Christi A. Patten

BACKGROUND Although alcohol-related morbidity and mortality have increased disproportionately among U.S. women, utilization of evidence-based alcohol treatment (EBAT) remains lower among women compared with men. Rural women face additional barriers to treatment access, including stigma, caregiving responsibilities, geographic isolation, and limited availability of services. Social media platforms such as Facebook may offer a sustainable approach to delivering peer support and EBAT access to rural women. OBJECTIVE This study aimed to describe the development and community-engaged refinement of Women-Peer Supported Alcohol Treatment and Liaison (Women-PALS), a peer-supported Facebook intervention to promote alcohol use reduction and evidence-based alcohol treatment uptake among rural females with mild-to-moderate alcohol use disorder. METHODS Intervention content (Facebook moderator postings) was created and adapted from existing evidence-based resources. The development and refinement were informed by rural females with lived experience and other stakeholder feedback through a Community Engagement Studio (n=9) and a rural Community Advisory Board (n=12). Feedback was sought on message clarity, cultural relevance, inclusivity, and acceptability of intervention postings. RESULTS Six posts were reviewed during the CE Studio; after incorporating CE Studio feedback, four were subsequently reviewed at the CAB meeting to elicit more in-depth feedback. Across both review stages, members consistently called for shorter, scannable content; authentic rural and demographically diverse imagery; reduced reliance on statistics or prevention-style messaging; and language that did not assume a specific parenting status, abstinence goal, or recovery stage. CONCLUSIONS Content and imagery changed considerably across the two review stages. Members favored short, action-oriented posts and peer-voiced language over statistics and top-down framing. They also asked that treatment goals not presuppose abstinence, that content avoid assumptions about parenthood and family structure, and that imagery balance local authenticity against participant privacy. These preferences have not been tested against outcomes and require further testing. Next steps include pilot testing of feasibility, acceptability, and preliminary efficacy.

Background: Immigrants to the United States often face challenges from limited healthcare access and less healthy environments which contribute to rising obesity and cardiovascular risk. Purpose: To assess the feasibility and effectiveness of a community-based social network intervention for cardiovascular risk reduction among Hispanic and Somali adults. Methods: A social network-informed, community-based participatory research-derived health promotion intervention was delivered by Hispanic and Somali lay health promoters (HPs) to members of their social networks over 1 year (12 biweekly sessions in months 0-6; 12 biweekly check-ins in months 7-12). Using a closed-cohort stepped wedge cluster randomized design, social networks were randomly assigned to receive the intervention immediately or after a delay of 1 year. Measurements at baseline, 6 months, and 12 months were derived from 6 of the American Heart Association’s “Life’s Simple 7”: BMI, blood pressure, fasting glucose, cholesterol, physical activity and dietary quality (range 0-12, with higher values indicating lower cardiovascular risk). Waist circumference and proportion of participants who achieved >5% body weight loss were also assessed. Results: Four hundred seventy-five participants were enrolled among 51 HPs (29 Hispanic; 22 Somali). There was a statistically significant improvement in cardiovascular risk in the intervention group (n = 246) compared with controls (n = 229) at 6 months (0.4 [1.8] vs. −0.1 [1.7]; P = .03) that was not sustained at 12 months (0.5 [1.9] vs. 0.3 [1.8]; P = .38). There was a statistically significant higher proportion of participants who lost >5% of body weight in the intervention group compared with controls at 12 months (37% [15] vs. 18% [7.9]; P = .02). Reductions in weight and waist circumference in the intervention group compared with controls did not achieve statistical significance. Conclusion: A social network intervention, delivered by lay HPs was feasible and resulted in a modest improvement of cardiovascular risk and clinically significant weight loss. Clinical Trial Identification Number: NCT05136339.

Plasma ceramides are recognized biomarkers of cardiovascular risk; however, racial and ethnic differences in their levels, as well as their association with cardiovascular health (CVH) among African-American populations, remain insufficiently studied. This study aimed to assess the association between ceramide scores and CVH, as well as atherosclerotic cardiovascular disease (ASCVD) risk, among African-American adults, and to compare ceramide scores between African-American and White adults. We conducted a secondary analysis of 2 U.S. studies including African-American and White adults. Collected data encompassed demographics, behavioral factors (e.g., diet) and clinical measures (e.g., plasma ceramide levels). Atherosclerotic cardiovascular disease risk was assessed using the American College of Cardiology/American Heart Association (ACC/AHA) 10-year pooled cohort equations, while CVH was evaluated using the American Heart Association (AHA) Life's Essential 8 (LE8) scoring system. Fifty-eight African-American adults (mean age: 54.6 years; 67.2% women) and 1,103 White adults (mean age: 64.5 years; 52.1% women) were included. Compared with White participants, African-Americans had significantly higher prevalence of obesity, hypertension, diabetes, and hyperlipidemia, but similar ASCVD risk (12.8% vs 12.6%; p = 0.65). No significant associations were observed between ceramide scores and either LE8 or ASCVD risk in African-Americans. Ceramide levels differed by race/ethnicity, with African-Americans showing lower concentrations of 18:0 (0.08 vs 0.10 μmol/L) and 24:1 (0.91 vs 1.17 μmol/L) species compared with White adults (both p < 0.001). No association was observed between ceramide scores and CVH or ASCVD risk in African-American adults. Despite having a less favorable cardiometabolic profile, African-Americans exhibited lower ceramide levels than White adults. These findings suggest that ceramide scores may not accurately reflect cardiovascular risk in African-American populations.

Cigarette smoking is associated with numerous adverse pregnancy outcomes, due in part to polycyclic aromatic hydrocarbons and free radicals produced by combustion. Less is known about the impact of smokeless tobacco (ST) use during pregnancy. Alaska Native women report higher rates of cigarette and ST use during pregnancy than non-Native women. We investigated oxidative stress and hypoxia pathways in term placentae from Alaska Native women who did (commercial or iqmik; n = 10) or did not ( n = 18) use ST during pregnancy. Despite substantial maternal exposure to nicotine, placentae of women who used ST had similar mRNA levels of antioxidant enzymes and markers of hypoxia compared to those who did not use tobacco. Although mRNA levels of angiogenesis markers vegf and vegfr2 were similar between groups, vegfr1 mRNA levels are increased in placentae of women using ST compared to women who did not use tobacco. Together these results suggest that, while ST use may not have as significant an effect on oxidative stress pathways in the placenta as cigarette smoking, an effect is present. It is not clear what this limited effect may have on the developing fetus.

The Mayo Clinic Center for Clinical and Translational Science Rural Health Research Core emphasizes community engagement to address healthcare access and delivery. In 2023, the Midwest Rural Health Research Community Advisory Board (CAB) was established to guide research. Eleven of 13 researchers presenting to the CAB in 2023 completed a survey assessing influence of CAB feedback across seven domains. All reported >1 domain influenced by CAB feedback, most commonly on study design, pre-research activities and implementation. CAB feedback shaped many aspects of the rural health research process. CAB members valued seeing how their input contributed to the research process.

Self-efficacy theory proposes that confidence to engage in a health behavior is associated with engaging in that specific behavior. Most research examining self-efficacy has been conducted with white young adult populations. This cross-sectional analysis examined the association of self-efficacy (i.e., confidence) for healthy eating and physical activity in two immigrant communities. At enrollment into the Healthy Immigrant Community study, a clinical weight management and cardiovascular risk reduction intervention set in southeastern Minnesota, 475 participants completed assessments about their confidence for healthy eating and physical activity. Measurements also included self-reports of dietary quality and intake, physical activity, quality of life, and biometric assessments. Study materials were available in English, Spanish, and Somali. In total, 450 adults (Hispanic/Latinx = 267; Somali = 183) completed measures at baseline and were included for analysis. Their average age was 45 years (range 18–87) and 59% were female. Confidence for healthy eating was significantly correlated with self-report of eating healthy snacks (p = < 0.0001) and less consumption of high-calorie drinks (p = 0.02) and regular soda (p = < 0.0001). Confidence to be physically active was significantly correlated with more self-reported physical activity (p = < 0.01). Confidence to eat healthy and be physically active appears to be correlated with having a healthier diet and higher levels of physical activity. Given the large sample size and strength of the associations, it also appears that the theoretical model of self-efficacy can be effectively measured and applied within these immigrant populations. Self-efficacy theory may be useful in understanding potential mediating mechanisms when designing future interventions with immigrant communities. ClinicalTrials.gov registration: NCT05136339; April 23, 2022.

Background: Chronic stress in African American individuals is multilayered amid the context of experiences of racism and discrimination. Cortisol dynamic range (CDR) may be an indicator of chronic stress, but CDR is understudied in African American populations compared with White populations, and is hypothesized to differ by sex. Objective: Using a community-engaged approach within the Fostering African-American Improvement in Total Health! (FAITH!) Heart Health+ ancillary study, we assessed the feasibility of participant-centric CDR collection, and its association with measures for individual, interpersonal, and structural stress and exposure to racism in medically underserved African American women and men. Methods: Participants residing in the Minneapolis-St Paul and Rochester, Minnesota areas provided survey data (everyday discrimination, perceived stress, mood, sleep quality, and high effort coping measures), and saliva samples (morning and afternoon) via at-home, self-collection kits for cortisol measurement. CDR was calculated as a difference in log cortisol levels (ie, log of the cortisol diurnal peak-to-nadir ratio). Geospatial Area Deprivation Index and the distance lived from George Floyd Square in Minneapolis were calculated. Linear regression examined the association between CDR and outcome variables. Results: Of consented participants (n=53), 70% (37/53) provided cortisol samples. The final analytic sample included 32 participants with complete and physiological diurnal cortisol curves (mean age 57.5 years, 62.5% [20/32] women). Lower (less dynamic) CDR in women (n=20) was associated with greater perceived stress (β=–0.07, P=.01), greater anxiety (β=–0.06, P=.01), higher Superwoman Schema score (β=–0.02, P=.04), and greater distance from George Floyd Square (β=–0.02, P=.01). No associations were observed in men (P>.05). Conclusions: The current results suggest that CDR from participant-led saliva collection is feasible and may serve as a biomarker of chronic and physiological stress in African American women, particularly those residing in underresourced areas.

BACKGROUND Rural residents who smoke tobacco face higher smoking prevalence and unique barriers to cessation support, including limited access to evidence-based treatments and digital health resources. The transition to digital smoking cessation interventions offers potential solutions but may exacerbate health disparities without a clear understanding of digital equity barriers in these populations. OBJECTIVE This formative evaluation study aimed to examine the barriers rural adults face in accessing digital smoking cessation interventions and to map these barriers to a digital health equity framework, to inform strategies for equitable program design. METHODS We conducted in-depth, semi-structured telephone interviews between January and April 2023 with 30 rural adults who smoke cigarettes. Participants, who resided in the Midwest (Minnesota, Wisconsin, Iowa) were recruited from a three-arm randomized pilot trial of digital smoking cessation interventions. Interview topics included rural living experiences, healthcare access, and efforts to quit smoking. Data were analyzed using inductive thematic analysis, then mapped to Richardson et al.’s Digital Health Equity framework to identify multilevel barriers and opportunities for intervention. RESULTS All 30 interview respondents were White, 67% were female, and the mean age was 51.9 years (SD 14.3). Three primary themes emerged: rural living conditions, healthcare access and navigation, and smoking cessation experiences. Major barriers to digital cessation support included unreliable internet connectivity, transportation and economic constraints, digital literacy challenges, lack of program personalization, social isolation, privacy concerns, and unaddressed mental health needs. Mapping to the digital health equity framework revealed nine modifiable barrier domains: digital infrastructure, economic inequities, transportation, digital literacy, adoption readiness, social isolation, privacy, integration of behavioral health, and navigation of government resources. CONCLUSIONS Rural adults encounter multiple, intersecting barriers to digital smoking cessation interventions that span structural, psychosocial, and individual domains. Addressing these inequities will require comprehensive solutions, including broadband investment, integrated mental health support, hybrid (digital and in-person) program delivery, targeted digital literacy training, and policy changes to ensure affordable access to telehealth cessation services. CLINICALTRIAL Clinical Trials Registry (NCT05209451)

Electronic health record data represent a rich data source; however, data accuracy must be considered prior to reporting health outcomes among American Indian and Alaska Native people. Using a hybrid approach to harmonizing data from multiple sources represents a valid method of assessing data integrity in this population.