APA Health CARE: A Student-Led Initiative Addressing Health Care Barriers Faced by the Asian and Pacific Islander American Immigrant Population in Los Angeles.

Asian and Pacific Islander Americans face cultural, linguistic, and financial barriers to accessing health care. APA Health CARE (APAHC), a UCLA student-led organization, attempts to bridge these disparities through free community health screenings, health education seminars, and follow-up procedures. From 2011 to 2018, participants' demographic and health-related information were recorded during health fairs and follow-up phone calls. Trends in participant characteristics were analyzed over time. Health fair data were compared to data from follow-up phone calls to assess the effectiveness of health fair education and referral practices. 5635 participants from 69 health fairs were screened over the 8-year period. Follow-up contact was attempted for 2258 participants, of which 555 responded. Over time, a greater proportion of participants reported higher income, health insurance, and access to a regular doctor. Of those contacted at follow-up, 32.3% reported visiting a doctor, 50.2% reported making lifestyle changes, and 68.0% of those who were uninsured at health fairs reported obtaining health insurance within 1 month of attendance. Despite an observed increase in the proportion of participants having insurance and a regular doctor, health fair attendance remained consistent, possibly due to Asian American immigrants' preference for services that are convenient and linguistically and culturally accessible. Attendees reported visiting a physician, making lifestyle changes, and obtaining health insurance based on health fair referrals, suggesting measurable success with referral uptake and follow through. Student-led initiatives similar to APAHC can serve as catalysts to increase health literacy and motivate communities to seek health insurance and care.

Parents' views on engaging families of middle school students in obesity prevention and control in a multiethnic population.

INTRODUCTION: Overweight and obesity remain significant public health risks for youth in the United States, particularly among racial/ethnic minority groups. Efforts at obesity prevention and control have targeted youth and family members in diverse settings. Although involving parents in obesity prevention programs for youth may improve the potential of these programs, less is known about parents' preferred methods of engagement, especially among racial/ethnic minority parents and parents whose primary language is not English. In this qualitative study, parents of middle-school-aged children were asked how best to engage their children in obesity prevention and control efforts. METHODS: We recruited 38 parents whose children attended Los Angeles middle schools to participate in focus groups. Two English-language focus groups with 14 parents of different racial/ethnic backgrounds and 2 Spanish language groups with 24 Latino parents were conducted from 2010 through 2011. We analyzed focus group transcripts by using content analysis using inductive and deductive techniques. RESULTS: Findings from focus groups confirmed that parents want to help their children avoid obesity but feel constrained in their ability to take action. Participants identified an overarching desire to become better parents as a potential incentive to engage in obesity prevention efforts. Parents advocated for family-focused approaches in obesity prevention programs, including family sports leagues and cooking classes. Most findings were consistent between language groups, but parents in the Spanish language groups cited language-related barriers. CONCLUSION: The development and testing of simple programs that are sustainable, community-based, and family-focused may empower families to address obesity prevention and control.

Get up, stand up, stand up for your health! Faculty and student perspectives on addressing prolonged sitting in university settings.

Objective: To assess awareness about prolonged sitting and acceptance of interventions to reduce bouts of prolonged sitting. Participants: Undergraduate, graduate, and professional students and faculty from a large public university. Methods: Eight focus groups were conducted with 4 groups of undergraduate students and 4 groups of graduate/professional students. Eight key informant interviews were conducted with faculty. Content analyses were performed using inductive and deductive techniques to elicit common themes. Results: Many students and faculty were not aware of the detrimental effects associated with prolonged sitting. Barriers to movement in university settings included social acceptability, environmental constraints, and academic requirements. Acceptable interventions included: faculty prompts, changes to pedagogy, educational campaigns, and structural changes to classroom designs. Conclusions: University settings represent an opportunity to address issues related to prolonged sitting that may address immediate health implications, as well as establish behaviors and practices that can be continued in work-based settings.

Parents' disclosure of their HIV infection to their children in the context of the family.

We interviewed 33 HIV-infected parents from the HIV Cost and Services Utilization Study (HCSUS), 27 of their minor children, 19 adult children, and 15 caregivers about the process of children learning that their parents were HIV positive. We summarize the retrospective descriptions of parents' disclosure of their HIV status to their children, from the perspective of multiple family members. We analyzed transcripts of these interviews with systematic qualitative methods. Both parents and children reported unplanned disclosure experiences with positive and negative outcomes. Parents sometimes reported that disclosure was not as negative as they feared. However, within-household analysis showed disagreement between parents and children from the same household regarding disclosure outcomes. These findings suggest that disclosure should be addressed within a family context to facilitate communication and children's coping. Parents should consider negative and positive outcomes, unplanned disclosure and children's capacity to adapt after disclosure when deciding whether to disclose.

Brief report: a qualitative analysis of discussions about HIV in families of parents with HIV.

OBJECTIVE: To explore communication about HIV prevention, risk behaviors, and transmission in families affected by HIV. METHODS: Semi-structured interviews were conducted with 33 parents with HIV, 27 children (9- to 17-years old), and 19 adult children (>or=18-years old) across the U.S. Coders reviewed transcripts, identified themes, and coded transcripts. RESULTS: Youth felt uncomfortable discussing HIV with their parent who has HIV because they worried about upsetting and reminding the parent of his/her illness. Adult children reported learning about HIV prevention by watching how the illness affected their parents. Few siblings reported talking with one another about HIV because they worried about upsetting their brother/sister and about their sibling unintentionally disclosing the parent's illness to others. CONCLUSIONS: Discussions between youth and their parent with HIV and their siblings vary, highlighting the need for further research in this area.

Evaluation of the dissemination of SNaX, a middle school-based obesity prevention intervention, within a large US school district.

Few evidence-based school obesity-prevention programs are disseminated. We used community-based participatory research principles to disseminate an evidence-based middle-school obesity-prevention program, Students for Nutrition and eXercise (SNaX), to a large, primarily Latino, school district. In the 2014-2015 school year, we trained a district "champion" to provide training and technical assistance to schools and supplied print- and web-based materials (www.snaxinschools.org). In one district region, 18 of 26 schools agreed to participate. We evaluated the dissemination process using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. All 18 schools implemented at least one SNaX component. Of 6,410 students who attended an informational session, 1,046 registered and 472 were selected to be Student Advocates, of whom 397 attended at least one meeting. Of 60 activities observed across schools, 77% were conducted with fidelity, but local resource constraints limited most activities to a relatively small number of Student Advocates (vs. the entire student body). Qualitative data from 46 school staff and 187 students indicated positive attitudes about the program. Teachers suggested that SNaX be implemented as part of the curriculum. In the 2015-2016 school year, 6 of the original schools continued to implement SNaX, and the champion trained 94 teachers from 57 schools districtwide. Cafeteria servings overall and fruit and vegetable servings, the primary outcomes, did not increase in SNaX schools versus matched-comparison schools. Our mixed-methods evaluation of SNaX showed acceptability and fidelity, but not effectiveness. Effectiveness may be improved by providing technical assistance to community stakeholders on how to tailor core intervention components while maintaining fidelity.

Home Sweet Home: Parent and Home Environmental Factors in Adolescent Consumption of Sugar-Sweetened Beverages.

OBJECTIVE: Sugar-sweetened beverages (SSBs) are key contributors to obesity among youth. We investigated associations among parental and home-related factors (parental attitudes and consumption; home availability) regarding 3 types of SSBs-soda, sports drinks, and fruit-flavored drinks-with consumption of each type of SSB in a general school-based sample of adolescents. METHODS: Data were collected across 3 school semesters, from 2009 to 2011. A total of 1313 seventh grade student-parent dyads participated. Students completed in-class surveys across 9 schools in a large Los Angeles school district; their parents completed telephone interviews. Youth were asked about their SSB consumption (soda, sports drinks, and fruit-flavored drinks), and parents were asked about their attitudes, consumption, and home availability of SSBs. RESULTS: We estimated expected rates of youth SSB consumption for hypothetical parents at very low (5th) and very high (95th) percentiles for home/parental risk factors (ie, they consumed little, had negative attitudes, and did not keep SSBs in the home; or they consumed a lot, had positive attitudes, and did keep SSBs in the home). Youth of lower-risk parents (at the 5th percentile) were estimated to drink substantially less of each type of beverage than did youth of higher-risk parents (at the 95th percentile). For example, youth with higher-risk parents averaged nearly double the SSB consumption of youth of lower-risk parents (2.77 vs 1.37 glasses on the previous day; overall model significance F22,1312 = 3.91, P < .001). CONCLUSIONS: Results suggest a need to focus on parental and home environmental factors when intervening to reduce youths' SSB consumption.

Do children know their parent's HIV status? Parental reports of child awareness in a nationally representative sample.

OBJECTIVE: To determine the rates and predictors of child awareness of parental human immunodeficiency virus (HIV) status and the effect of that knowledge on children. METHODS: Interviews were conducted with 274 parents from a nationally representative sample of HIV-infected adults receiving health care for HIV. The outcome measures were parental report of child's awareness of parental HIV status, how others reacted to child's parent having HIV, and reasons for nondisclosure. RESULTS: HIV-infected parents reported that 44% of their children (5-17 years old) were aware of their parent's HIV status, and parents had discussed with 90% of those children the possibility that HIV or acquired immunodeficiency syndrome (AIDS) might lead to their parent's death. Multivariate analyses revealed that parents with higher income, with an HIV risk group of heterosexual intercourse, with higher CD4 counts, with greater social isolation, and with younger children were less likely than others to report that their child knew the parent was HIV positive. Parents reported that 11% of children worried they could catch HIV from their parent. Reasons children did not know their parent's HIV status included that the parent was worried about the emotional consequences of disclosure (67%), was worried the child would tell other people (36%), and did not know how to tell their child (28%). CONCLUSIONS: HIV-infected parents often worry about the emotional consequences of disclosure to their children and that their children may tell others. More than a quarter of parents reported not knowing how to tell their children. Clinicians may be able to support and guide HIV-infected parents in deciding whether, when, and how to disclose their infection to their children.

Two-Year BMI Outcomes From a School-Based Intervention for Nutrition and Exercise: A Randomized Trial.

OBJECTIVES: This study examined the long-term effects on BMI of a randomized controlled trial of Students for Nutrition and Exercise, a 5-week, middle school-based obesity prevention intervention combining school-wide environmental changes, encouragement to eat healthy school cafeteria foods, and peer-led education and marketing. METHODS: We randomly selected schools from the Los Angeles Unified School District and assigned 5 to the intervention group and 5 to a wait-list control group. Of the 4022 seventh-graders across schools, a total of 1368 students had their height and weight assessed at baseline and 2 years' postintervention. RESULTS: A multivariable linear regression was used to predict BMI percentile at ninth grade by using BMI percentile at seventh grade, school indicators, and sociodemographic characteristics (child gender, age, Latino race/ethnicity, US-born status, and National School Lunch Program eligibility [as a proxy for low-income status]). Although the Students for Nutrition and Exercise intervention did not exhibit significant effects on BMI percentile overall, intervention students who were classified as obese at baseline (in seventh grade) showed significant reductions in BMI percentile in ninth grade (b = -2.33 percentiles; SE, 0.83; P = .005) compared with control students. This outcome translated into ∼9 pounds (∼4.1 kg) lower expected body weight after 2 years for an obese student in the intervention school at the mean height and age of the sample at baseline. CONCLUSIONS: Multilevel school-based interventions can have long-term effects on BMI among students who are obese. Future research should examine the mechanisms by which school-based obesity interventions can affect BMI over time.

Cost and Cost-Effectiveness of Students for Nutrition and eXercise (SNaX).

OBJECTIVE: To examine the cost and cost-effectiveness of implementing Students for Nutrition and eXercise (SNaX), a 5-week middle school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education. METHODS: Five intervention and 5 control middle schools (mean enrollment, 1520 students) from the Los Angeles Unified School District participated in a randomized controlled trial of SNaX. Acquisition costs for materials and time and wage data for employees involved in implementing the program were used to estimate fixed and variable costs. Cost-effectiveness was determined using the ratio of variable costs to program efficacy outcomes. RESULTS: The costs of implementing the program over 5 weeks were $5433.26 per school in fixed costs and $2.11 per student in variable costs, equaling a total cost of $8637.17 per school, or $0.23 per student per day. This investment yielded significant increases in the proportion of students served fruit and lunch and a significant decrease in the proportion of students buying snacks. The cost-effectiveness of the program, per student over 5 weeks, was $1.20 per additional fruit served during meals, $8.43 per additional full-priced lunch served, $2.11 per additional reduced-price/free lunch served, and $1.69 per reduction in snacks sold. CONCLUSIONS: SNaX demonstrated the feasibility and cost-effectiveness of a middle school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education. Its cost is modest and unlikely to be a significant barrier to adoption for many schools considering its implementation.

A randomized controlled trial of students for nutrition and eXercise: a community-based participatory research study.

PURPOSE: To conduct a randomized controlled trial of Students for Nutrition and eXercise, a 5-week middle school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education. METHODS: We randomly selected schools (five intervention, five waitlist control) from the Los Angeles Unified School District. School records were obtained for number of fruits and vegetables served, students served lunch, and snacks sold per attending student, representing an average of 1,515 students (SD = 323) per intervention school and 1,524 students (SD = 266) per control school. A total of 2,997 seventh-graders (75% of seventh-graders across schools) completed pre- and postintervention surveys assessing psychosocial variables. Consistent with community-based participatory research principles, the school district was an equal partner, and a community advisory board provided critical input. RESULTS: Relative to control schools, intervention schools showed significant increases in the proportion of students served fruit and lunch and a significant decrease in the proportion of students buying snacks at school. Specifically, the intervention was associated with relative increases of 15.3% more fruits served (p = .006), 10.4% more lunches served (p < .001), and 11.9% fewer snacks sold (p < .001) than would have been expected in its absence. Pre-to-post intervention, intervention school students reported more positive attitudes about cafeteria food (p = .02) and tap water (p = .03), greater obesity-prevention knowledge (p = .006), increased intentions to drink water from the tap (p = .04) or a refillable bottle (p = .02), and greater tap water consumption (p = .04) compared with control school students. CONCLUSIONS: Multilevel school-based interventions may promote healthy adolescent dietary behaviors.

Parental and home environmental facilitators of sugar-sweetened beverage consumption among overweight and obese Latino youth.

OBJECTIVE: To explore parental and home environmental facilitators of sugar-sweetened beverage (SSB) and water consumption among obese/overweight Latino youth. METHODS: Semistructured interviews were conducted with 55 overweight/obese Latino youth aged 10 to 18 and 55 parents, recruited from school-based clinics and a school in one West Coast district. All youth consumed SSBs regularly and lived in a home where SSBs were available. We used qualitative methods to examine key themes around beliefs about SSBs and water, facilitators of SSB and water consumption, and barriers to reducing SSB consumption. RESULTS: A few parents and youth believed that sports drinks are healthy. Although nearly all thought that water is healthy, most parents and about half of youth thought that tap water is unsafe. About half of parent-child dyads had discordant beliefs regarding their perceptions of tap water. About half of parents believed that homemade culturally relevant drinks (eg, aguas frescas), which typically contain sugar, fruit, and water, were healthy because of their "natural" ingredients. Participants cited home availability as a key factor in SSB consumption. About half of parents set no rules about SSB consumption at home. Among those with rules, most parent-child pairs differed on their beliefs about the content of the rules, and youth reported few consequences for breaking rules. CONCLUSIONS: Obesity programs for Latino youth should address misconceptions around water and should discuss culturally relevant drinks and sports drinks as potential sources of weight gain. Health care providers can help parents set appropriate rules by educating about the risks of keeping SSBs at home.

Employment, family leave, and parents of newborns or seriously ill children.

OBJECTIVES: Parents of newborns and children with special health care needs (CSHCN) often experience conflict between employment and family responsibilities. Family leave benefits such as the federal Family and Medical Leave Act and California's Paid Family Leave Insurance program help employed parents miss work to bond with a newborn or care for an ill child. The use of these benefits, however, is rare among mothers of CSHCN and fathers in general and limited even among mothers of newborns. We explored barriers to and experiences with leave-taking among parents of newborns and CSHCN. METHODS: We conducted semistructured qualitative interviews in 2008 with 10 mothers and 10 fathers of newborns and 10 mothers and 10 fathers of CSHCN in Los Angeles to explore their need for and experiences with family leave. Qualitative analytical techniques were used to identify themes in the transcripts. RESULTS: All parents reported difficulties in accessing and using benefits, including lack of knowledge by employers, complexity of rules and processes, and inadequacy of the benefits themselves. Parents of CSHCN also described being too overwhelmed to rapidly seek and process information in the setting of urgent and often unexpected health crises. Most parents expressed a clear desire for expert guidance and saw hospitals and clinics as potentially important providers. CONCLUSIONS: Even when parents are aware of family leave options, substantial barriers prevent many, especially parents of CSHCN, from learning about or applying for benefits. Clinics and hospitals might be opportune settings to reach vulnerable parents at times of need.

Low-income parents' views on the redesign of well-child care.

OBJECTIVE: To examine the perspectives of low-income parents on redesigning well-child care (WCC) for children aged 0 to 3 years, focusing on possible changes in 3 major domains: providers, locations, and formats. METHODS: Eight focus groups (4 English and 4 Spanish) were conducted with 56 parents of children aged 6 months to 5 years, recruited through a federally qualified health center. Discussions were recorded, transcribed, and analyzed by using the constant comparative method of qualitative analysis. RESULTS: Parents were mostly mothers (91%), nonwhite (64% Latino, 16% black), and <30 years of age (66%) and had an annual household income of <$35000 (96%). Parents reported substantial problems with WCC, focusing largely on limited provider access (especially with respect to scheduling and transportation) and inadequate behavioral/developmental services. Most parents endorsed nonphysician providers and alternative locations and formats as desirable adjuncts to usual physician-provided, clinic-based WCC. Nonphysician providers were viewed as potentially more expert in behavioral/developmental issues than physicians and more attentive to parent-provider relationships. Some alternative locations for care (especially home and day care visits) were viewed as creating essential context for providers and dramatically improving family convenience. Alternative locations whose sole advantage was convenience (eg, retail-based clinics), however, were viewed more skeptically. Among alternative formats, group visits in particular were seen as empowering, turning parents into informal providers through mutual sharing of behavioral/developmental advice and experiences. CONCLUSIONS: Low-income parents of young children identified major inadequacies in their WCC experiences. To address these problems, they endorsed a number of innovative reforms that merit additional investigation for feasibility and effectiveness.

HIV-related stigma among people with HIV and their families: a qualitative analysis.

We examined the interconnectedness of stigma experiences in families living with HIV, from the perspective of multiple family members. Semi-structured interviews were conducted with 33 families (33 parents with HIV, 27 children under age 18, 19 adult children, and 15 caregivers). Parents were drawn from the HIV Cost and Services Utilization Study, a representative sample of people in care for HIV in US. All of the families recounted experiences with stigma, including 100% of mothers, 88% of fathers, 52% of children, 79% of adult children, and 60% of caregivers. About 97% of families described discrimination fears, 79% of families experienced actual discrimination, and 10% of uninfected family members experienced stigma from association with the parent with HIV. Interpersonal discrimination seemed to stem from fears of contagion. Findings indicate a need for interventions to reduce HIV stigma in the general public and to help families cope with stigma.

Fears about HIV transmission in families with an HIV-infected parent: a qualitative analysis.

OBJECTIVE: Children of HIV-infected parents may be affected by their parents' disease even if not infected themselves. Because of advances in HIV treatment that have reduced the risk for vertical HIV transmission from mother to child, more HIV-infected adults are having children. Few studies have examined whether families with an HIV-infected parent experience fears about transmission to children and how they address such fears. In this article, we describe transmission-related fears in families with an HIV-infected parent. METHODS: We used semistructured qualitative interviews, conducted in person from March 2004 to March 2005, with 33 HIV-infected parents, 27 minor children who were 9 to 17 years of age, 19 adult children, and 15 caregivers (adult family members or friends who helped care for the children and/or parents) to investigate their fears about HIV transmission. The parents are a subset from the HIV Cost and Services Utilization Study, a study of people in care for HIV throughout the United States. We analyzed the interview transcripts for themes related to transmission fears. RESULTS: In many of the families, participants identified >or=1 HIV transmission-related fear. Themes included specific fears related to blood contact, bathroom items, kissing/hugging, and food. Families addressed their fears by educating children about modes of HIV transmission and establishing rules or taking precautions to reduce the risk for HIV transmission in the household. HIV-infected parents were also concerned about catching opportunistic infections from a sick child. CONCLUSIONS: Many of the fears experienced by HIV-infected parents and their children were based on misconceptions about modes of HIV transmission. Pediatricians and others who treat these children may be able to offer counseling to allay fears that family members have about household transmission of HIV.

Children of HIV-infected parents: custody status in a nationally representative sample.

OBJECTIVE: The purpose of this work was to determine the rates and predictors of custody status for children of HIV-infected parents. PARTICIPANTS AND METHODS: Data came from interviews of 538 parents with 1017 children (0-17 years old) from a nationally representative sample of HIV-infected adults receiving health care in the United States. Outcomes were collected at 2 survey waves and included child custody status and who, other than the HIV-infected parent, had custody of the child. Child custody status was categorized as (1) in custody of HIV-infected parent at both survey waves, (2) infected parent had custody at first survey wave but not second survey wave, (3) not in custody of infected parent at either survey wave, and (4) infected parent gained custody between survey waves. Potential custodians included (1) other biological parent, (2) state, foster, or adoptive parent, (3) grandparent, and (4) relative, friend, nonbiological parent, or other. Multinomial logistic regression modeled both outcomes. RESULTS: Forty-seven percent of the children were in the custody of their HIV-infected parent at both survey waves, 4% were in the parent's custody at the first but not second survey wave, 42% were not in custody at either survey wave, and the parent of 7% gained custody between survey waves. Parents cited drug use (62%) and financial hardship (27%) as reasons for losing custody. Children of HIV-infected fathers, older parents, parents living without other adults, parents with low CD4 counts, drug-using parents, and parents with > or = 1 hospital stay were less likely to be in their parent's custody at either survey wave. CONCLUSIONS: More than half of the children were not in custody of their HIV-infected parent at some time during the study period. Pediatricians and others taking care of children with HIV-infected parents may be able to offer counseling or referrals to assist parents with child custody issues.

Guardianship planning among HIV-infected parents in the United States: results from a nationally representative sample.

OBJECTIVE: The purpose of this work was to determine the rates and predictors of guardianship planning and preferred guardians among HIV-infected parents. PARTICIPANTS AND METHODS: Data were analyzed from interviews with 222 unmarried parents (who had 391 children) from a nationally representative sample of HIV-infected adults receiving health care. Outcome measures included parental report on the level of guardianship planning and on who their preferred guardian for each child was. Level of guardianship planning was categorized as follows: (1) parent had not identified a guardian; (2) parent had identified a guardian, but the guardian had not agreed; (3) identified guardian had agreed; and (4) legal documentation of guardianship plan was complete. We conducted bivariate and ordered logistic regression analyses on the level of guardianship planning and multinomial logistic regression on identification of preferred guardians. RESULTS: Twelve percent of unmarried HIV-infected parents had not identified a guardian; 6% had identified a guardian but gone no further; 53% said the identified guardian had agreed; and 28% had prepared legal documentation. The preferred guardians included other biological parents (17%), spouse/partners who were not biological parents (2%), grandparents (36%), other relatives (34%), friends (7%), unrelated adoptions (1%), and others (3%). Parents with the lowest CD4 counts and parents living without other adults were more likely to have completed the guardianship planning process. Nonrelatives were most often preferred by mothers and parents with higher CD4 counts; grandparents were most often preferred by younger parents and parents who prefer speaking Spanish. CONCLUSIONS: Pediatricians and others who take care of children with HIV-infected parents may be able to provide counseling and referrals for guardianship planning.