"Ancestral recipes": a mixed-methods analysis of MyPlate-based recipe dissemination for Latinos in rural communities.

BACKGROUND: The Latinx population experiences some of the highest rates of chronic disease, including obesity and type II diabetes. Such conditions may be especially burdensome in rural Latinx communities that often face barriers to accessing disease prevention resources and public health programs. METHODS: Diverse stakeholders (i.e., patients, community members, system of healthcare clinics, community food bank) tailored an existing cookbook, based on the U.S. Department of Agriculture MyPlate healthy eating and dietary guidelines, for local ingredients, health literacy, and language for rural Latinx and Indigenous Latin Americans. The cookbook recipes were disseminated widely via virtual cooking demonstrations, food distribution events, and social media. Pre- and posttest surveys were used to assess changes in diabetes knowledge measured by the 24-item American Diabetes Association Diabetic Knowledge Questionnaire and confidence in dietary behavior change over time measured by 4 questions of the 17-item Mediterranean Diet Index. A mixed effects, repeated measures analysis was conducted with gender ID, age range and educational attainment included as covariates and assessment interval as the predictor (pretest vs posttest) and change in confidence about adhering to four specific components of the Mediterranean diet. Focus groups elicited information on participants' motivation and ability to use the recipes and eat healthy foods following the virtual cooking demonstration participation. RESULTS: A total of 20 virtual cooking demonstrations were conducted and 60 participants completed a pretest survey and 54 a posttest survey, a subsample (n = 19) participated in one of three focus groups. Most participants were female, identified as Latinx/Hispanic, were between the ages of 40-49, and spoke Spanish. 17% identified as Indigenous Latin American specifically as Purépecha, an indigenous group from Michoacán, Mexico. Survey and focus group findings indicated at posttest an increase in diabetes knowledge among participants with no prior diagnosis of chronic health conditions and more confidence in limiting sugary beverages and refined wheat pasta/white rice among indigenous participants. Focus group discussions explicated the quantitative findings. CONCLUSION: This study brought together patients and key stakeholders committed to addressing the social determinants of health and it mobilized the community to develop culturally vetted health education materials. The findings indicate the need for increased access to evidence-based nutrition education and to culturally appropriate food products that can be easily incorporated into daily food preparation.

Using a participatory method to test a strategy supporting the implementation of a state policy on screening children for adverse childhood experiences (ACEs) in a Federally Qualified Health Center system: a stepped-wedge cluster randomized trial.

BACKGROUND: Adverse childhood experiences (ACEs) are potentially traumatic events occurring before age 18, such as maltreatment or exposure to violence. ACE screening is increasingly recommended to prevent and address physical and mental health conditions associated with ACEs. To promote ACE screening uptake, the state of California issued the "ACEs Aware" policy that provides Medicaid reimbursement for ACE screening annually for child primary care visits. However, policy directives alone often do not translate into effective screening efforts and greater access to care. Few rigorous studies have developed and tested implementation strategies for ACE pediatric screening policies. This study will fill this gap by testing a multifaceted implementation strategy in partnership with a Federally Qualified Health Center (FQHC) system serving low-income families in Southern California to support the ACE Aware policy. METHODS: We will use Implementation Mapping, with study process and consideration of determinants and mechanisms guided by the EPIS framework, to co-create and refine an implementation strategy. The proposed strategy is comprised of online training videos, a customized algorithm and use of technology to improve workflow efficiency, implementation training to internal FQHC personnel, clinic support and coaching, and written implementation protocols. A hybrid type 2, stepped-wedge cluster randomized trial design with five primary care clinics will test whether a multifaceted implementation strategy improves (a) fidelity to the ACE screening protocol, (b) reach defined as the proportion of eligible children screened for ACEs, and (c) the impact of the ACE policy on child-level mental health referrals and symptom outcomes. The study will use mixed methods with data to include electronic health records, surveys, and interviews with clinic personnel and caregivers. DISCUSSION: This study is designed to increase the capacity of FQHCs' inner context to successfully implement an outer context-initiated ACE policy designed to benefit pediatric patients. It capitalizes on a rare opportunity to use a co-creation approach to develop, adapt, refine, and pilot test an implementation strategy to maximize the impact of a new state-wide policy intended to improve ACE assessment and subsequent care to improve child health, particularly those from underserved communities. TRIAL REGISTRATION: Trial # NCT04916587  registered at ClinicalTrials.gov on June 4, 2021.

The Sociocultural Factors Underlying Latina Mothers' Infant Feeding Practices.

In this study, we examined the sociocultural factors underlying infant feeding practices. We conducted four focus groups with 19 Latina mothers of children 0 to 2 years of age enrolled in Early Head Start programs in the United States over a 1-year period. We found these mothers considered both science- and family-based feeding recommendations. However, advice from family was often inconsistent with science- and nutrition-based recommended feeding practices. In the interest of showing respect and preserving harmonious relationships, some mothers accepted family advice instead of recommended practices while others employed strategies to follow recommended practices without offending. Nutrition educators need to consider the intersection of macro, organizational, and community factors with micro-level processes in shaping the implementation of recommended feeding practices within family systems. Nutrition interventions for Latino families should capitalize on Latina mothers' strategies for navigating multiple information sources while preserving cultural values and family relationships.

Addressing Mental Health Needs: Perspectives of African Americans Living in the Rural South.

OBJECTIVE: Rural African Americans are disproportionately affected by social stressors that place them at risk of developing psychiatric disorders. This study aimed to understand mental health, mental health treatment, and barriers to treatment from the perspective of rural African-American residents and other stakeholders in order to devise culturally acceptable treatment approaches. METHODS: Seven focus groups (N=50) were conducted with four stakeholder groups: primary care providers, faith community representatives, college students and administrators, and individuals living with mental illness. A semistructured interview guide was used to elicit perspectives on mental health, mental health treatment, and ways to improve mental health in rural African-American communities. Inductive analysis was used to identify emergent themes and develop a conceptual model grounded in the textual data. RESULTS: Stressful living environments (for example, impoverished communities) and broader community-held beliefs (for example, religious beliefs and stigma) had an impact on perceptions of mental health and contributed to barriers to help seeking. Participants identified community-level strategies to improve emotional wellness in rural African-American communities, such as providing social support, improving mental health literacy, and promoting emotional wellness. CONCLUSIONS: Rural African Americans experience several barriers that impede treatment use. Strategies that include conceptualizing mental illness as a normal reaction to stressful living environments, the use of community-based mental health services, and provision of mental health education to the general public may improve use of services in this population.

Rural African Americans' Perspectives on Mental Health: Comparing Focus Groups and Deliberative Democracy Forums.

A number of approaches have been used to obtain community members' health perspectives. Health services researchers often conduct focus groups while political scientists and community groups may hold forums. To compare and contrast these two approaches, we conducted six focus groups (n = 50) and seven deliberative democracy forums (n = 233) to obtain the perspectives of rural African Americans on mental health problems in their community. Inductive qualitative analysis found three common themes: rural African Americans (1) understood stresses of poverty and racism were directly related to mental health, (2) were concerned about widespread mental illness stigma, and (3) thought community members could not identify mental health problems requiring treatment. Deductive analyses identified only minor differences in content between the two approaches. This single case study suggests that researchers could consider using deliberative democracy forums rather than focus groups with marginalized populations, particularly when seeking to mobilize communities to create community-initiated interventions.

Providers' Personal and Professional Contact With Persons With Mental Illness: Relationship to Clinical Expectations.

OBJECTIVE: Providers share many stigmatizing attitudes with the general public regarding persons with mental illness. These attitudes may contribute to suboptimal general medical care for patients with schizophrenia. This study tested the hypothesis that provider contact (personal and professional) with persons with mental illness would be associated with clinical expectations and that this relationship would be mediated by provider stigmatizing attitudes. METHODS: Between August 2011 and April 2012, 192 health care providers from five Veterans Affairs medical centers responded to a clinical vignette describing a patient with schizophrenia who is seeking treatment for back pain. Providers completed a survey to determine their expectations regarding the vignette patient's treatment adherence, ability to read and understand health education materials, and social and vocational functioning. Self-report data on the amount of contact each provider had with persons with mental illness in their practices and in their personal lives were also collected. RESULTS: Structural equation modeling showed that providers with greater professional contact with patients with mental illness in their clinical practice and greater personal contact with individuals with mental illness exhibited significantly lower stigmatizing attitudes toward the patient with schizophrenia in the vignette and were more likely to expect the vignette patient to have better treatment adherence, a better understanding of educational material, and higher social and vocational functioning. CONCLUSIONS: Greater personal and professional contact with persons with mental illness was associated with lower provider stigma and higher expectations of patient adherence, increased ability to understand educational material, and higher social and vocational functioning. It is possible that interventions involving contact with persons with mental illness could reduce providers' stigma.

Influence of schizophrenia diagnosis on providers' practice decisions.

OBJECTIVE: Persons with schizophrenia often receive suboptimal physical health care, but the reasons are poorly understood. Vignettes have been used to examine how a patient's race, gender, or physical health influences a provider's practice; in this study, we used vignettes to examine the effect of a mental health diagnosis (schizophrenia) on providers' clinical expectations and decision making regarding physical health care. METHOD: A cross-sectional survey was administered from August 2011 to April 2012 to 275 primary care and mental health providers in 5 US Department of Veterans Affairs medical centers. Vignettes described identical scenarios for patients with and without schizophrenia. The survey assessed providers' clinical expectations of patients (adherence, competence, ability to read and understand health education materials) and practice behaviors (referrals to weight reduction, pain management, and sleep study). RESULTS: Clinicians expected persons with schizophrenia would be less adherent to treatment (P = .04), less able to read and understand educational materials (P = .03), and less capable of managing their health and personal affairs (P < .01). Providers were less likely to refer a patient with schizophrenia to a weight-reduction program (P = .03). Other types of referral decisions (for pain management and sleep study) were not influenced by a schizophrenia diagnosis. CONCLUSIONS: For both mental health and primary care providers, a history of schizophrenia was found to negatively affect provider expectations of patients' adherence to treatment, ability to understand educational materials, and capacity to manage their treatment and financial affairs as well as some treatment decisions, such as referral to a weight-reduction program.

Healthcare providers' attitudes toward persons with schizophrenia.

OBJECTIVE: This study compared the attitudes of mental health and primary care providers toward persons with schizophrenia at 5 Veterans Affairs (VA) facilities. METHOD: This study utilized a cross-sectional anonymous survey, including clinical vignettes describing identical patient scenarios for a hypothetical patient with and without schizophrenia, to examine the differences in attitudes of primary care and mental health providers. The survey was distributed in 3 waves from August 2011 to April 2012. Participants included 351 VA providers from 5 VA medical centers, including 205 mental health providers (psychiatrists, psychologists, and mental health nurses) and 146 primary care providers (nurses and physicians). Providers' attitudes were assessed on 3 domains, including social distance, stereotyping, and attribution of mental illness. RESULTS: Primary care providers had significantly more negative attitudes toward the vignette patient with schizophrenia compared with the patient without schizophrenia on 2 of 3 attitude measures (stereotyping and attribution of mental illness); however, this difference was not observed for mental health providers on the 2 measures. Conclusions and Implication for Practice: Primary care providers' negative attitudes toward individuals with schizophrenia represent a potential target for interventions to reduce disparities in care for individuals with schizophrenia.

Building partnerships with rural Arkansas faith communities to promote veterans' mental health: lessons learned.

BACKGROUND: The Mental Health-Clergy Partnership Program established partnerships between institutional (Department of Veterans' Affairs [VA] chaplains, mental health providers) and community (local clergy, parishioners) groups to develop programs to assist rural veterans with mental health needs. OBJECTIVES: Describe the development, challenges, and lessons learned from the Mental Health-Clergy Partnership Program in three Arkansas towns between 2009 and 2012. METHODS: Researchers identified three rural Arkansas sites, established local advisory boards, and obtained quantitative ratings of the extent to which partnerships were participatory. RESULTS: Partnerships seemed to become more participatory over time. Each site developed distinctive programs with variation in fidelity to original program goals. Challenges included developing trust and maintaining racial diversity in local program leadership. CONCLUSIONS: Academics can partner with local faith communities to create unique programs that benefit the mental health of returning veterans. Research is needed to determine the effectiveness of community based programs, especially relative to typical "top-down" outreach approaches.

Mental health stigma and primary health care decisions.

People with serious mental illness have higher rates of mortality and morbidity due to physical illness. In part, this occurs because primary care and other health providers sometimes make decisions contrary to typical care standards. This might occur because providers endorse mental illness stigma, which seems inversely related to prior personal experience with mental illness and mental health care. In this study, 166 health care providers (42.2% primary care, 57.8% mental health practice) from the Veteran׳s Affairs (VA) medical system completed measures of stigma characteristics, expected adherence, and subsequent health decisions (referral to a specialist and refill pain prescription) about a male patient with schizophrenia who was seeking help for low back pain due to arthritis. Research participants reported comfort with previous mental health interventions. Path analyses showed participants who endorsed stigmatizing characteristics of the patient were more likely to believe he would not adhere to treatment and hence, less likely to refer to a specialist or refill his prescription. Endorsement of stigmatizing characteristics was inversely related to comfort with one׳s previous mental health care. Implications of these findings will inform a program meant to enhance VA provider attitudes about people with mental illness, as well as their health decisions.

Beliefs about depression and depression treatment among depressed veterans.

INTRODUCTION: Because of the misunderstanding and stigmatization of mental health disorders and treatment, health beliefs may be important in treatment seeking for depression. It is important to understand patients' beliefs about mental health disorders and mental health treatment to improve systems of care. METHODS: We studied beliefs about depression and depression treatment among patients in a randomized trial of a chronic care intervention to improve depression treatment in the Veterans Administration healthcare system (n = 395). The Depression Beliefs Inventory was used to assess beliefs regarding: (1) perceived need for depression treatment, (2) the efficacy of depression treatment, and (3) treatment barriers, including stigma, at baseline and 6 months. We calculated descriptive statistics on patients' baseline beliefs, and used multiple regression to investigate the extent to which beliefs changed in intervention and treatment as usual patients between baseline and 6-month assessments. We used logistic regression to investigate the relationship between beliefs and antidepressant initiation, adherence and clinical response. RESULTS: At baseline, 73% of our sample believed that they had depression, and 66% believed that taking antidepressants would be helpful for their depression. However, the depression intervention had few effects on beliefs, and individual beliefs were generally not associated with taking medication or clinical response. However, a summary measure of beliefs was found to have predictive validity with respect to initiating and adhering to antidepressant treatment. DISCUSSION: Our results highlight the potential difficulty in modifying individuals' attitudes regarding depression and depression treatment in chronic care models for depression interventions.