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Relationship Between Negative Mood and Health Behaviors in an Immigrant and Refugee Population

Journal of Immigrant and Minority Health, 2016 Sept 26 [Epub ahead of print]

Abstract: Immigrants experience an escalation of negative health behaviors after arrival to the United States. Negative mood is associated with poorer health behaviors in the general population; however, this relationship is understudied in immigrant populations. Adolescent (n = 81) and adult (n = 70) participants completed a health behavior survey for immigrant families using a community-based participatory research approach. Data was collected for mood, nutrition, and physical activity. Adolescents with positive mood drank less regular soda, and demonstrated more minutes, higher levels, and greater social support for physical activity (all ps < .05). Adults with positive mood reported more snacking on fruits/vegetables, greater self-efficacy for physical activity, and better physical well-being (all ps < .05). Negative mood was associated with low physical activity level and poor nutritional habits in adolescent and adult immigrants. Designing community-based programs offering strategies for mood management and healthy lifestyle change may be efficacious for immigrant populations.


Treatment Fidelity Among Family Health Promoters Delivering a Physical Activity and Nutrition Intervention to Immigrant and Refugee Families 

Health Educ Behav. 2016 Jun 6 [Epub ahead of print]

Abstract: Lack of treatment fidelity can be an important source of variation affecting the credibility and utility of outcomes from behavioral intervention research. Development and implementation of a well-designed treatment fidelity plan, especially with research involving underserved populations, requires careful conceptualization of study needs in conjunction with what is feasible in the population. The purpose of this article is to review a fidelity-monitoring plan consistent with the National Institutes of Health Behavior Change Consortium guidelines (e.g., design, training, delivery, receipt, and enactment) for an intervention trial designed to improve physical activity and nutrition among immigrant and refugee families. Description of the fidelity monitoring plan is provided and challenges related to monitoring treatment fidelity in a community-based participatory intervention for immigrant and refugee families are discussed.


Lessons Learned from Community-Led Recruitment of Immigrants and Refugee Participants for a Randomized, CommunityBased Participatory Research Study

Journal of Immigrant and Minority Health, 2016 March 16

Background: Ethnic minorities remain underrepresented in clinical trials despite efforts to increase their enrollment. Although community-based participatory research (CBPR) approaches have been effective for conducting research studies in minority and socially disadvantaged populations, protocols for CBPR recruitment design and implementation among immigrants and refugees have not been well described.

Methods: We used a community-led and community-implemented CBPR strategy for recruiting 45 Hispanic, Somali, and Sudanese families (160 individuals) to participate in a large, randomized, community-based trial aimed at evaluating a physical activity and nutrition intervention.

Results: We achieved 97.7 % of our recruitment goal for families and 94.4 % for individuals.

Conclusions: Use of a CBPR approach is an effective strategy for recruiting immigrant and refugee participants for clinical trials. We believe the lessons we learned during the process of participatory recruitment design and implementation will be helpful for others working with these populations.


Healthy immigrant families: Participatory development and baseline characteristics of a community-based physical activity and nutrition intervention

Contemporary Clinical Trials. 2015 Dec 4;47:22-31

Background: US immigrants often have escalating cardiovascular risk. Barriers to optimal physical activity and diet have a significant role in this risk accumulation.

Methods: We developed a physical activity and nutrition intervention with immigrant and refugee families through a community-based participatory research approach. Work groups of community members and health scientists developed an intervention manual with 12 content modules that were based on social-learning theory. Family health promoters from the participating communities (Hispanic, Somali, Sudanese) were trained to deliver the intervention through 12 home visits during the first 6months and up to 12 phone calls during the second 6months. The intervention was tested through a randomized community-based trial with a delayed-intervention control group, with measurements at baseline, 6, 12, and 24months. Primary measurements included accelerometer-based assessment of physical activity and 24-hour dietary recall. Secondary measures included biometrics and theory-based instruments.

Results: One hundred fifty-one individuals (81 adolescents, 70 adults; 44 families) were randomized. At baseline, mean (SD) time spent in moderate-to-vigorous physical activity was 64.7 (30.2) minutes/day for adolescents and 43.1 (35.4) minutes/day for adults. Moderate dietary quality was observed in both age groups. Biometric measures showed that 45.7% of adolescents and 80.0% of adults were overweight or obese. Moderate levels of self-efficacy and social support were reported for physical activity and nutrition.

Conclusions: Processes and products from this program are relevant to other communities aiming to reduce cardiovascular risk and negative health behaviors among immigrants and refugees.


Diabetes Knowledge, Attitudes and Behaviors Among Somali and Latino Immigrants

Journal of Immigrant and Minority Health. 2015 Dec 26. [Epub ahead of print]

Background: Persons from Somalia constitute the largest group of immigrants and refugees from Africa among whom diabetes-related health disparities are well documented.

Methods: As one of the first steps toward developing a behavioral intervention to address diabetes among Somali immigrants and refugees, we administered a face to face interview-based survey to Somali and Latino adults with diabetes in a single community to assess diabetes knowledge, attitudes and behaviors.

Results: Respondents (N = 78) reported several barriers to optimal diabetes management for physical activity and glucose self-monitoring, as well as a high burden of disease and negative perceptions of diabetes. High participant engagement in disease management, self-efficacy, and social support were important assets. Similarities suggest that the shared experiences of immigration and related systemic socioeconomic and linguistic factors play a significant role in the understanding and self-management of diabetes in these populations.

Conclusions: Together with previously collected qualitative work, the survey findings will inform development of a behavioral intervention to improve outcomes and reduce diabetes-related health disparities among immigrant and refugee groups to the U.S.

Stories for change: development of a diabetes digital storytelling intervention for refugees and immigrants to Minnesota using qualitative methods

BMC Public Health 2015 Dec 29;15(1):1311

Background: Immigrants and refugees are affected by diabetes-related health disparities, with higher rates of incident diabetes and sub-optimal diabetes outcomes. Digital storytelling interventions for chronic diseases, such as diabetes may be especially powerful among immigrants because often limited English proficiency minimizes access to and affects the applicability of the existing health education opportunities. Community-based participatory research (CBPR), whereby community members and academia partner in an equitable relationship through all phases of the research, is an intuitive approach to develop these interventions. The main objective of this study was to develop a diabetes digital storytelling intervention with and for immigrant and refugee populations.

Methods: We used a CBPR approach to develop a diabetes digital storytelling intervention with and for immigrant and refugee Somali and Latino communities. Building on an established CBPR partnership, we conducted focus groups among community members with type II diabetes for a dual purpose: 1) to inform the intervention as it related to four domains of diabetes self-management (medication management, glucose self-monitoring, physical activity, and nutrition); 2) to identify champion storytellers for the intervention development. Eight participants attended a facilitated workshop for the creation of the digital stories.

Results: Each of the eight storytellers, from the Somali and Latino communities with diabetes (four from each group), created a powerful and compelling story about their struggles and accomplishments related to the four domains of diabetes self-management.

Conclusions: This report is on a systematic, participatory process for the successful development of a diabetes storytelling intervention for Somali and Latino adults. Processes and products from this work may inform the work of other CBPR partnerships.


Perspectives on Physical Activity Among Immigrants and Refugees to a Small Urban Community in Minnesota

Journal of Immigrant and Minority Health, 2015 Feb;17(1):263-75

Background: Immigrants and refugees to the United States exhibit relatively low levels of physical activity, but reasons for this disparity are poorly understood.

Methods: 16 gender and age-stratified focus groups were conducted among 127 participants from heterogenous immigrant and refugee groups (Cambodian, Mexican, Somali, Sudanese) in a small Minnesota urban community. We found many similarities in perceived barriers and facilitators to physical activity between heterogeneous immigrant and refugee groups. While the benefits of physical activity were widely acknowledged, lack of familiarity and comfort with taking the first steps towards being physically active were the most significant barriers to physical activity. Participants described being motivated by social support from family, friends, and communities to be physically active.

Conclusion: Our findings suggest that shared experiences of immigration and associated social, economic, and linguistic factors influence how physical activity is understood, conceptualized and practiced.


Lessons Learned: Cultural and Linguistic Enhancement of Surveys Through Community-Based Participatory Research

Progress in Community Health Partnerships: Research, Education, and Action, Volume 8, Issue 3, Fall 2014

Background: Surveys are frequently implemented in community-based participatory research (CBPR), but adaptation and translation of surveys can be logistically and methodologically challenging when working with immigrant and refugee populations. We sought to describe a process of participatory adaptation and translation.

Methods: Within an established CBPR partnership, a survey about diabetes was adapted for health literacy and local relevance and then translated through a process of forward translation, group deliberation, and back translation.

Lessons Learned: The group deliberation process was the most time-intensive and important component of the process. The process enhanced community ownership of the larger project while maximizing local applicability of the product.

Conclusions: A participatory process of survey adaptation and translation resulted in significant revisions to approximate semantic, cultural, and conceptual equivalence with the original surveys. This approach is likely to enhance community acceptance of the survey instrument during the implementation phase.

Perceived impact of human subjects protection training on community partners in community based participatory research

Progress in Community Health Partnerships: Research Education, and Action, Volume 8, Issue 2, Summer 2014, pp. 241-248

Background: Human subjects protection training (HSPT) is a requirement of institutional review boards (IRBs) for individuals who engage in research. The lack of HSPT among community partners may contribute to power imbalance between community and academic members of communitybased participatory research (CBPR) partnerships. We sought to describe the implementation and evaluation of HSPT among community members of a CBPR partnership.

Methods: Seven community partners participated in HSPT through adaptation of an existing institutional program. Evaluation of program acceptability was measured through a 5-item survey (5-point Likert scales). A focus group with all seven participants was conducted to evaluate the impact of training on perceptions of research, characteristics of a successful program, and potential value of training to CBPR partnerships. Coding and inductive analysis were done on the transcript with NVIVO-9 software.

Results: The HSPT program was highly acceptable (mean score, 4.5 ± 0.2). Focus groups revealed that training implementation should be done as a cohesive group withthe opportunity to discuss concepts as they pertain to partnership projects. Training fostered an encouraging and safe environment, accommodated diverse learning styles,and promoted interaction. Participants reported improved trust in research as a result of the training. Perceived impact of the training on the CBPR partnership included improved transparency and enhanced camaraderie while establishing essential knowledge required for community leaders.

Conclusions: HSPT is feasible among community members of a CBPR partnership, and may improve perceptions of research while strengthening capacity of partnerships to impact community health.

A Focus Group Study of Healthy Eating Knowledge, Practices, and Barriers among Adult and Adolescent Immigrants and Refugees in the United States

International Journal of Behavioral Nutrition and Physical Activity 2014, 11:63

Background: Immigrants and refugees to the United States exhibit lower dietary quality than the general population, but reasons for this disparity are poorly understood. In this study, we describe the meanings of food, health and wellbeing through the reported dietary preferences, beliefs, and practices of adults and adolescents
from four immigrant and refugee communities in the Midwestern United States.

Methods: Using a community based participatory research approach, we conducted a qualitative research study with 16 audio-recorded focus groups with adults and adolescents who self-identified as Mexican, Somali, Cambodian, and Sudanese. Focus group topics were eating patterns, perceptions of healthy eating in the country of origin and in the U.S., how food decisions are made and who in the family is involved in food preparation and decisions, barriers and facilitators to healthy eating, and gender and generational differences in eating practices. A team of investigators and community research partners analyzed all transcripts in full before reducing data to codes through consensus. Broader themes were created to encompass multiple codes.

Results: Results show that participants have similar perspectives about the barriers (personal, environmental, structural) and benefits of healthy eating (e.g., ‘junk food is bad’). We identified four themes consistent across all four communities: Ways of Knowing about Healthy Eating (‘Meanings;’ ‘Motivations;’ ‘Knowledge Sources’), Eating Practices (‘Family Practices;’ ‘Americanized Eating Practices’ ‘Eating What’s Easy’), Barriers (‘Taste and Cravings;’ ‘Easy Access to Junk Food;’ ‘Role of Family;’ Cultural Foods and Traditions;’ ‘Time;’ ‘Finances’), and Preferences for Intervention (‘Family Counseling;’ Community Education;’ and ‘Healthier Traditional Meals.’). Some generational (adult vs. adolescents) and gender differences were observed.

Conclusions: Our study demonstrates how personal, structural, and societal/cultural factors influence meanings of food and dietary practices across immigrant and refugee populations. We conclude that cultural factors are not fixed variables that occur independently from the contexts in which they are embedded.


Physical Activity Among Somali Men in Minnesota: Barriers, Facilitators, and Recommendations

American Journal of Men’s Health 2014, 8:35

Background: Immigrants and refugees arrive to the United States healthier than the general population, but this advantage declines with increasing duration of residence. One factor contributing to this decline is suboptimal physical activity, but reasons for this are poorly understood. Persons from Somalia represent the largest African refugee population to the United States, yet little is known about perceptions of physical activity among Somali men.

Methods: Somali members of a community-based participatory research partnership implemented three age-stratified focus groups and three semistructured interviews among 20 Somali men in Rochester, Minnesota. Team-based inductive analysis generated themes for barriers and facilitators to physical activity.

Conclusion: Barriers to physical activity included less walking opportunities in the United States, embarrassment about exercise clothing and lack of familiarity with exercise equipment/modalities, fear of harassment, competing priorities, facility costs, transportation, and winter weather. Facilitators to physical activity included high knowledge about how to be active, success stories from others in their community as inspiration, and community cohesion. Findings may be used to derive interventions aimed to promote physical activity among Somali men in the United States.


Evaluation of a Tuberculosis Education Video Among Immigrants and Refugees at an Adult Education Center: A Community-Based Participatory Approach

Journal of Health Communication,0:1-11, 2013

Background: Tuberculosis disproportionately affects immigrants and refugees to the United States. Upon arrival to the United States, many of these individuals attend adult education centers, but little is known about how to deliver tuberculosis health information at these venues. Therefore, the authors used a participatory approach to design and evaluate a tuberculosis education video in this setting.

Methods: The authors used focus group data to inform the content of the video that was produced and delivered by adult learners and their teachers. The video was evaluated by learners for acceptability through 3 items with a 3-point Likert scale. Knowledge (4 items) and self-efficacy (2 items) about tuberculosis were evaluated before and after viewing the video. A total of 159 learners (94%) rated the video as highly acceptable. Knowledge about tuberculosis improved after viewing the video (56% correct vs. 82% correct; p < .001), as did tuberculosis-related self-efficacy (77% vs. 90%; p < .001).

Conclusion: Adult education centers that serve large immigrant and refugee populations may be excellent venues for health education, and a video may be an effective tool to educate these populations. Furthermore, a participatory approach in designing health education materials may enhance the efficacy of these tools.


Perceptions of Tuberculosis Among Immigrants and Refugees at an Adult Education Center: A Community-Based Participatory Research Approach

Journal of Immigrant and Minority Health 2012, 14:14–22

Background: English as a Second Language programs serve large foreign-born populations in the US with elevated risks of tuberculosis (TB), yet little is known about TB perceptions in these settings.

Methods: Using a community-based participatory research approach, we elicited perceptions about TB among immigrant and refugee learners and staff at a diverse adult education center. Community partners were trained in focus groups moderation. Ten focus groups were conducted with 83 learners and staff. Multi-level, team-based qualitative analysis was conducted to develop themes that informed a model of TB perceptions among participants. Multiple challenges with TB control and prevention were identified. There were a variety of misperceptions about transmission of TB, and a lack of knowledge about latent TB. Feelings and perceptions related to TB included secrecy, shame, fear, and isolation. Barriers to TB testing include low awareness, lack of knowledge about latent TB, and the practical considerations of transportation, cost, and work schedule conflicts. Barriers to medication use include suspicion of generic medications and perceived side effects.

Conclusion: We posit adult education centers with large immigrant and refugee populations as excellent venues for TB prevention, and propose several recommendations for conducting these programs. Content should dispel the most compelling misperceptions about TB transmission while clarifying the difference between active and latent disease. Learners should be educated about TB in the US and that it is curable. Finally, TB programs that include learners and staff in their design and implementation provide greater opportunity for overcoming previously unrecognized barriers.

Physical Activity and Nutrition among Immigrant and Refugee Women: A Community-Based Participatory Research Approach

Women’s Health Issues 22-2, 2012, e225-e232

Background: Immigrant and refugee populations arrive to the U.S. healthier than the general population, but the longer they reside, the more they approximate the cardiovascular risk profiles of the country. Among women, these declines are partly mediated by less physical activity and lower dietary quality upon immigration. Given the complex forces that influence these behaviors, a community-based participatory research (CBPR) approach is appropriate. Therefore, a socioculturally responsive physical activity and nutrition program was created with and for immigrant and refugee women in Rochester, Minnesota, through a CBPR approach.

Methods: Focus groups informed program content and revealed principles for designing the sessions. A 6-week program with two, 90-minute classes per week was conducted among 45 women (Hispanic, Somali, Cambodian, and non-immigrant African American). Average attendance was 22.5 women per class; 34 women completed the evaluation.

Results: Evaluation revealed high acceptability (average overall score of 4.85 out of 5 on the Physical Activity Class Satisfaction Questionnaire). After the intervention, participants were more likely to exercise regularly (p .001). They reported higher health-related quality of life (p .001) and self-efficacy for diet (p ¼ .36) and exercise (p ¼ .10). Likewise, there were trends for weight loss (87 vs 83.4 kg; p ¼ .65), decreased waist circumference (99.6 vs 95.5 cm; p ¼ .35), and lower blood pressure (125/80 vs 122/76 mm/Hg; p ¼ .27).

Conclusion: A CBPR approach to design and implement a socioculturally responsive fitness program was highly acceptable to immigrant and refugee women and demonstrated promising outcomes. Further testing of physical activity and nutrition interventions that arise organically from target communities are needed.

Screening for Tuberculosis at an Adult Education Center: Results of a Community-Based Participatory Process

American Journal of Public Health, July 2011, Vol. 101, No. 7

Objectives: We used a community-based participatory research (CBPR) approach to plan and implement free TB skin testing at an adult education center to determine the efficacy of CBPR with voluntary tuberculosis (TB) screening and the prevalence of TB infection among immigrant and refugee populations.

Methods: We formed a CBPR partnership to address TB screening at an adult education center that serves a large immigrant and refugee population in Rochester, Minnesota. We conducted focus groups involving educators, health providers, and students of the education center, and used this input to implement TB education and TB skin testing among the center’s students.

Results: A total of 259 adult learners volunteered to be skin-tested in April 2009; 48 (18.5%) had positive TB skin tests.

Conclusion: Our results imply that TB skin testing at adult education centers that serve large foreign-born populations may be effective. Our findings also show that a participatory process may enhance the willingness of foreign-born persons to participate in TB skin-testing efforts.


Capacity Building through Focus Group Training in Community-based Participatory Research

Education for Health, Volume 24, Issue 3, 2011

Background: Community-based participatory research (CBPR) emphasizes collaborative efforts among communities and academics where all members are equitable contributors. Capacity building through training in research methodology is a potentially important outcome for CBPR partnerships.

Objectives: To describe the logistics and lessons learned from building community research capacity for focus group moderation in the context of a CBPR partnership.

Methods: After orientation to CBPR principles, members of a US suburban community underwent twelve hours of interactive learning in focus group moderation by a national focus group expert. An additional eight-hour workshop promoted advanced proficiency and built on identified strengths and weaknesses. Ten focus groups were conducted at an adult education center addressing a health concern previously identified by the center’s largely immigrant and refugee population. Program evaluation was achieved through multiple observations by community and academic-based observers.

Results: Twenty-seven community and academic members were recruited through established relationships for training in focus group moderation, note-taking, and report compilation. Focus group training led to increased trust among community and research partners while empowering individual community members and increasing research capacity for CBPR.

Conclusion: Community members were trained in focus group moderation and successfully applied these skills to a CBPR project addressing a health concern in the community. This approach of equipping community members with skills in a qualitative research method promoted capacity building within a socio-culturally diverse community, while strengthening community-academic partnership. In this setting, capacity building efforts may help to ensure the success and sustainability for continued health interventions through CBPR.