¿No Hay Racismo?: application of the levels of racism framework to Latinx perspectives on barriers to health and wellbeing.

BACKGROUND: The purpose of this study is to increase understanding of the forms of systemic racism experienced by Latinx communities in North Carolina during the COVID-19 pandemic as identified by Latinx community health workers (CHWs) and community-based organization (CBO) leaders. METHODS: We held three focus groups in July 2022 (N = 16) with CHWs and CBO leaders in Spanish to discuss policy and community interventions that improved access to resources during the COVID-19 pandemic; policy or community interventions needed to improve care of Latinx communities; and lessons learned to improve the health of Latinx communities in the future. We performed directed and summative qualitative content analysis of the data in the original language using the Levels of Racism Framework by Dr. Camara Jones to identify examples of implicitly and explicitly discussed forms of systemic racism. RESULTS: Latinx CHWs and CBO leaders implicitly discussed numerous examples of all levels of racism when seeking and receiving health services, such as lack of resources for undocumented individuals and negative interactions with non-Latinx individuals, but did not explicitly name racism. Themes related to institutionalized racism included: differential access to resources due to language barriers; uninsured or undocumented status; exclusionary policies not accounting for cultural or socioeconomic differences; lack of action despite need; and difficulties obtaining sustainable funding. Themes related to personally-mediated racism included: lack of cultural awareness or humility; fear-inciting misinformation targeting Latinx populations; and negative interactions with non-Latinx individuals, organizations, or institutions. Themes related to internalized racism included: fear of seeking information or medical care; resignation or hopelessness; and competition among Latinx CBOs. Similarly, CHWs and CBO leaders discussed several interventions with systems-level impact without explicitly mentioning policy or policy change. CONCLUSION: Our research demonstrates community-identified examples of racism and confirms that Latinx populations often do not name racism explicitly. Such language gaps limit the ability of CHWs and CBOs to highlight injustices and limit the ability of communities to advocate for themselves. Although generally COVID-19 focused, themes identified represent long-standing, systemic barriers affecting Latinx communities. It is therefore critical that public and private policymakers consider these language gaps and engage with Latinx communities to develop community-informed anti-racist policies to sustainably reduce forms of racism experienced by this unique population.

Barriers and Facilitators Along the PrEP Continuum of Care Among Latinx Sexual Minoritized Men and Transgender Women: A Systematic Review.

Latinx cisgender sexually minoritized men (SMM) and transgender women (TW) in the U.S. are disproportionately affected by HIV. Although pre-exposure prophylaxis (PrEP) is a highly effective strategy for HIV prevention, rates of PrEP use among Latinx SMM and TW remain suboptimal. The main purpose of this systematic review was to (1) describe engagement in the various stages of the PrEP care continuum among Latinx SMM and TW, and (2) identify multilevel determinants that function as barriers or facilitators to engagement in the PrEP continuum of care for Latinx SMM and TW. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement (PRISMA). Five databases (MEDLINE, CINAHL, PsycINFO, Embase, Scopus) were searched to examine the available qualitative, quantitative, and mixed method studies relevant to the research question. A total of 56 studies were included, with the majority focusing on SMM and being cross-sectional in design. Barriers included PrEP knowledge, risk perception, intersecting stigma, and structural conditions. Community resources, social support, and PrEP navigation services facilitated engagement in the PrEP continuum of care. This review highlights the complex factors that influence PrEP care engagement among Latinx SMM and TW. These findings call for comprehensive, multilevel approaches to address inequities disparities in PrEP care engagement among these groups.

RESUMEN: Los hombres cisgénero sexualmente minorizados (SMM) y las mujeres transgénero (TW) latinx en EE. UU. son desproporcionadamente afectados por el VIH. Aunque la profilaxis previa a la exposición (PrEP) es una estrategia efectiva para la prevención del VIH, el uso de la PrEP entre SMM y TW latinx siguen siendo deficiente. El propósito principal de esta revisión sistemática fue describir la participación en las etapas del continuo de atención de la PrEP entre SMM y TW latinx, e identificar factores de multinivel que funcionan como barreras o facilitadores para la participación en el continuo de atención de la PrEP en estos grupos. Esta revisión se realizó de acuerdo con la Declaración de los Elementos de Informes Preferidos para Revisiones Sistemáticas y Metaanálisis (PRISMA). Cinco bases de datos (MEDLINE, CINAHL, PsycINFO, Embase, Scopus) se utilizaron para examinar los estudios cualitativos, cuantitativos y de métodos mixtos relevantes para la pregunta de esta investigación. Se incluyeron un total de 56 estudios, la mayoría se enforcaron en SMM y usaron diseño transversal. Las barreras incluyeron falta de conocimiento sobre PrEP, percepción de riesgo, estigma interseccional y condiciones estructurales. Los recursos comunitarios, el apoyo social y los servicios de navegación de PrEP facilitaron la participación en el continuo de atención de PrEP. Esta revisión resplandece los factores complejos que influyen en la participación del continuo de atención de PrEP entre SMM y TW latinx. Estos descubrimientos exigen enfoques holistas y de multinivel para abordar las disparidades en uso y acceso a de la PrEP entre estos grupos.

Acculturation, acculturative stress, and tobacco/nicotine use of Latin American immigrants.

OBJECTIVE: US Hispanics have several health disparities, greater tobacco/nicotine-related illnesses, lower access to smoking cessation, and lower rates of cessation. Understanding cultural constructs linked to tobacco/nicotine use may provide a greater understanding of future cultural adaptations of cessation interventions. This study used a multidimensional acculturation framework, with cultural practices, identity, and values, to test links between measures of acculturation stress, multidimensional acculturation (language-based enculturation and acculturation, cultural identity, familism), and tobacco/nicotine use, and interactions with gender. DESIGN: Participants were 391 adult Latin American immigrants (69% women); 12% self-reported tobacco/nicotine use in the past six months. RESULTS: Path analysis showed acculturative stress, ß = .16, and acculturation, ß = .20, were positively related to tobacco/nicotine use. Enculturation, familism, and Hispanic cultural identity were not related to tobacco/nicotine use. There were no significant acculturation by enculturation or gender interactions, but women were less likely to use tobacco/nicotine than men, ß = -.36. CONCLUSION: Findings suggest that tobacco/nicotine cessation interventions for Latino immigrants may be enhanced with an emphasis on the mitigation of acculturative stress, attention to the adoption of US cultural practices, and gender. Future research should examine specific sources of acculturative stress or social norms related to tobacco/nicotine use.

Challenges in the Transition from Acute Hospital Care to Home for Spanish-Speaking Latino Patients with TBI and Families: Perspectives of Healthcare Providers and Interpreters.

Language-based disparities negatively impact patient outcomes. Spanish-speaking Latino patients with traumatic brain injury (TBI) transitioning home from acute hospital care and their families have poor TBI-related outcomes; further, they have significant difficulties navigating the healthcare system due to care fragmentation and limited provider support. These challenges are exacerbated by language barriers. There are disproportionately fewer bilingual providers and interpreters in the U.S. healthcare system for patients with TBI for whom English is not their primary language. Although Spanish-speaking Latino patients with TBI and their families communicate with healthcare providers using interpreters on a regular basis, limited research has explored the healthcare delivery perspective. The purpose of this study was to understand the perspectives of healthcare providers and interpreters regarding their experience caring for or supporting Spanish-speaking Latino patients with TBI and their families during the transition home from acute hospital care. This qualitative descriptive study included 10 bilingual (English and Spanish-speaking) participants: 7 interdisciplinary providers and 3 interpreters; findings were analyzed using rapid qualitative analysis to inform intervention adaptation. Four themes were identified: 1) language misalignment decreases health literacy and increases length of stay; 2) TBI-related cognitive impairments, coupled with language differences, make communication challenging; 3) unique social contributors to health directly decrease health equity; and 4) recommendations to improve access and justice in transitional care. There are multiple opportunities to improve transitional care support provided to Spanish-speaking Latino patients with TBI and their families in a manner that is not currently being addressed in research or in practice.

Cost-A Hidden Aspect of Equity-Grounded Implementation Science.

This JAMA Forum discusses the cost of health inequities, the lack of attention to implementation science and the costs in the research enterprise, and provides recommendations for targeting cost in equity-grounded implementation science.

Determining the role of acculturative stress in predicting mental health service use among Latinx immigrants.

OBJECTIVES: Acculturative stress is an important factor that affects health for Latinx immigrants in the US, with multiple studies identifying a link between depression and acculturative stress in this population. However, far fewer studies have examined the specific role and relationship of acculturative stress on mental health service use in this population. Through the lens of Yang's 2016 Model of Immigrant Health Service Use, this study aimed to examine the role of acculturative stress in predicting mental health service use in a sample of Latinx immigrants in the Southeast US. DESIGN: We conducted a secondary data analysis from a longitudinal study of Latinx immigrant health (n = 391). RESULTS: Our study found that while total acculturative stress was not significantly associated with mental health service use in this sample, parenting stress was a significant predictor of mental health service use in the past six months when controlling for covariates (OR: 1.043, 95% CI [1.009, 1.078]). Additionally, important Predisposing and Need for Healthcare factors were significantly associated with mental health service use, specifically: males were less likely to utilize mental health services than females (OR: 0.401, 95% CI [0.166-0.968]), English language acculturation was positively associated with mental health service use (OR: 1.953, 95% CI [1.130, 3.377]), and depression was positively associated with mental health service use (OR: 1.107, 95% CI [1.027, 1.194]). CONCLUSION: These findings support the need for more culturally sensitive mental health services, and the need to develop strategies to engage males and less acculturated individuals in mental health services to promote health equity among Latinx immigrants.

Addressing Systemic Racism and Racialized Violence to Reduce Firearm Injury and Mortality Inequities.

This JAMA Forum discusses systemic racism and racialized violence, promising approaches to address inequities in firearm violence, and ways to treat the trauma of gun violence.

Service utilization among adolescents seeking trauma-related care: Differences by risk for suicide and ethnoracial background.

Adolescents from ethnoracially minoritized backgrounds increasingly report high rates of attempted suicide, trauma exposure, and limited access to mental healthcare services. However, less is known regarding their use of services across different youth-serving systems. This study examines the associations and interactions between self-injurious thoughts and behaviors (SITBs), race/ethnicity, and service sector utilization (mental healthcare, general healthcare, school, and social services) among a sample of trauma-exposed and treatment-seeking adolescents. Participants were treatment-seeking adolescents (N = 4406) ages 12-17 from the National Child Traumatic Stress Network Core Data Set who had available data for SITBs, race/ethnicity, services utilized, and other key variables. Mixed effects logistic regression was used to examine main and interactive effects for whether adolescents' race/ethnicity and SITBs were associated with service utilization in each of the identified service sectors. SITBs were associated with adolescents' utilization of mental healthcare (OR = 1.38 p < 0.001), general healthcare (OR = 2.30; p < 0.001), and school services (OR = 1.38 p < 0.001). NH Black adolescents reporting SITBs were less likely to use mental health services than other NH Black youths (OR = 0.53; p = 0.004). Hispanic adolescents reporting SITBs were more likely to utilize healthcare services than other Hispanic youths (OR = 1.51; p = 0.039). Trauma-exposed adolescents reporting SITBs are more likely to utilize mental healthcare, general healthcare, and school-based services than other trauma-exposed adolescents. However, NH Black adolescents experiencing SITBs may face additional barriers to utilizing mental healthcare services. Findings can be used to develop nursing practices and policies to address barriers faced by adolescents reporting SITBs.

Efficacy of BETTER transitional care intervention for diverse patients with traumatic brain injury and their families: Study protocol of a randomized controlled trial.

OBJECTIVE: The purpose of this study is to examine the efficacy of BETTER (Brain Injury, Education, Training, and Therapy to Enhance Recovery) vs. usual transitional care management among diverse adults with traumatic brain injury (TBI) discharged home from acute hospital care and families. METHODS: This will be a single-site, two-arm, randomized controlled trial (N = 436 people, 218 patient/family dyads, 109 dyads per arm) of BETTER, a culturally- and linguistically-tailored, patient- and family-centered, TBI transitional care intervention for adult patients with TBI and families. Skilled clinical interventionists will follow a manualized protocol to address patient/family needs. The interventionists will co-establish goals with participants; coordinate post-hospital care, services, and resources; and provide patient/family education and training on self- and family-management and coping skills for 16 weeks following hospital discharge. English- and Spanish-speaking adult patients with mild-to-severe TBI who are discharged directly home from the hospital without inpatient rehabilitation or transfer to other settings (community discharge) and associated family caregivers are eligible and will be randomized to treatment or usual transitional care management. We will use intention-to-treat analysis to determine if patients receiving BETTER have a higher quality of life (primary outcome, SF-36) at 16-weeks post-hospital discharge than those receiving usual transitional care management. We will conduct a descriptive, qualitative study with 45 dyads randomized to BETTER, using semi-structured interviews, to capture perspectives on barriers and facilitators to participation. Data will be analyzed using conventional content analysis. Finally, we will conduct a cost/budget impact analysis, evaluating differences in intervention costs and healthcare costs by arm. DISCUSSION: Findings will guide our team in designing a future, multi-site trial to disseminate and implement BETTER into clinical practice to enhance the standard of care for adults with TBI and families. The new knowledge generated will drive advancements in health equity among diverse adults with TBI and families. TRIAL REGISTRATION: NCT05929833.

A Hybrid Pragmatic and Factorial Cluster Randomized Controlled Trial for an Anti-racist, Multilevel Intervention to Improve Mental Health Equity in High Schools.

Systemic racism is pervasive in US society and disproportionately limits opportunities for education, work, and health for historically marginalized and minoritized racial and ethnic groups, making it an urgent issue of social justice. Because systemic racism is a social determinant of health prevalent across multiple social and institutional structures, it requires multilevel intervention approaches using effective designs and analytic methods to measure and evaluate outcomes. Racism is a fundamental cause of poor health outcomes, including mental health outcomes; thus, mental health services and programs that address racism and discrimination are key to promoting positive mental health of racial and ethnic minority youth. While multilevel interventions are well-suited for improving outcomes like youth mental health disparities, their evaluation poses unique methodological challenges, requiring specialized design and analytic approaches. There has been limited methodological guidance provided to researchers on how to test multilevel interventions using approaches that balance methodological rigor, practicality, and acceptability across stakeholder groups, especially within communities most affected by systemic racism. This paper addresses this gap by providing an example of how to rigorously evaluate a hypothetical, theoretically based, multilevel intervention promoting mental health equity in three US school systems using an anti-racist approach intervening at the macro- (i.e., school system), meso- (i.e., school), and micro- (i.e., family and student) levels to improve mental health in adolescents. We describe the design, sample size considerations, and analytic methods to comprehensively evaluate its effectiveness while exploring the extent to which the components interact synergistically to improve outcomes. The methodological approach proposed can be adapted to other multilevel interventions that include strategies addressing macro-, meso-, and micro-levels of influence.

Burned Out on Burnout-The Urgency of Equity-Minded Structural Approaches to Support Nurses.

This JAMA Forum discusses a health equity framework to address burnout and professional fulfillment among nurses.

Promoting Latinx health equity through community-engaged policy and practice reforms in North Carolina.

Introduction: The Latinx Advocacy Team & Interdisciplinary Network for COVID-19 (LATIN-19) is a unique multi-sector coalition formed early in the COVID-19 pandemic to address the multi-level health inequities faced by Latinx communities in North Carolina. Methods: We utilized the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework to conduct a directed content analysis of 58 LATIN-19 meeting minutes from April 2020 through October 2021. Application of the NIMHD Research Framework facilitated a comprehensive assessment of complex and multidimensional barriers and interventions contributing to Latinx health while centering on community voices and perspectives. Results: Community interventions focused on reducing language barriers and increasing community-level access to social supports while policy interventions focused on increasing services to slow the spread of COVID-19. Discussion: Our study adds to the literature by identifying community-based strategies to ensure the power of communities is accounted for in policy reforms that affect Latinx health outcomes across the U.S. Multisector coalitions, such as LATIN-19, can enable the improved understanding of underlying barriers and embed community priorities into policy solutions to address health inequities.

Systemic Racism Affecting Latinx Population Health During the COVID-19 Pandemic and Beyond: Perspectives of Latinx Community Health Workers and Community-Based Organization Leaders.

Introduction: The purpose of this study is to identify forms of systemic racism experienced by Latinx communities in North Carolina during the COVID-19 pandemic as identified by Latinx community health workers (CHWs) and community-based organization (CBO) leaders. Methods: We conducted three focus groups in July 2022 (N=16). We performed qualitative analysis of data using an iterative inductive approach of the original language in Dedoose. Results: Four central themes emerged: (1) Access to resources for Latinx individuals; (2) Immediate, transitional, and future fears; (3) Benefits of CHWs; and (4) Lessons learned. Discussion: Institutional and state policies often do not involve community members, such as CHWs and CBO leaders, at the start of the development process, leading to ineffective interventions that perpetuate health disparities and systemic racism. Health Equity Implications: Community-informed policy recommendations can improve alignment of community and policy priorities to create more effective interventions to address systemic racism and promote health equity.

Growing Up in an Era of Storms and Stress-Promoting Hope Among Adolescents in the Face of Climate Change.

This JAMA Forum discusses climate change efforts to promote hope among adolescents.

The BETTER Traumatic Brain Injury Transitional Care Intervention: A Feasibility Study.

This study aimed to investigate the feasibility, acceptability, and clinical outcome measures of BETTER (Brain Injury Education, Training, and Therapy to Enhance Recovery), a culturally tailored traumatic brain injury (TBI) transitional care intervention, among diverse younger adult patients with TBI (age 18-64) and their caregivers. Trained clinical interventionists addressed patient/family needs; established goals; coordinated post-hospital care and resources; and provided patient/family training on self- and family-management coping skills. Fifteen dyads enrolled (N = 31, 15 patients, 16 caregivers). All completed baseline data; 74.2% (n = 23; 10 patients, 13 caregivers) completed 8-week data; 83.8% (n = 26; 13 each) completed 16-week data. Approximately 38% (n = 12, 3 patients, 9 caregivers) completed acceptability data, showing positive experiences (mean = 9.25, range 0-10; SD = 2.01). Overall and mental quality of life (QOL) scores did not differ over time but physical QOL scores did improve over time (baseline: 30.3, 8 weeks: 46.5, 16 weeks: 61.6; p = 0.0056), which was considered to be a suitable outcome measure for a future trial. BETTER is a promising intervention with implications to improve TBI care standards. Research is needed to determine efficacy in a randomized trial.

The application of clique percolation method in health disparities research.

AIMS: Clique percolation, one of the joint community detection algorithms in network science, is a novel and efficient approach to detecting overlapping communities in real networks. The current study illustrated how clique percolation can help to identify overlapping communities within the complex networks underlying health disparities, particularly highlighting nodes with strong associations with more than one community. DESIGN: A cross-sectional study. METHODS: The study used a dataset on Latinx populations (N = 1654; mean age = 43.3 years; 53.1% women) as an example to demonstrate the role of such overlapping nodes in the network of syndemic conditions and their common risk factors. Syndemic conditions in the network included HIV risk, substance abuse (smoking, heavy alcohol consumption and marijuana use) and poor mental health. Moreover, the risk factors encompassed individual (education and income) and sociostructural (adverse childhood experiences [ACEs] and access to services) factors. The network was estimated using the R-package bootnet. Clique percolation was conducted on the estimated network using the R-package CliquePercolation. RESULTS: A total of three communities were detected, with HIV risk and poor mental health not being assigned to any community. In general, Community 1 was comprised of ACE categories, Community 2 included education, income and access to services and Community 3 included other syndemic conditions. Of note, two nodes were assigned to two communities: 'household dysfunction' to Communities 1 and 2 and 'smoking' to Communities 2 and 3. CONCLUSION: Household dysfunction might be the key connector, among other ACEs, to individual and structural barriers. Such barriers further exposed Latinx individuals to risky behaviours, especially smoking, which further linked to marijuana use and heavy alcohol consumption. IMPACT: Clique percolation facilitated our understanding of the complex systems of factors shaping health disparities. The overlapping nodes are promising intervention targets for reducing health disparities in this historically marginalized population. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Potential bias and lack of generalizability in electronic health record data: reflections on health equity from the National Institutes of Health Pragmatic Trials Collaboratory.

Embedded pragmatic clinical trials (ePCTs) play a vital role in addressing current population health problems, and their use of electronic health record (EHR) systems promises efficiencies that will increase the speed and volume of relevant and generalizable research. However, as the number of ePCTs using EHR-derived data grows, so does the risk that research will become more vulnerable to biases due to differences in data capture and access to care for different subsets of the population, thereby propagating inequities in health and the healthcare system. We identify 3 challenges-incomplete and variable capture of data on social determinants of health, lack of representation of vulnerable populations that do not access or receive treatment, and data loss due to variable use of technology-that exacerbate bias when working with EHR data and offer recommendations and examples of ways to actively mitigate bias.

Acculturative Stress, Resilience, and a Syndemic Factor Among Latinx Immigrants.

BACKGROUND: The process of immigration and subsequent adaptation can expose Latinx immigrants to chronic and compounding challenges (i.e., acculturative stress), but little is known about how resilience factors and these stressors interact to influence syndemic conditions, intertwined epidemics that disproportionally affect historically marginalized communities. OBJECTIVES: The purpose of this study was to describe the influence of acculturative stress and resilience on the syndemic factor underlying substance abuse, intimate partner violence, HIV risk, and mental conditions. METHODS: Baseline cross-sectional data from a community-engaged, longitudinal study of 391 adult (ages 18-44 years) Latinx immigrants in North Carolina were obtained using standardized measures available in English and Spanish. Structural equation modeling tested the syndemic model, and random forest variable importance identified the most influential types of acculturative stressors and resilience factors, including their interactions, on the syndemic factor. RESULTS: Results indicated that a single syndemic factor explained variations in heavy drinking, drug use, intimate partner violence, depression, and anxiety and fit the data well. Age, being a woman, acculturative stress, acculturation to the United States, and emotional support were significantly related to the syndemic factor. The relationship between acculturative stress and the syndemic factor was buffered by ethnic pride, coping, enculturation, social support, and individual resilience. The most influential acculturative stressors were marital, family, and occupation/economic stress. DISCUSSION: Findings from this study underscore the importance of considering the co-occurrence of behavioral and mental health conditions among Latinx immigrants. Health promotion programs for Latinx immigrants should address acculturative stress and bolster ethnic pride, social support, and coping as sources of resilience.