Stories from COVID-19 Reveal Hospitalized Patients with Limited English Proficiency Have Always Been Uniquely Prone to Social Isolation.

Through experiences with hospital visitor restrictions during the COVID-19 pandemic, a group of frontline trainees at the University of California San Francisco (UCSF) uncovered patient stories highlighting the unique challenges that patients with limited English proficiency (LEP) face in the hospital, particularly their vulnerability to social isolation. Here, we recount patient stories illustrative of this isolation, generated by insufficient professional interpreter use, ad hoc interpretation, and scarcity of media in preferred languages. When confronted with the social isolation faced by all patients during COVID-19, we more clearly saw the healthcare disparities affecting patients with LEP. A trainee-led videoconferencing initiative facilitating social calls between patients at UCSF and their loved ones proved especially helpful in reducing the disconnection that patients with LEP experience in the hospital. Motivated by the findings of this project, we advocate for other institutions to take similar action, such as hiring inpatient telehealth navigators and providing tablets for ad lib use. Enacting these changes will keep patients with LEP connected to their families and communities while in the hospital, an essential step towards establishing an equitable experience for patients with LEP.

What matters when exploring fidelity when using health IT to reduce disparities?

BACKGROUND: Implementation of evidence-based interventions often involves strategies to engage diverse populations while also attempting to maintain external validity. When using health IT tools to deliver patient-centered health messages, systems-level requirements are often at odds with 'on-the ground' tailoring approaches for patient-centered care or ensuring equity among linguistically diverse populations. METHODS: We conducted a fidelity and acceptability-focused evaluation of the STAR MAMA Program, a 5-month bilingual (English and Spanish) intervention for reducing diabetes risk factors among 181 post-partum women with recent gestational diabetes. The study's purpose was to explore fidelity to pre-determined 'core' (e.g. systems integration) and 'modifiable' equity components (e.g. health coaching responsiveness, and variation by language) using an adapted implementation fidelity framework. Participant-level surveys, systems-level databases of message delivery, call completion, and coaching notes were included. RESULTS: 96.6% of participants are Latina and 80.9% were born outside the US. Among those receiving the STAR MAMA intervention; 55 received the calls in Spanish (61%) and 35 English (39%). 90% (n = 81) completed ≥ one week. Initially, systems errors were common, and increased triggers for health coach call-backs. Although Spanish speakers had more triggers over the intervention period, the difference was not statistically significant. Of the calls triggering a health coach follow-up, attempts were made for 85.4% (n = 152) of the English call triggers and for 80.0% (n = 279) of the Spanish call triggers (NS). Of attempted calls, health coaching calls were complete for 55.6% (n = 85) of English-language call triggers and for 56.6% of Spanish-language call triggers (NS). Some differences in acceptability were noted by language, with Spanish-speakers reporting higher satisfaction with prevention content (p = < 0.01) and English-speakers reporting health coaches were less considerate of their time (p = 0.03). CONCLUSIONS: By exploring fidelity by language-specific factors, we identified important differences in some but not all equity indicators, with early systems errors quicky remedied and high overall engagement and acceptability. Practice implications include: (1) establishing criteria for languge-equity in interventions, (2) planning for systems level errors so as to reduce their impact between language groups and over time; and (3) examining the impact of engagement with language-concordant interventions on outcomes, including acceptability. Trial Registration National Clinical Trials registration number: CT02240420 Registered September 15, 2014. ClinicalTrials.gov.

Telehepatology Use and Satisfaction Among Vulnerable Cirrhosis Patients Across Three Healthcare Systems in the Coronavirus Disease Pandemic Era.

Background and Aims: Telehealth has emerged as an important mode of cirrhosis care delivery, but its use and satisfaction among vulnerable populations (eg, racial/ethnic minorities, socioeconomically disadvantaged, substance use disorders) are unknown. We evaluated digital capacity, telehealth use, satisfaction and associated factors among patients receiving hepatology care via telehealth (telehepatology) across 2 Veterans Affairs and 1 safety-net Healthcare systems. Methods: English- and Spanish-speaking adults with cirrhosis (N = 256) completed surveys on telehealth use and satisfaction, quality of life, pandemic stress, alcohol use and depression. Logistic regression analyses assessed telehealth use and general linear models evaluated telehealth satisfaction. Results: The mean age was 64.5 years, 80.9% were male and 35.9% Latino; 44.5% had alcohol-associated cirrhosis; 20.8% had decompensated cirrhosis; 100% had digital (phone/computer) capacity; and 75.0% used telehepatology in the prior 6 months. On multivariable analysis, participants with alcohol-associated (vs not) cirrhosis were less likely and those with greater pandemic stress were more likely to use telehepatology (odds ratio = 0.46 and 1.41, respectively; P < .05). Better quality of life was associated with higher telehepatology satisfaction and older age was associated with lower satisfaction (ß = 0.01 and -0.01, respectively; P < .05). Latinos had higher satisfaction, but alcohol use disorder was associated with less satisfaction with telehepatology visits (ß = 0.22 and -0.02, respectively; P < .05). Conclusion: Participants had high telehepatology capacity, yet demographics and alcohol-related problems influenced telehepatology use and satisfaction. Findings underscore the need for interventions to enhance patient experience with telehepatology for certain vulnerable groups including those with alcohol-associated cirrhosis in order to optimize care delivery.

The STAR-MAMA RCT: Bilingual Mobile Health Coaching for Postpartum Weight Loss.

INTRODUCTION: Gestational diabetes and overweight during pregnancy are associated with future type 2 diabetes. Postpartum weight loss can reduce diabetes risk. However, effective interventions for postpartum weight loss are lacking, in particular for Latina populations, despite their disproportionate burdens of gestational diabetes, overweight, and diabetes. STUDY DESIGN: This was a community-based RCT. SETTING/PARTICIPANTS: Researchers recruited pregnant individuals with gestational diabetes or BMI>25 kg/m2 from safety-net health care settings and Women, Infants, and Children offices in Northern California in 2014-2018. Of 180 individuals randomized to intervention (n=89) or control (n=91), 78% identified as Latina, 61% were primarily Spanish speaking, and 76% perceived their diabetes risk to be low. INTERVENTION: The intervention consisted of a 5-month postpartum telephone-based health coaching intervention delivered in English or Spanish. MAIN OUTCOME MEASURES: Data were collected through surveys at enrollment and 9-12 months after delivery and chart review up to 12 months after delivery. The primary outcome, weight change from prepregnancy to 9-12 months after delivery, was compared between the groups, overall and within strata defined a priori according to language (Spanish or English) and diabetes risk perception (none/slight or moderate/high). RESULTS: The intent-to-treat estimated intervention effect was +0.7 kg (95% CI= -2.4 kg, +3.8 kg; p=0.67). In stratified analyses, intervention effects remained nonsignificant but varied in direction: effects were favorable among English speakers and those with higher perceived diabetes risk, and unfavorable among Spanish speakers and those with lower perceived risk. Analyses were conducted in 2021-2022. CONCLUSIONS: A postpartum health coaching intervention, designed for low-income Latina women at increased risk for diabetes, did not reduce postpartum weight gain. Intervention effects were nonsignificantly more favorable among English speakers versus Spanish speakers, and among those who perceived their diabetes risk to be high versus low. TRIAL REGISTRATION: This study is registered at www. CLINICALTRIALS: gov NCT02240420.

Barriers and Enablers to COVID-19 Vaccination in San Francisco's Spanish-Speaking Population.

Populations at high risk for COVID-19- including Spanish speakers-may face additional barriers to obtaining COVID-19 vaccinations; by understanding their challenges, we can create more equitable vaccine interventions. In this study, we used interviews to identify barriers and enablers to COVID-19 vaccine uptake among participants in the San Francisco Department of Public Health contact tracing program. Data analysis employed Capability, Opportunity, Motivation Behavior model (COM-B) and the Behavior Change Wheel framework as guides to target barriers with interventions and supporting policies. This paper presents data from interviews focused on COVID-19 vaccine uptake that was part of a project to improve COVID-19 preventive behaviors in San Francisco. We completed seventeen interviews between February and May 2021; six (35%) were completed in English and 11 (65%) in Spanish. Barriers to vaccine uptake included an unprepared health system, fear of side effects, limited knowledge, and conflicting information. Behavioral factors influencing vaccine uptake were mainly related to physical opportunity, automatic motivation, and psychological capability. Interventions that could address the most significant number of barriers included education, enablement, and environmental restructuring. Finally, communication and marketing policies that use diverse multi-lingual social media and environmental planning that includes accessible vaccine sites for people with disabilities, literacy barriers, and limited English proficiency could significantly increase vaccination. Public health departments should tailor interventions to high-risk populations by understanding the specific barriers they face. This exploratory study suggests how implementation science can provide frameworks to achieve this.

A qualitative assessment of barriers and facilitators to implementing recommended infant nutrition practices in Mumbai, India.

BACKGROUND: Childhood malnutrition has been a longstanding crisis in Mumbai, India. Despite national IYCF (Infant Young Child Feeding) guidelines to promote best practices for infant/toddler feeding, nearly one-third of children under age five are stunted or underweight. To improve child nutrition, interventions should address the cultural, social, and environmental influences on infant feeding practices. This study is an in-depth qualitative assessment of family barriers and facilitators to implementing recommended nutrition practices in two Mumbai slum communities, within the context of an existing nutrition education-based intervention by a local non-governmental non-profit organization. METHODS: The population was purposively sampled to represent a variety of household demographics. Data were collected through 33 in-depth semi-structured interviews with caregivers (mothers and paternal grandmothers) of children age 0-2 years. Transcripts were translated and transcribed, and analyzed using qualitative analysis procedures and software. RESULTS: A complex set of barriers and facilitators influence mothers'/caregivers' infant-toddler feeding practices. Most infants were fed complementary foods and non-nutritious processed snacks, counter to IYCF recommendations. Key barriers included: lack of nutrition knowledge and experience, receiving conflicting messages from different sources, limited social support, and poor self-efficacy for maternal decision-making. Key facilitators included: professional nutrition guidance, personal self-efficacy and empowerment, and family support. Interventions to improve child nutrition should address mothers'/caregivers' key barriers and facilitators to recommended infant-toddler feeding practices. CONCLUSIONS: Nutrition interventions should prioritize standard messaging across healthcare providers, engage all family members, target prevention of early introduction of sugary and non-nutritious processed foods, and strengthen maternal self-efficacy for following IYCF recommended guidelines.

Early Childhood Junk Food Consumption, Severe Dental Caries, and Undernutrition: A Mixed-Methods Study from Mumbai, India.

In India, globalization has caused a nutrition transition from home-cooked foods to processed sugary snacks and drinks, contributing to increased early childhood caries (ECC). This mixed-methods study describes risk factors for ECC and associations with undernutrition in low-income communities in Mumbai. Interviews with mothers of 959 children, ages six-months through six-years, addressed maternal-child nutrition and oral health, and children received dental exams and anthropometric assessments. Focus groups with community health workers and mothers explored experiences and perceptions of oral health, nutrition, and ECC. Descriptive and logistic regression analyses of quantitative data, and content analysis of qualitative data were performed. Eighty percent of children lived 5 min from a junk-food store, over 50% consumed junk-food and sugary tea daily, 50% experienced ECC, 19% had severe deep tooth decay, 27% experienced mouth pain, and 56% experienced chronic and/or acute malnutrition. In children ages 3-6, each additional tooth with deep decay was associated with increased odds of undernutrition (Odds Ratio [OR] 1.10, Confidence Interval [CI] 1.02-1.21). Focus groups identified the junk-food environment, busy family life, and limited dental care as contributors to ECC. Policy interventions include limits on junk-food marketing and incorporating oral health services and counseling on junk-food/sugary drinks into maternal-child health programs.

Linking High Risk Postpartum Women with a Technology Enabled Health Coaching Program to Reduce Diabetes Risk and Improve Wellbeing: Program Description, Case Studies, and Recommendations for Community Health Coaching Programs.

Background. Low-income minority women with prior gestational diabetes mellitus (pGDM) or high BMIs have increased risk for chronic illnesses postpartum. Although the Diabetes Prevention Program (DPP) provides an evidence-based model for reducing diabetes risk, few community-based interventions have adapted this program for pGDM women. Methods. STAR MAMA is an ongoing randomized control trial (RCT) evaluating a hybrid HIT/Health Coaching DPP-based 20-week postpartum program for diabetes prevention compared with education from written materials at baseline. Eligibility includes women 18-39 years old, ≥32 weeks pregnant, and GDM or BMI > 25. Clinic- and community-based recruitment in San Francisco and Sonoma Counties targets 180 women. Sociodemographic and health coaching data from a preliminary sample are presented. Results. Most of the 86 women included to date (88%) have GDM, 80% were identified as Hispanic/Latina, 78% have migrant status, and most are Spanish-speaking. Women receiving the intervention indicate high engagement, with 86% answering 1+ calls. Health coaching callbacks last an average of 9 minutes with range of topics discussed. Case studies presented convey a range of emotional, instrumental, and health literacy-related supports offered by health coaches. Discussion. The DPP-adapted HIT/health coaching model highlights the possibility and challenge of delivering DPP content to postpartum women in community settings. This trial is registered with ClinicalTrials.gov NCT02240420.