The country of Burma (Myanmar) has been riddled with conflict, strife, and sectarian violence for over 30 years. Since 2006, the United States has taken in just over 150,000 refugees from Burma, of which an estimated 5,000 reside in Colorado. Once granted refugee status in the United States, the challenges that this population faces are enormous, including finding sustainable employment, affordable housing, and the lack of access to culturally competent healthcare. The newfound challenges of refugee life can be incredibly taxing both physically and mentally. When previous mental stressors, such as exposure to trauma in their home country, are combined with these newfound challenges, refugees are over two times more likely to exhibit Substance Abuse Disorder as defined by DSM-IV. The specific purpose of this study is to assess the effects of alcohol use on the local refugee population from Burma and formulate an appropriate intervention utilizing a community based participatory research (CBPR) model.

This research was undertaken in full partnership with the refugee community from Burma and its stakeholders in the greater Denver area.

A multiphase community-based participatory research model was utilized to conduct this research. True to the CBRP model, the first phase was establishing a partnership with the community, and subsequent identification of an issue ripe for intervention. A group of young adults from the refugee community were recruited to form the Youth Advisory Board. They identified alcohol use as the dominant health-related concern within their own community. With this issue identified, the project moved into phase two. Phase two involved conducting semi-structured one-on-one, audio-recorded interviews with members of the refugee community from Burma. The data from these interviews was then analyzed using immersion crystallization methodology. The next phase to be undertaken is presentation of the findings to the community and generation of a culturally competent intervention.

The analysis of the ten audio-recorded surveys showed the emergence of several qualitative themes related to the use of alcohol within this community. The use of alcohol as a coping mechanism for the stressors of refugee life is highly prevalent among males and this has a direct negative impact upon the family unit. In addition, there is a sense of personal responsibility and a lack of resources aiding cessation within the community.

This project expands upon current literature regarding the scope and impact of alcohol use within the community of refugees from Burma. In partnership with the community and its stakeholders, the qualitative themes generated from this research have identified a need for a culturally appropriate intervention to effectively address alcohol use in this vulnerable population.

PRAJAKTA ADSUL
Assistant Professor, University of New Mexico

The growing burden of cervical cancer in low- and middle-income countries (LMIC) has led to the introduction of new screening technologies, i.e. HPV based DNA tests, prompting recent guideline changes both in screening and treatment approaches. Several clinical trials have evaluated novel screening tests; however, limited information can be extracted from these trials to inform the implementation of the screening processes in real-world settings.

ESTAMPA is a multi-centric screening and triage study recruiting 50,000 women aged 30-64 years, in 12 sites from 9 Latin American countries.[1] The goal of the study is to evaluate different triage methods for HPV positive women and the feasibility of country/setting-specific implementation process. Using the Pragmatic Explanatory Continuum Indicator (PRECIS-2) [2] we conducted a facilitated group discussion with the primary coordinating team from the International Agency for Research on Cancer (IARC) and separately with the country specific study teams. In addition, we surveyed study teams (n=107) using previously validated measures [3] to assess acceptability, appropriateness, and feasibility of conducting the screening process in their context.

Overall, the PRECIS-2 tool allowed for a formal approach to assess pragmatic aspects ESTAMPA from the perspectives of the coordinating team that discussed the study with respect to the nine domains (scores in parenthesis) (Eligibility (5); Recruitment (3); Setting (5); Organization (3); Flexibility of delivery (4); Flexibility of intervention (2); Follow-up (4); Primary outcome (4); and Primary analysis (5). We are currently engaging with the country teams to generate a discussion using PRECIS-2 about the implementation of the trials in their settings. Results from the survey conducted on staff teams show overall acceptability at 63%, appropriateness at 80%, and feasibility at 71%.

Although ESTAMPA was not designed as a pragmatic trial, we found that it lies mostly in the pragmatic end of the continuum. The trial was conducted with “future implementation in mind” and followed the IARC model of conducting studies where participating countries were considered as partners in research and the study was implemented keeping in mind existing system characteristics. Using PRECIS-2 can help facilitate discussion surrounding the implementation of interventions and processes. This research can helps contextualize research findings and provide decision making guidance for future implementation of effective HPV cervical cancer screening programs in LMICs.

LISA ROSS DECAMP
Associate Professor, University of Colorado School of Medicine/Children’s Hospital Colorado

US born Latino children with immigrant parents, who comprise half of Latino children, have a higher rate of childhood obesity than other Latino children. The US Preventive Services Task Force recommends referral of all obese children to intensive weight management programs to decrease body mass index. When available, intensive programs are limited to clinical settings and do not address social determinants of health among Latino immigrant families. Active and Healthy Families (AHF), a Spanish-language, culturally tailored group visit program for children has demonstrated effectiveness in decreasing body mass index.1 AHF does not address families’ barriers to frequent engagement with the healthcare system nor social determinants barriers other than immigration. Adapting the intervention for community-based delivery may increase acceptability and family engagement.

To engage a stakeholder network in identifying adaptations of an evidence-based weight management intervention for community-based implementation.

Guided by the intervention mapping-adapt process, we solicited feedback from a stakeholder network from Aug 2018-Dec 2019.2 The network included 4 subcommittees: 1) Latino immigrant families including those who had participated in AHF delivered in a healthcare setting; 2) members of and leaders of community organizations; 3) healthcare services delivery leaders; and 4) researchers in health disparities and Latino health. Subcommittee activities included applying user-centered design principles and Photovoice, a participatory action research method.

Stakeholders identified three functions3 (i.e. essential components) of the evidence-based intervention: a collaborative, multidisciplinary facilitation model, use of the transtheoretical model of change to prompt family-level behavior change tailored to cultural values, and a financially sustainable reimbursement model. The network reached consensus on forms (strategies to meet each function) needed for community-based implementation. Form changes included: 1) different professional roles of facilitators to better align with availability of community experts, family preferences, and to contain costs; 2) incorporation of social determinants facilitators and barriers to behavior change and strategies to mitigate these barriers into the curriculum; and 3) addressing financial sustainability using the Medicare Diabetes Prevention Program as a model. (See Table 1)

Stakeholder engagement as part of an intervention mapping process defined functions of an evidence-based weight management intervention and key form changes for community-based vs. clinic-based implementation. Community-based implementation may better address some social determinants of health barriers to healthy weight for Latino children in immigrant families.