Background: People who inject drugs (PWID) are a medically and socially vulnerable population with a high incidence of overdose, mental illness, and infections like HIV and hepatitis C. Existing literature describes social and economic correlations to increased health risk, including stigma. Injection drug use stigma has been identified as a major contributor to healthcare disparities for PWID. However, data on this topic, particularly in terms of the interface between enacted, anticipated, and internalized stigma, is still limited. To fill this gap, we examined perspectives from PWID whose stigmatizing experiences impacted their views of the healthcare system and syringe service programs (SSPs) and influenced their decisions regarding future medical care. Methods: Semi-structured interviews conducted with 32 self-identified PWID in New York City. Interviews were audio recorded and transcribed. Interview transcripts were coded using a grounded theory approach by three trained coders and key themes were identified as they emerged. Results: A total of 25 participants (78.1%) reported at least one instance of stigma related to healthcare system engagement. Twenty-three participants (71.9%) reported some form of enacted stigma with healthcare, 19 participants (59.4%) described anticipated stigma with healthcare, and 20 participants (62.5%) reported positive experiences at SSPs. Participants attributed healthcare stigma to their drug injection use status and overwhelmingly felt distrustful of, and frustrated with, medical providers and other healthcare staff at hospitals and local clinics. PWID did not report internalized stigma, in part due to the availability of non-stigmatizing medical care at SSPs. Conclusions: Stigmatizing experiences of PWID in formal healthcare settings contributed to negative attitudes toward seeking healthcare in the future. Many participants describe SSPs as accessible sites to receive high-quality medical care, which may curb the manifestation of internalized stigma derived from negative experiences in the broader healthcare system. Our findings align with those reported in the literature and reveal the potentially important role of SSPs. With the goal of limiting stigmatizing interactions and their consequences on PWID health, we recommend that future research include explorations of mechanisms by which PWID make decisions in stigmatizing healthcare settings, as well as improving medical care availability at SSPs.

Objective The promotion of healthy lifestyles among persons with serious mental illness is an integral part of their recovery. The aims of this systematic literature review were to rate the methodological quality of lifestyle intervention outcome studies for persons with serious mental illness, summarize intervention strategies, examine physical health outcomes, and evaluate the inclusion of racial and ethnic minority groups in these studies. Methods Electronic bibliographic database searches were performed to locate studies conducted in the United States. Articles written in English and published in peer-reviewed journals between 1980 and 2009 were included. The authors used a standardized instrument to rate studies' methodological quality. Results Twenty-three articles were reviewed. Based on studies' methodological quality, three levels of evidence were found: single-group reports, quasi-experimental studies, and randomized controlled trials. Most interventions used behavioral techniques to improve dietary habits and increase physical activity. Twelve studies reported significant improvements in either weight loss or metabolic syndrome risk factors associated with receiving a lifestyle intervention. Persons from racial and ethnic minority groups were underrepresented, especially Hispanics and Asian Americans. Only one study included non–English-speaking participants. Conclusions Lifestyle interventions adapted to persons with serious mental illness show promise in reducing weight loss and some risk factors for metabolic syndrome. The under-representation of persons from racial or ethnic minority groups in this literature limits its generalizability. Implications for research and practice are discussed.

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Background The infant gut's ability to suppress immunologic reactions to food proteins could be influenced by levels of TGFβ in breast milk. We hypothesized that lower levels of TGFβ1 in the breast milk (BM) of mothers in the WHEALS birth cohort are associated with atopy at infant age 2-3 years. Methods We used data collected during infancy in addition to results of skin prick tests (SPT+) and measures of specific IgE>0.35 IU/ml (spIgE) to milk, egg, and peanut at infant age 2-3 years. Infants were classified as food allergic (FA) based on parental report of infant symptoms/diagnoses and information from clinical assessments. Results Data for 304 cohort members was analyzed. Among non-black infants, BM-TGFβ1 was lower for those classified as FA (versus no FA) and those SPT+ (versus SPT-), geometric mean=1100pg/ml versus 1417pg/ml, p=0.081; and 1100pg/ml versus 1415pg/ml, p=0.064, respectively. Among infants of non-atopic mothers, BM-TGFβ1 was lower for those with elevated (vs. not elevated) sIgE, geometric mean=1347pg/ml versus 1651 pg/ml, p=0.047. Using logistic regression, adjusted odds ratios describing the association of BM-TGFβ1 to the presence of atopic indicators in the infant were in the hypothesized direction only for non-black infants of non-atopic mothers: aORs for FA, sIgE and SPT+ were 0.08, 0.34, and 0.26 respectively; p=0.091, 0.13, and 0.23. Conclusion Immune benefit of BM-TGFβ1 could inform prevention strategies. Evidence of an association appears greatly influenced by infant race and maternal atopy. More research can determine if these relationships represent a modifiable risk factor for development of food allergy in certain subgroups.

Background and objective There is conflicting evidence of the effect of environmental tobacco smoke (ETS) on the development of allergic diseases in children. Studies have shown that this relationship differs depending on maternal history of the disease. We sought to employ the rigor of propensity score methods to assess this relationship using data from a birth cohort. Methods Using n=662 children from the Wayne County Health, Environment, Allergy and Asthma Longitudinal Study (WHEALS) we assessed the relationship between early life ETS and subsequent allergic sensitization via a positive skin prick test (SPT+) or at least 1 specific IgE ≥ 0.35 (sIgE+) in children aged 2–3 years. Propensity score estimation followed by full and nearest neighbor matching was compared to standard multivariable regression models. Results Among children without a maternal history of allergic disease ETS was positively associated with allergic sensitization in children with an adjusted odds ratio (aOR) for SPT+ of 2.32 (95% confidence interval (CI): 1.28–4.22) and the aOR for sIgE+ was 2.53 (95% CI: 1.43–4.48). Contrarily, for children with a positive maternal history the aOR for SPT+ and sIgE+ was 0.56 (95% CI: 0.24–1.32) and 0.43 (95% CI: 0.20–0.91), respectively. Conclusion Using propensity score methods to rigorously control for confounding factors we found that early life ETS exposure reduces the risk of allergic sensitization in children aged 2–3 years, but only in children with a positive maternal history. There is a strong association between early life ETS and the development of allergic sensitization for children without maternal history.

Background Suspected food allergies are the cause of more than 200,000 visits to the emergency department annually. Racial differences in the prevalence of food allergy have also been reported, but the evidence is less conclusive. Researchers continue to struggle with the identification of food allergy for epidemiologic studies. Objective To explore racial differences in IgE-mediated food allergy (IgE-FA) in a birth cohort. Methods We used a panel of board-certified allergists to systematically identify IgE-FA to egg, milk, or peanut in a multiethnic birth cohort in which patient medical history, patient symptoms, and clinical data were available through 36 months of age. Results Of the 590 infants analyzed, 52.9% were male and 65.8% African American. Sensitization (serum specific IgE >0.35 IU/mL) to the food allergens was significantly higher for African American children compared with non–African American children as has been previously reported. No statistically significant racial/ethnic differences in IgE-FA were observed; however, a higher proportion of African American children were designated as having peanut allergy, and the percentage of African American children with an IgE level greater than 95% predictive decision points for peanut was 1.7% vs 0.5% for non–African American children. With the use of logistic regression, race/ethnicity was not significantly associated with IgE-FA (adjusted odds ratio, 1.12; 95% confidence interval, 0.58–2.17; P = .75) but was associated with sensitization to more than 1 of the food allergens (adjusted odds ratio, 1.80; 95% confidence interval, 1.22–2.65; P = .003). Conclusion We did not observe an elevated risk of IgE-FA for African American children, although established differences in sensitization were observed. Racial/ethnic differences in sensitization must be taken into consideration when investigating disparities in asthma and allergy.

Background: Increased drug use has disproportionately impacted rural areas across the U.S. People who use drugs are at risk of overdose and other medical complications, including infectious diseases. Understanding barriers to healthcare access for this often stigmatized population is key to reducing morbidity and mortality, particularly in rural settings where resources may be limited. Methods: We conducted 20 semi-structured interviews with people who use drugs, including 17 who inject drugs, in rural southern Illinois between June 2018 and February 2019. Interviews were analyzed using a modified grounded theory approach where themes are coded and organized as they emerge from the data. Results: Participants reported breaches of trust by healthcare providers, often involving law enforcement and Emergency Medical Services, that dissuaded them from accessing medical care. Participants described experiences of mistreatment in emergency departments, with one account of forced catheterization. They further recounted disclosures of protected health information by healthcare providers, including communicating drug test results to law enforcement and sharing details of counseling sessions with community members without consent. Participants also described a hesitancy common among people who use drugs to call emergency medical services for an overdose due to fear of arrest. Conclusion: Breaches of trust by healthcare providers in rural communities discouraged people who use drugs from accessing medical care until absolutely necessary, if at all. These experiences may worsen healthcare outcomes and further stigmatize this marginalized community. Structural changes including reforming and clarifying law enforcement's role in Emergency Departments as well as instituting diversion policies during arrests may help rebuild trust in these communities. Other possible areas for intervention include stigma training and harm reduction education for emergency medicine providers, as well as developing and implementing referral systems between Emergency Departments and local harm reduction providers and medically assisted drug treatment programs.