Protocol of the HARMONY study: A culturally relevant, randomized-controlled, stress management intervention to reduce cardiometabolic risk in African American women.

BACKGROUND: African American Women (AAW) are at high risk for stress-related cardiometabolic (CM) conditions including obesity, heart disease, and diabetes. Prior interventions lack attention to culturally-nuanced stress phenomena (Superwoman Schema [SWS], contextualized stress, and network stress), which are positively and significantly associated with unhealthy eating and sedentary behavior. PURPOSE: The HARMONY Study is designed to test a culturally tailored mindfulness-based stress management intervention to address SWS, contextualized stress, and network stress as potential barriers to adherence to healthy exercise and eating goals. The study will help AAW build on their strengths to promote cardiometabolic health by enhancing positive reappraisal, self-regulation, and self-efficacy as protective factors against chronic stress-inducing biobehavioral morbidity and mortality risk. METHODS: This two-arm, randomized-controlled trial will test the effects of two group-based, online interventions. HARMONY 1 includes culturally-tailored exercise and nutrition education. HARMONY 2 includes mindfulness-based stress reduction, exercise, and nutrition education. We aim to recruit 200 AAW ≥ 18 years old with CM risk. RESULTS: Primary outcomes (actigraphy and carotenoid levels) and secondary outcomes (body composition, inflammatory markers, glucose metabolism, and stress) are being collected at baseline and 4-, 8-, and 12-months post-intervention. Intent-to-treat, data analytic approaches will be used to test group differences for the primary outcomes. DISCUSSION: This study is the first to address culturally-nuanced stress phenomena in AAW (SWS, network stress, and contextualized stress) using culturally-tailored stress management, exercise, and nutrition educational approaches to reduce biobehavioral CM risk among AAW. Quantitative and qualitative results will inform the development of scalable and sustainable CM risk-reduction programming for AAW. TRIAL REGISTRATION: The Multiple PIs registered the clinical trial (Identifier: NCT04705779) and reporting of summary results in ClinicalTrials.gov in accordance with the NIH Policy on the Dissemination of NIH-Funded Clinical Trial Information, within the required timelines.

A scoping review of the concept of resilience among African American women.

Resilience, thriving in the face of adversity, is a critical component of well-being in African American women. However, traditional definitions and approaches to operationalize resilience may not capture race- and gender-related resilience experiences of African American women. A more complete conceptualization of resilience may help facilitate future investigation of the mechanisms through which resilience influences health in this group. Our team conducted a scoping review of the literature published during twenty years, between 2000 and 2019, on resilience and health in African American women. We included a multidisciplinary set of databases (PubMed, CINAHL, PsycINFO, Scopus, Social Work Abstracts, Sociological Abstracts, Academic Search Premier). Using Covidence software a multi-step review process was conducted; 904 abstracts were initially screened for eligibility, 219 full-text studies were screened in stage two, and 22 remaining studies were reviewed for extraction. The studies reviewed revealed limitations of unidimensional approaches to conceptualizing/operationalizing resilience in African American women. The review highlighted culturally-relevant components of resilience including spirituality/religion, strength, survival, active coping, and social support. Findings highlight the importance of operationalizing resilience as a multidimensional construct so it can be optimally included in research designed to investigate the quality of life, cardiovascular risk, and other health outcomes in African American women.

Mapping definitions, measures and methodologies of assessing police violence in the health literature: a scoping review protocol.

INTRODUCTION: Police violence is a growing public health issue in the USA. Emerging evidence suggests that negative police encounters are associated with adverse physical and mental health outcomes. There is a critical need to examine the relationship between police violence and health disparities. However, the lack of consensus on a conceptual and operational definition of police violence is a limitation in scientific investigations on police violence and its health impacts. Here, we present the protocol for a scoping review that maps definitions, measures and methodologies of assessing police violence in the health literature. METHODS AND ANALYSIS: We will comprehensively search PubMed, Cumulative Index to Nursing and Allied Health Literature and APA PsycInfo databases. We will use the following string of key terms separated with the Boolean operator 'or': 'police violence', 'police brutality', 'police use of force', 'law enforcement violence', 'law enforcement brutality', 'law enforcement use of force' and 'legal intervention'. An English language limit will be applied. We will include studies published in English or that have an English language abstract available. Eligible studies will include: (1) a definition of police violence and/or (2) a measurement of police violence. ETHICS AND DISSEMINATION: This scoping review does not require ethical approval. The findings of this review will be disseminated through publication in a peer-reviewed journal and at conferences.

Superwoman Schema and John Henryism among African American women: An intersectional perspective on coping with racism.

RATIONALE: John Henryism and Superwoman Schema (SWS) are dispositional characteristics adopted to overcome the challenges of chronic psychosocial stress, and have particular salience for African American women. Both show protective and harmful effects on health and share conceptual similarities and distinctions, yet there is no empirical evidence of the potential overlap resulting in uncertainty about the unique roles they may each play concerning the health of African American women. OBJECTIVE: We examined: 1) whether and to what extent John Henryism and SWS represent similar or distinct constructs relevant to the unique sociohistorical and sociopolitical position of African American women, and 2) whether the two differentially predict health outcomes. METHODS: Data are from a purposive and socioeconomically diverse sample of 208 African American women in the San Francisco Bay Area. First, we conducted a progressive series of tests to systematically examine the conceptual and empirical overlap between John Henryism and SWS: correlation analysis, exploratory factor analysis (EFA), principal component analysis and k-modes cluster analysis. Next, we used multivariable regression to examine associations with psychological distress and hypertension. RESULTS: John Henryism and SWS were moderately correlated with one another (rs = 0.30-0.48). In both EFA and cluster analyses, John Henryism items were distinct from SWS subscale items. For SWS, feeling an obligation to present an image of strength and an obligation to help others predicted higher odds of hypertension (p < 0.05); having an intense motivation to succeed predicted lower odds (p = 0.048). John Henryism did not predict hypertension. Feeling an obligation to help others and an obligation to suppress emotions predicted lower levels of psychological distress (p < 0.05) whereas John Henryism predicted higher distress (p = 0.002). CONCLUSIONS: We discuss the implications of these findings for the measurement of culturally specific phenomena and their role in contributing to the unequal burden of ill health among African American women.

Honoring the past and charting the future: The International Society of Psychiatric Mental Health Nurses' commitment to advance diversity and equity in mental health care.

For more than two decades, the International Society of Psychiatric Nurses has dedicated its efforts to improving mental health care services worldwide, focusing on leveraging the psychiatric nursing workforce and advocating to eradicate systemic health disparities. Part of this labor included creating a culturally centered initiative, the Position Statement on Diversity, Cultural Competence and Access to Mental Health Care to fortify the cultural awareness of ISPN members to improve health-care quality delivered to diverse individuals, families, and communities across the life span and to improve these populations' access to mental health care.

Factor analysis of the Center for Epidemiological Studies Depression Scale in American Indian women.

The Center for Epidemiological Studies Depression Scale (CES-D) is widely used to assess depressive symptoms in the general population. It lacks validation for widespread use within the American Indian population, however. To address this gap, we explored and confirmed the factor structure of the CES-D among a community sample of southeastern American Indian women. We analyzed data from a sample of 150 American Indian women ages 18-50 from a southeastern tribe who had complete responses on the CES-D as part of a larger cross-sectional, community-engaged study. We performed exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to assess the measure's validity. We examined EFA models ranging from one to five factors, with the four-factor structure yielding the best overall model fit (CFI = 1.00, TLI = 0.99, RMSEA = 0.03). Differences between the four-factor EFA-retained structure from our sample and Radloff's four-factor structure emerged. Only the interpersonal factor was common to both factor structures. Our study findings confirm the validity of the original four-factor structure of the CES-D for younger adult American Indian women in the southeast. Contrasting findings with the EFA-retained structure, however, provide a more nuanced interpretation of our results.

Methodological Considerations in Scale Refinement with Diverse Populations: A Case Example Using the CES-D with a Community Sample of American Indian Women.

Although many psychometric assessments are used extensively in population-based research to determine psychopathology, these tools have not been thoroughly validated or appropriately adapted for use in diverse populations. Indeed, depression measurement studies among American Indian and female populations are scarce, omitting key opportunities to tailor psychological measurement for this population. To build psychometric evidence of measures in this population, we used a procedural method to examine a standard psychological instrument-the Center for Epidemiological Studies Depression Scale (CES-D)-with a community sample of southeast American Indian women. Our results showed strong psychometric reliability of the 20-item CES-D. The "effort" item presented diminished validity, as demonstrated by a negative counter-intuitive item-to-total correlation (ITC) value. Dropping the "effort" item resulted in a 19-item scale with a better fit in the within-group examination of community-based American Indian women. Compared to the 20-item CES-D scale, the revised 19-item measure ("effort" item removed) resulted in minimal changes to women's depression categories. However, we did detect patterns in shifts such that the 19-item scale generally underestimated (i.e., placed women in a lower category) depressive symptoms compared to the 20-item scale. Depending on their study goals, researchers engaging in population-based research should carefully weigh the use of original scales that allow for consistency in reporting with refined scales that fit psychometrically. We present the outlined method as a tool that expands on current approaches in scale refinement, and aids researchers in making more informed decisions regarding refined scales with diverse populations.

Association between superwoman schema, depression, and resilience: The mediating role of social isolation and gendered racial centrality.

OBJECTIVES: We examined dimensions of Superwoman Schema as predictors of both depression and resilience. We also investigated if social isolation and gendered racial centrality mediated these relationships. METHOD: We used path analysis to investigate the direct and indirect effects of an obligation to display an image of strength, emotional suppression, and resistance to vulnerability on depressive symptoms through social isolation. We also explored the direct and indirect effects of an intense motivation to succeed and an obligation to help others on resilience through gendered racial centrality. RESULTS: Emotional suppression and an obligation to help others were directly associated with depression. Emotional suppression, resistance to vulnerability, and an obligation to help others were indirectly associated with depression through social isolation. In contrast, an obligation to display an image of strength and an intense motivation to succeed was associated with resilience and gendered racial centrality. CONCLUSION: Findings highlight the unique complexity of Superwoman Schema as suggested within qualitative research. Black women's endorsement of Superwoman Schema may be both adaptive in navigating interlocking systems of oppression and psychologically distressing. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Life Course Racism and Depressive Symptoms among Young Black Women.

The objective of this study is to evaluate the life course effects of racism on depressive symptoms in young Black women and to identify particularly sensitive periods. Guided by life-course theory and using logistic regression, we analyzed baseline data on racism frequency and stress from racism at two time periods (before age 20 and during the 20s) and follow-up data (at approximate 20-month intervals) on depressive symptoms (using a modified 11-item Center for Epidemiologic Studies Depression Scale, CES-D) among 1612 Black women participants aged 23-34 years living in Detroit, MI. Of the 1612 women, 65% reported experiencing some racism at baseline, and 36.5% had high depressive symptoms at follow-up. Those who experienced high frequency of racism before age 20 had an increased risk for high depressive symptoms (RR = 1.26, 95% CI: 1.07, 1.46) compared to participants in the low racism frequency group. We observed similar associations for high vs. low stress from racism (RR = 1.30, 95% CI : 1.06, 1.54) and high vs. low combination of racism frequency and stress (RR = 1.38, 95% CI: 1.13, 1.64). These findings did not hold or were weaker when assessing racism during the 20s. Among women who experienced high racism across the two time periods, the risk of high depressive symptoms was higher than those who experienced low racism during both periods (RR = 1.49, 95% CI: 1.14, 1.86). The slightly stronger associations between racism and depressive symptoms in childhood and adolescence than in young adulthood suggest that early life might be a sensitive period for experiencing racism.

Superwoman Schema, Racial Identity, and Cellular Aging Among African American Women.

BACKGROUND AND OBJECTIVES: African American women experience faster telomere shortening (i.e., cellular aging) compared with other racial-gender groups. Prior research demonstrates that race and gender interact to influence culturally specific norms for responding to socially-relevant stress and other stress-coping processes, which may affect healthy aging. RESEARCH DESIGN AND METHODS: Data are from African American Women's Heart & Health Study participants who consented to DNA extraction (n = 140). Superwoman Schema (SWS) was measured using 5 validated subscales: presenting strength, emotion suppression, resisting vulnerability, motivation to succeed, and obligation to help others. Racial identity was measured using 3 subscales from the Multidimensional Inventory of Black Identity: racial centrality, private regard, and public regard. Relative telomere length (rTL) was measured using DNA extracted from blood samples. Path analysis tested associations and interactions between SWS and racial identity dimensions with rTL. RESULTS: For SWS, higher resistance to being vulnerable predicted longer telomeres. For racial identity, high private regard predicted longer telomeres while high public regard predicted shorter telomeres. Interactions were found between public regard and 2 SWS dimensions: among women with high public regard, emotion suppression (ß = 0.20, p < .05) and motivation to succeed (ß = 0.18, p < .05) were associated with longer rTL. The interaction between high centrality and emotion suppression predicted shorter rTL (ß = -0.17, p < .05). DISCUSSION AND IMPLICATIONS: Culturally specific responses to gendered racism and racial identity, developed early in life and shaped over the life course, are important psychosocial determinants of cellular aging among African American women.

Use of Food to Cope With Culturally Relevant Stressful Life Events Is Associated With Body Mass Index in African American Women.

BACKGROUND: Although stress is an established contributor to obesity (in general population studies), mechanisms to explain this association in African American women that incorporate culturally relevant frameworks have received little attention. OBJECTIVE: To investigate how stress is associated with body mass index (BMI) in this population, we examined multivariate models of BMI predicted by race-related, gender-related, and generic stressful life events and by use of food to cope with stress. We hypothesized that the three types of stressful life events would be indirectly associated with BMI through using food to cope with stress. METHODS: Psychometrically robust measures were included in surveys administered to a socioeconomically diverse sample of 189 African American women aged 21-78 years. Hypotheses were tested using structural equation modeling. We examined race-related, gender-related, and generic stressful life events as latent constructs indicated by exposure to and appraisal of potential stressors predicting a mediator, using food to cope, which predicted BMI; this model also included direct paths from the three latent stressful life event constructs to BMI. RESULTS: Almost every participant reported using food in some way to cope with stress; 33% and 42% met established criteria for overweight and obesity, respectively. The race-related stressful life event construct was the only latent construct predicting using food to cope with stress, and using food to cope with stress predicted BMI. A significance test of indirect effects demonstrated that the race-related stressful life event construct was indirectly associated with BMI through the mediator, using food to cope. DISCUSSION: Culturally relevant stress exposures and stress-related eating are important areas of foci for tackling overweight, obesity, and related health inequities in African American women. Findings highlight the importance of developing more complex models to understand the stress-related factors that elevate risk for overweight and obesity in this population.

Perceptions of superwoman schema and stress among African American women with pre-diabetes.

Three focus groups were conducted with African American women with elevated cardiometabolic risk to better understand how Superwoman Schema/the strong Black woman role influences their stress and how this cognitive-emotional aspect of health may need to be targeted in future research on cardiometabolic health disparities, such as prediabetes and diabetes. Results from this study revealed that participants' descriptions of stress and the superwoman role were consistent with the Superwoman Schema Conceptual Framework, including specific emphasis on 1) an obligation to manifest strength, 2) an obligation to suppress emotions and 3) an obligation to help others. Implications for targeting Superwoman Schema and stress as social determinants of health are described.

Student perspectives on recruiting underrepresented ethnic minority students to nursing: Enhancing outreach, engaging family, and correcting misconceptions.

BACKGROUND: Increasing the diversity of the nursing workforce is a high priority for addressing the nursing shortage and for developing a workforce capable of meeting the cultural needs of an increasingly diverse population. The purpose of this study was to identify student perspectives on the (1) influence of family, friends and others on nursing as a career choice and (2) optimal recruitment strategies to enhance diversity in schools of nursing. METHOD: Twenty-two diverse, underrepresented baccalaureate nursing students (including underrepresented ethnic minorities, economically disadvantaged students, and men) participated in two focus groups. Applied thematic analysis was used to organize the data and identify major themes. RESULTS: Participants perceptions involved two major thematic areas: (a) misconceptions of nursing, and (b) closing the gap, which had two sub-themes: facilitating support and encouragement and marketing nursing to younger groups. Recommendations for recruitment strategies included: providing applicants information to overcome myths and stereotypes about nursing, incorporating family members and friends into the recruitment process, highlighting nursing as a STEM field grounded in science and evidence-based practice, and engaging in outreach to educate elementary, middle, and high school students about the nursing profession. CONCLUSION: Findings provide direction for developing programming and collaborations to enhance recruitment of underrepresented students to nursing.

A Mixed-Methods, Randomized Clinical Trial to Examine Feasibility of a Mindfulness-Based Stress Management and Diabetes Risk Reduction Intervention for African Americans with Prediabetes.

African Americans have disproportionately high rates of stress-related conditions, including diabetes and diabetes-related morbidity. Psychological stress may negatively influence engagement in risk-reducing lifestyle changes (physical activity and healthy eating) and stress-related physiology that increase diabetes risk. This study examined the feasibility of conducting a randomized trial comparing a novel mindfulness-based stress management program combined with diabetes risk-reduction education versus a conventional diabetes risk-reduction education program among African American adults with prediabetes and self-reported life stress. Participants were recruited in collaboration with community partners and randomized to the mindfulness-based diabetes risk-reduction education program for prediabetes (MPD; n = 38) or the conventional diabetes risk-reduction education program for prediabetes (CPD; n = 30). The mindfulness components were adapted from the Mindfulness-based Stress Reduction Program. The diabetes risk-reduction components were adapted from the Power to Prevent Program and the Diabetes Prevention Program. Groups met for eight weeks for 2.5 hours, with a half-day retreat and six-monthly boosters. Mixed-methods strategies were used to assess feasibility. Psychological, behavioral, and metabolic data were collected before the intervention and at three and six months postintervention to examine within-group change and feasibility of collecting such data in future clinical efficacy research. Participants reported acceptability, credibility, and cultural relevance of the intervention components. Enrollment of eligible participants (79%), intervention session attendance (76.5%), retention (90%), and postintervention data collection attendance (83%, 82%, and 78%, respectively) demonstrated feasibility, and qualitative data provided information to further enhance feasibility in future studies. Both groups exhibited an A1C reduction. MPD participants had reductions in perceived stress, BMI, calorie, carbohydrate and fat intake, and increases in spiritual well-being. Considering the high prevalence of diabetes and diabetes-related complications in African Americans, these novel findings provide promising guidance to develop a larger trial powered to examine efficacy of a mindfulness-based stress management and diabetes risk-reduction education program for African Americans with prediabetes.

Racial discrimination, the superwoman schema, and allostatic load: exploring an integrative stress-coping model among African American women.

Racial discrimination has been linked to allostatic load (i.e., cumulative biological stress) among African American women. However, limited attention has been given to psychosocial processes involved in the stress response-critical for understanding biological pathways to health-in studies examining racial discrimination as a social determinant of health. We examined whether the superwoman schema (SWS), a multidimensional culture-specific framework characterizing psychosocial responses to stress among African American women, modifies the association between racial discrimination and allostatic load. We used purposive sampling to recruit a community sample of African American women ages 30-50 from five San Francisco Bay Area counties (n = 208). Path analysis was used to test for interactions while accounting for the covariance among SWS subscales using both linear and quadratic models. Significant interactions were observed between racial discrimination and four of the five SWS subscales. Feeling obligated to present an image of strength and an obligation to suppress emotions were each protective whereas feeling an intense motivation to succeed and feeling an obligation to help others exacerbated the independent health risk associated with experiencing racial discrimination. Our findings affirm the need to consider individual variability in coping and potentially other psychosocial processes involved in the stress response process, and offer several insights that may help elucidate the mechanisms by which racial discrimination gets "under the skin."

The Giscombe Superwoman Schema Questionnaire: Psychometric Properties and Associations with Mental Health and Health Behaviors in African American Women.

The purpose of this research was to examine the psychometric properties of the Giscombe Superwoman Schema Questionnaire. Three separate studies conducted with 739 African American women provided preliminary evidence that the Questionnaire's factor structure aligns with the Superwoman Schema Conceptual Framework and has good reliability. In addition, it is positively associated with perceived stress, depressive symptoms, using food to cope with stress, poor sleep quality, and physical inactivity. This study provides preliminary evidence to suggest that the Giscombe Superwoman Schema Questionnaire is psychometrically sound; Superwoman Schema is associated with health behaviors and psychological states that may increase risk for illness.

Innovative Clinical Training Site for Psychiatric Mental Health Nurse Practitioner Students: Elementary School-Based Group Therapy (Manuscript ID UMHN-2017-0143).

The aim of this clinical training site innovation is to develop accessible pediatric mental health clinical training sites for psychiatric mental health nurse practitioner (PMHNP) students. Mental health services in school settings provide treatment in the child's community and create opportunities for innovation and collaboration with teachers, school counselors, and school psychologists. School settings provide opportunities for early recognition of anxiety symptoms and accessible treatment that can help close the gap in clinical training sites for this population. Mild and moderate symptoms of anxiety often go untreated and may affect academic performance negatively. Cognitive behavioral play therapy is an effective treatment modality provided by PMHNP students and supports the roles of school personnel.