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To investigate whether patient-physician gender concordance influences the patient's perceptions of interpersonal processes of care and patient outcomes in Muslim patients with diabetes.We conducted a cross-sectional telephone survey involving 4152 randomly selected patients using electronic diabetes records. Outcome measures included perceptions of interpersonal processes of care, adherence to medications, and HbA1c. Linear mixed regression models were used to explore the associations between the outcome variables and patient gender and gender concordance.The best processes of care were observed consistently for female concordant dyads. In adjusted mixed models, lower Hurried Communication was associated with female concordant (-0.91, p 0.001) and female physician-male patient dyads (-0.82, p = 0.007). Higher Elicited Concerns was associated with female concordant (0.65, p = 0.003) and female physician-male patient dyads (0.59, p = 0.013). Higher Explained Results and Compassionate/Respectful were associated with female concordant dyads (0.83, p 0.001, and 0.55, p = 0.010 respectively). Lower HbA1c was independently linked with female concordant dyads (-0.84, p 0.001).This study highlights the importance of female gender concordance on perceptions of interpersonal processes of diabetes care and glycemic control.Strengthening physicians' communication skills with female patients should be taken into consideration.

COVID-related discrimination towards historically marginalized racial-ethnic groups in the United States has been well-documented; however, its impact on psychological distress and sleep (overall and within specific racial-ethnic groups) is largely unknown. We used data from our nationally representative, online survey of 5,500 American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, Latino, White, and multiracial adults, conducted from 12/2020-2/2021. Participants were asked how often they experienced discriminatory behaviors “because they think you might have COVID-19” (modified Everyday Discrimination Scale). Psychological distress was captured as having experienced anxiety-depression symptoms (Patient Health Questionairre-4, PHQ-4), perceived stress (modified Perceived Stress Scale), or loneliness-isolation (“How often have you felt lonely and isolated?”). Sleep disturbances were measured using the Patient-Reported Outcomes Information System Short Form Sleep Disturbance scale (PROMIS-SF 4a). Overall, 22.1% reported COVID-related discriminatory behaviors (sometimes/always: 9.7%; rarely: 12.4%). 48.4% of participants reported anxiety-depression symptoms (moderate/severe: 23.7% mild: 24.8%), 62.4% reported feeling stressed (moderate/severe: 34.3%; mild: 28,1%), 61.0% reported feeling lonely-isolated (fairly often/very often: 21.3%; almost never/sometimes: 39.7%), and 35.4% reported sleep disturbances (moderate/severe:19.8%; mild: 15.6%). Discrimination was only associated with increased psychological distress among racial-ethnic minorities. For example, COVID-related discrimination was strongly associated with anxiety-depression among Black/African American adults (mild: aOR=2.12, 95% CI=1.43-5.17; moderate/severe: aOR=5.19, 95% CI=3.35-8.05), but no association was observed among White or multiracial adults. Mitigating pandemic-related discrimination could help alleviate mental and sleep health disparities occurring among minoritized racial-ethnic groups.

Objectives. To determine the prevalence of COVID-19–related discrimination among major US racial/ethnic groups and estimate associations between discrimination, race/ethnicity, and other sociodemographic characteristics. Methods. We conducted a nationally representative online survey of 5500 American Indian/Alaska Native, Asian, Black/African American, Hawaiian/Pacific Islander, Latino (English and Spanish speaking), White, and multiracial adults from December 2020 to February 2021. Associations between sociodemographic characteristics and COVID-19–related discrimination were estimated via multinomial logistic regression. Results. A total of 22.1% of the participants reported experiencing discriminatory behaviors, and 42.7% reported that people acted afraid of them. All racial/ethnic minorities were more likely than White adults to experience COVID-19–related discrimination, with Asian and American Indian/Alaska Native adults being most likely to experience such discrimination (discriminatory behaviors: adjusted odd ratio [AOR] = 2.59; 95% confidence interval [CI] = 1.73, 3.89; and AOR = 2.67; 95% CI = 1.76, 4.04; people acting afraid: AOR = 1.54; 95% CI = 1.15, 2.07; and AOR = 1.84; 95% CI = 1.34, 2.51). Limited English proficiency, lower education, lower income, and residing in a big city or the East South Central census division also increased the prevalence of discrimination. Conclusions. COVID-19–related discrimination is common, and it appears that the pandemic has exacerbated preexisting resentment against racial/ethnic minorities and marginalized communities. Efforts are needed to minimize and discredit racially driven language and discrimination around COVID-19 and future epidemics. (Am J Public Health. 2022;112(3):453–466. https://doi.org/10.2105/AJPH.2021.306594 )

Purpose Among Latina breast cancer survivors, explore associations between rural/urban residence and health-related quality of life (HRQL), and whether associations are moderated by financial strain and low neighborhood cohesion. Methods We combined baseline data from two randomized controlled trials of a stress management intervention conducted among 151 urban and 153 rural dwelling Latinas with nonmetastatic breast cancer. Generalized linear models estimated associations between rural/urban status and HRQL (overall, emotional, social-family, physical, and functional well-being), and we examined moderation effects of financial strain and low neighborhood cohesion, controlling for age, marital status, and breast cancer characteristics. Results Rural women reported better emotional (β = 1.85; 95% CI = 0.37, 3.33), functional (β = 2.23; 95% CI = 0.69, 3.77), and overall (β = 5.68; 95% CI = 1.12, 10.25) well-being than urban women, regardless of degree of financial strain or neighborhood cohesion; moderation effects were not statistically significant. Financial strain was inversely associated with emotional (β = -2.34; 95% CI = 3.63, -1.05), physical (β = -2.56; 95% CI = -4.12, -1.01), functional (β = -1.61; 95% CI = -2.96, -0.26), and overall (β = -6.67; 95% CI = -10.96, -2.98) well-being. Low neighborhood cohesion was inversely associated with emotional (β = -1.27; 95% CI = -2.50, -0.04), social-family (β = -1.72; 95% CI = -3.02, -0.42), functional (β = -1.63; 95% CI = -2.92, -0.34), and overall (β = -5.95; 95% CI = 9.76, -2.14) well-being. Conclusions Rural Latina breast cancer survivors reported better emotional, functional and overall well-being than their urban counterparts. Greater financial strain and less neighborhood cohesion were associated with worse HRQL on most domains regardless of rural/urban context. Implications for Cancer Survivors Interventions that focus on increasing perceived neighborhood cohesion and reducing or better managing financial strain, could help improve Latina cancer survivors’ well-being.

To investigate how patient-physician interpersonal processes of care are related to levels of diabetes-related distress, diabetes medication-taking behavior, and HbA1c during conversations with patients about intensifying medication.We randomly recruited 1270 patients from diabetes specialty clinics in Tehran, Iran who were taking an additional oral diabetes medication or starting insulin during the prior 3 months. This interviewer-administered cross-sectional survey assessed multiple aspects of patient-physician interpersonal processes, diabetes-related distress, and diabetes medication-taking. Clinical history and HbA1c were collected from electronic medical records. Regression estimates and Structural Equation Modeling were used to test associations.Some communication scales indicated a significant relationship with total diabetes distress (P0.001). Diabetes medication-taking was associated with less diabetes distress (adjusted odds ratio [aOR]=0.45, P0.001), lower Hurried Communication (aOR=0.72, P = 0.013), higher Elicited Concerns (aOR=1.30, P = 0.012), and higher Explained Results (aOR=1.41, P0.001) scores. SEM analyses showed medication-taking behavior was associated with a 0.68 decrease in HbA1c. Hurried Communication and diabetes distress were directly associated with HbA1c.Aspects of patient-physician interpersonal processes at the time of intensifying diabetes treatment may be related to experiencing less distress, effective medication-taking, and improved HbA1c.The results are intended to inform communication strategies that physicians might incorporate into practice.

To examine associations of coping resources for psychological distress among newly diagnosed Spanish-speaking Latina women with breast cancer (LWBC).Analyses used baseline data from a randomized controlled trial of a stress management intervention among 151 LWBC.Dependent variables were health distress and anxiety. Coping resources at the intrapersonal, interpersonal, and organizational/community levels were included.At the intrapersonal level, self-efficacy for coping with breast cancer treatment was associated inversely with health distress and anxiety, and coping confidence with general problems was associated inversely with health distress. At the interpersonal level, having a sense of neighborhood cohesion was associated inversely with health distress. No organizational/community level resources were associated with health distress or anxiety.Interventions that enhance self-efficacy in coping and foster skills to identify sources of neighborhood support may decrease psychological distress for Spanish-speaking LWBC.

Background and ObjectivesThis paper describes the development and evaluation of a short caregiving self-efficacy measure. The self-administered 8-item Caregiver Self-Efficacy Scale (CSES-8) was developed to reflect components of typical caregiver support interventions and to be practical for inclusion in future self-efficacy and caregiving research.Research Design and MethodsWe administered the CSES-8 in 2 samples: participants in an intervention for caregivers of persons with cognitive disabilities, and a voluntary online survey for caregivers of adults. We evaluated the completion rate, item-scale correlations, reliability, descriptive statistics, and preliminary construct validity of the CSES-8 in both samples, and sensitivity to change in the intervention sample.ResultsThe intervention caregivers’ sample (N = 158) was 85% female (mean age = 65 years). The online survey sample (N = 138) was 90% female (mean age = 78). In both samples, the CSES-8 had excellent internal consistency reliability (.89 and .88) and good distribution with sufficient variability to detect change. Test–retest reliability was good in the online sample (.73). As evidence of construct validity, most hypotheses were confirmed in both samples. The CSES-8 was sensitive to change at 6 months for caregivers in the intervention program (p < .001).Discussion and ImplicationsThe CSES-8 is short, comprehensive with respect to common components of interventions to improve caregivers’ quality of life, and sensitive to change. It can serve a useful role exploring mechanisms by which caregiver intervention studies work, and it can be helpful in examining whether self-efficacy mediates the effect of these interventions on various outcomes such as psychological well-being.

To understand how the COVID-19 pandemic has affected caregivers, we assessed its perceived impact on caregiving through a new measure: the Caregiver COVID-19 Limitations Scale (CCLS-9), in Spanish and English. We also compared levels of caregiver self-efficacy and burden pre-COVID-19 and early in the pandemic. We administered surveys via internet to a convenience sample of caregivers in January 2020 (pre-pandemic, n = 221) and in April–June 2020 (English, n = 177 and Spanish samples, n = 144) to assess caregiver self-efficacy, depression, pain, and stress. We used the early pandemic surveys to explore the validity of the CCLS-9. The pre-COVID-19 survey and the April English surveys were compared to determine how the COVID-19 pandemic affected caregivers. The CCLS-9 had strong construct and divergent validity in both languages. Compared to pre-COVID-19, caregiver stress ( p = .002) and pain ( p = .009) were significantly greater early in COVID-19, providing evidence of its validity. COVID-19 added to caregiver stress and pain.

Group choir singing has been shown to have health benefits for older adults. However, because most studies have included predominantly white participants, it is unknown whether findings generalize to older adults from more diverse backgrounds. This multi-site qualitative study assessed perceived benefits of group singing for socioeconomically and racially/ethnically diverse older adults. We interviewed 31 choir participants, 6 music professionals and 6 administrators involved in a large, cluster-randomized trial. We used content analysis to identify themes. Psychosocial engagement was most commonly reported, with six components: emotional well-being, self-esteem, self-confidence, social connection and support, decreased loneliness, and cultural identity and multi-cultural appreciation. A few reported cognitive and physical benefits. They also suggest that group singing among ethnically diverse older adults can have multiple psychosocial benefits and enhance a sense of cultural identity and appreciation of other cultures. These findings can help in selecting structured outcome measures for choir interventions.

Interoceptive awareness is the conscious perception of sensations that create a sense of the physiological condition of the body. A validation study for the Japanese translation of the Multidimensional Assessment of Interoceptive Awareness (MAIA) surprised with a factor structure different from the original English-language version by eliminating two of eight scales. This prompted an exploration of the similarities and differences in interoceptive bodily awareness between Japanese and European Americans. Bicultural Japanese-Americans discussed concepts and experiences in the two cultures. We conducted focus groups and qualitative thematic analyses of transcribed recordings. 16 participants illustrated cross-cultural differences in interoceptive bodily awareness: switching between languages changes embodied experience; external versus internal attention focus; social expectations and body sensations; emphasis on form versus self-awareness; personal space; and mind-body relationship; context dependency of bodily awareness and self-construal. The participants explained key concepts that present challenges for a Japanese cultural adaptation of the MAIA, specifically the concept of self-regulation lost in the factor analysis. In Japanese culture, self-regulation serves the purpose of conforming to social expectations, rather than achieving an individual self-comforting sense of homeostasis. Our findings will inform the next phase of improving the MAIA's cross-cultural adaptation.

Background: Latinos are underrepresented in biomedical research, particularly biomarker research, yet they constitute the nation's largest ethnic/racial minority. Optimal methods for obtaining biospecimens for biomarker research among Latinos need to be identified. To minimize barriers and enhance participation, this study developed and tested tailored strategies for collecting biomarkers of chronic stress and premature aging among Spanish-speaking Latina breast cancer survivors. Methods: This study used a community-based participatory approach and selected hair and saliva as noninvasive biospecimens to assess telomere length, the cortisol awakening response (CAR), and hair cortisol concentration. We developed bilingual multimedia instructional materials, and community health workers assisted in collections. Telephone surveys assessed willingness to participate in future studies, barriers to sample collection, and recommendations for improving the strategies. Results: A total of 103 participants were recruited over 18 months from two rural sites in California, and 88 were retained at 6-month follow-up. At baseline, rates of donating salivary DNA for telomere length measurement, saliva for CAR analysis, and hair for cortisol concentration were 98%, 89%, and 52%, respectively. At follow-up, rates were 83%, 76%, and 55%, respectively. The majority of participants reported being very willing to provide hair (72%) or saliva (74%) for future studies. Conclusions: Our results support the feasibility of including minorities in biomedical research. We report excellent rates of saliva collection when community partners are engaged in the process, and when patient-centered and culturally tailored recruitment methods are implemented. Impact: The development of methods to facilitate the inclusion of minorities in biomedical research is critical to eliminate racial/ethnic health disparities.

Pilot studies test the feasibility of methods and procedures to be used in larger-scale studies. Although numerous articles describe guidelines for the conduct of pilot studies, few have included specific feasibility indicators or strategies for evaluating multiple aspects of feasibility. Additionally, using pilot studies to estimate effect sizes to plan sample sizes for subsequent randomized controlled trials has been challenged; however, there has been little consensus on alternative strategies. METHODS: In Section 1, specific indicators (recruitment, retention, intervention fidelity, acceptability, adherence, and engagement) are presented for feasibility assessment of data collection methods and intervention implementation. Section 1 also highlights the importance of examining feasibility when adapting an intervention tested in mainstream populations to a new more diverse group. In Section 2, statistical and design issues are presented, including sample sizes for pilot studies, estimates of minimally important differences, design effects, confidence intervals and non-parametric statistics. An in-depth treatment of the limits of effect size estimation as well as process variables is presented. Tables showing confidence intervals around parameters are provided. With small samples, effect size, completion and adherence rate estimates will have large confidence intervals. CONCLUSION: This commentary offers examples of indicators for evaluating feasibility, and of the limits of effect size estimation in pilot studies. As demonstrated, most pilot studies should not be used to estimate effect sizes, provide power calculations for statistical tests or perform exploratory analyses of efficacy. It is hoped that these guidelines will be useful to those planning pilot/feasibility studies before a larger-scale study.

Food insecurity increases the risks of diet-related chronic disease and mental health outcomes in low-income adults; however, the pathways underlying these associations have not been clearly identified. Chronic, psychological distress may represent an important pathway between food insecurity and health.To identify types of psychological distress, experiential descriptions, and the array of emotional responses and coping strategies specific to food insecurity among parents with children DESIGN: A phenomenological qualitative study using one-on-one, in-depth interviews.Forty-eight adults (parents) were recruited from the San Francisco Bay Area in 2016-17. Eligibility criteria included any experience of household food insecurity over the past 12 months, having a child aged 7 to 14 years, and both parent and child with the ability to speak English fluently.Data were analyzed using the constant comparative method to reveal emergent themes across multiple interviews.Parents discussed six themes related to the psychological distress of food insecurity: stress from the logistical and financial balancing act of feeding one's family, frustration and lack of choice associated with the high costs of healthy foods, stigma of using community resources, shame of not being able to provide for one's family, sadness about their cyclical and chronic food situation, and guilt over their inability to adequately provide for their children. Coping responses included negative responses, such as sleeping and drinking to avoid thinking about food insecurity, and positive responses of relying on their friends and family for support, staying hopeful, and spending time with their children.The commonality of emotional responses stemming from the experience of food insecurity can increase the risk for clinical anxiety and depression. Future development of interventions and policies to alleviate food insecurity must include social support and adequate safety systems.

Purpose: Low-income Latino immigrants lack access to mental health providers. We explored the feasibility of training promotores to deliver a stress management program in community settings. Methods: We trained promotores to deliver an 8-week intervention program comprising evidence-based cognitive-behavioral stress management techniques. Trained promotores then delivered the program to Spanish-speaking Latino immigrants. Results: Promotores (n=10) improved their knowledge significantly after the training (p

Our aim in this study was to assess the moderating role of patient-centred communication as a source of social support in the relationship between burden of diabetes and diabetes distress.Individuals with type 2 diabetes (N=1,267) completed validated tools of diabetes distress and multiple aspects of patient-centred communication. A path approach was used to evaluate the moderating role of patient-centred communication in the relationship between diabetes burden, as indicated by prescription of insulin and presence of complications, and distress.Lower Hurried Communication, higher Elicited Concerns/Responded, higher Explained Results/Medications, greater Patient-centred Decision-making and Compassionate/Respectful were significantly associated with lower distress after controlling for burden. Hurried Communication, Explained Results/Medications and Patient-centred Decision-making moderated the relation between insulin and diabetes distress.Our findings support the stress-buffering hypothesis of patient-centred communication and imply that aspects of patient-centred communication may protect against diabetes-related distress.

Objective\ud This study aimed to adapt the Multidimensional Assessment of Interoceptive Awareness (MAIA) questionnaire for younger respondents.\ud \ud Method\ud The language of the MAIA was revised and children aged 7–10 years (n = 212) and adolescents aged 11–17 years (n = 217) completed the questionnaire.\ud \ud Results\ud The original eight‐factor model was tested for fit using confirmatory factor analysis. The model had an acceptable fit in the total sample and younger subsample and overall fit in the older subsample was adequate following modification. Internal consistency was good, except for the Noticing, Not‐Distracting and Not‐Worrying scales. Results also demonstrated a negative linear relationship between the trusting scale and age, suggesting that youths may lose trust in their body as they age.\ud \ud Conclusion\ud The adapted MAIA can be used with a younger population and, depending on the research question, individual MAIA scales may be selected. The survey is available at https://osher.ucsf.edu/maia.

Background: Cancer-related self-efficacy, a multidimensional construct, is the confidence that one can overcome challenges associated with cancer and its treatment; higher levels have been associated with better psychosocial outcomes of breast cancer survivors. Little is known about factors that influence it among Latina breast cancer survivors. Purpose: Assess associations of several aspects of health care processes and of spirituality with self-efficacy for coping with breast cancer treatment among primarily Spanish-speaking Latina breast cancer survivors. Methods: We analyzed baseline data from a randomized controlled trial of a cognitive-behavioral stress management intervention that enrolled 151 Spanish-speaking Latinas within 1 year of breast cancer diagnosis. Multivariate linear regression models examined associations of health care processes (quality of breast cancer care and information, participating in medical care, difficulty engaging with doctors) and spirituality (meaning/peace, faith, acceptance) with self-efficacy for coping with breast cancer treatment. Results: Mean age was 51 (standard deviation [SD]=11), 66% completed high school or less, and most reported financial hardship in the past year (78%). Average time since diagnosis was 3.8 months (SD=2.7). In bivariate analyses, all six determinants were significantly associated with self-efficacy for coping with breast cancer treatment; participating in medical care (B=0.56, p

Background: In health disparities research, studies often fall short of their recruitment goals. Conducting a pilot feasibility study of recruitment in which data are collected systematically on recruitment processes can help investigators refine methods for the larger study. However, there are few guide­lines for conducting pilot feasibility studies, and recruitment methods are seldom the focus. Feasibility indicators differ from traditional reports of recruitment results by focusing on the extent to which recruitment goals are met.Methods: We present an organizing frame­work for assessing the feasibility of recruit­ment that includes eight steps, briefly: 1) specify recruitment goals; 2) specify recruit­ment processes; 3) establish a tracking sys­tem for each individual; 4) establish a track­ing database for monitoring processes and results; 5) implement recruitment and track each individual’s progress; 6) summarize re­cruitment results; 7) calculate and interpret feasibility measures - were goals met; and 8) if goals were not met, utilize tracking data to modify methods for the larger study. We describe methods within each step, with added details for steps 2-5 (the specific pro­cesses). The framework draws from a small literature on recruitment feasibility with a focus on health disparities populations. The guidelines blend well-known methods of recruitment with additional information on calculating feasibility indicators.Conclusion: These guidelines provide a first step in thinking systematically about recruitment feasibility, to advance the field of measuring feasibility. Feasibility indicators also can be used to track the effectiveness of innovative recruitment strategies as part of building the science of recruitment, es­pecially in disparities populations. Ethn Dis. 2020; 30(Suppl 2):745-754; doi:10.18865/ed.30.S2.745

Author(s): Napoles, Anna Maria; Santoyo-Olsson, Jasmine; Stewart, Anita L; Ortiz, Carmen; Samayoa, Cathy; Torres-Nguyen, Alma; Palomino, Helen; Coleman, LaVerne; Urias, Aday; Gonzalez, Nayeli; Cervantes, Silvia Araceli; Totten, Vicken Y | Abstract: ObjectiveWe report results of a community-based multisite, randomized controlled trial of Nuevo Amanecer (NA-II), a 10-week stress management program for rural, low literacy Latina breast cancer survivors.MethodsTrained peers delivered NA-II to Spanish-speaking Latinas with non-metastatic breast cancer in three rural communities. Women were randomized to receive the program immediately or wait 6 months. Assessments were conducted at baseline, 3 months, and 6 months. Primary outcomes were breast cancer-specific quality of life domains; secondary outcomes included general distress symptoms and stress management skills. Intention-to-treat analyses using repeated-measures linear regression models estimated changes in slope between groups.ResultsOf 153 participants (76 randomized to intervention, 77 to control group), 92% were retained at 6 months. Mean age was 54.8 years (SD = 10.5); 80% had less than high school education. There were no statistically significant treatment × time effects on quality of life. Compared to women in the control group, intervention group women reported greater improvements in anxiety at 6 months (-0.20 vs -0.02, P = .049; range 0-4) as well as three stress management skills: relaxation at 3 months (+0.98 vs -0.07, P l .0001; range 0-4) and 6 months (+0.82 vs +0.04, P l .001), awareness of tension at 3 months (+0.31 vs -0.19, P l .01; range 0-4) and 6 months (+0.29 vs -0.11, P l .05), and coping confidence at 3 months (+0.12 vs -0.23, P l .01; range 0-4).ConclusionsStress management programs delivered by trained peers in rural community settings can reduce anxiety and improve stress management skills among Latina breast cancer survivors.

ObjectivesTo test effects of the Community of Voices choir intervention on the health, well-being, and health care costs of racial/ethnically diverse older adults.MethodTwelve Administration-on-Aging-supported senior centers were cluster randomized into two groups: the intervention group started the choir immediately and a wait-list control group began the choir 6 months later. The choir program was designed for community-dwelling adults aged 60 years and older. The multimodal intervention comprises activities that engage participants cognitively, physically, and socially. Outcome measures assessed these three domains as well as health care utilization and costs. The intention-to-treat comparison was at 6 months.ResultsThe sample (N = 390) had a mean age of 71.3 years (SD = 7.2); 65% were nonwhite. Six-month retention was 92%. Compared to controls, intervention group members experienced significantly greater improvements in loneliness (p = .02; standardized effect size [ES = 0.34] and interest in life (p = .008, ES = 0.39). No significant group differences were observed for cognitive or physical outcomes or for health care costs.DiscussionFindings support adoption of community choirs for reducing loneliness and increasing interest in life among diverse older adults. Further efforts need to examine the mechanisms by which engagement in choirs improves aspects of well-being and reduces health disparities among older adults, including potential longer-term effects.ClinicalTrials.gov RegistrationNCT01869179 registered January 9, 2013.

Purpose: We examined the association between patient experience of care and utilization of hormone therapy (HT) in the treatment of non-metastatic hormone-receptor positive (HR+) breast cancer. Methods: Patients newly diagnosed with non-metastatic breast cancer were recruited from 2006 to 2010 for a longitudinal multisite cohort study in New York, NY, Detroit, MI, and Northern California. Of 1,145 patients surveyed, 797 had HR+ tumors eligible for HT and all necessary data. We assessed patient experience 4 to 8 weeks after recruitment using 6 subscales of the Interpersonal Processes of Care (IPC) survey: compassion, discrimination, and hurriedness in communication, as well as concern elicitation, result explanation, and patient-centered decision-making. Subscales ranged from 1 to 5 where higher values indicated better experiences. HT for 5 years is standard care for HR+ breast cancer so utilization was defined as time from diagnosis to HT initiation and time from HT initiation to early discontinuation before 5 years as calculated from follow-up survey responses. We evaluated the relationship between patient experience and utilization using Cox proportional hazard models, controlling for education, income, insurance, marital status, social support, site of care, age at diagnosis, stage, grade, tumor size, Charlson comorbidity index, and chemotherapy. Results: Median age at diagnosis was 59 years (interquartile range 51–66) with the majority diagnosed at clinical stage 1 (54%) and with low or moderate grade disease (78%). Less hurried communication was associated with increased probability of HT initiation (Hazards Ratio (HR) 1.15; 95% Confidence Interval (CI) 1.03, 1.30; p = 0.018). Conversely, more patient-centered decision-making was associated with increased probability of early discontinuation (HR 1.29; CI, 1.03, 1.63; p = 0.028). All other associations were null. Conclusion: While unhurried communication was associated with initiation of hormone therapy, patient-centered decision-making was associated with early discontinuation. Different aspects of patient experience may have vastly different relationships with patient utilization of health services. Actionable assessments of patient experience may require measurement along multiple dimensions.

Black, Latino, Pacific Islander, and American Indian/Alaska Native adults are more likely than White adults to experience SARS-CoV-2-related infections, hospitalizations, and mortality. We assessed intent to be vaccinated and concerns among 7 U.S. racial/ethnic groups (1,000 Black/African American, 500 American Indian/Alaska Native, 1,000 Asian, 1,000 Latino (500 English- and 500 Spanish-speaking), 500 Pacific Islander, 500 multiracial, and 1,000 White adults) in a cross-sectional online survey conducted December 2020-February 2021, weighted to be nationally representative within groups. Intent to be vaccinated was ascertained with: "If a COVID-19 vaccine becomes available, how likely are you to get vaccinated?" (not at all/slightly/moderately/very/extremely likely). Respondents identified which concerns would keep them from being vaccinated: cost, not knowing where, safety, effectiveness, side-effects, and other. Multinomial logistic regression models assessed associations of race/ethnicity with odds of being extremely/very/moderately, slightly likely to be vaccinated (ref=not at all), controlling for demographics and health. Overall, 30% were extremely likely, 22% not at all likely, and 48% unsure. Compared to White respondents, American Indian/Alaska Native (Adjusted Odds Ratio (AOR)=0.66, 95% CI, 0.47-0.92) and Black/African American (AOR=0.54, 95% CI, 0.41-0.72) respondents were less likely, and Asian (AOR=2.21, 95% CI, 1.61-3.02) and Spanish-speaking Latino respondents (AOR=3.74, 95% CI, 2.51-5.55) were more likely to report being extremely likely to be vaccinated. Side-effects (52%) and safety (45%) were overriding concerns. Intent and vaccination rates are changing rapidly; these results constitute a comprehensive baseline for ongoing vaccination efforts among U.S. racial and ethnic groups.

Author(s): Escalera, Cristian; Santoyo-Olsson, Jasmine; Stewart, Anita L; Ortiz, Carmen; Napoles, Anna Maria | Abstract: ObjectiveIntrusive thoughts, defined as unwanted and recurrent thoughts about a stressful experience, are associated with psychological distress in women with breast cancer. This study assessed moderating effects of various social support dimensions on associations between intrusive thoughts and psychological distress among Latina breast cancer survivors.MethodsWe used baseline data from a randomized controlled trial of a stress management intervention delivered to 151 Spanish-speaking Latinas with nonmetastatic breast cancer within 1 year of diagnosis. Intrusive thoughts, four dimensions of social support (emotional/informational, tangible, affectionate, and positive social interaction), and symptoms of anxiety and depression were assessed through in-person interviews. Information on age, time since diagnosis, breast cancer variables, history of depression, and marital status served as covariates. Generalized linear models were used to investigate bivariate and multivariate associations and to explore moderation effects of the four dimensions of social support.ResultsIn bivariate models, intrusive thoughts were associated positively with depression (β = .024, .001) and anxiety (β = .047, P l .001) symptoms. Adjusting for other factors, intrusive thoughts remained associated with depression symptoms (β = .022, .008), regardless of level of social support (for all support dimensions). For anxiety, there were significant interactions of tangible (β = -.013, .034) and affectionate (β = -.022, .005) support with intrusive thoughts. Intrusive thoughts were associated more strongly with anxiety symptoms among women reporting less tangible and affectionate support than those with higher levels of these types of support.ConclusionsTangible and affectionate support have protective effects on anxiety symptoms among Spanish-speaking Latina breast cancer survivors experiencing intrusive thoughts, but not depression symptoms.

Background Food insecurity, a condition of inadequate household food availability, affects 15.7% of US households with children. Food insecurity is generally believed to affect the quantity and quality of food consumed. However, an understudied but important aspect of the experience of food insecurity is psychological distress. Objective To critically explore the psychological distress associated with children’s food insecurity using children’s own reports of their experiences. Design In-depth qualitative interviews conducted with children to better understand the psychological distress associated with food insecurity. Participants/setting Sixty children (aged 7 to 14 years) were recruited from the San Francisco Bay Area. Children were eligible in the case that they spoke English fluently and their parent reported any experience of household food insecurity during the past year. Results Children discussed six themes related to the psychological distress associated with food insecurity: worrying about not having enough food, worrying about their parents’ well-being, anger and frustration about not having enough food, embarrassment about their family’s food situation, strain on the family’s dynamics due to food insecurity, and sadness over not having enough food. After describing their experiences, children described strategies they employed to tolerate or cope with food insecurity, including distracting from or using their imagination to cope with food insecurity, increasing tolerance of their family’s food situation, and appreciating their parents for providing food and resources. Conclusions Food insecurity contributes to children’s psychological distress. Given the known effects of chronic stress in childhood, the psychological distress of food insecurity may represent an important mechanism by which food insecurity adversely influences children’s growth and development and deserves investigation in future studies.

Rationale: Although lung transplantation aims to improve health-related quality of life (HRQL), existing instruments fail to include health domains considered important in this population. Objectives: We aimed to develop a comprehensive lung transplant–specific instrument to address this shortcoming. Methods: We developed a pool of 126 candidate items addressing domains previously identified as important by lung transplant recipients. Through cognitive interviews conducted in 43 transplant recipients, items deemed irrelevant or redundant were dropped. The 84 remaining items were field tested in lung transplant recipients. Exploratory and confirmatory factor analyses were used to evaluate the factor structure, and scales were evaluated for internal consistency and construct validity. Measurements and Main Results: The 84-item preliminary survey was administered to 201 lung transplant recipients with a mean age of 57.9 (±12.7) years; 46% were female. After factor analyses and internal consistency evaluation, we retained 60 items comprising the Lung Transplant Quality of Life (LT-QOL) Survey. The LT-QOL contains 10 scales that measure symptoms, health perceptions, functioning, and well-being. The confirmatory factor analysis model had good approximate fit (comparative fit index = 0.990; standardized root-mean-square residual = 0.062). Cronbach αs for the 10 scales ranged from 0.75 to 0.95. Interscale correlations were consistent with hypothesized relationships. Subjects with severe chronic lung allograft dysfunction (n = 13) reported significantly worse HRQL than subjects without chronic lung allograft dysfunction (n = 168) on 6 of the 10 LT-QOL scales. Conclusions: The LT-QOL is a new, multidimensional instrument that characterizes and quantifies HRQL in lung transplant recipients.

BACKGROUND Spanish-speaking Latina breast cancer survivors experience disparities in knowledge of breast cancer survivorship care, psychosocial health, lifestyle risk factors, and symptoms compared with their white counterparts. Survivorship care planning programs (SCPPs) could help these women receive optimal follow-up care and manage their condition. OBJECTIVE This study aimed to evaluate the feasibility, acceptability, and preliminary efficacy of a culturally and linguistically suitable SCPP called the Nuevo Amanecer (New Dawn) Survivorship Care Planning Program for Spanish-speaking breast cancer patients in public hospital settings, approaching the end of active treatment. METHODS The 2-month intervention was delivered via a written bilingual survivorship care plan and booklet, Spanish-language mobile phone app with integrated activity tracker, and telephone coaching. This single-arm feasibility study used mixed methods to evaluate the intervention. Acceptability and feasibility were examined via tracking of implementation processes, debriefing interviews, and postintervention satisfaction surveys. Preliminary efficacy was assessed via baseline and 2-month interviews using structured surveys and pre- and postintervention average daily steps count based on activity tracker data. Primary outcomes were self-reported fatigue, health distress, knowledge of cancer survivorship care, and self-efficacy for managing cancer follow-up health care and self-care. Secondary outcomes were emotional well-being, depressive and somatic symptoms, and average daily steps. RESULTS All women (n=23) were foreign-born with limited English proficiency; 13 (57%) had an elementary school education or less, 16 (70%) were of Mexican origin, and all had public health insurance. Coaching calls lasted on average 15 min each (SD 3.4). A total of 19 of 23 participants (83%) completed all 5 coaching calls. The majority (n=17; 81%) rated the overall quality of the app as “very good” or “excellent” (all rated it as at least “good”). Women checked their daily steps graph on the app between 4.2 to 5.9 times per week. Compared with baseline, postintervention fatigue (B=–.26; P=.02; Cohen d=0.4) and health distress levels (B=–.36; P=.01; Cohen d=0.3) were significantly lower and knowledge of recommended follow-up care and resources (B=.41; P=.03; Cohen d=0.5) and emotional well-being improved significantly (B=1.42; P=.02; Cohen d=0.3); self-efficacy for managing cancer follow-up care did not change. Average daily steps increased significantly from 6157 to 7469 (B=1311.8; P=.02; Cohen d=0.5). CONCLUSIONS We found preliminary evidence of program feasibility, acceptability, and efficacy, with significant 2-month improvements in fatigue, health distress, and emotional well-being and increased knowledge of recommended follow-up care and average daily steps. Tailored mobile phone and health coaching SCPPs could help to ensure equitable access to these services and improve symptoms and physical activity levels among Spanish-speaking Latina breast cancer survivors.

Author(s): Santoyo-Olsson, Jasmine; Stewart, Anita L.; Samayoa, Cathy; Palomino, Helen; Urias, Aday; Gonzalez, Nayeli; Torres-Nguyen, Alma; Coleman, LaVerne; Escalera, Cristian; Totten, Vicken Y.; Ortiz, Carmen; Napoles, Anna Maria | Abstract: ObjectivesAdapt a cognitive-behavioral stress management program (Nuevo Amanecer or NA) to be generalizable to rural, low literacy Spanish-speaking Latinas with breast cancer survivors at all phases of survivorship.MethodsApply the Transcreation Framework, a community-engaged translational model, to develop the adapted program (Nuevo Amanecer or NA-II), design a randomized controlled trial for community settings, identify recruiters and interventionists, and recruit participants into the trial.ResultsAdaptations included expanding the program from eight to ten weeks, simplifying materials, and increasing skills practice. We added stress management videos, healthy lifestyles information, and survivorship information. Interventionists were trained Latina breast cancer survivors. All core components of NA were retained in NA-II including managing the impact of cancer, information on breast cancer and its treatment, finding cancer information, getting support, managing thoughts, stress management techniques, and setting goals. Participants receive a program manual. Each session includes a review of that week’s content using the manual, practicing a stress-management skill, setting a specific goal, and reviewing videos. Spanish-speaking Latinas with non-metastatic breast cancer were recruited by community recruiters. Of 231 women approached, 24% refused, 10% were ineligible, and 153 (66%) were randomized to the intervention or a wait-list control group. The sample was vulnerable: 69% had l high school education, more than half had only Medicaid or no insurance, 91% was foreign born, and 48% reported financial hardship in the past year.ConclusionsApplying the Transcreation Framework to engage stakeholders in designing community-based RCTs enhanced congruence with community contexts and recruitment of this vulnerable population.

Introduction: Effective interventions tailored for rural Spanish-speaking Latina breast cancer survivors are needed to address their psychosocial health disparities. Purpose: Describe development of a rural community-based cognitive-behavioral stress management program, Nuevo Amanecer-R (NA-R) (New Dawn-R) and baseline characteristics of rural Latina breast cancer survivors enrolled in the RCT testing the program. Methods: Using community-based participatory research (CBPR) strategies, we applied a translational model appropriate for underserved populations that integrated an evidence-based intervention, a community best-practices program, and formative research to develop a program that could be delivered by trained breast cancer survivors (peers) in rural settings. We trained community recruiters to enroll, and collect hair and saliva biospecimens from, Spanish-speaking Latinas with nonmetastatic breast cancer in 3 rural California communities. Women were randomized to receive the program immediately or in 6 months. Primary outcomes include the Functional Assessment of Cancer Therapy-Breast Quality of Life (FACT-B) Total Score and its Physical, Social, Emotional, Functional Well-being, and Additional Concerns about Breast Cancer subscale scores (higher scores=better quality of life), with assessments at baseline, 3 months, and 6 months. Results: Based on input from survivors, advocates, and clinicians, modifications to the initial program for rural Latina survivors included further simplification of language, more visuals, developing stress management videos in Spanish and English, and expansion from 8 to 10 sessions to increase skills practice and healthy lifestyles information. Trained peers are delivering the 10-week NA-R program through weekly in-person 90-minute sessions in participants' homes. Components include managing the initial impact of cancer, finding cancer information and support, thoughts and mood management skills, behavioral stress management skills, and goal-setting. Of 231 women approached, 54 (24%) refused, 24 (10%) were ineligible, and 153 (66%) were randomized (76 to intervention, 77 to control group). To date, all baseline, 90% of 3-month, and 92% of 6-month assessments are completed. Participant characteristics are: mean age of 54.8 years (range, 28 to 88); 69% have < high school education; 66% are married; 80% have public/no health insurance; and 48% experienced financial hardship in the past year. Baseline FACT-B mean scores are: Total Score, 96.7 (possible range 0-144); Emotional Well-being, 17.3 (possible range 0-24); Functional Well-being, 18.2 (possible range 0-28); Social/Family Well-being, 18.2 (possible range 0-28); Physical Well-being, 20.4 (possible range 0-28); and Breast Cancer Concerns, 22.7 (possible range 0-36). Conclusions: Using CBPR principles in the design and implementation of community-based RCTs enhances cultural appropriateness, congruence with community contexts, and recruitment and retention. Citation Format: Jasmine Santoyo-Olsson, Anita L. Stewart, Carmen Ortiz, Steven Gregorich, Anna Maria Napoles. Baseline characteristics of rural Spanish-speaking Latina breast cancer survivors enrolled in a community-based RCT of a peer-delivered cognitive-behavioral stress management intervention: The Nuevo Amanecer rural trial [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A043.

Introduction: Compared to their white counterparts, Latina breast cancer survivors suffer from greater distress and poorer health-related quality of life. Yet little is known about the determinants of such distress. Purpose: Examine the independent associations of coping self-efficacy, social support, neighborhood cohesion, engagement with physicians, and financial hardship with depressive symptoms and perceived stress using baseline data from a randomized controlled trial of a stress management intervention among Spanish-speaking rural Latina breast cancer survivors. Methods: All data were self-reported and collected via in-person interviews in Spanish, except for medical information, which was obtained from medical records review. Bivariate linear models regressed either depressive symptoms (Patient Health Questionnaire-8) or stress (Perceived Stress Scale) on coping self-efficacy, social support, neighborhood cohesion, difficulty engaging with physicians, and financial hardship, controlling for demographic, medical factors, and study site. Hypothesized predictors that were statistically significant at p Results: In bivariate analyses, coping confidence (b = -2.50; p Conclusions: Interventions that focus on increasing women's coping confidence and sense of neighborhood cohesion, and services to reduce their financial hardship, could help alleviate psychosocial health disparities among rural Latina cancer survivors. Citation Format: Anna M. Napoles, Jasmine Santoyo-Olsson, Anita L. Stewart, Carmen Ortiz, Steven Gregorich. How do coping resources and financial hardship affect rural Latina breast cancer survivors' stress and depressive symptoms: The Nuevo Amanecer Rural Trial [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A103.

Aims To examine the psychometric characteristics and explore the preliminary validity of the Persian version of the Interpersonal Processes of Care Survey (P-IPC) to assess patient-physician communication in the context of diabetes care. Methods After adapting, translating, examining content validity, and pretesting the questionnaire, it was administered to 300 patients with diabetes. Confirmatory factor analysis identified the factor structure (scales). Variability, item-scale correlations, reliability, and construct validity of the final scales were examined. Results Factor analysis supported the hypothesized second-order factor model with 27 of the 29 items:11 first-, and 7 second-order common factors. Scale scores were calculated for the 7 second-order factors. Internal-consistency reliability for the 7 scales ranged from 0.60 to 0.90 and 2-week test–retest correlations ranged from 0.89 to 0.96. The communication and interpersonal style domains of the P-IPC demonstrated high ceiling effects suggesting good patient-physician communication. The P-IPC scales differentiated between patients in the language-concordant and language-discordant groups, and patterns of correlations with three patient satisfaction measures corresponded to hypotheses. Conclusion The P-IPC includes all of the second-order scales identified in the original IPC. Evidence of its reliability and validity suggest it can be useful for assessing patient-physician communication in the context of diabetes care.

Objectives: To report intention-to-treat results of a pragmatic, cluster-randomized trial to examine the effect of Community of Voices, a multi-modal community choir intervention, on the health and well-being of racial/ethnically and socioeconomically diverse older adults. Method: Twelve Administration-on-Aging-supported senior centers were randomized to receive the choir intervention immediately or after a six-month delay. We recruited community-dwelling adults aged 60 and over. The choir intervention was culturally tailored around three engagement components (cognitive, physical, and psychosocial) and delivered at senior centers by community-based music professionals. The main randomized comparison was at 6 months (after 23 choir sessions). Results: The sample (N=390) had a mean age of 71.3 (SD=7.2); 65% were from non-white racial/ethnic backgrounds. Study retention was 92%. Intention-to-treat analyses found a significant group-by-time interaction effect for two of six psychosocial outcomes: participants in the choir intervention experienced significant improvements in loneliness and interest in life compared to the wait-list controls. No significant group differences were observed for cognitive or physical outcomes. Discussion: The finding that singing in a choir can reduce loneliness and increase interest in life in diverse older adults are important because of the relatively low-cost and cultural salience of the intervention. This supports further efforts to examine how engagement in the arts may improve health and well-being and reduce health disparities in diverse older adults.

PurposeRacial/ethnic differences in cancer symptom burden are well documented, but limited research has evaluated modifiable factors underlying these differences. Our objective was to examine the role of patient-provider interactions to help explain the relationship between race/ethnicity and cancer-specific physical well-being (PWB) among women with breast cancer.MethodsThe Pathways Study is a prospective cohort study of 4505 women diagnosed with breast cancer at Kaiser Permanente Northern California between 2006 and 2013. Our analysis included white, black, Hispanic, and Asian participants who completed baseline assessments of PWB, measured using the Functional Assessment of Cancer Therapy for Breast Cancer, and patient-provider interactions, measured by the Interpersonal Processes of Care Survey (IPC) (N = 4002). Using step-wise linear regression, we examined associations of race/ethnicity with PWB, and changes in associations when IPC domains were added.ResultsWe observed racial/ethnic differences in PWB, with minorities reporting lower scores than whites (beta, black: - 1.79; beta, Hispanic: - 1.92; beta, Asian: - 1.68; p

Information is needed on implementation processes involved in translating evidence-based interventions (EBIs) into health disparity communities. In an RCT, Nuevo Amanecer, a cognitive-behavioral stress management (CBSM) program delivered by breast cancer survivors (compañeras) in community settings to Spanish-speaking Latina breast cancer survivors, was effective in improving quality of life and decreasing breast cancer concerns and depressive and bodily symptoms. Using mixed methods, we evaluated the processes of implementing Nuevo Amanecer. Program delivery was assessed by direct observation. Treatment receipt was assessed by participants' mastery and homework completion. Perceived benefits, quality, ease of use, usefulness of components, and suggested improvements were evaluated through participant surveys and semi-structured interviews of participants and compañeras. Eighty percent of women completed six or more of eight sessions. Observer ratings of program delivery indicated compañeras demonstrated fidelity 80-90% of the time for three components (e.g., following the manual), but only 10% for two components (e.g., modeling skills). Regarding treatment receipt, most participants completed all homework. Knowledge and skills mastery was high (mostly >85%). In program evaluations, 93% indicated the program helped them cope with breast cancer "quite a bit/extremely." Participants reported improved self-management skills and knowledge. Suggested improvements were to add more sessions to practice cognitive-behavioral coping skills and simplify exercises and homework. We conclude that CBSM programs can be delivered in community settings by trained peers with high fidelity, acceptability, and perceived usefulness. Results provided some areas where the program could be improved. Our rigorous evaluation illustrates methods for evaluating processes of translating EBIs for community implementation.Trial registrationNCT01383174 (ClinicalTrials.gov).

Author(s): Hays, Ron D; Weech-Maldonado, Robert; Teresi, Jeanne A; Wallace, Steven P; Stewart, Anita L

Interoception, the process by which the nervous system senses, interprets, and integrates signals originating from within the body, has become major research topic for mental health and in particular for mind-body interventions. Interoceptive awareness here is defined as the conscious level of interoception with its multiple dimensions potentially accessible to self-report. The Multidimensional Assessment of Interoceptive Awareness (MAIA) is an 8-scale state-trait questionnaire with 32 items to measure multiple dimensions of interoception by self-report and was published in November 2012. Its numerous applications in English and other languages revealed low internal consistency reliability for two of its scales. This study’s objective was to improve these scales and the psychometrics of the MAIA by adding three new items to each of the two scales and evaluate these in a new sample. Data were collected within a larger project that took place as part of the Live Science residency programme at the Science Museum London, UK, where visitors to the museum (N = 1,090) completed the MAIA and the six additional items. Based on exploratory factor analysis in one-half of the adult participants and Cronbach alphas, we discarded one and included five of the six additional items into a Version 2 of the MAIA and conducted confirmatory factor analysis in the other half of the participants. The 8-factor model of the resulting 37-item MAIA-2 was confirmed with appropriate fit indices (RMSEA = 0.055 [95% CI 0.052–0.058]; SRMR = 0.064) and improved internal consistency reliability. The MAIA-2 is public domain and available (www.osher.ucsf.edu/maia) for interoception research and the evaluation of clinical mind-body interventions.