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Immigrants tend to live in areas with higher co-ethnic density, and the effect of neighborhood ethnic composition could be particularly salient for health. This study explored associations between neighborhood ethnic composition and self-rated health among Asian immigrants. We analyzed data collected at baseline from 670 Chinese and Vietnamese immigrants enrolled in a lifestyle intervention trial. Residential addresses were geocoded and combined with neighborhood socio-demographic profiles based on census data. We used generalized estimating equations to examine neighborhood ethnic composition and self-rated health. Independent of individual-level factors, living in neighborhoods more densely populated by whites was associated with poor/fair self-rated health. Neighborhood household income and density of participants' own ethnic group were not associated with poor/fair self-rated health. More research is warranted to disentangle reasons why Chinese and Vietnamese immigrants living in white-concentrated neighborhoods reported poorer self-rated health, including investigating effects of discrimination, relative deprivation, and availability of social resources.

Introduction: Integrating behavioral health in primary care improves quality of care and outcomes for patients with comorbid conditions. Shortage of a trained behavioral health workforce limits adoption. Professional psychology training programs contribute to recruitment, retention, and development of skilled providers, who value and deliver behavioral health services in primary care. This study interviewed a cohort of established psychology training programs in real-world, state-wide clinical primary care settings and identified their strategies and challenges with teaching practices and program resources that impact the robust quality of training. Method: Between December 2020 and March 2021, we conducted semistructured interviews with 12 licensed psychologists who oversaw nine integrated primary care psychology training programs at the internship and postdoctoral levels across Washington State. Data were analyzed using a thematic approach. Results: Programs taught psychology trainees about integrated primary care via extensive onboarding, modeling and shadowing, structured learning environment, interprofessional education opportunities, flexible and cross-disciplinary supervision, and a psychologically safe space. Teaching challenges included balancing scheduled and curbside supervision, pivoting to telehealth, and aligning trainee expectations and program requirements. Training programs were funded through different and multiple sources, but most lacked a stable funding mechanism, compounded by barriers for psychology trainees to bill for services, a lack of control over organization's budgeting decisions, and instability in funding renewal. Conclusion: Synergistic support from program, organization, and system/policy levels are needed to align teaching activities with clinical practice environments and invest in the growth and sustainability of psychology training programs on integrated primary care. Keywords: behavioral health, integrated primary care, interprofessional education, psychology, workforce, Integrated primary care, in which teams of medical providers and their behavioral health counterparts work closely together to address population health needs, has emerged in response to calls for a [...]

We present interpretations of the idea that "epidemiologists count" in response to the current status of membership and diversity and inclusion efforts within the Society for Epidemiological Research (SER). We review whom epidemiologists count to describe the (mis)representation of SER membership and how categorizations of people reflect social constructions of identity and biases that exist in broader society. We argue that what epidemiologists count-how diversity and inclusion are operationalized-has real-world implications on institutional norms and how inclusive/non-inclusive environments are. Finally, we examine which epidemiologists count within the field and argue that inclusion can only be achieved when we address how resources and opportunities are distributed among epidemiologists. To improve diversity and inclusion within SER and beyond, we recommend that SER strengthen its commitment to diversity, inclusion, and equity by: 1) integrating this priority on all agendas; 2) enhancing efforts to improve self-awareness among members and accountability within the organization; 3) supporting the growth of a diversifying workforce in epidemiology; and 4) increasing the visibility of health disparities research and researchers in epidemiology.

Context: Digital therapeutics may be uniquely positioned to address challenges reported by providers in chronic pain (CP) management. Previous studies have shown patient-provider discordance in priorities for CP management, which can be addressed in digital therapeutics development to encourage implementation and use. Objective: To assess primary care providers' and patients' perceptions of CP treatment goals and motivators for use of a digital therapeutic delivering CP related behavioral interventions. Study Design: Quantitative surveys. Setting: Participants were recruited from four primary care clinics in Washington and Colorado, two patient support groups, and one research community stakeholder group. Population Studied: The sample included 31 patients and 39 providers. Most patients identified as male (61.3%), non-Hispanic White (96.8%) and had experienced pain for one year or longer (90.3%). A mix of provider roles were included: primary care providers (46.2%), behavioral health providers (41.0%), clinical pharmacists (5.1%), and nurses (5.1%). All providers had experience treating patients with CP. Outcomes: Participants rated 10 CP treatment goals (e.g., quality of life, self-management skills) and 11 motivators for use (e.g., coaching, insurance payment coverage) of digital therapeutics on a 5-point Likert-scale. Descriptive statistics and Chi- Square tests were computed. Results: Patients and providers differed in their perceptions of importance across all treatment goals. Patients' ratings of treatment goals ranged from least to very important, whereas providers uniformly rated all treatment goals as very or extremely important (p < .05), and provider ratings of importance were consistently higher than patients (p < .05). Patients and providers on average did not rate motivators for use very high and they differed in their perceptions across six specific motivators. Providers rated friend recommendations and coaching features as more likely to motivate use than patients did (p < .05). Providers tended to rate more uniformly than patients on motivators related to insurance covering most of the cost, it being recommended by a provider or friend, and if the program was personalized with coaching (p < .05). Conclusions: Incorporating digital therapeutics in routine primary care may help improve CP management by providing customizable features that address diverse treatment goals, and bridge differing perspectives between providers and patients., Presenters Kari Stephens, PhD, Kris (Pui Kwan) Ma, PhD, Ying Zhang, MD, MPH, Maria Prado, MPH, Margaret Au, Rachel Geyer, MPH, Brenda Mollis, MA, MPA, MPH, Susan Zbikowski, PhD, Deanna [...]

Context: Digital therapeutics are growing as a solution to improve access and quality of care. Increasing evidence has shown the efficacy of digital therapeutics in managing pain for patients, but they are underutilized by primary care providers who see over half of the patients with chronic pain. Engaging providers to develop and use digital therapeutics with patients in chronic pain management has become necessary. Objective: This study explored primary care providers' challenges and strategies in chronic pain management to identify needs and practice gaps that inform development of digital therapeutics for chronic pain. Study Design: Qualitative study, using a human-centered design approach. Setting: Eleven providers from four primary care clinics in Washington and Colorado participated in semi-structured interviews between July and October 2021. Population Studied: The sample (N=11) included seven primary care physicians, two behavioral health providers, one physician assistant and one nurse. Most providers worked in clinics affiliated with urban, academic health systems or in federally qualified health centers. Outcomes: Interviews focused on provider goals in chronic pain management, challenges and strategies used, and perceptions of digital therapeutics. Results: Four themes related to provider needs emerged: patient-provider alliance, team-based care, tracking and monitoring, and social determinants of health. Providers desired resources to streamline pain education, counseling, and goal setting with patients. Greater accessibility to multidisciplinary care team consultations and non-pharmacological pain treatments would be beneficial to providers and patients. Infrastructure and systems are needed for providers to systematically track and monitor patients' pain. Providers requested assistance with connecting underserved patients to wraparound social services and addressing healthcare access barriers. Conclusion: Digital therapeutics for chronic pain would benefit from incorporating multimodal features that strengthen patient-provider alliance, increase access to non-pharmacological treatment options, support population health tracking and management, and provide equitable solutions that require lower sophistication of device and Internet access. Leveraging digital therapeutics in healthcare settings requires meeting provider needs at individual care and system levels., Presenters Kris (Pui Kwan) Ma, PhD, Ying Zhang, MD, MPH, Maria Prado, MPH, Rachel Geyer, MPH, Brenda Mollis, MA, MPA, MPH, Susan Zbikowski, PhD, Deanna Waters, MA, Jo Masterson, MBA, [...]

Background and Objectives Most persons with dementia experience behavioral and psychological symptoms (BPSD). While there is evidence that structured activity programs can be beneficial for persons with dementia and their caregivers, it is not well understood how joint engagement in shared activities affects BPSD and caregiver stress. The purpose of this study was to examine the moderating effect of doing a shared activity on the BPSD and caregiver stress. Research Design and Methods This study used an intensive longitudinal observational design in which caregivers completed baseline and once-a-day diary surveys for 21 days. Caregivers were asked whether they did a pleasant noncare activity with their relative, the presence of 8 BPSD, and their stress level. A moderation model in a structural equation model examined the relationship between these variables. Results Our sample consisted of 453 caregivers (87.4% female, 51.4% non-Hispanic White, mean age 53 years [standard deviation { SD }: 14]) and person living with dementia whose mean age was 79 years (SD : 9). On days when the caregivers engaged in a shared activity together with person living with dementia, there was a significant decrease in the BPSD (estimate −0.038, standard error [ SE ] = 0.016, 95% confidence interval [CI]: −0.069, −0.007, p value = 0.018). The effects of engaging in a shared activity decreased the impact of caregiver stress by 0.052 (estimate −0.052, SE = 0.018, 95% CI: −0.087, −0.017, p value = 0.004). At the between-person level, no differences were found in BPSD across caregivers who engaged or did not engage in shared activities. Discussion and Implications The results of our study indicate that doing a shared activity is associated with reduced BPSD among persons with dementia and may buffer the impact of caregiver stress on BPSD. Shared activities should be considered a key intervention component for dementia caregivers. [ABSTRACT FROM AUTHOR]

Background: Autologous haematopoietic stem cell transplantation (AHSCT) has been explored as a therapeutic intervention in multiple sclerosis (MS) over the last two decades; however, prospective clinical trials of the most common myeloablative conditioning regimen, BEAM, are limited. Furthermore, patient selection, optimal chemotherapeutic regimen and immunological changes associated with disease response require ongoing exploration. We present the outcomes, safety and immune reconstitution (IR) of patients with active, treatment refractory MS.Methods: This study was a single-centre, phase II clinical trial of AHSCT for patients with active relapsing remitting (RRMS) and secondary progressive MS (SPMS). Patients underwent AHSCT using BEAM (carmustine, etoposide, cytarabine, melphalan)+antithymocyte globulin chemotherapeutic regimen.Outcomes: The primary outcome was event-free survival (EFS); defined as no clinical or radiological relapses and no disability progression. Multiparameter flow cytometry was performed for evaluation of post-transplant IR in both MS and lymphoma patients receiving the same chemotherapy regimen.Results: Thirty-five patients (20 RRMS, 15 SPMS) completed AHSCT, with a median follow-up of 36 months (range 12-66). The median Expanded Disability Status Scores (EDSS) was 6 (2-7) and patients had failed a median of 4 (2-7) disease modifying therapies. 66% failed treatment with natalizumab. EFS at 3 years was 60%, (70% RRMS). Sustained improvement in EDSS was seen in 15 (44%) of patients. There was no treatment-related mortality. A sustained rise in CD39+ T regulatory cells, immunosuppressive CD56hi natural killer cells and ablation of proinflammatory mucosal-associated invariant T cells was seen for 12 months following AHSCT in patients with MS. These changes did not occur in patients with lymphoma receiving the same chemotherapy for AHSCT.Conclusions: The EFS in our MS cohort is significantly greater than other high-efficacy immunosuppressive therapies and similar to other AHSCT studies despite a more heavily pretreated cohort.Trial Registration Number: ACTRN12613000339752. [ABSTRACT FROM AUTHOR]

Context: Digital therapeutics are growing as a solution to improve access and quality of care. Increasing evidence has shown the efficacy of digital therapeutics in managing pain for patients, but they are underutilized by primary care providers who see over half of the patients with chronic pain. Engaging providers to develop and use digital therapeutics with patients in chronic pain management has become necessary. Objective: This study explored primary care providers' challenges and strategies in chronic pain management to identify needs and practice gaps that inform development of digital therapeutics for chronic pain. Study Design: Qualitative study, using a human-centered design approach. Setting: Eleven providers from four primary care clinics in Washington and Colorado participated in semistructured interviews between July and October 2021. Population studied: The sample (N=11) included seven primary care physicians, two behavioral health providers, one physician assistant and one nurse. Most providers worked in clinics affiliated with urban, academic health systems or in federally qualified health centers. Outcomes: Interviews focused on provider goals in chronic pain management, challenges and strategies used, and perceptions of digital therapeutics. Results: Four themes related to provider needs emerged: patient-provider alliance, team-based care, tracking and monitoring, and social determinants of health. Providers desired resources to streamline pain education, counseling, and goal setting with patients. Greater accessibility to multidisciplinary care team consultations and nonpharmacological pain treatments would be beneficial to providers and patients. Infrastructure and systems are needed for providers to systematically track and monitor patients' pain. Providers requested assistance with connecting underserved patients to wraparound social services and addressing healthcare access barriers. Conclusion: Digital therapeutics for chronic pain would benefit from incorporating multimodal features that strengthen patient-provider alliance, increase access to non-pharmacological treatment options, support population health tracking and management, and provide equitable solutions that require lower sophistication of device and Internet access. Leveraging digital therapeutics in healthcare settings requires meeting provider needs at individual care and system levels. [ABSTRACT FROM AUTHOR]

Introduction: People with dementia can have many family and friends who might be affected by their deaths. Pursuing the long-term aim of understanding how dementia deaths affect close family and friends, this project lays groundwork through estimates of who those close family and friends are, with special attention to race and ethnicity., Method: Regression models estimated associations between dementia, race/ethnicity, and close family and friend network size, controlling for age, sex, education, marital status, and household wealth for 1386 deceased people with dementia from the Health and Retirement Study (2004 to 2018)., Results: Persons with dementia had an average of 9.4 close family and friends at death. But patterns of close family and friends were different among non-Latino Black (10.8), Latino (9.9), and non-Latino White (9.2) people with dementia at death. Notably, non-Latino White persons with dementia had the fewest close family (3.7), followed by non-Latino Black (5.1), and Latino (7.7) persons with dementia., Discussion: Knowing who might be affected by dementia deaths is the first step to explore how dementia-related deaths impact close family and friends. Future work can now sample bereaved family and friends of people with dementia to explore their experiences and develop culturally appropriate supports., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Context: COVID-19 has underscored the need to accelerate behavioral health (BH) integration in primary care, where many patients seek mental health services. Expanding BH integration requires a strong and sustainable BH workforce trained to work in primary care. Psychology internship is a critical period of development when doctorate-level therapists receive supervised clinical experiences with integrated primary care., Objective: To explore the strategies and challenges of teaching psychology trainees to practice BH in primary care., Study Design: Qualitative study., Setting: Nine out of 11 psychology internship and postdoctoral fellowship programs across the Washington State that provide integrated primary care training were recruited. Response rate was 82%., Population Studied: Twelve training leads and supervisors completed semi-structured interviews between December 2020 - March 2021., Outcome Measures: Interviews focused on participant experiences with providing educational training and supervision to psychology trainees practicing integrated primary care. Data were analyzed using grounded theory approach., Results: Four strategies emerged - orient trainees with extensive onboarding to the culture, context, and function of primary care; provide a psychologically safe space for open dialogues that facilitate professional identity development; model the skills needed to collaborate with primary care teams; and create a structured environment for trainees to practice the skills. Training leads and supervisors also reported three challenges - strategies to address trainees' difficulties with acculturating to the culture of primary care; loss of opportunities to shadow and interact with primary care providers due to telemedicine during COVID-19; and limitations of the traditional supervision structure to accommodate the unpredictable and urgent crises experienced by trainees in fast-paced primary care settings., Conclusion: Future recommendations include early exposure to primary care during psychology graduate training, a hybrid model of fixed and flexible supervision schedules, and intentional efforts to define and balance in-person and remote teaching for different types of training needs., Competing Interests: Authors report none., (2021 Annals of Family Medicine, Inc.)