Using pod based e-cigarettes and nicotine pouches to reduce harm for adults with low socioeconomic status who smoke: A pilot randomized controlled trial.

INTRODUCTION: Alternative Nicotine Delivery Systems (ANDS) such as e-cigarettes (EC) and oral nicotine pouches (ONP) may facilitate the substitution of smoking for those unwilling to quit. This pilot study assesses the harm reduction potential of EC and ONP among smokers with low socioeconomic status (SES). METHODS: Adults who smoked daily in the past 6 months, had a household income < 250% federal poverty level and had no intention of quitting smoking in the next 30 days were randomized 2:2:1 to 8 Weeks of 5% nicotine EC; 4mg ONP or assessment-only control (CC). The primary outcome was a within-group change in cigarettes per day (CPD) from Baseline to Week 8. RESULTS: 45 individuals were randomized (EC: N=18; ONP: N=18; CC: N=9). Analyses included 33 participants who completed the Week 8 visit. Mean age was 50.2 years (SD:10.7) and average CPD at baseline was 13.9 (SD: 10.1). For those randomized to EC, average CPD decreased from 14.7 (95%CI: 10.3; 19.1) at Baseline to 2.9 (95%CI: 0.09; 5.79) at Week 8 (p-value <0.001). For those randomized to ONP, average CPD decreased from 15.0 (95%CI: 5.02; 24.93) to 8.3 (95%CI: 1.34; 15.18) by Week 8 (p-value =0.01). In the EC and ONP groups, respectively, 4 (28.6%) and 1 (8.3%) participant fully switched from smoking to the ANDS product by Week 8. CONCLUSIONS: Individuals with low SES who smoke had lower CPD after switching to EC or ONP. These findings show the potential of ANDS in helping smokers switch to less harmful devices. IMPLICATIONS: This study provides novel evidence that e-cigarettes and nicotine pouches can be a harm reduction tool for individuals with lower SES who smoke and are not willing to quit smoking, contributing to reducing tobacco-related disparities in this population.

Recency of Cannabis Vaping in Sexual Minorities in Wave 5 of the Population Assessment of Tobacco and Health (PATH) Study.

BACKGROUND: Cannabis vaping is increasing in the United States. Among populations at-risk are sexual minorities (SM) who are more likely to vape cannabis compared to their heterosexual counterparts. Cannabis vaping has been associated with negative health outcomes and concomitant use of other substances with increased risk with more recent use. OBJECTIVES: This study examined the association between SM identification and recency of cannabis vaping (the last occasion that a participant used their vape device with cannabis) and number of puffs (the count of puffs that the participant took during their most recent use of their vape device with cannabis) using Wave 5 of the Population Assessment of Tobacco and Health (PATH) Study. RESULTS: In a weighted sample of participants who reported ever vaping cannabis (N = 5,331), 15% identified as SM, about 60% vaped cannabis in the past 3 or more days, and the mean number of puffs was 2 (SE = 0.17). Using multinomial logistic regression and zero-inflated negative binomial regression, the results showed that compared to heterosexual adults who reported not recently vaping cannabis, SM had higher probabilities of vaping cannabis in the past 3 or more days, 1-2 days, and the day of interview. CONCLUSION: SM individuals were more likely to recently vape cannabis, placing them at higher risk for respiratory diseases and use of other substances. Public health researchers and practitioners need to identify reasons for cannabis vaping in this population and implement targeted public health messaging to inform SM communities of the potential health effects of cannabis vaping.

A qualitative exploration of the continuum of help-seeking among Asian American breast cancer survivors.

Breast cancer rates among Asian American women are increasing. Despite this, there are limited studies on help-seeking among this population. Through a qualitative exploration, this paper examines the help-seeking experiences of Asian American breast cancer survivors. Asian American women (n = 52) with early-stage breast cancer were interviewed. Findings illustrate a continuum of experiences including: keeping diagnosis personal and not asking for help, keeping diagnosis personal but asking for limited help, and sharing diagnosis and seeking support. Results indicate that seeking support is a complex process for Asian Americans with breast cancer, with implications for survivorship and quality of life.

Perceived discrimination and cognitive function among older Puerto Ricans in Boston: The mediating role of depression.

OBJECTIVES: To examine (1) the association between perceived discrimination, including everyday perceived discrimination and major lifetime perceived discrimination, and cognitive function and (2) the mediating role of depression between discrimination and cognitive function among older Puerto Ricans. METHODS: Data came from the Boston Puerto Rican Health Study, collected from 562 Puerto Ricans aged 60+. Structural Equation Modelling was used to examine the association between discrimination and cognitive function and the mediating effect of depression. RESULTS: Everyday perceived discrimination was negatively associated with cognitive function, which was fully mediated by depression. Major Lifetime perceived discrimination was not associated with cognitive function. CONCLUSIONS: The findings contribute new information regarding the impact of perceived discrimination on cognitive function among older Puerto Ricans and underscore the importance of assessing experiences of discrimination to prevent depression and cognitive decline in this population.

Racial discrimination, ethnic-racial socialization, and cultural identities among Asian American youths.

OBJECTIVES: This study investigates whether and how racial discrimination is associated with ethnic-racial socialization in the family and how distinct aspects of ethnic-racial socialization influence children's ethnic and American identity among Filipino American and Korean American families. METHOD: The data are obtained from the Midwest Longitudinal Study of Asian American Families Project (N = 1,580; 379 Filipino American youths and 377 parents, and 410 Korean American youths and 414 parents; Mage of youths = 15.01). Using the bootstrapping and maximum likelihood with missing values approaches, we conducted path analyses to test the hypothesized associations concurrently and longitudinally for each ethnic group. RESULTS: Youth-reported racial discrimination was directly associated with weaker American identity, both concurrently and longitudinally. In concurrent models, racial discrimination experienced by both youth and parents was positively associated with youth-reported preparation for bias, which in turn was linked with stronger ethnic identity among Filipinos, whereas no indirect pathways reached statistical significance among Koreans. In longitudinal models, parent-reported discrimination was linked with higher levels of promotion of mistrust among both groups, which predicted weaker ethnic identity among Filipino youth but stronger American identity among Korean youth. CONCLUSIONS: The present study highlights how exposure to racial discrimination may have a lasting influence in cultural identity development among Asian Americans and possibly through ethnic-racial socialization in the family, which might have been shaped by such experiences. Our results also underscore the importance of considering the experiences of both children and parents in studies of discrimination and ethnic-racial socialization. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

"I don't have to explain, people understand": Acceptability and Cultural Relevance of a Mobile Health Lifestyle Intervention for Filipinos with Type 2 Diabetes.

BACKGROUND: Filipino Americans have the highest risk for obesity-related type 2 diabetes and related complications compared with all major Asian American subgroups. Identifying effective interventions to improve Filipino health outcomes are needed to reduce this health disparity. OBJECTIVE: To assess the acceptability and cultural relevance of the PilAm Go4Health program - a culturally adapted mobile health weight-loss lifestyle intervention including virtual social networking for Filipino Americans with type 2 diabetes. DESIGN SETTING PARTICIPANTS: Qualitative semi-structured post-program interviews explored perceptions of 45 Filipino Americans with type 2 diabetes in Northern California regarding their perceptions of the acceptability and cultural relevance of PilAm Go4Health. Participants' mean age was 57.6 years. Sixty-seven interviews were recorded, transcribed, and thematically analyzed by four independent coders. RESULTS: Over half (n=26, 57.8%) of the respondents found that a culturally tailored intervention program enhanced their engagement. All (n=45) of the respondents felt that mobile health technology promoted their self-efficacy. A majority of the respondents (n=29, 64.4%) expressed that they progressed from despair to self-efficacy as a result of their participation in the intervention. More than one-fourth of the participants (n=13, 28.8%) discussed that the intervention needed further cultural tailoring. CONCLUSIONS: Overall, PilAm Go4Health - a mobile health weight-loss lifestyle intervention - was acceptable and culturally relevant for Filipino Americans with type 2 diabetes. Findings may help inform clinician and researchers on effective intervention strategies for diabetes self-management when designing interventions for diverse populations.

Unmet Needs of Asian American and Pacific Islander Cancer Survivors.

In the USA, cancer is the leading cause of death for Asian Americans and Pacific Islanders (AAPIs), but little is known about the unmet needs of AAPI cancer survivors, especially from a national perspective. Using a community-based participatory research approach, we partnered with the Asian and Pacific Islander National Cancer Survivors Network and the Asian American Cancer Support Network to design and conduct a cross-sectional survey to understand the unmet needs of a national sample of AAPI cancer survivors. We assessed unmet needs in 10 domains: day-to-day activities, financial expenses, emotional concerns, medical treatment, cancer information, home care, nutrition, physical concerns, family relationships, and spirituality. We also assessed self-reported measures related to quality of life. This national sample of AAPI cancer survivors included people from 14 states and two territories who had been diagnosed with a broad range of cancers, including cancer of the breast, ovary/uterus/cervix, prostate, blood, and other sites. Over 80 % reported at least one unmet need. Participants reported an average of 8.4 unmet needs, spanning an average of 3.9 domains. Most commonly reported were unmet needs pertaining to physical concerns (66 %), day-to-day activities (52 %), and emotional concerns (52 %). This is the first report of unmet needs in a national sample of AAPI cancer survivors with a range of different cancer types. It describes the areas of greatest need and points to the importance of devoting more resources to identifying and addressing unmet needs for the underserved population of AAPI cancer survivors.

Social Influence of E-cigarette Use among Asian Americans in California.

Objectives: The use of e-cigarettes is on the rise in the United States (US). An understudied facet of e-cigarette use is the influence of social groups. The purpose of the present article is to examine the role of social groups in the use of e-cigarettes among Asian Americans. Methods: We conducted 12 semi-structured interviews of Asian Americans who use e-cigarettes living in California. Interviews were transcribed and analyzed using thematic analysis. Results: Findings showed that e-cigarette use is normalized and encouraged among peer groups and social gatherings, anecdotal success stories of their peers who were able to quit or reduce their use of combustible cigarettes using e-cigarettes were motivating, and vape shops provided a space for socialization and belonging. Conclusions: The findings illuminate that e-cigarette use is a mediator in Asian American social groups as an activity for collectivity and connection. Public health researchers and practitioners can address nicotine use or addiction among Asian Americans through group or peer targeted prevention and intervention strategies.

Correlates of smoking during COVID-19 in the LGBTQI + cancer survivor population.

PURPOSE: Stressors brought on by the pandemic may have further encouraged lesbian, gay, bisexual, transgender, queer, and intersex plus (LGBTQI +) cancer survivors to smoke. The purpose of this study is to examine factors associated with smoking among LGBTQI + cancer survivors during the pandemic. METHODS: We used a secondary data analysis of OUT: The National Cancer Survey. We conducted logistic regression analysis to examine the associations between psychological distress, binge drinking, and socio-demographic factors with ever use and current use of cigarettes, other tobacco, and nicotine products. RESULTS: Of the 1629 participants in our sample, 53% used in their lifetime and 13% reported current use. Correlates of increased ever use included being of older age (AOR = 1.02; 95% CI: 1.01, 1.03) and binge drinking (AOR = 2.47; 95% CI: 1.17, 5.20) while correlates of decreased ever use were among those with a graduate or professional degree (AOR = 0.40; 95% CI: 0.23, 0.71). Correlates of increased current use included being of Latine descent (AOR = 1.89; 95% CI: 1.07, 3.36), binge drinking (AOR = 3.18; 95% CI: 1.56, 6.48), without health insurance (AOR = 2.37; 95% CI: 1.10, 5.10), and being disabled (AOR = 1.64; 95% CI: 1.19, 2.26) while correlates of decreased current use were among cisgender women (AOR = 0.30; 95% CI: 0.12, 0.77), being of younger age (AOR = 0.98; 95% CI: 0.96, 0.99), and having a graduate or professional degree (AOR = 0.33; 95% CI: 0.15, 0.70). CONCLUSIONS: Our findings demonstrate that a proportion of LGBTQI + cancer survivors continue to smoke during the pandemic despite the increased risk involved with smoking. Furthermore, individuals with intersecting marginalized identities experience additional stressors that may have been further exacerbated by the conditions of the pandemic that encourage them to smoke. IMPLICATIONS FOR CANCER SURVIVORS: Quitting smoking after a cancer diagnosis can decrease the chances of recurrence and a new primary malignancy. In addition, practitioners and researchers should advocate towards examining and addressing systemic forms of oppression in institutions that LGBTQI + cancer survivors navigate during the pandemic.

Medical Mistrust, Perceived Discrimination, and Race: a Longitudinal Analysis of Predictors of COVID-19 Vaccine Hesitancy in US Adults.

The current manuscript has two aims. First, we examined whether race and ethnicity, perceived discrimination, medical mistrust, and other demographic factors were predictors of COVID-19 vaccine hesitancy and vaccine behavior. Second, we sought to assess whether medical mistrust and perceived discrimination mediate the relationship between race and ethnicity and vaccine behavior. Specifically, we hypothesized that individuals of color had increased COVID-19 vaccine hesitancy as compared to White individuals and perceived discrimination and medical mistrust mediated this relationship. Results revealed that when accounting for sociodemographic characteristics and COVID-19-related variables those with greater medical mistrust were more likely to have vaccine hesitancy. Additionally, after accounting for medical mistrust, Black non-Hispanic/Black Hispanic/White Hispanic individuals had lower odds of having the COVID-19 vaccine compared to White non-Hispanic individuals. Furthermore, combined perceived discrimination and medical mistrust indirectly mediated the relationship between race and ethnicity and having the COVID-19 vaccine. The findings of this study indicate the need for public health efforts to address sentiments of medical mistrust and experiences of perceived discrimination when combating COVID-19 vaccine hesitancy, especially within communities of color.

Change in E-cigarette risk perception and smoking behavior of Black and Latinx individuals who smoke.

INTRODUCTION: Trends in knowledge and beliefs about e-cigarette (EC) harm have been changing. Our study examined whether change in risk perception of ECs predicts cigarettes smoked per week (CPW) among Black and Latinx individuals who smoke enrolled in an EC switching randomized clinical trial (RCT). METHODS: We analyzed data from one arm of a 6-week EC RCT of individuals who smoke attempting to switch to nicotine salt pod system ECs (n = 110; Black, n = 57; Latinx, n = 53). Our explanatory variable was change in risk perception of ECs compared to combustible cigarettes (CC) from baseline to week 6. Our outcome was CPW measured by a 7-day timeline follow-back interview. A negative binomial GEE model was conducted to examine the association between risk perception and CPW at baseline and week 6. RESULTS: The mean CPW decreased from 82.8 (SD=49.8) at baseline to 15.8 (SD=29.8) at week 6. A one-level increase in EC risk perception (i.e., EC perceived as riskier than CC from baseline to week 6) was associated with an increase in CPW (IRR: 1.83, 95% CI: 1.03; 3.24). Latinx participants were more likely to have higher CPW as EC risk perception increased compared to Black participants (IRR=1.89, 95% CI: 1.09; 3.26). CONCLUSION: We found that CPW at week 6 was significantly higher as change in risk perception of EC relative to CC increased. Given the influence of risk perception on smoking behavior, people who smoke should be educated on the benefits and harms of ECs.

Socioeconomic status across the life course and smoking cessation among older adult smokers in the U.S.

INTRODUCTION: Socioeconomic status (SES) at different stages of the life course impacts late-life health. However, whether SES across the life course impacts smoking cessation in late-life is not known. PURPOSE: Assess how life course SES impacts smoking cessation among older smokers. METHODS: We identified 5,124 smokers, 50 years and older, from the 1998 to 2018 waves of the Health and Retirement Study. The outcome was self-reported smoking cessation. The main exposure was life course SES, defined as: low child and low adult SES (persistent low); low child, high adult SES (upward mobility); high child, low adult SES (downward mobility); and high child, high adult SES (persistent high). A multilevel mixed-effect logistic model was used to examine how life course SES predicts smoking cessation at age 65 and over time, adjusted for covariates. RESULTS: Compared to those with persistent high SES, those with persistent low SES, upward and downward SES were more likely to be Hispanic or non-Hispanic Black. The adjusted results showed that at age 65, compared to those with persistent high SES, those with persistent low SES (OR= 0.69, 95 % CI = [0.51-0.92]), upward SES (OR= 0.49, [0.32-0.75]), and downward SES (OR= 0.55, [0.40-0.76]) were less likely to quit. However, as age increased, only those with downward or persistent low SES were significantly less likely to quit compared to those with persistent high SES. DISCUSSION: Social mobility of SES from childhood to adulthood significantly impacts smoking cessation. Both stages of the life course should be considered to understand smoking behaviors.

The Role of Financial Strain and Educational Attainment on Smoking Abstinence of African Americans and Whites Who Smoke.

Objective: To examine if reduced financial strain and higher educational attainment would confer less advantage for successful cessation among African Americans than for White individuals. Design: A secondary data analysis of the Quit2Live study, a smoking cessation intervention for individuals who smoke. Setting: Recruited participants from a metropolitan city in the Midwest. Participants: The sample included 224 African American and 225 White individuals who smoke. Main Outcome Measures: Our outcome variable was cotinine-verified smoking abstinence at the end-of-treatment (week 12). Our explanatory variables were a combination of financial strain (high, low) and educational attainment (high, low). Methods: We implemented a logistic regression analysis and a two-way interaction of the combined financial strain and educational attainment variable and race on smoking abstinence. Results: About 25% of the study participants were low financial strain and high education, 41% high financial strain and high education, 23% high financial strain and low education, and 11% low financial strain and low education. A greater proportion of African Americans vs Whites were in the high financial strain/low educational attainment category (28% vs 18%, P = .01). Participants with high financial strain and low educational attainment had substantially lower odds of abstinence (OR = .29 [95% CI: .12, .68]) compared to participants with low financial strain and high educational attainment. Contrary to our hypothesis, race did not moderate this association. Conclusion: Findings highlight the constraining role of high financial strain and low educational attainment, irrespective of race, on smoking abstinence among smokers actively engaged in a quit attempt.

Centering Ethnic Studies in Health Education: Lessons From Teaching an Asian American Community Health Course.

Anti-Asian racism and violence dramatically increased during the COVID-19 pandemic. As a result, recent studies and reports are showing that the health and well-being of Asian Americans are negatively affected. To address this urgent problem, the field of health education and public health must be equipped with the critical frameworks and concepts to analyze racism and White supremacy and how it affects the health and well-being of Asian Americans. We argue that using an ethnic studies lens in health education can help educators, researchers, and practitioners teach and train health educators to address racism experienced by Asian Americans during COVID-19 in relation to their health. We will discuss the elements of ethnic studies and demonstrate how to use it as a lens in understanding health disparities in the Asian American population influenced and exacerbated by the COVID-19 pandemic.

Perceived Discrimination and Psychological Distress: A Survey of Filipinx Americans in Massachusetts during the COVID-19 Pandemic.

The onset of the COVID-19 pandemic has led to an upsurge of discrimination against Asian American populations, and Filipinx Americans (FA) have reported high cases of perceived discrimination. Prior studies have shown a relationship between experiences of discrimination and poor mental health. The purpose of this study was to examine the association of perceived discrimination and psychological distress among FA living in Massachusetts from a survey collected during the COVID-19 pandemic (N = 133). Multiple regression analysis revealed that experiences of perceived discrimination were associated with psychological distress. Older participants were less likely to report psychological distress. Compared to men, womxn were more likely to report psychological distress. Our findings highlight the potential mental health consequences of perceived discrimination experienced by FA, which may have been exacerbated during the COVID-19 pandemic.

A randomized controlled trial of a therapeutic relational agent for reducing substance misuse during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic disrupted access to treatment for substance use disorders (SUDs), while alcohol and cannabis retail sales increased. During the pandemic, we tested a tailored digital health solution, Woebot-SUDs (W-SUDs), for reducing substance misuse. METHODS: In a randomized controlled trial, we compared W-SUDs for 8 weeks to a waitlist control. U.S. adults (N = 180) who screened positive for substance misuse (CAGE-AID>1) were enrolled June-August 2020. The primary outcome was the change in past-month substance use occasions from baseline to end-of-treatment (EOT). Study retention was 84%. General linear models tested group differences in baseline-to-EOT change scores, adjusting for baseline differences and attrition. RESULTS: At baseline, the sample (age M = 40, SD = 12, 65% female, 68% non-Hispanic white) averaged 30.2 (SD = 18.6) substance occasions in the past month. Most (77%) reported alcohol problems, 28% cannabis, and 45% multiple substances; 46% reported moderate-to-severe depressive symptoms. Treatment participants averaged 920 in-app text messages (SD = 892, Median = 701); 96% of completed lessons were rated positively; and 88% would recommend W-SUDs. Relative to waitlist, W-SUDs participants significantly reduced past-month substance use occasions (M = -9.1, SE = 2.0 vs. M = -3.3, SE = 1.8; p = .039). Secondary substance use and mood outcomes did not change significantly by group; however, reductions in substance use occasions correlated significantly with increased confidence and fewer substance use problems, cravings, depression and anxiety symptoms, and pandemic-related mental health effects (p-value<.05). CONCLUSIONS: W-SUDs was associated with significant reductions in substance use occasions. Reduction in substance use occasions was associated with better outcomes, including improved mental health. W-SUDs satisfaction was high.

Race and Ethnicity in the Social Work Grand Challenges.

Race, ethnicity, and racism (RER) are interconnected with the critical problems tackled in the Grand Challenges for Social Work (GCSW). Yet, the extent to which the GCSW discuss the central role of RER is less clear. This article investigates how the GCSW integrate RER in their discourse. Using content analysis, authors examined all 21 concept papers that comprise the 12 initial GCSW to determine their attention to RER. Authors assessed whether each paper made any reference to race or ethnicity, whether race or ethnicity was considered as a primary theme, and whether racism was mentioned. Nine GCSW had at least one paper that mentioned race or ethnicity; seven had at least one paper that treated race and ethnicity as a major construct. Five GCSW contained at least one paper that discussed racism's impacts on their topical interests. None of the papers analyzed in the study defined or specified their conceptualization of racism. The GCSW are strategically positioned to widen and deepen social work's focus on RER, and the recent adoption of the 13th GCSW to "Eliminate racism" is an important first step. Authors encourage the social work field to embrace a more explicit, renewed, and continued commitment to eradicating systemic racism.

Job and family demands and burnout among healthcare workers: The moderating role of workplace flexibility.

Burnout is a growing problem among healthcare workers. Whereas there are numerous predictors of burnout, this article explores the compounding effects of job and family demands among nurses and Patient Care Associates (PCA). This study used the 2018 survey data of the Boston Hospital Health Workers Study (BHWHS) to assess the relationship of job and family demands, workplace flexibility, and burnout (N = 874). In addition, it aimed to evaluate the moderating effect of workplace flexibility and job and family demands on burnout. Results of the study demonstrate that active and high strained healthcare workers are associated with higher odds of experiencing burnout as well as workers who reported perceived low workplace flexibility. In addition, workplace flexibility is associated with reduced odds of experiencing burnout. Workplace flexibility moderated the relationship of childless married healthcare workers and burnout. The study shows that workplace flexibility plays a critical role in potentially reducing odds of burnout in the healthcare worker population. Assessing the perception and accessibility to workplace flexibility among workers is imperative to improve worker well-being and the quality of care provided to patients especially the current effects to worker's health during a pandemic.

Workplace Discrimination and Short Sleep Among Healthcare Workers: The Buffering Effect of People-Oriented Culture.

OBJECTIVE: Examine the association of discrimination and short sleep and the buffering effect of people-oriented culture in the workplace among nurses and patient care associates. METHODS: Used a mixed-methods design from the 2018 Boston Hospital Workers Health Study (N = 845) and semi-structured interviews among nurse directors (N = 16). RESULTS: We found that people-oriented culture reduced the odds of short sleep and slightly attenuated the association of discrimination and short sleep. People-oriented culture did not buffer the effects of discrimination on short sleep. Qualitative findings showed that discrimination occurred between co-workers in relation to their job titles and existing support in the workplace does not address discrimination. CONCLUSIONS: Healthcare industries need to implement specific programs and services aimed at addressing discrimination which can potentially improve health outcomes among workers.

Older Chinese Americans' Perspectives on Physical Activity: A Mixed Methods Study.

The benefits of physical activity for successful aging are well established. Few interventions however, target older Asian Americans who may have distinct needs for cultural and linguistic tailoring. The heterogeneity among Asian Americans underscores the need to elucidate specific physical activity preferences by ethnic subgroup. To better understand older Chinese Americans' perceptions about physical activity, we conducted a community-engaged, mixed methods study with 60 participants. Through survey and focus groups, four emerging themes characterized perceptions of physical activity: (a) physical activities benefit the body and mind, (b) traditional Chinese culture influences perceptions and preferences for physical activity, (c) physical activity presents opportunities for social engagement, and (d) physical activity facilitates family harmony. Design recommendations includes encouraging mind-body approaches, incorporating culturally specific practices, highlighting opportunities for social engagement, and emphasizing the potential for improved harmony.