Anti-Asian racism related stigma, racial discrimination, and protective factors against stigma: a repeated cross-sectional survey among university students during the COVID-19 pandemic

Background

Since the onset of the COVID-19 pandemic in March 2020, reports of anti-Asian American or Pacific Islander (AAPI) hate have increased in the United States. Institutions of higher education provide a unique opportunity to examine COVID-19 related stigma and protective factors in AAPI young adults enrolled in college.

Objective

The goal of this research was to examine COVID-19 related stigma among a diverse college student population. We posited that AAPI students experience more racial discrimination, internalized stigma, and/or anticipated racial discrimination than other students. We also sought to identify protective behavioral factors against stigma.

Methods

This study includes data from a repeated cross-sectional survey that was administered among college students at a large public university in the United States in April (n = 1,359) and November 2020 (n = 1,196). All university enrolled students with an active email account were eligible to participate in the online survey, which included questions about COVID-19 stigma (anticipated, enacted, internalized), stigma resistance, sources of COVID-19 information, lifestyle behaviors, and sociodemographic information. Binary logistic regression models were utilized to assess differences in stigma between race and ethnic groups and to identify factors associated with stigma.

Results

AAPI students were more likely to experience all three types of stigma compared to other race and ethnic groups. AAPI students in both waves were at least 2 times more likely to experience enacted stigma and 7.3 times more likely to experience anticipated stigma in the earlier wave compared to non-Hispanic White students. Students who had experienced enacted stigma were more likely to experience anticipated stigma, and those who experienced enacted and anticipated stigma were more likely to experience internalized stigma. Higher education level, living with neighbors/roommates, maintaining a healthy lifestyle, and thinking positively about oneself may act as protective factors against different types of stigma.

Conclusion

AAPI students have a greater risk of experiencing COVID-19 stigma compared to those from other race and ethnic groups. Universities should combat anti-AAPI sentiments and COVID-19 stigma and promote public health efforts to build resistance against the negative effects of stigma.

Use of Community-Engaged Research Approaches in Clinical Interventions for Neurologic Disorders in the United States: A Scoping Review and Future Directions for Improving Health Equity Research

BACKGROUND AND OBJECTIVES

Evidence suggests a significant prevalence of race and ethnic disparities in the United States among people with neurologic conditions including stroke, Alzheimer disease and related dementia (ADRD), Parkinson disease (PD), epilepsy, spinal cord injury (SCI), and traumatic brain injury (TBI). Recent neurologic research has begun the paradigm shift from observational health disparities research to intervention research in an effort to narrow the disparities gap. There is an evidence base that suggests that community engagement is a necessary component of health equity. While the increase in disparities focused neurologic interventions is encouraging, it remains unclear whether and how community-engaged practices are integrated into intervention design and implementation. The purpose of this scoping review was to identify and synthesize intervention studies that have actively engaged with the community in the design and implementation of interventions to reduce disparities in neurologic conditions and to describe the common community engagement processes used.

METHODS

Two databases, PubMed and CINAHL, were searched to identify eligible empirical studies within the United States whose focus was on neurologic interventions addressing disparities and using community engagement practices.

RESULTS

We identified 392 disparity-focused interventions in stroke, ADRD, PD, epilepsy, SCI, and TBI, of which 53 studies incorporated community engagement practices: 32 stroke studies, 15 ADRD, 2 epilepsy studies, 2 PD studies, 1 SCI study, and 1 TBI study. Most of the interventions were designed as randomized controlled trials and were programmatic in nature. The interventions used a variety of community engagement practices: community partners (42%), culturally tailored materials and mobile health (40%), community health workers (32%), faith-based organizations and local businesses (28%), focus groups/health need assessments (25%), community advisory boards (19%), personnel recruited from the community/champions (19%), and caregiver/social support (15%).

DISCUSSION

Our scoping review reports that the proportion of neurologic intervention studies incorporating community engagement practices is limited and that the practices used within those studies are varied. The major practices used included collaboration with community partners and utilization of culturally tailored materials. We also found inconsistent reporting and dissemination of results from studies that implemented community engagement measures in their interventions. Future directions include involving the community in research early and continuously, building curricula that address challenges to community engagement, prioritizing the inclusion of community engagement reporting in peer-reviewed journals, and prioritizing and incentivizing research of subpopulations that experience disparities in neurologic conditions.

Abstract WP183: Social Activities Are Positively Associated With Medication Adherence In Stroke Survivors

Introduction: Social support may influence illness incidence or recovery through effects on health-related behaviors, and one aspect is emotional support, which includes the offering of empathy, friendship, care, and trust along with information. While we have previously reported on the positive relationship of family and friend networks in risk reduction, our objective was to examine whether participation in formalized group activities was related to medication adherence post-stroke.

Methods: Using Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) data, information regarding religious and nonreligious social activities was collected at baseline. The outcome variable was measured by the self-reported 8-item Morisky Medication Adherence Scale (MMAS-8; score 0-8). Medium/high adherence (MMAS-8≥6) at 6- and 12-months post-discharge was modeled against social activities separately using logistic regression adjusting for age, gender, race/ethnicity, education, family and friend networks, NIH stroke scale at admission, and the intervention.

Results: Of the 541 participants who completed the baseline questionnaire, 286 and 344 had valid MMAS-8 scores for post 6-months and 12-months follow-up data collection. Medication adherence was poor among the participants. Only 44% for 6-months and 46% for 12-months had medium or high medication adherence. Participants going to nonreligious social events (n = 67, 21%) had higher odds of having medium/high medication adherence (OR = 3.08, 95% CI: 1.15-8.25) at 12-months.

Discussion: Nonreligious social activities, including meetings of social clubs or other non-religious groups not relevant to work, were shown to be positively related to 12-months post-discharge medication adherence among stroke patients. Social activities may play an important role in emotional support and may be an opportunity for targeted secondary stroke prevention.

Abstract WP186: Fewer Self-reported Memory Problems Are Associated With Better Blood Pressure Control Post-stroke

Introduction: Memory problems, a common cognitive issue, can have a negative influence on one’s ability to function and contributes to increased risk of secondary stroke.

Objective: To examine the association between self-reported memory problems at 6 months and blood pressure control at 12 months post-stroke.

Methods: This study utilized follow-up data from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) stroke risk factor reduction trial (n=226). Sample size was restricted to those who answered memory questions and had a 12-month blood pressure (BP) reading. Exclusion criteria for DESERVE included any significant memory disorder prior to the baseline stroke. Seven memory domain questions (Table 1) from the Stroke Impact Scale were used separately to assess the association with systolic BP, with control defined as ≤120mmHg, at 12 months in logistic regression models adjusted for race, gender, education, age, and intervention status. Models were additionally adjusted for 6-month BP control as a mediator.

Results: Participants were almost equally white (28%), Black (33%), or Hispanic (34%) and 52% were female with a mean age of 65 (SD=13). About 25% had BP control at 6 or 12 months. Memory measures were not significantly associated with BP control prior to adjusting for BP control at 6 months. After adjusting for 6-month BP control, participants with less difficulty remembering things that people just told them (OR=1.69, 95% CI: 1.09, 2.63) or remembering to do things (OR=1.76, 95% CI:1.09, 2.86) had better odds of having their BP controlled at 12 months. Memory items 2 and 4-7 did not show an association with better BP control.

Discussion: Stroke survivors who were better at remembering what people told them and remembering to do things were more likely to achieve blood pressure control 1-year post-stroke. Evaluating early memory post-stroke may be an important target for secondary prevention strategies and should be further researched.

Abstract WP225: Composition Of Egocentric Networks Among Stroke Survivors

Background: Social networks provide emotional and social support that may help prevent the onset of secondary stroke. Little is known about egocentric networks among stroke survivors and the type of support they provide.

Objective: To develop an understanding of the supportive role alters or personal contacts provide to stroke survivors and gain insight of participants' egocentric network.

Methods: Data obtained from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) trial, a skills-based, culturally tailored discharge educational intervention. Participants (n=552) identified up to 5 alters. Descriptive analyses were conducted to assess the relationship between participants and alters.

Results: Approximately, 34% of participants identified as Non-Hispanic (NH) Black followed by Hispanic (33%), NH White (28%), NH Asian Pacific Islanders (API) (3%). Majority of participants (n=462, 83%) reported having at least one alter. Most participants with ≥1 alter (92%) indicated talking to alter every day or several times a week. Yet all with an alter stated that they can talk to alter about an important health problem or medical decision. Among participants (n=543, p=.002), NH Blacks (n=38, 45%) and Hispanic (n=33, 39%) were more likely to report no alters compared to NH White (n=14, 16%; Figure).

Conclusions: Majority of participants reported having at least one person within their social network that they can talk to about their health problems. We are unable to determine if the first person that participants indicated may be the most influential person in health-related matters. The implications of these results may be relevant for future stroke interventions. Additional studies are needed to understand the type of influence alters have on stroke survivors in health-related behaviors and decisions that may help improve post-stroke outcomes. Further studies are also needed to assess health outcomes among isolated stroke patients by race.

Abstract WP81: The Association Between Health-related Locus Of Control And Post-stroke Disability, Quality Of Life, And Depression

Introduction: Beliefs regarding ones’ control over their health can lie internally, influenced by their own actions, or externally, controlled by others or due to chance.

Objective: To examine the association between health-related locus of control (HRLC) type and post-stroke disability, quality of life, and depression.

Methods: This study utilized data from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) trial (n=552). Participants were categorized into three groups based on their highest Multidimensional Health Locus of Control (MHLC) score. The Stroke Impact Scale (SIS) was used to assess post-stroke disability and quality of life. Linear regression was used to identify differences in each SIS domain score between the three groups while adjusting for the intervention. Depression was defined as a Center for Epidemiological Studies Depression (CESD) score ≥16. Logistic regression was used to examine differences in depression between the three groups while adjusting for the intervention.

Results: Of the 529 participants who completed the MHLC questionnaire at baseline, 179 (33.3%) were categorized into the internal group , 163 (30.8%) into the powerful others group, and 190 (35.9%) into the chance group. Of the 297 participants who completed the CESD questionnaires at 12 months, 163 (54.8%) scored ≥ 16. Participant’s mean scores for each SIS domain are reported in Table 1. For the SIS communication domain, the chance group’s mean score was 3.03 points lower than the powerful others group’s score (SE=1.39, p=.029). There were no statistically significant differences in scores for the other seven SIS domains or for depression between groups (Table 1).

Discussion: External HRLC based on chance may be a predictor of communication difficulties in patients post-stroke. However, mean communication scores are skewed. Control beliefs are important in post-stroke recovery. More research is needed to validate these findings.

Abstract WP70: Racial-ethnic Differences In Reintegrating To Normal Living Among Stroke Survivors

Background: In the continuum of care for stroke survivors, racial-ethnic disparities are most prominent during post-stroke rehabilitation. This includes reintegration of stroke survivors to normal living, an important component in stroke rehabilitation and predicts stroke survivors’ participation in typical daily activities and post-stroke depression. We assessed the association between racial-ethnic factors and ability of survivors to reintegrate to normal living at one-year post stroke.

Methods: Using data from the DESERVE (Discharge Educational Strategies for Reduction of Vascular Events) trial, we assessed reintegration to normal living (RNL) using the RNL index of 335 participants with acute stroke. Race and ethnicity were asked at baseline and the survivors’ RNL index was assessed at one-year follow-up. The RNL index was calculated from 11 questions rating survivor’s reintegration from 0-10 (no to complete integration). We used linear regression to assess variations in race-ethnicity on RNL index adjusting for intervention, age, sex, education, living arrangement, stroke history, and severity of recent stroke.

Results: At baseline, 27.8% identified as Non-Hispanic (NH) white, 31.6% identified as NH black, 34.9% identified as Hispanic and 5.7% identified as NH other. Crude mean RNL index was greater in the intervention arm than the usual care arm for Hispanics and NH blacks (Figure). In adjusted models, NH whites (5.88, CI: -2.9,14.8) and NH Blacks (6.63, CI: -1.1,14.3) had higher RNL index compared to Hispanics.

Conclusion: Racial-ethnic differences may play a clinically important role in reintegrating stroke survivors to normal living. Future interventions must be aimed at understanding fundamental causes of disparities that may lead to inequities in stroke survivors’ rehabilitation to better implement preventative strategies well before stroke incidence.

Abstract P723: Adaptation of Stroke Prevention Interventions for Low- and Middle-Income Countries: A Scoping Review

Introduction: Stroke is a leading cause of mortality globally, with 85% of stroke death occurring in low- and middle-income countries (LMICs). Translation of evidence-based stroke prevention interventions from their original setting to the novel context in which they will be implemented is often unreported; especially in LMICs where it has been severely understudied. Thus, our objective was to investigate how adaptation has been examined within research on stroke prevention interventions in LMICs through a scoping review of the available literature in order to highlight benefits and best-practices, identify gaps, and develop a greater understanding of these efforts that will ultimately support attempts to address the global burden of stroke.

Methods: This review was conducted in accordance with PRISMA-ScR guidelines. Five databases were searched (PubMed, PsycINFO, CINAHL, EMBASE, and Web of Science), for eligible studies using a search strategy developed in consultation with a research librarian. Two reviewers independently assessed the retrieved articles for selection based on the inclusion criteria (peer-reviewed empirical papers or protocols, reported on adaptation of stroke prevention interventions, and occurred in at least one LMIC) through a two phase process consisting of (1) title and abstract screening and (2) full-text screening. Discrepancies were resolved through discussion until consensus was reached. Data were charted and a narrative synthesis, guided by the FRAME framework, was used to analyze and interpret the findings.

Results: Of 380 articles retrieved, a total of six articles reporting adaptation of primary (n=4) or secondary (n=2) stroke prevention interventions in LMICs were identified. Types of interventions included use of community health workers (n = 2), use of mHealth tools (n=2), and interventions aimed at risk factor modification (n = 2). Adaptations were proactively planned, with multiple adaptation goals reported.

Conclusions: This is the first review of its kind to focus on adaptation of evidence-based stroke prevention interventions in LMICs. Through our systematic investigation, we highlight the need for additional research to assess the processes and outcomes of stroke prevention interventions.

Abstract P600: Social Network Structure and Function Are Associated With Blood Pressure Reduction in Stroke Survivors

Background: The risk of recurrence of stroke has been found to be modifiable through changes in health behavior and reducing key risk factors such as hypertension. Evidence suggests social networks can influence health behaviors and health outcomes; however, there is a lack of literature on the relationship between stroke survivor’s social network and secondary prevention efforts. In this study, we assessed the association between social network structure and systolic blood pressure (SBP) reduction at one-year post stroke.

Methods: Using data from the DESERVE (Discharge Educational Strategies for Reduction of Vascular Events) trial, we assessed the social networks of 552 participants who have had a mild/moderate stroke or transient ischemic attack (TIA). At baseline enrollment, participants were asked to identify up to 5 persons, or “alters,” with whom they discuss important matters, such as health. The data on the alters were then classified into structural and functional characteristics. The combination of the number of alters and the amount of alters that met the “optimal” level for each characteristic were used to determine the characteristics of the social network. We used linear regression models to quantify the SBP change on social network characteristics adjusting for age, gender, race-ethnicity, education, marital status, and prior stroke history.

Results: Stronger social networks were associated with greater SBP reduction. The overall mean SBP reduction at 12-month follow-up was 5.6 (±24.5) mmHg. On fully adjusted models having 3-5 alters compared to none (mean SBP reduction of 11.4 mmHg, p = 0.01) and having a family and friend network compared to a family-only network (mean SBP reduction of 7.6 mmHg, p = 0.01) were significantly associated with a larger SBP reduction.

Conclusion: Social networks may play an important role in blood pressure reduction in patients post stroke. Future interventions should involve social networks to help reduce vascular risk and enhance secondary prevention efforts.

Abstract P681: Implementation of Stroke Prevention Interventions in Low- and Middle-Income Countries: A Scoping Review

Background: Stroke is the second leading cause of death globally and an increasing concern in low- and middle-income countries (LMIC) where, due to limited capacity to treat stroke, preventative efforts are critically important. Although some research on evidence-based interventions for stroke prevention in LMIC exists, there remains a significant gap in understanding of their implementation across various contexts in LMIC.

Objectives: In this scoping review, our objective was to identify and synthesize the implementation outcomes (using Proctor et al.’s taxonomy, 2011) for stroke prevention interventions, as well as to describe the diverse interventions employed.

Methods: Eligible studies were empirical, focused on implementation of stroke prevention programs or policies, and occurred in at least one LMIC. Five databases were searched, including PubMed, PsycINFO, CINAHL, EMBASE, and Web of Science. Two reviewers independently assessed studies for selection and charted data; discrepancies were resolved through discussion with a third reviewer until consensus was reached. Narrative synthesis was used to analyze and interpret the findings.

Results: Studies were predominantly focused in Asia, targeting primary or secondary prevention, and facility-based. Interventions were conducted at the level of individual (n=11), system (n=12), or both (n=4). Various implementation outcomes were reported, most commonly cost (n=10), acceptability (n=7), fidelity (n=7), and feasibility (n=6), but also adoption (n=4), penetration (n=3), appropriateness (n=1), and sustainability (n=1).

Conclusions: Findings highlight the breadth of evidence-based interventions for stroke prevention available to implement in LMIC settings, including culturally acceptable education interventions, cost-effective medications, and community-based interventions implemented by community health workers. Implementation outcomes remain under-reported, and more rigorous research is needed to better plan and evaluate the implementation of these interventions to prevent stroke.

Estimated seroprevalence of SARS-CoV-2 antibodies among adults in Orange County, California

Clinic-based estimates of SARS-CoV-2 may considerably underestimate the total number of infections. Access to testing in the US has been heterogeneous and symptoms vary widely in infected persons. Public health surveillance efforts and metrics are therefore hampered by underreporting. We set out to provide a minimally biased estimate of SARS-CoV-2 seroprevalence among adults for a large and diverse county (Orange County, CA, population 3.2 million). We implemented a surveillance study that minimizes response bias by recruiting adults to answer a survey without knowledge of later being offered SARS-CoV-2 test. Several methodologies were used to retrieve a population-representative sample. Participants (n = 2979) visited one of 11 drive-thru test sites from July 10th to August 16th, 2020 (or received an in-home visit) to provide a finger pin-prick sample. We applied a robust SARS-CoV-2 Antigen Microarray technology, which has superior measurement validity relative to FDA-approved tests. Participants include a broad age, gender, racial/ethnic, and income representation. Adjusted seroprevalence of SARS-CoV-2 infection was 11.5% (95% CI: 10.5-12.4%). Formal bias analyses produced similar results. Prevalence was elevated among Hispanics (vs. other non-Hispanic: prevalence ratio [PR] = 1.47, 95% CI 1.22-1.78) and household income < $50,000 (vs. > $100,000: PR = 1.42, 95% CI: 1.14 to 1.79). Results from a diverse population using a highly specific and sensitive microarray indicate a SARS-CoV-2 seroprevalence of ~ 12 percent. This population-based seroprevalence is seven-fold greater than that using official County statistics. In this region, SARS-CoV-2 also disproportionately affects Hispanic and low-income adults.