Institutional Reform to Promote Antiracism: A Tool for Developing an Organizational Equity Action and Accountability Plan.

Racism is a public health problem. Systems, structures, policies, and practices perpetuate a culture built on racism. Institutional reform is needed to promote antiracism. This article describes 1) a tool used to develop an equity action and accountability plan (EAAP) that promotes antiracism in the Department of Health Behavior at the University of North Carolina at Chapel Hill's Gillings School of Global Public Health, 2) strategies that were developed, and 3) short-term outcomes and lessons learned. A study coordinator, not affiliated with the Department of Health Behavior, was hired to collect qualitative data that documented the lived experiences of students and alumni of color (ie, racial and ethnic minority students) over time in the department. Seeking action from faculty and departmental leadership, students engaged in collective organizing covered the department chair's office door with notes describing microaggressions, and visited faculty one-on-one to demand action. In response, 6 faculty members volunteered to form the Equity Task Force (ETF) to explicitly address students' concerns. The ETF identified priority areas for action based on 2 student-led reports, gathered resources from other institutions and the public health literature, and examined departmental policies and procedures. The ETF drafted the EAAP, solicited feedback, and revised it according to 6 priority strategies with actionable steps: 1) transform culture and climate, 2) enhance teaching, mentoring, and training, 3) revisit performance and evaluation of faculty and staff, 4) strengthen recruitment and retention of faculty of color, 5) increase transparency in student hiring practices and financial resources, and 6) improve equity-oriented research practices. This planning tool and process can be used by other institutions to achieve antiracist reform.

Intervening in the Cancer Care System: An Analysis of Equity-Focused Nurse Navigation and Patient-Reported Outcomes.

BACKGROUND: Nurse navigation can improve quality of cancer care and reduce racial disparities in care outcomes. Addressing persistent structurally-rooted disparities requires research on strategies that support patients by prompting structural changes to systems of care. We applied a novel conceptualization of social support to an analysis of racial equity-focused navigation and patient-reported outcomes. METHOD: We applied an antiracism lens to create a theory-informed definition of system-facing social support: intervening in a care system on a patient's behalf. Participants were adults with early-stage breast or lung cancer, who racially identified as Black or White, and received specialized nurse navigation (n = 155). We coded navigators' clinical notes (n = 3,251) to identify instances of system-facing support. We then estimated models to examine system-facing support in relation to race, perceived racism in health care settings, and mental health. RESULTS: Twelve percent of navigators' clinical notes documented system-facing support. Black participants received more system-facing support than White participants, on average (b = 0.78, 95% confidence interval [CI]: [0.25, 1.31]). The interaction of race*system-facing support was significant in a model predicting perceived racism in health care settings at the end of the study controlling for baseline scores (b = 0.05, 95% CI [0.01, 0.09]). Trends in simple slopes indicated that among Black participants, more system-facing support was associated with slightly more perceived racism; no association among White participants. DISCUSSION: The term system-facing support highlights navigators' role in advocating for patients within the care system. More research is needed to validate the construct system-facing support and examine its utility in interventions to advance health care equity.

Examining ACCURE's Nurse Navigation Through an Antiracist Lens: Transparency and Accountability in Cancer Care.

There are persistent disparities in the delivery of cancer treatment, with Black patients receiving fewer of the recommended cancer treatment cycles than their White counterparts on average. To enhance racial equity in cancer care, innovative methods that apply antiracist principles to health promotion interventions are needed. The parent study for the current analysis, the Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) intervention, was a system-change intervention that successfully eliminated the Black-White disparity in cancer treatment completion among patients with early-stage breast and lung cancer. The intervention included specially trained nurse navigators who leveraged real-time data to follow-up with patients during their treatment journeys. Community and academic research partners conducted thematic analysis on all clinical notes (n = 3,251) written by ACCURE navigators after each contact with patients in the specialized navigation arm (n = 162). Analysis was informed by transparency and accountability, principles adapted from the antiracist resource Undoing Racism and determined as barriers to treatment completion through prior research that informed ACCURE. We identified six themes in the navigator notes that demonstrated enhanced accountability of the care system to patient needs. Underlying these themes was a process of enhanced data transparency that allowed navigators to provide tailored patient support. Themes include (1) patient-centered advocacy, (2) addressing system barriers to care, (3) connection to resources, (4) re-engaging patients after lapsed treatment, (5) addressing symptoms and side effects, and (6) emotional support. Future interventions should incorporate transparency and accountability mechanisms and examine the impact on racial equity in cancer care.

Did the 2015 USPSTF Abnormal Blood Glucose Recommendations Change Clinician Attitudes or Behaviors? A Mixed-Method Assessment.

BACKGROUND: In 2015, the US Preventive Services Task Force (USPSTF) revised clinical recommendations to more broadly recommend abnormal blood glucose screening and more clearly recommend referral to behavioral interventions for adults with prediabetes. OBJECTIVE: To assess the effects of the 2015 USPSTF recommendation changes on abnormal blood glucose screening and referral to behavioral interventions, and to examine physicians' perceptions of the revised recommendation. DESIGN: We utilized a sequential, dependent mixed-methods triangulation design. PARTICIPANTS: A total of 33,444 patients meeting USPSTF abnormal blood glucose screening criteria within 15 health system-affiliated primary care practices and 20 primary care physicians in North Carolina. MAIN MEASURES: We assessed monthly abnormal blood glucose screening rate and monthly referral rate to behavioral interventions. To estimate trend changes in outcomes, we used segmented linear regression analysis of interrupted time-series data. We gathered physicians' perspectives on the 2015 USPSTF abnormal blood glucose recommendation including awareness of, agreement with, adoption of, and adherence to the recommendation. To analyze qualitative data, we used directed content analysis. KEY RESULTS: There was a slight significant change in trend in abnormal blood glucose screening rates post-recommendation. There was a slight, statistically significant decrease in referral rates to behavioral interventions post-recommendation. Physicians were generally unaware of the revisions to the 2015 USPSTF abnormal blood glucose recommendation; however, once the recommendations were described, physicians agreed with the screening recommendation but felt that the behavioral intervention referral recommendation was hard to implement. CONCLUSION: The 2015 USPSTF abnormal blood glucose guideline had little to no effect on abnormal blood glucose screening or referral to behavioral interventions in North Carolina practices. Potential interventions to improve these rates could include clinical decision tools embedded in the electronic health record and better referral systems for community-based diabetes prevention programs.

Using Participatory Methods to Assess PrEP Interest and Uptake Among Young People Living in the Southeastern US: A Mixed Methods Assessment.

Adolescents and young adults (AYA; 13-24 years-old) comprise 22% of new HIV infections in the United States (US), most of whom live in the South. We used the situated-Information, Motivation, Behavioral skills (sIMB) model to identify priorities for intervention on multi-level factors that influence HIV preventive care among Black AYA in Durham, North Carolina. We conducted two participatory workshops (ages 13-17, N = 6; ages 18-24, N = 7) to engage youth about how to discuss HIV. We also assessed sIMB constructs from a separate quantitative sample of youth to contextualize the workshop findings (N = 80). HIV knowledge was low overall, but lower among younger Black AYA, suggesting a need for comprehensive sexual education. Trusted adults provided sexual health information, motivation for health maintenance, and behavioral skills support. HIV prevention interventions should provide comprehensive sexual health education to Black AYA, be age-specific, and include social supporters like parents, teachers, and community members.

Youth Empowered Advocating for Health (YEAH): Facilitating Partnerships Between Prevention Scientists and Black Youth to Promote Health Equity.

Structural racism inflicts a disproportionate burden of stress and trauma within Black communities, resulting in physical and mental health inequities that impact Black youth. Yet few multilevel interventions exist to address these deeply rooted inequities from a preventive standpoint, and even fewer are informed by the participatory input of the impacted communities. To bridge these gaps, we developed a community-based prevention strategy that promotes agency and active resistance to structural racism, Youth Empowered Advocating for Health (YEAH), and implemented it across various settings. We outline the development, implementation, and expansion of YEAH as a tool for promoting optimal health among Black communities. Lastly, we discuss lessons learned and offer a framework outlining key principles for prevention scientists to partner with Black youth and engage them in translational science to address structural racism. This framework is aimed at driving policies, practices, and procedures that promote equitable and sustainable change for and with Black communities.

Race and gender differences in abnormal blood glucose screening and clinician response to prediabetes: A mixed-methods assessment.

The projected three-fold increase in diabetes burden by 2060 in the United States will affect certain race and gender groups disproportionately. The objective of this mixed-methods study was to assess differences in prediabetes screening and clinician response to prediabetes by patient race and gender. We utilized data from 18,742 patients seen between 11/1/15 and 4/30/17 who met criteria for blood glucose screening by the 2015 US Preventive Service Task Force recommendation and had at least one visit to a primary care practice within a large, academic health system located in North Carolina. We utilized generalized estimating equations with logistic regression to assess race and gender differences in two outcomes: prediabetes screening and clinician response to prediabetes. We conducted twenty in-depth interviews (October 2018-May 2019) with physicians to assess their approach to screening for and treating prediabetes. Black patients had 11% higher odds (95% CI:1.02-1.20) of being screened for prediabetes than White patients. Men had 19% higher odds (95% CI:1.09-1.30) of being screened for prediabetes than women. There were no significant differences in clinician response to prediabetes by patient race or gender. Qualitatively, physicians reported a non-systematic approach to prediabetes screening and follow-up care related to: 1) System-level barriers to screening and treatment; 2) Implicit bias; 3) Patient factors; and 4) Physician preferences for prediabetes treatment. Targeted risk-based screening for prediabetes along with increased treatment for prediabetes are critical for preventing diabetes and reducing diabetes-related disparities.

Awareness of and attitudes toward pre-exposure prophylaxis among African American women living in low-income neighborhoods in a Southeastern city.

African American women in the South are disproportionately affected by HIV but have often been ignored in HIV prevention efforts, including in the rollout of pre-exposure prophylaxis (PrEP). To inform strategies to promote PrEP awareness and access in this population, we conducted a venue-based community survey with 53 African American women living in low-income neighborhoods of a Southeastern city to understand women's knowledge of and attitudes toward PrEP. Awareness of PrEP was very low (37%) with only 16% being aware that PrEP is used for HIV prevention. The vast majority of women (85%) reported that they would use or would consider using PrEP, most frequently citing a general interest in HIV prevention or a lack of awareness of their partners' HIV status as motivations for their interest. Some women expressed concerns about side effects or low perceived HIV risk as disincentives for PrEP use. Information regarding side effects and HIV risk assessments will be needed to ensure the acceptable delivery of PrEP in this population.

Refining Black men's depression measurement using participatory approaches: a concept mapping study.

BACKGROUND: Despite cumulative socioeconomic disadvantage and risk factors, Black Americans have a lower prevalence of depression than whites. Given the emerging focus of depression as a public mental health crisis, culturally informed depression measures and scale development techniques are needed to better alleviate the mental health burden of socially marginalized populations. Yet, for Black men, race- and gender-related factors that position emotional vulnerability as a sign of weakness, may potentially mask the timely identification of mental health needs in this population. Thus, we address these gaps by employing a stakeholder-driven, community-engaged process for understanding Black men's depression experience. METHODS: We use concept mapping, a structured mixed methods approach, to determine how stakeholders of Black men's health conceptualize their depressive symptoms. Thirty-six stakeholders participated in a three-phase concept mapping study conducted in 2018. Three separate stakeholder groups were engaged for this study, including Black men, Black women, and primary care providers. RESULTS: Participants generated 68 characteristics of Black men's depression which were reflected within five conceptual clusters: (1) physical states; (2) emotional states; (3) diminished drive; (4) internal conflicts; (5) communication with others; and (6) social pressures. Using a content analysis approach, we found that items comprising the "social pressures" cluster were not reflected in any common depression scales. CONCLUSIONS: Findings from this study illustrate the similar and divergent pathways in which Black men express depressed mood. Furthermore, concept mapping results also yield a novel opportunity for culturally informed scale development in future research.

'It's like you don't have a roadmap really': using an antiracism framework to analyze patients' encounters in the cancer system.

Background: Cancer patients can experience healthcare system-related challenges during the course of their treatment. Yet, little is known about how these challenges might affect the quality and completion of cancer treatment for all patients, and particularly for patients of color. Accountability for Cancer Care through Undoing Racism and Equity is a multi-component, community-based participatory research intervention to reduce Black-White cancer care disparities. This formative work aimed to understand patients' cancer center experiences, explore racial differences in experiences, and inform systems-level interventions.Methods: Twenty-seven breast and lung cancer patients at two cancer centers participated in focus groups, grouped by race and cancer type. Participants were asked about what they found empowering and disempowering regarding their cancer care experiences. The community-guided analysis used a racial equity approach to identify racial differences in care experiences.Results: For Black and White patients, fear, uncertainty, and incomplete knowledge were disempowering; trust in providers and a sense of control were empowering. Although participants denied differential treatment due to race, analysis revealed implicit Black-White differences in care.Conclusions: Most of the challenges participants faced were related to lack of transparency, such that improvements in communication, particularly two-way communication could greatly improve patients' interaction with the system. Pathways for accountability can also be built into a system that allows patients to find solutions for their problems with the system itself. Participants' insights suggest the need for patient-centered, systems-level interventions to improve care experiences and reduce disparities.

The role of patient-physician relationship on health-related quality of life and pain in cancer patients.

PURPOSE: Health-related quality of life (HRQOL) and pain are important supportive cancer care outcomes. The patient-provider relationship, a modifiable care experience, has been linked to healthcare outcomes; however, less is known about associations between patient-provider relationship and supportive care outcomes in cancer patients. We examined the role of multiple aspects of the patient-provider relationship in explaining patterns of HRQOL and pain among breast and lung cancer patients. METHODS: Our analysis included 283 breast and lung cancer patients from two cancer centers. Clinical data and survey data on patient sociodemographic factors, physical and mental HRQOL, pain, and patient-physician relationship (i.e., doctor's respectfulness, time spent with doctors, patient involvement in decision-making, satisfaction with care, and following doctor's advice/treatment plan) were collected at baseline and during treatment. We estimated adjusted modified Poisson regression models to assess associations between patient-physician relationship factors and physical and mental HRQOL and pain. RESULTS: Compared with patients reporting suboptimal respect from doctors, patients reporting optimal respect were less likely to report below average physical HRQOL (adjusted risk ratio (ARR), 0.73; 95%CI, 0.62-0.86), below average mental HRQOL (ARR, 0.71; 95%CI, 0.54-0.93), and moderate-to-severe pain (ARR, 0.53; 95%CI, 0.35-0.79). Patients reporting optimal involvement in care decision-making and patients who reported following their doctor's advice/treatment plan were less likely to report below average mental HRQOL than their respective counterparts (ARR, 0.64; 95%CI, 0.50-0.83; ARR, 0.65; 95%CI, 0.48-0.86). CONCLUSION: Multiple patient-physician relationship factors account for variations in HRQOL and pain in cancer patients. These findings provide insight into potential targets for improving the patient-provider relationship and supportive cancer care outcomes.

Racial Differences in the Influence of Health Care System Factors on Informal Support for Cancer Care Among Black and White Breast and Lung Cancer Survivors.

This retrospective, secondary qualitative analysis investigates whether health system factors influence social support among Black and white breast and lung cancer survivors and racial differences in support. These data come from race- and cancer-stratified focus groups (n = 6) and interviews (n = 2) to inform a randomized controlled trial utilizing antiracism and community-based participatory research approaches. Findings indicate social support was helpful for overcoming treatment-related challenges, including symptom management and patient-provider communication; racial differences in support needs and provision were noted. Resources within individual support networks reflect broader sociostructural factors. Reliance on family/friends to fill gaps in cancer care may exacerbate racial disparities.

AMP!: A Cross-site Analysis of the Effects of a Theater-based Intervention on Adolescent Awareness, Attitudes, and Knowledge about HIV.

AMP! (Arts-based, Multiple component, Peer-education) is an HIV intervention developed for high school adolescents. AMP! uses interactive theater-based scenarios developed by trained college undergraduates to deliver messages addressing HIV/STI prevention strategies, healthy relationships, and stigma reduction towards people living with HIV/AIDS. We used a pre-test/post-test, control group study design to simultaneously assess intervention effect on ninth grade students in an urban county in California (N = 159) and a suburban county in North Carolina (N = 317). In each location, the control group received standard health education curricula delivered by teachers; the intervention group received AMP! in addition to standard health education curricula. Structural equation modeling was used to determine intervention effects. The post-test sample was 46 % male, 90 % self-identified as heterosexual, 32 % reported receiving free or reduced lunch, and 49 % White. Structural models indicated that participation in AMP! predicted higher scores on HIV knowledge (p = 0.05), HIV awareness (p = 0.01), and HIV attitudes (p = 0.05) at the post-test. Latent means comparison analyses revealed post-test scores were significantly higher than pre-test scores on HIV knowledge (p = 0.001), HIV awareness (p = 0.001), and HIV attitudes (p = 0.001). Further analyses indicated that scores rose for both groups, but the post-test scores of intervention participants were significantly higher than controls (HIV knowledge (p = 0.01), HIV awareness (p = 0.01), and HIV attitudes (p = 0.05)). Thus, AMP!'s theater-based approach shows promise for addressing multiple adolescent risk factors and attitudes concerning HIV in school settings.

A Critical Review of the Characteristics of Theater-Based HIV Prevention Interventions for Adolescents in School Settings.

Theater-based interventions are a viable prevention strategy for changing sexual health knowledge, attitudes, and behaviors related to HIV prevention. However, few studies have explored interventions in English-speaking, high-income countries such as the United States, Canada, or the United Kingdom. This article critically reviews the literature to identify key characteristics of theater-based HIV prevention strategies used for adolescents in school-settings in the United States, Canada, and the United Kingdom. Specifically, we identify the theatrical approach used in HIV prevention interventions, the behavioral theories that inform such interventions, and the study design and results of existing evaluation studies conducted in school settings. In the 10 articles reviewed, we found limited grounding in theory and the use of nonrigorous study design. To strengthen the evidence and practical application of theater-based HIV prevention interventions, we highlight three specific recommendations for practitioners and researchers: (1) define and operationalize the theater approach and techniques used, (2) ensure theater-based interventions are grounded in theory, and (3) conduct rigorous evaluation of theater-based interventions. These recommendations are key to strengthening future research on and implementation of theater-based interventions for HIV prevention.

Using Photovoice to Understand Barriers to and Facilitators of Cardiovascular Health Among African American Adults and Adolescents, North Carolina, 2011-2012.

INTRODUCTION: Cardiovascular disease is the leading cause of death in the United States, and mortality rates are higher among African Americans than among people of other races/ethnicities. We aimed to understand how African American adults and adolescents conceptualize cardiovascular health and perceive related barriers and facilitators. METHODS: This qualitative study was conducted as formative research for a larger study, Heart Healthy Lenoir, which aimed to reduce cardiovascular disease disparities among African Americans in eastern North Carolina, part of the widely-known "stroke belt" that runs through the southeastern United States. Using photovoice, a community-based participatory research method, we conducted eight 90-minute photovoice sessions with 6 adults and 9 adolescents in Lenoir County, North Carolina. Topics for each discussion were selected by participants and reflected themes related to cardiovascular health promotion. All sessions were transcribed and coded using a data-driven, inductive approach. RESULTS: Participants conceptualized cardiovascular health to have mental, spiritual, and social health dimensions. Given these broad domains, participants acknowledged many ecological barriers to cardiovascular health; however, they also emphasized the importance of personal responsibility. Facilitators for cardiovascular health included using social health (eg, family/community relationships) and spiritual health dimensions (eg, understanding one's body and purpose) to improve health behaviors. CONCLUSION: The perspectives of African American adults and adolescents elicited through this formative research provided a strong foundation for Heart Healthy Lenoir's ongoing engagement of community members in Lenoir County and development and implementation of its intervention to prevent cardiovascular disease.

Engaging African American Faith-Based Organizations in Adolescent HIV Prevention.

To reduce current HIV disparities among African American youth, it is imperative to find effective ways to extend the reach of evidence-based HIV prevention. One promising community resource to support this effort is faith-based organizations (FBOs), a credible and respected resource in the African American community. This paper describes the experiences, perceptions, and challenges that African American FBOs and faith leaders face in engaging in adolescent HIV prevention and highlights facilitators and barriers to implementing HIV prevention in African American FBOs. The findings suggest that African American FBOs and faith-based leaders are uniquely positioned to be instrumental resources in reducing African American youth HIV disparities.

Where is the faith? Using a CBPR approach to propose adaptations to an evidence-based HIV prevention intervention for adolescents in African American faith settings.

African American adolescents are at increased risk for HIV/AIDS. Using a community-based participatory research approach, we engaged three black churches in adapting an evidence-based HIV prevention intervention, Focus on Youth (FOY)+ImPACT, for faith settings. To identify potential adaptations to increase FOY's relevance, utility, and efficacy for faith settings, we conducted eight focus groups pre- and post-intervention. Recommendations for maintaining FOY's core elements and enhancing its cultural authenticity include the following: incorporating faith tools, building pastor capacity, strengthening parent-child communication skills, and expanding social support for parents and youth. Engaging faith communities in adapting and implementing evidence-based HIV prevention programs could reduce HIV/AIDS disparities.

Listening to the community: identifying obesity prevention strategies for rural preschool-aged children.

Multi-level interventions promoting healthy weight in rural preschool children aged 2-5 years are limited. With the goal of developing a community-informed obesity prevention intervention for rural preschool-aged children, the purpose of this descriptive study was to identify: (1) community settings and intervention strategies to prioritize for an intervention; (2) potential implementation challenges and solutions; and (3) immediate interventions the study team and community partners could collaboratively implement. Workshops occurred in two rural communities in Indiana (2 workshops) and North Carolina (2 workshops), with high obesity rates. A guide was developed to moderate discussions and participants voted to rank community settings and intervention strategies. There were 9-15 participants per workshop, including parents, childcare providers, and representatives of community organizations. Community settings identified as priorities for child obesity prevention included the home, educational settings (preschools), food outlets, recreational facilities, and social media. Priority intervention strategies included providing nutrition and physical activity education, increasing access to healthy foods and physical activity in the built environment, and enhancing food security. Potential intervention implementation challenges centered on poor parental engagement; using personalized invitations and providing transportation support to families were proffered solutions. Immediate interventions to collaboratively implement focused on making playgrounds esthetically pleasing for physical activity using game stencils, and nutrition education for families via quarterly newsletters. This participatory approach with community partners provided insight into two rural communities' needs for child obesity prevention, community assets (settings) to leverage, and potential intervention strategies to prioritize. Findings will guide the development of a multi-level community-based intervention.

Exploring the social and community context of African American adolescents' HIV vulnerability.

There is an increasing call for HIV prevention programs that target social determinants of HIV. The purpose of this study was to examine the experiences and perceptions of 12 African American adolescents to identify important social and community targets for HIV prevention. We used photovoice methodology to engage adolescents in a critical analysis of their experiences to arrive at a deeper understanding of the social determinants of HIV and determine specific action steps to reduce HIV risk. Analyses revealed a variety of social and environmental factors that affect the lives of African American adolescents by creating conditions that put them at greater risk for HIV. Study findings support mobilizing community action through raising awareness and advocating for increased neighborhood resources and institutional support. We conclude with research and practice implications for community-relevant HIV prevention among African American youth.