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BackgroundAccompanying the rising rates of reported mental distress during the COVID-19 pandemic has been a reported increase in the use of digital technologies to manage health generally, and mental health more specifically. ObjectiveThe objective of this study was to systematically examine whether there was a COVID-19 pandemic–related increase in the self-reported use of digital mental health tools and other technologies to manage mental health. MethodsWe analyzed results from a survey of 5907 individuals in the United States using Amazon Mechanical Turk (MTurk); the survey was administered during 4 week-long periods in 2020 and survey respondents were from all 50 states and Washington DC. The first set of analyses employed two different logistic regression models to estimate the likelihood of having symptoms indicative of clinical depression and anxiety, respectively, as a function of the rate of COVID-19 cases per 10 people and survey time point. The second set employed seven different logistic regression models to estimate the likelihood of using seven different types of digital mental health tools and other technologies to manage one’s mental health, as a function of symptoms indicative of clinical depression and anxiety, rate of COVID-19 cases per 10 people, and survey time point. These models also examined potential interactions between symptoms of clinical depression and anxiety, respectively, and rate of COVID-19 cases. All models controlled for respondent sociodemographic characteristics and state fixed effects. ResultsHigher COVID-19 case rates were associated with a significantly greater likelihood of reporting symptoms of depression (odds ratio [OR] 2.06, 95% CI 1.27-3.35), but not anxiety (OR 1.21, 95% CI 0.77-1.88). Survey time point, a proxy for time, was associated with a greater likelihood of reporting clinically meaningful symptoms of depression and anxiety (OR 1.19, 95% CI 1.12-1.27 and OR 1.12, 95% CI 1.05-1.19, respectively). Reported symptoms of depression and anxiety were associated with a greater likelihood of using each type of technology. Higher COVID-19 case rates were associated with a significantly greater likelihood of using mental health forums, websites, or apps (OR 2.70, 95% CI 1.49-4.88), and other health forums, websites, or apps (OR 2.60, 95% CI 1.55-4.34). Time was associated with increased odds of reported use of mental health forums, websites, or apps (OR 1.20, 95% CI 1.11-1.30), phone-based or text-based crisis lines (OR 1.20, 95% CI 1.10-1.31), and online, computer, or console gaming/video gaming (OR 1.12, 95% CI 1.05-1.19). Interactions between COVID-19 case rate and mental health symptoms were not significantly associated with any of the technology types. ConclusionsFindings suggested increased use of digital mental health tools and other technologies over time during the early stages of the COVID-19 pandemic. As such, additional effort is urgently needed to consider the quality of these products, either by ensuring users have access to evidence-based and evidence-informed technologies and/or by providing them with the skills to make informed decisions around their potential efficacy.

BackgroundDigital mental health interventions (DMHIs), which deliver mental health support via technologies such as mobile apps, can increase access to mental health support, and many studies have demonstrated their effectiveness in improving symptoms. However, user engagement varies, with regard to a user’s uptake and sustained interactions with these interventions. ObjectiveThis systematic review aims to identify common barriers and facilitators that influence user engagement with DMHIs. MethodsA systematic search was conducted in the SCOPUS, PubMed, PsycINFO, Web of Science, and Cochrane Library databases. Empirical studies that report qualitative and/or quantitative data were included. ResultsA total of 208 articles met the inclusion criteria. The included articles used a variety of methodologies, including interviews, surveys, focus groups, workshops, field studies, and analysis of user reviews. Factors extracted for coding were related to the end user, the program or content offered by the intervention, and the technology and implementation environment. Common barriers included severe mental health issues that hampered engagement, technical issues, and a lack of personalization. Common facilitators were social connectedness facilitated by the intervention, increased insight into health, and a feeling of being in control of one’s own health. ConclusionsAlthough previous research suggests that DMHIs can be useful in supporting mental health, contextual factors are important determinants of whether users actually engage with these interventions. The factors identified in this review can provide guidance when evaluating DMHIs to help explain and understand user engagement and can inform the design and development of new digital interventions.

BACKGROUND: Inadequate and inequitable access to quality behavioral health services and high costs within the mental health systems are long-standing problems. System-level (e.g., fee-for-service payment model, lack of a universal payor) and individual factors (e.g., lack of knowledge of existing resources) contribute to difficulties in accessing resources and services. Patients are underserved in County behavioral health systems in the United States. Orange Countys (California) Behavioral Health System Transformation project sought to improve access by addressing two parts of their system: developing a template for value-based contracts that promote payor-agnostic care (Part 1); developing a digital platform to support resource navigation (Part 2). Our aim was to evaluate facilitators of and barriers to each of these system changes. METHODS: We collected interview data from County or health care agency leaders, contracted partners, and community stakeholders. Themes were informed by the Consolidated Framework for Implementation Research. RESULTS: Five themes were identified related to behavioral health system transformation, including 1) aligning goals and values, 2) addressing fit, 3) fostering engagement and partnership, 4) being aware of implementation contexts, and 5) promoting communication. A lack of fit into incentive structures and changing state guidelines and priorities were barriers to contract development. Involving diverse communities to inform design and content facilitated the process of developing digital tools. CONCLUSIONS: The study highlights the multifaceted factors that help facilitate or hinder behavioral health system transformation, such as the need for addressing systematic and process behaviors, leveraging the knowledge of leadership and community stakeholders, fostering collaboration, and adapting to implementation contexts.

Peer support specialists (peers) who have the lived experience of, and are in recovery from, mental health challenges are increasingly being integrated into mental health care as a reimbursable service across the US. This study describes the ways peers were integrated into Help@Hand, a multi-site innovation project that engaged peers throughout efforts to develop and offer digital mental health interventions across counties/cities (sites) in California. Using a mixed methods design, we collected quantitative data via quarterly online surveys, and qualitative data via semi-annual semi-structured phone interviews with key informants from Help@Hand sites. Quantitative data were summarized as descriptive findings and qualitative data from interviews were analyzed using rapid qualitative analysis methods. In the final analytic phase, interview quotes were used to illustrate the complex realities underlying quantitative responses. 117 quarterly surveys and 46 semi-annual interviews were completed by key informants from 14 sites between September 2020 and January 2023. Peers were integrated across diverse activities for support and implementation of digital mental health interventions, including development of training and educational materials (78.6% of sites), community outreach (64.3%), technology testing (85.7%), technology piloting (90.9%), digital literacy training (71.4%), device distribution (63.6%), technical assistance (72.7%), and cross-site collaboration (66.7%). Peer-engaged activities shifted over time, reflecting project phases. Peer-provided digital literacy training and technology-related support were key ingredients for project implementations. This study indicates the wide range of ways peers can be integrated into digital mental health intervention implementations. Considering contextual readiness for peer integration may enhance their engagement into programmatic activities.

BACKGROUND: Technology-enabled services (TESs) have the potential to increase access to mental healthcare. However, little research has focused on how TESs can be integrated into publicly funded service settings. As part of the state-wide Help@Hand project, Marin County conducted a pilot implementation of myStrength, a digital cognitive behavioral therapy platform, to explore its potential to reduce loneliness among isolated older adults. We evaluated the pilot impact using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. METHOD: A single-site 6-month pilot implementation recruited English (n = 15) and Spanish-speaking (n = 15) isolated older adults who received a digital literacy course followed by 8 weeks of myStrength access and human support. We evaluated factors related to reach, effectiveness, adoption, and implementation using the perspectives of users and County staff. Descriptive statistics were used to examine reach, adoption, and implementation. Nonparametric tests, including Friedman and Wilcoxon signed-rank, were used to examine effectiveness. RESULTS: Reach: Compared to overall county demographics, platform users were majority female (93.1% vs. 50.5%), ethnoracialized (62.1% vs. 24.2%), and of lower socioeconomic status (Mdn = $35,000 vs. $131,008). Effectiveness: Users reported a significant (z = -2.62, p

With funding from the National Institutes of Health's Community Engagement Alliance, starting in fall 2020, 11 academic medical centers and 75 community partners came together as the California Alliance Against COVID-19 to address COVID-19 inequities in California. Using data from focus groups, statewide meetings, and a statewide partner survey, we describe how promotoras and community health workers (P/CHWs; n = 540) helped to promote access to COVID-19 information, testing, and vaccination. We highlight opportunities to promote health equity among other public health collaborators with a P/CHW model. (Am J Public Health. 2024;114(S1):S45-S49. https://doi.org/10.2105/AJPH.2023.307471).

BACKGROUND: Diabetes-related multi-morbidity and cultural factors place Latinas with diabetes at increased risk for stress, which can threaten illness management. Families provide an ideal focus for interventions that seek to strengthen interpersonal resources for illness management and, in the process, to reduce stress. The current study sought to examine whether participating in a dyadic intervention was associated with reduced perceived stress and, furthermore, whether this association was mediated by persuasion and pressure, two forms of health-related social control. METHOD: Latina mothers with diabetes and their at-risk adult daughters participated in either (1) a dyadic intervention that encouraged constructive collaboration to improve health behaviors and reduce stress, or (2) a usual-care minimal control condition. Actor-partner interdependence model analysis was used to estimate the effect of the intervention on dyads perceived stress, and mother-daughter ratings of health-related social control as potential mediators. RESULTS: Results revealed that participating in the intervention was associated with significantly reduced perceived stress for daughters, but not for mothers (β =  - 3.00, p = 0.02; β =  - 0.57, p = 0.67, respectively). Analyses also indicated that the association between the intervention and perceived stress was mediated by persuasion, such that mothers who experienced more health-related persuasion exhibited significantly less post-intervention perceived stress (indirect effect =  - 1.52, 95% CI = [- 3.12, - 0.39]). Pressure exerted by others, however, did not evidence a mediating mechanism for either mothers or daughters. CONCLUSION: These findings buttress existing research suggesting that persuasion, or others attempts to increase participants healthy behaviors in an uncritical way, may be a driving force in reducing perceived stress levels.

Single-cell technologies have become essential to driving discovery in both basic and translational investigative dermatology. Despite the multitude of available datasets, a central reference atlas of normal human skin, which can serve as a reference resource for skin cell types, cell states, and their molecular signatures, is still lacking. For any such atlas to receive broad acceptance, participation by many investigators during atlas construction is an essential prerequisite. As part of the Human Cell Atlas project, we have assembled a Skin Biological Network to build a consensus Human Skin Cell Atlas and outline a roadmap toward that goal. We define the drivers of skin diversity to be considered when selecting sequencing datasets for the atlas and list practical hurdles during skin sampling that can result in data gaps and impede comprehensive representation and technical considerations for tissue processing and computational analysis, the accounting for which should minimize biases in cell type enrichments and exclusions and decrease batch effects. By outlining our goals for Atlas 1.0, we discuss how it will uncover new aspects of skin biology.

BackgroundDigital mental health interventions (DMHIs) represent a promising solution to address the growing unmet mental health needs and increase access to care. Integrating DMHIs into clinical and community settings is challenging and complex. Frameworks that explore a wide range of factors, such as the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, can be useful for examining multilevel factors related to DMHI implementation efforts.ObjectiveThis paper aimed to identify the barriers to, facilitators of, and best practice recommendations for implementing DMHIs across similar organizational settings, according to the EPIS domains of inner context, outer context, innovation factors, and bridging factors.MethodsThis study stems from a large state-funded project in which 6 county behavioral health departments in California explored the use of DMHIs as part of county mental health services. Our team conducted interviews with clinical staff, peer support specialists, county leaders, project leaders, and clinic leaders using a semistructured interview guide. The development of the semistructured interview guide was informed by expert input regarding relevant inner context, outer context, innovation factors, and bridging factors in the exploration, preparation, and implementation phases of the EPIS framework. We followed a recursive 6-step process to conduct qualitative analyses using inductive and deductive components guided by the EPIS framework.ResultsOn the basis of 69 interviews, we identified 3 main themes that aligned with the EPIS framework: readiness of individuals, readiness of innovations, and readiness of organizations and systems. Individual-level readiness referred to the extent to which clients had the necessary technological tools (eg, smartphones) and knowledge (digital literacy) to support the DMHI. Innovation-level readiness pertained to the accessibility, usefulness, safety, and fit of the DMHI. Organization- and system-level readiness concerned the extent to which providers and leadership collectively held positive views about DMHIs as well as the extent to which infrastructure (eg, staffing and payment model) was appropriate.ConclusionsThe successful implementation of DMHIs requires readiness at the individual, innovation, and organization and system levels. To improve individual-level readiness, we recommend equitable device distribution and digital literacy training. To improve innovation readiness, we recommend making DMHIs easier to use and introduce, clinically useful, and safe and adapting them to fit into the existing client needs and clinical workflow. To improve organization- and system-level readiness, we recommend supporting providers and local behavioral health departments with adequate technology and training and exploring potential system transformations (eg, integrated care model). Conceptualizing DMHIs as services allows the consideration of both the innovation characteristics of DMHIs (eg, efficacy, safety, and clinical usefulness) and the ecosystem around DMHIs, such as individual and organizational characteristics (inner context), purveyors and intermediaries (bridging factor), client characteristics (outer context), as well as the fit between the innovation and implementation settings (innovation factor).

Adolescent COVID-19 vaccination has stalled at 53% in the United States. Vaccinating adolescents remains critical to preventing the continued transmission of COVID-19, the emergence of variants, and rare but serious disease in children, and it is the best preventive measure available to return to in-person schooling. We investigated parent-adolescent COVID-19 vaccine decision-making. Between 24 February and 15 March 2021, we conducted surveys and 12 focus groups with 46 parent-adolescent dyads in Southern California. Parents and adolescents completed a survey prior to participation in a focus group discussion, which focused on exploring COVID-19 vaccine acceptance or uncertainty and was guided by the 5C vaccine hesitancy model. Parents uncertain about vaccinating adolescents expressed low vaccine confidence and high COVID-19 disease risk complacency. Parents who accepted COVID-19 vaccination for adolescents expressed high confidence in health authority vaccine recommendations, high perceived COVID-19 risk, and collective responsibility to vaccinate children. Additionally, unique pandemic-related factors of vaccine acceptance included vaccinating for emotional health, resuming social activities, and vaccine mandates. Among parents, 46% were willing to vaccinate their adolescent, 11% were not, and 43% were unsure. Among adolescents, 63% were willing to vaccinate. Despite vaccine availability, 47% of adolescents remain unvaccinated against COVID-19. Factors associated with vaccine uncertainty and acceptability inform health care practitioner, school, community, and public health messaging to reach parents and adolescents.

The Home Health Value-based Purchasing (HHVBP) demonstration, incorporating a payment formula designed to incentivize both high-quality care and quality improvement, is expected to become a national program after 2022, when the demonstration ends. This study investigated the relationship between costs and several quality dimensions, to inform HHVBP policy. Using Medicare cost reports, OASIS and Home Health Compare data for 7,673 home health agencies nationally, we estimated cost functions with instrumental variables for quality. The estimated net marginal costs varied by composite quality measure, baseline quality, and agency size. For four of the five composite quality measures, the net marginal cost was negative for low-quality agencies, suggesting that quality improvement was cost saving for this agency type. As the magnitude of the net marginal cost is commensurate with the payment incentive planned for HHVBP, it should be considered when designing the incentives for HHVBP, to maximize their effectiveness.

BackgroundDigital mental health interventions have the potential to increase mental health support among isolated older adults. However, the older adult population can experience several barriers to accessing and using digital health resources and may need extra support to experience its benefits.ObjectiveThis paper aimed to understand what older adults experience as an important aspect of support during engagement in a digital mental health program. The program entailed 3 months of staff support to participate in digital literacy training and engage with the digital mental health platform myStrength, which offers support for a range of mental health challenges, including depression and anxiety.MethodsA total of 30 older adults participated in surveys and interviews to assess their experience of participating in a digital mental health program provided by county mental health services. As part of the program, participants attended 4 classes of digital literacy training, had access to the digital mental health platform myStrength for 2 months with staff support (and 10 months after the program without support), and received support from program staff during the entire 3-month program. Survey data were analyzed using descriptive statistics, and interview data were analyzed using thematic analysis.ResultsA thematic analysis of the interview data revealed that participants valued ongoing support in 3 main areas: technical support to assist them in using technology, guided support to remind them to use myStrength and practice skills they had learned, and social support to enable them to connect with others through the program. Furthermore, participants reported that social connections was the most important aspect of the program and that they were mainly motivated to participate in the program because it was recommended to them by trusted others such as a community partner or because they believed it could potentially help others.ConclusionsOur findings can be used to inform the design of future digital mental health programs for older adults who may have unique support needs in terms of dedicated technical support and ongoing guided support to use technology and social support to increase social connectedness.

ObjectiveTo describe the early activities and lessons of the Share, Trust, Organize, Partner COVID-19 California Alliance (STOP COVID-19 CA), the California awardee of the NIH-funded multi-state Community Engagement Alliance (CEAL) against COVID-19. The Alliance was established to ensure equity in Coronavirus-19 disease (COVID-19) research, clinical practice, and public health for communities most impacted by the COVID-19 pandemic.Study settingThe STOP COVID-19 CA Alliance network of 11 universities and affiliated partner community-based organizations (CBOs) across California.Study designMixed methods evaluation consisting of an analysis of activity (August 2020 to December 2021) detailed in reports submitted by community-academic teams and a survey (August 2021) of academic investigators and affiliated community-based organization (CBO) partners.Data collectionWe summarized activities from the 11 community-academic teams' progress reports and described results from an online survey of academic investigators and CBO partners in the California Alliance.Principal findingsA review of progress reports (n = 256) showed that teams fielded surveys to 11,000 Californians, conducted 133 focus groups, partnered with 29 vaccine/therapeutics clinical trials, and led more than 300 town halls and vaccine events that reached Californians from communities disproportionately impacted by COVID-19. Survey responses from academic investigators and CBO partners emphasized the importance of learning from the successes and challenges of the California Alliance teams' COVID-19 initiatives. Both academic and CBO respondents highlighted the need for streamlined federal and institutional administrative policies, and fiscal practices to promote more effective and timely operations of teams in their efforts to address the numerous underlying health and social disparities that predispose their communities to higher rates of, and poor outcomes from, COVID-19.ConclusionsSTOP COVID-19 CA represents a new and potentially sustainable statewide community engagement model for addressing health disparities in multiethnic/multicultural and geographically dispersed communities.

BackgroundApproximately 30% of people with multiple sclerosis (MS) require caregiving, with unknown prevalence of abuse and neglect. To explore these issues, we created the Scale to Report Emotional Stress Signs-Multiple Sclerosis (STRESS-MS). The objective was to develop, validate, and field-test a self-report questionnaire for screening people with MS for mistreatment.MethodsWe developed the STRESS-MS questionnaire and administered it to 102 adults with advanced MS-related disability and 97 primary informal caregivers, correlating responses with direct observation of mistreatment, conducting an item analysis, and evaluating validity using a Longitudinal, Expert, All Data (LEAD) panel.ResultsMost STRESS-MS subscales correlated highly with criterion-standard LEAD panel evaluations of mistreatment, with strong concurrent and discriminant validity. Nearly 53% of participants with MS reported experiencing psychological abuse; 9.8%, financial exploitation; 6.9%, physical abuse; 4.9%, neglect; and 3.9%, sexual abuse. Protective factors for people with MS included social support and older age; risk factors included depression and aggressiveness. The greatest risk factor was an informal caregiver who spent 20 or more hours per week caring for the person with MS.ConclusionsThe STRESS-MS questionnaire is reasonably reliable and valid for detecting caregiver mistreatment in adults with MS. Although most informal caregivers are not abusive, this study highlights an underrecognized need to detect and prevent abuse and neglect of people with MS.

With more than 10,000 mental health apps available, consumers and clinicians who want to adopt such tools can be overwhelmed by the multitude of options and lack of clear evaluative standards. Despite the increasing prevalence of curated lists, or app guides, challenges remain. Organizations providing mental health services to consumers have an opportunity to address these challenges by producing guides that meet relevant standards of quality and are tailored to local needs. This column summarizes an example of the collaborative process of app guide development in a publicly funded mental health service context and highlights opportunities and barriers identified through the process.

Objectives: This study examined the association between food insecurity status and healthcare access, utilization, and quality among adults aged 55 years and older. Methods: Data collected between 2011 and 2016 for the California Health Interview Survey were used. The sample included 72,212 individuals who were divided into three groups: food secure (FS), low food security (L-FS), and very low food security (VL-FS). Results: Logistic regression analyses controlled for demographics. Food insecurity was associated with decreased access to and quality of care and increased utilization. Specifically, VL-FS was more likely to delay care than FS. Additionally, VL-FS and L-FS had greater odds of visiting an emergency room than FS. Furthermore, VL-FS and L-FS were more likely to have a doctor who did not always explain aspects of care carefully compared to FS. Discussion: These findings suggest a need for increased screening for food insecurity in healthcare settings.

Home health performance gained visibility with the publication of Home Health Compare and the Home Health Value-Based Payment demonstration. Both provide incentives for home health agencies (HHA) to invest in quality improvements. The objective of this study is to identify the association between quality initiatives adopted by HHAs and improved performance. A 2018 national survey of 7459 HHAs, yielding a sample of 1192 eligible HHAs, provided information about 23 quality initiatives, which was linked to 5 composite Super Quality Measures (SQMs): ADL/pain, self-treatment, timely care, hospitalizations, and patient experience. Exclusions for missing data and outliers yielded a final analytical sample of 903 HHAs. Regression models estimated associations between quality initiatives and SQMs. The relationships between sixteen of the SQM/quality initiative pairs were positively associated with improvement and 7 were negatively associated. Web-based technologies for staff and care-givers improved performance but deteriorated patient experience. Web support-groups for staff and review of HHC rankings reduced hospitalization rates. While this study offers insights for quality improvement, a limitation may be a lack of sensitivity to the nuances of quality improvement implementation. Therefore, this study should be viewed as hypothesis-generating concerning initiatives likely to have the greatest potential meriting further investigation.

We used 2010-16 Medicare Cost Reports for 10,737 freestanding home health agencies (HHAs) to examine the impact of home health (HH) and nursing home (NH) certificate-of-need (CON) laws on HHA caseload, total and per-patient variable costs. After adjusting for other HHA characteristics, total costs were higher in states with only HH CON laws ($2,975,698), only NH CON laws ($1,768,097), and both types of laws ($3,511,277), compared with no CON laws ($1,538,536). Higher costs were driven by caseloads, as CON reduced per-patient costs. Additional research is needed to distinguish whether this is due to skimping on quality vs. economies of scale.

PurposeThis systematic review and meta-analysis evaluated the effectiveness of diabetes self-management education (DSME) in reducing glycosylated hemoglobin (A1C) levels in adult Latinos with type 2 diabetes (T2DM).MethodsFive databases were searched for DSME randomized controlled trials or quasi-experimental trials published between January 1997 and March 2019. A random effects model was utilized to calculate combined effect sizes. Subgroup analyses were performed to explore possible sources of heterogeneity between studies.ResultsTwenty-three unique studies met criteria for this systematic review and of these, 18 were included in the meta-analysis. Pooled estimate effect of DSME on A1C from the random effect model was -0.240 (95% confidence interval = -0.345, -0.135, p 8.0 [69 mmol/mol], and team-based approach.ConclusionsMeta-analysis results showed that culturally tailored DSME interventions significantly reduce AIC in Latinos with T2DM despite the heterogeneity across the studies.ImplicationsThe heterogeneity in the study methodologies reinforce the need for additional studies to better understand DSME interventions to reduce disparities in Latino adults with T2DM.

BackgroundDespite declining cancer incidence and mortality rates, Latina patients continue to have lower 5-year survival rates compared to their non-Hispanic white counterparts. Much of this difference has been attributed to lack of healthcare access and poorer quality of care. Research, however, has not considered the unique healthcare experiences of Latina patients.MethodsLatina women with prior diagnoses of stage 0-III breast cancer were asked to complete a cross-sectional survey assessing several socio-demographic factors along with their experiences as cancer patients. Using a series of linear regression models in a sample of 68 Mexican-American breast cancer survivors, we examined the extent to which patients' ratings of provider interpersonal quality of care were associated with patients' overall healthcare quality, and how these associations varied by acculturation status.ResultsFindings for Latina women indicated that both participatory decision-making (PDM) (β = 0.62, p < .0001) and trust (β = 0.53, p = .02) were significantly associated with patients' ratings of healthcare quality. The interaction between acculturation and PDM further suggested that participating in the decision-making process mattered more for less acculturated than for more acculturated patients (β = -0.51, p ≤ .01).ConclusionsThe variation across low and high acculturated Latinas in their decision-making process introduces a unique challenge to health care providers. Further understanding the relationship between provider-patient experiences and ratings of overall healthcare quality is critical for ultimately improving health outcomes.

ObjectivesTo identify consumers' preferences over care settings, such as physicians' offices, emergency rooms (ERs), urgent care centers, retail clinics, and virtual physicians on smartphones, for minor illnesses.Data sourcesA survey conducted between 9/27/16 and 12/7/16 emailed to all University of California, Irvine employees.Study designParticipants were presented with 10 clinical scenarios and asked to choose the setting in which they wanted to receive care. We estimated multinomial conditional logit regression models, conditioning the choice on out-of-pocket costs, wait time, travel time, and chooser characteristics.Data collection5451 out of 21 037 employees responded.Principal findingsOut-of-pocket costs and wait time had minimal impact on patient's preference for site of care. Choices were driven primarily by the clinical scenario and patient characteristics. For chronic conditions and children's well-visits, the doctor's office was the preferred choice by a strong majority, but for most acute conditions, either the ER (for high severity) or urgent care clinics (for lower severity) were preferred to the office setting, particularly among younger patients and those with less education.ConclusionsPatients have several alternatives to traditional physicians' offices and ERs. The low impact of out-of-pocket costs suggests that insurers interested in encouraging increased utilization of alternatives would need to consider substantial changes to benefit structure.

BACKGROUND: Millions of traumatized refugees worldwide have resettled in the United States. For one of the largest, the Cambodian community, having their mental health needs met has been a continuing challenge. A multicomponent health information technology screening tool was designed to aid provider recognition and treatment of major depressive disorder and posttraumatic stress disorder (PTSD) in the primary care setting. METHODS: In a clustered randomized controlled trial, 18 primary care providers were randomized to receive access to a multicomponent health information technology mental health screening intervention, or to a minimal intervention control group; 390 Cambodian American patients empaneled to participating providers were assigned to the providers randomized group. RESULTS: Electronic screening revealed that 65% of patients screened positive for depression and 34% screened positive for PTSD. Multilevel mixed effects logistic models, accounting for clustering structure, indicated that providers in the intervention were more likely to diagnose depression [odds ratio (OR), 6.5; 95% confidence interval (CI), 1.48-28.79; P=0.013] and PTSD (OR, 23.3; 95% CI, 2.99-151.62; P=0.002) among those diagnosed during screening, relative to the control group. Providers in the intervention were more likely to provide evidence-based guideline (OR, 4.02; 95% CI, 1.01-16.06; P=0.049) and trauma-informed (OR, 15.8; 95% CI, 3.47-71.6; P

INTRODUCTION: Exercise through video or virtual reality games (i.e. exergames) has grown in popularity among older adults; however, there is limited evidence on efficacy of exergaming on well-being related to health in this population. This systematic review examined the effectiveness of exergaming on health-related quality of life in older adults. METHODS: PRISMA guidelines for this systematic review. Several databases were searched using keywords to identify peer-reviewed journal articles in English. Randomized control trials that evaluated the effect of exergaming on health-related quality of life in older adults when compared to a control group and published between January 2007 to May 2017 were included. RESULTS: Nine articles that in total included 614 older adults with varying levels of disability, mean age 73.6 + 7.9 years old, and 67% female were analyzed. Significant improvements in health-related quality of life of older adults engaged in exergaming were reported in three studies. Sample sizes were small in 7 of the studies (N

Asian Americans are understudied in health research and often aggregated into one homogenous group, thereby disguising disparities across subgroups. Cambodian Americans, one of the largest refugee communities in the United States, may be at high risk for adverse health outcomes. This study compares the health status and healthcare experiences of Cambodian American refugees and immigrants. Data were collected via questionnaires and medical records from two community clinics in Southern California (n = 308). Chi square and t-tests examined the socio-demographic differences between immigrants and refugees, and ANCOVA models compared the mean differences in responses for each outcome, adjusting for age at immigration, education level, and clinic site. Cambodian American refugees reported overall lower levels of health-related quality of life (all p's

ObjectivesRecently, there has been a call to better understand Latino health and arrive at effective approaches for achieving health equity via research focusing on the association between cultural factors and health. This study examined whether familism, a cultural value that emphasizes warm and close family relationships, would attenuate the negative effects that perceived stress, a psychological process that can worsen health, can have on two physical health indicators- number of health conditions and bodily pain.MethodLatina mothers (n = 85, Mage = 52.68, SD = 6.60) with Type 2 diabetes and their daughters (n = 86, Mage = 27.69, SD = 7.61) whose weight put them at risk for also developing the condition were recruited to take part in a larger intervention study aimed at improving weight loss/dietary intake. Participants completed measures of familism, perceived stress, health conditions, and bodily pain.ResultsResults indicated that in the daughters, familism and perceived stress interacted to predict health conditions and bodily pain. As familism decreased, stress was associated with more health conditions and more bodily pain. These interactions were not significant for the mothers.ConclusionsFirst, familism has the potential to buffer the negative effect of stress in ways that are protective for health among Latinas at risk for diabetes. Second, this buffering effect has boundary conditions, suggesting that a better understanding is needed of how, for whom, and under what circumstances familism can be beneficial for health. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

BackgroundLatinos constitute 17% of the US population and are one of the largest ethnic groups; however, only 7.6% participate in research studies. There is a disproportionately high number of Latinos living with type 2 diabetes mellitus and are at increased risk for cardiovascular events. Research to elicit facilitators and barriers for participation in research and effective recruitment strategies is limited.AimsThis article reports the qualitative findings of a mixed-methods study examining perceived facilitators and barriers for research participation, and explores decision-making processes and ascertains ethnic values that influenced their decisions among Spanish-speaking Latinos with type 2 diabetes mellitus.MethodsSemi-structured interviews were conducted with 25 participants (mean age 50.8 ± 9.4 years, 76% women and 28% employed). Participants were asked to elaborate on perceived facilitators and barriers to research participation. All interviews were conducted in Spanish. Transcribed interviews were analyzed through conventional content analysis.ResultsThree themes emerged from transcribed interviews: (a) lowering barriers to access health-related expertise; (b) language concordance; and (c) trusting relationships. Perceived barriers to research participation included work schedule, childcare, transportation and ethnic beliefs.ConclusionStrategies to support learning, language concordance and establishing trusting relationships among Spanish-speaking Latinos may be key to increasing Latinos in research studies.

Background: People with disabilities face many health, economic and social disparities. Loneliness is recognized as a significant issue for this group however, its impact on students with disabilities (SWDs) remains a critically underexplored area of research. Importantly, as higher education continues its transition to the digital space, the potential to entrench social isolation and loneliness within this population has not been examined. This research seeks to explore the associations between SWDs, loneliness, online learning, and academic outcomes in a national survey of university students. Methods: Using the National College Health Assessment from Spring 2022, this study compared multiple outcomes between different groups of SWDs and students without disabilities. Two ordinal regression models were used to estimate associations between loneliness, disability type and learning mode (online vs. in-person), as well as cumulative grade average (CGA) with disability type. Results: All disability types included within this study were positively associated with increased odds of loneliness for those engaged in online learning compared to students without disabilities. Interactions indicate a significant effect of inperson learning compared with online learning for deaf or hard of hearing students, and those with multiple disabilities. Several disability groups reported decreased odds of higher CGA compared to students without disabilities. Conclusion: Loneliness is a significant issue for all SWD groups reported in this study. The impact of disability on academic outcomes is reported herein; however, its impact on medium-to-long term outcomes for these individuals remains unknown. To address inequities in higher education for SWDs, universities must invest more resources to holistically support these students. [ABSTRACT FROM AUTHOR]

Objectives Social networks undergo changes in later life, reflecting proactive decreases as well as increases in size, but relatively little is known about the factors that motivate older adults to expand their social ties. Loneliness might be expected to motivate older adults to expand their social ties. Paradoxically, however, studies of younger age groups have linked loneliness to a self-protective reluctance to initiate social contact. The current study investigated whether loneliness fosters or inhibits older adults' efforts to expand their social ties and whether successful efforts are related to gains in emotional health. Methods Loneliness, motivation to expand social ties, and emotional health were assessed in a subset of older participants (N  = 375) from the Later Life Study of Social Exchanges. Results Greater loneliness was associated with less interest, less investment of effort, and less success in making new ties and rekindling dormant ties. Nonetheless, lonelier older adults who expanded their social ties, particularly by rekindling dormant ties, exhibited some gains in emotional health over a 1-year period. Discussion Greater attention to the role of loneliness in older adults' motivations for making new ties or rekindling dormant ties will broaden our understanding of social network changes in later life. [ABSTRACT FROM AUTHOR]

This study explored the effects of integrating community members into the evaluation of clinical and translational science grants.The University of California, Irvine Institute for Clinical and Translational Sciences (ICTS) engaged 21 community reviewers alongside scientific reviewers in a 2-stage process of evaluating research proposals. In Stage 1 reviewers scored proposals, and during Stage 2 two study sections convened: one a mix of community reviewers and scientific reviewers, and one only engaging scientific reviewers. In total, 4 studies were discussed by both study sections.Comparisons of reviews revealed little difference between ratings of community reviewers and those of scientific reviewers, and that community reviewers largely refrained from critiquing scientific or technical aspects of proposals.The findings suggest that involving community reviewers early in the grant cycle, and exposing them to the entirety of the review process, can bolster community engagement without compromising the rigor of grant evaluations.

BackgroundHalf of Mexican-American women are under-active and nearly 78% are overweight/obese. The high lifetime risk of developing type 2 diabetes necessitates a culturally appropriate lifestyle intervention.PurposeUnidas por la Vida is a novel dyadic intervention that capitalizes on the centrality of family in Latino culture to mobilize an existing family dyad as a resource for health behavior change. The intervention aims to improve health behaviors and promote weight loss in two at-risk members of the same family: mothers with type 2 diabetes and their overweight/obese adult daughters who are at risk for developing diabetes.MethodsParticipants (N = 460 mother-adult daughter dyads) will be randomized into one of three conditions: 1) dyadic participation (mothers-daughters) in a lifestyle intervention; 2) individual participation (mothers alone; unrelated daughters alone) in a lifestyle intervention; and 3) mother-daughter dyads in a minimal intervention control group.ResultsThe primary outcome is weight loss. Secondary outcomes include physical activity, dietary intake, physiological measures (e.g. HbA1c), and body composition. Both the dyadic and individual interventions are expected to produce greater weight loss at 6, 12, and 18 months than those in minimal intervention control group, with women assigned to the dyadic intervention expected to lose more weight and to maintain the weight loss longer than women assigned to the individual intervention.ConclusionBecause health risks are often shared by multiple members of at-risk families, culturally appropriate, dyadic interventions have the potential to increase the success of behavior change efforts and to extend their reach to multiple family members.Trial registrationClinicalTrials.gov identifier NCT02741037.

Purpose of studyA currently proposed rule by the Centers for Medicare & Medicaid Services would require providers to devote more resources to discharge planning from hospitals to ensure the prioritization of patient preferences and goals in the discharge planning process. Annually, more than 3 million persons enter a nursing home in the United States, with the vast majority of patients coming directly from hospitals. Although early evidence suggests more family involvement than patient involvement in the discharge process, most of this work has relied on retrospective reports of the decision-making process postplacement. This article seeks to examine and compare the experiences and perspectives of patients and others involved in the selection of the nursing home (predominately adult children and spouses).Primary practice settingLarge academic medical hospital with patients being discharged to a skilled nursing facility.Methodology and sampleA total of 225 patients or their family members and involved others who completed an exit survey assessing their experiences and perspectives in selecting a skilled nursing home and in experiencing the discharge process more generally.ResultsPatients were the primary decision makers about 23% of the time but were often involved in the decision even when family members/involved others were primarily making decisions in the discharge process. Although patients were involved in the selection of the nursing home to a lesser degree than involved others, their level of satisfaction with the decision to be discharged to a skilled nursing home and their level of satisfaction with their personal level of involvement with the selection of the specific nursing home did not differ from the satisfaction ratings of the involved others. Furthermore, their confidence in the decision and their satisfaction with the decision did not differ from ratings provided by family members/involved others.Implications for case management practiceRecommendations for case management practice include (1) encouraging patients and their families to take an active role in the discharge process; (2) incorporating technology into the discharge process that promotes this active level of engagement; and (3) facilitating access to data to promote discharge to the highest quality nursing homes available.

This study examined whether disease-specific factors were important for how and how often White versus Vietnamese American spouses influenced their partners' diabetic diet. Results from a cross-sectional survey of 145 older adult spouses whose partners had type 2 diabetes revealed that Vietnamese American spouses used more frequent spousal influence (positive and negative) than White spouses. In addition, most of the factors associated with spousal influence differed for Vietnamese American and White spouses. Findings from this study highlight the importance of proximal and sociocultural factors in understanding older spouses' influence on their partners' diabetic diet.

ObjectiveTo test whether use of a personalized report card, Nursing Home Compare Plus (NHCPlus), embedded in a reengineered discharge process, can lead to better outcomes than the usual discharge process from hospitals to nursing homes.Data sources/settingPrimary data collected in the Departments of Medicine and Surgery at a University Medical Center between March 2014 and August 2015.Study designA randomized controlled trial in which patients in the intervention group were given NHCPlus. Participants included 225 patients or their family members/surrogates.Data collectionKey strokes of NHCPlus users were recorded to obtain information about usage. Users were surveyed about usability and satisfaction with NHCPlus. All participants were surveyed at discharge from the hospital. Survey data were merged with medical records.Principal findingsAbout 85 percent of users indicated satisfaction with NHCPlus. Compared to controls, intervention patients were more satisfied with the choice process (by 40 percent of the standard deviation p

ObjectivesThis study examined potential barriers to mental healthcare use of older adults from diverse ethnic and racial backgrounds.DesignData were obtained from the 2007, 2009, 2011-12, and 2013-14 California Health Interview Survey (CHIS), a population-based survey representative of California's noninstitutionalized population.ParticipantsThe total sample consisted of 75,324 non-Hispanic white (NHW), 6,600 black, 7,695 Asian and Pacific Islander (API), and 4,319 Hispanic adults aged 55 and older.ResultsResults from logistic regression analyses that controlled for multiple demographic and health status characteristics revealed ethnic and racial differences in reasons for not seeking treatment and for terminating treatment. Specifically, API and Hispanic adults had greater odds than NHWs of endorsing feeling uncomfortable talking to a professional as a reason for not seeking treatment. Hispanic respondents had lower odds of endorsing concerns about someone finding out than APIs, and APIs and blacks had significantly greater odds of endorsing this concern as a reason for not seeking treatment than NHWs. When asked about reasons for no longer receiving treatment, all respondents, irrespective of race or ethnicity, endorsed that they no longer needed treatment as the most frequent reason for terminating treatment, although specific ethnic and racial differences emerged with respect to perceptions of not getting better, lack of time or transportation, and lack of insurance coverage as reasons for no longer seeking treatment.ConclusionUnderstanding how barriers to mental health treatment differ for older adults from diverse ethnic and racial backgrounds is an important step toward designing interventions to overcome these obstacles and improve mental health outcomes.

The prevalence rate of depression in primary care is high. Primary care providers serve as the initial point of contact for the majority of patients with depression, yet, approximately 50% of cases remain unrecognized. The under-diagnosis of depression may be further exacerbated in limited English-language proficient (LEP) populations. Language barriers may result in less discussion of patients' mental health needs and fewer referrals to mental health services, particularly given competing priorities of other medical conditions and providers' time pressures. Recent advances in Health Information Technology (HIT) may facilitate novel ways to screen for depression and other mental health disorders in LEP populations. The purpose of this paper is to describe the rationale and protocol of a clustered randomized controlled trial that will test the effectiveness of an HIT intervention that provides a multi-component approach to delivering culturally competent, mental health care in the primary care setting. The HIT intervention has four components: 1) web-based provider training, 2) multimedia electronic screening of depression and PTSD in the patients' primary language, 3) Computer generated risk assessment scores delivered directly to the provider, and 4) clinical decision support. The outcomes of the study include assessing the potential of the HIT intervention to improve screening rates, clinical detection, provider initiation of treatment, and patient outcomes for depression and post-traumatic stress disorder (PTSD) among LEP Cambodian refugees who experienced war atrocities and trauma during the Khmer Rouge. This technology has the potential to be adapted to any LEP population in order to facilitate mental health screening and treatment in the primary care setting.

We examined racial/ethnic differences in patients' ratings of components of interpersonal quality [participatory decision making (PDM) style, being treated as an equal partner, and feelings of trust], and evaluated the association between each of these components and patients' ratings of overall healthcare quality among non-Hispanic white (NHW), Vietnamese American, and Mexican American patients with type 2 diabetes. The findings indicated that although all three components were significantly associated with ratings of overall healthcare quality, the significant interactions between race/ethnicity and both PDM style (β = -0.09, p

BackgroundAnnually more than 3 million people are admitted to one of the 15,965 skilled nursing facilities (SNFs) in the United States, with 90% of admissions occurring from a hospital. Although the Centers for Medicare and Medicaid Services (CMS) publishes several internet-based report cards, including one for nursing homes (Nursing Home Compare, NHC), they are not widely used. This is due, in part, to the complexity of the information available and the fact that the choice of nursing homes is typically made while in the hospital without access to the web-based NHC. We developed Nursing Home Compare Plus (NHCPlus) to address these limitations and to improve the decision-making process.Methods/designThis paper describes the design and rationale of a two-arm randomized controlled trial designed to test the effectiveness of NHCPlus compared to usual care only, in a sample of patients being discharged from the hospital to an SNF (N=229). Assessments were conducted within 24h prior to patient discharge and 30-days post discharge. Primary outcomes to be examined included the use of NHC, increased choice of nursing homes with better reported outcomes, and increased distance between patient/family residence and nursing home. Secondary outcomes included satisfaction with the decision to go to a nursing home, confidence in the choice of nursing home, and reduced hospital length of stay.DiscussionNHCPlus is an innovative mobile application designed to allow patients to personalize their choice of nursing homes to meet their medical needs and preferences. The application to other quality report cards is discussed.

AimsTo examine the relative contribution of glycaemic control (HbA1C) and depressive symptoms on diabetes-related symptom burden (hypoglycaemia and hyperglycaemia) in order to guide medication modification.MethodsSecondary analysis of medical records data and questionnaires collected from a racially/ethnically diverse sample of adult patients with type 2 diabetes (n = 710) from seven outpatient clinics affiliated with an academic medical centre over a 1-year period as part of the Reducing Racial Disparities in Diabetes: Coached Care (R2D2C2) study.ResultsResults from linear regression analysis revealed that patients with high levels of depressive symptoms had more diabetes-related symptom burden (both hypoglycaemia and hyperglycaemia) than patients with low levels of depressive symptoms (βs = 0.09-0.17, Ps < 0.02). Furthermore, results from two logistic regression analyses suggested that the odds of regimen intensification at 1-year follow-up was marginally associated with patient-reported symptoms of hypoglycaemia [adjusted odds ratio (aOR) = 1.24, 95% CI: 0.98-1.58; P = 0.08] and hyperglycaemia (aOR = 1.21, 95% CI: 1.00-1.46; P = 0.05), after controlling for patients' HbA1C, comorbidity, insulin use and demographics. These associations, however, were diminished for patients with high self-reported hypoglycaemia and high levels of depressive symptoms, but not low depressive symptoms (interaction terms for hypoglycaemia by depressive symptoms, aOR = 0.98, 95% CI: 0.97-0.99; P = 0.03).ConclusionsMental health symptoms are associated with higher levels of patient-reported of diabetes-related symptoms, but the association between diabetes-related symptoms and subsequent regimen modifications is diminished in patients with greater depressive symptoms. Clinicians should focus attention on identifying and treating patients' mental health concerns in order to address the role of diabetes-related symptom burden in guiding physician medication prescribing behaviour.

BackgroundGender differences in dyslipidemia are widely documented, but the contributors to these differences are not well understood. This study examines whether differences in quality of care, intensity of lipid-lowering medication regimen, and medication adherence can explain this disparity.MethodsSecondary analysis of medical records data and questionnaires collected from adult patients with type 2 diabetes (n = 1,369) from seven outpatient clinics affiliated with an academic medical center as part of the Reducing Racial Disparities in Diabetes: Coached Care (R2D2C2) study. Primary outcome was low-density lipoprotein (LDL) cholesterol.FindingsWomen had higher LDL cholesterol levels than men (mean [SD], 101.2 [35.2] vs. 92.3 [33.0] mg/dL; p

ObjectiveThis study sought to evaluate the feasibility of a pilot, dyad-based lifestyle intervention, the Unidas por la Vida program, for improving weight loss and dietary intake among high-risk Mexican American mothers who have Type 2 diabetes and their overweight/obese adult daughters.MethodMother-daughter dyads (N = 89) were recruited from two federally qualified health centers and randomly assigned to either the Unidas intervention or to the control condition. The 16-week Unidas intervention consisted of the following: (a) four group meetings, (b) eight home visits, and (c) booster telephone calls by a lifestyle community coach. The control condition consisted of educational materials mailed to participants' homes. Participants completed surveys at T1 (baseline) and T2 (16 weeks) that assessed various demographic, social network involvement, and dietary variables.ResultsUnidas participants lost significantly more weight at T2 (p < .003) compared with the control participants. Furthermore, intervention participants also were more likely to be eating foods with lower glycemic load (p < .001) and less saturated fat (p = .004) at T2. Unidas participants also reported a significant increase in health-related social support and social control (persuasion control only) and a decrease in undermining.ConclusionsThe Unidas program promoted weight loss and improved dietary intake, as well as changes in diet-related involvement of participants' social networks. The results from this study demonstrate that interventions that draw upon multiple people who share a health-risk have the potential to foster significant changes in lifestyle behaviors and in social network members' health-related involvement. Future research that builds on these findings is needed to elucidate the specific dyadic and social network processes that may drive health behavior change.

BackgroundThe Affordable Care Act is designed to decrease the numbers of uninsured patients in U.S. However, even with insurance, patients who have financial hardships may have difficulty obtaining their medications because of cost issues.ObjectiveAmong patients with type 2 diabetes, to examine the association between patients' self-reported financial pressures on cost-related medication non-adherence and glucose control. Additionally, to examine whether having insurance decrease the financial pressures of diabetes care.Design and participantsRacially/ethnically diverse patients (N = 1,361; 249 non-Hispanic whites, 194 Vietnamese, and 533 Mexican American) with type 2 diabetes were recruited from seven outpatient clinics for a cross-sectional, observational study.Key resultsAlthough both Vietnamese and Mexican-American patients reported having low annual incomes, more Mexican Americans reported the presence of financial barriers to getting medical care and perceived financial burden due to their diabetes, compared to whites and Vietnamese (p

BackgroundAsian Americans represent a mix of cultures and immigration experiences, which may put them differentially at risk for mental health problems. Yet, little is known about the mental health needs of older adults from various Asian subgroups compared to non-Hispanic whites.ObjectivesTo compare the prevalence rates of mental distress of Chinese, Filipino, South Asian, Japanese, Korean, and Vietnamese older adults (aged 55 and older) to that of non-Hispanic whites; and to examine subgroup differences in utilization of mental health services.MethodsA cross-sectional analysis of a population-based sample of California adults responding to the 2007 California Health Interview Survey. Multivariable logistic regression analysis was used to examine subgroup differences in mental health status and use of mental health services among the six different Asian subgroups and non-Hispanic whites, adjusting for respondents' demographic and health characteristics, socioeconomic status, and English-language proficiency.ResultsA total of 20,712 respondents were included. Filipino [aOR=2.25; 95% CI=1.14-4.47] and Korean Americans [aOR=2.10; 95% CI=1.06-4.17] were more likely to report symptoms indicative of mental distress compared to non-Hispanic whites, yet were less likely to have seen a primary care provider [Filipino: aOR=0.41; 95% CI=0.18-0.90; Korean: aOR=0.24; 95% CI = 0.08-0.69] or have taken a prescription medication [Filipino: aOR=0.20; 95% CI=0.10-0.40; Korean: aOR=0.15; 95% CI=0.05-0.40], even after adjusting for indicators of respondents' demographic and health characteristics, socioeconomic status, and English-language proficiency. In contrast, Japanese Americans were less likely to report symptoms indicative of mental distress [aOR=0.43; 95% CI=0.21-0.90], and were less likely to make use of mental health services compared to non-Hispanic whites.Discussion/conclusionsThe findings from this study not only highlight the unmet mental health needs among older Asian Americans, but also illustrate significant variations among the various Asian subgroups. Clinicians who work closely with these patients should regularly screen and assess older Asian adults for symptoms related to their mental health needs.