Publications

Abstract

This study examines whether age-related cognitive decline varies by race/ethnicity and how edentulism moderates these effects. Data from the Health and Retirement Study (2006–2020), including 23,669 respondents aged 51 and above across 189,352 person-wave observations were analyzed. Of all respondents, 13.4% were edentulous at baseline, with 65.4% identified as non-Hispanic White, 20.5% non-Hispanic Black, and 14.18% Hispanic. Results from linear mixed-effect models indicated that compared to non-Hispanic Whites, Hispanic and non-Hispanic Black participants exhibited lower baseline cognition scores but slower cognitive decline with age. For edentulous Hispanic participants, this slower rate of decline was attenuated by 0.03 units per year (95% CI: −0.06, −0.01, p =.049). The findings highlighted the need for targeted interventions and policies to improve oral health, particularly for Hispanic populations. Addressing oral health disparities could help mitigate cognitive decline in this group and reduce cognitive health disparities across racial/ethnic groups.

Abstract

Background: Prenatal anxiety affects between 20% and 30% of pregnant people and is associated with adverse prenatal health conditions, birth outcomes, and postpartum mental health challenges. Individuals from racial and ethnic minority groups, sexual and gender minority groups, and those with low income are all at heightened risk for prenatal anxiety due to disproportionate exposure to adverse social determinants of health. Digital cognitive behavioral therapy (dCBT) has been shown to reliably reduce anxiety in mostly White and middle- to higher-income samples, but its efficacy in low-income and marginalized pregnant people is understudied. Objective: We propose a randomized controlled trial of a dCBT (Daylight app, Big Health, Ltd) in a sample of low-income pregnant people oversampled for racial, ethnic, sexual, and gender minority identity. Methods: Participants (N=132) will be randomized to the intervention or waitlist control group using a 1:1 allocation ratio. The intervention will be a self-guided application that uses an online therapist to teach and encourage the practice of 4 key cognitive behavioral therapy skills (eg, identifying catastrophic thinking and increasing physical relaxation) that can reduce anxiety. The primary outcome will be generalized anxiety symptoms; secondary outcomes will include depressive symptoms, stress, pregnancy-specific anxiety, and insomnia symptoms. Focus groups with a subset of participants will provide qualitative data about the acceptability of dCBT. Results: Recruitment began in June 2024. Data will be analyzed using linear mixed models, which will be fit with treatment condition (dCBT and waitlist control group) as the between-group factor, time (baseline, 3, 6, and 10 weeks post randomization) as a within-group factor, and a group-by-time interaction. Linear mixed models produce unbiased parameter estimates in situations where there are different numbers of observations per record and will accommodate intent-to-treat and sensitivity analyses. Conclusions: This clinical trial will evaluate the efficacy and acceptability of a self-guided dCBT for prenatal anxiety among low-income and marginalized pregnant people, a group that continues to experience substantial barriers to accessing in-person evidence-based psychotherapy.

Abstract

Introduction: This study examined oral health trends of older immigrants in the US from 1999 to 2018 and disparities between immigrants and non-immigrants across different races/ethnicities. Methods: Data were from the 1999–2018 National Health and Nutrition Survey (NHANES). Outcome variables were self-reported poor oral health and significant tooth loss (i.e., < 20 permanent teeth). Participants were categorized into three groups as US natives, naturalized citizens, or noncitizen residents. The analytical sample comprised 13,424 older adults (ages 60+), including 10,087 US natives, 2280 naturalized citizens, and 1057 noncitizen residents. We assessed the trends in poor oral health and significant tooth loss across the three groups and conducted analyses stratified by race/ethnicity to examine within-group disparities. Results: From 1999 to 2018, noncitizen residents consistently showed higher rates of poor oral health and significant tooth loss compared to US natives and naturalized citizens. Multiple logistic regression model results showed that naturalized citizens were less likely (AOR = 0.79, p = 0.03) to report poor oral health. Stratified analyses by racial/ethnic groups showed that among Blacks, naturalized citizens were less likely to report poor oral health (AOR = 0.59, p = 0.02) than Blacks who were born in the US. Conclusion: While overall oral health improved among older immigrants from 1999 to 2018, oral health disparities persisted, especially between noncitizen residents and US natives. There were significant differences in oral health between Black immigrants and their US-born counterparts. Future research is needed to corroborate these findings and monitor the trend of oral health disparities.

Abstract

Background: HIV care continuum engagement is inadequate among African American/Black and Latine (AABL) young/emerging adults living with HIV in the United States. Within this population, some subgroups face barriers to research and are under-studied. Grounded in social action theory, the present study focuses on a diverse community-recruited cohort including those with non-suppressed HIV viral load. Using a sequential explanatory mixed methods design, we describe contextual self-regulatory resources (e.g., substance use, mental health), and their relationships to HIV management. Methods: Participants (N = 271) engaged in structured baseline assessments and biomarker testing (HIV viral load, drug screening). Being well-engaged in HIV care and HIV viral suppression were the primary outcomes. We purposively sampled a subset for maximum variability for in-depth interviews (N = 41). Quantitative data were analyzed via descriptive statistics and logistic regression, and results were used to develop qualitative research questions. Then, qualitative data were analyzed via directed content analysis. The joint display method was used to integrate results. Results: Participants’ mean age was 25 years (SD = 2). The majority (59%) were Latine/Hispanic and 41% were African American/Black. Nearly all were assigned male sex at birth (96%) and identified as gay/bisexual/queer (93%). The average HIV diagnosis was 4 years prior (SD = 3). The majority were well-engaged in HIV care (72%) and evidenced viral suppression (81%). Substance use (tobacco, marijuana, alcohol) was prevalent, mainly at low- and moderate-risk levels. Drug screening indicated marijuana, methamphetamine, and MDMA were the most common recent substances. Symptoms of depression and PTSD were associated with decreased odds of engagement in care. High-risk cannabis use was associated with decreased odds of HIV viral suppression. Qualitative results highlighted the prevalence of substance use in social networks and venues, and the importance of substances as a coping strategy, including for mental health distress. Tobacco and methamphetamine (but not marijuana) were described as problematic, and marijuana was used as harm reduction. Substance use was more common among those with non-suppressed versus suppressed HIV viral load. However, overall, substance use did not commonly interfere substantially with HIV management. Conclusions: The present study advances knowledge on AABL young/emerging adults living with HIV and highlights ways to improve screening and services.

Abstract

Rationale: Untreated mental health concerns during pregnancy can have a devastating impact on the well-being of the pregnant person and present risks to the developing fetus, birth outcomes, and child development. Despite these risks, patients report difficulty accessing or maintaining mental health treatment during pregnancy. Clinical reluctance among outpatient psychiatric mental health providers to provide medication management to pregnant patients has been proposed as a significant barrier to care, however, little is known regarding what creates and maintains this reluctance among providers. Objective: Explore outpatient psychiatric mental health providers’ beliefs, experiences, and treatment decisions with an emphasis on understanding reluctance to treat mental health concerns during pregnancy. Method: Using constructivist grounded theory, we conducted in-depth interviews with 21 outpatient psychiatric mental health providers, including psychiatric mental health nurse practitioners and psychiatrists who practiced with adult patients in the United States. Interviews were audio recorded and transcribed verbatim for analysis using dimensional and situational analysis techniques. Results: A lack of training, inadequate knowledge, and fear of personal consequences were frequently cited as motivating factors behind this reluctance. Providers often felt unprepared to treat pregnant clients and appeared to make treatment decisions to protect themselves from perceived legal consequences or to mitigate their own anxiety/discomfort rather than guided by evidence-based guidelines or patient interests. Conclusion: Many providers endorsed discomfort treating pregnant patients and observed this reluctance among peers and colleagues. The processes used to avoid discomfort and uncertainty may limit treatment opportunities for pregnant people in need of mental health care. The results of this study provide implications for education and clinical practice that may lead to improved access to mental health care among pregnant people.

Abstract

The COVID-19 pandemic profoundly impacted population mental health worldwide. Few studies examined how the neighborhood environment and online social connections might influence the social gradient in mental health during the pandemic lockdown. We aim to examine the moderating and mediating role of neighborhood environment and online social connections in the association between socioeconomic status (SES) and mental health outcomes. We conducted a cross-sectional online survey of 3763 Shanghai residents during the COVID-19 lockdown between April 29 and June 1, 2022. Employing OLS linear regression analyses, our findings reveal that SES was negatively associated with depressive symptoms (B = 0.173, p < 0.001) and anxiety (B = 0.147, p < 0.001). The findings supported our hypotheses that this disparity in mental health was partially mediated by neighborhood social capital, community management, and the extent of online social connections measured by the frequency of social connection through the social media WeChat (all p < 0.05). Additionally, neighborhood social capital, community management, and online social connections also mitigated SES-driven mental health inequalities (all p < 0.05). The study underscores the significance of the neighborhood environment and online social interactions in amplifying SES-related mental health effects, offering valuable insights for urban planning and health equity strategies.

Abstract

Obstructive sleep apnea (OSA), a condition with high prevalence, is characterized by reduced dilatory function of pharyngeal muscles, which can be influenced by upper airway narrowing, dilator muscle dysfunction, respiratory dysfunction, and genetics. Three of the most clinically important phenotypes of OSA include disturbed sleep, excessive sleepiness, and minimal symptoms, with varying implications for management and morbidity. This article reviews current perspectives on these OSA phenotypes, as well as the process of confirming a diagnosis of OSA. Lastly, this article delineates various current and future OSA therapy approaches through review and analysis of the existing literature with discussion on the outlook for OSA treatment.

Abstract

Introduction: Translations of patient-reported measures may not account for structural and cultural differences in shared languages spoken in multiple countries, such as English, Spanish, Arabic, or Russian. The objective of this research was to create a cross-cultural Spanish translation of the New York University (NYU) Electronic Patient Visit Assessment (ePVA)© for head and neck cancer (HNC), a patient-reported symptom measure available only in English. Methods: Using the Content Validity Index (CVI) methodology, an expert panel of nurses (n = 6) proficient in Spanish and English independently reviewed and rated a forward translation of the ePVA, a measure consisting of 21 categories of symptoms common to HNC. The panel rated the cultural relevance (1 = not relevant, 2 = somewhat relevant, 3 = very relevant, 4 = highly relevant) and translation equivalence (1 = yes or 0 = no) of each ePVA item. The CVI cultural relevance and translation equivalence scores for each item (item CVI) were calculated as the proportion of experts agreeing that the item was very relevant or highly relevant and the translation was equivalent. The scale CVI score was an average of the item CVI scores; the minimum accepted scale CVI score was.80. Items with CVI scores <0.59 were labeled as problematic items and evaluated through cognitive interviews with native Spanish-speaking patients (N = 4) diagnosed with HNC. Results: The translation was acceptable in cultural relevance (average CVI score = 0.95) and equivalence (average CVI score = 0.84). Cognitive interviews revealed 9 problematic items that differed in words and meaning, primarily addressing pain and swallowing symptoms. These items were refined and included in the final translation of the Spanish ePVA. Conclusion: These study findings underscore the need for survey instrument translations that account for variations in shared languages spoken across countries.

Abstract

This paper is an examination of the relationship between continuity of care with home health physical therapists following hospitalization and the likelihood of readmission. We conducted a retrospective cohort study. Using rehospitalization as the dependent variable, a continuity of care indicator variable was analyzed with a multivariable logistic regression. The indicator variable was created using the Bice-Boxerman Index to measure physical therapist continuity of care. The mean of the index (0.81) was used to separate between high continuity (0.81 or greater) of care and low continuity of care (lower than 0.81). The sample included 90,220 patients, with data coming from the linking of the Outcome Assessment and Information Set (OASIS) and an administrative dataset. All subjects lived in the NYC metro area. Inclusion criteria was a patient’s admission to their first home health care site following discharge occurring between 2010 and 2015, and individuals who identified as Male or Female. In comparison to low continuity of physical therapy, high continuity of physical therapy significantly decreased hospital readmissions (OR = 0.74, 95% CI 0.71-0.76, p ≤.001, AME = −4.28%). Interpersonal continuity of physical therapy care has been identified as a key factor in decreasing readmissions from the home care setting. The research suggests an increased emphasis in preserving physical therapist continuity following hospitalization should be explored, with the potential to reduce hospital readmissions.

Abstract

This paper is an examination of the relationship between continuity of care with home health physical therapists following hospitalization and the likelihood of readmission. We conducted a retrospective cohort study. Using rehospitalization as the dependent variable, a continuity of care indicator variable was analyzed with a multivariable logistic regression. The indicator variable was created using the Bice-Boxerman Index to measure physical therapist continuity of care. The mean of the index (0.81) was used to separate between high continuity (0.81 or greater) of care and low continuity of care (lower than 0.81). The sample included 90,220 patients, with data coming from the linking of the Outcome Assessment and Information Set (OASIS) and an administrative dataset. All subjects lived in the NYC metro area. Inclusion criteria was a patient’s admission to their first home health care site following discharge occurring between 2010 and 2015, and individuals who identified as Male or Female. In comparison to low continuity of physical therapy, high continuity of physical therapy significantly decreased hospital readmissions (OR = 0.74, 95% CI 0.71-0.76, p ≤.001, AME = −4.28%). Interpersonal continuity of physical therapy care has been identified as a key factor in decreasing readmissions from the home care setting. The research suggests an increased emphasis in preserving physical therapist continuity following hospitalization should be explored, with the potential to reduce hospital readmissions.

Abstract

Background: Spiritual care provided by chaplains plays a key role in cancer care in the United States, yet little is known about chaplaincy utilization among people of Dharmic religions (Hinduism, Buddhism, Sikhism, Jainism) with cancer. Methods: This multi-methods study reviewed the records of patients (aged 18 years and older) who were hospitalized at a dedicated cancer hospital (2015–2019) and conducted interviews with chaplains and adults of Dharmic religions (2020). Primary outcomes included measuring chaplaincy utilization (at least one chaplain visit) across different religions and identifying perceptions of chaplaincy. Secondary outcomes involved measuring unmet spiritual needs on admission, types of spiritual care needs, and variables associated with chaplaincy utilization. Results: Of 54,828 patients, 2% were of Dharmic religions (n = 1163; 58.4% Hindu, 33.2% Buddhist, 4.8% Sikh, 3.4% multiple, <1% Jain). Compared with others, those of Dharmic religions were younger (median age, 59 vs. 63 years; p <.001), predominantly East or South Asian (78.7% vs. 5.6%; p <.001), and had higher rates of advanced illness (22.6% vs. 15.2%; p <.001) but lower chaplaincy utilization (31.6% vs. 36.7%; p <.001). There were no significant differences in unmet spiritual needs on admission (Dharmic religions vs. others, 8.7% vs. 9.4%; p =.41). Ritual care was the most frequently documented spiritual care need (72%). Multivariable analysis indicated that longer length of stay, non-Dharmic religion, and advanced illness were associated with higher chaplaincy utilization. Themes identified from the interviews included unfamiliarity with chaplaincy, concerns about faith-discordant care, addressing spiritual care needs independently, and solutions for concordant care. Conclusions: People of Dharmic religions with cancer were less likely to use chaplaincy services. Barriers included unfamiliarity and faith discordance. Spiritual care incorporating faith-specific resources is urgently needed.

Abstract

Background: More than half of stroke survivors suffer from movement disorders after receiving routine rehabilitation treatment. Evidence suggests that virtual reality (VR)-based robotic training for lower limb rehabilitation is a promising approach for improving motor function recovery. Methods: A pilot open-label randomized controlled trial was conducted to explore the feasibility and preliminary effects of VR-based robotic training for lower limb rehabilitation in stroke patients with hemiplegia. We enrolled 42 stroke patients with hemiplegia, 21 received VR-based robotic training for lower limb rehabilitation and conventional rehabilitation treatment as the intervention, and 21 only received conventional rehabilitation treatment as the control. Results: Forty participants completed the trial. We found a statistically significant difference in lower limb motor function scores from baseline to week 4 between the intervention and control group (mean difference (MD): 6.5 vs 3.3, p<0.001). At week 4, participants in the intervention group demonstrated significant enhancements in balancing function, walking ability, activities of daily living, and quality of life (p<0.05). However, the intervention group did not show a significant improvement in global cognitive function compared to the control group (MD: 3.8 vs 3.7, p = 0.873). No adverse events were observed during the trial. Conclusion: The VR-based robotic training for lower limb rehabilitation showed promise in improving motor function, activities of daily living, and quality of life in stroke patients with hemiplegia. These preliminary findings support the feasibility of this approach and highlight the need for large-scale studies to validate its effectiveness.

Abstract

Purpose: Mental health conditions are the leading cause of preventable maternal mortality and morbidity, yet few investigations have examined perinatal bipolar disorders. This study sought to examine racial differences in the odds of having a bipolar disorder diagnosis in perinatal women across self-reported racial groups in a large sample in California, USA. Method: This cross-sectional study uses data from 3,831,593 women who had singleton live births in California, USA from 2011 to 2019 existing in a linked dataset which included hospital discharge records and birth certificates. International Classification of Diseases codes were used to identify women with a bipolar disorder diagnosis code on the hospital discharge record. Medical charts and birth certificate data was used to extract information on clinical and demographic covariate characteristics. Multivariable logistic regression was used to estimate the odds of having a bipolar disorder diagnosis across different self-reported racial groups. Results: We identified 19,262 women with bipolar disorder diagnoses. Differences in the presence of a bipolar disorder diagnosis emerged by self-reported race. In the fully adjusted model, Multiracial (selection of two races self-reported) women, compared to single-race White women had the highest odds of having a bipolar disorder diagnosis. Further examination of the all-inclusive Multiracial category revealed differences across subgroups where White/Black, White/American Indian Alaskan Native, and Black/American Indian Alaskan Native women had increased odds for bipolar disorder compared to single race White women. Conclusions: Differences in bipolar disorder diagnoses exist across racial categories and when compared to White women, Multiracial women had the highest odds of bipolar disorder and thus represent a perinatal population of focus for future intervention studies. The increased burden of mental health problems among Multiracial women is consistent with recent research that employs disaggregated race data. More studies of Multiracial women are needed to determine how self-reported racial categories are related to increased risk for perinatal bipolar disorder.

Abstract

Introduction: Although prostate magnetic resonance imaging (MRI) is commonly used in the diagnosis, staging and active surveillance of prostate cancer, little is known about patient perspectives on MRI. Methods: We performed a qualitative study consisting of in-depth, semi-structured interviews of patients with low- and intermediate-risk prostate cancer managed with active surveillance. Interviews focused on experiences with and knowledge of prostate MRI and MRI-ultrasound fusion biopsy during active surveillance. We purposively sampled patients who received prostate MRI as part of their clinical care, conducted interviews until reaching thematic saturation and performed conventional content analysis to analyse data. Results: Twenty patients aged 51–79 years (mean = 68 years) participated in the study. At diagnosis, 17 (85%) had a Gleason grade group 1, and three (15%) had a grade group 2 tumour. Overall, participants viewed prostate MRI as a valuable tool that accurately localizes and monitors prostate cancer over time, and they considered prostate MRI central to active surveillance monitoring. We identified five thematic categories related to MRI use: (1) the experiential aspects of undergoing an MRI scan; (2) the experience of visualizing one's own prostate and prostate cancer; (3) adequacy of provider explanations of MRI results; (4) confidence in prostate MRI in decision-making; and (5) the role of prostate MRI in longitudinal follow-up, including an interest in using MRI to modify the timing of, or replace, prostate biopsy. Conclusion: Patients value prostate MRI as a tool that enhances their confidence in the initial diagnosis and monitoring of prostate cancer. This work can inform future studies to optimize patient experience, education and counselling during active surveillance for prostate cancer.

Abstract

Foreign-born (first-generation) South Asians face a growing diet-related chronic disease burden. Little is known about whether the adult US-born (second-generation) children of South Asian immigrants can provide unique insights as changemakers in their parents’ dietary behaviors. This study aims to assess how second-generation South Asians describe and influence the dietary behaviors of their parents. Between October and November 2020, 32 second-generation South Asians [mean age 22.4 (SD 2.9), 53% female] participated in online interviews centered around factors involved in their (and their parents) eating behaviors. Thematic analysis revealed three types of parental dietary drivers (socioecological factors that impact the dietary choices of parents): goal-oriented (i.e., parents’ dietary intentionality), capacity-related (e.g., environmental barriers) and sociocultural (cultural familiarity, religion and traditions). Participants described three major mechanisms of influence: recommending new foods, cooking for parents, and bringing new foods home. These influences primarily occurred in the household and often involved participants leveraging their own nutritional knowledge and preferences to expand dietary diversity and healthier behaviors among their parents. Evidence suggests that second-generation South Asians may act as powerful agents of dietary change within their households and can provide novel insights to help address and overcome sociocultural, linguistic, and other structural barriers to better understanding and intervening in the health of the South Asian community.

Abstract

Context: Despite efforts to enhance equity, disparities in early palliative care (PC) access for historically minoritized patients with advanced breast cancer (ABC) persist. Insight into patient and clinician perspectives are needed to inform future models aimed at improving equity in PC access and outcomes. Objectives: To explore qualitative barriers and facilitators to early PC access in an urban setting with Black and Latina women with ABC. Methods: In this qualitative descriptive study, we conducted one-on-one interviews with Black and Latina women with ABC (N = 20) and interdisciplinary clinicians (N = 20) between February 2022 and February 2023. Participants were recruited from urban academic and community cancer clinics. Transcripts were analyzed using an inductive coding and thematic analysis approach. Results: Barriers identified by both patients and clinicians included lack of communication between oncology, PC, and primary care teams, limited understanding of PC among patients and non-PC clinicians, language and health literacy-related communication challenges, and racism and marginalization, including implicit bias and lack of diverse racial/ethnic representation in the supportive care workforce. Facilitators identified by both patients and clinicians included patient-to-patient referrals, support groups breaking cultural stigma on topics including self-advocacy and PC, referrals from trusted providers, and community organizations’ abilities to overcome challenges related to social determinants of health, most specifically logistical and financial support. Conclusions: Patients and clinicians reported similar barriers and facilitators to PC access, most commonly through the lens of care coordination and communication. These findings will inform future adaptation of a culturally and linguistically care model to improve access to early PC services for Black and Latina women with ABC.

Abstract

Objectives: This qualitative study explored experiences of 15 women in New York City who suffered physical, emotional, and socioeconomic consequences of severe maternal morbidity (SMM). This study aimed to increase our understanding of additional burdens these mothers faced during the postpartum period. Methods: Qualitative analysis of in-depth interviews (n = 15) with women who had given birth in NYC hospitals and experienced SMM. We focused on how experiences of SMM impacted postpartum recoveries. Grounded theory methodology informed analysis of participants’ one-on-one interviews. To understand the comprehensive experience of postpartum recovery after SMM, we drew on theories about social stigma, reproductive equity, and quality of care to shape constant-comparative analysis and data interpretation. Findings: Three themes were generated from data analysis: ‘Caring for my body’ defined by challenges during physical recuperation, ‘caring for my emotions’ which highlighted navigation of mental health recovery, and ‘caring for others’ defined by care work of infants and other children. Most participants identified as Black, Latinx and/or people of color, and reported the immense impacts of SMM across aspects of their lives while receiving limited access to resources and insufficient support from family and/or healthcare providers in addressing postpartum challenges. Conclusions for Practice: Findings confirm the importance of developing a comprehensive trauma-informed approaches to postpartum care as a means of addressing SMM consequences.