Faculty Bibliography

OBJECTIVES/OBJECTIVE:Immigrant adults tend to have better health than native-born adults despite lower incomes, but the health advantage decreases with length of residence. To determine whether immigrant adults have a health advantage over US-born adults in New York City, we compared cardiovascular disease (CVD) risk factors among both groups. METHODS:Using data from the New York City Health and Nutrition Examination Survey 2013-2014, we assessed health insurance coverage, health behaviors, and health conditions, comparing adults ages ≥20 born in the 50 states or the District of Columbia (US-born) with adults born in a US territory or outside the United States (immigrants, following the National Health and Nutrition Examination Survey) and comparing US-born adults with (1) adults who immigrated recently (≤10 years) and (2) adults who immigrated earlier (>10 years). RESULTS:< .05). Comparable proportions of immigrant adults and US-born adults were overweight or obese (67% vs 63%) and reported CVD (both 7%). Immigrant adults who arrived recently were less likely than immigrant adults who arrived earlier to have diabetes or high cholesterol but did not differ overall from US-born adults. CONCLUSIONS:Our findings may help guide prevention programs and policy efforts to ensure that immigrant adults remain healthy.

PURPOSE/OBJECTIVE:In this study we aim to estimate the change in metabolic syndrome (MetS) prevalence among New York City (NYC) adults between 2004 and 2013-2014 and identify key subgroups at risk. METHODS:We analyzed data from NYC Health and Nutrition Examination Survey. MetS was defined as having at least three of the following: abdominal obesity, low HDL, elevated triglycerides, glucose dysregulation, and elevated blood pressure. We calculated age-standardized MetS prevalence, change in prevalence over time, and prevalence ratios by gender and race/ethnicity groups. We also tested for additive interaction. RESULTS:In 2013-2014 MetS prevalence among NYC adults was 24.4% (95% CI, 21.4-27.6). Adults 65+ years and Asian adults had the highest prevalence (45.6% and 33.8%, respectively). Abdominal obesity was the most prevalent MetS component in 2004 and 2013-2014 (50.7% each time). Between 2004 and 2013-2014, MetS decreased by 18.2% (P = .04) among women. The decrease paralleled similar declines in elevated triglycerides and glucose dysregulation. In 2013-14, non-Latino Black women had higher risk of MetS than non-Latino Black men and non-Latino White adults. CONCLUSION/CONCLUSIONS:Age and racial/ethnic disparities in MetS prevalence in NYC were persistent from 2004 to 2013-2014, with Asian adults and non-Latino Black women at particularly high risk.

Diabetes and hypertension are socially patterned by individual race/ethnicity and by neighborhood economic context, but distributions among Asian subgroups are undercharacterized. We examined variation in prevalence for both conditions, comparing between US Asian subgroups, including within South Asian nationalities, and comparing within subgroups by neighborhood economic context. We obtained data on a non-probability sample of 633,664 patients ages 18-64 in New York City, NY, USA (2014-2017); 30,138 belonged to one of seven Asian subgroups (Asian Indian, Bangladeshi, Pakistani, Chinese, Korean, Japanese, and Filipino). We used electronic health records to classify disease status. We characterized census tract economic context using the Index of Concentration at the Extremes and estimated prevalence differences using multilevel models. Among Asian men, hypertension prevalence was highest for Filipinos. Among Asian women, hypertension prevalence was highest for Filipinas and Bangladeshis. Diabetes prevalence was highest among Pakistanis and Bangladeshis of both genders, exceeding all other Asian and non-Asian groups. There was consistent evidence of an economic gradient for both conditions, whereby persons residing in the most privileged neighborhood tertile had the lowest disease prevalence. The economic gradient was particularly strong for diabetes among Pakistanis, whose prevalence in the most deprived tertile exceeded that of the most privileged by 9 percentage points (95% CI 3, 14). Only Koreans departed from the trend, experiencing the highest diabetes prevalence in the most privileged tertile. US Asian subgroups largely demonstrate similar neighborhood economic gradients as other groups. Disaggregating Asian subgroups, including within South Asian nationalities, reveals important heterogeneity in prevalence.

PURPOSE OF REVIEW:To outline intervention efforts focused on reducing hypertension disparities in immigrant communities in the U.S. and to identify areas in the design, implementation, and evaluation of these interventions that warrant further exploration guided by an implementation science framework. RECENT FINDINGS:Studies examined (n = 11) included immigrant populations of African, Hispanic, and Asian origin. Men were underrepresented in most studies. Culturally tailored group-based educational sessions in religious or community spaces were common. Intervention agents included research assistants, registered nurses, community health workers, and faith-based organization volunteers. Community stakeholders were engaged in most studies, although most commonly for recruitment efforts. Surveys/interviews were used for intervention evaluation, and documentation of intervention activities and trainings was used to assess fidelity. Identified pathways for further intervention innovation included gender or migration-status-based targeting, diversifying intervention agents, enhancing mixed-method process evaluations, and tailoring to emerging needs during the COVID-19 pandemic.

BACKGROUND: Assessing implementation fidelity is critical for complex interventions to understand the reasons for their success or failure. However, few interventions systematically document and report implementation processes. Therefore, we sought to conduct concurrent process evaluation of CHORD (Community Health Outreach to Reduce Diabetes), a pragmatic, clusterrandomized, controlled trial aimed at evaluating the impact of a Community Health Workers (CHW) led, health coaching intervention (in-person and remotely) on preventing the onset of type 2 Diabetes Mellitus (DM).
METHOD(S): The study population included primary care patients with prediabetes range glycemia at 2 NYC safety-net hospitals (VA NY Harbor and Bellevue - BH). Primary care teams were randomized to receive the CHWdriven, one-year intervention. Of the 559 patients enrolled in the intervention arm, 79.4% completed an intake survey, constituting the analytic sample for fidelity assessment. The Conceptual Framework for Implementation Fidelity (CFIF) was applied to measure implementation fidelity and factors moderating fidelity of the 3 core intervention components: patient goal setting, education topic coaching with CHWs, and referrals made to address social determinants of health. Descriptive statistics and regression models were computed to determine factors related to fidelity.
RESULT(S): The 2 study sites contributed 60% (BH) and 40% (VA) of the sample. Protocol adherence was as intended in the protocol for the 3 core components with more than 80% of patients setting >1 goal and receiving coaching on >1 education topic, and 45.0% receiving >1 referral. After adjusting for patient gender, language, race, ethnicity, and age, the study site moderated adherence to goal setting (77.4% BH vs. 87.7% VA) and having >1 education session (78.9% BH vs. 88.3% VA). Study site also moderated rate of encounters (median number of encounters 6 BH vs 4 VA). Scores on the Patient Activation Measure had no impact on fidelity of core intervention components.
CONCLUSION(S): The CFIF was a useful approach to collect and analyze data concerning implementation fidelity of a complex behavioral intervention. The fidelity of CHORD implementation varied across its 3 core components and was moderated by implementation site. Despite being implemented in a research setting, interventions may not completely adhere to their core components, which can influence outcomes. Our study emphasizes the importance of examining implementation fidelity of complex interventions and of assessing moderating factors. Our study also empirically tested the CFIF using quantitative concurrent process evaluation of core intervention components. LEARNING OBJECTIVE #1: Describe the implementation fidelity of a complex behavioral intervention to prevent diabetes mellitus LEARNING OBJECTIVE #2: Describe how implementation fidelity varies by study implementation site

Hypertension affects a third of U.S. adults and is especially high among Asian American groups. The Racial and Ethnic Approaches to Community Health for Asian AmeRicans (REACH FAR) project delivers culturally adapted, evidence-based hypertension-related programs to Bangladeshi, Filipino, Korean, and Asian Indian communities in New York and New Jersey through 26 sites: ethnic grocery stores, restaurants, and Muslim, Christian, and Sikh faith-based organizations. Knowledge of the implementation mechanisms of culturally adapted programs is limited and is critical to inform the design and execution of such programs by and in community sites. We applied four categories of the Consolidated Framework for Implementation Research-intervention and individuals' characteristics, inner and outer setting-to analyze factors influencing implementation outcomes, that is, site leaders' perceptions about adopting, adapting, and sustaining REACH FAR. We conducted semistructured interviews with 15 leaders, coded them for implementation outcomes, and recoded them to identify contextual factors. Our findings show that REACH FAR resonated in sites where leaders perceived unhealthy diet and lifestyles in their communities (intervention characteristics), sites had historically engaged in health programs as a public-service mission (inner setting), and leaders identified with this mission (individuals' characteristics). Site leaders strived to adapt programs to respond to community preferences (outer setting) without compromising core objectives (inner setting). Leaders noted that program sustainability could be impeded by staff and volunteer turnover (inner setting) but enhanced by reinforcing programs through community networks (outer setting). The findings suggest that to facilitate implementation of culturally adapted health behavior programs through community sites, interventions should reinforce sites' organizational commitments and social ties.

In the United States (US), chronic disease risk factors are highly prevalent among Asian immigrant communities, who also exhibit low health screening rates. Perceived neighborhood social cohesion (NSC) has been associated with preventive healthcare use in the general US population, although it remains unexplored among Asian Americans (AAs). The aim of this study is to evaluate the association between NSC and preventive screening for hypertension, high cholesterol, diabetes, and depression among East, South and Southeast Asian American (EAA, SAA, SEAA) communities in New York City (NYC) using cross-sectional, locally collected data from 2013 to 2016. NSC was assessed using a 4-question scale to create an additive score between 4 and 16 and was analyzed both as a continuous and categorial variable (High, Medium, and Low tertiles). Recent screening was defined as a check-up within the last year for each of the included health conditions. A one-unit increase in NSC score was associated with increased odds of recent screening for high cholesterol in EAAs (AOR = 1.09, 95%CI:1.00-1.20); for high cholesterol, diabetes, and depression in SAAs (AOR = 1.08, 95%CI:1.00-1.20; AOR = 1.07, 95%CI:1.00-1.15; AOR = 1.15, 95%CI:1.06-1.25); and with high cholesterol among SEAAs (AOR = 1.12, 95%CI:1.00-1.25). Overall, NSC was an important facilitator for preventive screening behaviors for specific conditions in different groups, though was consistently associated with screening for high cholesterol in our sample. Enhancing NSC through family and community-based programming may be one strategy to encourage screening for preventive behaviors, though more research is needed to elucidate a precise mechanism.

Few studies integrate work and immigration as intersecting social determinants of health. We synthesize data from 12 focus groups (N = 97) originating from two separate community-engaged studies that originally centered on exploring barriers to health and hazards of work among immigrant Latinx women and men to explore the role of work in their overall health and well-being. The three major interrelated themes we drew from this research-hazards of work, value of work, and building agency to overcome risk-provide insights that can help to reframe and begin to operationalize how community-based health promotion practice might better incorporate workplace issues for Latinx low-wage workers. The value of work, and its subtheme, pride in performing well specifically, could be engaged by workers to actively change conditions for themselves and others. We discuss findings in light of previous occupational health research and implications for community-based intervention design and practice.