Mixed Methods Evaluation of Satisfaction with Two Culturally Tailored Substance use Prevention Programs for American Indian/Alaska Native Emerging Adults.

American Indian/Alaska Native (AI/AN) communities are disproportionately affected by the opioid epidemic. AI/AN emerging adults (ages 18-25) in urban areas are at particularly high risk, with the overdose death rate among urban-dwelling AI/AN people 1.4 times higher than rural-dwelling AI/AN people. Despite these challenges, there are no evidence-based culturally tailored prevention or intervention programs to address opioid, alcohol and other drug use among urban AI/AN emerging adults. This study focused on understanding AI/AN emerging adults' experiences with two culturally tailored programs addressing opioid, cannabis, and alcohol use as part of the randomized controlled trial for Traditions and Connections for Urban Native Americans (TACUNA) in order to enhance feasibility of this intervention. Using a convergent mixed methods design at 3-month follow-up, we collected satisfaction and experience ratings and written narratives (total n = 162; intervention n = 77; control n = 85) from a sample of urban-dwelling AI/AN emerging adults who participated in both programs. We analyzed data through simultaneous examination of qualitative and quantitative data. The quantitative ratings show that both programs were rated highly. The qualitative data contextualized these ratings, illustrating pathways through which specific components were perceived to cause desired or observed behavioral change in participants. Among the elements that mattered most to these participants were the convenience of the virtual format, having a comfortable and safe space to share personal stories, and learning new information about their social networks. Negative comments focused on workshop length and inconvenient scheduling. This is one of the first studies to explore participant satisfaction and experience with culturally tailored substance use programming among a historically marginalized and understudied population. It is important to consider the voices of urban-dwelling AI/AN people in program development because hidden factors, such as limited financial resources, limited time, and misalignment with cultural values may prevent existing programs from being feasible.

Enhancing sleep health in urban American Indian/Alaska Native adolescents: Implications for culturally tailored interventions.

BACKGROUND: Urban American Indian/Alaska Native (AI/AN) adolescents are vulnerable to sleep and other health-related disparities due to numerous social drivers, including historical trauma and relocation to urban areas. This study aims to identify strategies to increase protective factors and culturally tailor sleep health interventions for this population. METHODS: Using community-based participatory research, the NAYSHAW study conducted in-depth interviews with urban AI/AN adolescents aged 12-19 years to understand critical components needed for developing a culturally sensitive sleep health intervention. Data from two qualitative subsamples (N = 46) and parent surveys (N = 110) were analyzed, focusing on factors that affect sleep health behaviors, including parental involvement, technology, and traditional practices. RESULTS: Key findings include the detrimental impact of electronics use at night and protective effects of traditional practices on sleep. Parental involvement in sleep routines varied by adolescent's age. Adolescents desired sleep health education in interactive formats, whereas parents preferred workshops and digital applications for sleep health strategies. Findings suggest that interventions need to address electronics use and should also be culturally tailored to address the unique experiences of urban AI/AN adolescents. CONCLUSIONS: Results underscore the importance of utilizing community-based strategies to develop culturally tailored sleep interventions for underserved populations, specifically urban AI/AN adolescents. Integrating traditional practices with evidence-based sleep health strategies can provide a holistic approach to improving sleep and overall well-being. Parental education and involvement will be critical to the success of such interventions.

Design of the think PHRESH longitudinal cohort study: Neighborhood disadvantage, cognitive aging, and alzheimer's disease risk in disinvested, black neighborhoods.

BACKGROUND: Black Americans have disproportionately higher rates and earlier onset of Alzheimer's disease and related dementias (ADRD) relative to White Americans. We currently lack a comprehensive understanding of how the lived experience and broader societal factors, including cumulative exposure to structural racism and the mechanisms underlying the risks, may contribute to elevated ADRD risk in Black Americans. METHODS: The Think PHRESH study builds on existing, community-based research infrastructure, from the ongoing Pittsburgh Hill/Homewood Research on Neighborhood Change and Health (PHRESH) studies, to examine the contributions of dynamic neighborhood socioeconomic conditions across the lifecourse to cognitive outcomes in mid- and late-life adults living in two historically disinvested, predominantly Black communities (anticipated n = 1133). This longitudinal, mixed-methods study rests on the premise that neighborhood racial segregation and subsequent disinvestment contributes to poor cognitive outcomes via factors including (a) low access to educational opportunities and (b) high exposure to race- and socioeconomically-relevant stressors, such as discrimination, trauma, and adverse childhood events. In turn, these cumulative exposures foster psychological vigilance in residents, leading to cardiometabolic dysregulation and sleep disruption, which may mediate associations between neighborhood disadvantage and ADRD risk. This premise recognizes the importance of potential protective factors that may promote cognitive health, including neighborhood social cohesion, safety, and satisfaction. The proposed study will leverage our existing longitudinal data on risk/protective factors and biobehavioral mediators and will include: (1) up to three waves of cognitive assessments in participants ages 50 years + and one assessment in participants ages 35-49 years; clinical adjudication of ADRD will be completed in participants who are 50+, (2) extensive surveys of risk and protective factors, (3) two assessments of blood pressure and objectively measured sleep, (4) a comprehensive assessment of life and residential history; and (5) two rounds of in-depth qualitative interviews to reveal lifecourse opportunities and barriers experienced by Black Americans in achieving optimal cognitive health in late life. DISCUSSION: Understanding how structural racism has influenced the lived experience of Black Americans, including dynamic changes in neighborhood conditions over time, is critical to inform multi-level intervention and policy efforts to reduce pervasive racial and socioeconomic disparities in ADRD.

Changes in Sleep-Wake Patterns and Disturbances Before and During COVID-19 in Urban American Indian/ Alaska Native Adolescents.

BACKGROUND: COVID-19 has profoundly affected sleep, although little research has focused on high-risk populations for poor sleep health, including American Indian/Alaska Native (AI/AN) adolescents. METHODS: This is the first longitudinal study to examine changes in sleep with surveys completed before the pandemic and during the early months of COVID-19 in a sample of urban AI/AN adolescents (N = 118; mean age = 14 years at baseline; 63% female). We use a mixed-methods approach to explore how COVID-19 affected urban AI/AN adolescents' sleep, daily routines, and interactions with family and culture. Quantitative analysis examined whether pandemic-related sleep changes were significant and potential moderators of COVID-19's effect on sleep, including family and community cohesion and engagement in traditional practices. RESULTS: : Findings demonstrate changes in sleep, including increases in sleep duration, delays in bedtimes and waketimes, and increases in sleep-wake disturbances (p's <.001). Higher levels of family cohesion and higher levels of engagement in traditional practices moderated pandemic-related increases in weekday sleep duration. Qualitative analyses revealed changes in adolescents' sleep and daily behaviors, as well as strategies adolescents used to cope with pandemic-related disruptions in sleep and routines. CONCLUSION: Findings demonstrate positive and negative changes in sleep during COVID-19 stay-at-home orders, including simultaneous increases in sleep duration and sleep-wake disturbances. Results highlight the importance of considering multi-level influences on adolescent sleep, such as early school start times, family dynamics, and cultural factors. A multi-level approach may help guide prevention and intervention efforts to improve adolescent sleep health.

Food insecurity, participating in the Supplemental Nutrition Assistance Program, and the degree to which patients anticipate help from clinics to find food in Los Angeles County.

Healthcare clinics are uniquely positioned to screen for food insecurity and refer patients to food resources. This study examines this approach to address this social condition. A 2018 intercept survey of 1,103 adult patients recruited from across 11 clinic waiting rooms in Los Angeles County was conducted to describe the prevalence of food insecurity and whether Supplemental Nutrition Assistance Program (SNAP) participation and the degree to which patients anticipated their clinics to help them locate food varied by socio-demographic factors. The prevalence of food insecurity was high for this low-income survey sample (63.4%); 72% of Spanish-speaking Latinx reported experiencing it. For those who experienced food insecurity, older age was associated with lower odds of SNAP participation. Spanish-speaking Latinx had higher odds of anticipating help from a clinic to find food relative to English-speaking Latinx (Adjusted Odds Ratio 1.88, 95% Confidence Interval: 1.18, 2.98). An exploratory analysis showed that common reasons for not enrolling in SNAP included older adults not knowing how to apply to the program and Spanish-speaking Latinx worrying about citizenship status as it relates to the eligibility process. Findings revealed disparities in the prevalence of food insecurity and SNAP participation among patients of Los Angeles' low income clinics. Information from this study can help inform low-income clinics' efforts to intervene on food insecurity in their patient population.

Risk and Resilience Factors in Urban American Indian and Alaska Native Youth during the Coronavirus Pandemic.

American Indians and Alaska Natives suffer disproportionately from poverty and other inequities and are vulnerable to adverse health and socioeconomic effects of COVID-19. Using surveys and interviews (May - July 2020), we examined urban American Indian/Alaska Native adolescents' (N=50) health and behaviors, family dynamics, community cohesion, and traditional practice participation during COVID-19. About 20% of teens reported clinically significant anxiety and depression, 25% reported food insecurity, and 40% reported poor sleep. Teens also reported high family and community cohesion, and many engaged in traditional practices during this time. Although many teens reported problems, they also emphasized resilience strategies.

What Words Convey: The Potential for Patient Narratives to Inform Quality Improvement.

Policy Points Narratives about patients' experiences with outpatient care are essential for quality improvement because they convey ample actionable information that both elaborates on existing domains within patient experience surveys and describes multiple additional domains that are important to patients. The content of narrative feedback from patients can potentially be translated to improved quality in multiple ways: clinicians can learn from their own patients, groups of clinicians can learn from the experience of their peers' patients, and health system administrators can identify and respond to patterns in patients' accounts that reflect systemic challenges to quality. Consistent investment by payers and providers is required to ensure that patient narratives are rigorously collected, analyzed fully, and effectively used for quality improvement. CONTEXT: For the past 25 years, health care providers and health system administrators have sought to improve care by surveying patients about their experiences. More recently, policymakers have acted to promote this learning by deploying financial incentives tied to survey scores. This article explores the potential of systematically elicited narratives about experiences with outpatient care to enrich quality improvement. METHODS: Narratives were collected from 348 patients recruited from a nationally representative Internet panel. Drawing from the literature on health services innovation, we developed a two-part coding schema that categorized narrative content in terms of (a) the aspects of care being described, and (b) the actionability of this information for clinicians, quality improvement staff, and health system administrators. Narratives were coded using this schema, with high levels of reliability among the coders. FINDINGS: The scope of outpatient narratives divides evenly among aspects of care currently measured by patient experience surveys (35% of content), aspects related to measured domains but not captured by existing survey questions (31%), and aspects of care that are omitted from surveys entirely (34%). Overall, the narrative data focused heavily on relational aspects of care (43%), elaborating on this aspect of experience well beyond what is captured with communication-related questions on existing surveys. Three-quarters of elicited narratives had some actionable content, and almost a third contained three or more separate actionable elements. CONCLUSIONS: In a health policy environment that incentivizes attention to patient experience, rigorously elicited narratives hold substantial promise for improving quality in general and patients' experiences with care in particular. They do so in two ways: by making concrete what went wrong or right in domains covered by existing surveys, and by expanding our view of what aspects of care matter to patients as articulated in their own words and thus how care can be made more patient-centered. Most narratives convey experiences that are potentially actionable by those committed to improving health care quality in outpatient settings.

Development and Psychometric Evaluation of a Fatigability Index for Full-Time Wheelchair Users With Spinal Cord Injury.

OBJECTIVE: To develop and evaluate psychometrically a self-reported instrument assessing physical fatigability (PF) and mental fatigability (MF) in adults with spinal cord injury (SCI). DESIGN: Cross-sectional. SETTING: Peer-support groups at rehabilitation centers, online support groups. PARTICIPANTS: Adults with SCI (N=464) in the United States. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The dimensional structure was assessed by confirmatory factor analysis. The relationship between item responses and fatigability was measured with item response theory (graded response model). Reliability was measured with test information functions. Differential item functioning was evaluated with Wald chi-square tests and the weighted area between the curves. Construct validity was assessed using the known groups method. RESULTS: An 82-item pool was developed from prior qualitative research and consultations with rehabilitation experts. A non-probability sample (N=464) was used to evaluate the psychometric properties of the PF and MF scales. The item pool was reduced to 75 based on factor loadings and R2. Both scales are primarily unidimensional, despite moderate multidimensionality. There is good discrimination overall: 18 PF items and 26 MF items have high or very high discrimination power (slopes > 1.35). The measurement precision in the theta range -2.0 to 2.5 is the equivalent of 0.94 reliability for PF and 0.91 for MF. For both measures, F statistics P values were significant at P<.01, and means were higher for those with paraplegia vs quadriplegia, and for those with incomplete paraplegia. CONCLUSIONS: The Fatigability Index is the first instrument designed to assess physical and mental fatigability in adults with SCI. The index highlights causes of fatigue and areas requiring immediate intervention. Development of short-forms and further research on representative samples are necessary.

A comparison of perceptions of quality of life among adults with spinal cord injury in the United States versus the United Kingdom.

PURPOSE: To identify which aspects of life are most important to adults with spinal cord injury (SCI) and compare perspectives in the United States and the United Kingdom. METHODS: We conducted 20 in-depth interviews with adults with SCI (ten in the US and ten in the UK). Verbatim transcriptions were independently analyzed line-by-line by two coders using an inductive approach. Codes were grouped into themes about factors that constitute and affect quality of life (QOL). RESULTS: Five overarching themes emerged: describing QOL in the context of SCI; functional adjustment; medical care; financial resources; and socio-political issues. Twenty subthemes emerged on factors that affect QOL. Participants in both samples identified medical care as a key influence on QOL. The US group talked about a predominantly negative influence (e.g., fragmented primary and specialist care, insurance constraints, bureaucracy), whereas UK interviewees mentioned a predominantly positive influence (e.g., universal provision, including free and continuous care, free wheelchairs and home care, and length of rehabilitation commensurate with level of injury). Functional adjustment, such as physical and mental adjustment post-discharge and aging with SCI, was another important contributor to QOL, and varied by country. Most US interviewees reported poor knowledge about self-care post-discharge and poor quality of home adaptations compared to the UK group. CONCLUSIONS: For adults living with SCI, good QOL is essential for successful rehabilitation. Differences between interviewees from the two countries in perceived medical care and functional adjustment suggest that factors affecting QOL may relate to broader health system characteristics.

Patient and caregiver goals for dementia care.

PURPOSE: Most health outcome measures for chronic diseases do not incorporate specific health goals of patients and caregivers. To elicit patient-centered goals for dementia care, we conducted a qualitative study using focus groups of people with early-stage dementia and dementia caregivers. METHODS: We conducted 5 focus groups with 43 participants (7 with early-stage dementia and 36 caregivers); 15 participants were Spanish-speaking. Verbatim transcriptions were independently analyzed line-by-line by two coders using both deductive and inductive approaches. Coded texts were grouped into domains and developed into a goal inventory for dementia care. RESULTS: Participants identified 41 goals for dementia care within five domains (medical care, physical quality of life, social and emotional quality of life, access to services and supports, and caregiver support). Caregiver goals included ensuring the safety of the person with dementia and managing caregiving stress. Participants with early-stage dementia identified engaging in meaningful activity (e.g., work, family functions) and not being a burden on family near the end of life as important goals. Participants articulated the need to readdress goals as the disease progressed and reported challenges in goal-setting when goals differed between the person with dementia and the caregiver (e.g., patient safety vs. living independently at home). While goals were similar among English- and Spanish-speaking participants, Spanish-speaking participants emphasized the need to improve community education about dementia. CONCLUSIONS: Patient- and caregiver-identified goals for care are different than commonly measured health outcomes for dementia. Future work should incorporate patient-centered goals into clinical settings and assess their usefulness for dementia care.

Food recovery and produce distribution as a system strategy for increasing access to healthy food among populations experiencing food insecurity: lessons for post-pandemic planning.

Using data from an intercept survey of 428 adults who received free surplus produce at five distribution sites and qualitative data from 15 interviews with site personnel, we examined facilitators (e.g. community partnerships, coalition support) and challenges (e.g. limited refrigerated storage, lack of transportation infrastructure) to operating a food recovery and distribution program in Los Angeles County. Overall, this food system intervention appeared to fill an unmet need for recipients, nearly 80% of whom were food insecure and 60% visited a site several months/year or monthly. For many living in this county's underserved communities, this effort was instrumental in increasing access to healthy food before and during the COVID-19 pandemic. To sustain/expand this program's reach, local governments and food assistance programs should provide greater coordination and oversight, and invest more resources into this food recovery and distribution infrastructure.

Bidirectional Associations Between Daily Sleep and Wake Behaviors in Urban American Indian/Alaska Native Youth.

PURPOSE: This is the first study to examine daily, bidirectional associations between sleep and wake behaviors/mood in urban American Indian/Alaska Native (AI/AN) adolescents. METHODS: Participants were 142 urban AI/AN adolescents (mean age = 14 years, 58% female). Sleep was measured with actigraphy (total sleep time [TST] and sleep efficiency) and daily diary (bedtime, wakeup time, and sleep quality) over seven consecutive days. Wake behaviors (caffeine consumption, physical activity, participation in cultural activities, and electronic use after 8p.m.) and mood upon awakening (higher rating indicates greater happiness) were measured via daily diary for seven consecutive days. Multilevel models examined the degree to which nightly sleep predicted next day's wake behaviors and, conversely, wake behaviors and mood predicted nightly sleep, controlling for age, gender, and weekday/weekend. RESULTS: Earlier bedtime and wakeup times predicted greater participation in physical activity the following day. Later bedtime and wakeup time, worse sleep quality, and shorter TST predicted greater electronic use the following night. Earlier bedtime and wakeup time and better sleep quality predicted higher mood ratings. Conversely, greater caffeine consumption during the day predicted both later bedtime and wakeup time. Participation in cultural activities is predicted later bedtime. More nighttime electronic use predicted both later bedtime and wakeup time, poorer sleep quality, and worse TST and sleep efficiency. Higher mood ratings in the morning predicted earlier bedtime and later wakeup time. DISCUSSION: Findings highlight dynamic associations between sleep and wake behaviors and mood in AI/AN adolescents and may elucidate novel pathways for intervention and future research.

Sleep Problems and Health Outcomes Among Urban American Indian and Alaska Native Adolescents.

Importance: Adolescent sleep problems are prevalent, particularly among racial and ethnic minority groups, and can increase morbidity. Despite the numerous strengths of their racial and ethnic group, urban American Indian and Alaska Native adolescents face significant health disparities but are rarely included in health research. Understanding how sleep problems are associated with health outcomes among American Indian and Alaska Native adolescents may elucidate novel targets for interventions to promote health equity. Objective: To assess whether baseline sleep problems are associated with changes in behavioral and cardiometabolic health outcomes among urban American Indian and Alaska Native adolescents 2 years later. Design, Setting, and Participants: American Indian and Alaska Native adolescents were recruited via flyers and community events for an observational cohort study in California. Baseline assessments were conducted among 142 adolescents from March 1, 2018, to March 31, 2020, and follow-ups were conducted among 114 adolescents from December 1, 2020, to June 30, 2022. Exposures: Baseline actigraphy-assessed sleep duration and efficiency and self-reported sleep disturbances and social jet lag (absolute value of the difference in sleep midpoint on weekends vs weekdays; indicator of circadian misalignment). Main Outcomes and Measures: Main outcome measures included self-reported depression (measured using the Patient Health Questionnaire), anxiety (measured using the Generalized Anxiety Disorder 7-item scale), past year alcohol and cannabis use, body mass index, systolic blood pressure (SBP) and diastolic blood pressure (DBP), waist circumference, and glycosylated hemoglobin (HbA1c). Analyses examined whether baseline sleep was associated with health outcomes at follow-up, controlling for age, sex, and baseline outcome measures. Results: The baseline sample included 142 urban American Indian and Alaska Native adolescents (mean [SD] age, 14.0 [1.4] years; 84 girls [59%]), 80% of whom (n = 114; mean [SD] age, 14.1 [1.3] years; 71 girls [62%]) completed follow-ups. Linear or logistic regressions showed significant negative associations between shorter sleep duration and depression (ß = -1.21 [95% CI, -2.19 to -0.24]), anxiety (ß = -0.89 [95% CI, -1.76 to -0.03]), DBP (ß = -2.03 [95% CI, -3.79 to -0.28]), and HbA1c level (ß = -0.15 [95% CI, -0.26 to -0.04]) and likelihood of alcohol (odds ratio [OR], 0.57 [95% CI, 0.36-0.91]) and cannabis use (full week: OR, 0.59 [95% CI, 0.35-0.99]) at follow-up. Greater social jet lag was associated with significantly higher SBP (ß = 0.06 [95% CI, 0.01-0.11]) at follow-up. Conclusions and Relevance: This cohort study found significant associations between poor sleep and adverse changes in health outcomes. Findings highlight the importance of developing culturally responsive interventions that target sleep as a key modifiable risk factor to improve the health of American Indian and Alaska Native adolescents.

Because We Love You (BeWeL): A protocol for a randomized controlled trial of two brief interventions focused on social and cultural connectedness to reduce risk for suicide and substance misuse in young Alaska Native people.

Background: Suicide among young people in Alaska Native (AN) communities was nearly unheard of through the establishment of statehood in 1959, but in the 1970s, AN suicide rates began to double every five years, with most of the increase due to suicide among 15 to 25-year-olds. From 1960-1995, the suicide rate increased by approximately 500% during this period of rapid, imposed social transition. For example, families were forced to live in settlements and children were sent to boarding schools. These disruptions increased conditions associated with suicide risk (e.g., substance use disorders, cultural disconnection), and challenged the community-level social safety net of youth protective factors that might have moderated effects of these traumas. The present study addresses the significant gap in culturally appropriate evidence-based programming to address suicide prevention among AN young people as part of aftercare. Our key research questions and methodology have been informed by AN stakeholders, and the intervention approach is Indigenous-led. Methods: Our interventions are targeted toward Alaska Native young people ages 14-24 who present with suicide attempt, ideation, or associated risk behaviors, including alcohol-related injury in the Yukon-Kuskokwim region or the Interior. In a randomized controlled trial, 14-24-year-old AN individuals will receive either BeWeL (n = 185), which comprises a 45-minute virtual cultural talk addressing family and ancestral strengths and increasing protective factors, or BeWeL plus motivational interviewing with social networks, which includes an additional 15 minutes focused on discussion of the individual's social networks (n = 185). We will evaluate intervention effects on primary outcomes of suicide-intent risk, depression, anxiety, frequency of alcohol use, and alcohol consequences. Some of our secondary outcomes include individual and community protective factors, social networks, and awareness of connectedness. Discussion: This project has the potential to expand the range and effectiveness of suicide prevention services for AN young people and will help meet the need in Alaska to link clinical behavioral health services to AN community-based networks, and to engage local cultural resources in aftercare for individuals at risk for suicide. Findings have potential to provide practical information to advance the field of suicide prevention and enhance protective factors and resiliency among this population. Trial registration: ClinicalTrials.gov Identifier: NCT05360888.

Voices of Identity: Exploring Identity Development and Transformation among Urban American Indian/Alaska Native Emerging Adults.

Emerging adulthood shapes personal, professional, and overall well-being through identity exploration. This study addresses a gap in the minority identity literature by investigating how urban AI/AN emerging adults think about their identity and discussing challenges and protective factors associated with exploring their identity holistically. This mixed-methods study created a sampling framework based on discrimination experiences, cultural identity, social network support, mental health, and problematic substance use. We recruited 20 urban AI/AN emerging adults for interviews. We sought to gain deeper insights into their experiences and discussions surrounding identity formation and exploration. We provide descriptives for demographic characteristics and conducted a thematic analysis of the qualitative data from the interviews. Four themes emerged: a) being an urban AI/AN emerging adult means recognizing that one's identity is multifaceted; b) a multifaceted identity comes with tension of living in multiple worlds; c) the trajectory of one's identity grows over time to a deeper desire to connect with Native American culture; and d) understanding one's Native American background affects one's professional trajectory. Findings underscore the importance of developing programs to support well-being and identity development through cultural connection for urban AI/AN emerging adults.

Neighborhood determinants of sleep and the moderating role of cultural factors among native adolescents.

OBJECTIVE: This study examined the association between neighborhood social environment and sleep among urban American Indian and Alaska Native (AI/AN) adolescents as well as the moderating role of cultural factors in this association. METHOD: The analytic sample included 133 urban AI/AN adolescents (age 12-16, 57.1% female, Mage = 14.03, SDage = 1.35). Perceived neighborhood social environment included safety and cohesion. Cultural factors included AI/AN cultural identification and historical loss. Sleep duration, efficiency, and wake after sleep onset (WASO) were measured via actigraphy. Sleep disturbance was measured via a questionnaire. RESULTS: Greater neighborhood safety was significantly associated with lower sleep disturbance (b = -2.17, SE = 0.8, p = .008), higher sleep efficiency (b = 1.75, SE = 0.64, p = .006), and lower WASO (b = -8.60, SE = 3.34, p = .01). Neighborhood cohesion was not associated with any sleep outcomes. Cultural factors moderated the association between neighborhood social environment and sleep outcomes (p < .05). Specifically, both neighborhood safety and cohesion were associated with lower sleep disturbance, only among individuals reporting higher levels of AI/AN cultural identification. Further, neighborhood safety was associated with greater sleep efficiency and lower WASO (i.e., better sleep) only among adolescents with higher contemplation of historical loss. CONCLUSIONS: Findings highlight the importance of considering cultural factors in addressing sleep and health disparities. AI/AN cultural identification and a sense of historical loss may be important targets for identifying adolescents who might benefit the most from policies and interventions focused on improving the social environment in order to improve sleep and other health outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Food Insecurity Screening in Safety-Net Clinics in Los Angeles County: Lessons for Post-Pandemic Planning.

INTRODUCTION: Food insecurity is a major public health problem in the United States which was exacerbated by the COVID-19 pandemic. We used a multi-method approach to understand barriers and facilitators to implementing food insecurity screening and referrals at safety net health care clinics in Los Angeles County before the pandemic. METHODS: In 2018, we surveyed 1013 adult patients across eleven safety-net clinic waiting rooms in Los Angeles County. Descriptive statistics were generated to characterize food insecurity status, attitudes toward receiving food assistance, and use of public assistance programs. Twelve interviews with clinic staff explored effective and sustainable approaches to food insecurity screening and referral. RESULTS: Patients welcomed the opportunity to access food assistance in the clinic setting; 45% preferred discussing food issues directly with the doctor. Missed opportunities to screen for food insecurity and refer patients to food assistance were identified at the clinic level. Barriers to these opportunities included: competing demands on staff and clinic resources, difficulty establishing referral pathways, and doubts surrounding data. DISCUSSION: Integrating food insecurity assessment in clinical settings requires infrastructure support, staff training, clinic buy-in, and more coordination and oversight from local government, health center entities, and public health agencies.

The association between housing stability and perceived quality of life among emerging adults with a history of homelessness.

Many cities across the United States are experiencing homelessness at crisis levels, including rises in the numbers of unhoused emerging adults (18-25). Emerging adults experiencing homelessness may be at higher risk of experiencing negative outcomes, given that being unhoused increases risk for a variety of behaviors. To better understand the current living circumstances of emerging adults with a history of homelessness, as well as their perceptions about associations between housing stability and quality of life (QOL), we conducted 30 semi-structured in-depth interviews with individuals recruited from drop-in centers for youth experiencing homelessness. At the time of recruitment n=19 were stably housed and n=11 were unstably housed. Two coders analyzed these data inductively and deductively, using pre-identified domains and open coding. Coding reliability was assessed. Three main themes emerged, each with subthemes: 1) Housing quality (neighborhood safety, convenience, housing unit characteristics); 2) QOL before stable housing (physical and mental wellbeing, social wellbeing, and other determinants of QOL, such as encounters with law enforcement); and 3) Changes in QOL after stable housing (same subthemes as for pre-housing stability QOL). Findings indicated a pattern of perceived relationships between housing stability, housing quality, built and social environments, and QOL in the context of emerging adults who experienced or continued to experience homelessness. However, results were mixed with regards to the perceived effects of housing stability on alcohol and other drug use. Taken together, results indicate several areas of challenge, but also highlight opportunities to facilitate improvements in QOL among vulnerable emerging adults who experience homelessness.

Barriers and facilitators of antiretroviral therapy (ART) adherence habit formation in Sub-Saharan Africa: Evidence from a qualitative study in Kampala, Uganda.

RATIONALE: In 2020, nearly 40 million people lived with HIV/AIDS (PLWHA) worldwide, of whom 70% were receiving antiretroviral therapy (ART). Two-thirds of PLWHA reside in Sub-Saharan Africa (SSA), where rates of viral load suppression are often suboptimal and frequently attributed to low ART adherence. Strong pill-taking habits are often reported as a key strategy among those who successfully maintain medication adherence, yet not enough is known about the barriers and facilitators in SSA to pill-taking in response to the same contextual cue, which is a necessary step in the habit formation process. OBJECTIVE: To address this knowledge gap and to inform a subsequent intervention to promote context-dependent repetition, called anchoring, we used a formative qualitative approach to collect in-depth narratives about barriers and facilitators of the anchoring intervention for establishing ART pill-taking habits at the Mildmay Hospital in Kampala, Uganda. METHODS: We conducted interviews with 25 randomly selected patients starting ART, 5 expert patients, and 10 providers at Mildmay, and performed a rapid analysis to inform the intervention in a timely manner. RESULTS: We found that pill taking in response to the same contextual cue, or anchor, was threatened by stigma and food insecurity and that the COVID-19 pandemic exacerbated these barriers. We also determined that important linguistic changes were needed to the instructional materials and reminder messages in the subsequent intervention to avoid words and phrases with negative connotations for this target population. CONCLUSIONS: Several important barriers and facilitators to context-dependent pill taking in Uganda were identified through our formative research that helped to inform important revisions to our subsequent intervention. These findings underscore the importance of understanding local barriers and facilitators when designing and planning interventions, particularly when implementing theory-based intervention approaches that have yet to be tested in a new setting.

Risk and Resilience Among Families in Urban AI/AN Communities: the Role of Young Adults.

Urban American Indian/Alaska Native (AI/AN) young adults and their families are often geographically or socially distant from tribal networks and traditional social support. Young adults can be especially vulnerable to cultural and social disconnection, so understanding how AI/AN family functioning can augment resilience and protect against risk is important. This research precedes a preventive substance use intervention study and explores urban Native family functioning, emphasizing the role of young adults by analyzing data from 13 focus groups with urban AI/AN young adults (n = 32), parents (n = 25), and health providers (n = 33). We found that young adults can and want to become agents of family resilience, playing active roles in minimizing risks and strengthening family functioning in both practical and traditional ways. Also, extended family and community networks played a vital role in shaping family dynamics to support resilience. These resilience pathways suggest potential targets for intervention.