Beliefs and Narratives Associated with the Treatment of Chronic Pelvic Pain in Women

STUDY OBJECTIVE

Female patients with chronic pelvic pain (CPP) face complicated healthcare journeys, but narrative perspectives on CPP treatment are lacking.

DESIGN

We collected data in English and Spanish from discussion groups and individual interviews with stakeholders around female CPP.

SETTING

A tertiary care center for gynecologic care.

PATIENTS

Patients with CPP who self-identified as women/female, community healthcare workers, and providers who care for women with CPP.

INTERVENTIONS

We conducted discussion groups with all 3 types of stakeholders and individual interviews with female patients who have CPP.

MEASUREMENTS AND MAIN RESULTS

Patient participants completed condition specific validated questionnaires. De-identified transcripts were coded with NVivo software. We contrasted patient characteristics and codes between patients with CPP who did and did not report opioid use in the last 90 days. The mean pain score of patient participants was 6/10 ± 2/10, and 14 of 47 (28%) reported recent opioid use, without significant differences between patients with and without recent opioid use. Thematic saturation was achieved. Five main themes emerged: the debilitating nature of CPP, emotional impacts of CPP, challenges in CPP healthcare interactions, treatment for CPP, and the value of not feeling alone. Common threads voiced by stakeholders included difficulty discussing chronic pain with others, a sense of inertia in treatment, interest in alternative and less invasive treatments before more involved treatments, and the need for individualized, stepwise, integrated treatment plans. Participants agreed that opioids should be used when other treatments fail, but women recently using opioids voiced fewer concerns about addiction and positive experiences with opioid efficacy.

CONCLUSIONS

These findings among female patients with CPP and also among community healthcare workers and providers advocate for a move toward patient-centered care, particularly the acknowledgment that every woman experiences pain in a singular way. Furthermore, stakeholders voice a deep need for development of individualized treatment plans.

Associations between depression and diabetes among Latinx patients from low-income households in New Mexico

Depression and diabetes are co-occurring epidemics. This article explores the association between depression and diabetes in a cohort of Latinx patients with diabetes from low-income households. Data were gathered in Albuquerque, New Mexico (U.S.) between 2016 and 2020 as part of a patient-engaged comparative effectiveness trial comparing two culturally appropriate diabetes self-management programs-the Chronic Care Model (CCM) and the standard of care, Diabetes Self-Management Support Empowerment Model (DSMS). We proposed that the program most culturally and contextually situated in the life of the patient would have the greatest impact on diabetes self-management. Participants were enrolled as dyads-226 Latinx diabetes patient participants (PPs) from low-income households and 226 social support participants (SSPs). Data gathered at baseline, 3, 6, and 12 months included a measure of depression and A1c testing. Outcomes between programs were analyzed using longitudinal linear mixed modeling, adjusted for patient demographic characteristics and other potential confounding covariates. Patient A1c had an initial slight decrease at 3 months in both programs. At CCM, patients with a very high A1c (greater than 10%) demonstrated a clinically meaningful decrease in A1c over time. Patients at CCM experienced a large initial decrease in depression and continued to decrease throughout the study, while patients at DSMS showed a slight initial decrease through 6 months, but depression increased again by 12 months, nearly rebounding to baseline levels. A subgroup analysis revealed that a higher baseline A1c was associated with higher depression, and patients with higher A1c achieved greater reductions in depression at CCM than at DSMS. CCM scored higher on Consumer Assessment of Healthcare Providers and Systems cultural competence (CAHPS-CC). Interpretation of results suggests that the more culturally, contextually situated program, CCM, had better outcomes. This study demonstrates that culturally and contextually situating a diabetes intervention can deliver improved benefits for Latinx patients.

A patient-centered comparative effectiveness research study of culturally appropriate options for diabetes self-management

This project compared the effectiveness of two evidence-based models of culturally competent diabetes health promotion: The Diabetes Self-Management Support Empowerment Model (DSMS), and The Chronic Care Model (CCM). Our primary outcome was improvement in patient capacity for diabetes self-management as measured by the Diabetes Knowledge Questionnaire (DKQ) and the Patient Activation Measure (PAM). Our secondary outcome was patient success at diabetes self-management as measured by improvement in A1c, depression sores using the PHQ-9, and Body Mass Index (BMI). We also gathered data on the cultural competence of the program using the Consumer Assessment of Healthcare Providers and Systems Cultural Competence Set (CAHPS-CC). We compared patient outcomes in two existing sites in Albuquerque, New Mexico that serve a large population of Latino diabetes patients from low-income households. Participants were enrolled as dyads-a patient participant (n=226) and a social support participant (n=226). Outcomes over time and by program were analyzed using longitudinal linear mixed modeling, adjusted for patient participant demographic characteristics and other potential confounding covariates. Secondary outcomes were also adjusted for potential confounders. Interactions with both time and program helped to assess outcomes. This study did not find a difference between the two sites with respect to the primary outcome measures and only one of the three secondary outcomes showed differential results. The main difference between programs was that depression decreased more for CCM than for DSMS. An exploratory, subgroup analysis revealed that at CCM, patient participants with a very high A1c (>10) demonstrated a clinically meaningful decrease. However, given the higher cultural competence rating for the CCM, statistically significant improvement in depression, and the importance of social support to the patients, results suggest that a culturally and contextually situated diabetes self-management and education program design may deliver benefit for patients, especially for patients with higher A1c levels.

Our voices, our lives: Unforeseen stories after the violence and opening the door to becoming whole again

We are a group of 11 women in Albuquerque, New Mexico. Nine of us are immigrants from Mexico. One of us is from an immigrant household. One of us is neither. We have been working collaboratively on a research study called Tertulias (Spanish for "a social gathering"), which is an innovative women's peer support group approach we created to reduce social isolation, depression, and stress among women immigrants from Mexico, and to increase their resilience and sense of empowerment. In the process of implementing the Tertulias study, we are revealing the profound power of peer support, friendship, and small, quotidian kindnesses. But we are also exposing the immensity and scope of trauma, fear, loneliness, depression, and self-blame that exist in the Mexican immigrant community because of domestic violence. Our experience with domestic violence and with the consciousness-raising and support we found in Tertulias has made us want to be involved in a positive manner to do something about this issue in our community. We want our experience to mean something-to be used to make a difference. We are opening our hearts and sharing our stories and ideas. We wanted to be included as co-authors of this article because we want our stories to be received and heard by other women. We want to plant seeds to help other women find their inner strength to be able to escape from their chains. We have to return for others. It is a commitment-to understand how we were able to do it and share that with others. Through our experience participating in Tertulias, we learned that we could overcome what felt overwhelming and impenetrable. We could leave the violence and rediscover and recreate ourselves and our lives.

A Study of a Culturally and Contextually Situated Multimedia Approach to Recruit a Hard-to-Reach Spanish-Speaking Population for a Randomized Control Trial (RCT)

Study designs involving randomization can be difficult to communicate to participants, especially those with low literacy. The literature on strategies to explain research concepts is limited, especially for non-English speakers. We measured the effectiveness of a culturally and contextually situated multimedia approach to recruit a cohort of 60 female Mexican immigrants (FMI) to a randomized control trial (RCT) to reduce social isolation and depression. This strategy was designed to explain the concept of randomization, explain what participating in the research study entailed, and ensure informed consent. Potential participants viewed a presentation explaining the study and a video including animation with voice-over explaining the concept of randomization. We administered a pre/post survey. Respondents (N = 59) reported an increase in their understanding of randomization, intention to enroll, and attitude towards participating in research. We conclude that a culturally and contextually situated multimedia approach is an effective model when recruiting underrepresented populations with low literacy for RCTs.

Policy Implications of Structural Violence and Syndemic Dynamics: A Lens for Addressing Latinx Immigrant Diabetes Health Disparities

PURPOSE OF REVIEW

The purpose of this review is to explore using theoretical frameworks of structural violence and syndemics to understand Latinx health disparities with a focus on type 2 diabetes (T2D). We propose that combining these frameworks is a valuable approach for revealing complex root-cause dynamics and explaining the nuances of how and why health disparities exist. We discuss the importance of the relationship between T2D, fear, and stigma.

RECENT FINDINGS

Immigration policy creates structural conditions that invite unauthorized immigration while simultaneously excluding undocumented immigrants from access to healthcare resources. Structural exclusion then breeds fear of immigration status disclosure and deportation and, in the highly politicized immigration context that has emerged over the past two decades, also assigns social sigma to immigration status. Undocumented immigrants lack access to healthcare and health insurance; they cannot afford state-of-the-art drugs, they tend to be socially isolated and lack social capital to navigate systems; they are financially limited by poverty and lack of resources, emotionally taxed by the experience of discrimination, humiliation, and language-related challenges; and they have a toxic immigration stress load in the form of multidimensional fear. Potential areas for policy change are identified. Type 2 diabetes (T2D) follows racial, ethnic, and class fault lines that reflect unequal social and structural dynamics. Latinx immigrants are at disproportionate risk and explaining immigrant T2D social geography requires a holistic lens.

A randomized control trial to test a peer support group approach for reducing social isolation and depression among female Mexican immigrants

BACKGROUND

Female Mexican Immigrants (FMIs) experience high rates of depression compared with other populations. For this population, depression is often exacerbated by social isolation associated with the experience of immigration. Aim 1. To measure whether a culturally situated peer group intervention will reduce depression and stress associated with the experience of immigration. Aim 2. To test whether an intervention using a "women's funds of knowledge" approach results in improved resilience, knowledge and empowerment. Aim 3. To investigate whether a culturally situated peer group intervention using a women's funds of knowledge approach can give participants a sense and experience of social and physical connection ("emplacement") that is lost in the process of immigration.

METHODS

This mixed-methods study will implement "Tertulias" ("conversational gatherings" in Spanish), a peer support group intervention designed to improve health outcomes for FMI participants in Albuquerque, New Mexico. We will document results of the intervention on our primary hypotheses of a decrease in depression, and increases in resilience and social support, as well as on our secondary hypotheses of decreased stress (including testing of hair cortisol as a biomarker for chronic stress), and an increase in social connectedness and positive assessment of knowledge and empowerment.

DISCUSSION

This project will address mental health disparities in an underserved population that experiences high rates of social isolation. Successful completion of this project will demonstrate that health challenges that may appear too complex and too hard to address can be using a multi-level, holistic approach. Our use of hair samples to test for the 3-month average levels of systemic cortisol will contribute to the literature on an emerging biomarker for analyzing chronic stress.

TRIAL REGISTRATION

This study was registered with ClinicalTrials.gov on 2/3/20, Identifier # NCT04254198 .

Increasing the Number of Underrepresented Minority Behavioral Health Researchers Partnering With Underresourced Communities: Lessons Learned From a Pilot Research Project Program

To address critical health equity issues facing racially and ethnically diverse populations, it is essential to have researchers from similarly diverse backgrounds. Such researchers provide different perspectives that may lead to distinct research questions, novel interpretation of findings, and innovative recommendations for health promotion practice. There is a continuing need to increase the number of researchers leading health research studies who are from underrepresented minority populations (URMs). The literature demonstrates the effectiveness of mentoring for career development and the need to hone existing mentoring models. The TREE Center developed an innovative model for building capacity among early stage investigators, with a focus on URMs, to increase the inclusivity of the research pipeline. Our model involves community-engaged behavioral health research mentoring, career development, training for grantspersonship, and guidance for manuscript development and submission. A pilot project program provided opportunities for 10 early stage investigators to develop relationships with public health practitioners and other community partners, to obtain funding, to manage a complex pilot research project, and to generate preliminary data. Awardees worked with an academic mentor, a community mentor, and TREE Center faculty to conduct and disseminate their research. Lessons learned include the need to account for funding cycle timing, address challenges of recruiting URMs, consider overutilization of senior URM mentors, and overcome institutional bureaucracies that hinder transdisciplinary research across campuses. We discuss strategies for addressing these challenges. Our model is replicable and could be implemented, especially by academic programs interested in cultivating early stage URM investigators to conduct behavioral health research.

Training Patient Stakeholders Builds Community Capacity, Enhances Patient Engagement in Research

Our philosophical framework for research with low-income Latino patients with diabetes prioritizes hiring research staff who share the culture and language of the population of study. Inclusive research design requires an active role by patient stakeholders with training opportunities in a collaborative learning environment to allow patient stakeholder data collectors (PSDCs) to build on existing strengths and expertise. To develop this manuscript, our team reflected on our collective experiences in implementing research-specific trainings for PSDCs. Although our population of study is known to be difficult to recruit and retain, our PSDCs have successfully enrolled participants on schedule, and attrition is low. Although language, institutional requirements, and funding restrictions presented training challenges, we overcame these by using a flexible approach and by incorporating the data collectors' expertise in refining our protocols. We propose that our success in recruiting and retaining participants is a reflection of our engaged research strategy and framework and demonstrates that engagement promotes better science. However, our experience also demonstrates research institutions need to make policy and infrastructural improvements to reduce barriers and make engaged approaches more feasible.

Community-Based Participatory Research for Health

The new edition of Community-Based Participatory Research for Health by Nina Wallerstein and colleagues is an extremely valuable resource for a wide variety of stakeholders interested in collaborative work to promote health equity. This updated collection succinctly delineates the theory, history, principles, and practices of community-based participatory research (CBPR) to help the reader understand CBPR as an approach, a philosophy, and an ethic. This updated edition will serve as a helpful resource for those interested in incorporating CBPR principles and approaches into their work. The chapters are authored by leaders and innovators in CBPR who provide insights, share experiences, and describe case studies that expand our ability to understand and envision the transformative power of CBPR in practice. The book is divided thematically into seven parts plus 13 appendices. Updates to this edition align with critical dialogues about positionality, privilege, and power in a way that encourages healthy self-reflection.

Collaboration and Outside-the-Box Thinking to Overcome Training-Related Challenges for Including Patient Stakeholders as Data Collectors in a Patient-Engaged Research Project

Including patient stakeholders as active members of the research team is essential to a patient-engaged research design. To hire community-based research staff for a study comparing the effectiveness of diabetes self-management programs for Latinos, we had to provide phlebotomy training which was not allowed under the fiscal guidelines of our funders. By collaborating with partners at the Clinical and Translational Science Center, we were not only able to find a creative solution and provide phlebotomy training to our research staff but the process of creating the training also contributed to improved infrastructure for patient-engaged research at our institution.

Community–University Health Research Partnerships

In recent years, there have been positive changes to the health research landscape, with increasing interest amongst community organisations and university investigators in establishing research partnerships and with more funding opportunities for community-engaged work. However, creating a community–university partnership requires new skills, new types of knowledge, and new ways of creating and maintaining relationships. On both sides of the research equation, people are looking for guidance. The discussion here uses our experience to offer concrete tips in plain language for strategies that can be used to build capacity for community–university partnerships for organisations and researchers in pre-partnership and early partnership stages. We comment on debates about epistemology and knowledge production in research and how anthropologists are well positioned to contribute to this process.

A comparative effectiveness study of two culturally competent models of diabetes self-management programming for Latinos from low-income households

BACKGROUND

Diabetes risk is extremely high for Latinos from low-income households. Health guidelines recommend that individuals learn strategies to self-manage their diabetes, but getting people to adopt required lifestyle changes is challenging and many people are not able to prevent their pre-diabetes from escalating or effectively control their diabetes. Systematic reviews show that culturally competent self-management programs can significantly improve diabetes outcomes and different models for culturally competent programming have been developed.

METHODS

This patient-engaged study will compare the effectiveness of two distinct evidence-based models for culturally competent diabetes health promotion at two sites that serve a large Latino patient population from low-income households: 1) The Diabetes Self-Management Support Empowerment Model, an educational session approach, and 2) The Chronic Care Model, a holistic community-based program. Data collection will involve interviews, focus groups, surveys and assessments of each program; and testing of patient participants for A1c, depression, Body Mass Index (BMI), and chronic stress with hair cortisol levels. We will recruit a total of 240 patient-social support pairs: Patients will be adults (men and women over the age of 18) who: 1.) Enter one of the two diabetes programs during the study; 2.) Self-identify as "Latino;" 3.) Are able to identify a social support person or key member of their social network who also agrees to participate with them; 4.) Are not pregnant (participants who become pregnant during the study will be excluded); and 5.) Have household income 250% of the Federal Poverty Level (FPL) or below. Social supports will be adults who are identified by the patient participants.

PRIMARY OUTCOME

Improved capacity for diabetes self-management measured through improvements in diabetes knowledge and diabetes-related patient activation.

SECONDARY OUTCOME

Successful diabetes self-management as measured by improvements in A1c, depression scale scores, BMI, and circulating levels of cortisol to determine chronic stress.

DISCUSSION

Our hypothesis is that the program model that interfaces most synergistically with patients' culture and everyday life circumstances will have the best diabetes health outcomes.

TRIAL REGISTRATION

This study was registered with ClinicalTrials.gov on December 16, 2016 (Registration # NCT03004664 ).

Situating Food Insecurity in a Historic Albuquerque Community: The Whorled Relationship between Food Insecurity and Place

This article examines conceptualizations of the relationship between food insecurity and place. We use an ethnographically inspired and community-engaged approach to situate our analysis of fluid dynamics at work in a community with high levels of food insecurity. We propose that the relationship between place and people's experience of food insecurity is recursive, dialectical, and "whorled." This relationship reflects complex, interconnected, and multidimensional processes with consequences for the health of residents. Our research demonstrates the key nature of the health-place nexus by exploring how food insecurity articulates with place in unexpected ways that go beyond discussions of food, food environments, food access, food practices or food systems that have become common in the literature.

Implementing Physical Activity Recommendations in a Tri-Ethnic Rural Community through a Community-University Partnership

BACKGROUND

A tri-ethnic rural community with limited resources and a university Prevention Research Center (PRC) developed a partnership to promote evidence-based physical activity.

OBJECTIVE

The purpose of this study was to investigate how a community-university partnership can disseminate and implement ἀe Commu nity Guide's recommendations for increasing physical activity and create a model for other under-resourced communities experiencing high rates of chronic disease.

METHODS

Qualitative data collected through 47 semistructured interviews, meeting minutes, and local newspaper articles were coded for themes and analyzed for patterns across the data.

RESULTS

Implementation resulted in the creation of new paths and trails, increased walkability throughout the community, local park enhancements, and a community-wide campaign. Lessons learned included the importance of community-defined goals and outcomes, leadership, volunteerism, mutually beneficial goals, synergy, and having nontraditional partners.

CONCLUSION

This research provides a community-university partnership model for implementing evidence-based strategies to increase physical activity in rural communities.

Community Health Workers and Family Medicine Resident Education: Addressing the Social Determinants of Health

Neither the health care system nor the training of medical residents focus sufficiently on social determinants of health. Community health workers (CHWs) are a growing presence in health care settings. Culturally and linguistically competent, typically they are from underserved communities and spend more time addressing social determinants of health than others on the health care team. However, CHWs are an infrequent presence in resident clinical training environments. The University of New Mexico Family Medicine Residency placed family medicine residents at a community clinic in Albuquerque managed by CHWs, recognizing that CHWs' collaboration with residents would enhance resident competency in multiple domains. Residents gained skills from CHWs in inter-professional teamwork, cultural proficiency in patient care, effective communication, provision of cost-conscious care, and advocating for both individual and community health. Our model recognizes the value of CHW skills and knowledge and creates a powerful rationale for greater recognition of CHW expertise and integration of CHWs as members of the care team.

Understanding "agency" in the translation of a health promotion program

Health promotion interventions conducted under "ideal conditions" to prove their efficacy are often difficult to translate and disseminate for utilization in "real-world" settings. This article retrospectively integrates and analyzes the experience of three related projects. We investigate how the development and dissemination of a school-based nutrition and physical activity curriculum for American Indian elementary school children inspired the implementation of an across-the-lifespan train-the-trainer program that has trained more than 600 trainers in American Indian communities nationwide. This process provides an opportunity to explore how individuals in the community and the context in which the research was conducted affected project outcomes in ways which were not anticipated. Results challenge the use of "internal validity" as the primary measure of success in translation-dissemination-utilization research.

"Is always that sense of wanting … never really being satisfied": Women's Quotidian Struggles With Food Insecurity in a Hispanic Community in New Mexico

In this article, we explore women's everyday experiences with food insecurity. Women's narratives from a Hispanic community in New Mexico depict the poignant struggles women confront as they actively engage with buffering the experience of hunger to hide scarcity and mask and cope with emotional distress. These data give us a lens for understanding women's lives in the context of disparity as it relates to food insecurity as a public health issue and provide a way to conceptualize how social determinants operate and integrate with quotidian life activities and processes.

An Integrated Approach to Diabetes Prevention: Anthropology, Public Health, and Community Engagement

Diabetes is an enormous public health problem with particular concern within Hispanic communities and among individuals with low wealth. However, attempts to expand the public health paradigm to include social determinants of health rarely include analysis of social and contextual factors considered outside the purview of health research. As a result, conceptualization of the dynamics of diabetes health disparities remains shallow. We argue that using a holistic anthropological lens has the potential to offer insights regarding the nature of the interface between broader social determinants, health outcomes and health disparity. In a primarily Hispanic, immigrant community in Albuquerque, New Mexico, we conducted a mixed methods study that integrates an anthropological lens with a community engaged research design. Our data from focus groups, interviews, a survey and blood sampling demonstrate the need to conceptualize social determinants more broadly, more affectively and more dynamically than often considered. These results highlight a need to include, in addition to individual-level factors that are traditionally the focus of public health and more innovative structural factors that are currently in vogue, an in-depth, qualitative exploration of local context, social environment, and culture, and their interactions and intersectionality, as key factors when considering how to achieve change. The discussion presented here offers a model for culturally situated and contextually relevant scientific research. This model achieves the objectives and goals of both public health and anthropology while providing valuable insights and mechanisms for addressing health disparity such as that which exists in relation to diabetes among Hispanic immigrants in New Mexico. Such an approach has implications for how research projects are designed and conceptualizing social determinants more broadly. The discussion presented provides insights with relevance for both disciplines.

Health Disparity and Structural Violence: How Fear Undermines Health Among Immigrants at Risk for Diabetes

Diabetes is a national health problem, and the burden of the disease and its consequences particularly affect Hispanics. While social determinants of health models have improved our conceptualization of how certain contexts and environments influence an individual's ability to make healthy choices, a structural violence framework transcends traditional uni-dimensional analysis. Thus, a structural violence approach is capable of revealing dynamics of social practices that operate across multiple dimensions of people's lives in ways that may not immediately appear related to health. Working with a Hispanic immigrant community in Albuquerque, New Mexico, we demonstrate how structural forces simultaneously directly inhibit access to appropriate healthcare services and create fear among immigrants, acting to further undermine health and nurture disparity. Although fear is not normally directly associated with diabetes health outcomes, in the community where we conducted this study participant narratives discussed fear and health as interconnected.