys 1-5 and $5 per survey for surveys 6 and 7).
Check out the attached flyer. To learn more and take an eligibility survey, use the following link and code (or “cut and paste” the link into your preferred Internet browser): https://bit.ly/31zSXor and code R22.
We appreciate your considering participating in this study. As you may imagine, Biracial and Multiracial individuals can be difficult to reach and recruit for research studies. By participating (and forwarding this email to other groups and individuals), you will be helping to contribute to the body of accurate knowledge about the lives of Biracial and Multiracial individuals.
This study has been approved by the Yale University Institutional Review Board (HIC: 2000028402). If you have questions or concerns about participating, feel free to email our research team at yale.bis.study@gmail.com.
Student-led Projects
Effects of self-compassion practice on stress reactivity among sexual minority women
PI: Emily C. Helminen, MS; Faculty Research Mentor: Jillian R. Scheer, PhD
Funding: GLMA: Health Professionals Advancing LGBTQ Equality
Total Costs: $10,000
Project Period: 2022-2023
Project Summary:
Sexual minority women (SMW) face numerous health disparities relative to heterosexual women. Minority stress theory posits that SMW exhibit these poorer health outcomes because of the unique stress burdens related to one’s status as a sexual minority. However, research exploring the mechanistic relation between stress burdens and health disparities with SMW is underdeveloped. The way people respond to stress (i.e., stress reactivity) is one mechanism by which increased stress exposure leads to poor health. Heightened stress reactivity to acute stressors have been linked with negative health outcomes, and research has demonstrated that SMW exhibit heightened stress reactivity (e.g., higher peaks in cortisol) relative to heterosexual women. Research has also demonstrated that a brief self-compassion intervention can attenuate stress reactivity, indicating that stress reactivity represents a modifiable treatment target. However, no studies have examined whether self-compassion interventions can reduce heightened stress reactivity among SMW specifically. More broadly, no research has examined the acceptability of self-compassion interventions among SMW.
The purpose of this mixed-methods study is to examine: 1) the quantitative effects of a brief self-compassion intervention on stress reactivity to an acute psychosocial stressor among SMW in a pilot randomized controlled trial, and 2) the acceptability of the self-compassion intervention via post-experiment semi-structured qualitative interviews with participants.
Seventy SMW will be recruited and randomly assigned to a brief 40-minute self-compassion intervention group or a psychoeducation control group. Participants will be invited to the lab in groups of five or six, where they will receive the self-compassion or control intervention. Post-intervention, participants will undergo the Trier Social Stress Test for Groups (TSST-G). Throughout the experiment, stress reactivity will be evaluated by both self-report and physiological (i.e., heart rate, blood pressure, cortisol) measures. Data will be analyzed using linear mixed models to evaluate whether participants in the self-compassion condition exhibit significantly lower stress reactivity than participants in the control condition. For participants in the self-compassion condition, semi-structured interviews will be scheduled before they leave the lab. Interviews will be conducted virtually within a week of the experiment.
This study will be the first study to implement a self-compassion intervention targeting stress reactivity among SMW. We hypothesize that the self-compassion intervention will attenuate both self-report and physiological stress reactivity relative to the control intervention. If this is the case, this would provide evidence that self-compassion is an effective intervention to target heightened stress reactivity among SMW, and it represents a first step in demonstrating that self-compassion may be an important resource to improve SMW health outcomes. This will also be the first study to examine the acceptability of a self-compassion intervention among SMW. Data from the qualitative interviews will be used to inform the development of a tailored self-compassion intervention for SMW to further enhance on the ability of self-compassion to improve health outcomes among SMW.
Leveraging artificial intelligence and social media to predict stress hormone levels, probable PTSD, and hazardous drinking among sexual minority women: A pilot study
MPI: Cory J Cascalheira, BA, LSAA; Virinca Jaipuriyar, BA; Aubriana Schwarz, BS; Faculty Advisor and Expert Consultants: Jillian R. Scheer, PhD; Shah Hamdi, PhD
Funding: Bioscience TRAIN Mini-Grant
Total Costs: $1,000
Project Period: 2022-2023
Project Summary: At the cross-section of psychology (i.e., probable PTSD, hazardous drinking), biology (i.e., cortisol), and computer science (i.e., machine learning and social media), this pilot study has potential to make substantial contributions. If machine learning algorithms can predict probable PTSD, hazardous drinking, and stress hormone levels from social media, then: (a) a database of linguistic content that is highly predictive of clinical outcomes can be developed and shared with researchers; (b) the machine learning models could be integrated into smartphone apps as just-in-time, adaptive, automated interventions that link SMW to resources or prompt SMW to use coping skills; and (c) the models could be used by health professionals to predict real-time risk, possibly influencing treatment planning (e.g., targeting in-the-moment situations where symptoms and risk are most severe). This proof-of-concept pilot study will demonstrate the feasibility of predicting violence-related clinical constructs among an underexamined minoritized group, paving the way for better algorithm designs, novel prevention and intervention efforts, and larger research projects.