This Viewpoint reviews possible reasons for reported excess mortality and poor outcomes in racial/ethnic minority populations with COVID-19 and proposes research, public health, and clinical interventions to decrease health inequities in and beyond the pandemic.

Background Effective communication at hospital discharge is necessary for an optimal transition and to avoid adverse events. We investigated the association of a language barrier with patient understanding of discharge instructions. Methods Spanish, Chinese and English speaking patients admitted to two urban hospitals between 2005-2008, comparing patient understanding of follow-up appointment type, and medication category and purpose between limited English proficient (LEP) and English proficient (EP) patients. Results Of the 308 patients, 203 were LEP. Rates of understanding were low overall for follow-up appointment type (56%) and the 3 medication outcomes (category 48%, purpose 55%, both 41%). In unadjusted analysis, LEP were less likely than EP patients to know appointment type (50% vs. 66%; p = .01), medication category (45% vs. 54%; p = .05), and medication category and purpose combined (38% vs. 47%; p = .04), but equally likely to know medication purpose alone. These results persisted in the adjusted models for medication outcomes: LEP patients had lower odds of understanding medication category (OR 0.63; 95% CI 0.42-0.95); and category/purpose (OR 0.59; 95%CI 0.39-0.89). Conclusions Understanding of appointment type and medications post-discharge was low, with LEP patients demonstrating worse understanding of medications. System interventions to improve communication at hospital discharge for all patients, and especially those with LEP, are needed.

Despite evidence of ethnic differences in family caregivers’ experiences, the extent to which caregiver interventions are culturally tailored to address these differences is unknown. A systematic review of literature published from 1980–2009 identified: differences in caregiving experiences of African American, Latino and Chinese American caregivers; psychosocial support interventions in these groups; and cultural tailoring of interventions. Ethnic differences in caregiving occurred at multiple levels (intrapersonal, interpersonal, environmental) and in multiple domains (psychosocial health, life satisfaction, caregiving appraisals, spirituality, coping, self-efficacy, physical functioning, social support, filial responsibility, familism, views toward elders, use of formal services and health care). Only 18 of 47 intervention articles reported outcomes by caregiver ethnicity. Only 11 reported cultural tailoring; 8 were from the REACH initiative. Cultural tailoring addressed: familism, language, literacy, protecting elders, and logistical barriers. Results suggest that more caregiver intervention studies evaluating systematically the benefits of cultural tailoring are needed.

Objectives We evaluated a community-based, translational stress management program to improve health-related quality of life in Spanish-speaking Latinas with breast cancer. Methods We adapted a cognitive–behavioral stress management program integrating evidence-based and community best practices to address the needs of Latinas with breast cancer. Spanish-speaking Latinas with breast cancer were randomly assigned to an intervention or usual-care control group. Trained peers delivered the 8-week intervention between February 2011 and February 2014. Primary outcomes were breast cancer–specific quality of life and distress, and general symptoms of distress. Results Of 151 participants, 95% were retained at 6 months (between May 2011 and May 2014). Improvements in quality of life from baseline to 6 months were greater for the intervention than the control group on physical well-being, emotional well-being, breast cancer concerns, and overall quality of life. Decreases from baseline to 6 months were greater for the intervention group on depression and somatization. Conclusions Results suggest that translation of evidence-based programs can reduce psychosocial health disparities in Latinas with breast cancer. Integration of this program into community-based organizations enhances its dissemination potential.

Racial/ethnic minority communities are experiencing an undue burden from coronavirus disease 2019 (COVID-19), and the availability of Food and Drug Administration (FDA) authorized vaccines is critical for improving population health. National surveys assessing vaccination willingness and reports of vaccination administration by race/ethnicity indicate at least two areas that warrant attention: elevated vaccine hesitancy among African American and Latino adults, and the need to ensure equitable access to vaccination. COVID-19 vaccine hesitancy is not uniform within racial/ethnic minority populations; yet, given the disproportionate impact, understandable distrust, and widespread misinformation, there is an imperative to overcome challenges associated with vaccination willingness and uptake, as well as implementation and access. This Perspective discusses the complexity of drivers for each of these areas, which include individual, community, and structural factors. It also highlights two initiatives at the National Institutes of Health. One is focused on addressing misinformation and distrust through academic-community partnerships, and the other on community-engaged behavioral interventions to address the population-specific reasons for COVID-19 vaccine hesitancy, support informed decisionmaking, and promote equitable access among populations with health disparities. For the foreseeable future, proactive and persistent efforts around COVID-19 mitigation strategies, including vaccination, will remain of paramount importance for health equity.

BackgroundMethods for translating evidence-based behavioral interventions into real-world settings seldom account for the special issues in reaching health disparity populations.Main textThe objective of this article is to describe an innovative “transcreational” framework for designing and delivering interventions in communities to reduce health disparities. We define transcreation as the process of planning, delivering, and evaluating interventions so that they resonate with the community experiencing health disparities, while achieving intended health outcomes. The Transcreation Framework for Community-engaged Behavioral Interventions to Reduce Health Disparities comprises seven steps: 1) identify community infrastructure and engage partners; 2) specify theory; 3) identify multiple inputs for new program; 4) design intervention prototype; 5) design study, methods, and measures for community setting; 6) build community capacity for delivery; and 7) deliver transcreated intervention and evaluate implementation processes. Communities are engaged from the start and interventions are delivered by community-based interventionists and tested in community settings. The framework applies rigorous scientific methods for evaluating program effectiveness and implementation processes. It incorporates training and ongoing technical assistance to assure treatment fidelity and build community capacity.ConclusionsThis framework expands the types of scientific evidence used and balances fidelity to evidence and fit to the community setting. It can guide researchers and communities in developing and testing behavioral interventions to reduce health disparities that are likely to be sustained because infrastructure development is embedded in the research.

Objective We examined the influence of a broad spectrum of life experiences on longitudinal cognitive trajectories in a demographically diverse sample of older adults. Method Participants were 333 educationally, ethnically, and cognitively diverse older adults enrolled in a longitudinal aging study. Mixed-effects regression was used to measure baseline status in episodic memory, executive functioning, and semantic memory and change in a global cognition factor defined by change in these three domain-specific measures. We examined effects of life experience variables (literacy, childhood socioeconomic status, morphometric measures of physical development, life course physical and recreational activity) on longitudinal cognitive trajectories, covarying for age, APOE genotype and demographics (education, ethnicity, language). Results Non-Latino whites had higher baseline cognition, but life experience variables attenuated ethnic differences in cognitive scores. Age, literacy, childhood socioeconomic status and physical activity significantly influenced baseline cognition. Age, APOE ε4 and decline in intellectually and socially stimulating recreational activity from mid to late life were independently associated with increased late life cognitive decline. Higher literacy and late life recreational activity were associated with less decline. Literacy had similar effects for English and Spanish readers/speakers. Bilingual English and Spanish speakers did not differ from English Speakers in cognitive performance. Conclusions Life experience variables, especially literacy level, were strongly related to baseline cognition and substantially attenuated effects of race/ethnicity and education. Cognitive change was best explained by age, APOE ε4, literacy, and current recreational activities. Literacy had robust associations with baseline cognition and cognitive change in both English and Spanish speakers.

Background Limited English-proficient (LEP) patients suffer poorer quality of care and outcomes. Interpreters can ameliorate these disparities; however, evidence is lacking on the quality of different interpretation modes. Objective Compare accuracy of interpretation for in-person professional (IP), professional videoconferencing (VC), and ad hoc interpretation (AH). Design Cross-sectional study of transcribed audiotaped primary care visits Subjects 32 Spanish-speaking Latino patients; 14 clinicians Measures Independent coding of transcripts by four coders (two were internists) for accurate and inaccurate interpretation instances. Unit of analysis was a segment of continuous speech or text unit (TU). Two internists independently verified inaccurate interpretation instances and rated their clinical significance as clinically insignificant, mildly, moderately or highly clinically significant. Results Accurate interpretation made up 70% of total coded TUs and inaccurate interpretation (errors) made up 30%. Inaccurate interpretation occurred at twice the rate for AH (54% of coded TUs) versus IP (25%) and VC (23%) interpretation, due to more errors of omission (p<0.001) and answers for patient or clinician (p<0.001). Mean number of errors per visit was 27, with 7.1% of errors rated as moderately/highly clinically significant. In adjusted models, the odds of inaccurate interpretation were lower for IP (OR = −1.25, 95% CI −1.56, −0.95) and VC (OR = −1.05; 95% CI −1.26, −0.84) than for AH interpreted visits; the odds of a moderately/highly clinically significant error were lower for IP (OR = −0.06; 95% CI −1.05, 0.92) than for AH interpreted visits. Conclusions Inaccurate language interpretation in medical encounters is common and more frequent when untrained interpreters are used compared to professional in-person or via videoconferencing. Professional video conferencing interpretation may increase access to higher quality medical interpretation services.