A Qualitative Examination of Perceptions of Mindfulness Among Arab, Middle Eastern, and North African Americans: Implications for Cultural Adaptation of Mindfulness-Based Interventions.

Background: Mindfulness-based interventions (MBIs) are well-positioned to address health disparities among racial-ethnic minority communities, given their focus on stress reduction and potential for greater accessibility and acceptability than conventional mental health treatments. Yet, there are currently no peer-reviewed studies of MBIs in an Arab, Middle Eastern, or North African (MENA) American sample. Addressing this gap in the literature is critical for advancing integrative health equity, given the high burden of stress and high prevalence of stress-related health conditions among Arab/MENA Americans. Objective: The present study sought to explore perceptions of mindfulness among Arab/MENA Americans and identify potential cultural adaptations to MBIs for this population. Methods: 4 focus groups were conducted with 26 Arab/MENA American adults who had participated in an introductory mindfulness workshop. Participants were asked about their experience learning mindfulness skills, the usefulness of mindfulness for problems they face, the alignment of mindfulness with their cultural values and practices, and suggestions for adapting mindfulness programs. Qualitative coding of focus group session transcriptions was conducted to identify themes in the data. Conclusion: The participants in this study described experiencing high levels of stress and identified micro- and macro-level stressors related to their Arab/MENA American identity, including discrimination, exclusion, historical and intergenerational trauma, and protracted sociopolitical crises in their heritage countries. They viewed mindfulness as a potentially useful approach to coping with stress. At the same time, participants identified aspects of mindfulness that could be adjusted to better align with their cultural values and experiences. Potential adaptations to MBIs for Arab/MENA Americans were identified based on suggestions from participants and issues they raised while discussing cultural strengths, stressors they face, and perceived barriers and facilitators to engaging in mindfulness practice.

The Impact of the COVID-19 Pandemic on Depression, Anxiety, and Stress among Black Women with Depressive Symptoms at a Federally Qualified Health Center.

While the COVID-19 pandemic disproportionately impacted Black American communities, there is a lack of empirical research examining mental health experiences during the COVID-19 pandemic among this population. This report examines the relationship between the COVID-19 pandemic and stress, depression, and anxiety among Black women. A cohort study with supplementary data was conducted among 45 Black American women with depressive symptoms participating in an ongoing randomized controlled trial of a mindfulness-based intervention (M-Body) at a Federally Qualified Health Center. Depressive symptoms, anxiety, and stress were measured at multiple time points before and during the COVID-19 pandemic. On average, anxiety [Pre-pandemic: 7.4 (0.5); Peri-pandemic: 7.0 (0.6); MD: -0.4 (0.5), p = 0.18] did not change substantially during the pandemic compared to pre-pandemic levels. However, depression [Pre-pandemic: 19.7 (1.4); Peri-pandemic: 24.4 (1.5); MD: 4.7 (1.0), p < 0.01] worsened while stress [Pre-pandemic: 21.7 (0.4); Peri-pandemic: 20.5 (0.5); MD: -1.2 (0.5), p = 0.01] slightly improved. Individuals caring for children exhibited modest but not statistically significant elevations in pre-pandemic stress than those who did not. These disparities more than doubled during the pandemic for stress [MD: 1.9 (0.9), p = 0.04] and depression [MD: 3.8 (2.6), p = 0.16] but increased only slightly for anxiety [MD: 1.8 (1.0), p = 0.08]. These data indicate that the COVID-19 pandemic impacted mental health among Black women with depressive symptoms, and those caring for children reported greater increases in depression, anxiety, and stress than those who did not during the pandemic. Trial Registration: ClinicalTrials.gov NCT03620721. Registered on 8 August 2018.

Comparative effectiveness of a mindfulness-based intervention (M-Body) on depressive symptoms: study protocol of a randomized controlled trial in a Federally Qualified Health Center (FQHC).

BACKGROUND: Mindfulness-based interventions have been shown to improve psychological outcomes including stress, anxiety, and depression in general population studies. However, effectiveness has not been sufficiently examined in racially and ethnically diverse community-based settings. We will evaluate the effectiveness and implementation of a mindfulness-based intervention on depressive symptoms among predominantly Black women at a Federally Qualified Health Center in a metropolitan city. METHODS: In this 2-armed, stratified, individually randomized group-treated controlled trial, 274 English-speaking participants with depressive symptoms ages 18-65 years old will be randomly assigned to (1) eight weekly, 90-min group sessions of a mindfulness-based intervention (M-Body), or (2) enhanced usual care. Exclusion criteria include suicidal ideation in 30 days prior to enrollment and regular (>4x/week) meditation practice. Study metrics will be assessed at baseline and 2, 4, and 6 months after baseline, through clinical interviews, self-report surveys, and stress biomarker data including blood pressure, heart rate, and stress related biomarkers. The primary study outcome is depressive symptom score after 6 months. DISCUSSION: If M-Body is found to be an effective intervention for adults with depressive symptoms, this accessible, scalable treatment will widely increase access to mental health treatment in underserved, racial/ethnic minority communities. TRIAL REGISTRATION: ClinicalTrials.gov NCT03620721. Registered on 8 August 2018.

Spirituality, self-compassion, and anxiety among sexual minority men: a longitudinal mediation analysis.

BACKGROUND AND OBJECTIVE: Research related to anxiety among sexual minority men (SMM) typically focuses on risk factors. It has seldom examined factors that may be associated with lower levels of anxiety. This gap in the literature represents an opportunity to explore positive psychological factors that may be related to lower levels of anxiety among this group. Spirituality and self-compassion are two positive psychological factors that have been associated with reduced anxiety in general samples but have been understudied among SMM. This study aimed to determine the longitudinal associations between spirituality, self-compassion, and anxiety. DESIGN AND METHODS: Guided by an Afrocentric psychological framework, we conducted a secondary quantitative analysis with data from a racially and ethnically diverse sample of 697 U.S. SMM. RESULTS: Utilizing Hayes PROCESS Macro Model 4, we found that spirituality at baseline was positively associated with self-compassion at baseline, which in turn was inversely associated with anxiety at 12-month follow-up. CONCLUSIONS: Overall, our findings provide evidence that spirituality and self-compassion are two positive psychological factors that are inversely associated with anxiety among SMM.

The association of mindfulness and depression stigma among African American women participants in a mindfulness-based intervention: A pilot study.

Depression stigma is a potential barrier to engagement in and efficacy of depression treatment. This pilot study examined the association of mindfulness with depression stigma among participants in an eight-week mindfulness-based intervention for depressive symptoms. Thirty-one African American women with depressive symptoms were recruited from an urban Federally Qualified Health Center (FQHC) to participate in a mindfulness intervention (M-Body). Mindfulness, depressive symptoms, and depression stigma were assessed at baseline, eight weeks, and 16 weeks. Focus groups were conducted to examine participants' subjective experiences with the mindfulness intervention. Mindfulness significantly increased from baseline to eight weeks. There was a non-significant decrease in depression from baseline to eight weeks and a significant decrease in depression from baseline to 16 weeks. Depression stigma significantly increased from baseline to eight weeks and significantly decreased from eight to 16 weeks; however, depression stigma did not return to the baseline. An exploratory qualitative analysis of focus group data revealed themes related to direct and indirect factors that may perpetuate and maintain depression stigma. This is one of the first studies to explicitly explore the relationship between mindfulness, depression symptoms, and depression stigma among African American women.

Implementation Barriers and Experiences of Eligible Patients Who Failed to Enroll in Collaborative Care for Depression and Anxiety.

BACKGROUND: Effective and efficient implementation of the Collaborative Care Model (CoCM) for depression and anxiety is imperative for program success. Studies examining barriers to implementation often omit patient perspectives. OBJECTIVES: To explore experiences and attitudes of eligible patients referred to CoCM who declined participation or were unable to be reached, and identify implementation barriers to inform strategies. DESIGN: Convergent mixed-methods study with a survey and interview. PARTICIPANTS: Primary care patients at an academic medical center who were referred to a CoCM program for anxiety and depression by their primary care clinician (PCC) but declined participation or were unable to be reached by the behavioral health care manager to initiate care (n = 80). Interviews were conducted with 45 survey respondents. MAIN MEASURES: Survey of patients' referral experiences and behavioral health preferences as they related to failing to enroll in the program. Interview questions were developed using the Consolidated Framework for Implementation Research version 2.0 (CFIR 2.0) to identify implementation barriers to enrollment. KEY RESULTS: Survey results found that patients were uncertain about insurance coverage, did not understand the program, and felt services were not necessary. Referred patients who declined participation were concerned about how their mental health information would be used and preferred treatment without medication. Men agreed more that they did not need services. Qualitative results exhibited a variety of implementation determinants (n = 23) across the five CFIR 2.0 domains. Barriers included mental health stigma, perceiving behavioral health as outside of primary care practice guidelines, short or infrequent primary care appointments, prioritizing physical health over mental health, receiving inaccurate program information, low motivation to engage, and a less established relationship with their PCC. CONCLUSIONS: Multiple barriers to enrollment led to failing to link patients to care, which can inform implementation strategies to address the patient-reported experiences and concerns.

Stress, coping and the acceptability of mindfulness skills among pregnant and parenting women living with HIV in the United States: A focus group study.

Pregnant and parenting women living with HIV (WLWH) face high levels of psychological stress and mental illness but lack tailored and acceptable psychosocial treatments. The research team sought to inform the adaptation of a mindfulness intervention for pregnant and parenting WLWH through focus groups exploring psychosocial treatment needs and mindfulness intervention preferences. The research team conducted focus groups with pregnant and parenting WLWH (n = 16) and case managers (n = 6) recruited from a community-based enhanced case management program. The research team utilised an iterative inductive approach to coding of the transcripts from these focus groups. Five themes emerged: stressors, signs of stress, coping, lack of access and acceptability of care, and motivation and trust in care engagement. These focus groups revealed a desire for a group intervention that could decrease isolation while protecting against involuntary disclosure of HIV status. Participants expressed openness to mindfulness skills for coping with stress. The focus group participants' preference for a non-stigmatising group intervention supports the potential of a mindfulness-based group intervention to reduce stress and improve the mental health of pregnant and parenting women living with HIV.

Accounting for Context in Randomized Trials after Assignment.

Many preventive trials randomize individuals to intervention condition which is then delivered in a group setting. Other trials randomize higher levels, say organizations, and then use learning collaboratives comprised of multiple organizations to support improved implementation or sustainment. Other trials randomize or expand existing social networks and use key opinion leaders to deliver interventions through these networks. We use the term contextually driven to refer generally to such trials (traditionally referred to as clustering, where groups are formed either pre-randomization or post-randomization - i.e., a cluster-randomized trial), as these groupings or networks provide fixed or time-varying contexts that matter both theoretically and practically in the delivery of interventions. While such contextually driven trials can provide efficient and effective ways to deliver and evaluate prevention programs, they all require analytical procedures that take appropriate account of non-independence, something not always appreciated. Published analyses of many prevention trials have failed to take this into account. We discuss different types of contextually driven designs and then show that even small amounts of non-independence can inflate actual Type I error rates. This inflation leads to rejecting the null hypotheses too often, and erroneously leading us to conclude that there are significant differences between interventions when they do not exist. We describe a procedure to account for non-independence in the important case of a two-arm trial that randomizes units of individuals or organizations in both arms and then provides the active treatment in one arm through groups formed after assignment. We provide sample code in multiple programming languages to guide the analyst, distinguish diverse contextually driven designs, and summarize implications for multiple audiences.

Perspectives on Mental Illness Stigma Among African Immigrant Pregnant and Post-Partum Women in an Urban Setting: A Brief Report.

Purpose: This study assessed the perspectives of pregnant and postpartum African immigrant women on mental illness. Methods: We conducted a focus group session (n=14) among pregnant and postpartum African immigrant women in June 2020. We used an inductive driven thematic analysis to identify themes related to mental health stigma. Results: Five core themes emerged: conceptualization of mental health, community stigmatizing attitudes, biopsychosocial stressors, management of mental health, and methods to reduce stigma. Conclusion: Understanding the perspectives of pregnant African immigrant women at the intersection of their race, ethnicity, gender, and migration are necessary to improve engagement with mental health services.

The impact of participation in a mindfulness-based intervention on posttraumatic stress symptomatology among Black women: A pilot study.

Objective: Women, racial/ethnic minorities, and socioeconomically disadvantaged groups experience trauma and PTSD at a rate of up to four times the U.S. national average. The aim of the present study is to assess the association between participation in a mindfulness-based intervention delivered in a community health center and posttraumatic stress symptoms among socioeconomically disadvantaged, Black women with trauma histories. We hypothesized that participants would experience a significant reduction in trauma symptom severity from pre- to post-intervention. Method: Women were recruited from a community health center on the South Side of Chicago, Illinois. Participants completed self-report measures of trauma symptoms, mindfulness, depression, and stress. Pre/postintervention differences in symptom severity were analyzed with paired sample t tests and independent sample t tests. Results: A total of 36 women with trauma symptom data were assessed. There was a significant reduction of trauma symptom severity from baseline to end of treatment. A minority of participants endorsed slightly higher symptomatology at the end of treatment. Women whose trauma symptom severity increased were less symptomatic overall to begin treatment; they had significantly lower trauma and depressive symptom severity at baseline. Conclusions: Socioeconomically disadvantaged, Black women with moderate to severe trauma symptoms benefited from a mindfulness-based intervention delivered in a community health care setting. While some women with mild trauma symptoms may have become more aware of their symptoms through an intervention designed to increase awareness of thoughts and feelings, most women experienced a decrease in trauma symptom severity. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Mindfulness and Valued Living in the Face of Racism­Related Stress.

Objectives: Racism-related stress is associated with significant mental health costs, necessitating the development of coping strategies to mitigate the negative sequelae. Mindfulness and valued living (MVL)-based strategies may be uniquely beneficial in addressing the negative effects of racism-related stress for people of color (POC) by decreasing internalized messages, while increasing self-compassion, coping flexibility, and engagement in values-based actions. It is imperative that clinicians applying or recommending MVL strategies to POC for coping with racism-related stress understand the complex nature of racism and, given that complexity, consider how MVL may need to be adapted to be effective. This paper offers guidance to clinicians seeking to use MVL strategies with clients of color to cope with racism-related stress. Methods: We provide a brief contextual literature review on the nature of racism, mental health impacts of racism-related stress for POC, and selected models of coping with racism-related stress. We also review existing mindfulness literature in relation to coping with racism-related stress, while offering considerations for adapting MVL strategies specifically for coping with racism-related stress. Results: Altogether, the research points to the promise of MVL strategies as beneficial interventions for coping with racism-related stress, although more research is warranted. We recommend that clinicians consider the suggestions outlined to present MVL strategies to clients in culturally responsive, validating ways. Conclusions: Further research is needed to evaluate links between MVL strategies and mental health, and to evaluate whether discrimination-specific adaptations are beneficial in mitigating the mental health impacts of racism-related stress.

Mental Health Stigma Among Black Immigrant Women in An Urban Setting.

BACKGROUND: Mental health stigma results in unmet mental health needs. Research describing predictors of stigma remains limited among Black immigrants. We aim to examine stigma associated with mental illness among a group of Black immigrant women. METHODS: We examined data from 22 women from two Black immigrant community centers. We collected surveys on demographics, cultural beliefs, migration status, religiosity and mental health stigma. Simple linear regression was used to model the unadjusted association between each component variable and overall stigma scores. All analyses were conducted using R and assumed a two-sided, 5% level of significance. RESULTS: A linear relationship was found between author-generated scale, the Stigma and Culture Survey (SCS) and the Depression Self Stigma Scale (DSSS). Among respondents, use of religious resources was associated with less stigma (p-value: 0.04). Whereas spirituality and morality was associated with greater stigma (p-value: 0.003). United States citizenship was associated with less stigma (p-value: 0.0001). DISCUSSION/CONCLUSION: Religion and spirituality are critical to understanding mental health stigma among Black immigrants. Studies aimed at assessing and reducing stigma need to critically engage with cultural and religious factors.

Collaborative care for depression management in primary care: A randomized roll-out trial using a type 2 hybrid effectiveness-implementation design.

BACKGROUND: The Collaborative Care Model (CoCM) is a well-established treatment for depression in primary care settings. The critical drivers and specific strategies for improving implementation and sustainment are largely unknown. Rigorous pragmatic research is needed to understand CoCM implementation processes and outcomes. METHODS: This study is a hybrid Type 2 randomized roll-out effectiveness-implementation trial of CoCM in 11 primary care practices affiliated with an academic medical center. The Collaborative Behavioral Health Program (CBHP) was developed as a means of improving access to effective mental health services for depression. Implementation strategies are provided to all practices. Using a sequential mixed methods approach, we will assess key stakeholders' perspectives on barriers and facilitators of implementation and sustainability of CBHP. The speed and quantity of implementation activities completed over a 30-month period for each practice will be assessed. Economic analyses will be conducted to determine the budget impact and cost offset of CBHP in the healthcare system. We hypothesize that CBHP will be effective in reducing depressive symptoms and spillover effects on chronic health conditions. We will also examine differential outcomes among racial/ethnic minority patients. DISCUSSION: This study will elucidate critical drivers of successful CoCM implementation. It will be among the first to conduct economic analyses on a fee-for-service model utilizing billing codes for CoCM. Data may inform ways to improve implementation efficiency with an optimization approach to successive practices due to the roll-out design. Changes to the protocol and current status of the study are discussed.

Integrating Cultural Humility into the Medical Education Curriculum: Strategies for Educators.

ISSUE: The framework of cultural humility, which emphasizes curiosity and self-reflection over mastery, was identified over 20 years ago as a way to address implicit bias in health care, an important factor in health disparities. Despite growing interest from researchers and educators, as well as the urgent call to adopt these values, the foundational elements of cultural humility remain challenging to teach in medical education and have not yet been widely adopted. EVIDENCE: Health disparities persist throughout the United States among a growing population of diverse patients. The cultural humility framework undermines power imbalances by encouraging the clinician to view their patient as an expert of their own experience. This approach strengthens relationships within the community, illuminates racial and historical injustices, and contributes to equitable care. However, recent reviews have shown that humility-based principles have yet to be widely integrated into cultural curricula. Based on available evidence, this article introduces the foundational concepts of cultural humility with the aim of helping medical educators better understand and implement the principles of cultural humility into undergraduate medical education. IMPLICATIONS: Cultural humility is a powerful and feasible adjunct to help student physicians cultivate effective tools to provide the best patient care possible to an increasingly diverse patient population. However, there is little known about how best to implement the principles of cultural humility into existing undergraduate medical education curricula. The analyses and strategies presented provide educators with the background, instructional and curricular methods to enable learners to cultivate cultural humility. Future systematic research will need to focus on investigating design, implementation and impact.

Mental Health in Women Living With HIV: The Unique and Unmet Needs.

Women living with HIV (WLWH) experience depression, anxiety, and posttraumatic stress symptoms at higher rates than their male counterparts and more often than HIV-unaffected women. These mental health issues affect not only the well-being and quality of life of WLWH, but have implications for HIV management and transmission prevention. Despite these ramifications, WLWH are under-treated for mental health concerns and they are underrepresented in the mental health treatment literature. In this review, we illustrate the unique mental health issues faced by WLWH such as a high prevalence of physical and sexual abuse histories, caregiving stress, and elevated internalized stigma as well as myriad barriers to care. We examine the feasibility and outcomes of mental health interventions that have been tested in WLWH including cognitive behavioral therapy, mindfulness-based interventions, and supportive counseling. Future research is required to address individual and systemic barriers to mental health care for WLWH.

Mental health stigma among university health care students in Nigeria: a cross-sectional observational study.

INTRODUCTION: stigma is a key barrier to access and utilization of mental health services, particularly in low- and middle- income countries. The authors explore the specific content of mental health stigma among Nigerian university health care students at a national teaching hospital. These students are key stakeholders and represent a vital demographic to engage in stigma reduction initiatives. We evaluated the extent to which demographic characteristics, mood symptoms and utilization of resources are associated with stigma. METHODS: the authors examined data obtained from surveys completed by university health care students (N = 82) at Lagos University teaching hospital. Surveys assessed demographic background, mood symptoms and use of mental health services. Simple linear regression was used to model the unadjusted association between each component variable and overall stigma score. All analyses were conducted using R (version 3.5.3, 2019, The R Foundation) and assumed a two-sided, 5% level of significance. RESULTS: being a member of the minority ethnic group within our study population was associated with increased stigma. Individuals having greater need for mental health services (due to mood symptoms) were associated with increased stigma. Willingness to use medical services and community support from family and friends was associated with lower stigma. Religious themes were prominent among the majority of respondents. CONCLUSION: consideration of the content details of stigma among university health care students in Nigeria is essential to inform interventions and strategies to reduce stigma within this subgroup. Those students who have symptoms of depression or anxiety may have lower utilization of mental health services.

Acceptability of a mindfulness intervention for depressive symptoms among African-American women in a community health center: A qualitative study.

INTRODUCTION: In this study we examined the acceptability and feasibility of a mindfulness based group intervention for socio-economically disadvantaged women in an urban community health center (M-Body). METHOD: Women ages 18-65 with depressive symptoms who participated in an 8-week mindfulness based group intervention were invited to attend follow up focus groups about their experience. Inductive content analysis was used to identify themes from transcripts. RESULTS: All participants were African-American (N = 27). Participants had limited past experience with mindfulness. They reported benefits included anger management, increased control of thoughts, emotions and behaviors, enhanced awareness/focus and feeling calm and relaxed. Barriers to session attendance included transportation, employment, family responsibilities and child care. Participants suggested modifications such as providing the audio in multiple formats, increasing time spent doing yoga, modifying yoga postures and providing an orientation session. They stated that the content and delivery format of the group was acceptable. DISCUSSION: The mindfulness based intervention for depression was acceptable, reduced stress and improved coping and functioning among women in a community health center.

Implementation Research Methodologies for Achieving Scientific Equity and Health Equity.

Implementation science has great potential to improve the health of communities and individuals who are not achieving health equity. However, implementation science can exacerbate health disparities if its use is biased toward entities that already have the highest capacities for delivering evidence-based interventions. In this article, we examine several methodologic approaches for conducting implementation research to advance equity both in our understanding of what historically disadvantaged populations would need-what we call scientific equity-and how this knowledge can be applied to produce health equity. We focus on rapid ways to gain knowledge on how to engage, design research, act, share, and sustain successes in partnership with communities. We begin by describing a principle-driven partnership process between community members and implementation researchers to overcome disparities. We then review three innovative implementation method paradigms to improve scientific and health equity and provide examples of each. The first paradigm involves making efficient use of existing data by applying epidemiologic and simulation modeling to understand what drives disparities and how they can be overcome. The second paradigm involves designing new research studies that include, but do not focus exclusively on, populations experiencing disparities in health domains such as cardiovascular disease and co-occurring mental health conditions. The third paradigm involves implementation research that focuses exclusively on populations who have experienced high levels of disparities. To date, our scientific enterprise has invested disproportionately in research that fails to eliminate health disparities. The implementation research methods discussed here hold promise for overcoming barriers and achieving health equity.

A Mindfulness-Based Intervention for Low-Income African American Women with Depressive Symptoms Delivered by an Experienced Instructor Versus a Novice Instructor.

Introduction: In the present study, the authors pilot a streamlined mindfulness teacher training protocol for Federally Qualified Health Center (FQHC) staff and examine the distribution and variability of psychologic outcomes for participants in groups led by an experienced instructor compared to a FQHC staff instructor who received the streamlined training. Methods: Seventy-four adult women aged 18-65 with depressive symptoms enrolled to participate in the 8-week group mindfulness intervention led by an experienced instructor (N = 33) or a novice instructor (N = 41). The effect of instructor on the outcomes depression, stress, mindfulness, functioning, well-being, and depression stigma was assessed at baseline, 8, and 16 weeks. Results: Depressive symptoms and stress significantly decreased, and mindfulness significantly increased in the experienced and novice instructor groups. In the novice instructor group, there was also a significant increase in well-being and functioning. The change in depressive symptoms, stress, functioning, and well-being was significantly greater in the novice instructor group than the experienced instructor groups. Conclusions: Preliminary data suggest that health care staff who receive streamlined training to deliver mindfulness-based interventions have comparable outcomes as experienced instructors.