Translating Behavioral Interventions for Health Disparity Populations

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In FY20, we made significant progress on the three program objectives listed in the preceding section. We continued to publish manuscripts advancing frameworks, methods and measures for behavioral interventions to reduce health disparities, completed and published on the implementation and results of the NA-II RCT conducted in three rural communities, finalized the guide to implementation of the NA-II stress management program, and created a website (https://nuevoamanecer.ucsf.edu/home) that now hosts all of the intervention materials, evaluation tools, and supporting materials for the program. These accomplishments are described in further detail next. Regarding objective 1, the advancement of frameworks, methods and measures for behavioral interventions to reduce health disparities, we published several papers that provide guidance on successful methodological approaches for working with health disparities communities. One of these was a nested study in the NA-II trial that developed and tested participant-centered strategies for overcoming barriers to biospecimen collection among Spanish-speaking breast cancer survivors (Samayoa C, et al, 2020 CEBP). In that study, community health workers used bilingual, multimedia materials to instruct participants on collecting biospecimens over 3 days. Donation rates for salivary DNA for telomere analysis, saliva for cortisol awakening response, and hair for cortisol concentration analysis were 98%, 89% and 52%. Hair sample collection was low due to hair loss associated with cancer treatments. Results support the feasibility of including minorities in biomedical research, with excellent rates of saliva collection when community partners are engaged in the process, and patient-centered and culturally tailored recruitment methods are implemented. We published a new multidimensional framework demonstrating its preliminary validity for studying the effects of cancer health literacy on cancer screening behaviors among diverse populations (Echeverri M, et al, 2020 IJERPH). Another publication describes recommended guidelines for evaluating a recruitment plan and outcomes for feasibility studies of behavioral trials in diverse populations (Stewart AL, et al, 2020 Ethnicity and Disease). Other accomplishments related to objective 1, include publication of the results of interviews with intervention participants, interventionists, and administrators involved in a cluster RCT with diverse adults age 60 and older (n=390) conducted in 12 senior centers that tested the effects of community choirs on physical, emotional and cognitive health (Allison T, et al, Geriatric Nursing). Psychosocial benefits identified included: increased sense of well-being, improved self-esteem and self-efficacy, decreased loneliness, a sense of finding ones place in society, and a sense of cultural identity/appreciation. Participants described finding their voices in terms of assertiveness and vocal strength, and identified improvements in stamina, memory, attention and learning new skills. A conceptual framework for designing arts-engaged research for diverse populations was included. We also published a paper on future directions in delivery of mHealth interventions for supportive cancer care and the implications for diverse populations (Chan R, et al, 2020 Supportive Care in Cancer). Other published papers during FY20 included a paper describing community consultation methods for the development of an adapted Health Information National Trends Survey (HINTS) that was translated into 4 languages for use in under-represented communities of San Francisco. A collaborative, community-based approach led to a large, diverse sample and may serve as a model for recruiting diverse populations to add knowledge about cancer prevention preferences and behaviors. The study found that cancer screening adherence varied by race, ethnicity, and screening type, suggesting that targeted outreach efforts are needed to address disparate cancer screening behaviors within this diverse population. Another paper that sought to identify recommended practices for cancer survivorship programs in safety net primary care found in a survey study that safety net primary care providers (PCPs) prefer a shared care model for care of cancer survivors but are limited by lack of training, poor oncologist-PCP-patient communication, and poor delineation of roles (Dixit N, et al, 2019 Supportive Care in Cancer). Finally, in collaborations with NCI DECG investigators, published papers included one (Chen Y, et al, 2020 JAMA Network Open) that found that premature mortality rates are lower for U.S. Latino populations and several Latin American countries than for U.S. white populations (and higher rates of U.S. African American populations, especially women). Another paper found that during 2000-2017, 1.45 million drug poisoning, suicide, and alcohol-induced premature deaths (so-called deaths of despair) occurred in the U.S., 450,000 more than expected based on 2000 rates (Shiels MS, et al, 2020 JAMA Network Open). Demographic and geographic patterns varied by cause-of-death, suggesting that increasing death rates from these causes are not a single epidemic concentrated in one group or region. Both of these papers suggest that specialized interventions tailored for the underlying drivers of cause-specific premature death are urgently needed to reduce health disparities. Related to objective 2, the translation of NA-II, our stress management program for diverse populations, we published a paper that describes the application of our Transcreation Framework, a community-engaged translational model, to develop the adapted NA-II program, design a RCT for community settings, identify recruiters and interventionists, and recruit participants into the trial (Santoyo-Ollson J, et al, 2019 PLOS ONE). This paper provides a detailed example of how to engage community stakeholders in designing community-based RCTs that are more likely to succeed due to their congruence with the community contexts of vulnerable populations. In FY20, we completed data analyses and a manuscript on the main outcomes of a multisite, RCT of Nuevo Amanecer (NA-II), a 10-week stress management program for rural, low literacy Latina breast cancer survivors. Rural Spanish-speaking Latinas with non-metastatic breast cancer (N=153) were randomized to the intervention or a wait-list control group. We found that stress management programs delivered by trained peers in rural community settings can reduce anxiety and improve stress management skills among Latina breast cancer survivors (Napoles AM, et al, 2020 Psycho-Oncology). Related to objective 3, development of program implementation support for communities to implement NA-II, we finalized intervention manuals (English and Spanish languages) and the implementation guide for the Nuevo Amancer program. The project website is now live and contains all program materials so that it is accessible to the public for wider dissemination (https://nuevoamanecer.ucsf.edu/home.