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Xenia Mendez
Austin Nalen
Ann Abraham
Lena Musoka
1.What has gone right and wrong with PPE and distancing, per HBM

Wrong

Perceived susceptibility

some ppl (like younger ppl), think they are immune

Perceived severity

“Not so bad, just a cold/flu”

Perceived barriers

ppl that live in crowded areas that may have no way of distancing themselves.

Some people who choose not to wear a mask have a perceived barrier that they are losing personal freedom/autonomy.

In the beginning, shortage of PPE for the general population and essential workers.

Cues to action were conflicting and became political, this led to loss of credibility and trust of government, CDC.

Eg: different testing protocols & mask requirements changed

Barriers to testing caused barriers to beliefs about whether or not you needed to be tested.

If you are tested, then you’re supposed to quarantine and not go to work. But it’s a barrier if you can’t take time off work for financial reasons or fear of losing employment.

Right

Social distancing lines to shop and limited number of people in stores -- varied by states and counties.

CA sheltered in place early on.

Perceived benefits of an action

rhetoric around protecting other ppl especially for ppl with limited perceived susceptibility or severity.

2. How HBM & SDOH (social determinants) integrative or in conflict (critique/expand strategies in slide)

They are integrative because people have actual barriers as a result of COVID-19 such as needing to go to work, not being able to shelter in place as opposed to other people whose barriers are loss of personal freedom.

They are integrative because the social determinants of health probably influence a person's perceived barriers and susceptibility.

Essential workers who may be lower SES and they are forced to continue putting their health at risk and interacting with other ppl. Whereas ppl in a tech job are able to make a choice and stay home depending on their own beliefs.

OSHA complaints after pandemic started of coworkers being sick and still going to work, employees not given PPE or time off, not cleaning.

OSHA doesn’t have the capacity to attend to all issues and response time may lag, while COVID is an acute issue.

Hospitals were built to be efficient, but weren’t prepared for a pandemic. U.S was so busy turning health into a business, forgot health is about health.

3. How to guide next steps, including PPE & vaccines

Long-term investment in an infrastructure of accessible and sustainable PPE.

Vaccines: pushing through vaccine trials in an alarming rate.

Increase the influence we have and get ppl to shelter in place and social distance so that we have the time to roll out a vaccine.

Idea of self-efficacy and making it accessible, limiting barriers, and provide accurate of information on the vaccine (and other measures to protect ourselves and the community).

Perceived benefits: making sure ppl are informed about potential health benefits outcomes of a vaccine and answering ppl’s questions so that ppl are aware of the benefits.

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2. Given big differences in U.S. and Portugal contexts, what could be learned from/applied here? What would it take for us to get there given who we are?

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The Portugal case focuses on national drug policy - at a macro level in the ecological model. How is national drug policy manifested in specific experiences or resources at the neighborhood level, and how do these broader factors relate to how we would think about addiction informed by the TTM?

•	in the US: illegal, secret, fear around drugs
•	in Portugal: not illegal, more programs to help keep people more safe/healthy

•	Addiction: feelings of fear/shame, do not know how to get help or afraid to get help (could be arrested)
o	Hard drugs vs “soft” drugs

•	National policies establish social norms, internalized by people; may cause perceived barriers

Given big differences in U.S. and Portugal contexts, what could be learned from/applied here? What would it take for us to get there given who we are?

•	In US: harm reduction and challenges – meet people where they are at, clean needle exchange, Narcan, methadone services

•	Lessons from Portugal: increase access to safe spaces, health services, and decriminalize using drugs
o	Decrease in deaths from overdose, decrease danger
•	How to get there? 
o	have a less polarized society?? 
o	Foster empathy? Support mental health initiatives and shift social norms
o	Test for fentanyl and other more deadly additives 
o	Address social determinants/other factors surrounding drug use/dealing
	gun violence
	police violence and structural racism
	opioid prescription behaviors, marketing

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Context: 
Organization: Portugal has a smaller gov and smaller population, more economic opportunity, more social systems in place in the government
Cultural: Smaller communities, more homogeneous population. 

In the US, this kind of intervention could be better implemented through community interventions on a macro scale. Additionally, Portugal has a larger social support network that might be easier to initiate in order to attend to the communities in need. 

Race in the US and policing vs Portugal policing policy 
Historic issues with relation to drugs and racism. Opium – Asia

Argument against hard reduction and health approach 
-	taking away cost for individuals, people with use more. 
-	Or treatment is decriminalized, the cost is taken away

Public perception, stigma against drugs and being able to “pick yourself up by your boot-straps”, being independent and strong. 
-	Access to healthcare/Universal Care
o	More social programs to encourage individual health 
-	Smaller community 
-	Stigma: personal effects on the psychology of struggling individuals 
o	Internalizing judgement and community pressure
o	Claire Snell-Rood – deservingness and public health
-	Perspective of drug use: 
o	People stigmatize illegal use
o	Prescription is part of the “system”

Over-prescription drug 
-	UC problem with self-prescribing drugs that lead to drug abuse
o	Drugs in advertisement	
 

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Notes:

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1. What has gone right and wrong with PPE and distancing, per HBM.

-       Perceived susceptibility: There were beliefs around geographic barriers to the spread of COVID in early January and February – perception was that COVID was contained to certain parts of the world. There was early messaging around PPE use intended to preserve N-95 supply which led to misinformation around the efficacy of mask use in general (populations were told not to wear masks early on in the pandemic).

-       Perceived severity: Early and current information was that COVID had implications for older and sicker populations but not severity was low for younger and healthy populations.

-       Perceived benefits of an action: Confusion around benefits of wearing a mask in general and the benefits of unique types of masks. Varying numbers on efficacy rates. Thoughts that wearing a mask only protected a wearer vs. the environment.

-       Perceived barriers to taking that action: Perception that the wearer cannot breathe with a mask on and that they will develop hypoxia. Local government officials are also barriers to mask wearing.

2. How HBM & SDOH (social determinants) are integrative or in conflict (critique/expand strategies in slide)

HBM is integrative with SDOH because in both models there is a knowledge gap around the impact of barriers and belief systems on human health. HBM can directly impact and be impacted by social determinants. If people can be educated on their own susceptibility to COVID, severity of COVID, and barriers to health and structural determinants they can be more actionable in protecting their health status. i.e. Black members of society have to be aware of deal with the potential dangers associated with wearing a mask (police brutality) over the dangers of not wearing a mask (dangers of COVID).

3. How to guide next steps, including PPE & vaccines?
-       Create a coordinated effort with all 50 states with regard to priority vaccination populations, delivery mechanisms, solutions for reporting side-effects

-       Educate people about the vaccine (efficacy rates, side effects, cost)

-       Ensure no false marketing- political messaging is really important

-       Determine appropriate release date for maximum adherence

-       Develop administrative tactics that reach people in their communities

-       Focus on vulnerable communities through extra coordinated efforts to reach rural populations, define vulnerable populations, advocate for additional funding, secure affordability programs for coverage of costs

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Group 8:

Perceived susceptibility about C-19=
Many people in rural areas also did not see it as a threat. Young people are under the impression that they will not get sick. 

Perceived benefits= The benefits of Masks had been miscommunicated early on. Americans were told that they will not benefit from wearing a mask and many did not see any value. Many do not have the willingness to adapt to the changing science or changing recommendations. 


Perceived barriers= Many people are losing hope and think they are going to come down with the virus no matter what and are willing to take their chances. 

Perceived severity= Many people do not see C-19 as a threat due to widespread misinformation.

Next Steps:
-Spreading more correct information and debunking misinformation
-Provide clear and transparent evidence for the public 
-Make sure the vaccine isn’t used as an election tool
-Use more regulations
-Find a way to depoliticize the pandemic
-have health departments review the safety of restaurants

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Question 1

-U.S. does not view people as capable of change compared to Portugal. Portugal model accepts that people are at different stages.

-Portugal model addresses people at multiple levels—vans with methadone are for people in precontemplation stage. Case workers ask people about their experiences to determine what stage they are in, and what their needs are.

Question 2
-Decriminalization of marijuana in California-one way support was gained was showing the financial benefit, but in this case private prisons are benefiting from criminalization, so this is a barrier that would need to be overcome

-In Portugal, public health response was an essential component following decriminalization. Concern that our public health system in U.S. would not be responsive enough

-Difficult for physicians to prescribe methadone in the U.S.—policy barriers

-May not start with decriminalization but start with de-stigmatization of drug users and showing that we can help people live by providing Narcan, clean needles, etc. Incremental steps—maybe start state by state like it did with marijuana.
-Distinction between decriminalization and legalization is important.

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1) Example of resources at the neighborhood level: methodone vans make treatment available in a way that allows individuals to be more ready to move from pre-contemplation to contemplation/action phases. Key component of community support to drive action.

2)
- It's a cultural problem: the US shames drug users; the war on drugs was incredibly American and individualistic - criminalize perpetrators of "bad" actions instead of addressing root causes. Just kicking the proverbial can down the road, will have to deal with trickle-down problems in future generations (prison industrial complex). Would be beneficial to have mandatory incarceration caps at state level and tax over cap; policy will follow financial incentives.
- Decriminalization allows people to "come out of hiding" and seek help; how did Portugal manage this policy change, and what would it take for it to happen in the US? US has driven racist narrative that government shouldn't put funding into welfare programs. In America, individual perceptions of race still exist even when policy changes.
- Racism plays a role in criminalization. Cash bail also has racist and classist undertones ($ amounts set without considering context of social and environmental factors that contribute to form of crime); reform/elimination would be a good step towards improvement on this topic. Portugal also has issues with racism, but "of a different flavor" - masked as xenophobia and forced assimilation around immigration from North Africa.

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Question 1
- Need for a uniform, federal-level message/example rather than different state-level efforts
- low belief in perceived severity
- Many believe they are both low risk of infection and low risk of severe symptoms
- Individualistic mindset and a lack of regard for others
- "Hygiene theatrics"
Question 2
- Integrative:
ex. Low-income demographics may have limited access to health care and health information
- Compounding risks with behaviors (such as wearing masks)
Question 3
- Reception of messages is very complex; messages don't necessarily influence perception and behavior
- May necessitate mandates, policies, and enforcement
- Increasing education and awareness efforts

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Portugal approaches drug 
Group 18- option 1
Group 18- option 1
Group 27 - Option 1
Group 27 - Option 1
Group 20
Group 20
Question 1
Group 14
Group 14 
Discussion Option 1
Discussion Option 1

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Question 1
-Community Level:  Less policing, more rehab services/increased accessibility to health resources (trucks distributing methadone)
-Individual Level: Decreased fear of criminalization because of drug use, more likely to seek care for substance abuse or call for help in instances of overdose
-Relation to TTM: Contemplation (In Portugal because there is less criminalization, there is more of an internal drive to deciding to quit. Whereas in the US because of heavy criminalization it seems like the motivation to quit is highly external). Maintenance (In the reading talks about how individuals in Portugal still relapse, so we are curious to see how policies can support the maintenance stage). In Portugal there are so many resources that are visible and can aid individuals at all stages of the change process. In the U.S. we don't have as many resources and the resources are not as visible. Also the U.S. is highly segregated, so will resources being offered equally across communities?

Question 2
-Take a significant amount of political change and decreased polarization around these issues
-Shift from punishment
-Treating it as a medical issue rather than a criminal justice issue (more mediation rather that punitive measures)
-Shift in gun policy (in Portugal, drug use is not associated with violence)
-Fund organizations that are doing work in substance use
-Decrease opioid prescription use
-Change the stigma surrounding drug use
-Address the social and environmental factors which contribute to drug use (housing, minimum wage, etc.)
-We need to collect more data in areas that often are neglected in research and also create tailored interventions for substance use across different communities. Utilize community resources and mobilize leaders in communities.
-Harm Reduction!
-We are curious as to what the health seeking behaviors in the U.S. are as compared to Portugal. I.e. Portugal has universal health care coverage so how would that impact someone who is seeking treatment
-Universal Health Care
-Depoliticize victimless crime (i.e. Substance US). Shift away from our "war on drugs" mindset.

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Audrie Lin, Diana Ong, Carlos Vera, Gia Park
Option 1
1. Portugal decriminalized drugs whereas the US criminalized drug use. Portugal's drug policy seems to better match people where they are at in the stages of change, providing opportunities for treatment without forcing treatment or laying down punishments. For example, the methadone available freely allows people in Portugal to try the treatment more accessibly and explore their options. This could help them move from precontemplation to contemplation or contemplation to preparation and action.

Portugal allows for people to spiral up the stages of change without punishment or criminalization when the have relapses.

Portugal police provide drug quality testing to verify if a drug is safe to use. The nation supports people regardless of the stage that the people are, giving them time to reach the next stage from precontemplation to contemplation. This also helps to build trust between the people and social workers/law enforcers.

2. Incarceration is more expensive than providing treatments. We should move towards making legal punishments less severe and recognizing drug addiction as a health/mental issue. Overall, we should shift our focus from policing to treating.

We should have a tiered control of opioids, decreasing the risk of opioid addictions.

Shift focus: rather than blaming people, focus on improving public health and helping people.
We're preventing drug use -> We're preventing drug death.

Address structural racism challenges to drug use. We need to consider disparities for how the criminal justice system treats drug users of different races. This also brings in the Health Belief Model as those who are Black and drug users may be more likely to feel helpless to change due to stereotypes.

Provide price incentives; make alternative drugs more affordable.

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Pilar Marin
Liuhui Zhang
Shrey Saretha
Jordan Keen
Nadeem Abou-Arraj

1. The resources on a neighborhood level vary starkly between the US and Portugal. Because of decriminalization of drug use and focus on harm reduction and treatment of drug abuse as a medical disorder, the Portuguese have created local resources like social workers, clean needle exchanges, decentralized and accessible methadone treatment. These resources have been generally very successful on an ecological level, though there is still high variation in individual success, as the NYT article did recount stories of some Portuguese who were still struggling with active drug abuse. Additionally, by removing the fear of punishment for drug use, individuals in Portugal are more likely to seek medical care for overdose and drug use treatment.
2. Cultural conception of responsibility: US is more individual, whereas European and non-Western societies are more collective. Additionally, the US has taken a punitive approach toward drug use, which has largely remained unsuccessful. The US could learn from Portugal's emphasis on harm reduction, medicalization of substance use disorder, and investment in social support. In general, we advocate for shifting the approach from a model that places responsibility and focus on the individual to one that addresses the social context and ecological support surrounding individuals. In order to change cultural perceptions and barriers to harm reduction and medical treatment in the US, the US could place individuals with experience in substance use disorders in positions of leadership and power to better represent and incorporate their perspectives and experience. We advocate addressing the multiple socioeconomic and medical factors that co-occur with drug use disorders, such as improving housing, treating other mental health disorders, increasing social support and connectedness.

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Abena, Valerie, Erica, Rowan, Jennifer, Caroline

What has gone right and wrong with PPE and distancing, per HBM

Skepticism about masks due to conflicting messaging about mask-wearing effectiveness, undermined legitimacy of messaging source.

Perceived susceptibilit/severity:
Perceived severity: Younger people considered themselves unsusceptible/ comparable to the flu/ low risk and strong health outcomes leading to riskier behavior.

SDoH: health disparity outcome coinciding with push to reopen economy (reduced perceived susceptibility for privileged communities leading to riskier decisions for community (reopening the economy)

Barriers:
mask cost/benefit analysis
social distancing: essential workers, financial need, high occupancy household (cannot self-isolate)

Social structures that limit ability to make individual protective decisions.

How HBM & SDOH (social determinants) integrative or in conflict (critique/expand strategies in slide)

SDoH data

How to guide next steps, including PPE & vaccines?

Reflection within PH community about how we address mask-wearing and other protective measures.
--politicization

--debunking misinformation
--personalizing risks, tailor message to audience-- expand awareness of susceptibility network (your impact) vs susceptibility of individual

-Target different strategies to different transtheoretical stages:
pre-conception: anti-maskers: can media/celebrities increase awareness/ openness to science

Target: attitude towards vaccines(TPB) --distrust of Med Industrial Complex (related to systemic racism, other causes)
Intervention: increasing awareness/health education regarding vaccine

Target: attitude towards media/ information sources
Intervention: trusted community members i.e. pastors vs public officials/ media.

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1.What has gone right and wrong with PPE and distancing, per HBM
- perceived susceptibility to COVID (people think that they're not susceptible; "low-risk" people only considering it from an individual perspective)
- perceived severity: similar idea of low-risk individuals believing they're not vulnerable
- behavior changes "not worth it"
- perceived benefits: people don't necessarily see the benefits of their individual distancing/PPE behaviors esp when they don't know anyone who has been impacted
- perceived barriers from lockdown impacting economy/personal choice

2. How HBM & SDOH (social determinants) integrative or in conflict (critique/expand strategies in slide)
- self-efficacy: people in most vulnerable populations also may have the most perceived (and very real) barriers
- internalized cultural beliefs of "freedom" and rights to space and resources
- collectivist vs individualist thinking
3. How to guide next steps, including PPE & vaccines
- have basic leadership with transparency and clear planning
- trying to leverage peoples real fears of vaccines especially with the speedy timeline and general distrust of the government

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• We let everyone believe that if you're at low risk then it's not a problem for you (young people) because the consequences seemed not as bad for young people
• Perceived disability and severity - benefits for others versus yourself
• Not getting a direct benefit from wearing a mask - a mask is used to protect others
• Perceived barrier - knowing we have to go to work anyway
• People thinking they can't do anything about coronavirus and that everyone is going to end up getting it leading to a lack of any action - self-efficacy
• We are trying to create perceived benefits through advertising with the notion of protecting others
• People who aren't able to socially distance because of the type of job they have conflict with benefits - if you are a breadwinner then you have to think about how socioeconomic status affects social determinants of health and how you can't just not go to work because you have to make money to survive - puts them at a higher risk of coronavirus. The benefit of money may outweigh the risk of coronavirus.
• Housing - people who have to live in a smaller space with more people are less affluent and cause issues with education etc also affects social determinants of health. Homeless people also cannot do much about coronavirus (self-efficacy) plus there are so many more barriers for them regarding social determinants of health like housing, hygiene, food insecurity, etc.
• Next steps: More advertising to push people to take the benefits of protecting themselves and their family. Shift in using scare-tactics to encourage people to take coronavirus seriously. Instead of scaring people we are better of creating advertisements that focus on the benefits of protecting others.

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Discussion Option 1

#1:
- TTM: incarceration doesn't address the stages of change. In Portugal:
--precontemplation, contemplation, and preparation => outreach to community members, raising awareness of opportunities to take action
--clean needles, free methodone

#2:
- Portugal: better gun control, less violence with drug sales
- Portugal: de-stigmatized drug use, enable people to seek help, public health concern
- US: drug use is criminalized
- Look at prevalence of drug use post-intervention in Portugal, see how this would fit with the demographics in the U.S.

Other thoughts:
- Funding what we value (health vs profit)
- Decision-makers and cultural values vs Evidence
- Importance of addressing individual aspect: U.S. failed to do this

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Who monitors drug use?
US: police,
portugal: social workers/health-related people

Relationship to Substance Dependency
-portugal: flexibility w/r/t stage of users—allowing people to navigate their unique relationship to substance use, recognizing that it's not a linear journey: like a "chronic disease"
-US: blames the person, one & done type thing

The US view of addiction blames the user, and views it as a choice, rather than a product of circumstances
- to get to where portugal is, we would have to shift our culture
-interventions to help, not to punish

Barriers
-so difficult in the US, especially for preventive measures, less integreation so the continuum of care is not actually continuous
-portugal: outreach comes to you. smaller, more homogenous population so it is easier in a lot of ways
-big pharma + its relationship to substance use dependency in the US
-healthcare/medicaid: disparity in access to care, treatment in the US
-Police state: role of police is different in the US

Criminalizing drugs lead to concealed use
-public issue in portugal, public response, solutions to health

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What has gone right and wrong with PPE and distancing, per HBM

wrong:

lack of consensus of messaging (leaders, media) suscept/sensitivity to public

group mentality in USA regarding social distancing/masking behaviors (FREEDOM!!)

lack of access to PPE to public and essential workers

high cost/unavailable

lack of leadership to provide cues to action in USA, which was more present in other countries

mistrust of scientific figures, rise in conspiracy theories

masks are so visible and public, so turned into a representative signal

right:

In cities that adopted practices early (like SF) and normalized practices

example: city parks with spray-painted distance circles

private citizens creating masks at home (etsy),  other companies pivoting to provide PPE

Messaging that went well:

inherent trust in "20 sec washing" or "6 ft distance" or "groups of 10"

How HBM & SDOH (social determinants) integrative or in conflict (critique/expand strategies in slide)

social microcosms inform the messaging sources an individual receives around masks, handwashing, distancing

essential workers who can't stay home, or those experiencing homelessness may not be able to avoid the risks as they would like, barrier to self-efficacy

Members of groups who historically  or currently experienced injustice by medical/government establishments may be more wary or mistrustful of recs

Community institutions can provide reinforcement and normalizaiton of safer behaviors (churches and synagogues altering services for distancing reqs)

How to guide next steps, including PPE & vaccines?

Cohesive messaging from elected officials, scientists, and medical groups -- must all speak with one voice, and modeling that behavior too!

Finding spokespeople and champions within community groups to advocate -- celebrities, pastors of megachurches (if that's even possible), athletes, or from within smaller but trusted community groups

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In the context of the HPM model there are several concepts that helps describe the COVID-19 response.
Perceived susceptibility
perceived severity- people were originally comparing COVID-19 to the "regular flu".
People in different geographic locations experience life and risk differently since their communities are fundamentally different. By treating people in cities and in rural areas, you are losing people since  the susceptibility is different. Over-generalization reduces the buy-in for safe practices among the whole.

Perceived barriers- certain groups, felt that negative stereotypes impacted them wearing masks, and some groups could not afford masking.
social distancing, not everyone can stay at home. Homelessness and people with difficulties at home, or work that requires commuting does not allow them to stay at home.
Self-efficacy- people have doubts on which PPE and infection control practices are effective since messaging from governmental messaging has been confusing. For example, at first, it was stated that cloth masking was not effective and not recommended by the CDC. This policy has changed.

3. if a vaccine for COVID is released, but has a limited supply, how would it be offered to the public (perceived benefits/perceived susceptibility)? Based on susceptibility or made equally available for everyone?
Who should pay for this vaccine?
Stages of change model- whether people are ready for the vaccination, especially in light of the fact politicians are pushing to have the vaccine trials accelerated.

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Question 1
Components of HBM:
1. Perceived susceptibility has gone wrong, with widespread belief in COVID being a hoax. Initially, this was going better, as certain areas took shift action toward lockdowns as soon as there were a few cases.
2. Perceived severity has gone wrong, with misinformation on severity relative to flu and also at-risk populations. For example, young people may not take precautions. Shortfalls in testing early on also undermined perceived severity, as people underestimated the number of cases around them.
3. Perceived benefits of an action have been undermined by the preceding two shortcomings. Moreover, inconsistent messaging from public health officials, who are under political pressure, has led people to question to efficacy of interventions like mask wearing.
4. Perceived barriers to taking that action have taken the form of loss of faith in public health messaging. A misplaced trust in eventual herd immunity may de-incentivize action. Moreover, essential workers with limited access to PPE and concern for their job security may have little choice but to report to a workplace that doesn't meet social distancing guidelines.
5. Cues to action are likely highly dependent on context. In some settings, individuals may constantly encounter cues like message boards in public spaces, stickers on the ground in lines, and positive modeling from others around them. In other settings, cues may be limited to public health directives, like stay at home orders, which may be ignored for the reasons raised above.
6. COVID presents an interesting example of self- vs group-efficacy. Encouraging individuals to make cloth masks at home has gone well, as it empowers individuals to wear a mask even if they're not sure of where to get one. Highlighting the consequences of their actions with respect to their own loved ones, such as older or immunocompromised family members, has likely increased self-efficacy. But seeing others not wearing masks likely undermines group-efficacy, as individuals may feel that no matter how well they follow guidelines, they will be exposed by someone else who doesn't.

Question 2
The nature of essential work during the pandemic creates a link between COVID and SES. In our experience with the communities in which we grew up, those with lower SES, who may be essential workers, and may have more preexisting conditions, may be more likely to take COVID seriously, knowing well the consequences with respect to their poor health (HBM items 1-3). However, they may also face more obstacles (items 4 and 6) due to being excluded from the health system historically. As such, the links between HBM and SDOH are both integrative and in conflict.

Question 3
More aligned messaging across the levels of government would improve all aspects of the HBM. Open communication regarding plans for vaccine distribution would maintain faith in perceived benefits. Perceived barriers may be significant due to the dangerous anti-vaxxing movement, which may emphasize the short development period of COVID vaccines. Aligned messaging would need to challenge anti-vax messaging in a way that is tailored to individual communities. Self-efficacy may be undermined if individuals feel excluded from the process of distribution, due to real or perceived barriers with respect to cost or group membership. Self-efficacy is complicated with multiple-dose vaccines, as individuals may feel overwhelmed by information on when and how to receive subsequent doses.

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What has gone right and wrong with PPE and distancing, per HBM

Perceived susceptibility and severity has been low among people under 50 without pre-existing conditions.

There was a lot of confusion regarding what people should do, including wearing masks. This could be a perceived barrier to action, or a lower perceived benefit.

A lockdown's effects on economy and small business lowers the perceived benefit of locking down.

Not having national leader demonstrate proper PPE and distancing, while also discrediting the CDC and WHO was a lack of a queue to action.

Surgeon General PSAs regarding how to make masks was a good example of a queue to action.

Already experiencing health inequities, makes some people feel like they cannot protect themselves.

How HBM & SDOH (social determinants) integrative or in conflict (critique/expand strategies in slide)

Depending on what determinants are already effecting you, you may already have a baseline sense of self-efficacy, or lack thereof.

If your workplace does not provide PPE/does not encourage it, there may be a barrier to action.

In homes with large families, it is hard to practice social distancing which would be another barrier to action.

How to guide next steps, including PPE & vaccines?

Unified messaging on PPE, social distancing, and vaccines to show perceived benefit and to promote collective efficacy.

Tailor interventions for certain communities, so that it can have the most benefit.

Releasing data from clinical trials of vaccines to increase benefit of action for people who may not trust it.

Make PPE and vaccines more available for all people, reducing barriers to action.

Raising awareness about severe cases among young people to increase perceived risk and perceived severity to increase action.

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1. The Portugal model focused on broad social structures by decriminalizing drug use and removing much of the social stigma. Structural change may be critical to the "precontemplation" stage of TTM. Without the decriminalization, the on-the-ground work of methadone buses, targeted information campaigns, and individual case management that "meets people where they are" would be much more difficult if not impossible. In the clinical setting, there is often an element of judgement from providers that may prevent people from moving forward. In the U.S. would we be willing to dedicate the resources to individual interventions if drug use was decriminalized? Given the heterogeneity of the U.S. population, would structural changes become more or less racist, because structural changes inherently still happen within a prescribed structure. Decriminalization allows movement from precontemplation to contemplation. As the program develops and moves forward, it allows interventions to become even more specific and move individuals into preparation and action. In a smaller country, it is easier to see change and to see "rewards" that come from change that may spur society to accept future change and risk. Whereas, in the U.S., where our drug policies have largely failed, there is likely aversion to change because of the "negative rewards" we have experienced.

2. The heterogeneity of the U.S. population creates a huge barrier to treating addiction because so many (all?) of our criminal justice and drug laws are tied to race and racism, particularly against Black people. From a personal experience, Portugal is proud of its colonial history and may perhaps be as racist as the U.S., but because of their homogenous population they don't have as much of a history of creating racist legislation.

There are illnesses and diseases that are framed around "intention" in the American cultural context. In the U.S. we tend to believe that no one intended to get cancer, but there is an element of blame around addiction. The Portugal model shifts this framing dramatically by dealing with addition as a broad social issue rather than an individual fault. This cultural compassion allows the structural policy to address individual circumstances and be multifaceted in approach. However, questions remain about whether people who are not impacted by addiction are influenced by this model in their perception of addiction and stigma.

Marijuana use and its transfer into wealthy, white communities and subsequent decriminalization and changes in popular perception is also indicative of how racially charged drug use policies are in the U.S. Who is using drugs perhaps matters more than what drugs are being used.

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1) ...how do these broader factors related to how we would think about addition informed by the TTM?
- At a neighborhood level, offering medical attention and treatment in the lens of a chronic disease (Ex: clean syringes, methadone, etc).
- Offering counseling services (even in the short-term), can move people from precontemplation to contemplation.
- Upstream prevention and offering resources for sustainable change.
- Portugal's approach understands the reality of the spiral progression through stages of change (Ex: relapse) and Portugal's approach is willing to meet people at the stage that they're at with the appropriate resources and treatments.

2) Given big differences in U.S. and Portugal contexts, what could be learned...?

- There would have to be an approach change among people in positions of power to move away from punitive measures (Ex: mayor, governor, legislators, police departments, etc.).
- There are so many people making profits off of low-level drug offenses so we have to address that issue to.
- Safe injection sites and non-punitive measures would be a good place to start.
- Need to refocus on long-term goals and sustained benefits and not panic with short-sighted results. (Ex: Portugal expected an uptick in drug use immediately after decriminalization, but kept their eyes on the long-term decreases and health gains).
- Doctors in Portugal resisted overprescribing opioid medications.
- Portugal spends far less on health per household than the U.S. with better outcomes. So for the U.S., the million dollar question is persuading big companies that are contributing to the problem to realize the actual savings in long-term health gains and public health interventions. But they are incentivized for immediate profit, not long-term altruism or health gains.

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Prompt 1

Question 1

Decriminalization of use and focus on treatment lead to a culture of empathy and resources around help as opposed to narratives of “cracking down”

Methadone vans in Portugal (hugely contrasting to the process people in the United States have to go through in order to get access to methadone)

Safe needle exchanges in Portugal

Decriminalizing use leads to lower overdose rates (less fear of reporting use)

Focus on decreasing death rates (rather than focusing on decreasing the rates of drug use?)

Decriminalize USE but still make TRAFFICKING illegal

Focused on not allowing overprescription of opioids (especially in comparison to United States where so much drug use starts from legal prescriptions in healthcare)

U.S. firearm regulations would make it more difficult because of less violence associated with Portugal due to fewer firearms

TTM model: having help more accessible would create better outcomes in moving people along the “stages” (having a more open and welcoming system makes it easier for people to “accidentally” happen upon good treatment options tailored to them)

Cultural differences: individualistic vs. collective (US: responsibility on individuals to do the right thing around drug use) (US government is also at fault for the drug epidemic for their failure of regulating!!)

Question 2

Their decriminalization of drug use is closely tied to firearm regulations and prescription drug regulations

Move from individualism (current US culture) to a more collective approach to healthcare

We’ve seen local attempts to decriminalize drug use in the United States because of overwhelming number of people who are “repeat offenders” for low-level drug use

Emergency departments and police departments and public health departments need to be interconnected (communication and data connections)

Local attempts to do harm reduction approaches (as opposed to abstinence only models): safe use spaces

Trying to make sure someone is there to capture the moment someone moves into the action phase of TTM in order to help support them

There are huge societal costs that we are paying currently for the in-and-out-prison approach to drug usage!!

Changes in funding models would be necessary to implement the model in Portugal (Could this funding money come out of the big settlements with large pharmaceutical companies who pushed the use of prescription opioids?)

TTM model: maintenance! We don’t invest in maintenance, so there are high rates of relapse in the U.S. (our current treatment system views addiction as moral failing/infectious disease, when in reality, it is actually a chronic condition; interventions often look like 30 day intensive programs without further support)

U.S. maybe focuses too much on pre-contemplation or contemplation phases (public health campaigns and anti-drug advertisements, etc.) without supporting transitions from contemplation to preparation to action

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Fiona Ng
Jessica Valdez
Corrine Marquardt
Hollynd Boyden
Noah Reiner
Zoe Varner

Q1:

Marijuana (federally is still illegal; at state level, after one state legalized it, other states followed); can drug policies for other forms of drug follow this pattern?

Even after legalizing marijuana, stigma still exists within the culture

It may also create completion between larger/corporate and smaller farms (capitalism!)

Examples of neighborhood level interventions:

Legalizing mushroom in Oakland, Denver

TTM application:

Having a public health system in place provides the individual with a support system to enhance their behavioral changes related to addiction and drug use; a safety net system

Action (changing the environment for individuals who use): having methadone vans/clinics available

Q2:

Does Portugal have a privatized prison system?

If we don’t get rid of privatized prison systems, it will still be an incentive for the US to criminalize individuals who use drugs

How can the US implement a nationalized health intervention when each of the states differ so much in population size, governance, etc…

Can the Portugal model be applied more at a state-specific level than a national level intervention

California has legalized weed

What is the difference between legalization vs decriminalization?

Legalizing still has some criminalizing components attached to it (e.g., regulations, rhetorics)

How does this disproportionately impact BIPOC

As a nation, public health is not a priority in the US vs. Portugal; we need a cultural change!

As a society, Portugal has decided that drug use is a form of mental health issue and need medical intervention & social support

As a society, the US treats drug use as a crime, and that these individuals are not seens as “people” (esp the stigma around hard drugs like cocaine, heroin)

Stop “otherizing” individuals who uses drugs

How do you go about creating this cultural change? How long will it take?

How does the “culture change” shift based on who the burden is perceived to be on?

E.g., crack versus cocaine

E.g., “War on Drug” @ Black and Brown communities vs. “Opiate Pandemic” @ rural White communities

E.g., “Crack babies” vs. “structural factors affecting pregnancy”

How do we undo the harm already done?

Mass incarceration x prison industrial complex → serves as an incentive to criminalize drug use → country/industry does not want to frame drug use as a health concern

Everything in our society are interconnected

Voting rights for those who were imprisoned → their voices not heard during voting when it relates to these policies

E.g., follow suite with the CA policy to allow ex-inmates to become firefighters

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Portugal
US Drug policy comes from a criminal perspective at a societal level

- social resistance to decriminalization

- places that are interacting with individuals may adopt a more medicalized/disease orientation

vs.

Portugal approaches drug policy from a TTM model (through decriminalization) whereas on the individual level it might be the opposite.

Example of diabetes is a good one for
--

Gathering data and research to support sound policy around drug decriminalization

-- analogous to fight over safe consumption spaces which has been blocked by fed gov in cities (Baltimore, SF, Philadelphia)

-- discussion of different methods we have (methadone, Suboxone) vs. medicate heroin for treating addiction

--> sublocade (Extended release bup) - a much more US approach to look for an injection or pill to fix

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-Portugal decriminalized Opioid use - more money that can go into organizations at the community level
-Individuals do not have to fear being penalized, instead they can receive help.
-Criminalization is sort of like a band aid instead of a long-standing solution. Decriminalization uses the TTM because it looks at the individual -- what stage they're in--and tries to help them improve.
-It can help people to transition their thinking about substance use as a health issue rather than a crime.
-Stigma plays a huge role in preventing change and treatment
-The U.S. would face more challenges especially because other policies influence our ability to decriminalize drug use as well - such as drug laws
-The US would require changing attitudes towards individual health behaviors, and a realization on the part of the government that it would be less expensive to invest in social services than to keep spending on maintaining prisons
-Prescription of opioids in the U.S. helped skyrocket the epidemic while in Portugal they do not traditionally prescribe opioids for pain
-Opioid use has been recently tracked   by prescribers in the US which has reduced the amount of opioids being prescribed and possibly reducing the rate of opioid use disorder

OPTION 2 RESPONSES:
-individualism is an issue
-Some individuals are very serious about wearing masks, some are very against it
-Hard to discern the difference in attitudes and effort of different population groups -- some susceptible people are very cautious, and some are not, and those who are not keep the pandemic moving forward, so the cautious people don't reap the benefits
-People now think the pandemic is mostly politically motivated so harder to get people to follow social distancing and mask-wearing guidelines
-View vaccines and mask wearing as "patriotic" to encourage people to follow healthy guidelines?

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Question 1:

1. Drug use in Portugal is safer because the drug market is nonviolent due to the strict handgun regulation. Also, the decriminalization of drugs has led to safer drug use. For example, the risk of getting a ticket for drug use is a lot different than the risk of going to prison. Social worker intervention by providing safe needles and methadone as an opioid substitute. The US views drug addiction as a personal problem, and in Portugal drug addiction is viewed as a health problem, such as Diabetes. This has led to proper intervention from a health viewpoint.

2. More funding in public health for a public health approach to drug use, and less funding to the prison system to “crack down on drugs.” Drug use is decriminalized in Portugal and not the US, and has led to a much different outcome on safety and the number of overdoses. Differences in economies, SES, and homogeny. Because drug use in the US is criminalized, it has led to an increase in public health issues such as Hepatitis, overdoses, and violence. We would need a cultural shift on the view of drug use in order for the “Portugal Method” to be adopted (shift from criminalized to decriminalized). View drug use from a public health perspective and not a political perspective. We need to have stricter gun control policies because this will allow the drug market to be less violent. People need to understand that drug use is a normal part of a lot of people’s lives (make drug use less glamorized by removing the riskiness of a third party drug dealer). This has been observed in the legalization of weed in certain states.

Question 1

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1. What has gone right and wrong with PPE and distancing, per HBM

Right

Companies and sports teams adapting

Airlines and new requirements (although some are also doing poorly on this)

At least in the bay area (/some other communities around the US) mask wearing has become normalized

Messaging around  hospital capacity and supporting hospital workers?

Large gatherings like sports events and concerts have largely been stopped in person, but have still put in the effort to be adapted to the moment, whether that be virtual audiences, or award shows from different locations

People are interested in being tested (testing capacity < demand)-- perhaps not a stigma to getting tested--ties in to perceived benefits and self efficacy to change behavior based on test result

Wrong

Limited supply

Impact on health care works, on workers

Misinformation, where people get information, who they trust for information

Lack of guidance for businesses to continue service

Clear tie to elements of HBM model:

Perceived susceptibility

Perceived severity

Perceived benefits of an action

1. How HBM & SDOH (social determinants) integrative or in conflict (critique/expand strategies in slide)

1. Not wearing masks not just about not thinking that you are susceptible or the severity to which you will become sick if you do contract covid.

2. Another level of the calculus is going to be the perceived benefits and barriers to wearing a mask. For example, some may not think twice about wearing a mask whereas others have to consider the fact that they may be perceived as a greater threat to others (tie to speaker a few weeks ago who noted this for POC).

3. Perceived severity and perceived susceptibility

1. In rural areas

1. Less people around, perception of low susceptibility as a result and may not wear masks or get in the habit of wearing them in public place.

2. However, severity could theoretically be higher because resources and capacity in rural health settings are much more limited. But is this being communicated and understood in these communities? How are these two things at odds?

2. In more affluent areas

1. Individuals with health insurance may believe the consequences of covid are not as great in comparison to individuals who may not have the best health coverage, who are confident in their health care access and overall “health”

1. How to guide next steps, including PPE & vaccines?

1. In times like these the clarity of messaging is paramount. Unfortunately, institutions like the CDC have not done a great job at leading or being clear in this moment. The CDC has had conflicting messages or walking back guidance that they have just given. It ruins their credibility and makes people less willing to trust any experts.

2. Comorbidities - those with conditions that put them at higher risk are aware of this, but has this undercut the messaging to those who don’t have these conditions but could still suffer from COVID. Strengthen messaging regarding impact for everyone, not just a few.

3. Shaming culture. Need to build trust and improve communication - people often lie about their activities to each other for fear of judgment, which can make the whole situation worse because we don’t know what we need to make correct assessments before choosing activities

1. Instead of punishment and shaming, we should encourage dialogue on how to prioritize safety and create guidelines

4. Scaling up already existing mutual aid and community support networks so that these social support systems can support peoples preventative efforts, rather than just directing them

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1. The Portugal case focuses on national drug policy - at a macro level in the ecological model. How is national drug policy manifested in specific experiences or resources at the neighborhood level, and how do these broader factors relate to how we would think about addiction informed by the TTM?

1. Given big differences in U.S. and Portugal contexts, what could be learned from/applied here? What would it take for us to get there given who we are?

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What has gone right and wrong with PPE and distancing, per HBM

How HBM & SDOH (social determinants) integrative or in conflict (critique/expand strategies in slide)

How to guide next steps, including PPE & vaccines?

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