La vida en la frontera: protocol for a prospective study exploring stress and health resiliencies among Mexican-origin individuals living in a US-Mexico border community.

BACKGROUND: Mexican-origin adults living near the U.S.-Mexico border experience unique and pervasive social and ecological stressors, including poverty, perceived discrimination, and environmental hazards, potentially contributing to the high burden of chronic disease. However, there is also evidence that residents in high-density Mexican-origin neighborhoods exhibit lower prevalence rates of disease and related mortality than those living in other areas. Understanding the factors that contribute to health resiliencies at the community scale is essential to informing the effective design of health promotion strategies. METHODS: La Vida en la Frontera is a mixed-methods participatory study linking a multi-disciplinary University of Arizona research team with Campesinos Sin Fronteras, a community-based organization founded by community health workers in San Luis, Arizona. This paper describes the current protocol for aims 2 and 3 of this multi-faceted investigation. In aim 2 a cohort of N≈300 will be recruited using door-to-door sampling of neighborhoods in San Luis and Somerton, AZ. Participants will be surveyed and undergo biomarker assessments for indicators of health and chronic stress at three time points across a year length. A subset of this cohort will be invited to participate in aim 3 where they will be interviewed to further understand mechanisms of resilience and wellbeing. DISCUSSION: This study examines objective and subjective mechanisms of the relationship between stress and health in an ecologically diverse rural community over an extended timeframe and illuminates health disparities affecting residents of this medically underserved community. Findings from this investigation directly impact the participants and community through deepening our understanding of the linkages between individual and community level stress and chronic disease risk. This innovative study utilizes a comprehensive methodology to investigate pathways of stress and chronic disease risk present at individual and community levels. We address multiple public health issues including chronic disease and mental illness risk, health related disparities among Mexican-origin people, and health protective mechanisms and behaviors.

A Community Health Worker-Led Community-Clinical Linkage Model to Address Emotional Well-Being Outcomes Among Latino/a People on the US-Mexico Border.

INTRODUCTION: Compared with their non-Hispanic White counterparts, Latino/a people have limited access to health resources that might improve their emotional well-being. Interventions that prioritize the Latino/a population, address social determinants of health, and decrease health disparities are needed. The objective of this study was to describe a community-clinical linkage intervention led by community health workers (CHWs) in 3 Latino/a populations along the US-Mexico border. METHODS: Researchers at the Arizona Prevention Research Center conducted the Linking Individual Needs to Community and Clinical Services (LINKS) study during 2017-2018. Clinic-based CHWs referred participants to community-based CHWs who met with participants monthly for 6 months to assess participant needs, provide support for emotional well-being, and link them to resources. Two community-based CHWs collaborated to maximize participant care; they also administered an emotional well-being questionnaire at baseline and at 3-month and 6-month follow-up. We estimated changes in emotional well-being outcomes. RESULTS: Scores for social support, perceived hopefulness, and quality-of-life measures among 189 LINKS participants increased significantly during the study period, especially among men and participants with low baseline scores. For each of the 3 outcomes, the standardized change was approximately 0.28 per 3 months of intervention, a decrease of more than half an SD (0.56) during 6 months of follow-up. CONCLUSION: A CHW-led community-clinical linkage intervention can result in positive emotional well-being outcomes. We encourage policy makers, funders, and public health practitioners to further investigate such interventions as a solution to reduce disparities in emotional well-being.

Mechanisms of Racial Disparities in Cognitive Aging: An Examination of Material and Psychosocial Well-Being.

OBJECTIVES: We tested the hypothesis that education's effect on cognitive aging operates in part through measures of material and psychosocial well-being. METHOD: Our sample was of non-Latino black and white participants of the National Social Life Health and Aging Project who had valid cognitive assessments in Waves 2 and 3 (n = 2,951; age range: 48-95). We used structural equation modeling to test for mediation and moderated mediation by income, assets, perceived stress, social status, and allostatic load on the relationships between race, education, and cognition at two time points. RESULTS: Education consistently mediated the race-cognition relationship, explaining about 20% of the relationship between race and cognition in all models. Income and assets were moderated by race; these factors were associated with cognition for whites but not blacks. Social status mediated the association between race and cognition, and social status and perceived stress mediated the education-cognition pathway. Allostatic load was not a mediator of any relationship. DISCUSSION: Education remains the best explanatory factor for cognitive aging disparities, though material well-being and subjective social status help to explain a portion of the racial disparity in cognitive aging.

The role of social and behavioral risk factors in explaining racial disparities in age-related cognitive impairment: a structured narrative review.

Alzheimer's disease (AD) is a growing public health concern with large disparities in incidence and prevalence between African Americans (AAs) and non-Hispanic whites (NHWs). The aim of this review was to examine the evidence of association between six modifiable risk factors (education, smoking, physical inactivity, obesity, social isolation, and psychosocial stress) and Alzheimer's disease risk in AAs and NHWs. We identified 3,437 studies; 45 met inclusion criteria and were included in this review. Of the examined risks, education provided the strongest evidence of association with cognitive outcomes in AAs and NHWs. This factor may operate directly on Alzheimer's disease risk through the neurocognitive benefits of cognitive stimulation or indirectly through social status.

Protocol for LINKS (linking individual needs to community and clinical services): a prospective matched observational study of a community health worker community clinical linkage intervention on the U.S.-Mexico border.

BACKGROUND: Latinos are currently the largest and fastest growing racial/ethnic group in the United States and have the lowest rates nationally of regular sources of primary care. The changing demographics of Latino populations have significant implications for the future health of the nation, particularly with respect to chronic disease. Community-based agencies and clinics alike have a long history of engaging community health workers (CHWs) to provide a broad range of tangible and emotional support strategies for Latinos with chronic diseases. In this paper, we present the protocol for a community intervention designed to evaluate the impact of CHWs in a Community-Clinical Linkage model to address chronic disease through innovative utilization of electronic health records (EHRs) and application of mixed methodologies. Linking Individual Needs to Community and Clinical Services (LINKS) is a 3-year, prospective matched observational study designed to examine the feasibility and impact of CHW-led Community-Clinical Linkages in reducing chronic disease risk and promoting emotional well-being among Latinos living in three U.S.-Mexico border communities. METHODS: The primary aim of LINKS is to create Community-Clinical Linkages between three community health centers and their respective county health departments in southern Arizona. Our primary analysis is to examine the impact of the intervention 6 to 12-months post program entry. We will assess chronic disease risk factors documented in the EHRs of participants versus matched non-participants. By using a prospective matched observational study design with EHRs, we have access to numerous potential comparators to evaluate the intervention effects. Secondary analyses include modeling within-group changes of extended research-collected measures. This approach enhances the overall evaluation with rich data on physical and emotional well-being and health behaviors of study participants that EHR systems do not collect in routine clinical practice. DISCUSSION: The LINKS intervention has practical implications for the development of Community-Clinical Linkage models. The collaborative and participatory approach in LINKS illustrates an innovative evaluation framework utilizing EHRs and mixed methods research-generated data collection. TRIAL REGISTRATION: This study protocol was retrospectively registered, approved, and made available on Clinicaltrials.gov by NCT03787485 as of December 20, 2018.

State inequality, socioeconomic position and subjective cognitive decline in the United States.

BACKGROUND: Social gradients in health have been observed for many health conditions and are suggested to operate through the effects of status anxiety. However, the gradient between education and Alzheimer's disease is presumed to operate through cognitive stimulation. We examined the possible role of status anxiety through testing for state-level income inequality and social gradients in markers of socioeconomic position (SEP) for Alzheimer's disease risk. METHODS: Using data from the cross-sectional 2015 and 2016 Behavioral Risk Factor Surveillance System (BRFSS) and the U.S. Census Bureau's American Community Survey, we tested for the association between U.S. state-level income inequality and individual SEP on subjective cognitive decline (SCD) - a marker of dementia risk - using a generalized estimating equation and clustering by state. RESULTS: State income inequality was not significantly associated with SCD in our multivariable model (OR 1.2; 95% CI: 0.9, 1.6; p=0.49). We observed a clear linear relationship between household income and SCD where those with an annual household income of 50k to 75k had 1.4 (95% CI: 1.3, 1.6) times the odds and those with household incomes of less than $10,000 had 4.7 (95% CI: 3.8, 5.7) times the odds of SCD compared to those with household income of more than $75,000. We also found that college graduates (ref.) and those who completed high school (OR: 1.1; 95% CI 1.04, 1.2) fared better than those with some college (OR: 1.3, 95% CI 1.2, 1.4) or less than a high school degree (OR: 1.5; 95% CI: 1.4, 1.7). CONCLUSIONS: Income inequality does not play a dominant role in SCD, though a social gradient in individual income for SCD suggests the relationship may operate in part via status anxiety.

Community-Clinical Linkages With Community Health Workers in the United States: A Scoping Review.

Despite the proliferation of community-clinical linkage (CCL) interventions with community health workers (CHWs), little is known about the components of these programs or how linkages are realized. In this scoping review, we synthesize evidence concerning the role of CHWs in creating and sustaining CCLs aimed at improving individual health outcomes. Our inclusion criteria included peer-reviewed articles that described a CHW intervention in the United States that used a CCL model. A total of 2,776 titles and/or abstracts were screened and 47 articles underwent full text review. Two independent reviewers rated the screened articles based on additional criteria including the CHW connection to community and evidence of linkage follow up rather than simple referral. For the 11 peer-reviewed articles included in the final review, we describe the CHW's relationship to the community, training, and role within the intervention, linkage, and outcomes. We used a standardized framework to determine commonalities in CHW roles across the interventions. CCLs with CHWs positively affect the delivery of both clinical care and community resources across a range of disease areas in a variety of contexts. To identify effective CCL models, additional information on CHW training, CCL follow-up methods, and the CHW role in CCLs is recommended.

Perspectives on a US-Mexico Border Community's Diabetes and "Health-Care" Access Mobilization Efforts and Comparative Analysis of Community Health Needs over 12 Years.

This paper describes a community coalition-university partnership to address health needs in an underserved US-Mexico border, community. For approximately 15 years, this coalition engaged in community-based participatory research with community organizations, state/local health departments, and the state's only accredited college of public health. Notable efforts include the systematic collection of health-relevant data 12 years apart and data that spawned numerous health promotion activities. The latter includes specific evidence-based chronic disease-preventive interventions, including one that is now disseminated and replicated in Latino communities in the US and Mexico, and policy-level changes. Survey data to evaluate changes in a range of health problems and needs, with a specific focus on those related to diabetes and access to health-care issues-identified early on in the coalition as critical health problems affecting the community-are presented. Next steps for this community and lessons learned that may be applicable to other communities are discussed.

Documenting Community Health Worker Roles in Primary Care: Contributions to Evidence-Based Integration Into Health Care Teams, 2015.

The Patient Protection and Affordable Care Act provided community health workers (CHWs) with new opportunities, and current efforts develop evidence-based guidelines for CHW integration into clinical teams. This qualitative study documents CHW roles and activities in 3 federally qualified health care centers in southern Arizona. Community health worker clinical roles, activities, and integration varied by health center and were in flux. Integration included complementary roles, scheduled and everyday communications with team members, and documentation in the electronic health records. These findings contribute to evidence-based guidelines for CHW integration into clinical teams that are critical to maximizing CHW contributions to patient health improvements.

A Comparison of Methods for Capturing Patient Preferences for Delivery of Mental Health Services to Low-Income Hispanics Engaged in Primary Care.

BACKGROUND: Consideration of patient preferences regarding delivery of mental health services within primary care may greatly improve access and quality of care for the many who could benefit from those services. OBJECTIVES: This project evaluated the feasibility and usefulness of adding a consumer-products design method to qualitative methods implemented within a community-based participatory research (CBPR) framework. RESEARCH DESIGN: Discrete-choice conjoint experiment (DCE) added to systematic focus group data collection and analysis. SUBJECTS: Focus group data were collected from 64 patients of a Federally-Qualified Health Center (FQHC) serving a predominantly low-income Hispanic population. A total of 604 patients in the waiting rooms of the FQHC responded to the DCE. MEASURES: The DCE contained 15 choice tasks that each asked respondents to choose between three mental health services options described by the levels of two (of eight) attributes based on themes that emerged from focus group data. RESULTS: The addition of the DCE was found to be feasible and useful in providing distinct information on relative patient preferences compared with the focus group analyses alone. According to market simulations, the package of mental health services guided by the results of the DCE was preferred by patients. CONCLUSIONS: Unique patterns of patient preferences were uncovered by the DCE and these findings were useful in identifying pragmatic solutions to better address the mental health service needs of this population. However, for this resource-intensive method to be adopted more broadly, the scale of the primary care setting and/or scope of the issue addressed have to be relatively large.

Development and Psychometric Assessment of the Measure of Globalization Influence on Health Risk (MGIHR) Among Mexican Women with Breast Cancer.

Lacking in the literature are data addressing the extent to which changes in reproductive and lifestyle factors predispose women in developing nations to higher breast cancer rates, and the degree to which these are due to globalization influences. This article describes the development and psychometric assessment of an instrument intended to measure global, predominantly U.S., influences on breast cancer risk profile among women residing in Mexico. Using investigator consensus and a focus group methodology, the Measure of Globalization Influence on Health Risk (MGIHR) was developed and completed by 341 women. Psychometric analysis support the use of an 11-item Consumerism and Modernity scale and 7-item Reproductive Control and Gender Role scale. The MGIHR is a valid and reliable instrument for understanding changing lifestyle and reproductive factors for breast cancer risk and may provide a more complete understanding of breast cancer development and needed interventions.

State Medicaid expansion, community interventions, and health care disparities in a United States-Mexico border community.

OBJECTIVES: We investigated whether access to and use of health care services increased among residents of a low-income, predominantly Mexican American border community affected by the expansion of Arizona's Medicaid program in 2001 and multiple community-level programs and policies. METHODS: We used data from a probability sample of 1623 adult residents of Douglas, Arizona, who participated in cross-sectional health surveys in 1998 and 2010. Response rates were 83% and 86%, respectively. RESULTS: In 2010, participants were more likely to have a usual source of care, to have visited a provider in the previous year, and to have been screened for diabetes and hypertension and less likely to have delayed needed care or to have seen a regular provider in Mexico (P < .001 for all outcomes). Improvements in access to and use of health care were most pronounced among residents with less than a high school education, which reduced or eliminated educational disparities in health care. CONCLUSIONS: Expansion of public insurance programs can effectively reduce health care disparities when paired with other community-level policies and programs that target medically underserved populations.

Stress and sociocultural factors related to health status among US-Mexico border farmworkers.

This study examines factors relating to farmworkers' health status from sociocultural factors, including stress embedded within their work and community contexts. A cross-sectional household survey of farmworkers (N = 299) included social-demographics, immigration status descriptors, and a social-ecologically grounded, community-responsive, stress assessment. Outcomes included three standard US national surveillance measures of poor mental, physical, and self-rated health (SRH). Logistic regression models showed that higher levels of stress were significantly associated (Ps < .001) with increased risk for poor mental health and poor physical health considering all variables. Stress was not associated with SRH. Regarding two of the three outcomes, mental health and physical health, stress added explanatory power as expected. For poor SRH, a known marker for mortality risk and quite high in the sample at 38%, only age was significantly associated. Clinical and systems-level health promotion strategies may be required to mitigate these stressors in border-residing farmworkers.

A community health worker intervention to address the social determinants of health through policy change.

Public policy that seeks to achieve sustainable improvements in the social determinants of health, such as income, education, housing, food security and neighborhood conditions, can create positive and sustainable health effects. This paper describes preliminary results of Acción para la Salud, a public health intervention in which Community health workers (CHWs) from five health agencies engaged their community in the process of making positive systems and environmental changes. Academic-community partners trained Acción CHWs in community advocacy and provided ongoing technical assistance in developing strategic advocacy plans. The CHWs documented community advocacy activities through encounter forms in which they identified problems, formulated solutions, and described systems and policy change efforts. Strategy maps described the steps of the advocacy plans. Findings demonstrate that CHWs worked to initiate discussions about underlying social determinants and environment-related factors that impact health, and identified solutions to improve neighborhood conditions, create community opportunities, and increase access to services.

Establishing a professional profile of community health workers: results from a national study of roles, activities and training.

Community Health Workers (CHWs) have gained national recognition for their role in addressing health disparities and are increasingly integrated into the health care delivery system. There is a lack of consensus, however, regarding empirical evidence on the impact of CHW interventions on health outcomes. In this paper, we present results from the 2010 National Community Health Worker Advocacy Survey (NCHWAS) in an effort to strengthen a generalized understanding of the CHW profession that can be integrated into ongoing efforts to improve the health care delivery system. Results indicate that regardless of geographical location, work setting, and demographic characteristics, CHWs generally share similar professional characteristics, training preparation, and job activities. CHWs are likely to be female, representative of the community they serve, and to work in community health centers, clinics, community-based organizations, and health departments. The most common type of training is on-the-job and conference training. Most CHWs work with clients, groups, other CHWs and less frequently community leaders to address health issues, the most common of which are chronic disease, prevention and health care access. Descriptions of CHW activities documented in the survey demonstrate that CHWs apply core competencies in a synergistic manner in an effort to assure that their clients get the services they need. NCHWAS findings suggest that over the past 50 years, the CHW field has become standardized in response to the unmet needs of their communities. In research and practice, the field would benefit from being considered a health profession rather than an intervention.

Bicultural stress and adolescent risk behaviors in a community sample of Latinos and non-Latino European Americans.

OBJECTIVES: The study examined the relation between adolescent risk behaviors and bicultural stress due to discrimination, immigration, and acculturation factors. We hypothesized bicultural stress would be related to increased risk behavior and depressive symptoms independent of socioeconomic status, ethnic self-identification, and acculturation. DESIGN: Middle school student participants (n=519; median age 14) completed a self-report questionnaire on their risk behaviors, psychosocial antecedents, and socio-demographic factors. Latino (304) and non-Latino European American (215) students were surveyed through a large, urban, West Coast US school district. RESULTS: More bicultural stress was significantly related to reports of all risk behaviors (i.e. smoking, drinking, drug use, and violence) and depressive symptoms. Further, bicultural stress was a robust explanatory variable across sub-groups, and appears largely independent from depressive symptoms. CONCLUSION: The hypotheses were supported. Bicultural stress appears to be an important underlying factor for health disparities among US adolescents. Future research may consider promoting well-being in majority, as well as minority adolescents, through targeting sources of bicultural stressors or examining ways to moderate their effects on adolescent risk behaviors.

A prospective test of distal and proximal determinants of smoking initiation in early adolescents.

This study tests a broad array of determinants of utility for developing smoking preventive interventions using a population-based cohort of early adolescents. Multivariable logistic regressions using never-smokers at baseline (N=1137; age 11-14) showed a model of distal determinants was more predictive of initiation within the approximate 10 month follow up period than one of proximal determinants. When all determinants were simultaneously considered, lesser academic achievement and fewer environmental impediments to smoking most strongly predicted initiation. The findings are consistent with some current smoking prevention programs, however such programs may be further potent by using theory-based social development approaches and through reducing tobacco availability or social contexts where youth can smoke without another adult knowing.

Behavioural risk factors and protective factors in adolescents: a comparison of Latinos and non-Latino whites.

OBJECTIVES: This study investigated differences in behavioural health protective and risk factors in US Latino and non-Latino White adolescents as well as differences among Latinos with different levels of acculturation using a bicultural acculturation model. The bicultural model is consistent with current understanding of cultural change processes; however it has infrequently been applied to understand adolescent health outcomes. The outcomes included risk and health behaviours as well as mental health factors consistent with Jessor's framework for describing adolescents' health status. DESIGN: Participants included 1119 students randomly selected from all middle schools of a Northern California district. Respondents completed project staff administered self-reports surveys in their schools that included assessments of health behaviours, mental health, and socio-cultural variables-including acculturation level. RESULTS: Latinos were at higher risk than non-Latino Whites in the following areas: academic orientation, physical activity, and sunscreen use. Boys and those of lower social class were more likely to report use of various substances and violence. Among Latinos, those in the marginalised acculturation group-those with less attachments and adaptations to Latino and other cultures, showed less desirable mental health outcomes than the bicultural group. CONCLUSION: These results extend prior research by assessing the health needs of early adolescent youth. The study found important differences within Latinos using a bicultural acculturation model. The use of a bicultural acculturation model, or cultural orientation approach more generally, may have special utility for addressing health issues wherever minority populations interact with a dominant society.