Methodological Considerations in Scale Refinement with Diverse Populations: A Case Example Using the CES-D with a Community Sample of American Indian Women.

Although many psychometric assessments are used extensively in population-based research to determine psychopathology, these tools have not been thoroughly validated or appropriately adapted for use in diverse populations. Indeed, depression measurement studies among American Indian and female populations are scarce, omitting key opportunities to tailor psychological measurement for this population. To build psychometric evidence of measures in this population, we used a procedural method to examine a standard psychological instrument-the Center for Epidemiological Studies Depression Scale (CES-D)-with a community sample of southeast American Indian women. Our results showed strong psychometric reliability of the 20-item CES-D. The "effort" item presented diminished validity, as demonstrated by a negative counter-intuitive item-to-total correlation (ITC) value. Dropping the "effort" item resulted in a 19-item scale with a better fit in the within-group examination of community-based American Indian women. Compared to the 20-item CES-D scale, the revised 19-item measure ("effort" item removed) resulted in minimal changes to women's depression categories. However, we did detect patterns in shifts such that the 19-item scale generally underestimated (i.e., placed women in a lower category) depressive symptoms compared to the 20-item scale. Depending on their study goals, researchers engaging in population-based research should carefully weigh the use of original scales that allow for consistency in reporting with refined scales that fit psychometrically. We present the outlined method as a tool that expands on current approaches in scale refinement, and aids researchers in making more informed decisions regarding refined scales with diverse populations.

Qualitative Exploration of Dyadic Influence on Physical Activity Between Latina Patients With Osteoarthritis and a Supporter of Their Physical Activity.

OBJECTIVE: Research indicates that social support may promote physical activity; however, most Latina individuals with osteoarthritis (OA) are not sufficiently active. The purpose of this qualitative dyadic study was to explore how Latina patients with OA and a self-selected physical activity "supporter" motivate each other to be more active. Furthermore, perceptions of how OA symptoms impact support and physical activity were examined. METHODS: Semistructured dyadic interviews were conducted with Latina patients with OA and a member of their social network age ≥16 years who supports their physical activity (n = 14 dyads). We used framework analysis to reduce qualitative data to themes and subthemes. RESULTS: Daughters (n = 5), spouses (n = 4), sons (n = 2), a granddaughter (n = 1), a nephew (n = 1), and a friend (n = 1) provided support for the target behavior. In many cases, members of dyads said the motivation to engage in physical activity was reciprocated rather than focused solely on Latina patients with OA. Support was often reciprocated by engaging in physical activity together, using pressure, talking about being active, modeling physical activity, and helping with household responsibilities. Although participants agreed that physical activity was beneficial and Latina patients desired additional support when experiencing OA symptoms, there was concern about the safety of activity in the presence of symptoms. Several adult daughters indicated that their mothers' OA symptoms motivated their own physical activity. CONCLUSION: Dyadic strategies for promoting physical activity among Latina patients with OA and how support may be reciprocated were identified.

Gender Differences and Their Influences on T2DM Self-Management Among Spanish-Speaking Latinx Immigrants.

INTRODUCTION: Evidence suggests that gender may influence many aspects of type 2 diabetes (T2DM) self-management (SM) and we posit that limited English language-proficient Latinx immigrants face additional challenges. METHODS: Instruments and semi-structured interviews were used to examine gender differences on health literacy, diabetes knowledge, health-promoting behaviors, diabetes, eating and exercise self-efficacy (SE), and T2DM SM practices among a cohort of limited English language-proficient Latinx immigrants. Statistical and qualitative analysis procedures were performed comparing males and females. RESULTS: Thirty persons participated. Males tended to be older, have higher educational achievement, and more financial security than females. Physiologic measures tended worse among female participants. Health literacy and exercise SE scores were similar, but females scored lower on Eating and Diabetes SE. Forty-seven percent (n= 9) of the women reported a history of gestational diabetes mellitus and a majority of men (n = 7) cited difficulty with excessive alcohol. CONSUMPTION: Males appeared to receive more SM support compared to females. Females more frequently noted how family obligations and a lack of support impeded their SM. Work environments negatively influenced SM practices. CONCLUSION: Men and women have unique SM challenges and as such require individualized strategies and support to improve T2DM management.

Psychosocial factors related to Cardiovascular Disease Risk in Young African American Women: a systematic review.

OBJECTIVE: African American women are exposed to multiple adverse psychosocial factors, including racism, discrimination, poverty, neighborhood stress, anxiety, and depression. The impact of these psychosocial factors on cardiovascular disease (CVD) risk in women during early adulthood is limited. This review aims to summarize and synthesize the recent literature on psychosocial factors related to CVD risk in young African American women. METHODS: We conducted a comprehensive search of the literature in PubMed, APA PsycINFO, and CINAHL. We systematically reviewed the literature for studies examining associations between psychosocial factors (e.g. racism, discrimination, neighborhood stress, anxiety) and CVD risk factors (e.g. body mass index [BMI], blood pressure, diabetes) in African American women age 19-24 years. Eligible studies measured at least one psychosocial factor, a CVD risk factor, and included young adult African American women (age 19-24) or reported sex-stratified analyses. RESULTS: We identified nine studies that met our inclusion criteria: six cross-sectional and three longitudinal studies. Of these, eight studies reported that psychosocial factors (i.e. perceived stress, racial discrimination, internalized racism, depression) are related to higher BMI and blood pressure. The majority of studies were conducted among college students or had a small sample size (<200). The quality of six studies was rated as excellent; the remainder were good and fair. CONCLUSIONS: Findings from this review suggest that exposure to adverse psychosocial factors may be related to increased CVD risk in early adulthood (age 19-24) in African American women. However, larger prospective analyses are necessary to examine these associations.

Racial and Ethnic Disparities in Health Care and Health Outcomes for Pregnant Women With Diabetes.

This article summarizes the current literature on racial and ethnic differences among women with diabetes in pregnancy. The PubMed, Scopus, CINAHL, and Embase databases were searched for original qualitative or quantitative studies published in English from January 1, 2009, to May 31, 2020. Consensus statements were excluded. Results of this synthesis indicate that racial and ethnic differences exist among pregnant women with diabetes, including social determinants of health, disparities in maternity care and perinatal care, and maternal and neonatal health outcomes. Health care providers should implement tailored interventions that specifically target racial and ethnic disparities in maternal and neonatal health to promote health equity in pregnant women with diabetes and their offspring, including later in life.

Stay in treatment: Predicting dropout from pediatric weight management study protocol.

INTRODUCTION: Childhood obesity is a serious public health concern. Multidisciplinary pediatric weight management programs have been deemed effective. However, effectiveness of these programs is impacted by attrition, limiting health benefits to children, and inefficiently utilizing scarce resources. METHODS: We have developed a model (the Outcomes Forecasting System, OFS) that isolates variables associated with attrition from pediatric weight management, with the potential to forecast participant dropout. In Aim 1, we will increase the power and precision of the OFS and then validate the model through the consistent acquisition of key patient, family, and treatment data, from three different weight management sites. In Aim 2, external validity will be established through the application of the OFS at a fourth pediatric weight management program. Aim 3 will be a pilot clinical trial, incorporating an intervention built on the results of Aims 1 and 2 and utilizing the OFS to reduce attrition. DISCUSSION: A greater understanding of the patient, family, and disease-specific factors that predict dropout from pediatric weight management can be utilized to prevent attrition. The goal of the current study is to refine the OFS to a level of precision and efficiency to be a valuable tool to any weight management program. By identifying the most pertinent factors driving attrition across weight management sites, new avenues for treatment will be identified. This study will result in a valuable forecasting tool that will be applicable for diverse programs and populations, decrease program costs, and improve patient retention, adherence, and outcomes. CLINICALTRIALSGOV IDENTIFIER: NCT04364282.

A multi-component, community-engaged intervention to reduce cardiovascular disease risk in perimenopausal Latinas: pilot study protocol.

BACKGROUND: Cardiovascular disease (CVD) risk increases substantially during perimenopause. Latinas have a significantly worse CVD risk factor profile than non-Hispanic White women, potentially due to multiple sociocultural and environmental factors. To date, interdisciplinary interventions have not focused on improving nutrition, physical activity, stress management, and biologic CVD risk in perimenopausal Latinas. The purpose of this study is to examine the feasibility and initial efficacy of a multi-component intervention to reduce CVD risk in perimenopausal Latinas. METHODS: This is a two-group, repeated measures experimental study. Eighty perimenopausal Latinas (age 40-55 years) from two community groups will be randomized: one group will complete the intervention; the other will be a wait-list control. The intervention consists of 12-weekly sessions (education, physical activity, stress management, coping skills training), followed by 3 months of continued support, and 6 months of skill maintenance on their own. The primary outcomes include arterial stiffness, blood pressure, lipids, and blood glucose. Secondary outcomes are health behaviors (nutrition, physical activity, sleep, coping strategies), self-efficacy, and other biological factors related to CVD risk (adiposity, C-reactive protein, hair cortisol, vasomotor symptoms). We will assess changes in outcomes from Time 1 (baseline) to Time 2 (6 months) and Time 3 (12 months) using general linear mixed models to test the hypotheses. We will also evaluate the feasibility of the intervention by assessing enrollment and retention rates, barriers, and facilitators to enrollment, intervention fidelity, the suitability of study procedures, and participant satisfaction with the intervention and study protocol. We hypothesize the intervention group will decrease biologic CVD risk and improve health behaviors and self-efficacy significantly more than the wait-list control. DISCUSSION: Results from this study will contribute to knowledge on the feasibility of behavioral interventions, including stress management and coping skills training, which could reduce CVD burden among perimenopausal Latinas. Because Hispanic/Latinos are the largest ethnic minority in the United States (US), progress regarding CVD risk among perimenopausal Latinas may lead to significant improvement in the overall CVD burden in the US. TRIAL REGISTRATION: Prospectively registered, NCT04313751 (03/19/2020), Protocol version 1.0.

A Systematic Review of Patient-, Provider-, and Health System-Level Predictors of Postpartum Health Care Use by People of Color and Low-Income and/or Uninsured Populations in the United States.

Introduction: People of color and low-income and uninsured populations in the United States have elevated risks of adverse maternal health outcomes alongside low levels of postpartum visit attendance. The postpartum period is a critical window for delivering health care services to reduce health inequities and their transgenerational effects. Evidence is needed to identify predictors of postpartum visit attendance in marginalized populations. Methods: We conducted a systematic review of the peer-reviewed literature to identify studies that quantified patient-, provider-, and health system-level predictors of postpartum health care use by people of color and low-income and uninsured populations. We extracted study design, sample, measures, and outcome data from studies meeting our eligibility criteria, and used a modified Cochrane Risk of Bias tool to evaluate risk of bias. Results: Out of 2,757 studies, 36 met our criteria for inclusion in this review. Patient-level factors consistently associated with postpartum care included higher socioeconomic status, rural residence, fewer children, older age, medical complications, and previous health care use. Perceived discrimination during intrapartum care and trouble understanding the health care provider were associated with lower postpartum visit use, while satisfaction with the provider and having a provider familiar with one's health history were associated with higher use. Health system predictors included public facilities, group prenatal care, and services such as patient navigators and appointment reminders. Discussion: Postpartum health service research in marginalized populations has predominantly focused on patient-level factors; however, the multilevel predictors identified in this review reflect underlying inequities and should be used to inform the design of structural changes.

Family Influence on Children's Nutrition and Physical Activity Patterns in Oman.

PURPOSE: The objective of this study is to expand the understanding of the family influence on children's nutrition and physical activity patterns in Oman. DESIGN AND METHODS: A cross-sectional research design was used in this study. We recruited 204 dyads (a mother with a child) conveniently. Research data were collected in public cycle one schools, nongovernmental community centers, and home visits from five provinces in Oman. Study measures included a general information survey, anthropometric measurements, electronic children and family nutrition and physical activity questionnaires, and a single-day dietary recall for children. Univariate, bivariate, and multivariate analyses were used. RESULTS: Children's nutrition intake was significantly associated with parental education level, family income, and family nutrition and physical activity patterns, while children's physical activity patterns were significantly associated with maternal BMI and parental education level. CONCLUSIONS: Children's nutrition and physical activity patterns are associated with maternal BMI, family's sociodemographic characteristics, and family's nutrition and physical activity pattern. PRACTICE IMPLICATIONS: Family is a key element in shaping and influencing children's lifestyle-related behaviors. School-health programs that actively involve the families hold promise in promoting children's nutrition and physical activity pattern. Future research should be directed toward understanding the moderating and mediating factors.

Lifestyle-Related Determinants of Obesity Among Omani Children.

OBJECTIVES: This study aimed to examine the relationship between body mass index (BMI) z-scores and lifestyle-related factors including nutrition, physical activity, screen time and time spent sleeping in 6-10-year-old Omani children. METHODS: This cross-sectional study included mother-child dyads that were recruited from five provinces in Oman. Children's BMI measurements and questionnaires on nutrition intake, physical activity, screen time and time spent sleeping and a single-day dietary recall were collected. RESULTS: A total of 197 dyads were included in this study. The children's mean age was 7.7 ± 1.6 years and 53% were female. In this study, 17.4% of the children were classified as overweight or obese. No significant relationship was found between the children's BMI z-scores and nutrition intake, moderate-to-vigorous physical activity time or screen time (P ≥0.05). Increased time spent sleeping at night was positively associated with childhood obesity (P <0.05). CONCLUSION: The relationship between obesity and caloric intake, physical activity and screen time among children younger than 10 years seems to be moderated by certain factors that need to be investigated. Qualitative studies and questionnaires that are culturally sensitive are therefore needed.

Weight Stigmatization and Binge Eating in Asian Americans with Overweight and Obesity.

Weight stigma and binge eating have been found to be associated in Western populations; however, this relationship is understudied among Asian Americans. The aims of the study were to (1) investigate the prevalence of binge eating and its relationship with experienced weight stigma in higher-weight Asian Americans, and (2) examine whether the level of acculturation moderates this relationship. Data were collected from a cross-sectional study with 166 higher-weight Asian American adults living in North Carolina, United States. Demographic data, the frequency of experiencing weight stigma, the severity of binge eating, the levels of acculturation, the perceived racism against Asians, and perceived stress were assessed via self-reported questionnaires. The results indicated that experienced weight stigma was a significant independent predictor over and above the effects of other stressors, such as racism and general stress. The level of acculturation did not influence the relationship between the experienced weight stigma and binge eating after adjusting for relevant covariates. Our findings contribute to the limited literature examining weight stigma and binge eating among Asian American populations, highlighting that higher levels of experienced weight stigma are associated with a greater degree of binge eating.

Perceptions and Behaviors Related to Contraceptive Use in the Postpartum Period Among Women With Pregestational Diabetes Mellitus.

OBJECTIVE: To describe perceptions and behaviors related to contraception and preconception care and to test the association between these perceptions and contraceptive use in the postpartum period among women with pregestational diabetes mellitus. DESIGN: Cross-sectional, descriptive survey. SETTING: Three high-risk obstetric clinics in the Southeastern United States. PARTICIPANTS: Fifty-five women who were 18 years or older with pregestational Type 1 or Type 2 diabetes mellitus. METHODS: Between 4 and 8 weeks after birth, we used investigator-developed items and psychometrically validated scales to measure participants' perceptions and behaviors related to contraception and preconception care. We dichotomized use of contraception in the postpartum period as procedure/prescription or nonprescription/no method. We used multiple logistic regression to test the hypothesis that perceptions are associated with contraceptive use. RESULTS: When data were collected 4 to 8 weeks after birth, almost half (49%, n = 27) of the participants had resumed sexual activity; however, most (95%, n = 52) did not want another pregnancy in the next 18 months. Fifty-six percent (n = 31) of participants used procedure/prescription contraception, and 44% (n = 24) used nonprescription/no method. Those who perceived contraception use and preconception care to be beneficial were more likely to use procedure/prescription contraception (adjusted odds ratio = 1.52; 95% confidence interval [1.07, 2.17]). CONCLUSION: When caring for women in the postpartum period, providers should be mindful that women's perceptions of the benefits of contraception and preconception care may have implications for whether their use aligns with their reproductive goals and optimizes outcomes for future pregnancies.

The Space Between: Transformative Learning and Type 2 Diabetes Self-Management.

INTRODUCTION: Immigrant populations experience higher type 2 diabetes mellitus (T2DM) prevalence rates and worse health outcomes secondary to T2DM than native-born populations. But as the largest immigrant population in the United States, the experience of T2DM diagnosis and self-management among Spanish-speaking, limited English-language proficient Latinx immigrants remains largely unexamined. This study used semistructured interviews to explore these phenomena among a cohort of 30 recent Latinx immigrants. METHOD: All aspects of data collection were conducted in Spanish. Quantitative and qualitative data were collected. Data analysis included descriptive statistical procedures. Qualitative data analysis was conducted using a grounded theory approach. RESULTS: Patterns in the data analysis of 30 interviews identified accepting T2DM as a common transitional process that required significant changes in individuals' self-perspective and ways of being. Accepting T2DM was identified by the participants as a precursor to treatment initiation. And while for most participants this transition period was brief, for some it took months to years. Distinct transitional stages were identified, categorized, and considered within the context of several theoretical orientations and were observed to align with those in transformative learning. CONCLUSION: Understanding differing responses and processing of a T2DM diagnosis could be leveraged to better support patients' acceptance and transition into treatment.

The Process of Integrating an Evidence-Based Intervention into a Public Health Department to Improve Nutrition and Physical Activity Behaviors in Parents and Children.

The purpose of this manuscript is to describe a mutually beneficial collaboration with a Public Health Department and a University to implement an evidence-based program to teach nutrition and physical activity to improve adult and child outcomes. We first assessed the needs of the Public Health Department to build sustainable capacity. Next, all collaborators were invited to work together to focus on success. We invested in the leadership structure and strategically planned together. Finally, all of the collaborators worked together to practice cultural awareness. The process of implementing evidence-based programs allows all collaborators to emerge from the interaction stronger as a result of respectful dialogue and team building.

A community-engaged approach to investigate cardiovascular-associated inflammation among American Indian women: A research protocol.

American Indian women are more likely to die from cardiovascular disease (CVD) than White or African American women. Inflammatory processes may underlie CVD disparities by gender and race and may be critical to understanding population-specific drivers and potential buffers. Exposure to environmental air pollutants, especially particulate matter (PM), is known to be an important catalyst in CVD-associated inflammation. Positive psychological states, associated with low levels of inflammatory gene expression, could serve to moderate the inflammatory response to environmental air pollutants and ultimately lead to better cardiovascular health outcomes. The aim of the ongoing community-engaged and NIH-funded study described in this study protocol is to address the racial and gender gaps in CVD mortality by investigating the contextually relevant and culturally important determinants of health among American Indian women. In this paper we describe the procedures used to examine the relationship between environmental air pollutant exposures (PM10-2.5 and PM 2.5 ), psychological factors (e.g., depressive symptoms, posttraumatic stress symptoms, eudemonic well-being, and positive emotions), and cardiovascular-associated inflammation (hs-CRP, IL-6, Amyloid A, CBCs with differentials) in a sample of 150 women 18-50 years of age from the Lumbee Tribe in southeastern North Carolina. We describe lessons learned and strategies used in developing a community-engaged approach to enhance recruitment of American Indian women in biomedical research. The empirical data and community infrastructure resulting from this study will be foundational in designing and testing future interventions to reduce CVD-associated morbidity and mortality in American Indian women.

Weight stigma and acculturation in relation to hair cortisol among Asian Americans with overweight and obesity: A cross-sectional study.

Weight stigma is a pervasive problem for Americans, but little is known about its impact on the health of Asian Americans. Authors examined the relationship between weight stigma and cortisol and whether acculturation moderated this relationship. Asian Americans (n = 166) with overweight or obesity completed questionnaires and provided a 50-mg hair sample to assay cortisol. Results revealed a negative correlation between weight stigma and cortisol. However, this was no longer significant after controlling of relevant covariates. The level of acculturation did not significantly moderate this relationship. The non-significant relationships among weight stigma, cortisol, and acculturation are discussed along with future directions.

Childhood Overweight and Obesity is Increasing in Gulf Cooperation Council Countries: A Review of the Literature.

Introduction: A review was conducted to examine the prevalence and risk factors of developing overweight and obesity in children residing in Gulf Cooperation Council (GCC) countries. Method: PubMed, Medline, and Google Scholar databases using PRISMA guidelines were searched from January 1, 2007, to January 1, 2017. The inclusion criteria were (a) studies written in English, (b) clinical trials that examined risk factors of childhood overweight or obesity, (c) studies involving children 5 to 10 years of age, and (d) studies conducted in GCC countries. Results: Three main types of childhood obesity risk factors were identified (individual, familial, and lifestyle behavioral factors). The dietary, physical activity, and screen time lifestyle behavior risk factor findings were inconclusive. Discussion: Childhood obesity is increasing in GCC countries. Lifestyle behavior risk factors are still unclear. Researchers need to use instruments that have been psychometric tested and culturally acceptable. A follow-up review should be conducted.

A Nurse-Led and Teacher-Assisted Adolescent Healthy Weight Program to Improve Health Behaviors in the School Setting.

Adolescents with overweight and obesity are at risk for future health problems. The purpose of this study was to examine the feasibility and initial efficacy of a weight management intervention to help adolescents develop healthy nutrition and physical activity behaviors and improve their anthropometrics. This study used a single-group repeated measures design in a small school in Durham, North Carolina (NC). The intervention consisted of a nurse-led and teacher-assisted nutrition and physical activity education and exercise classes that met twice each week for 45-60 minutes for 7 weeks. Data were collected at Time 1 (baseline), Time 2 (after intervention completion), and Time 3 (after 3 months on their own). Interview feedback, low cost, and successful completion of all planned activities indicated that all stakeholders found the project beneficial and suitable for their school. This study suggests that a weight management intervention for adolescents was feasible in the school setting.

Rationale, design, and methodology for the healthy mothers-healthy children study: a randomized controlled trial.

BACKGROUND: Hispanic women and children who become overweight or obese are at risk for developing prediabetes, type 2 diabetes, and cardiovascular disease later in life. Interdisciplinary interventions which target Hispanic women and their 3-5-year old children to improve nutrition and physical activity behaviors, manage adiposity and weight in mothers, and prevent excessive adiposity and weight gain trajectory in their children offer promise to break the intergenerational cycle. METHODS: Using a randomized two-group, repeated measures experimental design, the goal of the proposed study is to investigate the efficacy of a 12-week nutrition and physical activity program including education, coping skills training, and home-based intervention in Hispanic women and their 3-5-year old children. The program includes 6 months of continued monthly contact to help overweight and obese Hispanic mothers and their children improve adiposity, weight (trajectory for children), health behaviors (nutrition and physical activity), and self-efficacy We will partner with two federally qualified health departments in Durham and Chatham counties, North Carolina to enroll participants. We will partner with community centers to deliver the intervention. A total of 294 Hispanic women with a BMI ≥ 25 kg/m2 and 294 Hispanic 3-5-year old children with a ≥ 25th BMI percentile will be enrolled over 4 years and randomized to the experimental or equal attention control group. Data will be collected at Time 1 (0 months [baseline]) to Time 2 (9 months [completion of the intervention]) and Time 1 to Time 3 (15 months [after 6 months with no contact from the study staff]). Data collected will include adiposity and weight in mothers and children (primary outcomes). Secondary outcomes will include health behaviors and self-efficacy in the mothers and in the children. We will also evaluate the cost of delivering the program for public health departments. We will use general linear mixed models to test the hypotheses. DISCUSSION: Decreasing overweight and obesity in Hispanic women and slowing adiposity and weight gain trajectory in young Hispanic children is urgently needed to decrease morbidity, mortality, and future health care costs. TRIAL REGISTRATION: NCT03866902. (March 7, 2019).