Developing sugar-sweetened beverage warning labels for young adults.

OBJECTIVE: There is a lack of qualitative research developing sugar-sweetened beverage (SSB) warning labels with their intended end users. We sought to identify promising SSB warning elements for improving label effectiveness and for future testing in policy and institutional settings. DESIGN: Mixed methods design using ten focus groups, a design task and a survey. The design task was used to generate ideas for an icon that would dissuade SSB consumption. The survey and focus group guide assessed participant perceptions of SSB warning label mock-ups of text (loss frame, gain frame and loss frame with attribution), colour and icon options. SETTING: Three large public universities in California from February to March 2018. PARTICIPANTS: Young adult SSB consumers (n 86) enrolled in one of three diverse California public universities. RESULTS: Participants perceived the following elements as most effective for reducing SSB consumption: loss-frame text with attribution to a credible source, yellow and red colour for label background and an image or icon to accompany the text. Preferred images included sugar near or inside of an SSB, intuitive shapes like a triangle with exclamation mark or octagon and a visual indicator of SSB sugar content compared with recommended limits. Support was high for using SSB warning labels in university cafeterias and on bottles/cans. CONCLUSIONS: Loss-frame text with a credible source, yellow or red label colour and icons could potentially enhance effectiveness of SSB warning labels and warrant further testing.

'Spending all this time stressing and worrying and calculating': marginal food security and student life at a Diverse Urban University.

OBJECTIVE: Food security status is a continuum ranging from high to very low food security. While marginal food security falls next to high food security on the spectrum, new quantitative research indicates marginal food security status is associated with negative health outcomes and poor academic performance among college students. Qualitative research focusing on college students experiencing marginal food security has not been conducted. The current study aims to qualitatively explore experiences of college students with marginal food security and to identify themes to better understand and provide context regarding how marginal food security impacts students. DESIGN: Students were recruited for semi-structured interviews with questions designed to study the challenges associated with students' food situations. All interviews were recorded and transcribed with themes identified via an inductive approach. SETTING: A large public university on the US west coast. PARTICIPANTS: Thirty college students. RESULTS: Key themes that emerged: purchasing cheap unhealthy foods, insufficient time to prepare and eat meals on a regular basis, stress and anxiety around the inability to eat healthy food and future health issues, self-perception of health when eating poorly along with physical symptoms and low academic motivation by not fully participating in their courses due to few healthy food options or missing meals. CONCLUSION: Marginal food security can potentially diminish students' health and their capacity to learn and succeed in their coursework. The results emphasise that students experiencing marginal food security should not be grouped with students experiencing high food security.

"The Ones that Care Make all the Difference": Perspectives on Student-Faculty Relationships.

Student-faculty (S-F) interactions that are conducive to students' learning can help reduce the retention and graduation gaps in higher education, especially for college students from underrepresented and underprivileged backgrounds. The aim of the study was to explore students' perceptions of their interactions with faculty, and the subjective impact of these interactions on students' academic and personal life. We analyzed qualitative data from a larger study with the goal of providing best practice models to support students experiencing displacement and food insecurity. Through purposive sampling techniques, 53 students from a diverse public university were recruited. Recruitment strategies focused on students who were likely to be facing academic, personal, and/or financial challenges that may affect their academic performance. Students were interviewed three to four times over a four to six-month period, using semi-structured interview guides. Our multidisciplinary team analyzed data thematically in team-based coding sessions using an online software. We identified four themes for faculty practices: (1) Creating Pedagogical Space, (2) Being Inclusive and Aware, (3) Being Engaged and Engaging Students, (4) Doing More Than Teaching. Based on students' perspectives, these practices lead to supportive and responsive S-F relationships that facilitate learning and success. The findings have implications related to how faculty can encourage caring S-F relationships and create conducive learning environments where students can thrive, especially during times of crisis.

Cultural Competence Training for Law Enforcement Responding to Domestic Violence Emergencies With the Deaf and Hard of Hearing: A Mixed-Methods Evaluation.

OBJECTIVE: To evaluate a training workshop for law enforcement as first responders for the purpose of increasing officers' cultural competency in working with Deaf and hard-of-hearing people (Deaf/HH) during domestic violence (DV) emergencies. METHOD: This evaluation assesses the efficacy of a 2-hour training workshop for law enforcement. Thirty-four participants completed questionnaires at pre- and postintervention to assess participants' (1) satisfaction with training; (2) skills in responding to Deaf/HH individual(s) in a DV emergency; (3) attitudes toward the Deaf/HH, including bias recognition, self-assessment of cultural competency, and perceived self-efficacy; and (4) knowledge of communication. Focus groups (FGs) were also conducted (n = 6 for FG1, n = 13 for FG2). SPSS software was used to analyze survey data; principal components analysis was conducted on the survey instruments. RESULTS: There were significant differences between pre- and posttests for several targeted outcomes, including knowledge and perceived self-efficacy. Both survey and FG results demonstrated that participants gained cultural competency skills as indicated by changes in attitudes toward the Deaf/HH, both in DV emergencies and in large-scale emergencies. CONCLUSION: Significant differences were evident between pre and posttest results in terms of knowledge and perceived self-efficacy. Nonetheless, survey participants demonstrated a lack of knowledge about policy and the law. Survey findings also suggest that while a onetime training can improve the perceived self-efficacy of participants, shifting attitudes about the capabilities of the Deaf/HH may require different training strategies. FG participants demonstrated a greater awareness of the complexity of working with this population in a DV emergency.

Responding to the deaf in disasters: establishing the need for systematic training for state-level emergency management agencies and community organizations.

BACKGROUND: Deaf and hard-of-hearing (Deaf/HH) individuals have been underserved before and during emergencies. This paper will assess Deaf/HH related emergency preparedness training needs for state emergency management agencies and deaf-serving community-based organizations (CBOs). METHODS: Four approaches were used: 1) a literature review; 2) results from 50 key informant (KI) interviews from state and territorial-level emergency management and public health agencies; 3) results from 14 KI interviews with deaf-serving CBOs in the San Francisco Bay Area; and 4) a pilot program evaluation of an emergency responder training serving the Deaf/HH in one urban community. RESULTS: Results from literature review and state and territorial level KIs indicate that there is a substantive gap in emergency preparedness training on serving Deaf/HH provided by state agencies. In addition, local KI interviews with 14 deaf-serving CBOs found gaps in training within deaf-serving CBOs. These gaps have implications for preparing for and responding to all-hazards emergencies including weather-related or earthquake-related natural disasters, terrorist attacks, and nuclear-chemical disasters. CONCLUSION: Emergency preparedness trainings specific to responding to or promoting preparedness of the Deaf/HH is rare, even for state agency personnel, and frequently lack standardization, evaluation, or institutionalization in emergency management infrastructure. This has significant policy and research implications. Similarly, CBOs are not adequately trained to serve the needs of their constituents.

Global Disability Justice In Climate Disasters: Mobilizing People With Disabilities As Change Agents.

Disabled people are highly susceptible to climate change impacts and disasters, yet they often remain sidelined or largely invisible. Policy makers, humanitarian agencies, and governments need to address the climate-related vulnerabilities that disabled people encounter during acute events and in the course of more creeping forms of climate change. As deaf researchers, we call for integrating disability justice into climate and disaster preparedness policies and practices worldwide. A disability justice approach can embrace the strengths that disabled people bring to disaster planning and climate mitigation and advocacy efforts. In this article we present case studies from different global regions to illustrate how disability is overlooked in responding to climate-related health impacts and disaster planning. We also draw particular attention to mutual aid networks led by disabled people in adapting to climate-related health impacts. We then suggest questions to help policy makers and practitioners integrate disability justice into their work. Above all, disabled people, organizations, and service providers should take ownership over the process of developing policies and actions to better prevent, prepare for, and respond to climate disasters.

Assessing the Emergency Response Role of Community-Based Organizations (CBOs) Serving People with Disabilities and Older Adults in Puerto Rico Post-Hurricane María and during the COVID-19 Pandemic.

In Puerto Rico, a host of factors makes the role of community-based organizations (CBOs) critically important in emergency preparedness and response (EPR) and disability-inclusive disaster risk reduction (DiDRR) addressing the needs of people with disabilities and older adults. The territory has been the site of recurring hurricanes, earthquakes, medical crises, and human-made disasters. Political, social, and economic problems unique to the archipelago have historically limited the preparedness and response capacity of governmental authorities, especially for its most at-risk populations. In a context of severe constraints on government resources, CBOs are positioned to play an outsized role in providing services for disabled and older adults before, during, and after emergencies. This study assesses the emergency preparedness and response capacity of CBOs (n = 22) for addressing the needs of people with disabilities and the elderly. Semi-structured, largely closed-ended interviews were conducted in Spanish with key informants at Puerto Rican CBOs. The interviews included questions about emergency preparedness and response training, as well as organizational capacity during COVID-19 and post-Hurricane María. This study posits that conditions in Puerto Rico place CBOs at the forefront of critical responsibilities including emergency preparedness and response, warranting assessment of their practices and resources to assist them in fulfilling their mission.

Food Worry in the Deaf and Hard-of-Hearing Population During the COVID-19 Pandemic.

OBJECTIVE: The coronavirus disease 2019 (COVID) pandemic has highlighted preexisting health disparities, including food insecurity, in the deaf and hard-of-hearing (DHH) population. We examined factors associated with food worry during the COVID-19 pandemic. METHODS: We collected survey data on worry about food shortages, worry about contracting COVID-19, and concerns about DHH people staying home and being lonely from April 17 through May 1, 2020, via a bilingual American Sign Language/English online survey platform. The sample consisted of 537 DHH adults living in the United States. We examined the relationship between demographic characteristics and food worry. We used logistic regression and model fitting to predict the likelihood of experiencing food worry. RESULTS: The mean (SD) age of survey respondents was 47 (16), and 25% of the sample identified as people of color. Forty-two percent of survey respondents had a high level of food worry. Increased worry about contracting COVID-19 and concerns about DHH people staying home and being lonely among DHH younger adults or those without a college degree predicted food worry. Gender and race/ethnicity did not contribute to the model for food worry. CONCLUSIONS: Food worry was explained by multiple, intersecting factors, including demographic variables, worry about contracting COVID-19, and concerns about loneliness. Interventions or programs implemented by DHH-serving organizations as well as government programs, social service providers, and food banks should be fully accessible to subgroups of DHH young adults without a college degree who are at risk for food insecurity.

Reflexivity and humility evoke a transformable methodology in a post disaster context.

OBJECTIVE: The process of reflexivity is used to critically examine the experience of conducting qualitative research with functionally diverse older adults in a post disaster context. METHODS: The design of the study began with an interpretative phenomenological framework, using in-depth interviews. Fifteen individuals with functional and access needs living in Puerto Rico were interviewed regarding their experiences after Hurricane María of 2017. FINDINGS: In the field, it was necessary to expand the initial design, and adjust to participants' preferences and needs, as well as situational characteristics, without compromising ethical standards of practice. The methodology transformed because of the need for flexibility requiring humility from the researchers. A more relational form of inquiry was warranted, which acknowledged the intersubjectivity of human experience. This entailed adapting to community involvement, building rapport with community leaders functioning as gatekeepers, and integrating family or friends in interviews. DISCUSSION: The reflexive approach allowed for a better understanding of the researcher's positionalities and how they influence the ability or inability to develop trust (e.g. insider/ outsider status, Puerto Rican/ US, with functional and access needs/ without functional and access needs). CONCLUSIONS: Given the shift toward relational inquiry and due to the challenges faced while carrying out the study, we suggest that post-disaster qualitative research would benefit from further including principles of indigenous decolonizing methodologies, which can be incorporated into studies using interpretative phenomenological analysis.

Investigating the Feasibility of a Restaurant Delivery Service to Improve Food Security among College Students Experiencing Marginal Food Security, a Head-to-Head Trial with Grocery Store Gift Cards.

Restaurant delivery services have gained in popularity among college students; however, students participating in the Supplemental Nutrition Assistance Program (SNAP) are not allowed to redeem their benefits via restaurant delivery services. This mixed-methods head-to-head crossover trial assessed whether college students experiencing marginal food security prefer benefits via a grocery store gift card (as a proxy for traditional SNAP benefits) or via a restaurant delivery service gift card of equivalent value, and which type of benefit is more effective at improving food security status. Thirty college students experiencing marginal food security were recruited to receive $80 in cash equivalent benefits to spend over a two-month period in the form of grocery store gift cards and restaurant delivery service gift cards. Participants completed surveys and interviews to measure their food security status and share their experiences with each benefit type. After four months of benefits, 48.3% of participants improved their food security status. However, neither type of benefit was statistically better at improving food security status. Most participants preferred grocery store benefits (89.7%) over restaurant delivery service benefits (10.3%). However, more research is needed to explore whether allowing SNAP recipients to redeem their benefits with restaurant delivery services is a viable mechanism to address food challenges among college students experiencing marginal food security.

Quality of Life and Needs of Deaf Informal Caregivers of Loved Ones with Alzheimer's and Related Dementia.

No studies have included the experiences and needs of informal caregivers who are deaf, use American Sign Language (ASL), and care for a loved one with Alzheimer's disease or related dementias (ADRD). The CDC's BRFSS Caregiver Module and PROMIS-Deaf Profile measures were administered via an online bilingual English/ASL platform between October 2019 and March 2020. Out of 194 deaf adult signers who completed an online survey, 42 respondents (mean age = 66; SD = 12; 74% White) endorsed informally caring for someone with a medical condition. In this survey subsample of informal caregivers, more years of education was significantly associated with higher generic quality of life and higher deaf-specific quality of life. A smaller subset of informal deaf informal caregivers who were currently taking care of loved ones with ADRD were then invited to participate in a semi-structured interview. Among the 22 informal caregivers who were interviewed, there was a strong agreement among the participants who felt that their quality of life as informal caregivers was worse than hearing informal caregivers who took care of loved ones with ADRD. Findings highlight the importance of a call to action to address the needs of deaf informal ADRD caregivers.

Peer support and food security in deaf college students.

Objective: The purpose of the study was to investigate whether peer support and demographic characteristics predicted food security among deaf college students. Participants: The sample included 166 deaf college students at Gallaudet University. Methods: Participants completed a bilingual online survey in American Sign Language (ASL) and English. This survey included USDA's 6-item food security survey, questions about peer support and socio-demographic characteristics. Results: Out of 166 students (mean age =23; SD = 6), 60.7% were food secure. About 26.4% were at-risk for low food security and another 12.9% had very low food security. The sample included respondents who identified as people of color (54%) and women (52%). Binary logistic regression revealed that compared to people who reported always receiving peer support, people who never received peer support were 16.3 times more likely to experience food insecurity (adj OR: 16.325, 95% CI 1.824-146.107). Conclusions: This study demonstrates a strong relationship between peer support and deaf college students' food security experiences.

State of the Profession: The Landscape of Disability Justice, Health Inequities, and Access for Patients With Disabilities.

The nursing profession can both perpetuate inequities and elevate the discourse around disability. Our article uses an intersectional lens to discuss the scope, magnitude, and determinants of health inequities that people with disabilities experience and the ways in which theoretical models of disability used in nursing education can further contribute to inequities. Our article makes the case for an intersectional social justice approach to nursing education by contextualizing the current state of affairs within historical and contemporary models of disability. This has the potential to be a revolutionary leap toward promoting health equity and upholding the Code of Ethics.

Deaf Women's Health: Adherence to Breast and Cervical Cancer Screening Recommendations.

INTRODUCTION: No prevalence studies on cancer screening adherence among Deaf women have been conducted in the past decade. Current data on breast and cervical cancer screening are needed from Deaf women who adhered or did not adhere to the U.S. Preventative Services Task Force screening guidelines. The objectives of this study were to assess whether disparities for cancer screening adherence persist for Deaf women compared with the general population and whether racial and ethnic disparities for adherence exist among Deaf women. METHODS: Data for adherence to Pap (n=529, Deaf women; n=1,119, hearing women) and mammogram screening (n=324, Deaf women; n=1,086, hearing women) were drawn from the Health Information National Trends Survey in American Sign Language (Deaf women; February-August 2017 and October 2017-May 2018) and the Health Information National Trends Survey 5, Cycle 1, data set (hearing women; January-May 2017). Data were analyzed in 2018. Propensity score model of the weighed samples estimated the probability of adherence among the entire sample and within the sample of Deaf women for each screening test. RESULTS: About 78% (n=415) of age-eligible Deaf women and 85% (n=956) of age-eligible hearing women adhered to Pap screening recommendations (p<0.001). For breast cancer screening, the adherence rates for 245 Deaf women and 891 hearing women were 76% and 82%, respectively (p<0.01). After adjusting for correlates, for Deaf women, disparities remained for cervical cancer screening but not breast cancer screening. Race and ethnicity were not associated with cancer screening adherence. CONCLUSIONS: This is a call to action for targeted, accessible health promotion interventions for age-eligible Deaf women to increase adherence to cervical cancer screening.

Conducting health policy analysis in primary care research: turning clinical ideas into action.

Healthcare guidelines play a prominent role in the day-to-day practice of primary care providers, and health policy research leads to the formation of these guidelines. Health policy research is the multidisciplinary approach to public policy explaining the interaction between health institutions, special interests and theoretical constructs. In this article, we demonstrate how primary care providers can conduct high-impact health policy research using Eugene Bardach's eightfold policy analysis framework in a primary care context. In a medical case, a woman with a history of total hysterectomy had scheduled a visit for a Papanicolaou (Pap) smear screening test as part of a well-woman health check-up with a family medicine resident. Conflicting recommendations on Pap smear screening after total hysterectomy sparked an investigation using the US Preventive Services Task Force criteria for conducting a health policy analysis. We illustrate broadly how clinical care dilemmas can be examined by using Bardach's broadly applicable health policy framework in order to inform meaningful policy change. Bardach's framework includes (1) defining the problem, (2) assembling evidence, (3) constructing alternatives, (4) selecting criteria, (5) projecting outcomes, (6) confronting trade-offs, (7) decision-making and (8) sharing the results of the process. The policy analysis demonstrated insufficient evidence to recommend Pap test screening after hysterectomy and the findings contributed to national recommendations. By following Bardach's steps, primary care researchers have a feasible and powerful tool for conducting meaningful health policy research and analysis that can influence clinical practice.

Deaf patient-provider communication and lung cancer screening: Health Information National Trends survey in American Sign Language (HINTS-ASL).

OBJECTIVE: To assess whether mode of communication and patient centered communication (PCC) with physicians were associated with the likelihood of deaf smokers inquiring about lung cancer screening. METHODS: An accessible health survey including questions about PCC, modes of communication, smoking status and lung cancer screening was administered in American Sign Language (HINTS-ASL) to a nationwide sample of deaf adults from February to August 2017. Of 703 deaf adults who answered the lung screening question, 188 were 55-80 years old. RESULTS: The odds ratio of asking about a lung cancer screening test was higher for people with lung disease or used ASL (directly or through an interpreter) to communicate with their physicians. PCC was not associated with asking about a lung cancer screening test. CONCLUSION: Current or former smokers who are deaf and use ASL are at greater risk for poorer health outcomes if they do not have accessible communication with their physicians. PRACTICE IMPLICATIONS: Optimal language access through interpreters or directly in ASL is critical when discussing smoking cessation or lung cancer screening tests. Counseling and shared decision-making will help improve high-risk deaf patients' understanding and decision-making about lung cancer screening.

Deaf and Hard-of-Hearing Learners in Emergency Medicine.

Approximately 23% of Americans over age 12 have some level of hearing loss.1 Emergency departments can reduce healthcare barriers for deaf and hard-of-hearing (DHoH) patients through improved patient-physician communication. DHoH students, once they become physicians, may provide one mechanism for reducing existing healthcare disparities and communication barriers for DHoH patients, and may be more adept with patients facing other communication barriers. A renewed interest in disability access and a commitment to social justice has increased efforts toward the inclusion of individuals with disabilities in medical education and training. Despite this increased interest and a growing number of DHoH students entering medical education, DHoH students continue to be dissuaded from specialty careers such as emergency medicine (EM) over concerns regarding effective communication and ability. Given the academic medicine communities' commitment to diversity, a recounting of the successful inclusion of DHoH students in EM can benefit medical education and practice. In this account, the authors reflect on the successful experiences of a visiting DHoH medical student in an academic EM rotation at a Level I trauma hospital that serves a diverse population, and they identify the potential challenges for DHoH students in an EM setting, offer solutions including reasonable accommodations, and provide commentary on the legal requirements for providing full and equal access for DHoH students. We secured permission from the student to share the contents of this article prior to publication.

Risk perception and perceived self-efficacy of deaf and hard-of-hearing seniors and young adults in emergencies.

OBJECTIVES: The authors explored the factors influencing risk perception and perceived self-efficacy before and during an emergency for deaf and hard-of-hearing (Deaf/HH) seniors and young adults. METHODS: The authors collected demographic survey data and conducted four focus groups with 38 Deaf/HH residents of the San Francisco Bay Area; two groups were with young adults (ages 18-35), including one group of college students and one group of young professionals, and two were with older adults (ages 50-90). RESULTS: Significant differences were found between Deaf/HH young adults and seniors in both the sources of self-efficacy and risk perception and their attitudes toward preparedness. All groups demonstrated high resilience. Deaf/HH young professionals expressed more concern about their risk in an emergency than Deaf/HH college students. Alternately, the risk perception of Deaf/HH older adults was often rooted in their past experiences (survival of past emergencies, inaccessibility of communications during drills). CONCLUSIONS: Policy implications include the need to dedicate more resources to increasing accessibility and relevance of emergency communications technology for Deaf/HH populations. This could help increase adaptability before, during, and after emergencies among all groups of Deaf/HH people, particularly among young Deaf/HH professionals.

Risk perception and perceived self-efficacy of deaf and hard-of-hearing seniors and young adults in emergencies.

OBJECTIVES: The authors explored the factors influencing risk perception and perceived self-efficacy before and during an emergency for deaf and hard-of-hearing (Deaf/HH) seniors and young adults. METHODS: The authors collected demographic survey data and conducted four focus groups with 38 Deaf/HH residents of the San Francisco Bay Area; two groups were with young adults (ages 18-35), including one group of college students and one group of young professionals, and two were with older adults (ages 50-90). RESULTS: Significant differences were found between Deaf/HH young adults and seniors in both the sources of self-efficacy and risk perception and their attitudes toward preparedness. All groups demonstrated high resilience. Deaf/HH young professionals expressed more concern about their risk in an emergency than Deaf/HH college students. Alternately, the risk perception of Deaf/HH older adults was often rooted in their past experiences (survival of past emergencies, inaccessibility of communications during drills). CONCLUSIONS: Policy implications include the need to dedicate more resources to increasing accessibility and relevance of emergency communications technology for Deaf/HH populations. This could help increase adaptability before, during, and after emergencies among all groups of Deaf/HH people, particularly among young Deaf/HH professionals.