Mind, body, and spirit: a constructivist grounded theory study of wellness among middle-class Black women.

Previous studies show that Black women in the United States experience disproportionately poorer health outcomes compared to women of other racial/ethnic groups. Recently the focus is on improving the health of Black women in the United States. However, there is little empirical evidence on what Black women need to improve their health to be well. The goal of this constructivist grounded theory was to increase the understanding of wellness among middle-class Black women (N = 30) in a large Midwestern city in the United States through an intersectional lens. The findings show that the connection and balance between mind, body, and spirit was the core experience of wellness among middle-class Black women. Mind, body, and spirit was described in three ways-(a) mentally managing, (b) physically caring for my body, and (c) connecting spiritually-with the women also noting the barriers and facilitators they endured to be well. Each of these categories highlight the tension middle-class Black women experience with trying to be well. Implications for future practice and research with middle-class Black women are discussed.

Integration of Arts and Health Sciences in Developing an Opera on Veteran Resilience and Recovery.

There is an emerging literature on research interviews to inform arts projects, but little on opera. This case study illustrates how research data informed an opera on Veteran recovery. Deidentified interviews were selected from 280 adults with a history of depression at 10-year follow-up to a randomized trial. Interviews were used to inform characters, storyline, and libretto. Ethical strategies included: changing details and merging stories and characters to create two Veterans and one spouse as leads, a storyline, and choral passages, with a focus on recovery from post-traumatic stress and homelessness. To engage a broad audience and address stigma, accessible composition techniques (melody, harmony) were used. We found that qualitative/mixed data can inform libretto and composition for an opera on Veteran recovery, through integrating art and health science.

Cross-sectional Comparison of Disparities by Race Using White vs Hispanic as Reference Among Children and Youths With Developmental Disabilities Referred for Speech Therapy.

Importance: Health care research on racial disparities among children and youths has historically used the White race as a reference category with which other racial and ethnic groups are compared, which may inadvertently set up Whiteness as a standard for health. Objective: To compare 2 interpretations of an analysis of racial disparities in speech therapy receipt among children and youths with developmental disabilities: a traditional, White-referenced analysis and a Hispanic majority-referenced analysis. Design, Setting, and Participants: This cross-sectional study used multiple logistic regression to analyze speech therapy referrals for children, adolescents, and transition age youths in an integrated health care system in Southern California from 2017 to 2020. Eligible participants were children and youths up to age 26 years with 1 or more diagnosed intellectual or developmental disability (eg, autism spectrum disorder, speech or language delay, developmental delay, Down syndrome, and others). Exposures: Child or youth race and ethnicity as reported by parents or caregivers (Asian, Black and African American, Hispanic and Latinx, American Indian or Alaskan Native, Native Hawaiian or Pacific Islander, White, multiple, and other). Main Outcomes and Measures: Receipt of speech therapy within 1 year of referral. Results: A total 66 402 referrals were included; 65 833 referrals (99.1%) were for children under age 17 years, 47 323 (71.3%) were for boys, and 39 959 (60.2%) were commercially insured. A majority of participants were identified as Hispanic (36 705 [55.3%]); 6167 (9.3%) were identified as Asian, 4810 (7.2%) as Black, and 14 951 (22.5%) as White. In the traditional racial disparities model where the reference category was White, referrals of children and youths who identified as Hispanic, Black, Pacific Islander, and other had lower odds of actual receipt of speech therapy compared with referrals for White children and youths (Hispanic: OR, 0.79; 95% CI, 0.75-0.83; Black: OR, 0.72; 95% CI, 0.66-0.78; Pacific Islander: OR, 0.74; 95% CI, 0.57-0.98). When using the majority race group (Hispanic) as the reference category, referrals for children and youths who identified as White (OR, 1.26; 95% CI, 1.20-1.30), Asian (OR, 1.21; 95% CI, 1.12-1.30), and multiracial (OR, 1.35; 95% CI, 1.08-1.71) had higher odds of resulting in actual service receipt in comparison with referrals for Hispanic children and youths. Conclusions and Relevance: The cross-sectional study demonstrates the value of decentering Whiteness in interpreting racial disparities research and considering racial differences against multiple referents. Racial disparities researchers should consider investigating multiple between-group differences instead of exclusively using White as the default reference category.

Integrated Methods for Applying Critical Race Theory to Qualitative COVID-19 Equity Research.

Background: Racism persists, underscoring the need to rapidly document the perspectives and experiences of Black, Indigenous and People of Color (BIPOC) groups as well as marginalized populations (eg, formerly incarcerated people) during pandemics. Objective: This methods paper offers a model for using Public Health Critical Race Praxis (PHCRP) and related critical methodologies (ie, feminist and decolonizing methods) to inform the conceptualization, methods, and dissemination of qualitative research undertaken in response to the evolving COVID-19 pandemic. Sample: Using purposive snowball sampling, we identified organizations involved with health equity and social justice advocacy among BIPOC and socially marginalized populations. Focus group participants (N=63) included community members, organizers, activists, and health workers. Design: We conducted topic-specific (eg, reproductive justice) and population-specific (eg, Asian and Pacific Islander) focus groups (N=16 focus groups) in rapid succession using Zoom software. Methods: A self-reflexive, iterative praxis guided theorization, data collection and analysis. We obtained community input on study design, the semi-structured discussion guide, ethical considerations and dissemination. Applying PHCRP, we assessed our assumptions iteratively. We transcribed each interview verbatim, de-identified the data, then used two distinct qualitative techniques to code and analyze them: thematic analysis to identify unifying concepts that recur across focus groups and narrative analysis to keep each participant's story intact. Results: The praxis facilitated relationship-building with partners and supported the iterative assessment of assumptions. Logistical constraints included difficulty ensuring the confidentiality of virtual discussions. Conclusions: These novel approaches provide an effective model for community-engaged qualitative research during a pandemic.

Impact of Opera on Mental Health Stigma: Pilot of Provider/Community Workshop.

BACKGROUND: Arts can influence mental health stigma, but little is known about impact of operas. We examined effects of a two-opera workshop on complicated grief and schizophrenia. METHODS: Pre-post audience surveys with post-workshop discussion. The primary outcome was a 4-item measure of willingness to engage with persons with grief or schizophrenia. Secondary outcomes were perceptions of art affecting stigma and stigma mediators. Of 47 participants, 33 had pre-post surveys for both operas. RESULTS: There was a significant pre-post opera increase in audience willingness to engage with persons with grief or schizophrenia (p < .001). Perceptions of impact on mediators such as empathy, were significantly greater for the opera on schizophrenia relative to grief (p < .001).. CONCLUSION: The pre- to post increase in audience willingness to engage with affected persons (primary) with greater impact on secondary mediators for the schizophrenia opera and post-discussion suggest that operas may be a forum for addressing mental health stigma and promoting empathy.

Lifetime Major Discrimination Experiences Moderate the Impact of Depressive Symptoms on Chronic Conditions among Black Americans.

To clarify the ways in which Black Americans' experiences of structural racism may influence their mental and physical health in distinct ways, the present study evaluated whether major discrimination moderates the association between depressive symptoms and chronic physical health conditions among this population. t-tests and chi-squared tests of significance were used to determine significant differences between women and men. The association between major discrimination and depressive symptoms was examined by assessing mean depressive symptoms scores across levels of major discrimination. ANOVA tests indicated whether there were significant differences in symptom scores across each discrimination category. Additional t-tests determined significant gender differences within each level of discrimination. Gender-stratified negative binomial models were used, and odds ratios (ORs) and 95% confidence intervals (CIs) were estimated for the relationship between depressive symptoms, major discrimination, and chronic conditions. Our findings indicated that the association between depressive symptoms and chronic conditions depends on lifetime experiences of major discrimination among Black Americans and varies significantly between women and men. Considering that major discrimination conditioned the depressive symptom-chronic conditions association among our sample, this provides insight into potential pathways for intervention in efforts to offset the detrimental mental and physical consequences of experiencing racism.

Psychometric Properties of the Altarum Consumer Engagement (ACE) Measure of Activation in Patients with Prediabetes.

BACKGROUND: Patient activation is associated with better outcomes in chronic conditions. OBJECTIVE: We evaluated the psychometric properties of the 12-item Altarum Consumer Engagement™ Measure (ACE-12) in patients with prediabetes. PARTICIPANTS: ACE-12 was administered to patients in the Prediabetes Informed Decisions and Education Study. MAIN MEASURES: We conducted an exploratory factor analysis followed by confirmatory factor analytic models. We evaluated item response categories using item characteristic curves. Construct validity was assessed by examining correlations of the ACE-12 scales with education, depressive symptoms, self-rated health, hemoglobin A1c, body mass index, and weight loss. KEY RESULTS: Participants (n = 515) had a median age of 58; 56% were female; 17% Hispanic; 54% were non-White. The scree plot and Tucker and Lewis reliability coefficient (0.95) suggested three factors similar to the original scales. One item loaded on the navigation rather than the informed choice scale. Ordinal alpha coefficients for the original scales were commitment (0.75); informed choice (0.71); and navigation (0.54). ICCs indicated that one or more of the response categories for 5 of the 12 items were never most likely to be selected. Patients with lower education were less activated on the commitment (r = - 0.124, p = 0.004), choice (r = - 0.085, p = 0.009), and overall score (r = - 0.042, p = 0.011). Patients with depressive symptoms had lower commitment (r = - 0.313, p ≤ 0.001) and overall scores (r = - 0.172, p = 0.012). Patients with poorer health scored lower on the Commitment (r = - 0.308, p ≤ 0.001), Navigation (r = - 0.137, p ≤ 0.001), and overall score (r = - 0.279, p ≤ 0.001). CONCLUSION: The analyses provide some support for the psychometric properties of the ACE-12 in prediabetic patients. Future research evaluating this tool among patients with other chronic conditions are needed to determine whether Q1 (I spend a lot of time learning about health) should remain in the informed choice or be included in the navigation scale. Additional items may be needed to yield acceptable reliability for the navigation scale.

Exploring the Relationship Between Self-Employment and Health Among Blacks.

Purpose: There is some evidence that self-employment may improve measures of cardiovascular and general health among the general population; however, no studies have examined this relationship among Non-Hispanic Blacks (NHBs). Studying the health implications of self-employment among NHBs is important because of the disparities that persist in both cardiovascular health and self-employment rates between NHBs and other racial/ethnic subgroups. Methods: A pooled cross-sectional analysis of data from the Behavioral Risk Factor Surveillance System (2000 to 2014) was used to explore the association between self-employment and the following self-reported outcomes: "no exercise," fruit consumption, vegetable consumption, days of alcohol consumption, fair or poor health, hypertension, poor mental health days, and poor physical health days among the total population of NHBs and across gender/income subgroups. Results: We find favorable associations between self-employment and several measures of cardiovascular health (increased fruit and vegetable consumption, reduced reports of "no exercise," and reduced reports of hypertension) and positive associations between self-employment, poor mental health days, and days of alcohol consumption among the total population. The nature of these associations varies across gender/income subgroup. Conclusions: Given the disparities between racial/ethnic subgroups with respect to adverse cardiovascular outcomes and the well-documented roles of exercise and blood pressure control in limiting cardiovascular disease, it is important to probe the relationship between self-employment and health among NHBs further.

Diabetes Prevention Program attendance is associated with improved patient activation: Results from the Prediabetes Informed Decisions and Education (PRIDE) study.

The Diabetes Prevention Program (DPP) is a 12-month behavior change program designed to increase physical activity and improve dietary patterns among patients at risk for Type 2 diabetes, in order to facilitate modest weight loss and improve cardio-metabolic profiles. It is unknown whether baseline patient activation is related to increased DPP uptake, and whether DPP attendance leads to subsequent improvement in patient activation. We analyzed data from 352 adult participants in the Prediabetes Informed Decisions and Education (PRIDE) trial of shared decision-making (SDM) in diabetes prevention, collected from November 2015 through September 2017. PRIDE participants completed baseline and 4-month follow-up surveys, including the Altarum Consumer Engagement (ACE) Measure™ of patient activation. We tracked DPP attendance over 8 months using data from partnering DPP providers. In multivariate models, we measured whether self-reported baseline activation was associated with DPP "uptake" (1+ session attended) or DPP "attendance" (9+ sessions). We also examined whether DPP attendance was associated with change in activation at 4-months follow-up. We did not find an association between baseline activation and DPP uptake or attendance. However, we did find that DPP attendance was associated with an increase in the overall ACE score (6.68 points, 95% CI 1.97-11.39, p = 0.005) and increased activation in 2 of the 3 ACE subscales (Commitment and Informed Choice). Our finding of increased patient activation with DPP attendance suggests a mechanism for the improved health outcomes seen in DPP real-world translational studies. This work has important implications for diabetes prevention and other behavior change programs.

Assessing Informal and Formal Diabetes Knowledge in African American Older Adults With Uncontrolled Diabetes.

Some researchers attribute the excess rates of diabetes complications among African American older adults compared to other racial/ethnic subgroups to low diabetes knowledge. Diabetes knowledge measures have a biomedical orientation, including knowledge of glycemic control and using diet and exercise to control blood sugar. Measures do not assess informal knowledge that patients obtain outside of the clinical environment. The distinction between formal and informal knowledge is meaningful for cultural groups such as African American individuals who have historically transferred knowledge about maintaining their health "through the grapevine." A qualitative approach was used to understand participants' informal diabetes knowledge. Three major themes identified addressed the threat that participants perceived when diagnosed, the social construction of diabetes knowledge through their lived and observed experiences, and the limited role that clinicians played in participants' diabetes knowledge acquisition. Findings reveal ways nurses can individualize the diabetes education they provide to African American older adults based on their experiential understanding. [Journal of Gerontological Nursing, 45(2), 35-41.].

Contemplative Practices: A Strategy to Improve Health and Reduce Disparities.

Health has many dimensions, and intolerance and lack of compassion may contribute to the poor health and disparities in our nation. Tolerance can convey an inherent paradox or dissonance that can be associated with stress. However, tolerance has a dimension of acceptance, an acknowledgement and acceptance of what "is" at the present moment, that can relieve tension associated with differing beliefs and practices. Compassionate consideration of others can be combined with acceptance to create harmony within and across individuals. In this article, we explore how contemplative practices can cultivate tolerance and compassion and contribute to improvements in individual and population health.

Developing and proposing the ethno-cultural gerontological nursing model.

By 2050, for the first time in U.S. history, almost half of elders will be from ethnic minority groups. To meet the needs of this rapidly diversifying population, nurses need to be able to marry transcultural nursing knowledge with gerontological nursing knowledge. The purpose of this article is to propose a new theoretical model for explaining health outcomes and health responses for older individuals in unique ethno-cultural groups and to discuss implications and applications of the model to transcultural gerontological nursing practice and research. The discussion will include (1) an overview of currently available theoretical knowledge in the area, (2) a description of the theory development process, (3) presentation of the proposed ethno-cultural gerontological nursing theoretical model, and (4) discussion of how this model can enhance nursing's contributions to reducing health disparities. This model is presented not as a finished product but as a basis for future discussion and refinement.