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We developed and tested a culturally appropriate, team-based, integrated primary care and behavioral health intervention in low income, Spanish-speaking Latinos with type 2 diabetes, at a federally qualified health center. This pragmatic randomized controlled trial included 456 Latino adults, 23–80 years, 63.7% female, with diabetes [recruitment glycosylated hemoglobin (HbA1c) ≥ 7.0%/53.01 mmol/mol)]. The Special Intervention occurred over 6 months and targeted improvement of HbA1c, blood pressure, and lipids. The intervention included: (i) four, same-day integrated medical and behavioral co-located visits; (ii) six group diabetes self-management education sessions addressing the cultural dimensions of diabetes and lifestyle messages; (iii) and care coordination. Usual Care participants received primary care provider led standard diabetes care, with referrals to health education and behavioral health as needed. HbA1c and lipids were obtained through electronic health records abstraction. Blood pressure was measured by trained research staff. Multi-level models showed a significant group by time interaction effect (B = −0.32, p < .01, 95% CI −0.49, −0.15), indicating statistically greater improvement in HbA1c level over 6 months in the Special Intervention group (ΔHbA1c = −0.35, p =

Objective To compare the effectiveness of usual care (UC) versus a culturally tailored integrated care model in improving mental health symptoms for Latino patients with Type 2 diabetes mellitus (T2DM). Methods We conducted a two-arm randomized controlled trial from 2015 to 2019 at a federally qualified health center. Participants were 456 adults ages 23–80 years who had a previous diagnosis of T2DM and were not currently using insulin. Participants were randomly assigned to Integrated Care Intervention (ICI; including behavioral/mental healthcare, medical visits, health education and care coordination) or UC; standard of care including referrals for health education and behavioral/mental health care where appropriate. Intention-to-treat, multilevel models were used to compare group × time changes in depression and anxiety symptoms (PHQ-8; GAD-7) and perceived stress (PSS-10) across 6 months. Results Participant mean age was 55.7 years, 36.3% were male, and 63.7% were primarily Spanish speaking. Baseline sociodemographic factors and mental health symptoms across study arms were balanced. Significant group × time interaction effects were observed for anxiety and depression symptoms (p < .05). Within the ICI and UC groups, mean depression symptom changes were −0.93 and −0.39 (p < .01); anxiety symptom changes were −0.97 (p < .01) and −0.11 (p = .35); and perceived stress changes were −1.56 and −1.27 (p < .01), respectively. Conclusions Although both ICI and UC showed decreases over time, the ICI group evidenced larger, statistically significant changes in both depression and anxiety. Adapted integrated models of behavioral and chronic disease management appear to be effective and could be considered for usual care practices. ClinicalTrials.gov Identifier NCT03983499

BACKGROUND: Asynchronous video directly observed therapy (VDOT) may reduce tuberculosis (TB) program costs and the burden on patients. We compared VDOT performance across three cities in the United States, each of which have TB incidence rates above the national average.METHODS: Patients aged ≥18 years who are currently receiving directly observed anti-TB treatment were invited to use VDOT for monitoring treatment. Pre- and post-treatment interviews and medical records were used to assess site differences in treatment adherence and patient characteristics and perceptions.RESULTS: Participants were enrolled in New York City, NY (n = 48), San Diego, CA (n = 52) and San Francisco, CA, USA (n = 49). Overall, the mean age was 41 years (range 18–87); 59% were male; most were Asian (45%) or Hispanic/Latino (30%); and 77% were foreign-born. The median fraction of expected doses observed (FEDO) was 88% (IQR 76–96). At follow-up, 97% thought VDOT was “very or somewhat easy to use” and 95% would recommend VDOT to other TB patients. Age, race/ethnicity, annual income, and country of birth differed by city (P < 0.05), but FEDO and VDOT perceptions did not.CONCLUSIONS: TB programs in three large US cities observed a high FEDO using VDOT while minimizing staff time and travel. Similar findings across sites support VDOT adoption by other large, urban TB programs.

Objectives. To compare usual care, inreach consisting of one-on-one education, mailed outreach offering a fecal immunochemical test (FIT), and a combination of outreach and inreach for promoting colorectal cancer (CRC) screening. Methods. We conducted a 4-arm randomized controlled trial from 2015 to 2018 at a US federally qualified health center near the California–Mexico border primarily serving low-income Hispanics/Latinos. A total of 673 individuals aged 50 to 75 years not up to date with screening were assigned to 1 of the 4 intervention groups. The primary outcome was CRC screening through 6 months follow-up. Results. A total of 671 patients were included in intention-to-screen analyses. Their mean age was 59.9 years, 48.9% were male, and 86.3% were primarily Spanish-speaking. Screening was 27.5% for usual care (95% confidence interval [CI] = 0.21, 0.34), 52.7% for inreach (95% CI = 0.45, 0.60), 77.2% for outreach (95% CI = 0.71, 0.83), and 78.9% for combination of inreach and outreach (95% CI = 0.73, 0.85; P Conclusions. Among individuals at high risk for noncompletion, inreach with one-on-one education nearly doubled, and outreach offering mailed FIT alone or in combination with inreach nearly tripled screening compared with usual care. Mailed FIT outreach was superior to inreach for promoting screening.

© 2018, Centers for Disease Control and Prevention (CDC). All rights reserved. We assessed video directly observed therapy (VDOT) for monitoring tuberculosis treatment in 5 health districts in California, USA, to compare adherence between 174 patients using VDOT and 159 patients using in-person directly observed therapy (DOT). Multivariable linear regression analyses identified participant-reported sociodemographics, risk behaviors, and treatment experience associated with adherence. Median participant age was 44 (range 18–87) years; 61% of participants were male. Median fraction of expected doses observed (FEDO) among VDOT participants was higher (93.0% [interquartile range (IQR) 83.4%–97.1%]) than among patients receiving DOT (66.4% [IQR 55.1%– 89.3%]). Most participants (96%) would recommend VDOT to others; 90% preferred VDOT over DOT. Lower FEDO was independently associated with US or Mexico birth, shorter VDOT duration, finding VDOT difficult, frequently taking medications while away from home, and having video-recording problems (p

Regular use of colorectal cancer screening can reduce incidence and mortality, but participation rates remain low among low-income, Spanish-speaking Latino adults. We conducted two distinct pilot studies testing the implementation of evidence-based interventions to promote fecal immunochemical test (FIT) screening among Latinos aged 50–75 years who were not up-to-date with CRC screening (n=200) at a large Federally-Qualified Health Center (FQHC) in San Diego, CA. One pilot focused on an opportunistic clinic visit “in-reach” intervention including a 30 minute session with a patient navigator, review of an educational “flip-chart”, and a take-home FIT kit with instructions. The second pilot was a system-level “outreach” intervention consisting of mailed materials (i.e., FIT kit, culturally and linguistically tailored instructions, and a pre-paid return envelope). Both received follow-up calls to promote screening completion and referrals for additional screening and treatment if needed. The primary outcome was FIT kit completion and return within three months assessed through electronic medical records. The in-reach pilot consisted of mostly insured (85%), women (82%) and Spanish-speaking (88%) patients. The outreach pilot consisted of mostly of Spanish-speaking (73%) women (64%), half of which were insured (50%). At three months follow-up, screening completion was 76% for in-reach, and 19% for outreach. These data demonstrate that evidence-based strategies to promote CRC screening can be implemented successfully within FQHCs, but implementation (particularly of mailed outreach) may require setting and population-specific optimization. Patient, provider and healthcare system related implementation approaches and lessons learned from this study may be implemented in other primary care settings.

Author(s): Armenta, RF; Collins, KM; Strathdee, SA; Bulterys, MA; Munoz, F; Cuevas-Mota, J; Chiles, P; Garfein, RS | Abstract: BackgroundPersons who inject drugs (PWID) might be at increased risk for Mycobacterium tuberculosis infection and reactivation of latent tuberculous infection (LTBI) due to their injection drug use.ObjectivesTo determine prevalence and correlates of M. tuberculosis infection among PWID in San Diego, California, USA.MethodsPWID aged 18 years underwent standardized interviews and serologic testing using an interferon-gamma release assay (IGRA) for LTBI and rapid point-of-care assays for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections. Independent correlates of M. tuberculosis infection were identified using multivariable log-binomial regression.ResultsA total of 500 participants met the eligibility criteria. The mean age was 43.2 years (standard deviation 11.6); most subjects were White (52%) or Hispanic (30.8%), and male (75%). Overall, 86.7% reported having ever traveled to Mexico. Prevalence of M. tuberculosis infection was 23.6%; 0.8% were co-infected with HIV and 81.7% were co-infected with HCV. Almost all participants (95%) had been previously tested for M. tuberculosis; 7.6% had been previously told they were infected. M. tuberculosis infection was independently associated with being Hispanic, having longer injection histories, testing HCV-positive, and correctly reporting that people with 'sleeping' TB cannot infect others.ConclusionsStrategies are needed to increase awareness about and treatment for M. tuberculosis infection among PWID in the US/Mexico border region.

Background Mobile health (mHealth) interventions have the potential to improve health through patient education and provider engagement while increasing efficiency and lowering costs. This raises the question of whether disparities in access to mobile technology could accentuate disparities in mHealth mediated care. This study addresses whether programs planning to implement mHealth interventions risk creating or perpetuating health disparities based on inequalities in smartphone ownership. Methods Video Directly Observed Therapy (VDOT) is an mHealth intervention for monitoring tuberculosis (TB) treatment adherence through videos sent by patients to their healthcare provider using smartphones. We conducted secondary analyses of data from a single-arm trial of VDOT for TB treatment monitoring by San Diego, San Francisco, and New York City health departments. Baseline and follow-up treatment interviews were used to assess participant smartphone ownership, sociodemographics and TB treatment perceptions. Univariate and multivariable logistic regression analyses were used to identify correlates of smartphone ownership. Results Of the 151 participants enrolled, mean age was 41 years (range: 18–87 years) and 41.1% were female. Participants mostly identified as Asian (45.0%) or Hispanic/Latino (29.8%); 57.8% had at most a high school education. At baseline, 30.4% did not own a smartphone, which was similar across sites. Older participants (adjusted odds ratio [AOR] = 1.09 per year, 95% confidence interval [CI]: 1.05–1.12), males (AOR = 2.86, 95% CI: 1.04–7.86), participants having at most a high school education (AOR = 4.48, 95% CI: 1.57–12.80), and those with an annual income below $10,000 (AOR = 3.06, 95% CI: 1.19, 7.89) had higher odds of not owning a smartphone. Conclusions Approximately one-third of TB patients in three large United States of America (USA) cities lacked smartphones prior to the study. Patients who were older, male, less educated, or had lower annual income were less likely to own smartphones and could be denied access to mHealth interventions if personal smartphone ownership is required.

OBJECTIVES: This study aimed to identify factors relating to adherence to an integrative model of care intervention for Hispanic/Latino patients with type 2 diabetes (T2D). METHODS: Baseline characteristics and 12-month intervention data from 225 Hispanic/Latino patients with T2D who were randomized to the intervention arm of the Latinos Understanding the Need for Adherence in Diabetes (LUNA-D) trial were analyzed. Linear regressions were conducted to determine which factors (sex, age, BMI, place of birth, family diabetes history, annual household income, employment, education, current smoking, marital status, controlled or uncontrolled glycated hemoglobin [HbA1c, ≤ 7% or > 7%, respectively], depression, anxiety, or diabetes distress) predicted adherence to three intervention components: group health education classes (GHEC), behavior health consultations (BHC), and medical examinations (ME). Logistic regression was conducted to identify factors that predicted poor (≤50%) or adequate ( > 50%) adherence to the total intervention. RESULTS: Results of linear regressions are means ± standard error. Controlled HbA1c status predicted poorer GHEC (β = −1.9 ± 4.7, P 50% adherence to all intervention components were: poorly controlled HbA1c (OR = 6.2, 95% CI: 3.0, 12.6, P

Aims: The aim of this study was to examine the relationships between psychological distress (anxiety, depression, and diabetes-distress), diabetes self-management (DSM) behaviors, and cardiovascular disease (CVD) risk factors/diabetes control among adult primary care, non-insulin using Hispanic/Latino patients with type 2 diabetes. Methods: This abstract presents a cross-sectional analysis of the baseline data from an ongoing clinical trial of 456 Hispanic/Latino participants with type 2 diabetes (mean age 55.2 ± 9.8 years; 63.7% female) at a federally qualified health center in San Diego. General linear models were used to examine associations between anxiety, depression, and diabetes-distress (assessed using the Patient Health Questionnaire-8 [PHQ-8], the Generalized Anxiety Disorder 7-item scale [GAD-7], and the Diabetes Distress scale-2, respectively), DSM behaviors (assessed using the Summary of Diabetes Self-Care Activities Assessment [SDSCA]), and markers of CVD risk (glycated hemoglobin [HbA1c], body mass index, systolic and diastolic blood pressure, and HDL and LDL cholesterol), controlling for the demographics variables of age, sex, and education. Results: Moderate depression and anxiety symptoms (defined as a PHQ-8 and GAD-7 cutoff of 10) were present in the study sample at rates of 21.5% and 15.4%, respectively. Poorly controlled diabetes (HbA1c > 8.0%) was present in 40.6% of the sample. After controlling for covariates, all three indicators of psychological distress showed significant, negative associations with SDSCA (DSM) scores (p < 0.01). Depression and anxiety symptoms were positively associated with LDL cholesterol (p = 0.020 and p = 0.022, respectively). No other associations among psychological distress and CVD risk factors were significant. DSM behaviors were not associated with any CVD risk factors. Conclusions: Depression and anxiety affect a large percentage of the Hispanic/Latino population. As greater depression and anxiety symptoms were associated with worsened diabetes self-management behaviors, for example diet and glucose monitoring, there may be implications for DSM and other CVD risk factors. Psychosocial dimensions of health are important to consider when providing care and promoting self-management behaviors in this population, as promoted by frameworks such as the integrative care model.

Author(s): Zuniga, Maria Luisa; Collins, Kelly; Munoz, Fatima; Moser, Kathleen; Rangel, Gudelia; Cuevas-Mota, Jazmine; Clark, Maureen; Burgos, Jose Luis; Garfein, Richard S

Unsafe injection practices significantly increase the risk of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infection among injection drug users (IDUs). We examined individual and socio-environmental factors associated with unsafe injection practices in young adult IDUs in San Diego, California. Of 494 IDUs, 46.9 % reported receptive syringe sharing and 68.8 % sharing drug preparation paraphernalia in the last 3 months. Unsafe injection practices were associated with increased odds of having friends who injected drugs with used syringes, injecting with friends or sexual partners, and injecting heroin. Perceived high susceptibility to HIV and perceived barriers to obtaining sterile syringes were associated with increased odds of receptive syringe sharing, but not with sharing injection paraphernalia. Over half the IDUs reported unsafe injection practices. Our results suggest that personal relationships might influence IDUs' perceptions that dictate behavior. Integrated interventions addressing individual and socio-environmental factors are needed to promote safe injection practices in this population.

Research is lacking on factors associated with antiretroviral therapy (ART) sub-optimal adherence among U.S. Latinos, who are disproportionately affected by HIV and face substantial health care barriers. We examined self-reported, patient-initiated changes to ART (i.e., made small/major changes from the antiretroviral drugs prescribed) among HIV-positive Latinos. Trained interviewers administered surveys to 230 participants currently on ART in San Diego, U.S. and Tijuana, Mexico. We identified factors independently associated with ART changes. Participants were Spanish-language dominant (86%), mean age of 41 years, male (77%), and born in Mexico (93%). Patient-initiated changes to ART were reported in 43% of participants. Being female, having ≥1 sexual partner (past 3 months), ≥6 years since HIV diagnosis and poor health were associated with increased odds of ART changes. Findings raise concern about sub-optimal adherence among this binational population. Longitudinal studies are needed to further explore adherence barriers and avenues for intervention.

To determine whether condom access is associated with consistent condom use among female sex workers (FSWs) in Tijuana and Ciudad Juarez, between 2004 and 2006 we administered a questionnaire to 924 FSWs who reported unprotected sex with a client in the past 2 months. Of these women, 43% reported consistent ("often" or "always") condom use, 74% said condoms were available, and 38% reported having access to free condoms. In a logistic regression, factors positively associated with consistent condom use were condom availability (adjusted odds ratio [AOR] = 2.00; 95% confidence interval [CI]: 1.32-3.03), condom affordability (AOR = 1.72; 95% CI: 1.25-2.38) and self-efficacy (AOR = 2.16; 95% CI: 1.54-3.04). Factors inversely associated with consistent condom use included poor financial status (AOR = 0.65; 95% CI: 0.47-0.90), methamphetamine use (AOR = 0.58; 95% CI: 0.40-0.83), alcohol use (AOR = 0.68; 95% CI: 0.49-0.96), and recent injection drug use (AOR = 0.62; 95% CI: 0.39-0.97). While increased condom availability may improve condom use among FSWs in general, interventions to broaden condom use among lower income and drug-using FSWs are critically needed.

Persons who inject drugs (PWID) are at increased risk for blood-borne virus (BBV) infections and overdose resulting from high-risk injecting practices. Studies of prefilled syringe use ([PFSU] using a syringe that already contained drug solution when it was obtained by the user), an injection practice previously described in Eastern Europe, suggest that it increases susceptibility to BBV. However, little is known about this practice in the USA. Data were obtained from an ongoing cohort study of PWID to determine the prevalence and assess correlates of PFSU in San Diego, CA. Baseline interviews assessed socio-demographics and drug use behaviors. Logistic regression was used to identify factors independently associated with ever using a prefilled syringe (yes/no). Participants (n = 574) were predominately males (73.9 %) and white (50.9 %) with a mean age of 43.4 years (range 18–80); 33.3 % reported ever using prefilled syringes, although only 4.9 % reported use in the past 6 months. In multivariable analyses, PFSU was independently associated with ever having a rushed injection due to police presence [adjusted odds ratio (AOR) = 2.51, 95 % CI 1.66, 3.79], ever being in prison (AOR = 1.80, 95 % CI 1.23, 2.63), injecting most often in public versus private places in the past 6 months (AOR = 1.66, 95 % CI 1.11, 2.48), and injecting drugs in Mexico (AOR = 1.70, 95 % CI 1.16, 2.49). Results indicate that a history of PFSU is common and associated with environmental factors that may also increase risk for adverse health outcomes. Studies are needed to better understand PFSU in order to develop interventions to prevent adverse outcomes associated with their use.

exico SUMMARY BACKGROUND: Although directly observed therapy (DOT) is recommended worldwide for monitoring anti-tuberculosis treatment, transportation and personnel requirements limit its use. OBJECTIVE: To evaluate the feasibility and acceptability of ‘video DOT’ (VDOT), which allows patients to record and transmit medication ingestion via videos watched remotely by health care providers to document adherence. METHODS: We conducted a single-arm trial among tuberculosis (TB) patients in San Diego, California, USA, (n ¼ 43) and Tijuana, Mexico (n ¼ 9) to represent high- and low-resource settings. Pre-/post-treatment interviews assessed participant characteristics and experiences. Adherence was defined as the proportion of observed doses to expected doses. RESULTS: The mean age was 37 years (range 18–86), 50% were male, and 88% were non-Caucasian. The mean duration of VDOT use was 5.5 months (range 1– 11). Adherence was similar in San Diego (93%) and Tijuana (96%). Compared to time on in-person DOT, 92% preferred VDOT, 81% thought VDOT was more confidential, 89% never/rarely had problems recording videos, and 100% would recommend VDOT to others. Seven (13%) participants were returned to in-person DOT and six (12%) additional participants had their phones lost, broken or stolen. CONCLUSIONS: VDOT was feasible and acceptable, with high adherence in both high- and low-resource settings. Efficacy and cost-effectiveness studies are needed. KEY W ORDS: US-Mexico border; drug resistance; medication adherence; DOT; cellular phone; mHealth

Health-related vulnerabilities associated with deportation are understudied. We conducted a cross-sectional study to identify factors associated with history of deportation from the US to Mexico among HIV-positive Latinos. From 2009 to 2010, we recruited a convenience sample from HIV clinics in San Diego, US and Tijuana, Mexico. Of 283 participants, 25% reported a prior deportation. Factors independently associated with increased odds of deportation history were being male [adjusted odds ratio (AOR) 2.77; 95% CI 1.18-6.48], having ≤high-school education (AOR 3.87; 95% CI 1.84-8.14), ever using cocaine (AOR 2.46; 95% CI 1.33-4.57), and reporting personalized HIV-stigma: "some have told me HIV is what I deserve for how I lived" (AOR 2.23; 95% CI 1.14-4.37). Lower self-reported antiretroviral medication adherence (AOR 0.35; 95% CI 0.12-0.96) and perceiving HIV-stigma: "most people believe a person who has HIV is dirty" (AOR 0.49; 95% CI 0.25-0.94) were associated with decreased odds of deportation history. Deportation is associated with specific socioeconomic indicators that are known to impact the health of individuals living with HIV.

Most studies of female sex workers (FSWs) conducted in the Mexico-US border region have focused on individual HIV risk, centered on sexual behaviors and substance abuse patterns. Little attention has been drawn to the reality that sex workers are often parents whose children potentially face vulnerabilities unique to their family situation. The objective of the present study was to identify the vulnerabilities faced by the children of FSWs in two Mexican-US border cities. From 2008 to 2010, 628 FSW-injection drug users underwent interviewer-administered surveys and HIV/STI testing. Approximately one in five participants (20%) reported having a parent involved in sex work and majority referred it was their mother (88%). Close to one-third of participants (31%) reported first injecting drugs

Latinos living with HIV residing in the US-Mexico border region frequently seek care on both sides of the border. Given this fact, a border health perspective to understanding barriers to care is imperative to improve patient health outcomes. This qualitative study describes and compares experiences and perceptions of Mexican and US HIV care providers regarding barriers to HIV care access for Latino patients living in the US-Mexico border region. In 2010, we conducted in-depth qualitative interviews with HIV care providers in Tijuana (n = 10) and San Diego (n = 9). We identified important similarities and differences between Mexican and US healthcare provider perspectives on HIV care access and barriers to service utilisation. Similarities included the fact that HIV-positive Latino patients struggle with access to ART medication, mental health illness, substance abuse and HIV-related stigma. Differences included Mexican provider perceptions of medication shortages and US providers feeling that insurance gaps influenced medication access. Differences and similarities have important implications for cross-border efforts to coordinate health services for patients who seek care in both countries.

Author(s): Collins, K; Munoz, F; Moser, K; Cerecer-Callu, P; Raab, F; Flick, A; Rios, P; Zuniga, ML; Cuevas-Mota, J; Burgos, JL; Rodwell, T; Rangel, MG; Patrick, K; Garfein, RS