Partnering With Community Health Workers to Address COVID-19 Health Inequities: Experiences of the California Alliance Against COVID-19.

With funding from the National Institutes of Health's Community Engagement Alliance, starting in fall 2020, 11 academic medical centers and 75 community partners came together as the California Alliance Against COVID-19 to address COVID-19 inequities in California. Using data from focus groups, statewide meetings, and a statewide partner survey, we describe how promotoras and community health workers (P/CHWs; n = 540) helped to promote access to COVID-19 information, testing, and vaccination. We highlight opportunities to promote health equity among other public health collaborators with a P/CHW model. (Am J Public Health. 2024;114(S1):S45-S49. https://doi.org/10.2105/AJPH.2023.307471).

"Ancestral recipes": a mixed-methods analysis of MyPlate-based recipe dissemination for Latinos in rural communities.

BACKGROUND: The Latinx population experiences some of the highest rates of chronic disease, including obesity and type II diabetes. Such conditions may be especially burdensome in rural Latinx communities that often face barriers to accessing disease prevention resources and public health programs. METHODS: Diverse stakeholders (i.e., patients, community members, system of healthcare clinics, community food bank) tailored an existing cookbook, based on the U.S. Department of Agriculture MyPlate healthy eating and dietary guidelines, for local ingredients, health literacy, and language for rural Latinx and Indigenous Latin Americans. The cookbook recipes were disseminated widely via virtual cooking demonstrations, food distribution events, and social media. Pre- and posttest surveys were used to assess changes in diabetes knowledge measured by the 24-item American Diabetes Association Diabetic Knowledge Questionnaire and confidence in dietary behavior change over time measured by 4 questions of the 17-item Mediterranean Diet Index. A mixed effects, repeated measures analysis was conducted with gender ID, age range and educational attainment included as covariates and assessment interval as the predictor (pretest vs posttest) and change in confidence about adhering to four specific components of the Mediterranean diet. Focus groups elicited information on participants' motivation and ability to use the recipes and eat healthy foods following the virtual cooking demonstration participation. RESULTS: A total of 20 virtual cooking demonstrations were conducted and 60 participants completed a pretest survey and 54 a posttest survey, a subsample (n = 19) participated in one of three focus groups. Most participants were female, identified as Latinx/Hispanic, were between the ages of 40-49, and spoke Spanish. 17% identified as Indigenous Latin American specifically as Purépecha, an indigenous group from Michoacán, Mexico. Survey and focus group findings indicated at posttest an increase in diabetes knowledge among participants with no prior diagnosis of chronic health conditions and more confidence in limiting sugary beverages and refined wheat pasta/white rice among indigenous participants. Focus group discussions explicated the quantitative findings. CONCLUSION: This study brought together patients and key stakeholders committed to addressing the social determinants of health and it mobilized the community to develop culturally vetted health education materials. The findings indicate the need for increased access to evidence-based nutrition education and to culturally appropriate food products that can be easily incorporated into daily food preparation.

Continuum of Trauma: Fear and Mistrust of Institutions in Communities of Color During the COVID-19 Pandemic.

Historical, cultural, and social trauma, along with social determinants of health (SDOH), shape health outcomes, attitudes toward medicine, government, and health behaviors among communities of color in the United States (U.S.). This study explores how trauma and fear influence COVID-19 testing and vaccination among Black/African American, Latinx/Indigenous Latin American, and Native American/Indigenous communities. Leveraging community-based participatory research methods, we conducted 11 virtual focus groups from January to March of 2021 with Black/African American (n = 4), Latinx/Indigenous Latin American (n = 4), and Native American/Indigenous (n = 3) identifying community members in Inland Southern California. Our team employed rapid analytic approaches (e.g., template and matrix analysis) to summarize data and identify themes across focus groups and used theories of intersectionality and trauma to meaningfully interpret study findings. Historical, cultural, and social trauma induce fear and mistrust in public health and medical institutions influencing COVID-19 testing and vaccination decisions in communities of color in Inland Southern California. This work showcases the need for culturally and structurally sensitive community-based health interventions that attend to the historical, cultural, and social traumas unique to racial/ethnic minority populations in the U.S. that underlie fear and mistrust of medical, scientific, and governmental institutions.

The Role of Anti-Racist Community-Partnered Praxis in Implementing Restorative Circles Within Marginalized Communities in Southern California During the COVID-19 Pandemic.

The COVID-19 pandemic has exacerbated the adverse influence of structural racism and discrimination experienced by historically marginalized communities (e.g., Black, Latino/a/x, Indigenous, and transgender people). Structural racism contributes to trauma-induced health behaviors, increasing exposure to COVID-19 and restricting access to testing and vaccination. This intersection of multiple disadvantages has a negative impact on the mental health of these communities, and interventions addressing collective healing are needed in general and in the context of the COVID-19 pandemic. The Share, Trust, Organize, and Partner COVID-19 California Alliance (STOP COVID-19 CA), a statewide collaborative of 11 universities and 75 community partners, includes several workgroups to address gaps in COVID-19 information, vaccine trial participation, and access. One of these workgroups, the Vaccine Hesitancy Workgroup, adopted an anti-racist community-partnered praxis to implement restorative circles in historically marginalized communities to facilitate collective healing due to structural racism and the COVID-19 pandemic. The project resulted in the development of a multilevel pre-intervention restorative process to build or strengthen community-institutional partnerships when procurement of funds has been sought prior to community partnership. This article discusses this workgroup's role in advancing health justice by providing a community-based mental health intervention to marginalized communities in Southern California while using an antiracist praxis tool to develop a successful community-institutional partnership and to live up to the vision of community-based participatory research.

Perceptions of the Coronavirus and COVID-19 testing and vaccination in Latinx and Indigenous Mexican immigrant communities in the Eastern Coachella Valley.

BACKGROUND: A novel coronavirus, SARS-CoV-2 (known as COVID-19), spread rapidly around the world, affecting all and creating an ongoing global pandemic. Across the United States, Latinx and Indigenous populations have been disproportionately affected by COVID-19 cases and death rates. An examination of the perceptions and beliefs about the spread of the virus, COVID-19 testing, and vaccination amongst racial-ethnic minority groups, specifically Latinx and Indigenous Latin American immigrant communities, is needed to alleviate the widespread disparity in new cases and deaths. METHODS: This study was carried out from August 2020 to January 2021 and used community-based participatory research to engage community partners and build the capacity of community health workers (i.e., promotores de salud) and pre-medical and medical students in conducting qualitative research. The objective of the study was to examine the structural and social determinants of health on perceptions of the coronavirus, its spread, and decisions around COVID-19 testing and vaccination. Data collection included ethnography involving observations in public settings and focus groups with members of Latinx and Indigenous Mexican farm-working communities in the Eastern Coachella Valley, located in the Inland Southern California desert region. A total of seven focus groups, six in Spanish and one in Purépecha, with a total of 55 participants were conducted. Topics covered include perceptions of the coronavirus and its spread, as well as COVID-19 testing and vaccination. RESULTS: Using theme identification techniques, the findings identify structural and social factors that underly perceptions held by Latinx and Indigenous Mexican immigrants about the virus and COVID-19, which, in turn, shape attitudes and behaviors related to COVID-19 testing and vaccination. Common themes that emerged across focus groups include misinformation, lack of trust in institutions, and insecurity around employment and residency. CONCLUSIONS: This immigrant population is structurally vulnerable to historical and present-day inequalities that put them at increased risk of COVID-19 exposure, morbidity, and mortality. Study findings indicate a significant need for interventions that decrease structural vulnerabilities by addressing issues of (dis)trust in government and public health among this population.

Grow well/Crecer bien: a protocol for research on infant feeding practices in low-income families.

BACKGROUND: The prevalence of obesity among children remains high. Given obesity's significant lifelong consequences, there is great interest in preventing obesity early in life. There is a need to better understand the relation of common infant feeding styles and practices to obesity in infants using longitudinal study designs. There is also an urgent need to understand the role of caregivers other than mothers in feeding. A better understanding of variation in feeding styles and practices can inform the identification of risk groups and the tailoring of interventions to them. METHODS: In partnership with Early Head Start programs across four counties in southern California, mothers and infants will be enrolled in a two-year longitudinal study collecting survey and anthropometric data. A subsample of mothers and their selected other caregivers will participate in qualitative research involving feeding diaries and dyadic interviews. The results will be used to develop and test an enhanced nutrition education program. DISCUSSION: We outline a study methodology to examine feeding styles and practices and their association with early childhood obesity risk and enhance an existing intervention to promote healthy infant feeding and growth among children in low-income families.

Veteran-centered barriers to VA mental healthcare services use.

BACKGROUND: Some veterans face multiple barriers to VA mental healthcare service use. However, there is limited understanding of how veterans' experiences and meaning systems shape their perceptions of barriers to VA mental health service use. In 2015, a participatory, mixed-methods project was initiated to elicit veteran-centered barriers to using mental healthcare services among a diverse sample of US rural and urban veterans. We sought to identify veteran-centric barriers to mental healthcare to increase initial engagement and continuation with VA mental healthcare services. METHODS: Cultural Domain Analysis, incorporated in a mixed methods approach, generated a cognitive map of veterans' barriers to care. The method involved: 1) free lists of barriers categorized through participant pile sorting; 2) multi-dimensional scaling and cluster analysis for item clusters in spatial dimensions; and 3) participant review, explanation, and interpretation for dimensions of the cultural domain. Item relations were synthesized within and across domain dimensions to contextualize mental health help-seeking behavior. RESULTS: Participants determined five dimensions of barriers to VA mental healthcare services: concern about what others think; financial, personal, and physical obstacles; confidence in the VA healthcare system; navigating VA benefits and healthcare services; and privacy, security, and abuse of services. CONCLUSIONS: These findings demonstrate the value of participatory methods in eliciting meaningful cultural insight into barriers of mental health utilization informed by military veteran culture. They also reinforce the importance of collaborations between the VA and Department of Defense to address the role of military institutional norms and stigmatizing attitudes in veterans' mental health-seeking behaviors.

The Morality of Disordered Eating and Recovery in Southern Italy.

Scholars have traced the processes through which moral subjectivities are constituted in culturally meaningful ways through eating disorders and recovery practices, demonstrating how subjective meanings of eating disorders and recovery from them are imbued with moral undertones and become meaningful ways of existing within specific historical and cultural contexts. Drawing on ethnographic insights and interviews with young women with disordered eating histories in southern Italy, we show how suffering from eating disorders and recovery from them enables women to retool their identities and craft moral selves. We draw attention to the value of medical anthropology in the care and comprehension of well-being of girls and women suffering from disordered eating.

Effects of social and spatial contexts on young latinas' methamphetamine use initiation.

In this article, we examine methamphetamine (meth) use initiation as influenced by Latinas' social positions within institutions (e.g., family and economy). We conducted ethnographic fieldwork in five women's residential substance use treatment facilities in Los Angeles County with women who considered meth to be their primary drug of choice. Using an urban ethnographic framing, we demonstrate the effects of low-income young Latinas' spatial- and social-context rendered vulnerability to abuse and neglect, and the resulting emotional distress, on meth use initiation. When considering pathways to substance use intervention for vulnerable Latina girls and women, clinicians, researchers, and policy makers need to understand substance use pathways as dynamic processes to cope with psychosocial stress while living in communities with easy access to illicit substances such as methamphetamine.

The Role of Social Capital in African Americans' Attempts to Reduce and Quit Cocaine Use.

BACKGROUND: Research examining substance users' recovery has focused on individual-level outcomes while paying limited attention to the contexts within which individuals are embedded, and the social processes involved in recovery. OBJECTIVES: This paper examines factors underlying African American cocaine users' decisions to reduce or quit cocaine use and uses practice theory to understand how lifestyle changes and shifts in social networks facilitate access to the capital needed to change cocaine use patterns. METHODS: The study, an in-depth analysis of substance-use life history interviews carried out from 2010 to 2012, included 51 currently not-in-treatment African American cocaine users in the Arkansas Mississippi Delta region. A blended inductive and deductive approach to data analysis was used to examine the socio-cultural and economic processes shaping cocaine use and recovery. RESULTS: The majority of participants reported at least one lifetime attempt to reduce or quit cocaine use; motivations to reduce use or quit included desires to meet social role expectations, being tired of using, and incarceration. Abstinence-supporting networks, participation in conventional activities, and religious and spiritual practices afforded access to capital, facilitating cocaine use reduction and sobriety. CONCLUSIONS: Interventions designed to increase connection to and support from nondrug using family and friends with access to recovery capital (e.g., employment, faith community, and education) might be ideal methods to reduce substance use among minorities in low-income, resource-poor communities.

The Criminal Justice Experience of African American Cocaine Users in Arkansas.

BACKGROUND: African Americans are incarcerated at rates much higher than other racial and ethnic groups in the United States. OBJECTIVES: We sought to qualitatively explore the relationships between ongoing involvement in the criminal justice system and continued drug use in a population of urban and rural African American cocaine users in a southern state. METHODS: Semi-structured qualitative interviews were conducted among African American cocaine users in Arkansas between 2010 and 2012. Participants resided in both rural (two counties located in the eastern Arkansas Mississippi delta region) and urban (the county including the capital city of Little Rock) areas. RESULTS: Numerous important themes emerged from participants' narratives, including chronic involvement with the criminal justice system (being a "career criminal"), continued access to drugs while incarcerated, relapse, and reincarceration and lack of access to effective drug treatment. Conclusion/Importance: The themes which emerged from our data speak to the collective experience that many substance using populations in the United States face in dealing with the criminal justice system. Our findings highlight the need to better, more holistic ways of engaging African American substance users in community based substance use treatment and supportive services.

A culture of future planning: perceptions of sexual risk among educated young adults.

In this study we examined how social processes, specifically the acquisition of postsecondary education and capital, shaped perceptions of sexual risk and impacted sexual practices and sexual health among young adults. Using qualitative research methods we collected and analyzed data among students attending a 4-year university in the northeastern region of the United States over a 1-year period. By analyzing participants' narratives, we found that the reproduction of shared norms and values encouraged educated young adults to focus on educational and professional success, pressing many of them to be concerned about preventing pregnancy rather than preventing disease transmission, and increasing their risk for sexually transmitted infections, including HIV/AIDS. Sexual-health educators need to address how social processes shape sexual practices, encourage educated young adults to challenge unequal gender expectations, and consider how sexually transmitted infections might also interfere with life plans.

The Religious and Spiritual Dimensions of Cutting Down and Stopping Cocaine Use: A Qualitative Exploration Among African Americans in the South.

This study qualitatively examines the religious and spiritual dimensions of cutting down and stopping cocaine use among African Americans in rural and urban areas of Arkansas. The analyses compare and contrast the narrative data of 28 current cocaine users living in communities where the Black church plays a fundamental role in the social and cultural lives of many African Americans, highlighting the ways that participants used religious symbols, idiomatic expression, and Biblical scriptures to interpret and make sense of their substance-use experiences. Participants drew on diverse religious and spiritual beliefs and practices, including participation in organized religion, reliance on a personal relationship with God, and God's will to cut down and stop cocaine use. Our findings suggest that culturally sensitive interventions addressing the influence of religion and spirituality in substance use are needed to reduce cocaine use and promote recovery in this at-risk, minority population.

The role of borderline personality disorder and depression in the relationship between sexual assault and body mass index among women veterans.

This article examines lifetime sexual assault (LSA) and mental health history as risk factors associated with body mass index (BMI) in a population of women veterans. This cross-sectional study of a retrospective cohort of 948 Veterans Affairs (VA)-enrolled midwestern enlisted rank women veterans included computer-assisted telephone interviews. Findings show that 33.4% of the participants had a BMI of 30.0 or more meeting the criteria for obesity and 62.5% reported lifetime attempted or completed sexual assault. Greater BMI was positively associated with older age, less education, LSA, depression, and borderline personality disorder (BPD) and negatively associated with current substance use disorder in multivariate models. Mediation analysis found that the relationship between sexual assault and BMI was completely mediated by BPD and depression. Interventions should combine physical and mental health care in gender-specific services for overweight women veterans with trauma histories and mental health conditions.

The pew versus the couch: relationship between mental health and faith communities and lessons learned from a VA/clergy partnership project.

The history of the relationship between religion and mental health is one of commonality, conflict, controversy, and distrust. An awareness of this complex relationship is essential to clinicians and clergy seeking to holistically meet the needs of people in our clinics, our churches, and our communities. Understanding this relationship may be particularly important in rural communities. This paper briefly discusses the history of this relationship and important areas of disagreement and contention. The paper moves beyond theory to present some current practical tensions identified in a brief case study of VA/Clergy partnerships in rural Arkansas. The paper concludes with a framework of three models for understanding how most faith communities perceive mental health and suggests opportunities to overcome the tensions between "the pew" and "the couch."

Seeking care across the US-Mexico border: The experiences of Latinx and Indigenous Mexican caregivers of children with asthma or respiratory distress.

BACKGROUND: Many Latinx and Indigenous Mexican populations in the United States Southwest live in unincorporated communities in the US-Mexico borderlands called colonias. These environmental justice communities often lack basic infrastructure, including healthcare services, prompting many to seek services across the border. However, due to geopolitical factors more vulnerable caregivers are limited to utilize healthcare services in the US. This paper reports the experiences and healthcare decision-making of caregivers living in colonias in the US-Mexico border region who care for children with respiratory health conditions. METHODS: This study was carried out from September to December 2020. Focus groups and interviews were conducted with Latinx and Indigenous Mexican caregivers of children with asthma or respiratory distress. Qualitative interviews elicited caregivers' perspectives on the environmental factors affecting children's chronic health conditions and use of healthcare services. The analysis employed the concept of structure vulnerability to theorize geography as a structural determinant of health for caregivers faced with making healthcare decisions for their suffering from respiratory health conditions. A survey was administered to collect basic sociodemographic information. RESULTS: A total of 36 caregivers participated in the study. Structural factors including unincorporated community status and government inaction intersected with social determinants of health to prompt caregivers to cross the US-Mexico border to access healthcare services in Mexico for their children. Yet, more vulnerable caregivers (i.e., those without documentation status in the US) and their children, accessing healthcare services in the US was not an option limiting caregivers' ability to meet their children's healthcare needs. In such cases, geography acts as a structural determinant of health. CONCLUSION: This study shows the importance of geography in health. Rural unincorporated colonias located in the borderlands are precariously located and lack basic critical infrastructure including healthcare access. Within such places, historically and socially marginalized populations become invisible, are subject to the health effects of environmental hazards, and are limited depending on their positionality and thus vulnerability to healthcare services.

Creating Cultures of Health in the Academy: Bringing Together Top-Down and Ground-Up Approaches.

This article reports on a 3-year longitudinal study focused on the impact of cross-sector, collective impact approaches to creating cultures of campus health. The study sought to understand the integration of health and well-being concepts into university operations, including business practices and policies, as well as the contribution of public health initiatives focused on health-promoting universities to creating cultures of campus health for students, staff, and faculty. Research was carried out from spring 2018 to spring 2020 via focus group data collection and rapid qualitative analysis involving template and matrix analysis. A total of 18 focus groups were conducted across the 3-year study, six with students, eight with staff, and four with faculty. The initial cohort included 70 participants: 26 students, 31 staff, and 13 faculty. Qualitative analysis findings indicate a general pattern of change over time from a primary focus on well-being characterized by programs and services (e.g., fitness classes) to policy and structural-level interventions (e.g., stairwell beautification and hydration stations) promoting well-being for all. Grass-top and grassroots leadership and action were instrumental to changes in working and learning environments, policies, and campus environment/infrastructure. This work contributes to the growing literature on health-promoting universities and colleges and demonstrates the critical role of both top-down and ground-up approaches and leadership efforts to create more equitable and sustainable cultures of campus health and well-being.

Social determinants of health among noncitizen deported US veterans: A participatory action study.

This qualitative study examines the social determinants of health among noncitizen deported United States veterans. We utilized Photovoice, a participatory action research method used to inform structural level change, with 12 veterans. Audio-recorded semi-structured interviews explored photos and discussed deportation's effects on veteran health. We performed rapid template and matrix analysis of interview transcripts. Interviews were conducted in Tijuana, Mexico from December 2018 to January 2019. Study findings show that veterans prioritize returning to the United States to improve their quality of life. Analysis of photos and narrative text indicated that deportation caused social, economic, and political insecurities. Veterans struggled to maintain access to necessities post-deportation. Disrupted social networks compounded their situation, resulting in chronic stress and poor health outcomes. The findings from this study offer insight into the ways deportation acts as a social determinant of health. The findings suggest modifying veteran reintegration programs, as well as reforming criminal justice and immigration laws, such as creating more Veteran Treatment Courts and allowing immigration judges to consider military history during deportation proceedings involving noncitizen veterans.

Latinx and Indigenous Mexican Caregivers' Perspectives of the Salton Sea Environment on Children's Asthma, Respiratory Health, and Co-Presenting Health Conditions.

This research investigated Latinx and Indigenous Mexican caregivers' perspectives of the Salton Sea's environment (e.g., dust concentrations and other toxins) on child health conditions. The Salton Sea is a highly saline drying lakebed located in the Inland Southern California desert borderland region and is surrounded by agricultural fields. Children of Latinx and Indigenous Mexican immigrant families are especially vulnerable to the Salton Sea's environmental impact on chronic health conditions due to their proximity to the Salton Sea and structural vulnerability. From September 2020 to February 2021, we conducted semi-structured interviews and focus groups with a total of 36 Latinx and Indigenous Mexican caregivers of children with asthma or respiratory distress living along the Salton Sea. A community investigator trained in qualitative research conducted interviews in Spanish or Purépecha, an indigenous language spoken by immigrants from Michoacán, Mexico. Template and matrix analysis was used to identify themes and patterns across interviews and focus groups. Participants characterized the Salton Sea's environment as toxic, marked by exposure to sulfuric smells, dust storms, chemicals, and fires, all of which contribute to children's chronic health conditions (e.g., respiratory illnesses such as asthma, bronchitis, and pneumonia, co-presenting with allergies and nosebleeds). The findings have important environmental public health significance for structurally vulnerable child populations in the United States and globally.

Challenges to Engaging Women Veterans in Quality Improvement From Patient Care to Policy: Women's Health Managers' Perspectives.

INTRODUCTION: Patients are uniquely positioned to identify issues and to provide innovative solutions to problems impacting their care. Yet, patient engagement in quality improvement (QI) and health care governance remains limited and underexplored. In the Veterans Health Administration, the work of women's health managers (WHMs) includes engaging women veterans, a numerical minority with unique health care needs, in QI. We aimed to understand the extent to which WHMs engage women veterans along a continuum, highlight challenges to engagement, and identify potential strategies to facilitate multilevel patient engagement. METHODS: Data were generated from a multisite evaluation to improve delivery of comprehensive women's health care in Veterans Health Administration primary care sites. We conducted 39 semistructured interviews with WHMs across 21 sites. Guided by Carman et al.'s patient engagement framework, we analyzed the interviews using rapid-qualitative and content analysis methods. RESULTS: When effectively engaged, women veterans were important champions and partners in QI activities to improve the structure and delivery of care. However, most WHMs engaged women veterans in mainly informal or passive ways-that is, solicited feedback through comment cards, surveys, focus groups, and townhall meetings-and did not report pursuing more in-depth or long-term forms of engagement. WHMs also identified a variety of facilitators and challenges to engaging women veterans in QI. CONCLUSIONS: There may be unanticipated benefits to health care policy from engaging patients in QI, especially for patients with unique health care needs who represent a minority within the health care system. However, managers require training and workflow integration of patient engagement tasks to increase their efficiency and allow for meaningful patient engagement.