Community Health Centers In Massachusetts Research Articles

Prenatal aneuploidy screening in a low-risk Hispanic population: price elasticity and cost-effectiveness

Background: In October 2015, the Massachusetts Medicaid program temporarily stopped reimbursing the ICD-10 code used by certain communities for serum aneuploidy screening. This change resulted in a substantial number of patients without aneuploidy screening for approximately three years.Objective: To determine the change in utilization and cost-effectiveness of prenatal aneuploidy serum screening in a low-risk Hispanic Medicaid population in Massachusetts.Study Design: We conducted a retrospective chart review of Spanish-speaking pregnant patients under 35 years of age receiving aneuploidy serum screening at a Massachusetts community health center. The study compared aneuploidy serum screening rates before and after May 2016, when the Massachusetts Medicaid program, MassHealth, temporarily discontinued reimbursement for the screening. Based on these rates, we developed a Markov cohort simulation model to assess the economic value of reimbursed aneuploidy screening versus non-reimbursed or limited screening. Clinical outcomes included trisomy 21, live births, and therapeutic abortions for a trisomy 21 diagnosis. Economic outcomes included discounted quality-adjusted life years and lifetime medical costs, net health benefit, and incremental cost-effectiveness ratios.Results: Before the MassHealth policy change, 69% (55/80) of pregnant individuals selected quad or sequential screens, compared to 9% (10/112) post-policy change. Traditional aneuploidy serum screening in a low-risk (aged <35 years) Hispanic population was considered cost-saving (i.e., resulted in lower incremental costs and higher incremental benefits compared to non-reimbursed or limited screening).Conclusions: From a U.S. healthcare payer perspective, aneuploidy serum screening for Hispanic pregnant individuals under 35 years of age is economically advantageous compared to limited screening.

Implementing expanded COVID-19 testing in Massachusetts community health centers through community partnerships: Protocol for an interrupted time series and stepped wedge study design

BackgroundCommunity Health Centers (CHCs) are a critical source of care for low-income and non-privately insured populations. During the pandemic, CHCs have leveraged their infrastructure and role as a trusted source of care to engage the communities they serve in COVID-19 testing. MethodsTo directly address the impact that COVID-19 has had on historically marginalized populations in Massachusetts, we designed a study of community-engaged COVID-19 testing expansion: (1) leveraging existing partnerships to accelerate COVID-19 testing and rapidly disseminate effective implementation strategies; (2) incorporating efforts to address key barriers to testing participation in communities at increased risk for COVID-19; (3) further developing partnerships between communities and CHCs to address testing access and disparities; (4) grounding the study in the development of a shared ethical framework for advancing equity in situations of scarcity; and (5) developing mechanisms for communication and science translation to support community outreach. We use a controlled interrupted time series design, comparing number of COVID-19 tests overall and among people identified as members of high-risk groups served by intervention CHCs compared with six matched control CHCs in Massachusetts, followed by a stepped wedge design to pilot test strategies for tailored outreach by CHCs. ConclusionsHere, we describe a community-partnered strategy to accelerate COVID-19 testing in historically marginalized populations that provides ongoing resources to CHCs for addressing testing needs in their communities. The study aligns with principles of community-engaged research including shared leadership, adequate resources for community partners, and the flexibility to respond to changing needs over time.

Prevalence of Cannabis Use and Cannabis Route of Administration among Massachusetts Adults in Buprenorphine Treatment for Opioid Use Disorder

Background Recent prevalence estimates of cannabis use among individuals receiving medication treatment for OUD (MOUD) are lacking, and no study has characterized cannabis route of administration (cROA) in this population. These knowledge gaps are relevant because cannabis’ effects and health outcomes vary by cROA and the availability and perceptions of cROA (e.g., vaping devices) are changing. Methods The Vaping In Buprenorphine-treated patients Evaluation (VIBE) cross-sectional survey assessed the prevalence and correlates of cannabis use and cROA among adults receiving buprenorphine MOUD from 02/20 to 07/20 at five community health centers in Massachusetts, a state with legal recreational and medical cannabis use. Results Among the 92/222 (41%) respondents reporting past 30-day cannabis use, smoking was the most common cROA (75%), followed by vaping (38%), and eating (26%). Smoking was more often used as a single cROA vs. in combination others (p = 0.01), whereas vaping, eating, and dabbing were more often used in combination with another cROA (all p < 0.05). Of the 39% of participants reporting multiple cROA, smoking and vaping (61%), and smoking and eating (50%), were the most prevalent combinations. Nonwhite race (vs. white) and current cigarette smoking (vs. no nicotine use) were associated with past 30-day cannabis use in multiple logistic regression. Conclusions Prevalence of past 30-day cannabis use among individuals receiving buprenorphine MOUD in Massachusetts in 2020 was nearly double the prevalence of cannabis use in Massachusetts’ adult general population in 2019 (21%). Our data are consistent with state and national data showing smoking as the most common cROA.

Addressing COVID-19 Testing Inequities Among Underserved Populations in Massachusetts: A Rapid Qualitative Exploration of Health Center Staff, Partner, and Resident Perceptions.

IntroductionAccess to COVID-19 testing has been inequitable and misaligned with community need. However, community health centers have played a critical role in addressing the COVID-19 testing needs of historically disadvantaged communities. The aim of this paper is to explore the perceptions of COVID-19 testing barriers in six Massachusetts communities that are predominantly low income and describe how these findings were used to build tailored clinical-community strategies to addressing testing inequities.MethodsBetween November 2020 and February 2021, we conducted 84 semi-structured qualitative interviews with 107 community health center staff, community partners, and residents. Resident interviews were conducted in English, Spanish, Vietnamese, and Arabic. We used a 2-phase framework analysis to analyze the data, including deductive coding to facilitate rapid analysis for action and an in-depth thematic analysis applying the Social Ecological Model.ResultsThrough the rapid needs assessment, we developed cross-site suggestions to improve testing implementation and communications, as well as community-specific recommendations (e.g., locations for mobile testing sites and local communication channels). Upstream barriers identified in the thematic analysis included accessibility of state-run testing sites, weak social safety nets, and lack of testing supplies and staffing that contributed to long wait times. These factors hindered residents' abilities to get tested, which was further exacerbated by individual fears surrounding the testing process and limited knowledge on testing availability.DiscussionOur rapid, qualitative approach created the foundation for implementing strategies that reached underserved populations at the peak of the COVID-19 pandemic in winter 2021. We explored perceptions of testing barriers and created actionable summaries within 1–2 months of data collection. Partnering community health centers in Massachusetts were able to use these data to respond to the local needs of each community. This study underscores the substantial impact of upstream, structural disparities on the individual experience of COVID-19 and demonstrates the utility of shifting from a typical years' long research translation process to a rapid approach of using data for action.

Using HIV Surveillance and Clinic Data to Optimize Data to Care Efforts in Community Health Centers in Massachusetts: The Massachusetts Partnerships for Care Project.

We describe Data to Care processes of the Massachusetts Partnerships for Care (MA P4C) project and identify factors associated with engagement, retention, and viral suppression outcomes. The Massachusetts Department of Public Health and participating community health centers generated lists of patients not in care based on a temporal gap in laboratory results, missed clinic visits, and provider concern regarding engagement. The Massachusetts Department of Public Health and community health centers reviewed the lists monthly and identified out-of-care patients in need of linkage or re-engagement. Between October 2015 and June 2017, of 1418 patients potentially out of care, 83 (5.9%) were confirmed to be out of care. Forty-four of those out of care (53%) received services or were re-engaged in care within 90 days, 45 (54%) were retained in care, and 40 (48%) were virally suppressed. The odds of being re-engaged or retained were lower for patients who were 6 months out-of-care (vs. those newly diagnosed). Patients with an AIDS-defining condition had increased odds of retention and viral suppression. The odds of viral suppression were reduced for patients who reported exposure categories other than men who have sex with men and were younger (30-49 years vs. ≥50 years). Although rates of re-engagement, retention, and viral suppression were low, the MA P4C Data to Care procedures provided a means for accurate ascertainment of out-of-care status. Future Data to Care programs should investigate the factors that contribute to disengagement from care.

Proactive Population Health Strategy to Offer Tobacco Dependence Treatment to Smokers in a Primary Care Practice Network.

Population-based strategies can expand the reach of tobacco cessation treatment beyond clinical encounters. To determine the effect of two population-based tobacco cessation strategies, compared with usual care, on providing tobacco treatment outside of clinical encounters. 3-arm pragmatic randomized controlled trial. Current smokers ≥ 18years old with a primary care provider at one of five community health centers in Massachusetts were identified via the electronic health record (n = 5225) and recruited using automated phone calls. One intervention group involved engagement with a health system-based tobacco coach (internal care coordination), and the other connected patients to a national quitline (external community referral). Proportion of smokers with documentation of any evidence-based cessation treatment in the 6months after enrollment. Of 639 individuals who responded to the proactive treatment offer, 233 consented and were randomized 1:1:1 to study arm. At 6-month follow-up, the pooled intervention group, compared with usual care, had higher documentation of any smoking cessation treatment (63% vs. 34%, p < 0.001), cessation medication prescription (52% vs. 30%, p = 0.002), and counseling (47% vs. 9%, p < 0.001). Internal care coordination was more effective than external community referral at connecting smokers to any cessation treatment (76% vs. 50%, p = 0.001) and at providing cessation medication (66% vs. 39%, p < 0.001), but comparable at linking smokers to cessation counseling resources. Smokers responding to a population-based, proactive outreach strategy had better provision of tobacco cessation treatment when referred to either a health system-based or community-based program compared with usual care. The health system-based strategy outperformed the quitline-based one in several measures. Future work should aim to improve population reach and test the effect on smoking cessation rates. ClinicalTrials.gov NCT03612895.

Barriers and Pathways to Providing Long-Acting Reversible Contraceptives in Massachusetts Community Health Centers: A Qualitative Exploration.

Structural barriers to the provision of long-acting reversible contraceptive (LARC) methods at community health centers have been identified in quantitative research, but the processes and behaviors by which center staff respond to these barriers are poorly understood. Focus group discussions were conducted with clinical, support and administrative staff at three Massachusetts community health centers between April 2014 and January 2015. The centers were purposively selected to constitute a sample with diverse characteristics. Overall, 57 individuals participated in seven focus groups. Data were analyzed inductively using a modified grounded theory approach, and typical pathways to obtaining LARC methods were identified. Community health center staff provided contradictory descriptions of their facilities' protocols and practices. Patients' pathways to obtaining LARC methods were idiosyncratic and clinician-dependent, and resulted in patients' waiting between one week and three months to receive their preferred method. Providers' individual comfort with and perceived competence in contraceptive counseling often shaped patients' pathways to care. Overall, staff did not consider same-day insertion of LARC methods a feasible goal. Counseling protocols, insurance verification practices and logistical challenges in ordering and stocking devices were identified as major barriers to timely placement. Efforts to improve LARC provision at community health centers should include the education of staff in how expeditious placement constitutes clinical best practice and the implementation of infrastructural changes to support staff in efficiently counseling patients, scheduling placements and procuring LARC devices regardless of patients' insurance coverage.

Feasibility of a proactive text messaging intervention for smokers in community health centers.

BackgroundFew smokers receive evidence-based cessation services during primary care visits.ObjectiveWe aimed to assess the feasibility of a proactive text messaging program for primary care patients who smoke.MethodsWe used electronic health records to identify smokers who had a mobile phone number listed from two community health centers in Massachusetts. Between March 2014 and June 2015, patients were screened by their primary care physician and then sent a proactive text message inviting them to enroll by texting back. Patients who opted in were asked about their readiness to quit. The text message program included messages from the QuitNowTXT library and novel content for smokers who were not ready to quit.ResultsAmong 949 eligible smokers, 88 (9.3%) enrolled after receiving a single proactive text message. Compared with those who did not enroll, enrollees were more often female (54/88, 61% vs 413/861, 48.0%, P=.02), but otherwise did not differ in age, race, insurance status, or comorbidities. In all, 28% (19/67) of enrollees reported they were not ready to quit in the next 30 days, 61% (41/67) were ready to quit, and 11% (7/67) already quit. The median time in the program was 9 days (interquartile range 2-32 days). Of current smokers, 25% (15/60) sent one or more keyword requests to the server. These did not differ by readiness to quit.ConclusionsA proactively delivered text messaging program targeting primary care patients who smoke was feasible and engaged both smokers ready to quit and those not ready to quit. This method shows promise as part of a population health model for addressing tobacco use outside of the primary care office.

Strengthening integration of clinical and public health systems to prevent maternal-child obesity in the First 1,000 Days: A Collective Impact approach

IntroductionObesity interventions may be most effective if they begin in the earliest stages of life, support changes across family, clinical, and public health systems, and address socio-contextual factors. MethodsThe First 1000Days is a systematic program starting in early pregnancy lasting through the first 24months of infancy to prevent obesity among low-income mother-infant pairs in three community health centers in Massachusetts. The program uses a Collective Impact approach to create the infrastructure for sustained, system-wide changes for obesity prevention across early life clinical and public health services, including Obstetrics, Pediatrics, Adult Medicine, Behavioral Health, Nutrition, Community Health, the Women, Infants and Children (WIC) program, and the Maternal, Infant and Childhood Home Visiting program. Program components include 1) staff and provider training; 2) enhanced gestational weight gain and infant overweight tracking; 3) universal screening of adverse health behaviors and socio-contextual factors; 4) universal patient navigation to support individual behavior change and social needs, while strengthening integration of clinical and public health services; 5) individualized health coaching for mother-infant pairs at high risk of obesity; and 6) educational materials to support behavior change. ResultsA quasi-experimental evaluation design will examine changes, between 2015 and 2019, in gestational weight gain and prevalence of infant overweight from 0 to 24months of age. ConclusionsThe First 1000Days program will examine the effectiveness of an early life obesity prevention program for mother-infant pairs. If successful, the program could provide a model for chronic disease prevention and health promotion among vulnerable families starting in early life.

Abstract B88: Prevalence of HPV vaccination of Cambodian American adolescents: Mother-daughter communication, knowledge, and demographic factors in vaccination

Abstract Purpose: To assess the socio-cultural factors, the level of knowledge of HPV infection, and mother-child communication about STD among Cambodian American mothers and their implications for HPV vaccination of their daughters. Background: Cervical cancer incidence and mortality has decreased significantly over the last 30 years largely due to cervical cancer screening and HPV vaccination. However, cervical cancer is still five times higher among Southeast Asian women as compared to White women. HPV is vaccine preventable and mothers play an important role in promoting vaccination and health education of their children. However, there is a dearth of literature on knowledge level and the social and cultural factors influencing vaccination behaviors among Cambodian American parents. As a result, it is difficult to develop an effective HPV prevention program. Methods: A descriptive, correlational, cross-sectional survey designed was employed. Cambodian-American mothers were recruited by collaborative working with Cambodian American community health leaders from Cambodian cluster areas including temples, Khmer restaurants, cultural fairs, Khmer serving community health centers in Massachusetts. 130 Cambodian American mothers completed a health survey by face-to-face interviews in either English or Khmer. Outcome variable was HPV vaccination among their daughters. The main predictor of interest was mother's age, percent of life in the U.S., income, and education in the U.S., English reading, HPV knowledge, and comfort level of speaking with their daughters about STD. Results: Of 130 Khmer mothers, 92% were born in Cambodian, only 47% attended/finished high school in the U.S., and 213% reported that monthly family income from all sources was less than $1,000. Daughters' vaccination rate is 29% while sons' is only 16%. Their knowledge about HPV was very low and thought that their daughters had more knowledge about STD than they have. Logistic regression analysis showed that Cambodian daughters had significantly higher odds of vaccination if their mothers showed higher level of English reading, knowledge, or heard about HPV. However, after adjusting only mother's HPV knowledge significantly associated with daughters' HPV vaccinations. Conclusions: The strikingly low rates of HPV vaccination among Cambodian girls and boys underscore the need to improve vaccination. The findings can be used to help the development of intervention addressing low HPV-related knowledge and targeted HPV vaccination promotion programs for Cambodian Americans which in turn will help to prevent continued cervical cancer disparities. Citation Format: Haeok Lee, Minjin Kim, Ling Shi, Thiem Linda, Sonith Peou. Prevalence of HPV vaccination of Cambodian American adolescents: Mother-daughter communication, knowledge, and demographic factors in vaccination. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B88.

Barriers to Use of Workers' Compensation for Patient Care at Massachusetts Community Health Centers

To examine barriers community health centers (CHCs) face in using workers' compensation insurance (WC). Leadership of CHCs in Massachusetts. We used purposeful snowball sampling of CHC leaders for in-depth exploration of reimbursement policies and practices, experiences with WC, and decisions about using WC. We quantified the prevalence of perceived barriers to using WC through a mail survey of all CHCs in Massachusetts. Emergent coding was used to elaborate themes and processes related to use of WC. Numbers and percentages of survey responses were calculated. Few CHCs formally discourage use of WC, but underutilization emerged as a major issue: "We see an awful lot of work-related injury, and I would say that most of it doesn't go through workers' comp." Barriers include lack of familiarity with WC, uncertainty about work-relatedness, and reliance on patients to identify work-relatedness of their conditions. Reimbursement delays and denials lead patients and CHCs to absorb costs of services. Follow-up studies should fully characterize barriers to CHC use of WC and experiences in other states to guide system changes in CHCs and WC agencies. Education should target CHC staff and workers about WC.

Chronic Disease Self-Management and Health Literacy in Four Ethnic Groups

Research from several fields has explored health literacy as a multidimensional construct. The authors' multimethod study, “The Impact of Cultural Differences on Health Literacy and Chronic Disease Outcomes,” assessed health literacy and chronic disease self-management among 296 patients from four ethnic groups (Vietnamese, African American, White, Latino) at a Massachusetts community health center between 2006 and 2010. Health literacy was assessed using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA), the Rapid Estimate of Adult Literacy in Medicine (REALM), and the Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA) measures. Qualitative research methods, including in-depth interviews (n = 34), home visits (n = 12), chronic disease diaries (n = 15), and focus groups (n = 47), were completed with a subset of participants. Qualitative interviews indicated a wide range of interpretations of S-TOFHLA questions in which participants substituted their own illness or health care experiences for the abstract examples offered in the instrument, at times leading to incorrect responses. Situating these responses in a broader social and cultural context, this article describes examples of the wide range of chronic disease self-management abilities among participants with limited education and/or low health literacy. It also discusses the culturally variable health beliefs identified among participants interviewed that may play important roles in their chronic disease self-management practices.

Barriers and Facilitators to Routine HIV Testing: Perceptions from Massachusetts Community Health Center Personnel

Since 2006, the Centers for Disease Control and Prevention (CDC) has recommended routine, voluntary HIV testing for persons aged 13-64 in all health care settings, including the elimination of separate informed consent, which remains in effect in five states including Massachusetts. Community health centers (CHCs) represent an important HIV testing site for at-risk populations. From April to December 2008 a qualitative interview was administered to one senior personnel from each of 30 CHCs in Massachusetts, to identify barriers and facilitators to implementing CDC recommendations and to elucidate strategies to improve routine HIV testing. The following themes emerged as routine HIV testing barriers: (1) provider time constraints, including time to administer counseling and separate informed consent; (2) lack of funding, staff, and space; (3) provider, patient, and community discomfort; (4) inconsistent levels of awareness regarding CDC recommendations; and (5) perceived incompatibility with Massachusetts HIV testing policy. Facilitators included designation of personnel to serve as organizational "champions" for routine testing and use of clinical reminders within electronic medical records to prompt HIV testing. Strategies identified to improve routine HIV testing rates among Massachusetts CHCs included more explicit state-level guidelines; organizational buy-in; collaborative analysis to integrate testing within existing activities; and provider, patient and community education.

Barriers to Routine HIV Testing among Massachusetts Community Health Center Personnel

We assessed the extent to which Centers for Disease Control and Prevention (CDC) recommendations have influenced routine HIV testing among Massachusetts community health center (CHC) personnel, and identified specific barriers and facilitators to routine testing. Thirty-one CHCs were enrolled in the study. We compared those that did and did not receive funding support from the federal Ryan White HIV/AIDS Program. An anonymous survey was administered to a maximum five personnel from each CHC, including a senior administrator, the medical director, and three medical providers. Overall, 137 participants completed the survey. Among all CHCs, 53% of administrators reported having implemented routine HIV testing at their CHCs; however, only 33% of medical directors/providers reported having implemented routine HIV testing in their practices (p<0.05). Among administrators, 60% of those from Ryan White-supported CHCs indicated that both they and their CHCs were aware of CDC's recommendations, compared with 27% of administrators from non-Ryan White-supported CHCs. The five most frequently reported barriers to the implementation of routine HIV testing were (1) constraints on providers' time (68%), (2) time required to administer counseling (65%), (3) time required to administer informed consent (52%), (4) lack of funding (35%), and (5) need for additional training (34%). In a multivariable logistic regression model, the provision of on-site HIV testing by nonmedical staff resulted in increased odds of conducting routine HIV testing (odds ratio [OR] = 9.84, 95% confidence interval [CI] 1.77, 54.70). However, the amount of time needed to administer informed consent was associated with decreased odds of providing routine testing (OR=0.21, 95% CI 0.05, 0.92). Routine HIV testing is not currently being implemented uniformly among Massachusetts CHCs. Future efforts to increase implementation should address personnel concerns regarding time and staff availability.

A Note from the Editor

A Note from the Editor Virginia M. Brennan, PhD, MA, Editor, Faculty Member In the heart of the long summer, after a spring full of weather-related calamities world-wide, we turn our thoughts to wellness and the prevention of disease. The present issue has four themes: • Wellness and Clinical Care • Race. Ethnicity, and Cancer • Race, Ethnicity, and Other Conditions • Health Policy Supplementing this issue is a volume guest-edited by Dr. Rueben C. Warren, Director of the National Center for Bioethics in Research and Health Care at Tuskegee University, on faith communities and pandemic flu preparedness (JHCPU 22.3 Suppl). That volume is an outgrowth of a conference sponsored jointly by the Interdenominational Theological Center and the Centers for Disease Control and Prevention in Atlanta. The regular issue opens with an ACU Column on the role of clinicians in empowering others concerning the built environment, followed by two Commentaries, both proposing new approaches to persistent problems. Sana Loue, of Case Western Reserve University, explores the Islamic construction of jihad as a possible tool in the fight against the spread of HIV/AIDS, offering a scholarly exploration of the construct's religious and pragmatic facets. Luke Shaefer and Matthew Miller from the University of Michigan discuss pros and cons of expanding access to oral health care by establishing mid-level dental practitioners more widely in the U.S. The authors explain, "Mid-level dental providers [MDPs] are generally permitted to perform basic preventive and basic restorative dental procedures under the direct, indirect, or general (depending on the model) supervision of a dentist, with the goal of extending access to care to underserved populations. The ability to provide basic restorative care such as fillings and simple extractions is the main feature differentiating MDPs from programs in some states that allow dental hygienists to provide dental hygiene and preventive care outside of a dental office or clinic. Mid-level dental providers now practice in a variety of capacities in more than 50 countries, including Great Britain, New Zealand, Australia, and Canada. Alaska and Minnesota are the only two U.S. states that have approved MDP providers, but policymakers in a number of other states are seriously considering such proposals." The Brief Communication by Carlos Quiñonez and colleagues from the University of Toronto on expanding dental coverage for low-income populations (in Part 4) complements this Commentary nicely. Part 1: Wellness and Clinical Care Part 1 opens with a Report from the Field by Monica Avillar and colleagues from the University of Texas Health Science Center at San Antonio on developing and [End Page vii] sustaining community health workers, who have become crucial contributors to care in many facilities serving low-income and other underserved populations. Recommendations include establishing training standards, evaluating the financial benefits of employing community health workers, strategizing Medicaid reimbursement, and creating support networks. The Original Paper by Judith Savageau and colleagues on recruiting and retaining primary care physicians in Massachusetts community health centers complements the paper by Avillar et al. Next, a Brief Communication by a team of psychiatrists from the Federal Neuropsychiatric Hospital in Enugu State, Nigeria, led by Dr. Muideen O. Bakare, reports on neuropsychiatric diagnoses and psychotropic medication prescription in their child and adolescent program. The work provides important baseline data for the region. Three of the remaining Original Papers in Part 1 concern social and interactive elements in well-being and clinical care. Shoshana Bardach and colleagues from the University of Kentucky explore how vulnerable rural residents manage multiple comorbidities and what types of support they find most helpful. Felicia Hodge and Karabi Nandy from the UCLA School of Nursing report on their survey of 457 American Indian adults who receive care at one of 13 rural health care sites in California. The focus of their research is wellness, both how it is understood by the respondents, especially how it is shaped by cultural connectivity, and also how it is affected by adverse childhood events. The authors recommend culturally-tailored education and interventions. Vanessa Watts Simonds, of the Robert Wood Johnson Center for Health Policy at the University of New Mexico, and colleagues report on their exploration of patient-provider interactions in a rural...

CALL ME: Meeting Asian Youth Where They Are

The article focuses on the success of the Lowell, Massachusetts Community Health Center's introduction of a Teen Help Card to promote health care and social services to inner-city Asian teenagers.

Impact of Intervention Dose on Cancer-Related Health Behaviors among Working-Class, Multiethnic, Community Health Center Patients

To examine the relationship between intervention dose and health behavior change in Healthy Directions-Health Centers, an intervention designed to reduce cancer risk factors. DESIGN. Analysis of intervention condition participant data from a randomized controlled trial. Community health centers in Massachusetts. Patients residing in low-income, working-class, multiethnic neighborhoods. Components were clinician endorsement, in-person counseling session and four telephone counseling sessions with a trained health advisor, and social-contextual tailored materials. Intervention dose was number of six possible intervention components completed by each participant. Changes in fruit and vegetable consumption, red meat consumption, physical activity, and multivitamin intake between baseline (n=1088) and 8-month follow-up (n=967; 89% of baseline sample) were determined. Bivariate and multivariate associations between intervention dose and change in health behaviors were examined. In multivariate analysis, the association between intervention dose and increase in multivitamin intake approached significance (p < .07). Seventy percent of participants completed all intervention activities. In bivariate analysis, completion of four telephone counseling calls was associated with decrease in red meat consumption (p < .05). These findings indicate that future studies should examine the number, content, and length of contacts needed for behavior change. The results also suggest that health centers are a channel for reaching diverse populations, as shown by the high level of intervention implementation.

Linguistic and cultural barriers to care.

Primarily because of immigration, Asian Americans are one of the fastest growing and most ethnically diverse minority groups in the United States. However, little is known about their perspectives on health care quality. To examine factors contributing to quality of care from the perspective of Chinese- and Vietnamese-American patients with limited English language skills. Qualitative study using focus groups and content analysis to determine domains of quality of care. Four community health centers in Massachusetts. A total of 122 Chinese- and Vietnamese-American patients were interviewed in focus groups by bilingual interviewers using a standardized, translated moderator guide. Domains of quality of care mentioned by patients in verbatim transcripts. In addition to dimensions of health care quality commonly expressed by Caucasian, English-speaking patients in the United States, Chinese- and Vietnamese-American patients with limited English proficiency wanted to discuss the use of non-Western medical practices with their providers, but encountered significant barriers. They viewed providers' knowledge, inquiry, and nonjudgmental acceptance of traditional Asian medical beliefs and practices as part of quality care. Patients also considered the quality of interpreter services to be very important. They preferred using professional interpreters rather than family members, and preferred gender-concordant translators. Furthermore, they expressed the need for help in navigating health care systems and obtaining support services. Cultural and linguistically appropriate health care services may lead to improved health care quality for Asian-American patients who have limited English language skills. Important aspects of quality include providers' respect for traditional health beliefs and practices, access to professional interpreters, and assistance in obtaining social services.