Age-related differences in the association between financial hardship and weight change during the COVID-19 pandemic.

Objective: To examine the association of financial hardship with weight changes in the US during the COVID-19 pandemic. Methods: We used data from the COVID-19's Unequal Racial Burden survey, a nationally representative, cross-sectional, online survey of diverse adults living in the US, 12/2020-2/2021. This study included 1000 Asian, Black, Latino (half Spanish-speaking), and White adults and 500 American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and multiracial adults (5500 total). Age-specific (18-39, 40-59, ≥60) associations between financial hardship domains and weight change were estimated using multinomial logistic regression, adjusted for demographic and health characteristics. Results: Financial hardship during the COVID-19 pandemic was prevalent across all age groups (18-39: 76.2 %; 40-59: 75.6 %; ≥60: 50.6 %). Among adults aged 18-39 and ≥ 60 years old, food insecurity was significantly associated with weight loss (18-39: aOR = 1.42, 95 % CI = 1.04, 1.95; ≥60: aOR = 3.67, 95 % CI = 1.50, 8.98). Among all age groups, unmet healthcare expenses was also associated with weight loss (18-39: aOR = 1.31, 95 % CI = 1.01, 1.70; 40-59: aOR = 1.49, 95 % CI = 1.06, 2.08; ≥60: aOR = 1.73, 95 % CI = 1.03, 2.91). Among adults aged 18-39 and ≥ 60 years old, lost income was significantly associated with weight gain (18-39: aOR = 1.36, 95 % CI = 1.09-1.69; ≥60: aOR = 1.46, 95 % CI = 1.04, 2.06), and among adults 40-59 years old, experiencing increased debt was significantly associated with weight gain (aOR = 1.50, 95 % CI = 1.13, 1.99). Conclusions: For those aged 18-39 and ≥ 60 years old experiencing financial hardship during the COVID-19 pandemic was associated with both weight loss and weight gain. Less correlation was observed among adults aged 40-59.

Evaluating the implementation of Nuevo Amanecer-II in rural community settings using mixed methods and equity frameworks.

BACKGROUND: The 10-week Nuevo Amanecer-II intervention, tested through a randomized controlled trial, reduced anxiety and improved stress management skills among Spanish-speaking Latina breast cancer survivors. This paper describes the implementation and equity evaluation outcomes of the Nuevo Amanecer-II intervention delivered in three California rural communities. METHODS: Using implementation and equity frameworks, concurrent convergent mixed methods were applied to evaluate implementation (feasibility, fidelity, acceptability, adoption, appropriateness, and sustainability) and equity (shared power and capacity building) outcomes. Quantitative data were collected using tracking forms, fidelity rating forms, and program evaluation surveys; qualitative data were collected using semi-structured in-depth interviews. Respondents included community-based organization (CBO) administrators, recruiters, compañeras (interventionists), and program participants. RESULTS: Of 76 women randomized to the intervention, 65 (86%) completed at least 7 of 10 sessions. Participants' knowledge (85% correct of 7 questions) and skills mastery were high (85% able to correctly perform 14 skills). Mean fidelity ratings across compañeras ranged from 3.8 (modeled skills) to 5.0 (used supportive/caring communication); 1-5 scale. The program was rated as very good/excellent by 90% of participants. Participants and compañeras suggested including family members; compañeras suggested expanding content on managing thoughts and mood and healthy living and having access to participant's survivorship care plan to tailor breast cancer information. CBOs adopted the program because it aligned with their priority populations and mission. Building on CBOs' knowledge, resources, and infrastructure, implementation success was due to shared power, learning, responsibility, and co-ownership, resulting in a co-created tailored program for community and organizational contexts. Building intervention capacity prior to implementation, providing funding, and ongoing technical support to CBOs were vital for fidelity and enhancement of recruiter and compañera professional skills. Two of three CBOs created plans for program sustainability beyond the clinical trial; all administrators discussed the need for new funding sources to sustain the program as delivered. CONCLUSIONS: Building on community assets and using equitable participatory research processes were central to the successful implementation of a peer-delivered psychosocial intervention in three rural communities among Spanish-speaking Latinas with breast cancer.

Racial/Ethnic Disparities in Financial Hardship During the First Year of the Pandemic.

Introduction: The economic impact of the COVID-19 pandemic has been substantial, yet little is known about the financial effects resulting from lost employment or financial hardship racial-ethnic disparities. Methods: We conducted a nationally representative, online survey of 5500 English- and Spanish-speaking American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, Latino, White, and multiracial adults, from December 2020 to February 2021. Six financial hardship domains were measured (lost income, debt, unmet expenses, unmet health care expenses, housing insecurity, and food insecurity). Prevalence of financial hardship among each racial-ethnic group was estimated using multivariable Poisson regression. Results: Overall, 70.3% reported experiencing financial hardship; debt (57.6%), lost income (44.5%), and unmet expenses (33.7%) were most common. American Indian/Alaska Native (adjusted prevalence ratio [aPR]=1.19, 95% confidence interval [CI]=1.04 to 1.35), Black/African American (aPR=1.18, 95% CI=1.06 to 1.32), Latino (English-speaking: aPR=1.15, 95% CI=1.01 to 1.31; Spanish-speaking: aPR=1.27, 95% CI=1.12 to 1.45), and Native Hawaiian/Pacific Islander (aPR=1.21, 95% CI=1.06 to 1.38) adults were more likely to experience financial hardship, compared with White adults. American Indian/Alaska Native, Black/African American, Spanish-speaking Latino, and Native Hawaiian/Pacific Islander adults were also more likely to report hardship in almost all hardship domains (e.g., housing insecurity: aPRs=1.37-1.91). Conclusions: Racial/ethnic minorities were more likely to experience financial hardship during the pandemic. The prevalence of lost income was similar across most racial/ethnic groups, suggesting that preexisting wealth disparities led to some groups being less able to handle the economic shocks caused by the COVID-19 pandemic. Financial hardship may be underestimated for communities without English or Spanish fluency. Without intervention, financial hardship will likely exacerbate wealth disparities in the United States.

COVID-19 vaccination willingness and uptake among low-income Black/African American, Latino, and White adults living in the U.S.

The purpose of this study was to assess differences in COVID-19 vaccine willingness and uptake between low-income and non-low-income adults and across race-ethnicity. We utilized data from the COVID-19's Unequal Racial Burden online survey, which included baseline (12/17/2020-2/11/2021) and 6-month follow-up (8/13/2021-9/9/2021) surveys. The sample included 1,500 Black/African American, Latino, and White low-income adults living in the U.S. (N = 500 each). A non-low-income cohort was created for comparison (n = 1,188). Multinomial logistic regression was used to assess differences in vaccine willingness and uptake between low-income and non-low-income adults, as well as across race-ethnicity (low-income adults only). Only low-income White adults were less likely to be vaccinated compared to their non-low-income counterparts (extremely willing vs. not at all: OR = 0.58, 95% CI = 0.39-0.86); low-income Black/African American and Latino adults were just as willing or more willing to vaccinate. At follow-up, only 30.2% of low-income adults who reported being unwilling at baseline were vaccinated at follow-up. White low-income adults (63.6%) appeared less likely to be vaccinated, compared to non-low-income White adults (80.9%), low-income Black/African American (70.7%), and low-income Latino adults (72.4%). Distrust in the government (46.6), drug companies (44.5%), and vaccine contents (52.1%) were common among those unwilling to vaccinate. This prospective study among a diverse sample of low-income adults found that low-income White adults were less willing and less likely to vaccinate than their non-low-income counterparts, but this difference was not observed for Black/African American or Latino adults. Distrust and misinformation were prevalent among those who remained unvaccinated at follow-up.

Financial Hardship and Psychological Distress During the Pandemic: A Nationally Representative Survey of Major Racial-Ethnic Groups in the United States.

Introduction: While financial hardship has been consistently linked to psychological distress, little research exists on associations between financial hardship experienced during the pandemic and mental health. Methods: We conducted a nationally representative, online survey of American Indian/Alaska Native, Asian, Black/African American, Latino (English and Spanish speaking), Native Hawaiian/Pacific Islander, White, and multiracial adults, 12/2020-2/2021 (n=5500). Six financial hardship domains were measured (lost income, debt, unmet expenses, unmet health care expenses, housing insecurity, and food insecurity). Psychological distress measures included anxiety-depression symptoms (Patient Health Questionnaire-4), perceived stress (modified Perceived Stress Scale), and loneliness-isolation ("In the past month, how often have you felt lonely and isolated?"). Associations between financial hardship and psychological distress were estimated using multinomial logistic regression. Results: Overall, 70.3% of participants reported experiencing financial hardship (substantial hardship: 21.3%; some hardship: 27.4%; and a little hardship: 21.6%), with Spanish-speaking Latino (87.3%) and Native Hawaiian/Pacific Islander (79.2%) adults being most likely. Debt (57.6%), lost income (44.5%), and unmet expenses (33.7%) were the most common. There was a dose-response association between financial hardship and moderate/severe anxiety-depression symptoms (a little hardship: adjusted odds ratio [aOR]=1.42, 95% confidence interval [CI]=1.12-1.80; some hardship: aOR=3.21, 95% CI=2.58-3.98; and substantial hardship: aOR=8.15, 95% CI=6.45-10.29). Similar dose-response trends were observed with perceived stress and loneliness-isolation. No racial-ethnic difference in the association between financial hardship during the pandemic and psychological distress was seen. Discussion: Financial hardship has had a major impact on psychological distress during the pandemic; moreover, while no racial-ethnic difference in the effect of financial hardship was observed, because racial-ethnic minorities experienced greater hardship, financial hardship may exacerbate psychological distress disparities.

Impact of COVID-related Discrimination on Psychological Distress and Sleep Disturbances across Race-Ethnicity.

COVID-related discrimination towards historically marginalized racial-ethnic groups in the United States has been well-documented; however, its impact on psychological distress and sleep (overall and within specific racial-ethnic groups) is largely unknown. We used data from our nationally representative, online survey of 5,500 American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, Latino, White, and multiracial adults, conducted from 12/2020-2/2021. Participants were asked how often they experienced discriminatory behaviors "because they think you might have COVID-19" (modified Everyday Discrimination Scale). Psychological distress was captured as having experienced anxiety-depression symptoms (Patient Health Questionairre-4, PHQ-4), perceived stress (modified Perceived Stress Scale), or loneliness-isolation ("How often have you felt lonely and isolated?"). Sleep disturbances were measured using the Patient-Reported Outcomes Information System Short Form Sleep Disturbance scale (PROMIS-SF 4a). Overall, 22.1% reported COVID-related discriminatory behaviors (sometimes/always: 9.7%; rarely: 12.4%). 48.4% of participants reported anxiety-depression symptoms (moderate/severe: 23.7% mild: 24.8%), 62.4% reported feeling stressed (moderate/severe: 34.3%; mild: 28,1%), 61.0% reported feeling lonely-isolated (fairly often/very often: 21.3%; almost never/sometimes: 39.7%), and 35.4% reported sleep disturbances (moderate/severe:19.8%; mild: 15.6%). Discrimination was only associated with increased psychological distress among racial-ethnic minorities. For example, COVID-related discrimination was strongly associated with anxiety-depression among Black/African American adults (mild: aOR=2.12, 95% CI=1.43-5.17; moderate/severe: aOR=5.19, 95% CI=3.35-8.05), but no association was observed among White or multiracial adults. Mitigating pandemic-related discrimination could help alleviate mental and sleep health disparities occurring among minoritized racial-ethnic groups.

Financial strain, neighborhood cohesion, and health-related quality of life among rural and urban Spanish-speaking Latina breast cancer survivors.

PURPOSE: Among Latina breast cancer survivors, explore associations between rural/urban residence and health-related quality of life (HRQL), and whether associations are moderated by financial strain and low neighborhood cohesion. METHODS: We combined baseline data from two randomized controlled trials of a stress management intervention conducted among 151 urban and 153 rural dwelling Latinas with nonmetastatic breast cancer. Generalized linear models estimated associations between rural/urban status and HRQL (overall, emotional, social-family, physical, and functional well-being), and we examined moderation effects of financial strain and low neighborhood cohesion, controlling for age, marital status, and breast cancer characteristics. RESULTS: Rural women reported better emotional (ß = 1.85; 95% CI = 0.37, 3.33), functional (ß = 2.23; 95% CI = 0.69, 3.77), and overall (ß = 5.68; 95% CI = 1.12, 10.25) well-being than urban women, regardless of degree of financial strain or neighborhood cohesion; moderation effects were not statistically significant. Financial strain was inversely associated with emotional (ß = -2.34; 95% CI = 3.63, -1.05), physical (ß = -2.56; 95% CI = -4.12, -1.01), functional (ß = -1.61; 95% CI = -2.96, -0.26), and overall (ß = -6.67; 95% CI = -10.96, -2.98) well-being. Low neighborhood cohesion was inversely associated with emotional (ß = -1.27; 95% CI = -2.50, -0.04), social-family (ß = -1.72; 95% CI = -3.02, -0.42), functional (ß = -1.63; 95% CI = -2.92, -0.34), and overall (ß = -5.95; 95% CI = 9.76, -2.14) well-being. CONCLUSIONS: Rural Latina breast cancer survivors reported better emotional, functional and overall well-being than their urban counterparts. Greater financial strain and less neighborhood cohesion were associated with worse HRQL on most domains regardless of rural/urban context. IMPLICATIONS FOR CANCER SURVIVORS: Interventions that focus on increasing perceived neighborhood cohesion and reducing or better managing financial strain, could help improve Latina cancer survivors' well-being.

Racial/ethnic disparities in intent to obtain a COVID-19 vaccine: A nationally representative United States survey.

Black, Latino, Pacific Islander, and American Indian/Alaska Native adults are more likely than White adults to experience SARS-CoV-2-related infections, hospitalizations, and mortality. We assessed intent to be vaccinated and concerns among 7 U.S. racial/ethnic groups (1,000 Black/African American, 500 American Indian/Alaska Native, 1,000 Asian, 1,000 Latino (500 English- and 500 Spanish-speaking), 500 Pacific Islander, 500 multiracial, and 1,000 White adults) in a cross-sectional online survey conducted December 2020-February 2021, weighted to be nationally representative within groups. Intent to be vaccinated was ascertained with: "If a COVID-19 vaccine becomes available, how likely are you to get vaccinated?" (not at all/slightly/moderately/very/extremely likely). Respondents identified which concerns would keep them from being vaccinated: cost, not knowing where, safety, effectiveness, side-effects, and other. Multinomial logistic regression models assessed associations of race/ethnicity with odds of being extremely/very/moderately, slightly likely to be vaccinated (ref = not at all), controlling for demographics and health. Overall, 30% were extremely likely, 22% not at all likely, and 48% unsure. Compared to White respondents, American Indian/Alaska Native (Adjusted Odds Ratio (AOR) = 0.66, 95% CI, 0.47-0.92) and Black/African American (AOR = 0.54, 95% CI, 0.41-0.72) respondents were less likely, and Asian (AOR = 2.21, 95% CI, 1.61-3.02) and Spanish-speaking Latino respondents (AOR = 3.74, 95% CI, 2.51-5.55) were more likely to report being extremely likely to be vaccinated. Side-effects (52%) and safety (45%) were overriding concerns. Intent and vaccination rates are changing rapidly; these results constitute a comprehensive baseline for ongoing vaccination efforts among U.S. racial and ethnic groups.

Guidelines for Evaluating the Feasibility of Recruitment in Pilot Studies of Diverse Populations: An Overlooked but Important Component.

Background: In health disparities research, studies often fall short of their recruitment goals. Conducting a pilot feasibility study of recruitment in which data are collected systematically on recruitment processes can help investigators refine methods for the larger study. However, there are few guidelines for conducting pilot feasibility studies, and recruitment methods are seldom the focus. Feasibility indicators differ from traditional reports of recruitment results by focusing on the extent to which recruitment goals are met. Methods: We present an organizing framework for assessing the feasibility of recruitment that includes eight steps, briefly: 1) specify recruitment goals; 2) specify recruitment processes; 3) establish a tracking system for each individual; 4) establish a tracking database for monitoring processes and results; 5) implement recruitment and track each individual's progress; 6) summarize recruitment results; 7) calculate and interpret feasibility measures - were goals met; and 8) if goals were not met, utilize tracking data to modify methods for the larger study. We describe methods within each step, with added details for steps 2-5 (the specific processes). The framework draws from a small literature on recruitment feasibility with a focus on health disparities populations. The guidelines blend well-known methods of recruitment with additional information on calculating feasibility indicators. Conclusions: These guidelines provide a first step in thinking systematically about recruitment feasibility, to advance the field of measuring feasibility. Feasibility indicators also can be used to track the effectiveness of innovative recruitment strategies as part of building the science of recruitment, especially in disparities populations.

Patient-physician communication in the context of diabetes care: Adaptation and assessment of psychometric properties of a Persian version of the interpersonal process of care survey (P-IPC).

AIMS: To examine the psychometric characteristics and explore the preliminary validity of the Persian version of the Interpersonal Processes of Care Survey (P-IPC) to assess patient-physician communication in the context of diabetes care. METHODS: After adapting, translating, examining content validity, and pretesting the questionnaire, it was administered to 300 patients with diabetes. Confirmatory factor analysis identified the factor structure (scales). Variability, item-scale correlations, reliability, and construct validity of the final scales were examined. RESULTS: Factor analysis supported the hypothesized second-order factor model with 27 of the 29 items:11 first-, and 7 second-order common factors. Scale scores were calculated for the 7 second-order factors. Internal-consistency reliability for the 7 scales ranged from 0.60 to 0.90 and 2-week test-retest correlations ranged from 0.89 to 0.96. The communication and interpersonal style domains of the P-IPC demonstrated high ceiling effects suggesting good patient-physician communication. The P-IPC scales differentiated between patients in the language-concordant and language-discordant groups, and patterns of correlations with three patient satisfaction measures corresponded to hypotheses. CONCLUSION: The P-IPC includes all of the second-order scales identified in the original IPC. Evidence of its reliability and validity suggest it can be useful for assessing patient-physician communication in the context of diabetes care.

A Community Choir Intervention to Promote Well-Being Among Diverse Older Adults: Results From the Community of Voices Trial.

OBJECTIVES: To test effects of the Community of Voices choir intervention on the health, well-being, and health care costs of racial/ethnically diverse older adults. METHOD: Twelve Administration-on-Aging-supported senior centers were cluster randomized into two groups: the intervention group started the choir immediately and a wait-list control group began the choir 6 months later. The choir program was designed for community-dwelling adults aged 60 years and older. The multimodal intervention comprises activities that engage participants cognitively, physically, and socially. Outcome measures assessed these three domains as well as health care utilization and costs. The intention-to-treat comparison was at 6 months. RESULTS: The sample (N = 390) had a mean age of 71.3 years (SD = 7.2); 65% were nonwhite. Six-month retention was 92%. Compared to controls, intervention group members experienced significantly greater improvements in loneliness (p = .02; standardized effect size [ES = 0.34] and interest in life (p = .008, ES = 0.39). No significant group differences were observed for cognitive or physical outcomes or for health care costs. DISCUSSION: Findings support adoption of community choirs for reducing loneliness and increasing interest in life among diverse older adults. Further efforts need to examine the mechanisms by which engagement in choirs improves aspects of well-being and reduces health disparities among older adults, including potential longer-term effects. CLINICALTRIALS.GOV REGISTRATION: NCT01869179 registered January 9, 2013.

Transcreation: an implementation science framework for community-engaged behavioral interventions to reduce health disparities.

BACKGROUND: Methods for translating evidence-based behavioral interventions into real-world settings seldom account for the special issues in reaching health disparity populations. MAIN TEXT: The objective of this article is to describe an innovative "transcreational" framework for designing and delivering interventions in communities to reduce health disparities. We define transcreation as the process of planning, delivering, and evaluating interventions so that they resonate with the community experiencing health disparities, while achieving intended health outcomes. The Transcreation Framework for Community-engaged Behavioral Interventions to Reduce Health Disparities comprises seven steps: 1) identify community infrastructure and engage partners; 2) specify theory; 3) identify multiple inputs for new program; 4) design intervention prototype; 5) design study, methods, and measures for community setting; 6) build community capacity for delivery; and 7) deliver transcreated intervention and evaluate implementation processes. Communities are engaged from the start and interventions are delivered by community-based interventionists and tested in community settings. The framework applies rigorous scientific methods for evaluating program effectiveness and implementation processes. It incorporates training and ongoing technical assistance to assure treatment fidelity and build community capacity. CONCLUSIONS: This framework expands the types of scientific evidence used and balances fidelity to evidence and fit to the community setting. It can guide researchers and communities in developing and testing behavioral interventions to reduce health disparities that are likely to be sustained because infrastructure development is embedded in the research.

Recruitment and baseline characteristics of the Community of Voices choir study to promote the health and well-being of diverse older adults.

OBJECTIVE: To describe the recruitment and baseline results of the Community of Voices study that aims to examine the effect of a community choir intervention on the health and well-being of older adults from diverse racial/ethnic and socioeconomic backgrounds. METHOD: Using community-based participatory research methods, we recruited adults age 60 and over from 12 Administration on Aging-supported senior centers in San Francisco into a 2-arm cluster-randomized controlled trial of the community choir intervention. Multiple outreach methods were used. We tracked outreach, screening, and recruitment metrics and collected demographics and baseline outcomes via community-based, interviewer-administered surveys and performance measures of cognition, physical function, and psychosocial variables. RESULTS: The study contacted 819 individuals, screened 636, and enrolled 390 diverse older adults over a 42-month, phased recruitment period. The mean age was 71.2 (SD = 7.3), and the majority were women. Two-thirds of the sample are non-white, and 20% of participants reported having financial hardship. DISCUSSION: Outreach and recruitment methods used in the Community of Voices trial facilitated enrollment of a large proportion of minority and lower-SES older adults in the final sample. Similar recruitment approaches could serve as a model for recruiting diverse racial/ethnic and socioeconomic older adults into research.

Study protocol for a cluster randomized trial of the Community of Voices choir intervention to promote the health and well-being of diverse older adults.

BACKGROUND: Older adults are the fastest growing segment of the United States population. There is an immediate need to identify novel, cost-effective community-based approaches that promote health and well-being for older adults, particularly those from diverse racial/ethnic and socioeconomic backgrounds. Because choral singing is multi-modal (requires cognitive, physical, and psychosocial engagement), it has the potential to improve health outcomes across several dimensions to help older adults remain active and independent. The purpose of this study is to examine the effect of a community choir program (Community of Voices) on health and well-being and to examine its costs and cost-effectiveness in a large sample of diverse, community-dwelling older adults. METHOD/DESIGN: In this cluster randomized controlled trial, diverse adults age 60 and older were enrolled at Administration on Aging-supported senior centers and completed baseline assessments. The senior centers were randomly assigned to either start the choir immediately (intervention group) or wait 6 months to start (control). Community of Voices is a culturally tailored choir program delivered at the senior centers by professional music conductors that reflects three components of engagement (cognitive, physical, and psychosocial). We describe the nature of the study including the cluster randomized trial study design, sampling frame, sample size calculation, methods of recruitment and assessment, and primary and secondary outcomes. DISCUSSION: The study involves conducting a randomized trial of an intervention as delivered in "real-world" settings. The choir program was designed using a novel translational approach that integrated evidence-based research on the benefits of singing for older adults, community best practices related to community choirs for older adults, and the perspective of the participating communities. The practicality and relatively low cost of the choir intervention means it can be incorporated into a variety of community settings and adapted to diverse cultures and languages. If successful, this program will be a practical and acceptable community-based approach for promoting health and well-being of older adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT01869179 registered 9 January 2013.

Nuevo Amanecer: results of a randomized controlled trial of a community-based, peer-delivered stress management intervention to improve quality of life in Latinas with breast cancer.

OBJECTIVES: We evaluated a community-based, translational stress management program to improve health-related quality of life in Spanish-speaking Latinas with breast cancer. METHODS: We adapted a cognitive-behavioral stress management program integrating evidence-based and community best practices to address the needs of Latinas with breast cancer. Spanish-speaking Latinas with breast cancer were randomly assigned to an intervention or usual-care control group. Trained peers delivered the 8-week intervention between February 2011 and February 2014. Primary outcomes were breast cancer-specific quality of life and distress, and general symptoms of distress. RESULTS: Of 151 participants, 95% were retained at 6 months (between May 2011 and May 2014). Improvements in quality of life from baseline to 6 months were greater for the intervention than the control group on physical well-being, emotional well-being, breast cancer concerns, and overall quality of life. Decreases from baseline to 6 months were greater for the intervention group on depression and somatization. CONCLUSIONS: Results suggest that translation of evidence-based programs can reduce psychosocial health disparities in Latinas with breast cancer. Integration of this program into community-based organizations enhances its dissemination potential.

Maternal acculturation and the prenatal care experience.

BACKGROUND: Acculturation may influence women's perceptions of health care experiences and may explain the epidemiologic paradox, whereby foreign-born women have lower rates of adverse birth outcomes than United States (US)-born women. We evaluated the relationship between maternal acculturation and specific dimensions of prenatal interpersonal processes of care (IPC) in ethnically diverse women. METHODS: Cross-sectional analysis of 1243 multiethnic, postpartum women who delivered at Kaiser Permanente Medical Center in Walnut Creek or San Francisco General Hospital. Women retrospectively reported on their experiences in seven domains of IPC during their pregnancy pertaining to communication, decision making, and interpersonal style. The primary independent variables were four measures of maternal acculturation: birthplace, English language proficiency, the number of years residing in the US, and age at immigration to the US. Generalized linear models, stratified by infant outcome, measured the association between each maternal acculturation measure and specific IPC domains while adjusting for type of health insurance, demographic, and reproductive factors. RESULTS: Approximately 60% of the sample was foreign-born, 36% reported low English proficiency, 43% had resided in the US <10 years, and 35% were age 20 years or older when they immigrated to the US. Over 64% of the women reported having public insurance during pregnancy. In adjusted analyses among women who delivered term and normal birth weight infants, less acculturated women and women with non-private health insurance were more likely to have higher mean IPC scores when compared to more acculturated or US-born women and women with private health insurance, respectively. CONCLUSION: In a large and ethnically diverse sample of childbearing women in Northern California, less acculturated pregnant women reported better prenatal care experiences than more acculturated and US-born women, another dimension of the "epidemiologic paradox." However, the relationship between acculturation and IPC, as reported during the postpartum period, differed according to infant outcomes.

Randomized controlled trial of Nuevo Amanecer: a peer-delivered stress management intervention for Spanish-speaking Latinas with breast cancer.

BACKGROUND: Latinas with breast cancer suffer symptom and psychosocial health disparities. Effective interventions have not been developed for or tested in this population. PURPOSE: We describe community-based participatory research methods used to develop and implement the Nuevo Amanecer program, a culturally tailored, peer-delivered cognitive-behavioral stress management intervention for low-income Spanish-speaking Latinas with breast cancer, and unique considerations in implementing a randomized controlled trial to test the program in community settings. METHODS: We applied an implementation science framework to delineate the methodological phases used to develop and implement the Nuevo Amanecer program and trial, emphasizing community engagement processes. RESULTS: In phase 1, we established project infrastructure: academic and community co-principal investigators, community partners, community advisory board, steering committee, and funding. In phase 2, we identified three program inputs: formative research, a community best-practices model, and an evidence-based intervention tested in non-Latinas. In phase 3, we created the new program by integrating and adapting intervention components from the three sources, making adaptations to accommodate low literacy, Spanish language, cultural factors, community context, and population needs. In phase 4, we built community capacity for the program and trial by training field staff (recruiters and interventionists embedded in community sites), compensating field staff, and creating a system for identifying potential participants. In phase 5, we implemented and monitored the program and trial. Engaging community partners in all phases has resulted in a new, culturally tailored program that is suitable for newly diagnosed Latinas with breast cancer and a trial that is acceptable and supported by community and clinical partners. Lessons learned Engagement of community-based organizations and cancer survivors as research partners and hiring recruiters and interventionists from the community were critical to successful implementation in community settings. Having culturally and linguistically competent research staff with excellent interpersonal skills facilitated implementation. Facilitating and maintaining excellent communication among community partners was imperative to troubleshoot implementation issues. Randomization was challenging due to community concerns about assigning women to a control group. Patient privacy regulations and the need for extensive outreach to establish relationships between community partners and clinical sites hampered initial recruitment. LIMITATIONS: These were resource-intensive processes to develop and implement the program that need to be compared to less-intensive alternatives. CONCLUSION: Engaging community members in design and implementation of community-based programs and trials enhances cultural appropriateness and congruence with the community context. If the randomized trial demonstrates that the intervention is effective, it will fill a gap in evidence-based programs to address ethnic disparities in quality of life among Spanish-speaking Latinas with breast cancer.

Methods for translating evidence-based behavioral interventions for health-disparity communities.

Populations composed of racial/ethnic minorities, disabled persons, and people with low socioeconomic status have worse health than their counterparts. Implementing evidence-based behavioral interventions (EBIs) to prevent and manage chronic disease and disability in community settings could help ameliorate disparities. Although numerous models of implementation processes are available, they are broad in scope, few offer specific methodological guidance, and few address the special issues in reaching vulnerable populations. Drawing from 2 existing models, we describe 7 methodological phases in the process of translating and implementing EBIs in communities to reach these vulnerable groups: establish infrastructure for translation partnership, identify multiple inputs (information gathering), review and distill information (synthesis), adapt and integrate program components (translation), build general and specific capacity (support system), implement intervention (delivery system), and develop appropriate designs and measures (evaluation). For each phase, we describe specific methodological steps and resources and provide examples from research on racial/ethnic minorities, disabled persons, and those with low socioeconomic status. Our methods focus on how to incorporate adaptations so that programs fit new community contexts, meet the needs of individuals in health-disparity populations, capitalize on scientific evidence, and use and build community assets and resources. A key tenet of our approach is to integrate EBIs with community best practices to the extent possible while building local capacity. We discuss tradeoffs between maintaining fidelity to the EBIs while maximizing fit to the new context. These methods could advance our ability to implement potentially effective interventions to reduce health disparities.

Asian Indian views on diet and health in the United States: importance of understanding cultural and social factors to address disparities.

This study describes Asian Indian immigrant perspectives surrounding dietary beliefs and practices to identify intervention targets for diabetes and heart disease prevention. Participants were asked about conceptualizations of relationships between culture, food, and health during 4 focus groups (n = 38). Findings reveal influences of beliefs from respondents' native India, preservation of cultural practices within the US social structure, conflicts with subsequent generations, and reinterpretation of health-related knowledge through a lens, hybridizing both "native" and "host" contexts. Galvanization of ethnically valued beliefs incorporating family and community structures is needed for multipronged approaches to reduce disproportionate burdens of disease among this understudied minority community.

Quality of life (QOL) of older adult community choral singers in Finland.

BACKGROUND: Enhancing quality of life (QOL) of older adults is an international area of focus. Identifying factors and experiences that contribute to QOL of older adults helps promote optimal levels of functioning. This study examines the relationship between perceived benefits associated with choral singing and QOL among community-dwelling older adults. METHODS: One hundred seventeen older adults who sing in community choirs in Jyväskylä, Finland, completed self-report measures of QOL (WHOQOL-Bref), depressive symptoms, and a questionnaire about the benefits of singing in choir. Correlational analyses and linear regression models were used to examine the association between the benefits of singing in choir and QOL. RESULTS: Both correlation and regression analyses found significant relationships between the benefits of choral singing and three QOL domains: psychological, social relationships, and environment. These associations remained significant after adjusting for age and depressive symptoms. As hypothesized, older choral singers who reported greater benefits of choir singing had higher QOL in multiple domains. The older choral singers in the study also reported few symptoms of depression and high overall QOL and satisfaction with health. CONCLUSION: Results suggest that singing in a community choir as an older adult may positively influence several aspects of QOL. These results suggest that community choral singing may be one potential avenue for promoting QOL in older adults.