Cultural challenges for adapting behavioral intervention frameworks: A critical examination from a cultural psychology perspective.

We introduce the bias and equivalence framework to highlight how concepts, methods, and tools from cultural psychology can contribute to successful cultural adaptation and implementation of behavioral interventions. To situate our contribution, we provide a review of recent cultural adaptation research and existing frameworks. We identified 68 different frameworks that have been cited when reporting cultural adaptations and highlight three major adaptation dimensions that can be used to differentiate adaptations. Regarding effectiveness, we found an average effect size of zr = 0.24 (95%CI 0.20, 0.29) in 24 meta-analyses published since 2014, but also substantive differences across domains and unclear effects of the extent of cultural adaptations. To advance cultural adaptation efforts, we outline a framework that integrates key steps from previous cultural adaptation frameworks and highlight how cultural bias and equivalence considerations in conjunction with community engagement help a) in the diagnosis of behavioral or psychological problems, b) identification of possible interventions, c) the selection of specific mechanisms of behavior change, d) the specification and documentation of dose effects and thresholds for diagnosis, e) entry and exit points within intervention programs, and f) cost-benefit-sustainability discussions. We provide guiding questions that may help researchers when adapting interventions to novel cultural contexts.

Building Trust and Partnership with Black Pediatric Patients and their Caregivers.

Systemic racism embedded within the US health care system results in disproportionately worse health outcomes for Black pediatric patients and their caregivers. One meaningful mechanism through which these health disparities persist is through discriminatory treatment and anti-Black bias from clinicians. Strengthening care provided to Black pediatric patients and their caregivers requires that clinicians adopt culturally tailored communication strategies that promote health equity and counter racism. We conducted a scoping review of evidence-based communication practices in the medical literature that improve care for Black pediatric patients. We mapped the specific practices to the Presence 5 for Racial Justice framework and identified cross-cutting themes to describe practices across the five domains. There are three cross-cutting themes that underlie the recommended practices: 1) promote unbiased implementation of clinician communication strategies (eg, providing equitable recommendations for preventive care), 2) tailor care to Black pediatric patients (eg, explore the importance of the family unit), and 3) address racism experienced by Black pediatric patients and their caregivers (eg, acknowledge any previous negative experiences with the health care system). This review highlights communication practices that clinicians can adopt to build trusting relationships, empower Black families, and promote racial justice in clinical care. Future opportunities include expanding to system level change and validating these practices with patients and clinicians.

An exploratory analysis of factors associated with spontaneous preterm birth among pregnant veterans with post-traumatic stress disorder.

BACKGROUND: Pregnant veterans with post-traumatic stress disorder (PTSD) are at increased risk for spontaneous preterm birth, yet the underlying reasons are unclear. We examined factors associated with spontaneous preterm birth among pregnant veterans with active PTSD. METHODS: This was an observational study of births from administrative databases reimbursed by the Veterans Health Association (VA) between 2005 and 2015. Singleton livebirths among veterans with active PTSD within 12 months prior to childbirth were included. The primary outcome was spontaneous preterm birth. Maternal demographics, psychiatric history, and pregnancy complications were evaluated as exposures. Covariates significant on bivariate analysis, as well as age and race/ethnicity as a social construct, were included in multivariable logistic regression to identify factors associated with spontaneous preterm birth. Additional analyses stratified significant covariates by the presence of active concurrent depression and explored interactions between antidepressant use and preeclampsia. RESULTS: Of 3,242 eligible births to veterans with active PTSD, 249 (7.7%) were spontaneous preterm births. The majority of veterans with active PTSD (79.1%) received some type of mental health treatment, and active concurrent depression was prevalent (61.4%). Preeclampsia/eclampsia (adjusted odds ratio [aOR] 3.30, 95% confidence interval [CI] 1.67-6.54) and ≥6 antidepressant medication dispensations within 12 months prior to childbirth (aOR 1.89, 95% CI 1.29-2.77) were associated with spontaneous preterm birth. No evidence of interaction was seen between antidepressant use and preeclampsia on spontaneous preterm birth (p=0.39). Findings were similar when stratified by active concurrent depression. CONCLUSION: Among veterans with active PTSD, preeclampsia/eclampsia and ≥6 antidepressant dispensations were associated with spontaneous preterm birth. While the results do not imply that people should discontinue needed antidepressants during pregnancy in veterans with PTSD, research into these factors might inform preterm birth prevention strategies for this high-risk population.

Moving beyond inquiry: a secondary qualitative analysis on promoting racial justice in clinical care.

BACKGROUND: Anti-Black racism is prevalent in medicine, and anti-racism training is needed in medical education. One such training is the Presence 5 for Racial Justice (P5RJ) Curriculum which covers evidence-based anti-racism communication strategies that promote health equity for Black patients. The P5RJ Curriculum was developed using feedback from clinicians and trainees with diversity, equity, and inclusion (DEI) experience. In this study, we identify themes in recommended anti-racism language and phrases that surveyed clinicians and trainees use to promote racial justice and health equity in clinical care for Black patients. METHODS: Secondary analysis of survey responses to identify themes in qualitative data. DATASET: Survey responses of specific phrases for anti-racism communication based on P5RJ Curriculum feedback. POPULATION STUDIED: N = 50 respondents (27 clinicians, 17 medical trainees, 6 unreported) recruited through convenience sampling and listservs of clinicians with DEI experience. An inductive qualitative analysis was performed on survey responses to identify emerging themes. RESULTS: Emerging themes from survey responses reflected four communication practices: "Inquiry" was the predominant practice (59%), followed by "Empathy" (25%), "Statements of Allyship" (9%), and "Self-Accountability" (8%). CONCLUSION: Inquiry and empathy may be predominant communication practices when addressing anti-Black racism in medicine. There is an opportunity to expand anti-racism communication tools with statements of self-accountability and allyship. Future research is necessary to analyze the patient voice on clinician communication practices that promote anti-racism in clinical care.

Teaching Anti-Racism in the Clinical Environment: The Five-Minute Moment for Racial Justice in Healthcare.

Dismantling racism in health care demands that medical education promote racial justice throughout all stages of medical training. However, racial bias can be fostered unintentionally, influencing the way we make decisions as clinicians with downstream effects on patient health and health equity. The development of any anti-racism curriculum in medicine requires the ability to identify racial bias in practices we have not previously recognized as explicitly racist or unjust. This has limited the creation and delivery of effective anti-racism education in health care.

Say My Name: Understanding the Power of Names, Correct Pronunciation, and Personal Narratives.

Introduction: Names are a reflection of identity and often have personal meaning. The chronic mispronunciation of names can undermine one's identity and be experienced as a microaggression. This workshop aims to provide historical context for names as well as resources for correct name pronunciation. Methods: We developed a 60-minute interactive virtual workshop with didactics, small-group sharing of personal experiences, and case discussions. We used an anonymous postworkshop survey to evaluate workshop effectiveness. Results: We presented the workshop at one local academic conference and two local educational conferences to learners of all levels from medical students to faculty. We collected postworkshop survey results from 78 participants of diverse racial and ethnic backgrounds. Participants reported learning historical context, ways to ask about correct name pronunciation, correcting name mispronunciation, documenting pronunciation, and sources for applications to practice. The main barriers to implementing workshop lessons included personal and structural factors. Discussion: This workshop effectively fills an educational gap by addressing the importance of correct name pronunciation in order to provide a more inclusive environment for clinicians and patients alike.

Veteran Postpartum Health: VA Care Team Perspectives on Care Coordination, Health Equity, and Trauma-Informed Care.

INTRODUCTION: A growing number of veterans are having children, and pregnancy is an opportunity to engage with health care. Within the Veterans Health Administration (VA), the VA maternity care coordination program supports veterans before, during, and after pregnancy, which are periods that inherently involve transitions between clinicians and risk care fragmentation. Postpartum transitions in care are known to be especially tenuous, with low rates of primary care reengagement. The objective of this study is to better understand this transition from the perspectives of the VA care teams. MATERIALS AND METHODS: Eight semi-structured qualitative interviews with VA team members who work in maternity care were conducted at a single VA center's regional network. Interviews explored the transition from maternity care to primary care to understand the care team's perspective at three levels: patient, clinician, and systems. Rapid qualitative analysis was used to identify emergent themes. RESULTS: Participants identified facilitators and opportunities for improvement in the postpartum transition of care. Patient-clinician trust is a key facilitator in the transition from maternity to primary care for veterans, and the breadth of VA services emerged as a key system-level facilitator to success. Interviewees also highlighted opportunities for improvement, including more trauma-informed practices for nonbinary veterans, increased care coordination between VA and community staff, and the need for training in postpartum health with an emphasis on health equity for primary care clinicians. CONCLUSIONS: The Department of Veterans Affairs Healthcare System care team perspectives may inform practice changes to support the transition from maternity to primary care for veterans. To move toward health equity, a system-level approach to policy and programming is necessary to reduce barriers to primary care reengagement. This study was limited in terms of sample size, and future research should explore veteran perspectives on VA postpartum care transitions.

The Presence 5 for Racial Justice Framework for anti-racist communication with Black patients.

OBJECTIVE: To identify communication practices that clinicians can use to address racism faced by Black patients, build trusting relationships, and empower Black individuals in clinical care. DATA SOURCES: Qualitative data (N = 112 participants, August 2020-March 2021) collected in partnership with clinics primarily serving Black patients in Leeds, AL; Memphis, TN; Oakland, CA; and Rochester, NY. STUDY DESIGN: This multi-phased project was informed by human-centered design thinking and community-based participatory research principles. We mapped emergent communication and trust-building strategies to domains from the Presence 5 framework for fostering meaningful connection in clinical care. DATA COLLECTION METHODS: Interviews and focus group discussions explored anti-racist communication and patient-clinician trust (n = 36 Black patients; n = 40 nonmedical professionals; and n = 24 clinicians of various races and ethnicities). The Presence 5 Virtual National Community Advisory Board guided analysis interpretation. PRINCIPAL FINDINGS: The emergent Presence 5 for Racial Justice (P5RJ) practices include: (1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address bias and structural determinants of health; (2) Listen intently and completely without interruption and listen deeply for the potential impact of anti-Black racism on patient health and interactions with health care; (3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort and consent, and referral planning; (4) Connect with the patient's story, acknowledging socioeconomic factors influencing patient health and focusing on positive efforts; (5) Explore emotional cues by noticing and naming patient emotions, and considering how experiences with racism might influence emotions. CONCLUSION: P5RJ provides a framework with actionable communication practices to address pervasive racism experienced by Black patients. Effective implementation necessitates clinician self-reflection, personal commitment, and institutional support that offers time and resources to elicit a patient's story and to address patient needs.

The Impact of a Comic Book Intervention on East African-American Adolescents' HPV Vaccine-Related Knowledge, Beliefs and Intentions.

HPV vaccine uptake is low among East African-American (EAA) adolescents. We developed a comic book and evaluated the impact on HPV/HPV-vaccine knowledge, beliefs and vaccine intentions. The intervention was delivered to HPV-unvaccinated EAA adolescents attending educational dinners with their mothers. Adolescents aged 14-17 were sequentially assigned alternately to a pre- or post-test. Results were compared with chi-squared tests and generalized estimating equation models adjusted for age, gender, and mother's language. Among 136 (pre-test = 64, post-test = 72) participants (90% Somali), pre/post differences were observed for proportions of correct responses to questions on HPV (44.0% vs. 82.9%, RR:1.87[95%CI 1.54-2.27]), HPV-vaccine knowledge (42.8% vs. 75.4%, RR:1.74[95%CI 1.46-2.07]), comfort discussing HPV/HPV vaccine with parents (57.8% vs. 90.3% somewhat/very comfortable, RR:1.55[95%CI 1.24-1.94]), and willingness (37.5% vs. 83.3% probably/definitely willing, RR:2.16[95%CI 1.55-3.01]) and intention (34.4% vs. 86.1% somewhat/very likely, RR:2.38[95%CI:1.69-3.37]) to get vaccinated. The intervention improved participants' HPV/HPV-vaccine knowledge, beliefs and vaccine intentions. Similar interventions could be adapted for other racial/ethnic minorities.

Presence 5 for Racial Justice Workshop: Fostering Dialogue Across Medical Education to Disrupt Anti-Black Racism in Clinical Encounters.

INTRODUCTION: Anti-Black racism has strong roots in American health care and medical education. While curricula on social determinants of health are increasingly common in medical training, curricula directly addressing anti-Black racism are limited. Existing frameworks like the Presence 5 framework for humanism in medicine can be adapted to develop a novel workshop that promotes anti-racism communication. METHODS: We performed a literature review of anti-racism collections and categorized anti-racism communication practices using the Presence 5 framework to develop the Presence 5 for Racial Justice Workshop. Implementation included an introductory didactic, a small-group discussion, and a large-group debrief. Participants evaluated the workshop via an online survey, and we analyzed the resulting qualitative feedback. RESULTS: A total of 17 participants took part in two workshops, with nine of the participants responding to the evaluation survey. Themes that emerged from survey responses included strengths of and improvements for the workshop structure (protected time for anti-racism discussion, dialogue between learners and faculty) and content (specific phrases and language, practicing self-reflection). DISCUSSION: The workshop provides participants with a semistructured discussion around the five anti-racism communication practices. Barriers to implementation include incorporating the workshop into existing curricula and ensuring diverse learners. Barriers to evaluating the workshop include the low survey response rate. Recommendations to improve the workshop include using case-based discussion and varying the workshop structure according to institutional needs. Next steps include an implementation study to evaluate the acceptability, feasibility, and effectiveness of the workshop.

Nonmedical Transdisciplinary Perspectives of Black and Racially and Ethnically Diverse Individuals About Antiracism Practices: A Qualitative Study.

Importance: Overwhelming evidence that anti-Black racism is associated with health inequities is driving clinician demand for antiracism practices that promote health equity. Objective: To investigate how nonmedical professionals address personally mediated, institutional, and internalized racism and to adapt these practices for the clinical setting. Design, Setting, and Participants: Using an approach from human-centered design for this qualitative study, virtual qualitative interviews were conducted among 40 professionals from nonmedical fields to investigate antiracism practices used outside of medicine. Inductive thematic analysis was conducted to identify latent themes and practices that may be adaptable to health care, subsequently using an established theoretical framework describing levels of racism to interpret and organize themes. Convenience and purposive sampling was used to recruit participants via email, social media, and electronic flyers. Main Outcomes and Measures: Antiracism practices adapted to medicine. Results: Among 40 professionals from nonmedical fields, most were younger than age 40 years (23 individuals [57.5%]) and there were 20 (50.0%) women; there were 25 Black or African American individuals (62.5%); 4 East Asian, Southeast Asian, or South Asian individuals (10.0%); 3 individuals with Hispanic, Latinx, or Spanish origin (7.5%); and 3 White individuals. Participants described personally mediated, institutional, and internalized antiracism practices that may be adaptable to promote health equity for Black patients. Personally mediated antiracism practices included dialogue and humble inquiry, building trust, and allyship and shared humanity; clinicians may be able to adopt these practices by focusing on patient successes, avoiding stigmatizing language in the electronic health record, and using specific phrases to address racism in the moment. Institutional antiracism practices included education, representation, and mentorship; in the health care setting, clinics may be able to develop staff affiliate groups, focus on improving racial health equity outcomes, and conduct antiracism trainings. Internalized antiracism practices centered on authenticity; clinicians may be able to write positionality statements reflecting their identity and the expertise they bring to clinical encounters. Conclusions and Relevance: This study's findings suggest that antiracism practices from outside the health care sector may offer innovative strategies to promote health equity by addressing personally mediated, institutional, and internalized racism in clinical care.

Casualties of the World War II metaphor: women's reproductive health fighting for narrative inclusion in COVID-19.

While the COVID-19 pandemic progresses, politicians and media outlets in the USA have compared the pandemic with World War II (WWII). Though women's reproductive health has been affected by both COVID-19 and WWII, these specific health needs are not included in either event's mainstream narrative. This article explores the pandemic's war metaphor through the lens of women's reproductive health, arguing for a reframing of the metaphor. Narrative-building determines how health needs are perceived and addressed. A modification of the WWII metaphor can ensure that the narrative formulating around COVID-19 is inclusive of the women's reproductive health needs that are eminently present.

Presence for racial justice: disrupting racism through physician-patient communication.

Context: Anti-Black racism is firmly rooted in US healthcare, but many clinicians do not have the tools and language to question their biases and address racism in clinical practice, eg biased communication practices such as "non-compliance" in medical documentation. Objective: Presence 5 for Racial Justice (P5RJ) leverages the Presence 5 patient-provider communication framework to identify anti-racism communication practices that support trusting relationships between physicians and Black patients and empower Black individuals in clinical care. Study design: For this multi-phased community-based participatory research (CBPR) overseen by an advisory board of clinicians and patients at four community clinics, we conducted a literature review, interviews with Black patients, clinician small-group discussions, and design thinking interviews with non-medical professionals. We mapped emergent communication practices to Presence 5 domains to create P5RJ. Setting: Four primary care clinics primarily serving Black patients in Oakland CA; Rochester NY; Leeds AL; Memphis TN. Population Studied: Total 113 participants (40 non-medical interviews, 37 Black patients interviewed, 12 advisory board members, 24 clinicians in discussion); 30 reviewed articles. Outcomes: Strategies on how providers, through communication and connection in the clinical visit, can navigate and address structural, institutional, and personally mediated forms of racism faced by Black patients. Results: P5RJ practices included: 1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address emergent bias and social determinants of health; 2) Listen intently and completely by using focused interpersonal listening without interruption and deep listening for racism impacts; give patients time and space to tell their story; 3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort, consent, and referral planning; 4) Connect with the patient's story by acknowledging socio-political factors influencing patient health and focusing on positive efforts/events to encourage patient agency; 5) Explore emotional cues by noticing and naming patient emotions and considering how racial trauma might influence these emotions. Conclusion: P5RJ practices offer strategies to reflect on clinician biases, address racism and known gaps in care for Black patients and promote health equity in their clinical care.

Postpartum Transition of Care: Racial/Ethnic Gaps in Veterans' Re-Engagement in VA Primary Care after Pregnancy.

INTRODUCTION: Pregnancy presents an opportunity to engage veterans in health care. Guidelines recommend primary care follow-up in the year postpartum, but loss to follow-up is common, poorly quantified, and especially important for those with gestational diabetes (GDM) and hypertension. Racial maternal inequities are well-documented and might be exacerbated by differential postpartum care. This study explores variation in postpartum re-engagement in U.S. Department of Veteran Affairs health care system (VA) primary care to identify potential racial/ethnic inequities in this care transition. METHODS: We conducted a complete case analysis of the 2005-2014 national VA birth cohort (n = 18,414), and subcohorts of veterans with GDM (n = 1,253) and hypertensive disorders of pregnancy (HDP; n = 2,052) using VA-reimbursed discharge claims and outpatient data. Outcomes included incidence of any VA primary care visit in the postpartum year; in age-adjusted logistic regression, we explored race/ethnicity as a primary predictor. RESULTS: In the year after a VA-covered birth, the proportion of veterans with one or more primary care visit was 53.8% overall, and slightly higher in the GDM (56.0%) and HDP (57.4%) subcohorts. In adjusted models, the odds of VA primary care follow-up were significantly lower for Black/African American (odds ratio, 0.87; 95% confidence interval, 0.81-0.93), Asian (odds ratio, 0.76; 95% confidence interval, 0.61-0.95), and Hawaiian/other Pacific Islander (odds ratio, 0.73; 95% confidence interval, 0.55-0.96) veterans, compared with White veterans. Among the subcohorts with GDM or HDP, there were no significant associations between primary care and race/ethnicity. CONCLUSIONS: One-half of veterans re-engage in VA primary care after childbirth, with significant racial differences in this care transition. Re-engagement for those with the common pregnancy complications of HDP and GDM is only slightly higher, and less than 60%. The potential for innovations such as VA maternity care coordinators to address such gaps merits attention.

The impact of an educational forum intervention on East African mothers' HPV vaccine-related knowledge, attitudes, and intentions to vaccinate their adolescent children.

OBJECTIVE: HPV vaccine uptake in U.S. East African adolescents is low. We developed and evaluated a culturally-targeted interactive educational intervention for East African immigrant mothers to increase HPV-vaccine-related knowledge, attitudes, and intentions to vaccinate adolescent children. METHODS: Eligible mothers had ≥ 1 11-17-year-old child and reported all children's HPV vaccination status as unvaccinated or unknown. The intervention was delivered via 10 dinners in the Seattle metropolitan area (8 with the Somali community, 2 with the Ethiopian community). Educational presentations and pre/post-tests on knowledge, attitudes, and intentions were conducted in the participants' native language by a co-ethnic physician. Pre/post differences in responses were evaluated with McNemar's tests and GEE models. HPV vaccination uptake 6-months post-intervention was evaluated using state immunization registry data. RESULTS: Of 115 participating mothers, most (84%) were Somali and < 40 years of age (60%). Median years of formal education was 8 (range 0-16), and 61% reported a household income <$25,000. Knowledge of HPV/HPV-vaccines was low pre-intervention, with correct responses ranging from 4% to 39% (61%-91% of responses were "not sure"); correct post-intervention responses ranged from 29% to 97%. Pre-intervention, only 12% of mothers thought they had enough information to make a decision about vaccination, compared to 90% post-intervention. Pre-intervention, only 16% of mothers reported that they were somewhat or very likely to vaccinate their child, compared to 83% post-intervention. All pre/post comparisons were statistically significantly different (p < 0.0001). Although mothers were more likely to report correct HPV-related knowledge and positive vaccine attitudes and intentions post-intervention, only two mothers' children initiated HPV vaccination within 6 months after the intervention. CONCLUSIONS: Results illustrate that a culturally targeted educational intervention effectively increased East African mothers' HPV vaccine-related knowledge, attitudes, and intentions to vaccinate their adolescent children. Future research should identify additional intervention components that can bridge the gap between intention and behavior to facilitate HPV vaccine uptake.

Development and evaluation of an online continuing education course to increase healthcare provider self-efficacy to make strong HPV vaccine recommendations to East African immigrant families.

OBJECTIVE: To develop and evaluate an online continuing education (CE) course designed to improve healthcare provider self-efficacy to make strong adolescent HPV vaccine recommendations to East African immigrant families. METHODS: Focus groups with providers and East African immigrant mothers informed course development. Providers serving East African immigrant families were recruited to view the course and complete pre-/post-test and two-month follow-up surveys. Pre-/post differences were compared with paired t-tests. RESULTS: 202 providers completed the course and pre-/post-test; 158 (78%) completed two-month follow-up. Confidence to make strong HPV vaccine recommendations to East African families increased from 68% pre-test to 98% post-test. Confidence to address common parental concerns also increased: safety, 54% pre-test, 92% post-test; fertility, 55% pre-test, 90% post-test; child too young, 68% pre-test, 92% post-test; and pork gelatin in vaccine manufacturing, 38% pre-test, 90% post-test. Two-month follow-up scores remained high (97% for overall confidence, 94%-97% for addressing parental concerns). All pre-/post-test and pre-test/two-month follow-up comparisons were statistically significant (p < 0.05). CONCLUSIONS: The online CE course focused on culturally appropriate strategies for making strong recommendations and addressing specific parental concerns was effective for increasing provider self-efficacy to recommend HPV vaccination to East African families. Similar courses could be tailored to other priority populations.

True Choice in Reproductive Care: Using Cultural Humility and Explanatory Models to Support Reproductive Justice in Primary Care.

Reproductive justice is the human right to maintain personal bodily autonomy, have children, not have children, and to parent children in safe and sustainable communities. Historically, marginalized individuals have experienced reproductive oppression in multiple forms. This oppression continues in modern times through health policy and patient-clinician communication. To combat this, the framework of reproductive justice outlines four key actions: analyzing power systems, addressing intersecting oppressions, centering the most marginalized, and joining together across issues and identities. Primary care clinicians have a unique role and responsibility to carry out these four key actions in order to provide patient centered reproductive care. To translate reproductive justice into clinical practice, clinicians care can use reflective practice, the framework of cultural humility, and the concepts from the explanatory model of illness.