Limited Evidence of Shared Decision Making for Prostate Cancer Screening in Audio-Recorded Primary Care Visits Among Black Men and their Healthcare Providers.

Prostate-specific antigen (PSA)-based prostate cancer screening is a preference-sensitive decision for which experts recommend a shared decision making (SDM) approach. This study aimed to examine PSA screening SDM in primary care. Methods included qualitative analysis of audio-recorded patient-provider interactions supplemented by quantitative description. Participants included 5 clinic providers and 13 patients who were: (1) 40-69 years old, (2) Black, (3) male, and (4) attending clinic for routine primary care. Main measures were SDM element themes and "observing patient involvement in decision making" (OPTION) scoring. Some discussions addressed advantages, disadvantages, and/or scientific uncertainty of screening, however, few patients received all SDM elements. Nearly all providers recommended screening, however, only 3 patients were directly asked about screening preferences. Few patients were asked about prostate cancer knowledge (2), urological symptoms (3), or family history (6). Most providers discussed disadvantages (80%) and advantages (80%) of PSA screening. Average OPTION score was 25/100 (range 0-67) per provider. Our study found limited SDM during PSA screening consultations. The counseling that did take place utilized components of SDM but inconsistently and incompletely. We must improve SDM for PSA screening for diverse patient populations to promote health equity. This study highlights the need to improve SDM for PSA screening.

Factors Influencing Patient Satisfaction and Loyalty as Perceived by Dentists and Their Patients.

OBJECTIVE: This study aimed to identify the key aspects of patients' dental care experience that influenced their self-perceived satisfaction and loyalty. Also examined was the agreement between patients and dentists regarding these factors. METHODS: Questionnaires were administered to 1121 patients and 77 dentists, focusing on demographic information and 15 selected items related to the patients' last dental visit. Descriptive and linear regression analyses were conducted. RESULTS: The study included participants from 41 practices. Factors significantly influencing satisfaction and loyalty included location convenience, treatment quality, trust in dentists' decisions, visit frequency satisfaction, clear treatment explanations, dentist's interest in symptoms, patient-dental personnel attachment, and dentist's knowledge of the patient and their medical records. While overall agreement between patients and dentists was high, some areas exhibited notable disagreement. CONCLUSIONS: The findings mostly align with existing literature, underscoring the importance of communication, trust, and a personal patient-dentist relationship in promoting satisfaction and loyalty. However, they also show that local, generally not reported factors might be at play, which necessitates dentists' awareness and consideration of the local context for optimal outcomes.

Protocol: A multi-modal, physician-centered intervention to improve guideline-concordant prostate cancer imaging.

BACKGROUND: Almost half of Veterans with localized prostate cancer receive inappropriate, wasteful staging imaging. Our team has explored the barriers and facilitators of guideline-concordant prostate cancer imaging and found that (1) patients with newly diagnosed prostate cancer have little concern for radiographic staging but rather focus on treatment and (2) physicians trust imaging guidelines but are apt to follow their own intuition, fear medico-legal consequences, and succumb to influence from imaging-avid colleagues. We used a theory-based approach to design a multi-level intervention strategy to promote guideline-concordant imaging to stage incident prostate cancer. METHODS: We designed the Prostate Cancer Imaging Stewardship (PCIS) intervention: a multi-site, stepped wedge, cluster-randomized trial to determine the effect of a physician-focused behavioral intervention on Veterans Health Administration (VHA) prostate cancer imaging use. The multi-level intervention, developed according to the Theoretical Domains Framework (TDF) and Behavior Change Wheel, combines traditional physician behavior change methods with novel methods of communication and data collection. The intervention consists of three components: (1) a system of audit and feedback to clinicians informing individual clinicians and their sites about how their behavior compares to their peers' and to published guidelines, (2) a program of academic detailing with the goal to educate providers about prostate cancer imaging, and (3) a CPRS Clinical Order Check for potentially guideline-discordant imaging orders. The intervention will be introduced to 10 participating geographically distributed study sites. DISCUSSION: This study is a significant contribution to implementation science, providing VHA an opportunity to ensure delivery of high-quality care at the lowest cost using a theory-based approach. The study is ongoing. Preliminary data collection and recruitment have started; analysis has yet to be performed. TRIAL REGISTRATION: CliniclTrials.gov NCT03445559. Prospectively registered on February 26, 2018.

Clinical Trial Protocol for a Randomized Trial of Community Health Worker-led Decision Coaching to Promote Shared Decision-making on Prostate Cancer Screening Among Black Male Patients and Their Providers.

We propose a randomized controlled trial to evaluate the effectiveness of a community health worker-led decision-coaching program to facilitate shared decision-making for prostate cancer screening decisions by Black men at a primary care federally qualified health center.

Randomized trial of community health worker-led decision coaching to promote shared decision-making for prostate cancer screening among Black male patients and their providers.

BACKGROUND: Black men are disproportionately affected by prostate cancer, the most common non-cutaneous malignancy among men in the USA. The United States Preventive Services Task Force (USPSTF) encourages prostate-specific antigen (PSA) testing decisions to be based on shared decision-making (SDM) clinician professional judgment, and patient preferences. However, evidence suggests that SDM is underutilized in clinical practice, especially among the most vulnerable patients. The purpose of this study is to evaluate the efficacy of a community health worker (CHW)-led decision-coaching program to facilitate SDM for prostate cancer screening among Black men in the primary care setting, with the ultimate aim of improving/optimizing decision quality. METHODS: We proposed a CHW-led decision-coaching program to facilitate SDM for prostate cancer screening discussions in Black men at a primary care FQHC. This study enrolled Black men who were patients at the participating clinical site and up to 15 providers who cared for them. We estimated to recruit 228 participants, ages 40-69 to be randomized to either (1) a decision aid along with decision coaching on PSA screening from a CHW or (2) receiving a decision aid along with CHW-led interaction on modifying dietary and lifestyle to serve as an attention control. The independent randomization process was implemented within each provider and we controlled for age by dividing patients into two strata: 40-54 years and 55-69 years. This sample size sufficiently powered the detection differences in the primary study outcomes: knowledge, indicative of decision quality, and differences in PSA screening rates. Primary outcome measures for patients will be decision quality and decision regarding whether to undergo PSA screening. Primary outcome measures for providers will be acceptability and feasibility of the intervention. We will examine how decision coaching about prostate cancer screening impact patient-provider communication. These outcomes will be analyzed quantitatively through objective, validated scales and qualitatively through semi-structured, in-depth interviews, and thematic analysis of clinical encounters. Through a conceptual model combining elements of the Preventative Health Care Model (PHM) and Informed Decision-Making Model, we hypothesize that the prostate cancer screening decision coaching intervention will result in a preference-congruent decision and decisional satisfaction. We also hypothesize that this intervention will improve physician satisfaction with counseling patients about prostate cancer screening. DISCUSSION: Decision coaching is an evidence-based approach to improve decision quality in many clinical contexts, but its efficacy is incompletely explored for PSA screening among Black men in primary care. Our proposal to evaluate a CHW-led decision-coaching program for PSA screening has high potential for scalability and public health impact. Our results will determine the efficacy, cost-effectiveness, and sustainability of a CHW intervention in a community clinic setting in order to inform subsequent widespread dissemination, a critical research area highlighted by USPSTF. TRIAL REGISTRATION: The trial was registered prospectively with the National Institute of Health registry ( www.clinicaltrials.gov ), registration number NCT03726320 , on October 31, 2018.

Attitudes among working professionals toward immigrants and refugees living in Ecuador: Impacts on health and well-being.

OBJECTIVE: To explore attitudes toward immigrants and refugees living in Ecuador. DESIGN AND MEASURES: A transnationalism framework informed this qualitative study, which utilized a semi-structured interview guide to elicit responses from participants about their attitudes toward immigrants and refugees. Interviews were conducted in Spanish, audio-taped, transcribed, coded, and analyzed in Spanish to identify emergent themes. Demographic data were analyzed using SPSS. SAMPLE: Participants (n = 50) were recruited from five sectors that interact with refugees: health care, the press, the police, nongovernmental organizations, and education. Fifty interviews were conducted with adults in Quito, Ecuador, in 2017. RESULTS: Participants reported concerns about the health and well-being of immigrants and refugees, expressed a willingness to assist them, but within limits, noted discrimination and bias against refugees, and cited social policies and human rights as factors that influenced their attitudes. CONCLUSIONS: Our findings indicate that immigrants and refugees face challenges which impact their health and well-being, according to participants in the study. Social policies can influence attitudes, but are also affected by rapidly shifting immigration patterns. Migration flows in South America is an under-studied area of research, with opportunity for further public health nursing inquiry.

Clinical Trials Participation Among African Americans and the Ethics of Trust: Leadership Perspectives.

Background: Assuring health equity throughout the U.S. continues to challenge the public and private research enterprise. Even with some progress, racial and ethnic health disparities continue, particularly among African Americans. Health equity for African Americans is improbable unless participation in clinical trials is measurably increased. Method: To inform efforts to enhance participation, interviews were conducted with three African American leadership groups from across the country to document their perceptions of why the research community is unable to engage African Americans effectively in clinical trials. The results of thirty-five interviews, conducted from three leadership groups, were analyzed and are reported in this article. The leadership groups include health/education, faith, and civic society. Ethical Considerations: This research was conducted based upon the ethical protocols of the National Center for Bioethics in Research and Health Care, research ethics, and confidentiality. Results: Findings indicate that trustworthiness must precede trust; both are essential in enhancing African American participation in research, especially in less understood clinical trials. Conclusion: Respondents agreed that the research community must demonstrate trustworthiness before trust can be established. They also indicated the importance of increasing the number of African American researchers in leadership roles. Also, suggestions were made regarding the need to develop short and long-term positive relationships between the research community and the African American population, at various levels, if increases in participation in clinical trials are expected. With the likely development of new clinical research and the attention to increasing excess deaths among African Americans, there must be representative numbers of African Americans and other underserved populations in leadership roles if health disparities are to be eliminated and health equity is to be achieved.

Adulterants and altruism: A qualitative investigation of "drug checkers" in North America.

BACKGROUND: "Drug checking" has become a common harm reduction method used to test illicit substances, such as ecstasy, for purity and/or the presence of adulterants. Formal drug-checking services have been operating for decades, and the use of personal reagent test kits appears to be relatively common; however, little attention has been devoted to understanding the role and broader experiences of 'drug-checkers' (i.e., people who test their own and/or other people's substances). As such, it remains unknown who is engaging in this practice, their motivations for drug-checking, and what barriers they may experience. We addressed this research gap by interviewing people who check drugs about their experiences, with a goal of better understanding drug checking practices. METHODS: We conducted in-depth interviews with 32 adults in North America who reported testing drugs. Coding was conducted in an inductive manner and thematic analysis was used to identify relevant themes. RESULTS: Over half (56.2%) of our sample was affiliated with a drug checking organization. Among non-affiliated checkers (43.8%), the majority (57.1%) tested for friends, 21.4% tested only for themselves, and 21.4% were people who sold drugs and tested for their clients. Motivations were driven largely by altruism, described by checkers as wanting to protect their peers from exposure to adulterants. People interviewed who sold drugs were altruistic in the same manner. Barriers to checking-particularly at nightclubs and festivals-included perceived illegality of test kits and denied approval to test drugs at venues, although many checkers circumvented this barrier by checking drugs without such approval. CONCLUSIONS: Drug checkers in North America seek to educate people who use drugs about the risk of exposure to unexpected substance types, but they face various barriers. Policy change could help ensure that these potentially life-saving services can be provided without fear of fines and/or criminal prosecution.

Ceremonial "plant medicine" use and its relationship to recreational drug use: an exploratory study.

BACKGROUND: The ceremonial use of psychoactive/hallucinogenic plant based drugs, such as ayahuasca, psilocybin and others, is a growing trend in the United States (US) and globally. To date, there has been little research documenting how many people are using psychoactive substances in this context, who the users are, what benefits/risks exist in the use of these drugs and the relationship between ceremonial drug use and recreational drug use.In this paper we describe a cohort of plant medicine facilitators in the US and explore how they differentiate plant medicine use from recreational drug use. METHODS: Using modified ethnography, individual interviews were conducted in 2016 with 15 participants who are currently facilitating plant medicine ceremonies in the US. Descriptive content analysis was performed to discover themes and to inform a larger mixed-method study. RESULTS: Ceremonial drug use was seen by participants as a natural healing and treatment modality used in the context of community and ritual. Three main themes were identified relating to participants' differentiation between ceremonial plant medicine use and recreational drug use: 1) participants see a clear delineation between plant medicine use and recreational drug use; 2) plant medicine is seen as a potential treatment for addiction, but concerns exist regarding potential interference with recovery; and 3) plant medicine use may influence recreational use. CONCLUSIONS: More research is needed on who is using plant medicine, motivators for use, perceived and real risks and benefits of plant medicine use and harm reduction techniques regarding safe ingestion.

A Framework for Using eHealth Interventions to Overcome Medical Mistrust Among Sexual Minority Men of Color Living with Chronic Conditions.

The purpose of this paper is to present a stepwise, multi-construct, innovative framework that supports the use of eHealth technology to reach sexual minority populations of color to establish trustworthiness and build trust. The salience of eHealth interventions can be leveraged to minimize the existing paradigm of medical mistrust among sexual minority populations of color living with chronic illnesses. These interventions include virtual environments and avatar-led eHealth videos, which address psychosocial and structural-level challenges related to mistrust. Our proposed framework addresses how eHealth interventions enable technology adoption and usage, anonymity, co-presence, self-disclosure, and social support and establish trustworthiness and build trust.

Patient decision-making regarding left ventricular assist devices : A multiple case study.

OBJECTIVES: To understand how patients make decisions regarding a left ventricular assist device (LVAD). DESIGN: A qualitative multiple case study design was used to explore the context and influence of individuals regarding patients' decision-making processes through: 1) detailed, in-depth interviews of those mostly involved in the patient's decision and 2) pertinent data including observations, medical records, educational information and physical artifacts. Data clusters and patterns of co-occurring codes were examined using thematic analysis. MAIN OUTCOME MEASURES: Themes were extrapolated from individual case summaries to provide an in-depth analysis of each case and a cross-case analysis across the multiple cases. The predominant theme, consistent with other studies, was the salience of survival. FINDINGS: This case study approach revealed new themes beyond those of prior studies. Patients considered: 1) self-care management for patients without a caregiver, 2) acceptability and future expectations of the LVAD and 3) the role of nurses in eliciting patients' fears, values and preferences. CONCLUSION: The patients' decision-making processes regarding an LVAD involve a cost-benefit analysis of the anticipated needs and consequences of the LVAD. Acceptability of the device is relevant to clinical practice and public policy. Nurses have a unique role in seeking patients' concerns, an essential component of shared decision-making.

Knowledge and behaviours related to oral health among underserved older adults.

OBJECTIVE: To examine the mouth and body knowledge, beliefs and behaviours of Dominican, Puerto Rican and African American older adults, and their relationships to oral and general health and health care. BACKGROUND: In his seminal framework, Handwerker posited that the norms, attitudes and behaviours related to the experience of disease and treatment reflect where patients live and have lived and are seeking and have sought care, along with their webs of social and health relations. This framework guides the analysis for the present study, wherein qualitative data are used to understand mouth and body knowledge, beliefs and behaviours among racial/ethnic minority older adults, ie, why individuals do what they do and what it means to them. MATERIALS AND METHODS: Focus groups were conducted in Spanish or English with 194 racial/ethnic minority older adults living in northern Manhattan who participated in one of 24 focus group sessions about improving oral health. All groups were digitally audio-recorded, transcribed and translated into English from Spanish, where apt. Analysis involved the classification of evidence from all datasets, organised to identify patterns and relationships. RESULTS: Four themes were manifest in the data regarding cultural understandings of the mouth, the body and health: (a) the ageing mouth and its components; (b) the mouth in relation to the body, health and disease; (c) social meanings of the mouth; and (d) care of the ageing mouth. CONCLUSION: Underserved older adults from diverse cultural backgrounds understand the importance of their mouths to both their overall health and social lives.

Recruitment of racial/ethnic minority older adults through community sites for focus group discussions.

BACKGROUND: Despite a body of evidence on racial/ethnic minority enrollment and retention in research, literature specifically focused on recruiting racially/ethnically diverse older adults for social science studies is limited. There is a need for more rigorous research on methodological issues and the efficacy of recruitment methods. Cultural obstacles to recruitment of racial/ethnic minority older adults include language barriers, lack of cultural sensitivity of target communities on the part of researchers, and culturally inappropriate assessment tools. METHODS: Guided by the Consolidated Framework for Implementation Research (CFIR), this study critically appraised the recruitment of racial/ethnic minority older adults for focus groups. The initial approach involved using the physical and social infrastructure of the ElderSmile network, a community-based initiative to promote oral and general health and conduct health screenings in places where older adults gather, to recruit racial/ethnic minority adults for a social science component of an interdisciplinary initiative. The process involved planning a recruitment strategy, engaging the individuals involved in its implementation (opinion leaders in senior centers, program staff as implementation leaders, senior community-based colleagues as champions, and motivated center directors as change agents), executing the recruitment plan, and reflecting on the process of implementation. RESULTS: While the recruitment phase of the study was delayed by 6 months to allow for ongoing recruitment and filling of focus group slots, the flexibility of the recruitment plan, the expertise of the research team members, the perseverance of the recruitment staff, and the cultivation of change agents ultimately resulted in meeting the study targets for enrollment in terms of both numbers of focus group discussions (n = 24) and numbers of participants (n = 194). CONCLUSIONS: This study adds to the literature in two important ways. First, we leveraged the social and physical infrastructure of an existing program to recruit participants through community sites where older adults gather. Second, we used the CFIR to guide the appraisal of the recruitment process, which underscored important considerations for both reaching and engaging this underserved population. This was especially true in terms of understanding the disparate roles of the individuals involved in implementing and facilitating the recruitment plan.

Emergency contraceptive pill users' risk perceptions for sexually transmitted infections and future unintended pregnancy.

BACKGROUND AND PURPOSE: The availability of emergency contraception pills (ECP) over the counter (OTC) has the potential to reduce the incidence of unintended pregnancy; however, the increased risk for sexually transmitted infection (STI) acquisition, related to unprotected intercourse, has not been adequately addressed. The purpose of this study is to gain insight into risk perceptions for STIs and subsequent unintended pregnancy in women who have purchased ECP OTC. METHODS: Twenty-one women, aged 18-24, attending a private university in an urban setting, who purchased and used ECP OTC participated in 1-h, individual interviews. CONCLUSIONS: Narrative, descriptive findings indicated that these women did not consider themselves at risk for STI or unintended pregnancy, despite having used ECP OTC. Pregnancy prevention was paramount for these women, which overshadowed concerns regarding STIs. IMPLICATIONS FOR PRACTICE: Women at risk for unintended consequences of sexual activity are not fully cognizant of those potential outcomes and do not take measures to prevent their occurrence. The availability of ECP OTC offers protection against unintended pregnancy; however, opportunities for health promotion and prevention counseling may be lost.

A qualitative study to understand guideline-discordant use of imaging to stage incident prostate cancer.

BACKGROUND: Approximately half of veterans with low-risk prostate cancer receive guideline-discordant imaging. Our objective was to identify and describe (1) physician knowledge, attitudes, and practices related to the use of imaging to stage prostate cancer, (2) patient attitudes and behaviors related to use of imaging, and (3) to compare responses across three VA medical centers (VAMCs). METHODS: A qualitative approach was used to explore patient and provider knowledge and behaviors relating to the use of imaging. We conducted 39 semi-structured interviews total-including 22 interviews with patients with newly diagnosed with prostate cancer and 17 interviews with physicians caring for them-between September 2014 and July 2015 at three VAMCs representing a spectrum of inappropriate imaging rates. After core theoretical concepts were identified, the Theoretical Domains Framework (TDF) was selected to explore linkages between themes within the dataset and existing domains within the framework. Interviews were audio-recorded, transcribed verbatim, and then coded and analyzed using Nvivo software. RESULTS: Themes from patient interviews were categorized within four TDF domains. Patients reported little interest in staging as compared to disease treatment (goals), and many could not remember if they had imaging at all (knowledge). Patients tended to trust their doctor to make decisions about appropriate tests (beliefs about capabilities). Some patients expressed a minor concern for radiation exposure, but anxiety about cancer outcomes outweighed these fears (emotion). Themes from physician interviews were categorized within five TDF domains. Most physicians self-reported that they know and trust imaging guidelines (knowledge) yet some were still likely to follow their own intuition, whether due to clinical suspicion or years of experience (beliefs about capabilities). Additionally, physicians reported that medico-legal concerns, fear of missing associated diagnoses (beliefs about consequences), influence from colleagues who image frequently (social influences), and the facility where they practice influences rates of imaging (environmental context). CONCLUSIONS: Interviews with patients and physicians suggest that physicians are the primary (and in some cases only) decision-makers regarding staging imaging for prostate cancer. This finding suggests a physician-targeted intervention may be the most effective strategy to improve guideline-concordant prostate cancer imaging.

Linguistic and Cultural Adaptation of a Computer-Based Counseling Program (CARE+ Spanish) to Support HIV Treatment Adherence and Risk Reduction for People Living With HIV/AIDS: A Randomized Controlled Trial.

BACKGROUND: Human immunodeficiency virus (HIV) disease in the United States disproportionately affects minorities, including Latinos. Barriers including language are associated with lower antiretroviral therapy (ART) adherence seen among Latinos, yet ART and interventions for clinic visit adherence are rarely developed or delivered in Spanish. OBJECTIVE: The aim was to adapt a computer-based counseling tool, demonstrated to reduce HIV-1 viral load and sexual risk transmission in a population of English-speaking adults, for use during routine clinical visits for an HIV-positive Spanish-speaking population (CARE+ Spanish); the Technology Acceptance Model (TAM) was the theoretical framework guiding program development. METHODS: A longitudinal randomized controlled trial was conducted from June 4, 2010 to March 29, 2012. Participants were recruited from a comprehensive HIV treatment center comprising three clinics in New York City. Eligibility criteria were (1) adults (age ≥18 years), (2) Latino birth or ancestry, (3) speaks Spanish (mono- or multilingual), and (4) on antiretrovirals. Linear and generalized mixed linear effects models were used to analyze primary outcomes, which included ART adherence, sexual transmission risk behaviors, and HIV-1 viral loads. Exit interviews were offered to purposively selected intervention participants to explore cultural acceptability of the tool among participants, and focus groups explored the acceptability and system efficiency issues among clinic providers, using the TAM framework. RESULTS: A total of 494 Spanish-speaking HIV clinic attendees were enrolled and randomly assigned to the intervention (arm A: n=253) or risk assessment-only control (arm B, n=241) group and followed up at 3-month intervals for one year. Gender distribution was 296 (68.4%) male, 110 (25.4%) female, and 10 (2.3%) transgender. By study end, 433 of 494 (87.7%) participants were retained. Although intervention participants had reduced viral loads, increased ART adherence and decreased sexual transmission risk behaviors over time, these findings were not statistically significant. We also conducted 61 qualitative exit interviews with participants and two focus groups with a total of 16 providers. CONCLUSIONS: A computer-based counseling tool grounded in the TAM theoretical model and delivered in Spanish was acceptable and feasible to implement in a high-volume HIV clinic setting. It was able to provide evidence-based, linguistically appropriate ART adherence support without requiring additional staff time, bilingual status, or translation services. We found that language preferences and cultural acceptability of a computer-based counseling tool exist on a continuum in our urban Spanish-speaking population. Theoretical frameworks of technology's usefulness for behavioral modification need further exploration in other languages and cultures. TRIAL REGISTRATION: ClinicalTrials.gov NCT01013935; https://clinicaltrials.gov/ct2/show/NCT01013935 (Archived by WebCite at http://www.webcitation.org/6ikaD3MT7).

Feasibility and acceptability of an audio computer-assisted self-interview version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary care patients.

BACKGROUND: This study explores the feasibility and acceptability of a computer self-administered approach to substance use screening from the perspective of primary care patients. METHODS: Forty-eight patients from a large safety net hospital in New York City completed an audio computer-assisted self-interview (ACASI) version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and a qualitative interview to assess feasibility and acceptability, comprehension, comfort with screening questions, and preferences for screening mode (interviewer or computer). Qualitative data analysis organized the participants' feedback into major themes. RESULTS: Participants overwhelmingly reported being comfortable with the ACASI ASSIST. Mean administration time was 5.2 minutes (range: 1.6-14.8 minutes). The major themes from the qualitative interviews were (1) ACASI ASSIST is feasible and acceptable to patients, (2) Social stigma around substance use is a barrier to patient disclosure, and (3) ACASI screening should not preclude personal interaction with providers. CONCLUSIONS: The ACASI ASSIST is an appropriate and feasible approach to substance use screening in primary care. Because of the highly sensitive nature of substance use, screening tools must explain the purpose of screening, assure patients that their privacy is protected, and inform patients of the opportunity to discuss their screening results with their provider.

In our country tortilla doesn't make us fat: cultural factors influencing lifestyle goal-setting for overweight and obese Urban, Latina patients.

Obesity disproportionately affects Latina adults, and goal-setting is a technique often used to promote lifestyle behavior change and weight loss. To explore the meanings and dimensions of goal-setting in immigrant Latinas, we conducted four focus groups arranged by language ability and country of origin in an urban, public, primary care clinic. We used a narrative analytic approach to identify the following themes: the immigrant experience, family dynamics, and health care. Support was a common sub-theme that threaded throughout, with participants relying on the immigrant community, family, and the health care system to support their goals. Participants derived satisfaction from setting and achieving goals and emphasized personal willpower as crucial for success. These findings should inform future research on how goal-setting can be used to foster lifestyle behavior change and illustrate the importance of exploring the needs of Latino sub-groups in order to improve lifestyle behaviors in diverse Latino populations.

Sending-country violence and receiving-country discrimination: effects on the health of Colombian refugees in Ecuador.

This study explored factors affecting the health and well being of recent refugees from Colombia in Ecuador. Data collection focused on how sending-country violence and structural violence in a new environment affect immigrant health vulnerability and risk behaviors. A qualitative approach included ethnographic observation, media content analysis, focus groups, and individual interviews with refugees (N = 137). The focus groups (5) provided perspectives on the research domains by sex workers; drug users; male and female refugees; and service providers. Social and economic marginalization are impacting the health and well being of this growing refugee population. Data illustrate how stigma and discrimination affect food and housing security, employment and health services, and shape vulnerabilities and health risks in a new receiving environment. Widespread discrimination in Ecuador reflects fears, misunderstanding, and stereotypes about Colombian refugees. For this displaced population, the sequelae of violence, combined with survival needs and lack of support and protections, shape new risks to health and well-being.