Yuri Jang, Ph.D. - US grants

The proposed study is in response to the NIA Behavioral and Social Research on Aging (BSR) special initiative #1 Health Disparities. The investigation focuses on one of the fastest-growing but understudied minority populations: Korean American elders. The underlying concern is with the significance of experiences associated with aging, acculturation, and health. Guided by a stress and coping model, the study conceptualizes health conditions and acculturation as potential stressors, health perception and acculturative stressfulness as appraisals, a variety of psychosocial and cultural factors as coping resources, and subjective well-being as outcome. Subjective well-being is indexed by depressive symptoms and life satisfaction. Specific aims are: (1) to assess the connections between potential stressors (health conditions and acculturation) and outcomes (depressive symptoms and life satisfaction), (2) to examine whether the connections between stressors and outcomes are mediated through appraisals (health perceptions and acculturative stressfulness), and (3) to examine how psychosocial and cultural resources (sense of mastery, social network, social support, religiosity, filial satisfaction, and family solidarity) modify the connections among stressors, appraisals, and outcomes. Probability samples of Korean American older adults aged 65 and older (n=310) will be drawn from two cities in Florida. Face-to-face interviews will be conducted using the Korean version of a structured questionnaire. A series of regression analyses with tests of direct, mediating, and moderating effects will provide answers for the proposed research questions. The unique approach with the differentiation of acculturative stressfulness from the level of acculturation will not only address the conventional stress model but also specific issues sensitive to the study population. Elucidation of the intervening roles of health perception and acculturative stressfulness may guide intervention strategies to prevent or minimize the adverse emotional consequences of stressors by altering negative perceptions of and attitudes towards stressors. Further, the identification of protective psychosocial and cultural resources will serve as a basis for developing/implementing culturally competent and effective social services and programs. This study is an important step in expanding our understanding of the unique experiences of minority elders; further research will be developed based on the results from this pilot research.

[unreadable] DESCRIPTION (provided by applicant): The proposed study is written in response to the heightened need for research designed to help reduce mental health disparities. The investigation focuses on one of the fastest growing but understudied and underserved ethnic minority groups: Korean American elders. Building upon our previous findings that Korean American older adults have high levels of mental health problems yet underutilize mental health services, the proposed study conceptualizes low mental health literacy as a major reason for service underutilization and a central focus of intervention efforts. The overall goals are to better understand the levels of mental health literacy manifest in the target population and to develop/test an educational intervention. The proposed study includes three phases: (1) data collection with a mixed methodology including a survey and focus groups; (2) development of an educational intervention program, and (3) pilot testing and evaluation. Survey data drawing on structured questionnaires will be used to assess the level of mental health literacy and to determine facilitators and barriers of mental health literacy. In order to provide a more in-depth assessment of mental health literacy, data from focus groups will also be used. The latter discussions will be conducted with Korean American older adults, their family members, health care professionals, and religious leaders. Various mental health issues and ways to promote community mental health and service utilization will serve as focal points for diverse perspectives. Findings from the survey data and focus groups will guide the development of a culturally appropriate and acceptable educational intervention program. An educational brochure in Korean will be written with the twin goals of increasing mental health literacy and making positive changes in attitudes toward mental disorders and service utilization. We will also adopt a peer-led education strategy where lay peer leaders are trained to deliver an educational session. The session includes not only the brochure but also peer-education and group discussion. The peer-based approach allows greater sensitivity to the unique characteristics of ethnic minority communities, where informal leaders play a significant role. During the third and final phase, an experiment with three randomized conditions (control, general brochure, and peer-led education) will be conducted to explore the effectiveness of the educational brochure and peer-led education strategy. We hypothesize that 1) those in the treatment groups (general brochure and peer-led education) would show increased knowledge of depression and positive changes in attitudes toward mental illness and service use compared to those in the control group, and 2) peer-led education would be more effective than the brochure-only approach. Pilot testing and evaluation will serve as an important means to assess effect size of intervention and feasibility of the program for implementation in a subsequent project. We also hope to use our findings to develop a protocol for application to other ethnic minority groups. [unreadable] [unreadable] Public Health Relevance: Building upon previous findings that Korean American older adults have high levels of mental health problems yet underutilize mental health services, the proposed study conceptualizes low mental health literacy as a major reason for service underutilization and a central focus of intervention efforts. The overall goals of the study are (1) to better understand the levels of mental health literacy manifest in the target population and (2) to develop/test an educational intervention. [unreadable] [unreadable] [unreadable]

DESCRIPTION (provided by applicant): Limited English proficiency (LEP) is a unique vulnerability of older immigrants that poses a significant risk to health and healthcare. Given tha social and environmental contexts play a critical role in the lives of persons with LEP, this application investigates how social connectedness and neighborhood/community characteristics (e.g., ethnic density, health service environments in the neighborhood) influence the link between LEP and health/healthcare. We used Korean American elders as the target group. Our selection was based on the fact that they are members of a rapidly expanding LEP population (i.e., Korean is ranked 4th in the languages spoken by LEP individuals in the U.S.) and that they manifest marked disparities in health and healthcare. The project aims to explore the direct and interactive roles of social connectedness and neighborhood characteristics (1) in the relation between LEP and health and (2) in the relation between LEP and healthcare. The negative impact of LEP on health/healthcare is expected to be greater when individuals lack social connections and/or when they live in areas lack ethnically oriented resources and services. The project employs an innovative and synergistic mix of Social Network Analysis (SNA) and Geographic Information Systems (GIS). To capture the heterogeneity of the population, we will use 3 sites that combine to represent a continuum of Korean American population density: New York (high), Texas (intermediate) and Florida (low). Following focus groups with Community Advisory Boards, direct assessments of ethnic communities will be conducted. At each site, a master list of ethnically oriented services (including health services) will be generated, and each identified service will be geo-coded. Subsequently, 900 Korean Americans (aged e 65, 300 at each site) will be surveyed using a probability sampling procedure. In addition to the traditional survey measures, name-generator approaches will be used to explore participants' social network members and places for healthcare. Using SNA, information from the name generators (names and addresses of people and places) will be indexed to represent (1) social connectedness and (2) engagement with health services at the community. Using GIS, the survey data will be linked to a file combining the 2010 Census and the area resource map derived from the direct community assessment. The combined file will include variables such as proportions of Koreans in the neighborhood and general as well as ethnically-oriented area health services. Multi-Level Models (MLM) will be used to explore the research questions and hypotheses. The results will not only enhance our understanding of the mechanisms underlying LEP vulnerability but also identify individual- and community-level factors (both in people and places) that could be used in health planning and interventions. The overall approach and findings will inform how to develop effective interventions to reduce language barriers and ensure access to appropriate health services for diverse LEP populations.

PROJECT SUMMARY Limited English proficiency (LEP) among caregivers for individuals with Alzheimer's disease or related dementias (ADRD) poses a critical barrier to the caregivers' access to evidence-based interventions (EBIs). Cultural adaptation, a promising method to close the gap, requires a systematic approach to ensure the balance between fidelity and fit. Using Korean Americans as a target group and the Savvy Caregiver Program (SCP) as a target EBI, we plan to test a systematic model of cultural adaptation that can be applied to other EBIs and other LEP groups. As a first step toward the goal, we will use the R21 grant award to employ a three- step model of cultural adaptation: (1) Information Gathering, (2) Preliminary Adaptation Design and Testing, and (3) Full Adaptation Design and Testing. Building on the team's prior work on Information Gathering, we aim to design and test preliminary adaptation (surface-level language attunement) and full adaptation (deep structure-level modification) of the SCP. Through a back-translation method followed by expert reviews, we will prepare a Korean version of the SCP caregiver/trainer manuals. We will recruit and train two Korean-speaking interventionists, and each of them will deliver the linguistically attuned SCP to six participants (total n = 12). Eligibility criteria include Korean Americans who provide primary care for a family member with ADRD and who speak English less than ?very well.? Each participant will receive the 12-hour (2 hours weekly for 6 weeks) in- person group SCP sessions and be evaluated for adherence, acceptability, and satisfaction. In addition, we will develop an SCP Key Principles Test to assess the intactness of the SCP core principles after adaptation modifications. We will use a mixed quantitative and qualitative methodology to seek feedback on cultural relevance of each program component from both participants and interventionists. All SCP sessions will be video-recorded for fidelity assessment and subsequent cultural adaptations. We will develop a Full Cultural Adaptation Worksheet to conduct a deep structure-level adaptation via a data-driven cultural assessment (e.g., video-recorded session analysis, feedback from preliminary testing participants, and examples of cultural adaptation in literature review), followed by iterative feedback loops involving multiple stakeholders (SCP developer, researchers with cultural competence, content and cultural experts, and a community advisory board). The interventionists will deliver the fully adapted SCP to three new groups of six caregivers (total n = 18) following the refined protocols. Although the study is explorative in nature, we anticipate that preliminary linguistic attunement will help the SCP reach out to ADRD caregivers with LEP, but that we will observe better engagement outcomes in the fully adapted SCP. We will compile the entire process of cultural adaptation, along with a worksheet and evaluation tools, into a manual for use with other LEP groups. The findings will form a solid foundation for a larger, definitive study with a clinical trial (e.g., R01) to examine program efficacy and provide a translational model for reducing barriers to EBIs for diverse LEP groups.

PROJECT SUMMARY Building upon the evidence that limited English proficiency (LEP) poses a critical risk to older immigrants' oral health and dental care, the proposed study focuses on older Korean Americans as an initial target group for evaluating an oral health education and navigation program designed to promote older LEP immigrants' use of preventive dental services. The study is based on four premises: (1) oral health knowledge and healthcare navigation skills are critical imperatives in reducing oral health disparities in LEP populations and, thus, are important intervention targets, (2) bilingual and bicultural community health worker (CHW) participation is critical in reaching out to older LEP immigrants, (3) language diversities in LEP populations, as well as differences in personal needs, necessitate a sustainable method to personalize the intervention (i.e., computerized tailoring), and (4) the combination of ?human touch? (CHWs) and ?digital touch? (technology) requires a pilot test to evaluate feasibility and acceptability. The program we envision is an oral health education and navigation assistance program that is personalized by a computerized tailoring system and delivered by CHWs. The long-term goal of the program, inspired by the Transtheoretical Model (TTM) and the Fogg Behavioral Model (FBM), is to promote both proximal (oral health knowledge and self-efficacy) and distal (use of preventive dental services) outcomes. As a first step toward the goal, this R21 study pursues the following activities: (1) focus group with a Community Advisory Board, (2) assessment of the local dental service environment, (3) content development for education and navigation materials, (4) development of a computerized tailoring system, (5) development of protocols for CHW training and monitoring, and (6) pilot testing and evaluation of the program. Each step will be guided by the principles of Community-Based Participatory Research (CBPR). The products from these initial activities will include a content library of oral health education materials and local resources for dental care, a computerized tailoring system, and a protocol for CHW training and monitoring. Pilot testing will be conducted with 40 older Korean Americans who meet the eligibility criteria (having LEP and no use of preventive dental services in the past 12 months). Each participant will be assigned to one of four trained CHWs and will receive a personalized one-on-one education session (30 minutes, using an iPad). The research team will contact participants three months later to determine whether they had used any preventive dental services since the education session. Using an adaptive design, a CHW-led personalized navigation assistance program will be provided to non-users. The research team will collect and analyze data from both the participants and the CHWs, including quantitative data on participation rate and satisfaction with the program and qualitative feedback. The findings will form a solid foundation for a larger, definitive study with a clinical trial (e.g., R01) to identify behavioral health outcomes and provide a translational model for reducing barriers to preventive dental services for diverse LEP groups.