Scott C Carvajal

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• Carvajal, S. C., Rosales, C. B., & Zapien, J. G. (2017). Emergent Public Health Issues in the US-Mexico Border Region. Frontiers Media SA. doi:10.3389/978-2-88945-047-3

Journals/Publications

• Carson, W. O., Valenti, M., Begay, K., Carvajal, S., Carroll, S. R., Yuan, N. P., & Cordova-Marks, F. M. (2025). Evaluating Indigenous Identity and Stress as Potential Barriers to Accessing On-Campus Healthcare for Indigenous Students at a Large Southwestern University. International Journal of Environmental Research and Public Health, 22(Issue 9). doi:10.3390/ijerph22091409
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  Introduction: This study examined the relationship between Indigenous identity, perceived stress, and healthcare utilization for Indigenous students on-campus. Methods: Potential participants included undergraduate and graduate Indigenous students from Tribal Nations within the United States. Participants were recruited through community partnerships and in person communication. This survey included the Perceived Stress Scale (PSS-10), the Multiethnic Identity Measure (MEIM), and university Campus Health Service Health and Wellness Survey. Results: 153 Indigenous students from United States-based Tribal Nations participated in this survey. While there appears to be a relationship between Indigenous identity, perceived stress, and Campus Health utilization, the results were not significant for the second tertile (OR: 1.1 (0.4, 2.7)) or third tertile (1.4 (0.5, 3.3)). Students who reported “Yes” or “Unsure” to questions on if their insurance needed them to go outside of the university were far less likely to use Campus Health (Yes OR: 0.2 (0.08–0.5)); (Unsure OR: 0.09 (0.03–0.3)) and CAPS (Yes OR: 0.2 (0.09–0.6)); (Unsure OR: 0.2 (0.04–0.4)). Discussion: This study saw a complex relationship between Indigenous identity, perceived stress, and campus health utilization; however, the findings are not statistically significant. There are distinctions in on campus health care usage when adjusting for undergraduate or graduate student status and health insurance literacy. Conclusion: The research findings offer many promising avenues for future work around Indigenous identity, affordability of healthcare, and importance of health literacy.
• Cordova, F. M., Carroll, S. R., Carvajal, S. C., Begay, K., Valenti, M., Carson, W., Yuan, N. P., Cordova, F. M., Carroll, S. R., Carvajal, S. C., Begay, K., Valenti, M., Carson, W., & Yuan, N. P. (2025).

  Evaluating Indigenous identity and stress as potential barriers to accessing on-campus healthcare for Indigenous students at a large southwestern university

  . International Journal of Environmental Research and Public Health.
• Cordova, F. M., Carvajal, S. C., McClelland, J., Goldtooth-Halwood, R., Curley, C., Carson, W., & Yuan, N. P. (2024).

  Examining Indigenous identity as a protective factor in mental health well-being research in the United States: A scoping review

  . International Journal of Environmental Research and Public Health.
• Crocker, R. M., Duenas, K. R., Castro, I., Ingram, M., Torres, E., & Carvajal, S. C. (2025). Knowledge of the Stress–Health Link as a Source of Resilience Among Mexicans in the Arizona Borderlands. Qualitative Health Research, 35(Issue 2). doi:10.1177/10497323241251776
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  Mexicans who migrate to the United States endure significant stressors related to the migration process and social and environmental conditions of life in the United States. Given that chronic stress exposure has been linked to the onset of health conditions, these ecological factors may expose them to increased risk for poor health. However, Mexicans have many positive health outcomes compared to those monitored nationally, making it crucial to understand possible sources of resilience in this population. Here, we investigate Mexicans’ lay health knowledge in response to stress as a possible source of health-related resilience. Health knowledge is considered a central facet of practical and traditional knowledge as well as adaptive modes of intelligence and has a tangible impact on health. Using an ethnographically grounded community-based participatory research design informed by the theory of embodiment, our hybrid team of bilingual university and community-based researchers interviewed Mexican-origin residents (N = 30) living in rural southwestern Arizona about how they experienced and responded to stress and incorporated it into their etiological frameworks. Thematic analysis revealed that participants paid close attention to how stress presented itself in their bodies, which informed their understanding of its potentially harmful health impacts and motivated them to employ multiple stress reduction strategies. Our results highlight the breadth of Mexicans’ lay health knowledge, thereby challenging dominant narratives about low rates of health literacy in this population. Findings can be harnessed to optimize potential health protective effects in home and community settings as well as to inform preventive and clinical interventions.
• Crocker, R. M., Yeo, S., Cordova-Marks, F. M., Castro, I., Torres, E., & Carvajal, S. C. (2025). “Don't leave it all to science”: How Mexicans living along the US-Mexico border view health and care seeking. Wellbeing, Space and Society, 9(Issue). doi:10.1016/j.wss.2025.100288
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  The geographic and cultural distribution of the health beliefs that inform how people interpret disease etiologies, engage in the clinical arena, utilize traditional remedies, and respond to health promotion programming is an important and understudied topic. The impacts of place-based factors on health concepts may be especially critical among geographically displaced populations, who tend to face a similar and concerning host of barriers to medical care access and societal stressors. In this community-based participatory research study, we use qualitative interviews (n=30) among a sample of binationally mobile Mexicans living near the US-Mexico border in southern Arizona to explore how border residence shapes Mexicans’ health and healing world views and care-seeking practices. Findings centered around 1) participants’ binational mobility which reinforced their connections with Mexican healing practices and medical services and provided an escape valve in the face of US-based barriers to care; 2) their integrated mind-body-soul health concepts that grounded them in their ecological and social surroundings; 3) their commitment to taking a primary role in their own healing including localized health challenges and their views on the role of doctors, and 4) barriers to health management tied to labor conditions, border crossing stressors, and perceived ill effects of biomedical care. In conclusion, proximity to the border and binational mobility are shown here to reinforce Mexicans’ cultural health concepts and facilitate their ability to maintain a more active role in their own care-seeking practices and to circumvent some critical US-based barriers to medical services.
• Lothrop, N., Gutenkunst, S., Fimbres, J., Quijada, C., Chaires, M., Cortez, I., Sandoval, F., Camargo, F. J., Ramírez, D. M., Gallardo, E. V., Torabzadeh, E., Wagoner, R., Lopez-Galvez, N., Ingram, M., Carvajal, S., Billheimer, D., Wolf, A. M., & Beamer, P. I. (2025). Characterizing full-shift worker exposures to VOCs in small-sized auto repair shops in the Tucson, Arizona, USA metropolitan area. Scientific Reports, 15(Issue 1). doi:10.1038/s41598-025-08546-6
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  Auto repair shops employ 1% of the US labor force. These workers are constantly exposed to volatile organic compounds (VOCs), which have known and often irreversible health effects, yet exposure studies are sparse. Our goal was to assess what exposure factors were related to total personal and shop-level specific VOC exposures for entire shifts in marginalized, predominantly Spanish-speaking workers in auto repair shops. Full-shift, real-time worker exposure factors like activities and ventilation conditions were recorded, along with personal total VOCs and shop-level specific VOC samples. The relationship of total VOCs with activity and ventilation, along with shift and shop, was analyzed using linear mixed effects modeling. Specific VOC concentrations were combined into hazard scores for potential health risks based on EPA inhalation reference or reference dose. Personal exposures were characterized by episodic peaks, with the highest peaks during spraying brake cleaner and painting activities in 22/35 shifts. Shift within shop and shop accounted for about half the variation in total VOC exposures to workers (35% and 15%, respectively), while activity and ventilation explained almost none. Acetone and toluene were detected in all samples. While worker exposure patterns were characterized by infrequent but very high peak exposures to total VOCs related to aerosolization activities, activities were only slightly predictive of VOC exposure overall. Instead, shift within shop and shop explained just half the variability. While additional study on exposure factors is needed, this should be done with a focus on interventions tailored to worker and shop.
• Maldonado, A., Torres, E., Flores, M., Rodriguez, M., Villavicencio, E. A., Torres, R., Castro, I., Torres, F., Loya, J. C., Alkhouri, N., & Carvajal, S. (2025). The association between neighborhood context, allostatic load, and metabolic dysfunction-associated steatosis liver disease in Mexican-origin farmworkers along the Southern Arizona US/Mexico border. SSM - Population Health, 32(Issue). doi:10.1016/j.ssmph.2025.101862
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  Background: Mexican-origin farmworkers experience disproportionately high rates of chronic diseases which increase their risk for metabolic dysfunction-associated steatosis liver disease (MASLD). While it has been found that neighborhood-level factors influence health as much as individual-level characteristics, including allostatic load (ALoad), these factors have been less examined in MASLD research. This study examined the association between perceived neighborhood environment, ALoad, and MASLD. It also examined whether ALoad is a mediator between perceived neighborhood context and MASLD. Methods: Multivariable binary logistic and linear regressions were fitted to analyze data from a community-based sample of 151 Mexican-origin farmworkers residing in the Southern Arizona border region. Self-reported data on six dimensions of neighborhood context was collected. Allostatic load was calculated as an index of physiological dysregulation. Hepatic steatosis and fibrosis were assessed by liver stiffness measurements (LSM) and controlled attenuation parameter (CAP) through FibroScan®. MASLD were identified as having a CAP score of ≥288 dB/m. Results: The mean age was 49.7 ± 14.1 years, mean BMI 31.9 ± 6.5 kg/m2, and 9.9 % had type 2 diabetes. The mean CAP score was, M = 265.8 ± 61.0 with 41.1 % of the sample exhibiting MASLD status. Perceived neighborhood violence was not associated with MASLD status; however, it was negatively associated with ALoad, (p = 0.003). ALoad was a negative mediator between perceived violence and MASLD status (p = 0.004). Conclusion: The results of this study inform the development of culturally relevant strategies to reduce Mexican-origin farmworkers’ risk for MASLD that are highly responsive to the structural and systemic forces that shape their lived experience.
• Muniz, F., Carlos, M., Hunter, A., Fox, M. J., Nuno, V. L., Carvajal, S. C., & Yuan, N. P. (2022).

  Participation in a culturally-grounded program strengthens cultural identity, self-esteem, and resilience in urban Indigenous adolescents

  . American Indian Alaska Native Mental Health Research.
• Torres, R., Ingram, M., Flores, M. A., Ruiz, J., Carvajal, S. C., Duenas, K., & Yuan, N. P. (2025).

  Psychometric properties of the “Inventario de Resiliencia” in an adult Mexican Origin population living in the southwest United States

  . Journal of Prevention & Intervention in the Community.
• Coco, L., Leon, K., Navarro, C., Piper, R., Carvajal, S., & Marrone, N. (2024). "Close to My Community": A Qualitative Study of Community Health Worker-Supported Teleaudiology Hearing Aid Services. Ear and Hearing, 45(5). doi:10.1097/aud.0000000000001507
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  Objectives: Given well-documented disparities in rural and minority communities, alternative service delivery models that help improve access to hearing care are needed. This article reports on a study of older Latino adults with hearing loss who received hearing aid services with Community Health Workers (CHWs) providing support via teleaudiology. The present study used qualitative data to explore perceptions of this novel service delivery model. Design: Participants completed semistructured interviews related to their experiences in the intervention approximately 17 weeks after the hearing aid fitting appointment. Two coders independently coded the data, using an iterative deductive and inductive thematic analysis approach. Inter-rater reliability was good (κ = 0.80). Results: Of the 28 participants, 19 were interviewed (CHW group: n = 9, 8 females; non-CHW group: n = 10, 9 females). Both groups of participants reported experiencing barriers in access to care and reported positive experiences with teleaudiology and with hearing aids as part of the trial. CHW group participants reported interactions with patient-site facilitators that were indicative of patient-centeredness. Conclusions: Results demonstrate the feasibility and potential effectiveness of trained CHWs as patient-site facilitators in teleaudiology-delivered hearing aid services for adults.
• Ingram, M., Wilkinson-Lee, A. M., Mantina, N. M., Velasco, M., Coronado, G., Gallegos, M., & Carvajal, S. C. (2024). A Community-Based Participatory Approach in Applying the Sociocultural Resilience Model in U.S-Mexico Border Communities. Progress in community health partnerships : research, education, and action, 18(1), 131-139.
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  Behavioral models play a key role in identifying pathways to better health and provide a foundation for health promotion interventions. However, behavioral models based in epidemiological research may be limited in relevance and utility in practice.
• Ingram, M., Wilkinson-Lee, A. M., Mantina, N. M., Velasco, M., Coronado, G., Gallegos, M., & Carvajal, S. C. (2024). A Community-Based Participatory Approach in Applying the Sociocultural Resilience Model in U.S–Mexico Border Communities. Progress in Community Health Partnerships: Research, Education, and Action, 18(Issue). doi:10.1353/cpr.2024.a922337
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  Background: Behavioral models play a key role in identifying pathways to better health and provide a foundation for health promotion interventions. However, behavioral models based in epidemiological research may be limited in relevance and utility in practice. Objectives: We describe a participatory approach within a community-based participatory research partnership for integrating epidemiological and community perspectives into the application of the sociocultural resilience model (SRM). The SRM posits that cultural processes have a sym-biotic relationship with health-promoting social processes, which contribute to the health advantages among Mexican-origin and other Latinx populations. Methods: Community action board members engaged with academic partners to interpret and apply the SRM to a community-clinical linkages intervention implemented in the context of three U.S.–Mexico border communities. In a two-day workshop, partners engaged in a series of iterative discussions to reach common definitions and measures for SRM constructs. Results: Partners described daily cultural processes as the food they eat, how they communicate, and a collectivist approach to getting things done. For intervention activities, the partners opted for intergenerational storytelling, sharing of food, and artistic forms of expression. Partners included measures of cultural nuances such as border identity and the complexities that often arise from navigating bicultural norms. Conclusions: Collaborative approaches within community-based participatory research partnerships can facilitate the adaptation and measurement of conceptual health behavior models in community practice.
• Larson, E. K., Ingram, M., Dougherty, E., Velasco, M., Guzman, V., Jackson, A., Patel, K., Carvajal, S. C., & Wilkinson-Lee, A. M. (2024). Centering the role of community health workers in social risk screening, referral, and follow-up within the primary care setting. BMC Primary Care, 25(Issue 1). doi:10.1186/s12875-024-02590-3
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  Background: Community health workers (CHWs) remain an underutilized resource in social risk diagnostics in the primary care setting. This process evaluation study seeks to assess the role of CHWs in social risk screening, referral, and follow-up through process mapping to identify barriers to the process for future quality improvement efforts. Methods: Researchers at the Arizona Prevention Research Center (AzPRC) engaged with two Federally Qualified Health Centers (FQHCs) in two of Arizona’s major urban areas to evaluate their internal processes for social risk screening and intervention. The Consolidated Framework for Implementation Research (CFIR) was used to direct a process mapping exercise to visually describe the workflow, gaps, and barriers to identifying and addressing social risk. Results: The process unveiled key areas for health system improvements in the community setting, the organizational setting, and in the implementation of social risk screening, referral, and follow-up. Further, process maps highlight the potential resources needed for effective CHW integration to address social risk in the primary care setting. Conclusions: Our findings demonstrate the importance of organizational tools, such as process mapping, to assist primary care settings in evaluating internal processes for quality improvement in addressing social risk and in effectively integrating the CHW workforce. Subsequent research will evaluate rates of social risk screening, referral, and follow-up within all of Arizona’s FQHCs and propose models for CHW integration to address social risk in primary care and strengthen social risk screening reach and effectiveness.
• Morales, M., Wilkinson-Lee, A., Ingram, M., Guernsey De Zapien, J., Sepulveda, R., Carvajal, S., & Nuño, T. (2024). Risk factors associated with loneliness among mexican-origin adults in southern Arizona. BMC Public Health, 24(1). doi:10.1186/s12889-024-19199-x
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  This study examines factors associated with symptoms of loneliness among a sample (n = 213) of mostly Mexican-origin adults at risk of chronic diseases in Southern Arizona’s Pima, Yuma, and Santa Cruz counties. It uses baseline data from a community-based participatory research partnership and multinominal logistic regression models. Controlling for chronic diseases and sociodemographic characteristics, perceived social support and hope exhibit negative main effects on loneliness when comparing individuals who experienced loneliness for 5–7 days in the preceding week with those who did not encounter such feelings during the same period (adjusted odds ratio, AOR = 0.49 and 0.47; 95% confidence interval, CI = 0.34–0.73 and 0.29–0.75, respectively). However, when considered together, perceived social support and hope display a positive and statistically significant combined effect on loneliness (AOR = 1.03; 95% CI = 1.01–1.06). Holding all covariates constant, individuals reporting loneliness for 5–7 days exhibit a relative risk ratio of 1.24 (95% CI = 1.06–1.46) for a one-unit increase in physical problem severity compared to those who do not experience loneliness. Moreover, being 65 years old or older (AOR = 0.16, 95% CI = 0.03–0.84), and having been born in Mexico and lived in the US for less than 30 years (AOR = 0.12, 95% CI = 0.02–0.74) are associated with negative main effects on loneliness when comparing individuals who experienced loneliness 1–2, and 5–7 days in the preceding week with those who did not feel loneliness during the same timeframe, respectively. Recognizing the crucial role of loneliness in shaping health outcomes for Mexican-origin adults, our findings underscore the significance of fostering supportive environments that not only enhance well-being but also cultivate robust community bonds within the US-Mexico border region.
• Ruiz, J., Hughes, S., Flores, M., Custer, B., Ingram, M., Carvajal, S., Rosales, C., Kamel, H., Vassallo, R., & France, C. (2024). Neighborhood ethnic density and disparities in proximal blood donation opportunities. Transfusion, 64(6). doi:10.1111/trf.17847
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  Background: Despite being the largest racial/ethnic minority group in the United States, Hispanic/Latinos (H/L) are significantly underrepresented among blood donors. A lack of proximal blood donation opportunities may be one factor contributing to these disparities. However, few studies have investigated this possibility. Study Design and Methods: Proprietary data on mobile blood collections in Maricopa County, Arizona, were gathered for the period of January 01, 2022 to April 30, 2022 and paired with census tract information using ArcGIS. Maricopa County encompasses the city of Phoenix with a total population of approximately 4.5 million people, including 1.5 million H/L residents. Blood drive count was regressed on H/L ethnic density and total population, and model estimates were exponentiated to obtain odds ratios (ORs) and 95% confidence intervals (CIs). Results: During the specified period, approximately 27,000 red blood cell units were collected through mobile drives. Consistent with expectations, when controlling for total neighborhood population, each 10% increase in H/L ethnic density lowered the odds of having a blood drive in the corresponding neighborhood by 12% (OR = 0.88, 95% CI (0.83, 0.92), p
• Ingram, M., Dueñas, K. R., Castro, I., Vázquez, L., Crocker, R. M., Larson, E. K., Guernsey de Zapien, J., Torres, E., & Carvajal, S. C. (2023). The Use of Qualitative Methods to Guide the Development of the Border Resilience Scale in a Participatory Research Study. International journal of environmental research and public health, 20(9).
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  U.S.-Mexico border residents experience pervasive social and ecological stressors that contribute to a high burden of chronic disease. However, the border region is primarily composed of high-density Mexican-origin neighborhoods, a characteristic that is most commonly health-promoting. Understanding factors that contribute to border stress and resilience is essential to informing the effective design of community-level health promotion strategies. La Vida en La Frontera is a mixed-methods, participatory study designed to understand factors that may contribute to border resilience in San Luis, Arizona. The study's initial qualitative phase included interviews with 30 Mexican-origin adults exploring community perceptions of the border environment, cross-border ties, and health-related concepts. Border residents described the border as a Mexican enclave characterized by individuals with a common language and shared cultural values and perspectives. Positive characteristics related to living in proximity to Mexico included close extended family relationships, access to Mexican food and products, and access to more affordable health care and other services. Based on these findings, we co-designed the 9-item Border Resilience Scale that measures agreement with the psychosocial benefits of these border attributes. Pilot data with 60 residents suggest there are positive sociocultural attributes associated with living in border communities. Further research should test if they mitigate environmental stressors and contribute to a health-promoting environment for residents.
• Ingram, M., Dueñas, K. R., Castro, I., Vázquez, L., Crocker, R. M., Larson, E. K., de Zapien, J. G., Torres, E., & Carvajal, S. C. (2023). The Use of Qualitative Methods to Guide the Development of the Border Resilience Scale in a Participatory Research Study. International Journal of Environmental Research and Public Health, 20(Issue 9). doi:10.3390/ijerph20095703
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  U.S.-Mexico border residents experience pervasive social and ecological stressors that contribute to a high burden of chronic disease. However, the border region is primarily composed of high-density Mexican-origin neighborhoods, a characteristic that is most commonly health-promoting. Understanding factors that contribute to border stress and resilience is essential to informing the effective design of community-level health promotion strategies. La Vida en La Frontera is a mixed-methods, participatory study designed to understand factors that may contribute to border resilience in San Luis, Arizona. The study’s initial qualitative phase included interviews with 30 Mexican-origin adults exploring community perceptions of the border environment, cross-border ties, and health-related concepts. Border residents described the border as a Mexican enclave characterized by individuals with a common language and shared cultural values and perspectives. Positive characteristics related to living in proximity to Mexico included close extended family relationships, access to Mexican food and products, and access to more affordable health care and other services. Based on these findings, we co-designed the 9-item Border Resilience Scale that measures agreement with the psychosocial benefits of these border attributes. Pilot data with 60 residents suggest there are positive sociocultural attributes associated with living in border communities. Further research should test if they mitigate environmental stressors and contribute to a health-promoting environment for residents.
• Lohr, A. M., Bell, M. L., Coulter, K., Marston, S., Thompson, M., Carvajal, S. C., Wilkinson-Lee, A. M., Gerald, L. B., & Korchmaros, J. (2023). The Association Between Duration of School Garden Exposure and Self-Reported Learning and School Connectedness. Health Education and Behavior, 50(Issue 5). doi:10.1177/10901981221084266
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  When students feel connected to their school, they experience positive health and academic outcomes. In contrast, school disengagement is a predictor of dropout, delinquency, and substance use. School garden programming has the potential to help children achieve academic outcomes and feel connected to their school. Unfortunately, most school garden research has been conducted with white, affluent study participants. We describe the results of a secondary analysis utilizing data from an evaluation of a university-supported community school garden program (CSGP). Using a cross-sectional survey study design, we examined the impact of school garden programming in Title I schools on primarily Latino/a (Hispanic) elementary student self-reported learning and feelings of school connectedness by comparing students with ≤1 year exposure to those with >1 year. Social cognitive theory formed the conceptual basis for the analysis. Duration of school garden exposure did not have a significant association with self-reported learning or feelings of school connectedness. Regardless of past exposure, fifth-grade students, females, and those who identify as Latino/a (Hispanic) felt that school garden programming improved their learning. Latino/a (Hispanic) students who participate in school garden programming may also feel a greater sense of connection to their teachers and peers at school. Qualitative results demonstrated that most students enjoyed spending time in the garden and indicated that participating in the program helped them learn new things and feel connected to their school. If individuals who may be disadvantaged because of systemic racism, such as Latino/a (Hispanic) students, can benefit from school garden programming, such interventions should be further investigated and prioritized.
• Lothrop, N., Sandoval, F., Cortez, I., Wagoner, R., Lopez-Galvez, N., Parra, K., Wolf, A., Wertheim, B., Quijada, C., Lee, A., Griffin, S., Bell, M., Carvajal, S., Ingram, M., & Beamer, P. (2023). Studying full-shift inhalation exposures to volatile organic compounds (VOCs) among Latino workers in very small-sized beauty salons and auto repair shops. Frontiers in Public Health, 11. doi:10.3389/fpubh.2023.1300677
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  Background: One in every 200 US jobs is in a beauty salon or auto repair shop, where workers are regularly exposed to volatile organic compounds (VOCs) that may cause a range of short- and long-term health issues. In these shops, Latino workers are overrepresented and lack culturally and linguistically appropriate industrial hygiene resources. This leaves a gap in knowledge on inhalation exposures to VOCs in this hard-to-reach and ubiquitous worker population. Objective: Our goal was to recruit hard-to-reach, predominantly Spanish-speaking workers in beauty salons and auto repair shops and monitor total VOC inhalation exposures for over entire work shifts, with minimal impact on workers, clients, and business. Methods: We developed and refined measurement and exposure assessment methods for personal and area full-shift VOC inhalation exposures. Results: With minimal participant loss, we measured over 500 h of real-time, personal VOC exposures and recorded activities and other exposure factors for 47 participants, while also documenting chemical inventories and quantifying indoor area concentrations of specific VOCs among 10 auto repair shops and 10 beauty salons. Conclusion: Lessons learned from our study can assist future studies of inhalation exposures in other hard-to-reach occupational populations.
• Morales, M., Ingram, M., Coulter, K. M., Nuño, T., Wilkinson-Lee, A. M., Guernsey De Zapien, J. E., & Carvajal, S. (2023). Factors Associated with Depressive Symptoms among Mexican-Origin Adults in a Community Sample at the US Mexico Border Region. International Journal of Environmental Research and Public Health, 20(Issue 11). doi:10.3390/ijerph20116017
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  Using baseline data from three partnering federally qualified health centers, we examined factors associated with depressive symptoms among Mexican-origin adults at risk of chronic disease living in three counties in Southern Arizona (i.e., Pima, Yuma, and Santa Cruz). Multivariable linear regression models identified correlates of depressive symptoms for this population controlling for sociodemographic characteristics. Among 206 participants, 85.9% were female and 49% were between 45 and 64 years of age. The proportion of depressive symptoms was 26.8%. Low levels of physical pain and high levels of hope and social support were also reported. Physical pain was positively and significantly related to depressive symptoms (β = 0.22; 95% CI = 0.13, 0.30). Conversely, hope was negatively and significantly associated with depressive symptoms (β = −0.53; 95% CI = −0.78, −0.29). A better understanding of factors related to depressive symptoms among Mexican-origin adults is necessary to fulfill their mental health needs, as well as to achieve health equity and to eliminate health disparities in the US–Mexico border region.
• Morales, M., Ingram, M., Coulter, K. M., Nuño, T., Wilkinson-Lee, A. M., Guernsey De Zapien, J. E., & Carvajal, S. (2023). Factors Associated with Depressive Symptoms among Mexican-Origin Adults in a Community Sample at the US Mexico Border Region. International journal of environmental research and public health, 20(11).
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  Using baseline data from three partnering federally qualified health centers, we examined factors associated with depressive symptoms among Mexican-origin adults at risk of chronic disease living in three counties in Southern Arizona (i.e., Pima, Yuma, and Santa Cruz). Multivariable linear regression models identified correlates of depressive symptoms for this population controlling for sociodemographic characteristics. Among 206 participants, 85.9% were female and 49% were between 45 and 64 years of age. The proportion of depressive symptoms was 26.8%. Low levels of physical pain and high levels of hope and social support were also reported. Physical pain was positively and significantly related to depressive symptoms (β = 0.22; 95% CI = 0.13, 0.30). Conversely, hope was negatively and significantly associated with depressive symptoms (β = -0.53; 95% CI = -0.78, -0.29). A better understanding of factors related to depressive symptoms among Mexican-origin adults is necessary to fulfill their mental health needs, as well as to achieve health equity and to eliminate health disparities in the US-Mexico border region.
• Morales, M., Ingram, M., Sepulveda, R., Nuño, T., Wilkinson-Lee, A. M., Guernsey De Zapien, J. E., & Carvajal, S. (2023). Risk Factors Associated with Diabetes among Mexican-Origin Adults in Southern Arizona. International Journal of Environmental Research and Public Health, 20(Issue 12). doi:10.3390/ijerph20126126
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  Diabetes is the seventh leading cause of death in the United States, and it is particularly problematic among the Latine population. This study employed multivariable logistic regression models to examine how hypertension, depression, and sociodemographics were associated with diabetes in a cross-sectional sample of Mexican-origin adults living in three counties of Southern Arizona. The overall prevalence of diabetes from this primary care sample was 39.4%. Holding covariates at fixed values, individuals having hypertension were 2.36 (95% CI: 1.15, 4.83) times more likely to have diabetes, when compared to individuals not having hypertension. The odds of having diabetes for individuals with ≥12 years of educational attainment were 0.29 (95% CI: 0.14, 0.61) times the corresponding odds of individuals with
• Morales, M., Ingram, M., Sepulveda, R., Nuño, T., Wilkinson-Lee, A. M., Guernsey De Zapien, J. E., & Carvajal, S. (2023). Risk Factors Associated with Diabetes among Mexican-Origin Adults in Southern Arizona. International journal of environmental research and public health, 20(12).
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  Diabetes is the seventh leading cause of death in the United States, and it is particularly problematic among the Latine population. This study employed multivariable logistic regression models to examine how hypertension, depression, and sociodemographics were associated with diabetes in a cross-sectional sample of Mexican-origin adults living in three counties of Southern Arizona. The overall prevalence of diabetes from this primary care sample was 39.4%. Holding covariates at fixed values, individuals having hypertension were 2.36 (95% CI: 1.15, 4.83) times more likely to have diabetes, when compared to individuals not having hypertension. The odds of having diabetes for individuals with ≥12 years of educational attainment were 0.29 (95% CI: 0.14, 0.61) times the corresponding odds of individuals with
• Rivers, P., Palmer, K. N., Okechukwu, A., McClelland, D. J., Garcia, D. O., Sun, X., Pogreba-Brown, K., Carvajal, S. C., & Marrero, D. G. (2023). Immigration Status and Chronic Disease Outcomes – a Scoping Review. (listed). doi:10.21203/rs.3.rs-3143647/v1
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  Abstract Background Undocumented immigrants face significant barriers to accessing regular medical care in the U.S. This is a concern especially for individuals with chronic conditions. This scoping review provides an overview of the current knowledge on chronic health outcomes for undocumented immigrants compared to documented immigrants or US-born citizens. Methods The review process was conducted in accordance with the PRISMA-ScR guidelines, and the selection of studies was based on pre-defined criteria. Results Nine articles were included. Key information such as population details, and study details, outcomes, and limitations are presented. There was conflicting evidence as to whether undocumented immigrants have poorer health outcomes, with undocumented immigrants faring better on nine (43%) measures, faring worse on nine (43%), and with no difference found on three (14%) measures when compared to documented immigrants or US-born citizens. Conclusion Undocumented individuals face significant barriers to accessing the same level of health care for their chronic conditions, but it is unclear if this translates to poorer health outcomes. Future, rigorous studies are recommended to address this gap and better understand the health of this vulnerable population.
• Rivers, P., Sun, X., Garcia, D. O., Pogreba-Brown, K., Carvajal, S. C., & Marrero, D. G. (2023). Development and internal validation of three multivariable prediction models of Hispanic immigrant documentation status utilizing two samples from the southwestern United States (Preprint). (listed). doi:10.2196/preprints.50482
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  BACKGROUND Research on undocumented populations is sparse, both because documentation status is rarely ascertained in studies, and because undocumented individuals are less likely overall to participate in research studies. A better understanding of the health of these individuals is important, though, and one method that has been proposed to examine outcomes for this group without putting them at additional risk is through predictive modelling. OBJECTIVE Develop and internally validate a predictive model of documentation status. METHODS Utilizing combined data from two population-based samples in Arizona in which documentation status were collected, three prediction models of documentation status were created and internally validated. Models created used multiple imputation by chained equations (MICE), and two machine learning algorithms: random forests machine learning and support vector machine. Predicted documentation status was modelled from demographic, health behavior, and disease status indicators commonly collected in public health research studies. The performance of each model was assessed in terms of accuracy, precision, recall, and Matthews correlation coefficient (MCC). RESULTS The combined sample consisted of 473 individuals, of whom 85 were undocumented. The sample included 209 men and 263 women, aged 20 to 83 years of age at the time of their participation in the respective studies. The MICE model had the lowest rates of accuracy (64.3%), precision (0.81), recall (0.74), and MCC (-0.07). The random forests model was slightly better with an accuracy of 73.1%, precision of 0.82, recall of 0.86, and MCC of 0.002. The support vector machine was the strongest in all categories, with an accuracy of 90.7%, precision of 0.90, recall of 0.99, and MCC of 0.66. CONCLUSIONS Utilizing predictive models could protect the safety of vulnerable individuals as well as make possible investigation into potentially undocumented individuals in settings where it would be impractical or impossible to gather information on documentation status first-hand. The results of the current analysis demonstrate some promise and further investigation, particularly the support vector machine model.
• Tucker, K., Ingram, M., Doubleday, K., Piper, R., Sander, A., Flores, R., Martinez, D., & Carvajal, S. (2023). Results From La Vida Buena (The Good Life): A Quasi-Experimental Intervention of a Community Health Worker-Led Family-Based Childhood Obesity Program for Latino Children 5-8 Years of Age on the U.S.-Mexico Border. Health promotion practice, 24(6), 1196-1205.
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  To evaluate the effectiveness of the 8-week, community health worker (CHW)-led La Vida Buena childhood obesity program among Latino children 5 to 8 years old in a rural county along the U.S.-Mexico border.
• Beamer, P., Carvajal, S., Honan, J., Ingram, M., Quijada, C., Chaires, M., Fimbres, J., Ornelas, C., Sneed, S., Stauber, L., Spitz, R., Sandoval, F., Billheimer, D., & Wolf, A. M. (2022). Understanding the Impacts of the COVID-19 Pandemic on Small Businesses and Workers Using Quantitative and Qualitative Methods. Annals of Work Exposures and Health. doi:10.1093/annweh/wxac048
• Carvajal, S. C., Nuno, V. L., Thomas, R., Mcclelland, D. J., Nair, R. L., Delgado, M. Y., & Coulter, K. K. (2022). Future Orientation and Latinx Adolescent Development: A Scoping Review. Adolescent Research Review.
• Carvajal, S. C., Nuno, V. L., Thomas, R., Mcclelland, D. J., Nair, R. L., Delgado, M. Y., & Coulter, K. K. (2023). Future Orientation and Latinx Adolescent Development: A Scoping Review. Adolescent Research Review.
• Carvajal, S., Doubleday, K., Ingram, M., Tucker, K., Piper, R., Sander, A., Flores, R., & Martinez, D. (2022). Results From La Vida Buena (The Good Life): A Quasi-Experimental Intervention of a Community Health Worker–Led Family-Based Childhood Obesity Program for Latino Children 5–8 Years of Age on the U.S.-Mexico Border. Health Promotion Practice, 152483992211126. doi:10.1177/15248399221112691
• Coco, L., Carvajal, S. C., Navarro, C., Piper, R., & Marrone, N. (2022). Community Health Workers as Patient-Site Facilitators in Adult Hearing Aid Services via Synchronous Teleaudiology: Feasibility Results from the Conexiones Randomized Controlled Trial. Ear & Hearing, 44(1), 28-42. doi:10.1097/aud.0000000000001281
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  Objectives: The purpose of this study was to investigate the feasibility of Community Health Workers (CHWs) as patient-site facilitators in teleaudiology-facilitated hearing aid services to improve hearing aid rehabilitation outcomes for older Hispanic/Latino adults in a medically underserved, rural, US-Mexico border community. Design: A total of 28 adults (aged 55 to 89) with bilateral hearing loss participated in this study. Individuals were randomized to one of two teleaudiology intervention arms that differed at the level of the patient-site facilitator. Participants in the experimental group were assisted locally by trained CHW facilitators. Participants in the control group were assisted locally by trained university student facilitators. Synchronous (real-time) teleaudiology hearing aid services took place with participants located at a rural community health center and the clinician located a university 70 miles away. The results of this feasibility study are presented within the reach, effectiveness, adoption, implementation fidelity, and maintenance implementation framework. Results: Regarding reach, the participants in this study population are historically under-represented in research (primarily low-income Hispanic/Latino older adults). A total of 57 individuals were recruited, 47 were consented and assessed for eligibility and 28 individuals met inclusion criteria and were randomized. The average age of participants was 73.9 years, (range: 55 to 89 years) and most individuals were female (75%). Most participants (86%) reported having incomes less than $20,000 annually. Effectiveness results (via the Self Efficacy for Situational Communication Management Questionnaire) showed that both groups (CHW and control) significantly improved listening self-efficacy from pre-fitting baseline and no difference between groups was observed. Regarding datalogging, at the short-term follow-up, participants in the CHW group wore their hearing aids for more hours/day on average compared with participants in the control group. Implementation fidelity was high for both groups. Long-term maintenance of CHW-supported teleaudiology appears feasible given that training and institutional support is in place. Conclusions: Teleaudiology-delivered hearing aid services were feasible when facilitated locally by trained CHWs. Future efficacy and effectiveness research is warranted with CHWs and teleaudiology, potentially leading to a significant reduction in barriers for rural and medically under-resourced communities.
• Coulter, K., Delgado, M. Y., Nair, R. L., McClelland, D. J., Thomas, R., Nuño, V. L., & Carvajal, S. C. (2022). Future Orientation and Latinx Adolescent Development: A Scoping Review. (listed). doi:10.1007/s40894-022-00190-9
• Coulter, K., Ingram, M., Lohr, A., Figueroa, C., Coronado, G., Espinoza, C., Esparza, M., Monge, S., Velasco, M., Itule-Klasen, L., Bowen, M., Wilkinson-Lee, A., & Carvajal, S. (2022). Adaptation of a Community Clinical Linkages Intervention to the COVID-19 Pandemic: A Community Case Study. Frontiers in Public Health, 10(Issue). doi:10.3389/fpubh.2022.877593
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  In this community case study, we describe the process within an academic-community partnership of adapting UNIDOS, a community health worker (CHW)-led community-clinical linkages (CCL) intervention targeting Latinx adults in Arizona, to the evolving landscape of the COVID-19 pandemic. Consistent with community-based participatory research principles, academic and community-based partners made decisions regarding changes to the intervention study protocol, specifically the intervention objectives, participant recruitment methods, CHW trainings, data collection measures and management, and mode of intervention delivery. Insights from this case study demonstrate the importance of community-based participatory research in successfully modifying the intervention to the conditions of the pandemic and also the cultural background of Latinx participants. This case study also illustrates how a CHW-led CCL intervention can address social determinants of health, in which the pandemic further exposed longstanding inequities along racial and ethnic lines in the United States.
• Coulter, K., Ingram, M., Lohr, A., Figueroa, C., Coronado, G., Espinoza, C., Esparza, M., Monge, S., Velasco, M., Itule-Klasen, L., Bowen, M., Wilkinson-Lee, A., & Carvajal, S. (2022). Adaptation of a Community Clinical Linkages Intervention to the COVID-19 Pandemic: A Community Case Study. Frontiers in public health, 10, 877593.
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  In this community case study, we describe the process within an academic-community partnership of adapting UNIDOS, a community health worker (CHW)-led community-clinical linkages (CCL) intervention targeting Latinx adults in Arizona, to the evolving landscape of the COVID-19 pandemic. Consistent with community-based participatory research principles, academic and community-based partners made decisions regarding changes to the intervention study protocol, specifically the intervention objectives, participant recruitment methods, CHW trainings, data collection measures and management, and mode of intervention delivery. Insights from this case study demonstrate the importance of community-based participatory research in successfully modifying the intervention to the conditions of the pandemic and also the cultural background of Latinx participants. This case study also illustrates how a CHW-led CCL intervention can address social determinants of health, in which the pandemic further exposed longstanding inequities along racial and ethnic lines in the United States.
• Crocker, R. M., Duenas, K., Vázquez, L., Ingram, M., Cordova-Marks, F. M., Torres, E., & Carvajal, S. (2022). "Es Muy Tranquilo Aquí": Perceptions of Safety and Calm among Binationally Mobile Mexican Immigrants in a Rural Border Community. International journal of environmental research and public health, 19(14).
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  Perceptions of community can play an important role in determining health and well-being. We know little, however, about residents' perceptions of community safety in the Southwestern borderlands, an area frequently portrayed as plagued by disorder. The qualitative aim of this community-based participatory research study was to explore the perceptions of Mexican-origin border residents about their communities in southern Yuma County, Arizona. Our team of University of Arizona researchers and staff from Campesinos Sin Fronteras, a grassroots farmworker support agency in Yuma County, Arizona, developed a bilingual interview guide and recruited participants through radio adds, flyers, and cold calls among existing agency clientele. Thirty individual interviews with participants of Mexican origin who live in and/or work in rural Yuma County were conducted remotely in 2021. Participants overwhelmingly perceived their communities as both calm and safe. While some participants mentioned safety concerns, the vast majority described high levels of personal security and credited both neighbors and police for ensuring local safety. These perceptions were stated in direct contrast to those across the border, where participants had positive familial and cultural ties but negative perceptions regarding widespread violence. In conclusion, we argue that to understand environmental factors affecting health and well-being in Mexican immigrant populations, it is critical to examine the role of binational external referents that color community perceptions.
• Crocker, R. M., Duenas, K., Vázquez, L., Ingram, M., Cordova-Marks, F. M., Torres, E., & Carvajal, S. (2022). “Es Muy Tranquilo Aquí”: Perceptions of Safety and Calm among Binationally Mobile Mexican Immigrants in a Rural Border Community. International Journal of Environmental Research and Public Health, 19(Issue 14). doi:10.3390/ijerph19148399
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  Perceptions of community can play an important role in determining health and well-being. We know little, however, about residents’ perceptions of community safety in the Southwestern borderlands, an area frequently portrayed as plagued by disorder. The qualitative aim of this community-based participatory research study was to explore the perceptions of Mexican-origin border residents about their communities in southern Yuma County, Arizona. Our team of University of Arizona researchers and staff from Campesinos Sin Fronteras, a grassroots farmworker support agency in Yuma County, Arizona, developed a bilingual interview guide and recruited participants through radio adds, flyers, and cold calls among existing agency clientele. Thirty individual interviews with participants of Mexican origin who live in and/or work in rural Yuma County were conducted remotely in 2021. Participants overwhelmingly perceived their communities as both calm and safe. While some participants mentioned safety concerns, the vast majority described high levels of personal security and credited both neighbors and police for ensuring local safety. These perceptions were stated in direct contrast to those across the border, where participants had positive familial and cultural ties but negative perceptions regarding widespread violence. In conclusion, we argue that to understand environmental factors affecting health and well-being in Mexican immigrant populations, it is critical to examine the role of binational external referents that color community perceptions.
• Duenas, K. R., Ingram, M., Crocker, R. M., Pace, T. W., de Zapien, J. G., Torres, E., & Carvajal, S. C. (2022). La vida en la frontera: protocol for a prospective study exploring stress and health resiliencies among Mexican-origin individuals living in a US-Mexico border community. BMC Public Health, 22(Issue 1). doi:10.1186/s12889-022-14826-x
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  Background: Mexican-origin adults living near the U.S.-Mexico border experience unique and pervasive social and ecological stressors, including poverty, perceived discrimination, and environmental hazards, potentially contributing to the high burden of chronic disease. However, there is also evidence that residents in high-density Mexican-origin neighborhoods exhibit lower prevalence rates of disease and related mortality than those living in other areas. Understanding the factors that contribute to health resiliencies at the community scale is essential to informing the effective design of health promotion strategies. Methods: La Vida en la Frontera is a mixed-methods participatory study linking a multi-disciplinary University of Arizona research team with Campesinos Sin Fronteras, a community-based organization founded by community health workers in San Luis, Arizona. This paper describes the current protocol for aims 2 and 3 of this multi-faceted investigation. In aim 2 a cohort of N≈300 will be recruited using door-to-door sampling of neighborhoods in San Luis and Somerton, AZ. Participants will be surveyed and undergo biomarker assessments for indicators of health and chronic stress at three time points across a year length. A subset of this cohort will be invited to participate in aim 3 where they will be interviewed to further understand mechanisms of resilience and wellbeing. Discussion: This study examines objective and subjective mechanisms of the relationship between stress and health in an ecologically diverse rural community over an extended timeframe and illuminates health disparities affecting residents of this medically underserved community. Findings from this investigation directly impact the participants and community through deepening our understanding of the linkages between individual and community level stress and chronic disease risk. This innovative study utilizes a comprehensive methodology to investigate pathways of stress and chronic disease risk present at individual and community levels. We address multiple public health issues including chronic disease and mental illness risk, health related disparities among Mexican-origin people, and health protective mechanisms and behaviors.
• Duenas, K. R., Ingram, M., Crocker, R. M., Pace, T. W., de Zapien, J. G., Torres, E., & Carvajal, S. C. (2022). La vida en la frontera: protocol for a prospective study exploring stress and health resiliencies among Mexican-origin individuals living in a US-Mexico border community. BMC public health, 22(1), 2442.
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  Mexican-origin adults living near the U.S.-Mexico border experience unique and pervasive social and ecological stressors, including poverty, perceived discrimination, and environmental hazards, potentially contributing to the high burden of chronic disease. However, there is also evidence that residents in high-density Mexican-origin neighborhoods exhibit lower prevalence rates of disease and related mortality than those living in other areas. Understanding the factors that contribute to health resiliencies at the community scale is essential to informing the effective design of health promotion strategies.
• Hunter, A., Carlos, M., Muniz, F. B., Nuño, V. L., Fox, M. J., Carvajal, S., Lameman, B., & Yuan, N. (2022). PARTICIPATION IN A CULTURALLY GROUNDED PROGRAM STRENGTHENS CULTURAL IDENTITY, SELF-ESTEEM, AND RESILIENCE IN URBAN INDIGENOUS ADOLESCENTS. American Indian and Alaska Native Mental Health Research, 29(Issue 1). doi:10.5820/aian.2901.2022.1
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  Culturally grounded after-school programs (ASPs) aim to promote health and well-being among Indigenous youth. Native Spirit is a 10-session ASP that focuses on local cultural values and activitiesfacilitated by local cultural practitioners. This pilot study used a singlegroup, pretest-posttest design (N = 18) with Indigenous adolescents ingrades 7-12 and conducted participant interviews (N = 11) to assess theimpact of the program on cultural identity, self-esteem, and resilience.There were immediate post-program increases in mean strength in culturalidentity (p = 0.002), resilience (p = 0.161), and self-esteem (p = 0.268).Themes related to benefits of program participation included curiosity andcommitment to cultural identity, increases in self-esteem, and ability tobuild resilience. This study provides new insights on the relationshipbetween cultural engagement and adolescent health.
• Lohr, A. M., Alves, S. S., Coulter, K., Redondo-Martinez, F., Coronado, G. D., David, C., Espinoza, C., Ingram, M., Carvajal, S. C., & Wilkinson-Lee, A. M. (2022). Community Health Worker-Led Community Clinical on the U.S. / Mexico Border: Lessons Learned. Progress in Community Health Partnerships: Research, Education, and Action, 16(Issue 1). doi:10.1353/cpr.2022.0009
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  Background: Community–clinical linkages (CCLs) connect public health organizations and health care providers to better support patients. Community health workers (CHWs), representatives from priority populations with special connections to their community, can lead CCLs.
• Moreno Ramírez, D., Gutenkunst, S., Honan, J., Ingram, M., Quijada, C., Chaires, M., Sneed, S. J., Sandoval, F., Spitz, R., Carvajal, S., Billheimer, D., Wolf, A. M., & Beamer, P. I. (2022). Thinking on your feet: Beauty and auto small businesses maneuver the risks of the COVID-19 pandemic. Frontiers in Public Health, 10. doi:10.3389/fpubh.2022.921704
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  On March 11, 2020, the World Health Organization officially declared SARS-CoV-2 a pandemic, and governments and health institutions enacted various public health measures to decrease its transmission rate. The COVID-19 pandemic made occupational health disparities for small businesses more visible and created an unprecedented financial burden, particularly for those located in communities of color. In part, communities of color experienced disproportionate mortality and morbidity rates from COVID-19 due to their increased exposure. The COVID-19 pandemic has prompted the public to reflect on risks daily. Risk perception is a critical factor influencing how risk gets communicated and perceived by individuals, groups, and communities. This study explores competing risk perceptions regarding COVID-19, economic impacts, vaccination, and disinfectant exposures of workers at beauty salons and auto shops in Tucson, Arizona, using a perceived risk score measured on a scale of 1–10, with higher scores indicating more perceived risk. The primary differences between respondents at beauty salons and auto shops regarding their perceived risks of COVID-19 vaccination were between the vaccinated and unvaccinated. For every group except the unvaccinated, the perceived risk score of getting the COVID-19 vaccine was low, and the score of not getting the COVID-19 vaccine was high. Study participants in different demographic groups ranked economic risk the highest compared to the other five categories: getting the COVID-19 vaccine, not getting the COVID-19 vaccine, COVID-19, disinfection, and general. A meaningful increase of four points in the perceived risk score of not getting the COVID-19 vaccine was associated with a 227% (95% CI: 27%, 740%) increase in the odds of being vaccinated. Analyzing these data collected during the coronavirus pandemic may provide insight into how to promote the health-protective behavior of high-risk workers and employers in the service sector during times of new novel threats (such as a future pandemic or crisis) and how they process competing risks.
• Nuño, T., Sierra, L. A., Wilkinson-Lee, A. M., Carvajal, S. C., Zapien, J. d., Coulter, K., Figueroa, C. A., Morales, M., Sepulveda, R., Sepulveda, R., & Ingram, M. (2022). The Arizona Prevention Research Center partnerships in Arizona to promote COVID-19 vaccine health equity. Frontiers in Public Health, 10(Issue). doi:10.3389/fpubh.2022.944887
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  Vaccine hesitancy in the face of the COVID-19 pandemic is a complex issue that undermines our national ability to reduce the burden of the disease and control the pandemic. The COVID-19 pandemic revealed widening health disparities and disproportionate adverse health outcomes in terms of transmission, hospitalizations, morbidity and mortality among Arizona's Latinx rural, underserved, farmworker, disabled and elderly populations. In March 2021, ~8.1% of those vaccinated were Latinx, though Latinxs make up 32% of Arizona's population. The Arizona Vaccine Confidence Network (AzVCN) proposed to leverage the expertise of the Arizona Prevention Research Center (AzPRC) and the resources of the Mel and Enid Zuckerman College of Public Health (MEZCOPH) Mobile Health Unit (MHU) to identify, implement and evaluate a MHU intervention to increase uptake of COVID-19 vaccines.The AzVCN focused efforts on Latinx, rural, un/underinsured and farmworker communities in the four Arizona border counties that are at greater risk of COVID-19 morbidity and mortality and may have limited access to vaccination and other essential health services. The AzVCN used listening sessions to create a feedback loop with key stakeholders and critical health care workers to validate barriers/enablers and identify solutions to increase vaccination uptake emerging from the network. The AzVCN also implemented a community-based intervention using community health workers (CHWs) based in a MHU to increase knowledge of the COVID-19 vaccines, reduce vaccination hesitancy and increase vaccination uptake among Latinx rural, un/underinsured and farmworker populations in Southern Arizona.AzVCN outcomes include: identification of enablers and barriers of COVID-19 vaccination in the priority populations; identification of strategies and solutions to address vaccine hesitancy and increase vaccine uptake among priority population; and evidence that the proposed solutions being tested through the AzVCN contribute to increased vaccine uptake among the priority populations.Through these efforts the AzPRC contributed to the CDC's Vaccinate with Confidence Strategy by collaborating with CHWs and other key stakeholders to engage directly with communities in identifying and addressing structural and misinformation barriers to vaccine uptake.
• Wilkinson-Lee, A. M., Carvajal, S. C., Ingram, M., Espinoza, C., David, C., Coronado, G., Redondo-Martinez, F., Coulter, K., Alves, S., & Lohr, A. M. (2022). Community Health Worker-Led Community Clinical Linkages on the U.S. / Mexico Border: Lessons Learned. Progress in Community Health Partnerships, 16(1).
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  We are in the process of writing this manuscript and should submit by end of spring 2020.
• Yuan, N. P., Carvajal, S., Hunter, A. M., Carlos, M., Nuño, V. L., & Tippeconnic‐Fox, M. J. (2022). Native Spirit: Development of a culturally grounded after‐school program to promote well‐being among American Indian adolescents. American Journal of Community Psychology, 70(1-2), 242-251. doi:10.1002/ajcp.12590
• Carvajal, S. C., Doubleday, K., Coulter, K., Ingram, M., Espinoza, C., Redondo, F., Wilkinson-Lee, A., & Lohr, A. (2021). An Integrated Mixed Methods Approach to Clarifying Delivery, Receipt and Potential Benefits of CHW-Facilitated Social Support in a Health Promotion Intervention. BMC Health Services Research. doi:10.21203/rs.3.rs-384433/v1
• Carvajal, S. C., Wilkinson-Lee, A. M., Gerald, L. B., Dubinsky, E., McClelland, D. J., Van Gorden, N., & Lohr, A. M. (2021). Updating Search Strategies for Literature Reviews with OUR2D2: An Open Source Computer Application. Journal of the Medical Library Association, 109(2), 317-322. doi:10.5195/jmla.2021.1105
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  Background: While writing a scoping review, we needed to update our search strategy. We wanted to capture articles generated by our additional search terms and articles published since our original search. Simultaneously, we strove to optimize project resources by not re-screening articles that had been captured in our original results. Case Presentation: In response, we created Open Update Re-run Deduplicate (OUR2D2), a computer application that allows the user to compare search results from a variety of library databases. OUR2D2 supports Extensible Markup Language (XML) files from EndNote and comma-separated values (CSV) files using article titles for comparisons. We conducted unit tests to ensure appropriate functionality as well as accurate data extraction and analysis. We tested OUR2D2 by comparing original and updated search results from PubMed, Embase, Clarivate Web of Science, CINAHL, Scopus, ProQuest Dissertation and Theses, and Lens and estimate that this application saved 21 hours of work during the screening process. Conclusions: OUR2D2 could be useful for individuals seeking to update literature review strategies across fields without re-screening articles from previous searches. Because the OUR2D2 source code is freely available with a permissive license, we recommend this application for researchers conducting literature reviews who need to update their search results over time, want a powerful and flexible analysis framework, and may not have access to paid subscription tools.
• Coco, L., Carvajal, S., Colina, S., Wong, A., Ingram, M., Marrone, N., & Piper, R. (2021). Prioritizing Community in Research Decision-Making Through Partnership. Innovation in Aging, 5(Supplement_1), 471-472. doi:10.1093/geroni/igab046.1824
• Coulter, K., Ingram, M., Lohr, A. M., Bell, M. L., & Carvajal, S. (2021). Examining associations between community health worker-rated health and mental health among Latino adults with chronic disease. International Journal of Environmental Research and Public Health, 18(Issue 1). doi:10.3390/ijerph18010100
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  Latinos with chronic disease often experience comorbid depression, but confront barriers to mental health treatment. Community health workers (CHWs) develop trusting relationships with the communities they serve, and may be uniquely positioned to identify Latinos with mental health care needs. Research has not examined whether their rating of clients’ health is indicative of their mental health. This mixed-methods study examines CHWs’ appraisals of Latino adults’ health and their relation to mental health outcomes, and explores factors informing CHWs’ rating of health status. The current study utilized baseline data from the Linking Individual Needs to Community and Clinical Services (LINKS) study. We assessed associations between CHW-rated health (CHWRH), or rating of health status as poor–excellent, and mental health outcomes with multilevel linear regression modelling. We qualitatively analyzed CHWs’ written perceptions of participants’ health status to understand what influenced their health rating. The quantitative results showed that CWHRH was significantly related to depressive symptoms and emotional problems severity. The qualitative results showed that CHWs took a holistic and ecological approach in rating health. The findings suggest that CHWRH could be indicative of mental health among Latino adults. Further studies investigating CHWRH as an independent indicator of mental health are warranted.
• Ingram, M., Coulter, K., Doubleday, K., Espinoza, C., Redondo, F., Wilkinson-Lee, A. M., Lohr, A. M., & Carvajal, S. C. (2021). An integrated mixed methods approach to clarifying delivery, receipt and potential benefits of CHW-facilitated social support in a health promotion intervention. BMC health services research, 21(1), 793.
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  Social support plays a critical role in physical and emotional health, making it an important component of community health worker (CHW) health promotion interventions. Different types of support operate in different ways, however, and the relationship between the nature of CHW support and the subsequent health benefit for their clients is not well understood.
• Krupp, K., Madhivanan, P., Killgore, W. D., Ruiz, J. M., Carvajal, S., Coull, B. M., & Grandner, M. A. (2021). Neurological Manifestations in COVID-19: An Unrecognized Crisis in Our Elderly?. Advances in geriatric medicine and research, 3(3).
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  As of December 2020, there were more than 900,000 COVID-19 hospitalizations in the US with about 414,000 among individuals aged 65 years and older. Recent evidence suggests a growing number of older patients continue to suffer serious neurological comorbidities including polyneuropathy, cerebrovascular disease, central nervous system infection, cognitive deficits, and fatigue following discharge. Studies suggest that complaints manifest late in disease and persist beyond resolution of acute COVID-19 symptoms. Recent research reports that neurocognitive symptoms are correlated with severe disease, older age, male gender, and comorbidities including hypertension, renal failure, and neoplastic disease. The underlying causes are unclear, but current hypotheses include hypoxic-ischemic brain injury, immunopathological mechanisms, and neurotropism of SARS-CoV-2 infection. There is a pressing need for more research into the underlying mechanisms of post-COVID-19 neurological sequela, particularly in the elderly, a population already burdened with neurocognitive disorders.
• Lohr, A. M., Doubleday, K., Ingram, M., Wilkinson-Lee, A. M., Coulter, K., Krupp, K., Espinoza, C., Redondo-Martinez, F., David, C., & Carvajal, S. C. (2021). A Community Health Worker-Led Community-Clinical Linkage Model to Address Emotional Well-Being Outcomes Among Latino/a People on the US-Mexico Border. Preventing Chronic Disease, 18(Issue). doi:10.5888/pcd18.210080
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  Introduction Compared with their non-Hispanic White counterparts, Latino/a people have limited access to health resources that might improve their emotional well-being. Interventions that prioritize the Latino/ a population, address social determinants of health, and decrease health disparities are needed. The objective of this study was to describe a community-clinical linkage intervention led by community health workers (CHWs) in 3 Latino/a populations along the US-Mexico border. Methods Researchers at the Arizona Prevention Research Center conducted the Linking Individual Needs to Community and Clinical Services (LINKS) study during 2017-2018. Clinic-based CHWs referred participants to community-based CHWs who met with participants monthly for 6 months to assess participant needs, provide support for emotional well-being, and link them to resources. Two community-based CHWs collaborated to maximize participant care; they also administered an emotional well-being questionnaire at baseline and at 3-month and 6-month follow-up. We estimated changes in emotional well-being outcomes. Results Scores for social support, perceived hopefulness, and quality-of-life measures among 189 LINKS participants increased significantly during the study period, especially among men and participants with low baseline scores. For each of the 3 outcomes, the standardized change was approximately 0.28 per 3 months of intervention, a decrease of more than half an SD (0.56) during 6 months of follow-up. Conclusion A CHW-led community-clinical linkage intervention can result in positive emotional well-being outcomes. We encourage policy makers, funders, and public health practitioners to further investig- ate such interventions as a solution to reduce disparities in emotional well-being.
• Lohr, A. M., Doubleday, K., Ingram, M., Wilkinson-Lee, A. M., Coulter, K., Krupp, K., Espinoza, C., Redondo-Martinez, F., David, C., & Carvajal, S. C. (2021). A Community Health Worker-Led Community-Clinical Linkage Model to Address Emotional Well-Being Outcomes Among Latino/a People on the US-Mexico Border. Preventing chronic disease, 18, E76.
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  Compared with their non-Hispanic White counterparts, Latino/a people have limited access to health resources that might improve their emotional well-being. Interventions that prioritize the Latino/a population, address social determinants of health, and decrease health disparities are needed. The objective of this study was to describe a community-clinical linkage intervention led by community health workers (CHWs) in 3 Latino/a populations along the US-Mexico border.
• Lohr, A. M., Krause, K. C., McClelland, D. J., Van Gorden, N., Gerald, L. B., Del Casino, V., Wilkinson-Lee, A., & Carvajal, S. C. (2021). The impact of school gardens on youth social and emotional learning: a scoping review. Journal of Adventure Education and Outdoor Learning, 21(Issue 4). doi:10.1080/14729679.2020.1838935
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  Social and Emotional Learning (SEL) has five competencies: relationship skills, responsible decision-making, self-awareness, social awareness, and self-management. A promising practice to promote positive SEL is school garden programming. There is a need to understand how school gardens impact SEL by consolidating existing research. In this scoping review, we synthesized evidence describing the impact of school gardens on youth SEL. We included studies that described school garden interventions, collected data from youth, and measured SEL. We screened 1589 abstracts and 76 full-text articles. Eight studies met the inclusion criteria. While the included qualitative studies demonstrated that school garden programming can positively influence SEL, the included quantitative studies had few statistically significant results. Thus, at this time we can only say that qualitative research from five studies suggests that school garden programs have the potential to successfully enhance experiences that promote SEL but more research is needed to further investigate this claim.
• Lohr, A. M., Van Gorden, N., McClelland, D. J., Dubinsky, E., Gerald, L. B., Wilkinson-Lee, A., & Carvajal, S. C. (2021). Updating search strategies for literature reviews with OUR2D2: An open-source computer application. Journal of the Medical Library Association, 109(Issue 2). doi:10.5195/jmla.2021.1105
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  Background: While writing a scoping review, we needed to update our search strategy. We wanted to capture articles generated by our additional search terms and articles published since our original search. Simultaneously, we strove to optimize project resources by not rescreening articles that had been captured in our original results. Case presentation: In response, we created Open Update Re-run Deduplicate (OUR2D2), a computer application that allows the user to compare search results from a variety of library databases. OUR2D2 supports extensible markup language (XML) files from EndNote and comma-separated values (CSV) files using article titles for comparisons. We conducted unit tests to ensure appropriate functionality as well as accurate data extraction and analysis. We tested OUR2D2 by comparing original and updated search results from PubMed, Embase, Clarivate Web of Science, CINAHL, Scopus, ProQuest Dissertation and Theses, and Lens and estimate that this application saved twenty-one hours of work during the screening process. Conclusions: OUR2D2 could be useful for individuals seeking to update literature review strategies across fields without rescreening articles from previous searches. Because the OUR2D2 source code is freely available with a permissive license, we recommend this application for researchers conducting literature reviews who need to update their search results over time, want a powerful and flexible analysis framework, and may not have access to paid subscription tools.
• Lohr, A. M., Van Gorden, N., McClelland, D. J., Dubinsky, E., Gerald, L. B., Wilkinson-Lee, A., & Carvajal, S. C. (2021). Updating search strategies for literature reviews with OUR2D2: an open-source computer application. Journal of the Medical Library Association : JMLA, 109(2), 317-322.
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  While writing a scoping review, we needed to update our search strategy. We wanted to capture articles generated by our additional search terms and articles published since our original search. Simultaneously, we strove to optimize project resources by not rescreening articles that had been captured in our original results.
• Lott, B. E., Halkiyo, A., Kassa, D. W., Kebede, T., Dedefo, A., Ehiri, J., Madhivanan, P., Carvajal, S., & Soliman, A. (2021). Health workers' perspectives on barriers and facilitators to implementing a new national cervical cancer screening program in Ethiopia. BMC women's health, 21(1), 185.
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  Cervical cancer disproportionately affects women in sub-Saharan Africa, compared with other world regions. In Ethiopia, a National Cancer Control Plan published in 2015, outlines an ambitious strategy to reduce the incidence and mortality of cervical cancer. This strategy includes widespread screening using visual inspection with acetic acid (VIA). As the national screening program has rolled out, there has been limited inquiry of provider experiences. This study aims to describe cancer control experts' perspectives regarding the cancer control strategy and implementation of VIA.
• Lott, B. E., Halkiyo, A., Kassa, D. W., Kebede, T., Dedefo, A., Ehiri, J., Madhivanan, P., Carvajal, S., & Soliman, A. (2021). Health workers’ perspectives on barriers and facilitators to implementing a new national cervical cancer screening program in Ethiopia. BMC Women's Health, 21(Issue 1). doi:10.1186/s12905-021-01331-3
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  Background: Cervical cancer disproportionately affects women in sub-Saharan Africa, compared with other world regions. In Ethiopia, a National Cancer Control Plan published in 2015, outlines an ambitious strategy to reduce the incidence and mortality of cervical cancer. This strategy includes widespread screening using visual inspection with acetic acid (VIA). As the national screening program has rolled out, there has been limited inquiry of provider experiences. This study aims to describe cancer control experts’ perspectives regarding the cancer control strategy and implementation of VIA. Methods: Semi-structured interviews with 18 participants elicited provider perspectives on cervical cancer prevention and screening. Open-ended interview questions queried barriers and facilitators to implementation of a new national screening program. Responses were analyzed using thematic analysis and mapped to the Integrated Behavioral Model. Participants were health providers and administrators with positionality as cancer control experts including screening program professionals, oncologists, and cancer focal persons at town, zone, and federal health offices at eleven government facilities in the Arsi, Bale, and Shoa zones of the Oromia region, and in the capital Addis Ababa. Results: The cancer control plan and screening method, VIA, were described by participants as contextually appropriate and responsive to the unique service delivery challenges in Ethiopia. Screening implementation barriers included low community- and provider-awareness of cervical cancer and screening, lack of space and infrastructure to establish the screening center, lack of materials including cryotherapy machines for the “screen-and-treat” approach, and human resource issues such as high-turnover of staff and administration. Participant-generated solutions included additional training for providers, demand creation to increase patient flow through mass media campaigns, decentralization of screening from large regional hospitals to local health centers, improved monitoring and evaluation, and incentivization of screening services to motivate health providers. Conclusions: As the Ethiopian government refines its Cancer Control Plan and scales up screening service implementation throughout the country, the findings from this study can inform the policies and practices of cervical cancer screening. Provider perspectives of barriers and facilitators to effective cancer control and screening implementation reveal areas for continued improvement such as provider training and coordination and collaboration in the health system.
• Peterson, R. L., Butler, E. A., Ehiri, J. E., Fain, M. J., & Carvajal, S. C. (2021). Mechanisms of Racial Disparities in Cognitive Aging: An Examination of Material and Psychosocial Wellbeing. The journals of gerontology. Series B, Psychological sciences and social sciences, 76(3), 574-582.
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  We tested the hypothesis that education's effect on cognitive aging operates in part through measures of material and psychosocial wellbeing.
• Richards, J., Chambers, R. S., Begay, J. L., Jackson, K., Tingey, L., Patel, H., Carvajal, S., Carroll, S. R., Teufel-Shone, N., & Barlow, A. (2021). Diné (Navajo) female perspectives on mother-daughter communication and cultural assets around the transition to womanhood: a cross-sectional survey. BMC women's health, 21(1), 341.
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  The inclusion of protective factors ("assets") are increasingly supported in developing culturally grounded interventions for American Indian (AI) populations. This study sought to explore AI women's cultural assets, perspectives, and teachings to inform the development of a culturally grounded, intergenerational intervention to prevent substance abuse and teenage pregnancy among AI females.
• Richards, J., Chambers, R. S., Begay, J. L., Jackson, K., Tingey, L., Patel, H., Carvajal, S., Carroll, S. R., Teufel-Shone, N., & Barlow, A. (2021). Diné (Navajo) female perspectives on mother–daughter communication and cultural assets around the transition to womanhood: a cross-sectional survey. BMC Women's Health, 21(Issue 1). doi:10.1186/s12905-021-01473-4
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  Background: The inclusion of protective factors (“assets”) are increasingly supported in developing culturally grounded interventions for American Indian (AI) populations. This study sought to explore AI women’s cultural assets, perspectives, and teachings to inform the development of a culturally grounded, intergenerational intervention to prevent substance abuse and teenage pregnancy among AI females. Methods: Adult self-identified AI women (N = 201) who reside on the Navajo Nation completed a cross-sectional survey between May and October 2018. The 21-question survey explored health communication around the transition to womanhood, cultural assets, perceptions of mother–daughter reproductive health communication, and intervention health topics. Univariate descriptive analyses, chi squared, and fisher’s exact tests were conducted. Results: Respondents ranged in age from 18 to 82 years, with a mean age of 44 ± 15.5 years. Women self-identified as mothers (95; 48%), aunts (59; 30%), older sisters (55; 28%), grandmothers (37; 19%), and/or all of the aforementioned (50; 25%). 66% (N = 95) of women admired their mother/grandmother most during puberty; 29% (N = 58) of women were 10–11 years old when someone first spoke to them about menarche; and 86% (N=172) felt their culture was a source of strength. 70% (N = 139) would have liked to learn more about reproductive health when they were a teenager; 67% (N = 134) felt Diné mothers are able to provide reproductive health education; 51% (N = 101) reported having a rite of passage event, with younger women desiring an event significantly more than older women. Responses also indicate a disruption of cultural practices due to government assimilation policies, as well as the support of male relatives during puberty. Conclusions: Results informed intervention content and delivery, including target age group, expanded caregiver eligibility criteria, lesson delivery structure and format, and protective cultural teachings. Other implications include the development of a complementary fatherhood and/or family-based intervention to prevent Native girls’ substance use and teen pregnancy.
• Valdez, E. S., Valdez, L., Korchmaros, J., Garcia, D. O., Stevens, S., Sabo, S., & Carvajal, S. (2021). Socioenvironmental Risk Factors for Adolescent Marijuana Use in a United States-Mexico Border Community. American journal of health promotion : AJHP, 35(1), 20-27.
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  We examined how socioenvironmental risk factors unique to the United States-Mexico border, defined as border community and immigration stress, normalization of drug trafficking, and perceived disordered neighborhood stress, contribute to tobacco, alcohol, and marijuana use among adolescents residing there.
• Butler, E. A., Carvajal, S. C., Ehiri, J. E., Fain, M. J., & Peterson, R. L. (2020). Mechanisms of Racial Disparities in Cognitive Aging: An Examination of Material and Psychosocial Well-Being. The Journals of Gerontology: Series B, 76(3), 574-582. doi:10.1093/geronb/gbaa003
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  Abstract Objectives We tested the hypothesis that education’s effect on cognitive aging operates in part through measures of material and psychosocial well-being. Method Our sample was of non-Latino black and white participants of the National Social Life Health and Aging Project who had valid cognitive assessments in Waves 2 and 3 (n = 2,951; age range: 48–95). We used structural equation modeling to test for mediation and moderated mediation by income, assets, perceived stress, social status, and allostatic load on the relationships between race, education, and cognition at two time points. Results Education consistently mediated the race–cognition relationship, explaining about 20% of the relationship between race and cognition in all models. Income and assets were moderated by race; these factors were associated with cognition for whites but not blacks. Social status mediated the association between race and cognition, and social status and perceived stress mediated the education–cognition pathway. Allostatic load was not a mediator of any relationship. Discussion Education remains the best explanatory factor for cognitive aging disparities, though material well-being and subjective social status help to explain a portion of the racial disparity in cognitive aging.
• Butler, E. A., Carvajal, S. C., Ehiri, J. E., Fain, M. J., & Peterson, R. L. (2020). The role of social and behavioral risk factors in explaining racial disparities in age-related cognitive impairment: a structured narrative review.. Neuropsychology, development, and cognition. Section B, Aging, neuropsychology and cognition, 27(2), 173-196. doi:10.1080/13825585.2019.1598539
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  Alzheimer's disease (AD) is a growing public health concern with large disparities in incidence and prevalence between African Americans (AAs) and non-Hispanic whites (NHWs). The aim of this review was to examine the evidence of association between six modifiable risk factors (education, smoking, physical inactivity, obesity, social isolation, and psychosocial stress) and Alzheimer's disease risk in AAs and NHWs. We identified 3,437 studies; 45 met inclusion criteria and were included in this review. Of the examined risks, education provided the strongest evidence of association with cognitive outcomes in AAs and NHWs. This factor may operate directly on Alzheimer's disease risk through the neurocognitive benefits of cognitive stimulation or indirectly through social status.
• Carvajal, S. C., Colina, S., Ingram, M., Marrone, N., Piper, R., & Wong, A. (2020). Task Sharing in Hearing Care: Putting Principles Into Practice to Advance Access to Hearing Care. Innovation in Aging, 4(Supplement_1), 807-807. doi:10.1093/geroni/igaa057.2932
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  Abstract Task sharing, through models such as community health workers (CHWs), is considered an efficacious and cost-effective approach to extending access, addressing disparities, and building capacity. Increasingly, task sharing is recognized as a promising approach within sensory health. This session will share results from an NIH-funded trial of a first-in-kind CHW-delivered intervention along the U.S.-Mexico border. Trained CHWs provided a 5-week group aural rehabilitation program that included education and counseling on age-related hearing loss. A total of 136 Spanish-speaking older adults with hearing loss were randomized. Those in the immediate treatment group reported significantly greater use of communication strategies post-intervention, which was maintained over 1 year. Participants were more likely to report taking action on their hearing at 6 months (OR:1.56, p=0.001) and 1 year (OR:1.82, p=0.001). Building upon lessons learned, including post-intervention focus groups, the presentation will share guiding principles on the application of task sharing to support sensory health.
• Carvajal, S. C., Fox, M. J., Nuno, V. L., Yuan, N. P., & Hunter, A. (2020). Effectiveness of culturally relevant after-school programs on health and developmental strengths among Indigenous youth: A systematic review. Journal of Adolescent Health.
• Carvajal, S. C., Wilkinson-Lee, A. M., Del Casino, V. J., Gerald, L. B., Van Gorden, N., Mcclelland, D. J., Krause, K. C., & Lohr, A. M. (2021). The Impact of School Gardens on Youth Social and Emotional Learning: A Scoping Review. Journal of Adventure Education and Outdoor Learning. doi:DOI: 10.1080/14729679.2020.1838935
• Carvajal, S., Garcia, D. O., Korchmaros, J., Sabo, S., Stevens, S., Valdez, L., & Valdez, E. S. (2020). Socioenvironmental Risk Factors for Adolescent Marijuana Use in a United States-Mexico Border Community. American Journal of Health Promotion, 35(1), 20-27. doi:10.1177/0890117120927527
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  Purpose: We examined how socioenvironmental risk factors unique to the United States-Mexico border, defined as border community and immigration stress, normalization of drug trafficking, and perceived disordered neighborhood stress, contribute to tobacco, alcohol, and marijuana use among adolescents residing there. Design: Cross-sectional design. Setting: The study was conducted at a high school on the United States-Mexico border. Subjects: A sample of 445 primarily Hispanic students (ages 14-18). Measure: Perceived Disordered Neighborhood Stress Scale, Border Community and Immigration Stress Scale, and Normalization of Drug Trafficking Scale. Analysis: Logistic regression assessed the association between the socioenvironmental risk factors and past 30-day tobacco, alcohol, and marijuana use. Results: Participants with higher border community and immigration stress scores were significantly more likely to have used tobacco (adjusted odds ratio [aOR] = 1.41, P
• Coulter, K., Ingram, M., Lohr, A. M., Bell, M. L., & Carvajal, S. (2020). Examining Associations between Community Health Worker-Rated Health and Mental Health among Latino Adults with Chronic Disease. International journal of environmental research and public health, 18(1).
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  Latinos with chronic disease often experience comorbid depression, but confront barriers to mental health treatment. Community health workers (CHWs) develop trusting relationships with the communities they serve, and may be uniquely positioned to identify Latinos with mental health care needs. Research has not examined whether their rating of clients' health is indicative of their mental health. This mixed-methods study examines CHWs' appraisals of Latino adults' health and their relation to mental health outcomes, and explores factors informing CHWs' rating of health status. The current study utilized baseline data from the Linking Individual Needs to Community and Clinical Services (LINKS) study. We assessed associations between CHW-rated health (CHWRH), or rating of health status as poor-excellent, and mental health outcomes with multilevel linear regression modelling. We qualitatively analyzed CHWs' written perceptions of participants' health status to understand what influenced their health rating. The quantitative results showed that CWHRH was significantly related to depressive symptoms and emotional problems severity. The qualitative results showed that CHWs took a holistic and ecological approach in rating health. The findings suggest that CHWRH could be indicative of mental health among Latino adults. Further studies investigating CHWRH as an independent indicator of mental health are warranted.
• Lohr, A. M., Krause, K. C., Mcclelland, D. J., Van Gorden, N., Gerald, L. B., Del Casino, V. J., Wilkinson-Lee, A. M., & Carvajal, S. C. (2020). The Impact of School Gardens on Youth Social and Emotional Learning: A Scoping Review. Journal of Adventure Education and Outdoor Learning. doi:DOI: 10.1080/14729679.2020.1838935
• Lott, B. E., Trejo, M. J., Baum, C., McClelland, D. J., Adsul, P., Madhivanan, P., Carvajal, S., Ernst, K., & Ehiri, J. (2020). Interventions to increase uptake of cervical screening in sub-Saharan Africa: A scoping review using the integrated behavioral model. BMC Public Health, 20(Issue 1). doi:10.1186/s12889-020-08777-4
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  Background: Sub-Saharan Africa (SSA) experiences disproportionate burden of cervical cancer incidence and mortality due in part to low uptake of cervical screening, a strategy for prevention and down-staging of cervical cancer. This scoping review identifies studies of interventions to increase uptake of cervical screening among women in the region and uses the Integrated Behavioral Model (IBM) to describe how interventions might work. Methods: A systematic search of literature was conducted in PubMed, Web of Science, Embase, and CINAHL databases through May 2019. Screening and data charting were performed by two independent reviewers. Intervention studies measuring changes to uptake in screening among women in SSA were included, with no restriction to intervention type, study setting or date, or participant characteristics. Intervention type and implementation strategies were described using behavioral constructs from the IBM. Results: Of the 3704 citations the search produced, 19 studies were selected for inclusion. Most studies were published between 2014 and 2019 (78.9%) and were set in Nigeria (47.4%) and South Africa (26.3%). Studies most often assessed screening with Pap smears (31.6%) and measured uptake as ever screened (42.1%) or screened during the study period (36.8%). Education-based interventions were most common (57.9%) and the IBM construct of knowledge/skills to perform screening was targeted most frequently (68.4%). Willingness to screen was high, before and after intervention. Screening coverage ranged from 1.7 to 99.2% post-intervention, with six studies (31.6%) reporting a significant improvement in screening that achieved ≥60% coverage. Conclusions: Educational interventions were largely ineffective, except those that utilized peer or community health educators and mHealth implementation strategies. Two economic incentivization interventions were moderately effective, by acting on participants' instrumental attitudes, but resulted in screening coverage less than 20%. Innovative service delivery, including community-based self-sampling, acted on environmental constraints, striving to make services more available, accessible, and appropriate to women, and were the most effective. This review demonstrates that intent to perform screening may not be the major determinant of screening behavior, suggesting other theoretical frameworks may be needed to more fully understand uptake of cervical screening in sub-Saharan Africa, particularly for health systems change interventions.
• Lott, B. E., Trejo, M. J., Baum, C., McClelland, D. J., Adsul, P., Madhivanan, P., Carvajal, S., Ernst, K., & Ehiri, J. (2020). Interventions to increase uptake of cervical screening in sub-Saharan Africa: a scoping review using the integrated behavioral model. BMC public health, 20(1), 654.
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  Sub-Saharan Africa (SSA) experiences disproportionate burden of cervical cancer incidence and mortality due in part to low uptake of cervical screening, a strategy for prevention and down-staging of cervical cancer. This scoping review identifies studies of interventions to increase uptake of cervical screening among women in the region and uses the Integrated Behavioral Model (IBM) to describe how interventions might work.
• Lutrick, K., Clark, R., Nuño, V. L., Bauman, S., & Carvajal, S. (2020). Latinx bullying and depression in children and youth: A systematic review. Systematic Reviews, 9(Issue 1). doi:10.1186/s13643-020-01383-w
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  Background: Bullying is associated with negative health outcomes such as depression. Most studies target non-Latinxs, though they often experience higher rates of bullying and depression. This review examines the inclusion of Latinxs in studies of bullying and depression and factors unique to them. Methods: Databases were searched for articles related to bullying and depression. Two reviewers found 957 publications and identified 17 for inclusion. Results: All 17 studies demonstrated a relationship between bullying and depression. Nine examined variables unique to Latinxs. Conclusions: Studies that included variables unique to Latinxs found a stronger relationship between bullying and depression. Inclusive measures and design are key to understanding and reducing the consequences of bullying in this population.
• Lutrick, K., Clark, R., Nuño, V. L., Bauman, S., & Carvajal, S. (2020). Latinx bullying and depression in children and youth: a systematic review. Systematic reviews, 9(1), 126.
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  Bullying is associated with negative health outcomes such as depression. Most studies target non-Latinxs, though they often experience higher rates of bullying and depression. This review examines the inclusion of Latinxs in studies of bullying and depression and factors unique to them.
• Valdez, E. S., Skobic, I., Valdez, L., O Garcia, D., Korchmaros, J., Stevens, S., Sabo, S., & Carvajal, S. (2020). Youth Participatory Action Research for Youth Substance Use Prevention: A Systematic Review. Subst Use Misuse. 2020;55(2):314-328.
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  A growing body of research points to the efficacy of participatory methods in decreasing rates of alcohol, tobacco, and other drug use and other risky behaviors among youth. However, to date, no systematic review of the literature has been conducted on Youth Participatory Action Research (YPAR) for youth substance use prevention. This review draws on the peer-reviewed literature on YPAR in the context of youth substance use prevention published from January 1, 1998 through April 30, 2018. We summarize (1) the published evidence regarding YPAR for youth substance use prevention; (2) the level of youth engagement in the research process; (3) the methodologies used in YPAR studies for youth substance use prevention; and (4) where more research is needed. We used Reliability-Tested Guidelines for Assessing Participatory Research Projects to assess the level of youth engagement in the research process. In all, we identified 15 unduplicated peer-reviewed, English-language articles that referenced YPAR, Community Based Participatory Research, youth, and substance use prevention. Our findings indicated that youth participation in research and social action resulted in increased community awareness of substance use and related solutions. This supports the premise of youth participation as an agent of community change by producing community-specific substance use data and prevention materials. Identified weaknesses include inconsistent levels of youth engagement throughout the research process, a lack of formalized agreements between youth and researchers with regard to project and data management, and a lack of outcome evaluation measures for assessing YPAR for youth substance use prevention.
• Butler, E. A., Carvajal, S. C., Ehiri, J. E., Fain, M. J., & Peterson, R. (2019). P4-636: THE ROLE OF SOCIAL STATUS AND CHRONIC STRESS FOR RACIAL DISPARITIES IN COGNITIVE AGING. Alzheimers & Dementia, 15(7S_Part_30), P1571-P1571. doi:10.1016/j.jalz.2019.08.185
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  Racial disparities in cognitive aging are well established, with education hypothesized to play a key role via cognitive stimulation and the resulting contribution to cognitive reserve. In the broader health disparities literature, education is hypothesized to operate via its contribution to social status and association with discrimination, both of which influence experiences with chronic stress. We used structural equation modeling to test for mediational effects of subjective and objective measures of social status (household income; household wealth; perceived social status) and chronic stress (allostatic load, comprised of blood pressure, BMI, HbA1c, C-reactive protein and DHEA; perceived stress scale) in the relationships between race, education and cognitive function at two time points using data from the National Social Life Health and Aging Project. Household wealth mediated the relationships between race and time 2 cognition, and education and time 2 cognition at p
• Carvajal, S., Korchmaros, J., O Garcia, D., Sabo, S., Skobic, I., Stevens, S., Valdez, L., & Valdez, E. S. (2019). Youth Participatory Action Research for Youth Substance Use Prevention: A Systematic Review. Substance Use & Misuse, 55(2), 314-328. doi:10.1080/10826084.2019.1668014
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  Background: A growing body of research points to the efficacy of participatory methods in decreasing rates of alcohol, tobacco, and other drug use and other risky behaviors among youth. However, to date, no systematic review of the literature has been conducted on Youth Participatory Action Research (YPAR) for youth substance use prevention. This review draws on the peer-reviewed literature on YPAR in the context of youth substance use prevention published from January 1, 1998 through April 30, 2018. Methods: We summarize (1) the published evidence regarding YPAR for youth substance use prevention; (2) the level of youth engagement in the research process; (3) the methodologies used in YPAR studies for youth substance use prevention; and (4) where more research is needed. We used Reliability-Tested Guidelines for Assessing Participatory Research Projects to assess the level of youth engagement in the research process. Results: In all, we identified 15 unduplicated peer-reviewed, English-language articles that referenced YPAR, Community Based Participatory Research, youth, and substance use prevention. Conclusions: Our findings indicated that youth participation in research and social action resulted in increased community awareness of substance use and related solutions. This supports the premise of youth participation as an agent of community change by producing community-specific substance use data and prevention materials. Identified weaknesses include inconsistent levels of youth engagement throughout the research process, a lack of formalized agreements between youth and researchers with regard to project and data management, and a lack of outcome evaluation measures for assessing YPAR for youth substance use prevention.
• Gerald, J. K., Fisher, J. M., Brown, M. A., Clemens, C. J., Moore, M. A., Carvajal, S. C., Bryson, D., Stefan, N., Billheimer, D., & Gerald, L. B. (2019). School-supervised use of a once-daily inhaled corticosteroid regimen: A cluster randomized trial. Journal of Allergy and Clinical Immunology, 143(Issue 2). doi:10.1016/j.jaci.2018.06.048
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  Background: School-supervised use of a once-daily inhaled corticosteroid regimen (supervised therapy) can improve medication adherence and asthma control. Objective: We sought to evaluate the effectiveness of supervised therapy in a unique setting and population. Methods: We conducted a cluster randomized trial of supervised therapy in 20 elementary schools with a disproportionate enrollment of low-income Latino students. Schools were purposively selected, matched, and randomized to receive 9 months of supervised therapy with mometasone furoate or usual care. All English- or Spanish-speaking students with self-reported asthma were eligible. The Asthma Control Questionnaire (ACQ) was interviewer administered quarterly at school. Students in supervised therapy schools were hypothesized to have lower ACQ scores than students in usual-care schools. Results: Of 393 enrolled students, 189 students receiving immediate intervention and 143 students receiving delayed intervention provided 1 or more ACQ data points, were between 6 and 10 years of age, and were included in the primary analysis. At baseline, 39% of students reported taking a controller medication, and 24% had well-controlled asthma. Eighty percent of students receiving immediate intervention were prescribed mometasone. Schools administered 98% of prescribed doses when students attended school. Absences, weekends, and holidays reduced calendar adherence to 53%. During the first year, the mean ACQ score for students receiving immediate and delayed intervention was 1.55 (95% CI, 1.41-1.70) and 1.64 (95% CI, 1.47-1.80), respectively. The estimated treatment effect was −0.08 (95% CI, −0.31 to 0.14). Discussion: Compared with usual care, supervised therapy did not improve asthma control among this population of Latino students. Additional research is warranted to confirm these results.
• Gerald, J. K., Fisher, J. M., Brown, M. A., Clemens, C. J., Moore, M. A., Carvajal, S. C., Bryson, D., Stefan, N., Billheimer, D., & Gerald, L. B. (2019). School-supervised use of a once-daily inhaled corticosteroid regimen: A cluster randomized trial. The Journal of allergy and clinical immunology, 143, 755-764.
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  School-supervised use of a once-daily inhaled corticosteroid regimen (supervised therapy) can improve medication adherence and asthma control.
• Lohr, A. M., Ingram, M., Carvajal, S. C., Doubleday, K., Aceves, B., Espinoza, C., Redondo, F., Coronado, G., David, C., & Bell, M. L. (2019). Protocol for LINKS (linking individual needs to community and clinical services): A prospective matched observational study of a community health worker community clinical linkage intervention on the U.S.-Mexico border. BMC Public Health, 19(Issue 1). doi:10.1186/s12889-019-6725-1
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  Background: Latinos are currently the largest and fastest growing racial/ethnic group in the United States and have the lowest rates nationally of regular sources of primary care. The changing demographics of Latino populations have significant implications for the future health of the nation, particularly with respect to chronic disease. Community-based agencies and clinics alike have a long history of engaging community health workers (CHWs) to provide a broad range of tangible and emotional support strategies for Latinos with chronic diseases. In this paper, we present the protocol for a community intervention designed to evaluate the impact of CHWs in a Community-Clinical Linkage model to address chronic disease through innovative utilization of electronic health records (EHRs) and application of mixed methodologies. Linking Individual Needs to Community and Clinical Services (LINKS) is a 3-year, prospective matched observational study designed to examine the feasibility and impact of CHW-led Community-Clinical Linkages in reducing chronic disease risk and promoting emotional well-being among Latinos living in three U.S.-Mexico border communities. Methods: The primary aim of LINKS is to create Community-Clinical Linkages between three community health centers and their respective county health departments in southern Arizona. Our primary analysis is to examine the impact of the intervention 6 to 12-months post program entry. We will assess chronic disease risk factors documented in the EHRs of participants versus matched non-participants. By using a prospective matched observational study design with EHRs, we have access to numerous potential comparators to evaluate the intervention effects. Secondary analyses include modeling within-group changes of extended research-collected measures. This approach enhances the overall evaluation with rich data on physical and emotional well-being and health behaviors of study participants that EHR systems do not collect in routine clinical practice. Discussion: The LINKS intervention has practical implications for the development of Community-Clinical Linkage models. The collaborative and participatory approach in LINKS illustrates an innovative evaluation framework utilizing EHRs and mixed methods research-generated data collection. Trial registration: This study protocol was retrospectively registered, approved, and made available on Clinicaltrials.gov by NCT03787485 as of December 20, 2018.
• Lohr, A. M., Ingram, M., Carvajal, S. C., Doubleday, K., Aceves, B., Espinoza, C., Redondo, F., Coronado, G., David, C., & Bell, M. L. (2019). Protocol for LINKS (linking individual needs to community and clinical services): a prospective matched observational study of a community health worker community clinical linkage intervention on the U.S.-Mexico border. BMC public health, 19(1), 399.
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  Latinos are currently the largest and fastest growing racial/ethnic group in the United States and have the lowest rates nationally of regular sources of primary care. The changing demographics of Latino populations have significant implications for the future health of the nation, particularly with respect to chronic disease. Community-based agencies and clinics alike have a long history of engaging community health workers (CHWs) to provide a broad range of tangible and emotional support strategies for Latinos with chronic diseases. In this paper, we present the protocol for a community intervention designed to evaluate the impact of CHWs in a Community-Clinical Linkage model to address chronic disease through innovative utilization of electronic health records (EHRs) and application of mixed methodologies. Linking Individual Needs to Community and Clinical Services (LINKS) is a 3-year, prospective matched observational study designed to examine the feasibility and impact of CHW-led Community-Clinical Linkages in reducing chronic disease risk and promoting emotional well-being among Latinos living in three U.S.-Mexico border communities.
• Marrone, N., Ingram, M., Bischoff, K., Burgen, E., Carvajal, S. C., & Bell, M. L. (2019). Self-reported hearing difficulty and its association with general, cognitive, and psychosocial health in the state of Arizona, 2015. BMC Public Health, 19(Issue 1). doi:10.1186/s12889-019-7175-5
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  Background: Hearing loss is among the leading causes of disability in persons 65 years and older worldwide and is known to have an impact on quality of life as well as social, cognitive, and physical functioning. Our objective was to assess statewide prevalence of self-reported hearing ability in Arizona adults and its association with general health, cognitive decline, diabetes and poor psychosocial health. Methods: A self-report question on hearing was added to the 2015 Behavioral Risk Factor Surveillance System (BRFSS), a telephone-based survey among community-dwelling adults aged > 18 years (n = 6462). Logistic and linear regression were used to estimate the associations between self-reported hearing loss and health outcomes. Results: Approximately 1 in 4 adults reported trouble hearing (23.2, 95% confidence interval: 21.8, 24.5%), with responses ranging from "a little trouble hearing" to being "deaf." Adults reporting any trouble hearing were at nearly four times higher odds of reporting increased confusion and memory loss (OR 3.92, 95% CI: 2.94, 5.24) and decreased odds of reporting good general health (OR = 0.50, 95% CI: 0.40, 0.64) as compared to participants reporting no hearing difficulty. Those reporting any trouble hearing also reported an average 2.5 more days of poor psychosocial health per month (β = 2.52, 95% CI: 1.64, 3.41). After adjusting for sex, age, questionnaire language, race/ethnicity, and income category the association between diabetes and hearing loss was no longer significant. Conclusions: Self-reported hearing difficulty was associated with report of increased confusion and memory loss and poorer general and psychosocial health among Arizona adults. These findings support the feasibility and utility of assessing self-reported hearing ability on the BRFSS. Results highlight the need for greater inclusion of the full range of hearing disability in the planning process for public health surveillance, programs, and services at state and local levels.
• Marrone, N., Ingram, M., Bischoff, K., Burgen, E., Carvajal, S. C., & Bell, M. L. (2019). Self-reported hearing difficulty and its association with general, cognitive, and psychosocial health in the state of Arizona, 2015. BMC public health, 19(1), 875.
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  Hearing loss is among the leading causes of disability in persons 65 years and older worldwide and is known to have an impact on quality of life as well as social, cognitive, and physical functioning. Our objective was to assess statewide prevalence of self-reported hearing ability in Arizona adults and its association with general health, cognitive decline, diabetes and poor psychosocial health.
• Peterson, R. L., Carvajal, S. C., McGuire, L. C., Fain, M. J., & Bell, M. L. (2019). State inequality, socioeconomic position and subjective cognitive decline in the United States. SSM - Population Health, 7. doi:10.1016/j.ssmph.2019.100357
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  Background: Social gradients in health have been observed for many health conditions and are suggested to operate through the effects of status anxiety. However, the gradient between education and Alzheimer's disease is presumed to operate through cognitive stimulation. We examined the possible role of status anxiety through testing for state-level income inequality and social gradients in markers of socioeconomic position (SEP) for Alzheimer's disease risk. Methods: Using data from the cross-sectional 2015 and 2016 Behavioral Risk Factor Surveillance System (BRFSS) and the U.S. Census Bureau's American Community Survey, we tested for the association between U.S. state-level income inequality and individual SEP on subjective cognitive decline (SCD) – a marker of dementia risk – using a generalized estimating equation and clustering by state. Results: State income inequality was not significantly associated with SCD in our multivariable model (OR 1.2; 95% CI: 0.9, 1.6; p=0.49). We observed a clear linear relationship between household income and SCD where those with an annual household income of 50k to 75k had 1.4 (95% CI: 1.3, 1.6) times the odds and those with household incomes of less than $10,000 had 4.7 (95% CI: 3.8, 5.7) times the odds of SCD compared to those with household income of more than $75,000. We also found that college graduates (ref.) and those who completed high school (OR: 1.1; 95% CI 1.04, 1.2) fared better than those with some college (OR: 1.3, 95% CI 1.2, 1.4) or less than a high school degree (OR: 1.5; 95% CI: 1.4, 1.7). Conclusions: Income inequality does not play a dominant role in SCD, though a social gradient in individual income for SCD suggests the relationship may operate in part via status anxiety.
• Peterson, R. L., Carvajal, S. C., McGuire, L. C., Fain, M. J., & Bell, M. L. (2019). State inequality, socioeconomic position and subjective cognitive decline in the United States. SSM - population health, 7, 100357.
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  Social gradients in health have been observed for many health conditions and are suggested to operate through the effects of status anxiety. However, the gradient between education and Alzheimer's disease is presumed to operate through cognitive stimulation. We examined the possible role of status anxiety through testing for state-level income inequality and social gradients in markers of socioeconomic position (SEP) for Alzheimer's disease risk.
• Peterson, R. L., Fain, M. J., A Butler, E., Ehiri, J. E., & Carvajal, S. C. (2019). The role of social and behavioral risk factors in explaining racial disparities in age-related cognitive impairment: a structured narrative review. Neuropsychology, development, and cognition. Section B, Aging, neuropsychology and cognition. Apr 6:1-24. Epub..
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  Alzheimer's disease (AD) is a growing public health concern with large disparities in incidence and prevalence between African Americans (AAs) and non-Hispanic whites (NHWs). The aim of this review was to examine the evidence of association between six modifiable risk factors (education, smoking, physical inactivity, obesity, social isolation, and psychosocial stress) and Alzheimer's disease risk in AAs and NHWs. We identified 3,437 studies; 45 met inclusion criteria and were included in this review. Of the examined risks, education provided the strongest evidence of association with cognitive outcomes in AAs and NHWs. This factor may operate directly on Alzheimer's disease risk through the neurocognitive benefits of cognitive stimulation or indirectly through social status.
• Salerno Valdez, E., Korchmaros, J., Sabo, S., Garcia, D. O., Carvajal, S., & Stevens, S. (2019). How the U.S.-Mexico border influences adolescent substance use: Youth participatory action research using photovoice. International Journal of Drug Policy, 73(Issue). doi:10.1016/j.drugpo.2019.07.011
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  Introduction: The purpose of this study is to use Youth Participatory Action Research (YPAR) methods and Photovoice to identify the perceived environmental factors that influence substance use among adolescents living at the U.S.-Mexico border. Methods: One academic and a local youth health coalition engaged in Youth Participatory Action Research (YPAR) using Photovoice and qualitative methods to examine the perceived factors influencing adolescent substance use in their border community. Results: Identified novel risk factors for adolescent substance use on the border included the normalization of drug trafficking, normalization of substance use, and cross-border access to substances. Novel protective factors included living in a close-knit binational community and having strong binational family and social support systems. The findings also illustrate a nexus of 'factors' wherein risk and protective elements overlap. Conclusion: This study contributes to the broader literature on international border health and how living in a border space influences adolescent substance use. The examination of influential border-bound factors provides a more complete understanding of the experiences of youth living on the U.S.-Mexico border, and informs the field of the importance of considering the border experience for future prevention and risk reduction efforts with border adolescents.
• Salerno Valdez, E., Korchmaros, J., Sabo, S., Garcia, D. O., Carvajal, S., & Stevens, S. (2019). How the U.S.-Mexico border influences adolescent substance use: Youth participatory action research using photovoice. The International journal on drug policy, 73, 146-155.
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  The purpose of this study is to use Youth Participatory Action Research (YPAR) methods and Photovoice to identify the perceived environmental factors that influence substance use among adolescents living at the U.S.-Mexico border.
• Tucker, K. M., Ingram, M., Doubleday, K., Piper, R., & Carvajal, S. C. (2019). La Vida Buena (The Good Life) evaluation: a quasi experimental intervention of a community health worker-led family-based childhood obesity program for Latino children 5-8 years of age on the US-Mexico border. BMC public health, 19(1), 759.
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  Due to multiple and interacting factors, Latino children are disproportionately at risk for overweight and obesity in the United States. Childhood obesity increases the risk for adverse physical and psychosocial outcomes throughout the lifespan. Intensive behavioral interventions recommended in primary care settings may not conform to current practices, and the most vulnerable populations are often unable to access these services. Community Health Workers (CHWs) offer a promising approach to bridging the gap between vulnerable communities and culturally competent services. La Vida Buena (The Good Life) is an 8-week family-focused intervention for Latino children 5-8 years old and their parents or caregivers who are patients at a Federally-Qualified Community Health Center (FQHC). It is a culturally and linguistically appropriate curriculum, facilitated by CHWs, that targets family behaviors to foster a healthy lifestyle in order to prevent and mitigate childhood overweight and obesity.
• Valdez, L. A., Garcia, D. O., Ruiz, J., Oren, E., & Carvajal, S. (2019). Understanding Social and Cultural Contexts of Alcohol Misuse in Mexican-Origin Hispanic Men. Health Education and Behavior, 46(Issue 4). doi:10.1177/1090198119826212
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  Evidence suggests that Hispanic and non-Hispanic White men (NHW) have comparable prevalence rates of alcohol use. However, Hispanic men consistently have higher prevalence rates of alcohol misuse compared with NHW men. Consequently, Hispanic men experience disproportionate levels of adverse health consequences of alcohol misuse when compared with NHW men. The aim of this study was to explore Hispanic male perspectives and opinions regarding alcohol use patterns that may lead to disparate rates of alcohol misuse in Hispanic males. Demographic data were collected with questionnaires. Twenty semistructured one-on-one interviews were completed in English and Spanish with Mexican-origin Hispanic men (age: 44.6 ± 11.3 years). A thematic analysis was conducted using a hybrid deductive–inductive strategy with an a priori codebook supplemented with iterative analysis of transcripts. Results suggest that alcohol misuse patterns in Hispanic males are influenced by an interaction between alcohol-related social norms and learned expressions of masculinity; a lack of knowledge of the alcohol-related health risks that further perpetuate the normalization of alcohol misuse; and expressions of masculinity and adaptive coping that lead to alcohol misuse as an escape from life stressors. Given the rapid expansion of the Hispanic population in the United States, and the disparate consequences of alcohol misuse in this population, it is imperative to consider the complex and often compounded impact of sociocultural norms and the social context on misuse-related behaviors. Viable prevention and treatment strategies should be addressed thought multicomponent, community-level strategies that more comprehensively address the complexities of alcohol misuse in this population.
• Valdez, L. A., Garcia, D. O., Ruiz, J., Oren, E., & Carvajal, S. (2019). Understanding Social and Cultural Contexts of Alcohol Misuse in Mexican-Origin Hispanic Men. Health education & behavior : the official publication of the Society for Public Health Education, 46(4), 648-655.
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  Evidence suggests that Hispanic and non-Hispanic White men (NHW) have comparable prevalence rates of alcohol use. However, Hispanic men consistently have higher prevalence rates of alcohol misuse compared with NHW men. Consequently, Hispanic men experience disproportionate levels of adverse health consequences of alcohol misuse when compared with NHW men. The aim of this study was to explore Hispanic male perspectives and opinions regarding alcohol use patterns that may lead to disparate rates of alcohol misuse in Hispanic males. Demographic data were collected with questionnaires. Twenty semistructured one-on-one interviews were completed in English and Spanish with Mexican-origin Hispanic men (age: 44.6 ± 11.3 years). A thematic analysis was conducted using a hybrid deductive-inductive strategy with an a priori codebook supplemented with iterative analysis of transcripts. Results suggest that alcohol misuse patterns in Hispanic males are influenced by an interaction between alcohol-related social norms and learned expressions of masculinity; a lack of knowledge of the alcohol-related health risks that further perpetuate the normalization of alcohol misuse; and expressions of masculinity and adaptive coping that lead to alcohol misuse as an escape from life stressors. Given the rapid expansion of the Hispanic population in the United States, and the disparate consequences of alcohol misuse in this population, it is imperative to consider the complex and often compounded impact of sociocultural norms and the social context on misuse-related behaviors. Viable prevention and treatment strategies should be addressed thought multicomponent, community-level strategies that more comprehensively address the complexities of alcohol misuse in this population.
• Bell, M. L., Carvajal, S. C., Mcguire, L. C., & Peterson, R. (2018). P3-590: STATE INEQUALITY, SOCIOECONOMIC STATUS AND SUBJECTIVE COGNITIVE DECLINE FROM THE BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM, 2015-2016. Alzheimers & Dementia, 14(7S_Part_25). doi:10.1016/j.jalz.2018.06.1956
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  Alzheimer's disease prevalence is projected to increase by 40%, affecting 11.6 million Americans by 2025. In the absence of a cure, reducing modifiable risk factors is the best strategy to prevent or delay cognitive decline and dementia. Studies show a positive association between cognitive functioning in older years and markers of individual socioeconomic status (SES), which reflects a growing body of research that demonstrates a social gradient between health and social status. We merged state-level Gini coefficients and income quintiles from the U.S. Census Bureau's 2015 American Community Survey with the 2015 and 2016 Behavioral Risk Factor Surveillance System (BRFSS). Gini coefficients are a single number indicator of income inequality ranging from 0 (all income is evenly distributed to the population) to 1 (all income is distributed to a single individual in the population). Subjective cognitive decline (SCD) was measured by self-reported changes to memory and thinking, and was asked of BRFSS participants aged 45 and older in 35 participating states and Washington D.C. Using a generalized estimating equation, we tested for the effects of individual income and education, and state-level inequality on subjective cognitive decline (SCD), clustering by state and controlling for age, sex and race. The odds of SCD increased as income and education declined. After accounting for individual income and education, the odds of SCD increased by 1.36 (95% CI: 1.04, 1.8) times for each 0.1 increase in the Gini coefficient. The odds of SCD were higher in states that were less economically equal, as measured by the Gini coefficient. These findings suggest that more equitable economic contexts may protect against SCD beyond the protective effect observed for higher individual income and education.
• Carvajal, S. C., Coco, L., Colina, S., Ingram, M., Marrone, N., & Piper, R. (2018). COMMUNITY-BASED HEARING LOSS EDUCATION AND SUPPORT GROUPS FOR OLDER HISPANIC/LATINO ADULTS.. Innovation in Aging, 2(suppl_1), 361-361. doi:10.1093/geroni/igy023.1334
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  Envisioning hearing health care from a community-based approach provides a new pathway for hearing loss identification, evaluation, and treatment. Hearing loss can have a significant impact on communication and quality of life for individuals as well as their family and communities. This presentation will highlight the development and implementation of a community-based hearing health education intervention. We will discuss the partnership between community health workers and audiologists that was formed to identify and serve individuals and families experiencing the consequences of hearing loss in an underserved rural community. Following identification of hearing loss, educational sessions emphasizing peer-support and communication training were used to provide participants with strategies for effective communication. Results suggest increased use of communication strategies, improved adaptations in social environments, and overcoming barriers in access to care. This presentation will provide recommendations for those serving older adults to enhance communication across the lifespan and promote healthy aging.
• Carvajal, S. C., Huang, S., Bell, M. L., Denman, C., Guernsey de Zapien, J., Cornejo, E., Chang, J., Staten, L. K., & Rosales, C. (2018). Behavioral and subjective health changes in US and Mexico border residing participants in two promotora-led chronic disease preventive interventions. Health Education Research, 33(Issue 6). doi:10.1093/her/cyy037
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  Chronic diseases are the primary health burden among Mexican-origin populations and health promotion efforts have not been able to change negative population trends. This research presents behavioral and subjective health impacts of two related community health worker (CHW) interventions conducted in the US–Mexico border region. Pasos Adelante (United States) and Meta Salud (Mexico) are 12–13 week CHW-led preventive interventions implemented with Mexico-origin adults. Curricula include active learning modules to promote healthy dietary changes and increasing physical activity; they also incorporate strategies to promote social support, empowerment and group exercise components responsive to their communities. Questionnaire data at baseline (N ¼ 347 for Pasos; 171 for Meta Salud), program completion and 3-month follow-up were analyzed. Results showed statistically significant improvements in multiple reported dietary, physical activity and subjective health indicators. Furthermore, at follow-up across both cohorts there were 10% improvements in participants’ meeting recommended physical activity guidelines, consumption of whole milk, days of poor mental health and self-rated health. While this study identifies some robust health improvements and contributes to the evidence base for these interventions current dissemination, the lack of change observed for some targeted behaviors (e.g. time sitting) suggests they may have stronger overall impacts with curricula refinement.
• Carvajal, S. C., Huang, S., Bell, M. L., Denman, C., Guernsey de Zapien, J., Cornejo, E., Chang, J., Staten, L. K., & Rosales, C. (2018). Behavioral and subjective health changes in US and Mexico border residing participants in two promotora-led chronic disease preventive interventions. Health education research, 33(6), 522-534.
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  Chronic diseases are the primary health burden among Mexican-origin populations and health promotion efforts have not been able to change negative population trends. This research presents behavioral and subjective health impacts of two related community health worker (CHW) interventions conducted in the US-Mexico border region. Pasos Adelante (United States) and Meta Salud (Mexico) are 12-13 week CHW-led preventive interventions implemented with Mexico-origin adults. Curricula include active learning modules to promote healthy dietary changes and increasing physical activity; they also incorporate strategies to promote social support, empowerment and group exercise components responsive to their communities. Questionnaire data at baseline (N = 347 for Pasos; 171 for Meta Salud), program completion and 3-month follow-up were analyzed. Results showed statistically significant improvements in multiple reported dietary, physical activity and subjective health indicators. Furthermore, at follow-up across both cohorts there were ≥10% improvements in participants' meeting recommended physical activity guidelines, consumption of whole milk, days of poor mental health and self-rated health. While this study identifies some robust health improvements and contributes to the evidence base for these interventions current dissemination, the lack of change observed for some targeted behaviors (e.g. time sitting) suggests they may have stronger overall impacts with curricula refinement.
• Garcia, D. O., Carvajal, S. C., Oren, E., Ruiz, J., Flores, M. A., & Valdez, L. A. (2017). Gender and Cultural Adaptations for Diversity: A Systematic Review of Alcohol and Substance Abuse Interventions for Latino Males.. Substance Use and Misuse.
• Lohr, A. M., Ingram, M., Nuñez, A. V., Reinschmidt, K. M., & Carvajal, S. C. (2018). Community-Clinical Linkages With Community Health Workers in the United States: A Scoping Review. Health Promotion Practice, 19, 349-360.
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  Despite the proliferation of community-clinical linkage (CCL) interventions with community health workers (CHWs), little is known about the components of these programs or how linkages are realized. In this scoping review, we synthesize evidence concerning the role of CHWs in creating and sustaining CCLs aimed at improving individual health outcomes. Our inclusion criteria included peer-reviewed articles that described a CHW intervention in the United States that used a CCL model. A total of 2,776 titles and/or abstracts were screened and 47 articles underwent full text review. Two independent reviewers rated the screened articles based on additional criteria including the CHW connection to community and evidence of linkage follow up rather than simple referral. For the 11 peer-reviewed articles included in the final review, we describe the CHW's relationship to the community, training, and role within the intervention, linkage, and outcomes. We used a standardized framework to determine commonalities in CHW roles across the interventions. CCLs with CHWs positively affect the delivery of both clinical care and community resources across a range of disease areas in a variety of contexts. To identify effective CCL models, additional information on CHW training, CCL follow-up methods, and the CHW role in CCLs is recommended.
• Lohr, A. M., Ingram, M., Nuñez, A. V., Reinschmidt, K. M., & Carvajal, S. C. (2018). Community–Clinical Linkages With Community Health Workers in the United States: A Scoping Review. Health Promotion Practice, 19(Issue 3). doi:10.1177/1524839918754868
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  Despite the proliferation of community–clinical linkage (CCL) interventions with community health workers (CHWs), little is known about the components of these programs or how linkages are realized. In this scoping review, we synthesize evidence concerning the role of CHWs in creating and sustaining CCLs aimed at improving individual health outcomes. Our inclusion criteria included peer-reviewed articles that described a CHW intervention in the United States that used a CCL model. A total of 2,776 titles and/or abstracts were screened and 47 articles underwent full text review. Two independent reviewers rated the screened articles based on additional criteria including the CHW connection to community and evidence of linkage follow up rather than simple referral. For the 11 peer-reviewed articles included in the final review, we describe the CHW’s relationship to the community, training, and role within the intervention, linkage, and outcomes. We used a standardized framework to determine commonalities in CHW roles across the interventions. CCLs with CHWs positively affect the delivery of both clinical care and community resources across a range of disease areas in a variety of contexts. To identify effective CCL models, additional information on CHW training, CCL follow-up methods, and the CHW role in CCLs is recommended.
• Valdez, L. A., Flores, M., Ruiz, J., Oren, E., Carvajal, S., & Garcia, D. O. (2018). Gender and Cultural Adaptations for Diversity: A Systematic Review of Alcohol and Substance Abuse Interventions for Latino Males. Substance Use and Misuse, 53(Issue 10). doi:10.1080/10826084.2017.1417999
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  Background: Latino men are disproportionately affected by the consequences of alcohol and substance abuse when compared to non-Latino white men. Latino men also face greater barriers to accessing, engaging, and completing alcohol and substance abuse treatment services. Culturally adapted interventions are promoted to overcome these barriers. However, the effectiveness of these efforts is unclear. Objectives: The purpose of this review was to summarize the published evidence regarding gender-adapted and culturally adapted alcohol and substance abuse treatment that aims to improve physical, behavioral, and social outcomes in Latino men. Methods: A systematic literature search was conducted for articles reporting on culturally and/or gender-adapted alcohol and/or substance abuse interventions designed exclusively for Latino adults, including a Latino population sample of at least 10% and any proportion of Latino male participants. A thematic analysis based on predetermined themes was used to evaluate the nature of adaptations. Results: Searches yielded 2685 titles, resulting in 12 articles that fit review parameters. The most scientifically rigorous findings suggest culturally adapted interventions may outperform standard treatment. Nevertheless, a fraction of the interventions did not improve outcomes compared to standard treatment. Considering the scarce number of publications, it is difficult to discern if null findings reflect ineffective interventions or methodological limitations. Conclusions: While studies are limited and findings are mixed, culturally tailored work shows promise. The growth rate of the Latino population and the current epidemic nature of substance abuse in the United States generate urgency to identify methods to diminish the disparate burden of alcohol and substance abuse in Latinos.
• Valdez, L. A., Flores, M., Ruiz, J., Oren, E., Carvajal, S., & Garcia, D. O. (2018). Gender and Cultural Adaptations for Diversity: A Systematic Review of Alcohol and Substance Abuse Interventions for Latino Males. Substance use & misuse, 53(10), 1608-1623.
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  Latino men are disproportionately affected by the consequences of alcohol and substance abuse when compared to non-Latino white men. Latino men also face greater barriers to accessing, engaging, and completing alcohol and substance abuse treatment services. Culturally adapted interventions are promoted to overcome these barriers. However, the effectiveness of these efforts is unclear.
• Valdez, L. A., Garcia, D. O., Ruiz, J., Oren, E., & Carvajal, S. (2018). Exploring Structural, Sociocultural, and Individual Barriers to Alcohol Abuse Treatment Among Hispanic Men. American Journal of Men's Health, 12(Issue 6). doi:10.1177/1557988318790882
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  Hispanic men have poor access to alcohol abuse treatment, low treatment engagement, and low treatment completion rates despite the contrasting burden of alcohol-related consequences they face. The purpose of this study was to examine Hispanic male perspectives regarding alcohol abuse treatment-seeking behaviors and the structural, sociocultural, and individual factors that may influence initiation and continued engagement in treatment in this population. Individual interviews were conducted with a sample of 20 Hispanic men (age: 44.6 ± 11.3 years). Thematic analysis was completed using a hybrid deductive–inductive approach centered in an a priori codebook that was further supplemented with iterative exploration of transcripts. Results suggested treatment-seeking behaviors were highly influenced by (a) structural factors related to poor treatment access, as well as lack of linguistic- and cultural-responsiveness of available treatment; (b) sociocultural factors related to difficulties problematizing alcohol abuse due to lack of community awareness, societal normalization of consumption, and stigmatization of alcohol abuse treatment; and (c) individual factors related to lack of individual knowledge. This work highlights the perceived lack of congruency between available treatment and the linguistic, cultural, and gender norms of Hispanic men. There is need for responsive treatment strategies that comprehensively consider the gendered- and sociocultural-factors that govern treatment seeking and engagement behaviors. Findings also suggest a need for targeted alcohol abuse awareness building efforts in the Hispanic community. Specifically, the detrimental effects of alcohol-related problems and potential benefits of treatment should be addressed in order to diminish social stigma of abuse and of treatment.
• Valdez, L. A., Garcia, D. O., Ruiz, J., Oren, E., & Carvajal, S. (2018). Exploring Structural, Sociocultural, and Individual Barriers to Alcohol Abuse Treatment Among Hispanic Men. American journal of men's health, 12(6), 1948-1957.
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  Hispanic men have poor access to alcohol abuse treatment, low treatment engagement, and low treatment completion rates despite the contrasting burden of alcohol-related consequences they face. The purpose of this study was to examine Hispanic male perspectives regarding alcohol abuse treatment-seeking behaviors and the structural, sociocultural, and individual factors that may influence initiation and continued engagement in treatment in this population. Individual interviews were conducted with a sample of 20 Hispanic men (age: 44.6 ± 11.3 years). Thematic analysis was completed using a hybrid deductive-inductive approach centered in an a priori codebook that was further supplemented with iterative exploration of transcripts. Results suggested treatment-seeking behaviors were highly influenced by (a) structural factors related to poor treatment access, as well as lack of linguistic- and cultural-responsiveness of available treatment; (b) sociocultural factors related to difficulties problematizing alcohol abuse due to lack of community awareness, societal normalization of consumption, and stigmatization of alcohol abuse treatment; and (c) individual factors related to lack of individual knowledge. This work highlights the perceived lack of congruency between available treatment and the linguistic, cultural, and gender norms of Hispanic men. There is need for responsive treatment strategies that comprehensively consider the gendered- and sociocultural-factors that govern treatment seeking and engagement behaviors. Findings also suggest a need for targeted alcohol abuse awareness building efforts in the Hispanic community. Specifically, the detrimental effects of alcohol-related problems and potential benefits of treatment should be addressed in order to diminish social stigma of abuse and of treatment.
• Huang, S., Bell, M. L., Carvajal, S. C., Chang, J., Cornejo, E., Denman, C. A., Rosales, C., Staten, L. K., & Zapien, J. G. (2017). Health behavior changes in Latino US-Mexico border residing adults participating in chronic disease preventive interventions. The European health psychologist, 19.
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  Background: Non-communicable diseases are the leading cause of death among Mexican-origin adults. There is growing evidence for the effectiveness of community health worker led group interventions in lowering risk. This study aims to examine the behavioral and perceived health impacts of one such intervention tested in a US border community--Pasos Adelante, and contrasts those findings with those of its Northern Mexico adapted and delivered intervention, Meta Salud. The former is a Centers for Disease Control disseminated intervention based on its clinical impact, but little is known about which behavioral change objectives have been successfully addressed. Methods: The primary data comes from the largest cohort to date for evaluating Pasos (N =347); participants were recruited from community and clinical settings. Pasos was developed from a social cognitive theory-based intervention with extensive adaptations based on community participatory methods. Questionnaire data at baseline, conclusion of program, and at 6-month post program initiation were analyzed (e.g., generalized linear logistic mixed models). Findings: Pasos participants reported more physical activity (e.g., meeting CDC guidelines), healthier dietary choices and more positive perceived health at both post program assessments. Across both interventions, participants showed improved indicators of physical activity, whole milk consumption, sugary drink consumption, fruit consumption, mental health and self-rated health (ps
• Ingram, M., Doubleday, K., Bell, M. L., Lohr, A., Murrieta, L., Velasco, M., Blackburn, J., Sabo, S., De Zapien, J. G., & Carvajal, S. C. (2017). Community health worker impact on chronic disease outcomes within primary care examined using electronic health records. American Journal of Public Health, 107(Issue 10). doi:10.2105/ajph.2017.303934
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  Objectives. To investigate community health worker (CHW) effects on chronic disease outcomes using electronic health records (EHRs). Methods.Weexamined EHRs of 32 147 patients at risk for chronic disease during 2012 to 2015. Variables included contact with clinic-based CHWs, vitals, and laboratory tests. We estimated a mixed model for all outcomes. Results. Within-group findings showed statistically significant improvements in chronic disease indicators after exposure to CHWs. In health center 1, HbA1c (glycated hemoglobin) decreased 0.15 millimoles per mole (95% confidence interval [CI] = -0.24, -0.06), body mass index decreased 0.29 kilograms per meter squared (CI = -0.39, -0.20), and total cholesterol decreased 11.9 milligrams per deciliter (CI = -13.5, -10.2). In health center 2, HbA1c decreased 0.43 millimoles per mole (CI = -0.7, -0.17), body mass index decreased by 0.08 kilograms per meter squared (CI = -0.14, -0.02), and triglycerides decreased by 22.50 milligrams per deciliter (CI = -39.0, -6.0). Total cholesterol of 3.62 milligrams per deciliter (CI = -6.6, -0.6) in health center 1 was the only improvement tied to CHW contact. Conclusions. Although patients' chronic disease indicators consistently improved, between-group models provided no additional evidence of impact. EHRs' evolution may elucidate CHW contributions moving forward.
• Ingram, M., Doubleday, K., Bell, M. L., Lohr, A., Murrieta, L., Velasco, M., Blackburn, J., Sabo, S., Guernsey de Zapien, J., & Carvajal, S. C. (2017). Community Health Worker Impact on Chronic Disease Outcomes Within Primary Care Examined Using Electronic Health Records. American journal of public health, 107(10), 1668-1674.
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  To investigate community health worker (CHW) effects on chronic disease outcomes using electronic health records (EHRs).
• Reinschmidt, K. M., Ingram, M., Morales, S., Sabo, S. J., Blackburn, J., Murrieta, L., David, C., & Carvajal, S. C. (2017). Documenting Community Health Worker Roles in Primary Care: Contributions to Evidence-Based Integration Into Health Care Teams, 2015. The Journal of ambulatory care management, 40(4), 305-315.
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  The Patient Protection and Affordable Care Act provided community health workers (CHWs) with new opportunities, and current efforts develop evidence-based guidelines for CHW integration into clinical teams. This qualitative study documents CHW roles and activities in 3 federally qualified health care centers in southern Arizona. Community health worker clinical roles, activities, and integration varied by health center and were in flux. Integration included complementary roles, scheduled and everyday communications with team members, and documentation in the electronic health records. These findings contribute to evidence-based guidelines for CHW integration into clinical teams that are critical to maximizing CHW contributions to patient health improvements.
• Reinschmidt, K. M., Ingram, M., Morales, S., Sabo, S. J., Blackburn, J., Murrieta, L., David, C., & Carvajal, S. C. (2017). Documenting Community Health Worker Roles in Primary Care: Contributions to Evidence-Based Integration into Health Care Teams, 2015. Journal of Ambulatory Care Management, 40(Issue 4). doi:10.1097/jac.0000000000000178
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  The Patient Protection and Affordable Care Act provided community health workers (CHWs) with new opportunities, and current efforts develop evidence-based guidelines for CHW integration into clinical teams. This qualitative study documents CHW roles and activities in 3 federally qualified health care centers in southern Arizona. Community health worker clinical roles, activities, and integration varied by health center and were in flux. Integration included complementary roles, scheduled and everyday communications with team members, and documentation in the electronic health records. These findings contribute to evidence-based guidelines for CHW integration into clinical teams that are critical to maximizing CHW contributions to patient health improvements.
• Reinschmidt, K. M., Ingram, M., Schachter, K., Sabo, S., Verdugo, L., & Carvajal, S. (2017). The Impact of Integrating Community Advocacy Into Community Health Worker Roles on Health-Focused Organizations and Community Health Workers in Southern Arizona. The Journal of ambulatory care management, 38(3), 244-53.
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  Organizational environments may encourage community health workers (CHWs) to engage community members in improving their communities. We conducted open-ended interviews and focus groups to explore how participation in the Acción intervention, which trained CHWs in community advocacy, affected organizational capacity to support their CHWs. Supervisors described improved organizational recognition and trust of CHWs. Organizational leaders reported organizational benefits and increased appreciation of CHW leadership. Both expressed increased interest in future advocacy trainings. Limiting factors included organizational mission, CHW position descriptions, and funding. Findings indicate that, with training and funding, CHW community advocacy can be integrated into organizations with congruent missions.
• Rosales, C. B., de Zapien, J. E., Chang, J., Ingram, M., Fernandez, M. L., Carvajal, S. C., & Staten, L. K. (2017). Perspectives on a US-Mexico Border Community's Diabetes and "Health-Care" Access Mobilization Efforts and Comparative Analysis of Community Health Needs over 12 Years. Frontiers in public health, 5, 152.
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  This paper describes a community coalition-university partnership to address health needs in an underserved US-Mexico border, community. For approximately 15 years, this coalition engaged in community-based participatory research with community organizations, state/local health departments, and the state's only accredited college of public health. Notable efforts include the systematic collection of health-relevant data 12 years apart and data that spawned numerous health promotion activities. The latter includes specific evidence-based chronic disease-preventive interventions, including one that is now disseminated and replicated in Latino communities in the US and Mexico, and policy-level changes. Survey data to evaluate changes in a range of health problems and needs, with a specific focus on those related to diabetes and access to health-care issues-identified early on in the coalition as critical health problems affecting the community-are presented. Next steps for this community and lessons learned that may be applicable to other communities are discussed.
• Rosales, C. B., de Zapien, J. E., Chang, J., Ingram, M., Fernandez, M. L., Carvajal, S. C., & Staten, L. K. (2017). Perspectives on a Us-Mexico Border community's Diabetes and "health-care" access Mobilization efforts and comparative analysis of community health needs over 12 Years. Frontiers in Public Health, 5(Issue). doi:10.3389/fpubh.2017.00152
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  This paper describes a community coalition-university partnership to address health needs in an underserved US-Mexico border, community. For approximately 15 years, this coalition engaged in community-based participatory research with community organizations, state/local health departments, and the state's only accredited college of public health. Notable efforts include the systematic collection of health-relevant data 12 years apart and data that spawned numerous health promotion activities. The latter includes specific evidence-based chronic disease-preventive interventions, including one that is now disseminated and replicated in Latino communities in the US and Mexico, and policy-level changes. Survey data to evaluate changes in a range of health problems and needs, with a specific focus on those related to diabetes and access to health- care issues-identified early on in the coalition as critical health problems affecting the community-are presented. Next steps for this community and lessons learned that may be applicable to other communities are discussed.
• Sabo, S., Flores, M., Wennerstrom, A., Bell, M. L., Verdugo, L., Carvajal, S., & Ingram, M. (2017). Community Health Workers Promote Civic Engagement and Organizational Capacity to Impact Policy. Journal of Community Health, 42(Issue 6). doi:10.1007/s10900-017-0370-3
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  Community health workers (CHW) have historically served to link structurally vulnerable populations to broad support systems. Emerging evidence suggests that CHWs engage in various forms of advocacy to promote policy and systems change. We assessed the impact of CHW community advocacy on community change, defined as civic engagement, organizational capacity and policy and systems change. Data are drawn from the 2014 National Community Health Worker Advocacy Survey (N = 1776) aimed to identify the state of the CHW profession, and their impact on health disparities through community advocacy and policy engagement. Our primary analysis used multiple linear regression to assess the association between CHW advocacy and community change. As predicted, there was a significant, positive association between CHW advocacy and change in community conditions. Additionally, both adjusted and sensitivity models had similar standardized beta estimates for advocacy, and adjusted R2 statistics. CHW advocacy predicts positive change in community conditions and further advances the CHW Community Advocacy Framework designed to support and monitor CHW community advocacy to reduce health disparities through advocacy and policy change.
• Sabo, S., Flores, M., Wennerstrom, A., Bell, M. L., Verdugo, L., Carvajal, S., & Ingram, M. (2017). Community Health Workers Promote Civic Engagement and Organizational Capacity to Impact Policy. Journal of community health, 42(6), 1197-1203.
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  Community health workers (CHW) have historically served to link structurally vulnerable populations to broad support systems. Emerging evidence suggests that CHWs engage in various forms of advocacy to promote policy and systems change. We assessed the impact of CHW community advocacy on community change, defined as civic engagement, organizational capacity and policy and systems change. Data are drawn from the 2014 National Community Health Worker Advocacy Survey (N = 1776) aimed to identify the state of the CHW profession, and their impact on health disparities through community advocacy and policy engagement. Our primary analysis used multiple linear regression to assess the association between CHW advocacy and community change. As predicted, there was a significant, positive association between CHW advocacy and change in community conditions. Additionally, both adjusted and sensitivity models had similar standardized beta estimates for advocacy, and adjusted Rstatistics. CHW advocacy predicts positive change in community conditions and further advances the CHW Community Advocacy Framework designed to support and monitor CHW community advocacy to reduce health disparities through advocacy and policy change.
• Winkler, J. L., Walsh, M. E., DeBlois, M., Mare, J., & Carvajal, S. C. (2017). Kind Discipline: Developing a Roadmap through a Concept Mapping Process. Evaluation and Program Planning.
• Winkler, J. L., Walsh, M. E., de Blois, M., Maré, J., & Carvajal, S. C. (2017). Kind discipline: Developing a conceptual model of a promising school discipline approach. Evaluation and Program Planning, 62(Issue). doi:10.1016/j.evalprogplan.2017.02.002
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  This formative evaluation develops a novel conceptual model for a discipline approach fostering intrinsic motivation and positive relationships in schools. We used concept mapping to elicit and integrate perspectives on kind discipline from teachers, administrators, and other school staff. Three core themes describing kind discipline emerged from 11 identified clusters: (1) proactively developing a positive school climate, (2) responding to conflict with empathy, accountability, and skill, and (3) supporting staff skills in understanding and sharing expectations. We mapped the identified components of kind discipline onto a social ecological model and found that kind discipline encompasses all levels of that model including the individual, relational, environmental/structural, and even community levels. This contrasts with the dominant individual-behavioral discipline approaches that focus on fewer levels and may not lead to sustained student and staff motivation. The findings illustrate the importance of setting and communicating clear expectations and the need for them to be collaboratively developed. Products of the analysis and synthesis reported here are operationalized materials for teachers grounded in a “be kind” culture code for classrooms.
• Winkler, J. L., Walsh, M. E., de Blois, M., Maré, J., & Carvajal, S. C. (2017). Kind discipline: Developing a conceptual model of a promising school discipline approach. Evaluation and program planning, 62, 15-24.
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  This formative evaluation develops a novel conceptual model for a discipline approach fostering intrinsic motivation and positive relationships in schools. We used concept mapping to elicit and integrate perspectives on kind discipline from teachers, administrators, and other school staff. Three core themes describing kind discipline emerged from 11 identified clusters: (1) proactively developing a positive school climate, (2) responding to conflict with empathy, accountability, and skill, and (3) supporting staff skills in understanding and sharing expectations. We mapped the identified components of kind discipline onto a social ecological model and found that kind discipline encompasses all levels of that model including the individual, relational, environmental/structural, and even community levels. This contrasts with the dominant individual-behavioral discipline approaches that focus on fewer levels and may not lead to sustained student and staff motivation. The findings illustrate the importance of setting and communicating clear expectations and the need for them to be collaboratively developed. Products of the analysis and synthesis reported here are operationalized materials for teachers grounded in a "be kind" culture code for classrooms.
• Herman, P. (2016). A Comparison of Methods for Capturing Patient Preferences for Delivery of Mental Health Services to Low-Income Hispanics Engaged in Primary Care.. The Patient: Patient-Centered Outcomes Research.
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  Herman, P.M., Ingram, M., Cunningham, C.E., Rimas, H s, Murrieta, L. c, Schachter, K., de Zapien, J.G., & Carvajal, S.C. (2016). A Comparison of Methods for Capturing Patient Preferences for Delivery of Mental Health Services to Low-Income Hispanics Engaged in Primary Care. The Patient: Patient-Centered Outcomes Research, Aug;9(4):293-301. PMID: 26689700.
• Herman, P. (2016). Patient Preferences of a Low-Income Hispanic Population for Mental Health Services in Primary Care.. Administration and Policy in Mental Health.
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  Herman, P.M., Ingram, M., Rimas, H.s, Carvajal, S., & Cunningham, C.E. (2016). Patient Preferences of a Low-Income Hispanic Population for Mental Health Services in Primary Care. Administration and Policy in Mental Health. PMID: 26410547
• Herman, P. M., Ingram, M., Cunningham, C. E., Rimas, H., Murrieta, L., Schachter, K., de Zapien, J. G., & Carvajal, S. C. (2016). A Comparison of Methods for Capturing Patient Preferences for Delivery of Mental Health Services to Low-Income Hispanics Engaged in Primary Care. Patient, 9(Issue 4). doi:10.1007/s40271-015-0155-7
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  Background: Consideration of patient preferences regarding delivery of mental health services within primary care may greatly improve access and quality of care for the many who could benefit from those services. Objectives: This project evaluated the feasibility and usefulness of adding a consumer-products design method to qualitative methods implemented within a community-based participatory research (CBPR) framework. Research Design: Discrete-choice conjoint experiment (DCE) added to systematic focus group data collection and analysis. Subjects: Focus group data were collected from 64 patients of a Federally-Qualified Health Center (FQHC) serving a predominantly low-income Hispanic population. A total of 604 patients in the waiting rooms of the FQHC responded to the DCE. Measures: The DCE contained 15 choice tasks that each asked respondents to choose between three mental health services options described by the levels of two (of eight) attributes based on themes that emerged from focus group data. Results: The addition of the DCE was found to be feasible and useful in providing distinct information on relative patient preferences compared with the focus group analyses alone. According to market simulations, the package of mental health services guided by the results of the DCE was preferred by patients. Conclusions: Unique patterns of patient preferences were uncovered by the DCE and these findings were useful in identifying pragmatic solutions to better address the mental health service needs of this population. However, for this resource-intensive method to be adopted more broadly, the scale of the primary care setting and/or scope of the issue addressed have to be relatively large.
• Herman, P. M., Ingram, M., Rimas, H., Carvajal, S., & Cunningham, C. E. (2016). Patient Preferences of a Low-Income Hispanic Population for Mental Health Services in Primary Care. Administration and Policy in Mental Health and Mental Health Services Research, 43(Issue 5). doi:10.1007/s10488-015-0687-0
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  We used a discrete-choice conjoint experiment to model the mental health services preferences of patients of a federally-qualified health center serving a primarily low-income, Hispanic farmworker population in southwestern Arizona. The two attributes that had the largest influence on patient choices (i.e., received the highest importance scores) were where patients receive these services and the language and cultural awareness of the provider who prescribed their treatment. Simulations indicated that the clinic could substantially improve its patients’ welfare with even a single change. The single most effective change in terms of patient preferences would be to offer behavioral health services onsite.
• Rosales, C. B., Carvajal, S., & de Zapien, J. E. (2016). Editorial: Emergent Public Health Issues in the US-Mexico Border Region. Frontiers in public health, 4, 93.
• Rosales, C. B., Carvajal, S., & de Zapien, J. E. (2016). Editorial: Emergent Public Health Issues in the US–Mexico Border Region. Frontiers in Public Health, 4(Issue). doi:10.3389/fpubh.2016.00093
• Denman, C. A., Bell, M. L., Cornejo, E., De Zapien, J. G., Carvajal, S., & Rosales, C. (2015). Changes in health behaviors and self-rated health of participants in Meta Salud: A primary prevention intervention of NCD in Mexico. Global Heart, 10(Issue 1). doi:10.1016/j.gheart.2014.12.007
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  Background Meta Salud was a community health worker-facilitated intervention for the prevention of noncommunicable diseases in Northern Mexico. Objectives This analysis examined changes in perceived health, eating habits, and physical activity immediately and 3 months after the intervention. The impact on the resulting behavioral and psychological factors are reported. Methods This was a nonrandomized intervention study with 1 baseline and 2 post-intervention follow-ups. Outcome evaluation consisted of anthropometric measurements, laboratory tests, and a lifestyle questionnaire. Results The most consistent patterns were increases in metabolic equivalent of task values expended per day from baseline to post-intervention (difference = 996; 95% confidence interval [CI]: 81 to 1,912) and to 3-month follow-up (difference = 1,073; 95% CI: 119 to 2,028); greater likelihood of meeting Centers for Disease Control and Prevention daily exercise recommendations, with an increase from 49% to 60% at post-intervention (OR: 1.6, 95% CI: 1.0 to 2.4) and 63% at follow-up (OR: 1.7, 95% CI: 1.7 to 2.7); lesser likelihood for consuming whole milk, from 38% to 59% (OR: 2.9, 95% CI: 1.8 to 4.7); fewer daily servings of packaged foods, from 0.72 to 0.57 (difference = -0.16; 95% CI: -0.28 to -0.03); fewer days of poor mental health, from 9.3 to 5.8 (difference = -3.4; 95% CI: -5.1 to -1.7); and greater likelihood for reporting good self-rated health, from 41% to 54% post-intervention (OR: 2.1, 95% CI: 1.3 to 3.6) and 57% at follow-up (OR: 2.5, 95% CI: 1.5 to 4.4). Changes in other outcomes, although in the expected direction of association, were not statistically significant. Conclusions The study identified important strategies for making feasible dietary changes in the consumption of whole milk, sugary drinks, and packaged foods, yet there is still a need to identify strategies for improving consumption of healthy foods. There was stronger evidence for ways of improving physical activity as opposed to other outcome measures. Overall, it highlights the importance of behavioral and psychosocial factors as key intervention targets in preventing noncommunicable diseases in low- and middle-income countries.
• Denman, C. A., Bell, M. L., Cornejo, E., de Zapien, J. G., Carvajal, S., & Rosales, C. (2015). Changes in health behaviors and self-rated health of participants in Meta Salud: a primary prevention intervention of NCD in Mexico. Global heart, 10(1), 55-61.
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  Meta Salud was a community health worker-facilitated intervention for the prevention of noncommunicable diseases in Northern Mexico.
• Herman, P. M., Ingram, M., Cunningham, C. E., Rimas, H., Murrieta, L., Schachter, K., de Zapien, J. G., & Carvajal, S. C. (2015). A Comparison of Methods for Capturing Patient Preferences for Delivery of Mental Health Services to Low-Income Hispanics Engaged in Primary Care. The patient.
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  Consideration of patient preferences regarding delivery of mental health services within primary care may greatly improve access and quality of care for the many who could benefit from those services.
• Herman, P. M., Ingram, M., Rimas, H., Carvajal, S., & Cunningham, C. E. (2015). Patient Preferences of a Low-Income Hispanic Population for Mental Health Services in Primary Care. Administration and policy in mental health.
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  We used a discrete-choice conjoint experiment to model the mental health services preferences of patients of a federally-qualified health center serving a primarily low-income, Hispanic farmworker population in southwestern Arizona. The two attributes that had the largest influence on patient choices (i.e., received the highest importance scores) were where patients receive these services and the language and cultural awareness of the provider who prescribed their treatment. Simulations indicated that the clinic could substantially improve its patients' welfare with even a single change. The single most effective change in terms of patient preferences would be to offer behavioral health services onsite.
• Ingram, M., Murrietta, L., De Zapien, J. G., Herman, P., & Carvajal, S. C. (2015). Community health workers as focus group facilitators: A participatory action research method to improve behavioral health services for farmworkers in a primary care setting. Action Research, 13(1), 48-64. doi:10.1177/1476750314565913
• Ingram, M., Murrietta, L., de Zapien, J. G., Herman, P. M., & Carvajal, S. C. (2015). Community health workers as focus group facilitators: A participatory action research method to improve behavioral health services for farmworkers in a primary care setting. Action Research, 13(Issue 1). doi:10.1177/1476750314565913
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  Farmworkers living in US-Border communities experience numerous stressors in their daily lives that place them at risk for behavioral health problems, particularly anxiety and depression. Given challenges to accessing care, farmworkers are most likely to receive services in the primary care setting. In this paper, we describe a participatory action research (PAR) approach in which community health workers (CHWs) use focus groups to engage the patient population in discussing behavioral health issues and identifying preferences for care within a Federally Qualified Health Center. The CHWs were trusted members of the community who participated in the articulation of research questions, development and implementation of protocols, participant recruitment, and data collection. CHWs encouraged focus group members to represent their community in the co-construction of knowledge regarding perceptions of behavioral health and priorities for care. This research illustrates that CHWs, as representatives for patients’ needs and a bridge between the health care system and communities, can play a vital role as intermediate actors in generating patient participation in PAR.
• Ingram, M., Sabo, S. J., Gomez, S., Piper, R., de Zapien, J. G., Reinschmidt, K. M., Schachter, K. A., & Carvajal, S. C. (2015). Taking a Community-Based Participatory Research Approach in the Development of Methods to Measure a Community Health Worker Community Advocacy Intervention. Progress in Community Health Partnerships: Research, Education, and Action, 9(Issue 1). doi:10.1353/cpr.2015.0001
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  Background: Public health advocacy is by necessity responsive to shifting sociopolitical climates, and thus a challenge of advocacy research is that the intervention must by definition be adaptive. Moving beyond the classification of advocacy efforts to measurable indicators and outcomes of policy, therefore, requires a dynamic research approach. Objectives: The purposes of this article are to (1) describe use of the CBPR approach in the development and measurement of a community health worker (CHW) intervention designed to engage community members in public health advocacy and (2) provide a model for application of this approach in advocacy interventions addressing communitylevel systems and environmental change. Methods: The Kingdon three streams model of policy change provided a theoretical framework for the intervention. Research and community partners collaboratively identified and documented intervention data. We describe five research methods used to monitor and measure CHW advocacy activities that both emerged from and influenced intervention activities. Discussion: Encounter forms provided a longitudinal perspective of how CHWs engaged in advocacy activities in the three streams. Strategy maps defined desired advocacy outcomes and health benefits. Technical assistance notes identified and documented intermediate outcomes. Focus group and interview data reflected CHW efforts to engage community members in advocacy and the development of community leaders. Application of Lessons Learned: We provide a model for application of key principles of CPBR that are vital to effectively capturing the overarching and nuanced aspects of public health advocacy work in dynamic political and organizational environments.
• Ingram, M., Sabo, S. J., Gomez, S., Piper, R., de Zapien, J. G., Reinschmidt, K. M., Schachter, K. A., & Carvajal, S. C. (2015). Taking a community-based participatory research approach in the development of methods to measure a community health worker community advocacy intervention. Progress in community health partnerships : research, education, and action, 9(1), 49-56.
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  Public health advocacy is by necessity responsive to shifting sociopolitical climates, and thus a challenge of advocacy research is that the intervention must by definition be adaptive. Moving beyond the classification of advocacy efforts to measurable indicators and outcomes of policy, therefore, requires a dynamic research approach.
• Ingram, M., Schachter, K. A., Guernsey de Zapien, J., Herman, P. M., & Carvajal, S. C. (2015). Using participatory methods to enhance patient-centred mental health care in a federally qualified community health center serving a Mexican American farmworker community. Health expectations : an international journal of public participation in health care and health policy, 18(6), 3007-18. doi:10.1111/hex.12284
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  Mexican American farmworkers experience high rates of mental health conditions; however, it is difficult for them to access care. Patient-centred care is a systems-wide approach to improving the delivery of services for diverse populations in the primary care setting.
• Nodora, J. N., Carvajal, S. C., Robles-Garcia, R., Agraz, F. P., Daneri-Navarro, A., Meza-Montenegro, M. M., Gutierrez-Millan, L. E., & Martinez, M. E. (2015). Development and Psychometric Assessment of the Measure of Globalization Influence on Health Risk (MGIHR) Among Mexican Women with Breast Cancer. Journal of Immigrant and Minority Health, 17(Issue 4). doi:10.1007/s10903-014-0042-7
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  Lacking in the literature are data addressing the extent to which changes in reproductive and lifestyle factors predispose women in developing nations to higher breast cancer rates, and the degree to which these are due to globalization influences. This article describes the development and psychometric assessment of an instrument intended to measure global, predominantly U.S., influences on breast cancer risk profile among women residing in Mexico. Using investigator consensus and a focus group methodology, the Measure of Globalization Influence on Health Risk (MGIHR) was developed and completed by 341 women. Psychometric analysis support the use of an 11-item Consumerism and Modernity scale and 7-item Reproductive Control and Gender Role scale. The MGIHR is a valid and reliable instrument for understanding changing lifestyle and reproductive factors for breast cancer risk and may provide a more complete understanding of breast cancer development and needed interventions.
• Nodora, J. N., Carvajal, S. C., Robles-Garcia, R., Agraz, F. P., Daneri-Navarro, A., Meza-Montenegro, M. M., Gutierrez-Millan, L. E., & Martinez, M. E. (2015). Development and Psychometric Assessment of the Measure of Globalization Influence on Health Risk (MGIHR) Among Mexican Women with Breast Cancer. Journal of immigrant and minority health / Center for Minority Public Health, 17(4), 1025-32.
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  Lacking in the literature are data addressing the extent to which changes in reproductive and lifestyle factors predispose women in developing nations to higher breast cancer rates, and the degree to which these are due to globalization influences. This article describes the development and psychometric assessment of an instrument intended to measure global, predominantly U.S., influences on breast cancer risk profile among women residing in Mexico. Using investigator consensus and a focus group methodology, the Measure of Globalization Influence on Health Risk (MGIHR) was developed and completed by 341 women. Psychometric analysis support the use of an 11-item Consumerism and Modernity scale and 7-item Reproductive Control and Gender Role scale. The MGIHR is a valid and reliable instrument for understanding changing lifestyle and reproductive factors for breast cancer risk and may provide a more complete understanding of breast cancer development and needed interventions.
• Reinschmidt, K. M., Ingram, M., Schachter, K. A., Sabo, S. J., Verdugo, L., & Carvajal, S. C. (2015). The Impact of Integrating Community Advocacy into Community Health Worker Roles on Health-Focused Organizations and Community Health Workers in Southern Arizona. Journal of Ambulatory Care Management, 38(3), 244-253.
• Reinschmidt, K. M., Ingram, M., Schachter, K., Sabo, S., Verdugo, L., & Carvajal, S. (2015). The impact of integrating community advocacy into community health worker roles on health-focused organizations and community health workers in southern Arizona. Journal of Ambulatory Care Management, 38(Issue 3). doi:10.1097/jac.0000000000000092
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  Organizational environments may encourage community health workers (CHWs) to engage community members in improving their communities. We conducted open-ended interviews and focus groups to explore how participation in the Acción intervention, which trained CHWs in community advocacy, affected organizational capacity to support their CHWs. Supervisors described improved organizational recognition and trust of CHWs. Organizational leaders reported organizational benefits and increased appreciation of CHW leadership. Both expressed increased interest in future advocacy trainings. Limiting factors included organizational mission, CHW position descriptions, and funding. Findings indicate that, with training and funding, CHW community advocacy can be integrated into organizations with congruent missions.
• Schachter, K. A., Carvajal, S. C., Herman, P. M., Ingram, M., & Zapien, J. G. (2015). Using participatory methods to enhance patient-centred mental health care in a federally qualified community health center serving a Mexican American farmworker community.. Health expectations : an international journal of public participation in health care and health policy, 18(6), 3007-18. doi:10.1111/hex.12284
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  Mexican American farmworkers experience high rates of mental health conditions; however, it is difficult for them to access care. Patient-centred care is a systems-wide approach to improving the delivery of services for diverse populations in the primary care setting..We describe the application of community-based participatory research methods to assess and address gaps in perceptions of mental health care between providers and migrant workers living in a US-Mexico Border community..A federally qualified health centre (FQHC) serving a community of approximately 60 000 agricultural workers who live in Yuma County and harvest vegetables during the winter season..We conducted patient focus groups (n = 64) and FQHC staff interviews (n = 16) to explore attributes and dimensions of patient-centred mental health care..Patients and staff both prioritized increased access to mental health care and patient-centred care, while patients were more concerned with interpersonal care and providers with coordination of care. All participants stressed the relationship between life events and mental health and the centrality of family in care. Patients also emphasized the importance of a good attitude, the ability to solve problems, positive family relationships and reliance on faith. Patients suggested that the FQHC inform patients about mental health resources, provide community informational talks to address stigma, and offer support groups..The participatory approach of this qualitative study resulted in a wealth of data regarding patient preferences that will enable the FQHC to develop protocols and training to provide patient-centred mental health-care services for their community.
• Carvajal, S. C. (2014). Structural determinants of mortality and the role of behavior: A comment on Whitley et al.. Annals of Behavioral Medicine, 47(Issue 2). doi:10.1007/s12160-013-9560-0
• Carvajal, S. C. (2014). Structural determinants of mortality and the role of behavior: a comment on Whitley et al. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine, 47(2), 133-4.
• Carvajal, S. C., Kibor, C., McClelland, D. J., Ingram, M., de Zapien, J. G., Torres, E., Redondo, F., Rodriguez, K., Rubio-Goldsmith, R., Meister, J., & Rosales, C. (2014). Stress and Sociocultural Factors Related to Health Status Among US-Mexico Border Farmworkers. Journal of immigrant and minority health / Center for Minority Public Health.
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  This study examines factors relating to farmworkers' health status from sociocultural factors, including stress embedded within their work and community contexts. A cross-sectional household survey of farmworkers (N = 299) included social-demographics, immigration status descriptors, and a social-ecologically grounded, community-responsive, stress assessment. Outcomes included three standard US national surveillance measures of poor mental, physical, and self-rated health (SRH). Logistic regression models showed that higher levels of stress were significantly associated (Ps 
• Carvajal, S. C., Kibor, C., McClelland, D. J., Ingram, M., de Zapien, J. G., Torres, E., Redondo, F., Rodriguez, K., Rubio-Goldsmith, R., Meister, J., & Rosales, C. (2014). Stress and Sociocultural Factors Related to Health Status Among US–Mexico Border Farmworkers. Journal of Immigrant and Minority Health, 16(Issue 6). doi:10.1007/s10903-013-9853-1
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  This study examines factors relating to farmworkers’ health status from sociocultural factors, including stress embedded within their work and community contexts. A cross-sectional household survey of farmworkers (N = 299) included social-demographics, immigration status descriptors, and a social-ecologically grounded, community-responsive, stress assessment. Outcomes included three standard US national surveillance measures of poor mental, physical, and self-rated health (SRH). Logistic regression models showed that higher levels of stress were significantly associated (Ps < .001) with increased risk for poor mental health and poor physical health considering all variables. Stress was not associated with SRH. Regarding two of the three outcomes, mental health and physical health, stress added explanatory power as expected. For poor SRH, a known marker for mortality risk and quite high in the sample at 38 %, only age was significantly associated. Clinical and systems-level health promotion strategies may be required to mitigate these stressors in border-residing farmworkers.
• Denman, C. A., Rosales, C., Cornejo, E., Bell, M. L., Munguía, D., Zepeda, T., Carvajal, S., & Guernsey de Zapien, J. (2014). Evaluation of the community-based chronic disease prevention program Meta Salud in Northern Mexico, 2011-2012. Preventing chronic disease, 11, E154.
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  Meta Salud is a community health worker-facilitated intervention in Hermosillo, Sonora, Mexico, and was adapted from Pasos Adelante, a similar evidence-based intervention developed for a Latino population in the United States-Mexico border region. The objective of this study was to examine outcomes for Meta Salud and compare them with outcomes for Pasos Adelante.
• Denman, C. A., Rosales, C., Cornejo, E., Bell, M. L., Munguía, D., Zepeda, T., Carvajal, S., & de Zapien, J. G. (2014). Evaluation of the community-based chronic disease prevention program Meta Salud in Northern Mexico, 2011-2012. Preventing Chronic Disease, 11(Issue 9). doi:10.5888/pcd11.140218
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  Introduction: Meta Salud is a community health worker-facilitated intervention in Hermosillo, Sonora, Mexico, and was adapted from Pasos Adelante, a similar evidence-based intervention developed for a Latino population in the United States-Mexico border region. The objective of this study was to examine outcomes for Meta Salud and compare them with outcomes for Pasos Adelante. Methods: This pretest-posttest study took place during 13 weeks among low-income residents of an urban area. The program provided information on topics such as heart health, physical activity, nutrition, diabetes, healthy weight, community health, and emotional well-being; included individual and group activities aimed at motivating behavior change and encouraged participants to engage in brisk physical activity. Results: We found significant decreases from baseline to conclusion in body mass index, waist circumference, hip circumference, weight, triglycerides, and low-density lipoprotein (LDL) cholesterol. From baseline to 3-month follow-up, we found significant decreases in body mass index, waist circumference, weight, LDL cholesterol, and glucose, and an increase in high-density lipoprotein cholesterol. Outcomes for Meta Salud were similar to those found for Pasos Adelante. Conclusion: The physiological improvements found among participants in Meta Salud and comparable changes among participants in Pasos Adelante suggest a scalable and effective behavioral intervention for regions of the United States and Mexico that share a common boundary or have similar cultural and linguistic characteristics.
• Ingram, M., Schachter, K. A., Sabo, S. J., Reinschmidt, K. M., Gomez, S., De Zapien, J. G., & Carvajal, S. C. (2014). A community health worker intervention to address the social determinants of health through policy change. Journal of Primary Prevention, 35(Issue 2). doi:10.1007/s10935-013-0335-y
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  Public policy that seeks to achieve sustainable improvements in the social determinants of health, such as income, education, housing, food security and neighborhood conditions, can create positive and sustainable health effects. This paper describes preliminary results of Accion para la Salud, a public health intervention in which Community health workers (CHWs) from five health agencies engaged their community in the process of making positive systems and environmental changes. Academic-community partners trained Acción CHWs in community advocacy and provided ongoing technical assistance in developing strategic advocacy plans. The CHWs documented community advocacy activities through encounter forms in which they identified problems, formulated solutions, and described systems and policy change efforts. Strategy maps described the steps of the advocacy plans. Findings demonstrate that CHWs worked to initiate discussions about underlying social determinants and environment-related factors that impact health, and identified solutions to improve neighborhood conditions, create community opportunities, and increase access to services. © Springer Science+Business Media New York 2013.
• Ingram, M., Schachter, K. A., Sabo, S. J., Reinschmidt, K. M., Gomez, S., De Zapien, J. G., & Carvajal, S. C. (2014). A community health worker intervention to address the social determinants of health through policy change. The journal of primary prevention, 35(2), 119-23.
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  Public policy that seeks to achieve sustainable improvements in the social determinants of health, such as income, education, housing, food security and neighborhood conditions, can create positive and sustainable health effects. This paper describes preliminary results of Acción para la Salud, a public health intervention in which Community health workers (CHWs) from five health agencies engaged their community in the process of making positive systems and environmental changes. Academic-community partners trained Acción CHWs in community advocacy and provided ongoing technical assistance in developing strategic advocacy plans. The CHWs documented community advocacy activities through encounter forms in which they identified problems, formulated solutions, and described systems and policy change efforts. Strategy maps described the steps of the advocacy plans. Findings demonstrate that CHWs worked to initiate discussions about underlying social determinants and environment-related factors that impact health, and identified solutions to improve neighborhood conditions, create community opportunities, and increase access to services.
• Langellier, B. A., De Zapien, J. G., Rosales, C., Ingram, M., & Carvajal, S. C. (2014). State medicaid expansion, community interventions, and health care disparities in a united states-mexico border community. American Journal of Public Health, 104(Issue 8). doi:10.2105/ajph.2014.302013
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  Objectives. We investigated whether access to and use of health care services increased among residents of a low-income, predominantly Mexican American border community affected by the expansion of Arizona's Medicaid program in 2001 and multiple community-level programs and policies. Methods. We used data from a probability sample of 1623 adult residents of Douglas, Arizona, who participated in cross-sectional health surveys in 1998 and 2010. Response rates were 83% and 86%, respectively. Results. In 2010, participants were more likely to have a usual source of care, to have visited a provider in the previous year, and to have been screened for diabetes and hypertension and less likely to have delayed needed care or to have seen a regular provider in Mexico (P < .001 for all outcomes). Improvements in access to and use of health care were most pronounced among residents with less than a high school education, which reduced or eliminated educational disparities in health care. Conclusions. Expansion of public insurance programs can effectively reduce health care disparities when paired with other community-level policies and programs that target medically underserved populations.
• Langellier, B. A., Guernsey de Zapien, J., Rosales, C., Ingram, M., & Carvajal, S. C. (2014). State Medicaid expansion, community interventions, and health care disparities in a United States-Mexico border community. American journal of public health, 104(8), e94-e100.
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  We investigated whether access to and use of health care services increased among residents of a low-income, predominantly Mexican American border community affected by the expansion of Arizona's Medicaid program in 2001 and multiple community-level programs and policies.
• Sabo, S., Shaw, S., Ingram, M., Teufel-Shone, N., Carvajal, S., de Zapien, J. G., Rosales, C., Redondo, F., Garcia, G., & Rubio-Goldsmith, R. (2014). Everyday violence, structural racism and mistreatment at the US-Mexico border. Social Science and Medicine, 109(Issue). doi:10.1016/j.socscimed.2014.02.005
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  Immigration laws that militarize communities may exacerbate ethno-racial health disparities. We aimed to document the prevalence of and ways in which immigration enforcement policy and militarization of the US-Mexico border is experienced as everyday violence. Militarization is defined as the saturation of and pervasive encounters with immigration officials including local police enacting immigration and border enforcement policy with military style tactics and weapons. Data were drawn from a random household sample of US citizen and permanent residents of Mexican descent in the Arizona border region (2006-2008). Qualitative and quantitative data documented the frequency and nature of immigration related profiling, mistreatment and resistance to institutionalized victimization. Participants described living and working in a highly militarized environment, wherein immigration-related profiling and mistreatment were common immigration law enforcement practices. Approximately 25% of respondents described an immigration-related mistreatment episode, of which 62% were personally victimized. Nearly 75% of episodes occurred in a community location rather than at a US port of entry. Participant mistreatment narratives suggest the normalization of immigration-related mistreatment among the population. Given border security remains at the core of immigration reform debates, it is imperative that scholars advance the understanding of the public health impact of such enforcement policies on the daily lives of Mexican-origin US permanent residents, and their non-immigrant US citizen co-ethnics. Immigration policy that sanctions institutional practices of discrimination, such as ethno-racial profiling and mistreatment, are forms of structural racism and everyday violence. Metrics and systems for monitoring immigration and border enforcement policies and institutional practices deleterious to the health of US citizens and residents should be established. © 2014 Elsevier Ltd.
• Sabo, S., Shaw, S., Ingram, M., Teufel-Shone, N., Carvajal, S., de Zapien, J. G., Rosales, C., Redondo, F., Garcia, G., & Rubio-Goldsmith, R. (2014). Everyday violence, structural racism and mistreatment at the US-Mexico border. Social science & medicine, 109, 66-74.
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  Immigration laws that militarize communities may exacerbate ethno-racial health disparities. We aimed to document the prevalence of and ways in which immigration enforcement policy and militarization of the US-Mexico border is experienced as everyday violence. Militarization is defined as the saturation of and pervasive encounters with immigration officials including local police enacting immigration and border enforcement policy with military style tactics and weapons. Data were drawn from a random household sample of US citizen and permanent residents of Mexican descent in the Arizona border region (2006-2008). Qualitative and quantitative data documented the frequency and nature of immigration related profiling, mistreatment and resistance to institutionalized victimization. Participants described living and working in a highly militarized environment, wherein immigration-related profiling and mistreatment were common immigration law enforcement practices. Approximately 25% of respondents described an immigration-related mistreatment episode, of which 62% were personally victimized. Nearly 75% of episodes occurred in a community location rather than at a US port of entry. Participant mistreatment narratives suggest the normalization of immigration-related mistreatment among the population. Given border security remains at the core of immigration reform debates, it is imperative that scholars advance the understanding of the public health impact of such enforcement policies on the daily lives of Mexican-origin US permanent residents, and their non-immigrant US citizen co-ethnics. Immigration policy that sanctions institutional practices of discrimination, such as ethno-racial profiling and mistreatment, are forms of structural racism and everyday violence. Metrics and systems for monitoring immigration and border enforcement policies and institutional practices deleterious to the health of US citizens and residents should be established.
• Schachter, K. A., Ingram, M. -., Jacobs, L., De Zapien, J. G., Hafter, H., & Carvajal, S. C. (2014). Developing an action learning community advocacy/leadership training program for community health workers and their agencies to reduce health disparities in Arizona border communities. Journal of Health Disparities Research and Practice, 7(2), 14.
• Carvajal, S. C., Miesfeld, N., Chang, J., Reinschmidt, K. M., de Zapien, J. G., Fernandez, M. L., Rosales, C., & Staten, L. K. (2013). Evidence for long-term impact of Pasos Adelante: Using a community-wide survey to evaluate chronic disease risk modification in prior program participants. International Journal of Environmental Research and Public Health, 10(Issue 10). doi:10.3390/ijerph10104701
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  Effective community-level chronic disease prevention is critical to population health within developed and developing nations. Pasos Adelante is a preventive intervention that aims to reduce chronic disease risk with evidence of effectiveness in US-Mexico residing, Mexican origin, participants. This intervention and related ones also implemented with community health workers have been shown to improve clinical, behavioral and quality of life indicators; though most evidence is from shorter-term evaluations and/or lack comparison groups. The current study examines the impact of this program using secondary data collected in the community 3-6 years after all participants completed the program. A proportional household survey (N = 708) was used that included 48 respondents who indicated they had participated in Pasos. Using propensity score matching to account for differences in program participants versus other community residents (the program targeted those with diabetes and associated risk factors), 148 natural controls were identified for 37 matched Pasos participants. Testing a range of behavioral and clinical indicators of chronic disease risk, logistic regression models accounting for selection bias showed two significant findings; Pasos participants were more physically active and drank less whole milk. These findings add to the evidence of the effectiveness of Pasos Adalente and related interventions in reducing chronic disease risk in Mexican-origin populations, and illustrate the use of innovative techniques for using secondary, community-level data to complement prior evaluation research. © 2013 by the authors; licensee MDPI, Basel, Switzerland.
• Carvajal, S. C., Miesfeld, N., Chang, J., Reinschmidt, K. M., de Zapien, J. G., Fernandez, M. L., Rosales, C., & Staten, L. K. (2013). Evidence for long-term impact of Pasos Adelante: using a community-wide survey to evaluate chronic disease risk modification in prior program participants. International journal of environmental research and public health, 10(10).
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  Effective community-level chronic disease prevention is critical to population health within developed and developing nations. Pasos Adelante is a preventive intervention that aims to reduce chronic disease risk with evidence of effectiveness in US-Mexico residing, Mexican origin, participants. This intervention and related ones also implemented with community health workers have been shown to improve clinical, behavioral and quality of life indicators; though most evidence is from shorter-term evaluations and/or lack comparison groups. The current study examines the impact of this program using secondary data collected in the community 3-6 years after all participants completed the program. A proportional household survey (N = 708) was used that included 48 respondents who indicated they had participated in Pasos. Using propensity score matching to account for differences in program participants versus other community residents (the program targeted those with diabetes and associated risk factors), 148 natural controls were identified for 37 matched Pasos participants. Testing a range of behavioral and clinical indicators of chronic disease risk, logistic regression models accounting for selection bias showed two significant findings; Pasos participants were more physically active and drank less whole milk. These findings add to the evidence of the effectiveness of Pasos Adalente and related interventions in reducing chronic disease risk in Mexican-origin populations, and illustrate the use of innovative techniques for using secondary, community-level data to complement prior evaluation research.
• Carvajal, S. C., Rosales, C., Rubio-Goldsmith, R., Sabo, S., Ingram, M., McClelland, D. J., Redondo, F., Torres, E., Romero, A. J., O'Leary, A. O., Sanchez, Z., & De Zapien, J. G. (2013). The border community and immigration stress scale: A preliminary examination of a community responsive measure in two southwest samples. Journal of Immigrant and Minority Health, 15(Issue 2). doi:10.1007/s10903-012-9600-z
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  Understanding contemporary socio-cultural stressors may assist educational, clinical and policy-level health promotion efforts. This study presents descriptive findings on a new measure, the border community and immigration stress scale. The data were from two community surveys as part of community based participatory projects conducted in the Southwestern US border region. This scale includes stressful experiences reflected in extant measures, with new items reflecting heightened local migration pressures and health care barriers. Stressors representing each main domain, including novel ones, were reported with frequency and at high intensity in the predominantly Mexican-descent samples. Total stress was also significantly associated with mental and physical health indicators. The study suggests particularly high health burdens tied to the experience of stressors in the US border region. Further, many of the stressors are also likely relevant for other communities within developed nations also experiencing high levels of migration. © 2012 Springer Science+Business Media, LLC.
• Carvajal, S. C., Rosales, C., Rubio-Goldsmith, R., Sabo, S., Ingram, M., McClelland, D. J., Redondo, F., Torres, E., Romero, A. J., O'Leary, A. O., Sanchez, Z., & de Zapien, J. G. (2013). The border community and immigration stress scale: a preliminary examination of a community responsive measure in two Southwest samples. Journal of immigrant and minority health / Center for Minority Public Health, 15(2).
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  Understanding contemporary socio-cultural stressors may assist educational, clinical and policy-level health promotion efforts. This study presents descriptive findings on a new measure, the border community and immigration stress scale. The data were from two community surveys as part of community based participatory projects conducted in the Southwestern US border region. This scale includes stressful experiences reflected in extant measures, with new items reflecting heightened local migration pressures and health care barriers. Stressors representing each main domain, including novel ones, were reported with frequency and at high intensity in the predominantly Mexican-descent samples. Total stress was also significantly associated with mental and physical health indicators. The study suggests particularly high health burdens tied to the experience of stressors in the US border region. Further, many of the stressors are also likely relevant for other communities within developed nations also experiencing high levels of migration.
• Chang, J., Guy, M. C., Rosales, C., de Zapien, J. G., Staten, L. K., Fernandez, M. L., & Carvajal, S. C. (2013). Investigating social ecological contributors to diabetes within Hispanics in an underserved U.S.-Mexico border community. International journal of environmental research and public health, 10(8).
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  Hispanics bear a disproportionate burden of diabetes in the United States, yet relations of structural, socio-cultural and behavioral factors linked to diabetes are not fully understood across all of their communities. The current study examines disparities and factors associated with diabetes in adult Hispanics of Mexican-descent (N = 648) participating in a population survey of an underserved rural U.S.-Mexico border community. The overall rate of diabetes prevalence rate in the sample, based on self-report and a glucose testing, was 21%; much higher than rates reported for U.S. adults overall, for all Hispanic adults, or for Mexican American adults specifically. Acculturation markers and social determinants of health indicators were only significantly related to diabetes in models not accounting for age. Older age, greater BMI (>30), greater waist-to-hip ratio as well as lower fruit and vegetable consumption were significantly related to increased likelihood of diabetes when all structural, cultural, behavioral, and biological factors were considered. Models with sets of behavioral factors and biological factors each significantly improved explanation of diabetes relative to prior social ecological theory-guided models. The findings show a critical need for diabetes prevention efforts in this community and suggest that health promotion efforts should particularly focus on increasing fruit and vegetable consumption.
• Chang, J., Guy, M. C., Rosales, C., de Zapien, J. G., Staten, L. K., Fernandez, M. L., & Carvajal, S. C. (2013). Investigating social ecological contributors to diabetes within Hispanics in an underserved U.S.-Mexico border community.. International Journal of Environmental Research and Public Health, 10(Issue 8). doi:10.3390/ijerph10083217
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  Hispanics bear a disproportionate burden of diabetes in the United States, yet relations of structural, socio-cultural and behavioral factors linked to diabetes are not fully understood across all of their communities. The current study examines disparities and factors associated with diabetes in adult Hispanics of Mexican-descent (N = 648) participating in a population survey of an underserved rural U.S.-Mexico border community. The overall rate of diabetes prevalence rate in the sample, based on self-report and a glucose testing, was 21%; much higher than rates reported for U.S. adults overall, for all Hispanic adults, or for Mexican American adults specifically. Acculturation markers and social determinants of health indicators were only significantly related to diabetes in models not accounting for age. Older age, greater BMI (>30), greater waist-to-hip ratio as well as lower fruit and vegetable consumption were significantly related to increased likelihood of diabetes when all structural, cultural, behavioral, and biological factors were considered. Models with sets of behavioral factors and biological factors each significantly improved explanation of diabetes relative to prior social ecological theory-guided models. The findings show a critical need for diabetes prevention efforts in this community and suggest that health promotion efforts should particularly focus on increasing fruit and vegetable consumption.
• Ingram, M. -., Schachter, K. A., Sabo, S. J., Reinschmidt, K. M., Gomez, S., De Zapien, J. G., & Carvajal, S. C. (2014). A community health worker intervention to address the social determinants of health through policy change. Journal of Primary Prevention.
• Ingram, M., Schachter, K. A., Sabo, S., Reinschmidt, K. M., Gomez, S., De Zapien, J. G., Carvajal, S. C., Ingram, M., Schachter, K. A., Sabo, S., Reinschmidt, K. M., Gomez, S., De Zapien, J. G., & Carvajal, S. C. (2014). A community health worker intervention to address the social determinants of health through policy change.. The Journal of Primary Prevention.
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  Public policy that seeks to achieve sustainable improvements in the social determinants of health, such as income, education, housing, food security and neighborhood conditions, can create positive and sustainable health effects. This paper describes preliminary results of Accion para la Salud, a public health intervention in which Community health workers (CHWs) from five health agencies engaged their community in the process of making positive systems and environmental changes. Academic-community partners trained Accion CHWs in community advocacy and provided ongoing technical assistance in developing strategic advocacy plans. The CHWs documented community advocacy activities through encounter forms in which they identified problems, formulated solutions, and described systems and policy change efforts. Strategy maps described the steps of the advocacy plans. Findings demonstrate that CHWs worked to initiate discussions about underlying social determinants and environment-related factors that impact health, and identified solutions to improve neighborhood conditions, create community opportunities, and increase access to services.
• Sabo, S. J., Ingram, M. -., Reinschmidt, K. M., Schachter, K. A., Jacobs, L., De Zapien, J. G., Robinson, L., & Carvajal, S. C. (2013). Predictors and a Framework for Fostering Community Advocacy as a Community Health Worker Core Function to Eliminate Health Disparities. American Journal of Public Health, 103(7).
• Sabo, S., Ingram, M., Reinschmidt, K. M., Schachter, K., Jacobs, L., De Zapien, J. G., Robinson, L., & Carvajal, S. (2013). Predictors and a framework for fostering community advocacy as a community health worker core function to eliminate health disparities. American Journal of Public Health, 103(Issue 7). doi:10.2105/ajph.2012.301108
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  Objectives. Using a mixed-method, participatory research approach, we investigated factors related to community health worker (CHW) community advocacy that affect social determinants of health. Methods. We used cross-sectional survey data for 371 CHWs to assess demographics, training, work environment, and leadership qualities on civic, political, and organizational advocacy. We present advocacy stories to further articulate CHW activities. The data reported are from the recently completed National Community Health Workers Advocacy Study. Results. CHWs are involved in advocacy that is community-focused, although advocacy differs by intrinsic leadership, experience, training, and work environment. We propose a framework to conceptualize, support, and evaluate CHW advocacy and the iterative processes they engage in. These processes create opportunities for community voice and action to affect social and structural conditions that are known to have wide-ranging health effects on communities. Conclusions. The framework presented may have utility for CHWs, their training programs, and their employers as well as funders and policymakers aiming to promote health equity. Copyright © 2012 by the American Public Health Association®.
• Sabo, S., Ingram, M., Reinschmidt, K. M., Schachter, K., Jacobs, L., Guernsey de Zapien, J., Robinson, L., & Carvajal, S. (2013). Predictors and a framework for fostering community advocacy as a community health worker core function to eliminate health disparities. American journal of public health, 103(7), e67-73.
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  Using a mixed-method, participatory research approach, we investigated factors related to community health worker (CHW) community advocacy that affect social determinants of health.
• Carvajal, S. C. (2012). Global positive expectancies in adolescence and health-related behaviours: Longitudinal models of latent growth and cross-lagged effects. Psychology and Health, 27(Issue 8). doi:10.1080/08870446.2011.633241
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  Constructs representative of global positive expectancies (GPE) such as dispositional optimism and hope have been theoretically and empirically linked to many positive mental and physical health outcomes. However such expectancies' health implications for adolescents, as well as their trajectory over time, are less well understood than for adult populations. This study tested whether GPE predict the key indicators of adolescents' future physical health status, their health-related behaviours. A prospective longitudinal study design was employed whereby a diverse population-based cohort (N = 744; mean age at baseline = 12) completed three surveys over approximately 18 months. Rigorous tests of causal predominance and reciprocal effects were conducted through latent growth and cross-panel structural equation models. Results showed GPE systematically decreased during the course of the study, yet higher initial levels of GPE predicted less alcohol drinking, healthier food choice and greater physical activity over time. GPE's protective relationships towards health protective behaviours (vs. health risk behaviours that also included tobacco smoking) appear more independent from depressive symptomatology, and the primary findings were robust across socio-demographic groups. © 2012 Copyright Taylor and Francis Group, LLC.
• Carvajal, S. C. (2012). Global positive expectancies in adolescence and health-related behaviours: longitudinal models of latent growth and cross-lagged effects. Psychology & health, 27(8), 916-37.
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  Constructs representative of global positive expectancies (GPE) such as dispositional optimism and hope have been theoretically and empirically linked to many positive mental and physical health outcomes. However such expectancies' health implications for adolescents, as well as their trajectory over time, are less well understood than for adult populations. This study tested whether GPE predict the key indicators of adolescents' future physical health status, their health-related behaviours. A prospective longitudinal study design was employed whereby a diverse population-based cohort (N = 744; mean age at baseline = 12) completed three surveys over approximately 18 months. Rigorous tests of causal predominance and reciprocal effects were conducted through latent growth and cross-panel structural equation models. Results showed GPE systematically decreased during the course of the study, yet higher initial levels of GPE predicted less alcohol drinking, healthier food choice and greater physical activity over time. GPE's protective relationships towards health protective behaviours (vs. health risk behaviours that also included tobacco smoking) appear more independent from depressive symptomatology, and the primary findings were robust across socio-demographic groups.
• Garcia, R. Z., Carvajal, S. C., Wilkinson, A. V., Thompson, P. A., Nodora, J. N., Komenaka, I. K., Brewster, A., Cruz, G. I., Wertheim, B. C., Bondy, M. L., & Martínez, M. E. (2012). Factors that influence mammography use and breast cancer detection among Mexican-American and African-American women. Cancer Causes and Control, 23(Issue 1). doi:10.1007/s10552-011-9865-x
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  Objective: This study examined factors that influence mammography use and breast cancer detection, including education, health insurance, and acculturation, among Mexican-American (MA) and African-American (AA) women. Methods: The study included 670 breast cancer cases (388 MAs and 282 AAs), aged 40-86 years at diagnosis. Data on mammography use, detection, and delay in seeking care were collected via questionnaires and medical records. Using a language-based bidimensional acculturation measure, MAs were classified as English-dominant (n = 67), bilingual (n = 173), and Spanish-dominant (n = 148). Mammography prior to diagnosis was assessed by racial/ethnic acculturation subgroup using logistic regression. Results: In age-adjusted models, mammography use was non-significantly lower among English-dominant (OR = 0.84; 95% CI: 0.45-1.59) and bilingual (OR = 0.86; 95% CI: 0.55-1.35) MAs and significantly lower among Spanish-dominant MAs (OR = 0.53; 95% CI: 0.34-0.83) than among AA women. After adjustment for education or insurance, there was no difference in mammography use by race/ethnicity and acculturation subgroup. Despite high self-reported mammography use (75%), a large proportion of cases reported self-detection (59%) and delay in seeking care >90 days (17%). Conclusions: These findings favor promoting culturally appropriate messaging about the benefits and limitations of mammography, education about breast awareness, and prompt reporting of findings to a health professional. © 2011 Springer Science+Business Media B.V.
• Garcia, R. Z., Carvajal, S. C., Wilkinson, A. V., Thompson, P. A., Nodora, J. N., Komenaka, I. K., Brewster, A., Cruz, G. I., Wertheim, B. C., Bondy, M. L., & Martínez, M. E. (2012). Factors that influence mammography use and breast cancer detection among Mexican-American and African-American women. Cancer causes & control : CCC, 23(1), 165-73.
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  This study examined factors that influence mammography use and breast cancer detection, including education, health insurance, and acculturation, among Mexican-American (MA) and African-American (AA) women.
• Ingram, M., Reinschmidt, K. M., Schachter, K. A., Davidson, C. L., Sabo, S. J., De Zapien, J. G., & Carvajal, S. C. (2012). Establishing a professional profile of Community Health Workers: Results from a national study of roles, activities and training. Journal of Community Health, 37(Issue 2). doi:10.1007/s10900-011-9475-2
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  Community Health Workers (CHWs) have gained national recognition for their role in addressing health disparities and are increasingly integrated into the health care delivery system. There is a lack of consensus, however, regarding empirical evidence on the impact of CHW interventions on health outcomes. In this paper, we present results from the 2010 National Community Health Worker Advocacy Survey (NCHWAS) in an effort to strengthen a generalized understanding of the CHW profession that can be integrated into ongoing efforts to improve the health care delivery system. Results indicate that regardless of geographical location, work setting, and demographic characteristics, CHWs generally share similar professional characteristics, training preparation, and job activities. CHWs are likely to be female, representative of the community they serve, and to work in community health centers, clinics, community-based organizations, and health departments. The most common type of training is on-the-job and conference training. Most CHWs work with clients, groups, other CHWs and less frequently community leaders to address health issues, the most common of which are chronic disease, prevention and health care access. Descriptions of CHW activities documented in the survey demonstrate that CHWs apply core competencies in a synergistic manner in an effort to assure that their clients get the services they need. NCHWAS findings suggest that over the past 50 years, the CHW field has become standardized in response to the unmet needs of their communities. In research and practice, the field would benefit from being considered a health profession rather than an intervention. © Springer Science+Business Media, LLC (outside the USA) 2011.
• Ingram, M., Reinschmidt, K. M., Schachter, K. A., Davidson, C. L., Sabo, S. J., De Zapien, J. G., & Carvajal, S. C. (2012). Establishing a professional profile of community health workers: results from a national study of roles, activities and training. Journal of community health, 37(2), 529-37.
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  Community Health Workers (CHWs) have gained national recognition for their role in addressing health disparities and are increasingly integrated into the health care delivery system. There is a lack of consensus, however, regarding empirical evidence on the impact of CHW interventions on health outcomes. In this paper, we present results from the 2010 National Community Health Worker Advocacy Survey (NCHWAS) in an effort to strengthen a generalized understanding of the CHW profession that can be integrated into ongoing efforts to improve the health care delivery system. Results indicate that regardless of geographical location, work setting, and demographic characteristics, CHWs generally share similar professional characteristics, training preparation, and job activities. CHWs are likely to be female, representative of the community they serve, and to work in community health centers, clinics, community-based organizations, and health departments. The most common type of training is on-the-job and conference training. Most CHWs work with clients, groups, other CHWs and less frequently community leaders to address health issues, the most common of which are chronic disease, prevention and health care access. Descriptions of CHW activities documented in the survey demonstrate that CHWs apply core competencies in a synergistic manner in an effort to assure that their clients get the services they need. NCHWAS findings suggest that over the past 50 years, the CHW field has become standardized in response to the unmet needs of their communities. In research and practice, the field would benefit from being considered a health profession rather than an intervention.
• Rubio-goldsmith, R., Carvajal, S. C., Desapien, J., Ingram, M., Mcclelland, D. J., O'leary, A. O., Redondo, F., Romero, A. J., Rosales, C., Sabo, S., Sanchez, Z., & Torres, E. (2012). The Border Community & Immigration Stress Scale and Associations to Health Outcomes. Journal of Immigrant and Minority Health.
• Agraz, F. P., Carvajal, S. C., Daneri, A., Gutierrez, L. E., Martinez, M. E., Meza, M., Nodora, J., & Robles, R. (2011). Abstract A94: Assessment of Westernization in Mexican women with breast cancer. Cancer Epidemiology, Biomarkers & Prevention, 20(10_Supplement), A94-A94. doi:10.1158/1055-9965.disp-11-a94
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  Purpose of Study: Until recently, breast cancer (BC) was relatively rare in Mexico; although incidence is less than half of that in the US, it is now the most commonly diagnosed cancer in women. BC is most common in industrialized regions and in the northern parts of Mexico. This study provides validation results for a measure of Westernization, or more specifically, US social, lifestyle and cultural influences among Mexican women with invasive BC. Study participants are a sub-sample of the Ella Binational Breast Cancer Study. The creation and validation of a Westernization instrument is the first step in understanding US influence on lifestyle and reproductive factors that play a key role in BC risk and appear to influence tumor subtype. Experimental Procedures: A 26-item Westernization survey was administered via interview to 341 Mexican women residing in Obregon and Hermosillo Sonora, as well as Guadalajara, Jalisco between 2009 and 2010. The Westernization instrument was developed through focus group and content expert review. The guiding themes included materialism, individualism, modernity, and reproductive and gender-related norms. The instrument contains three subsections with response formats to reflect various beliefs and behaviors consistent with the themes. The instrument was part of a larger BC risk factor questionnaire, which included questions on demographics, socioeconomic status, as well as all major BC risk factors (e.g., parity, breast feeding, family history, obesity, tobacco). Data Summary: Among the respondents, the mean age was 54.4 years (+ 12.6) and 64% had less than the equivalent of a high school education. The mean number of full term pregnancies was 3.9 (+ 2.4) and the mean age at first full term birth was 22.7 years (+ 5.1); 86% reported ever breastfeeding. The mean body mass index (kg/m2) was 28.6 (+ 5.5); 2.0% were current smokers, 27.6% were former smokers, and 70.4% were never smokers; 8.9% reported a positive family history of BC. Psychometric analysis proceeded on each subsection of the instrument separately. The first subsection reflected 11 modernity related behavioral items. An exploratory principal components analysis showed two factors had eigen values significantly (p .01). Consequently a two-factor solution was determined to be robust and guided sub-scale development. The sub-scale reflected consumerism (e.g., eating fast food frequently, shopping to distract from one9s feelings), was maximized at .84 when two lesser items were removed. The sub-scale reflected use of electronic devices, α = .67 when two lesser fitting items were removed. As traditional or gendered sex role responses (2nd subsection) were “yes/no” (I have/will do this), an alternative psychometric approach was done. The adjusted reliability coefficient was .79 for these seven items and removing no items raised this coefficient, suggesting all items should be used in this measure. Next, sub-scale scores were derived and associations were examined, total modernity was significantly negatively associated with traditional gender norms and age. Conclusions: The results show that this new instrument has sound psychometrics in its first two subsections. The instrument may be used as a complimentary measure in sophisticated models of culture which are applied to Mexican and US Mexican immigrants. The next steps in this study will examine the components of Westernization and their relations to known protective and risk factors of BC and tumor sub-types. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A94.
• Carvajal, S. C., Estrada, B. D., Estrada, A. L., & Jones-rodriguez, G. (2011). Determinants of HIV Risk and Protective Needle-Sharing Behaviors Among Drug Injectors. Journal of Applied Biobehavioral Research, 16(2), 98-120. doi:10.1111/j.1751-9861.2011.00067.x
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  Few studies have tested a broad range of theory-based determinants of injection-related risk and protective behaviors. The current study hypothesize relationships among attitudinal beliefs, normative influences, perceived self-efficacy, intentions, and performing these behaviors consistent with the theory of planned behavior and related models. The conceptual model was tested in a cross-sectional sample of 895 drug injectors recruited from street settings in the southwestern United States and who completed a face-to-face interview. Structural equation modeling results showed intention and self-efficacy most consistently predicted needle sharing and bleaching considering all other model variables. Discussion focuses on the value of using these theoretical concepts to examine needle sharing and other behaviors among injection drug users and their relevance for developing HIV-reduction interventions.
• Davis, M. F., Adam, M., Carvajal, S., Sechrest, L., & Reyna, V. F. (2011). Using Rasch modeling to measure acculturation in youth. Journal of applied measurement, 12(4), 324-38.
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  Ethnic differences in health outcomes are assumed to reflect levels of acculturation, among other factors. Health surveys frequently include language and social interaction items taken from existing acculturation instruments. This study evaluated the dimensionality of responses to typical bilinear items in Latino youth using Rasch modeling. Two seven-item scales measuring Anglo-Hispanic orientation were adapted from Marin and Gamba (1996) and Cuellar, Arnold, and Maldonado (1995). Most of the items fit the Rasch model. However, there were gaps in both the Hispanic and Anglo scales. The Anglo items were not well targeted for the sample because most students reported they always spoke English. The lack of variability found in a heterogeneous sample of Latino youth has negative implications for the common practice of relying on language as a measure of acculturation. Acculturation instruments for youth probably need more sensitive items to discriminate linguistic differences, or to measure other factors.
• Davis, M. F., Adam, M., Carvajal, S., Sechrest, L., & Reyna, V. F. (2011). Using rasch modeling to measure acculturation in youth. Journal of Applied Measurement, 12(Issue 4).
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  Ethnic differences in health outcomes are assumed to reflect levels of acculturation, among other factors. Health surveys frequently include language and social interaction items taken from existing acculturation instruments. This study evaluated the dimensionality of responses to typical bilinear items in Latino youth using Rasch modeling. Two seven-item scales measuring Anglo-Hispanic orientation were adapted from Marin and Gamba (1996) and Cuellar, Arnold, and Maldonado (1995). Most of the items fit the Rasch model. However, there were gaps in both the Hispanic and Anglo scales. The Anglo items were not well targeted for the sample because most students reported they always spoke English. The lack of variability found in a heterogeneous sample of Latino youth has negative implications for the common practice of relying on language as a measure of acculturation. Acculturation instruments for youth probably need more sensitive items to discriminate linguistic differences, or to measure other factors.
• Bondy, M. L., Brewster, A. M., Carvajal, S. C., Cruz, G., Daneri, A., Gutierrez, L. E., Komenaka, I. K., Martinez, M. E., Meza, M., Nodora, J., Pond, E., Thompson, P. A., Wertheim, B. C., Wilkinson, A. V., & Zenuk, R. L. (2010). Abstract PR-5: Risk factor distribution among women of Mexican descent by level of acculturation: Findings from the ELLA Binational Breast Cancer Study. Cancer Epidemiology, Biomarkers & Prevention, 19(10_Supplement), PR-7-PR-7. doi:10.1158/1055-9965.disp-10-pr-7
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  Purpose of Study: Studies have shown that breast cancer (BC) risk is higher in U.S.-born Hispanics than foreign-born Hispanics and is modified by age at migration, duration of residence in the U.S., and level of acculturation. Furthermore, epidemiological data support the notion of distinct reproductive factor associations for specific BC tumor subtypes. The aim of this study is to assess the association between established BC risk factors and level of acculturation and country of residence among Mexican American (MA) and Mexican BC cases. Experimental Procedures: This case-only study examined the risk factor profile in 606 Mexican and 488 MA (20% US-born and 80% foreign-born) women, with a confirmed diagnosis of invasive BC, who were recruited into the ELLA Binational Breast Cancer Study between March 1,2007, and May 31,2010. Participants completed an interviewer-administered risk factor questionnaire, consented to a medical record review, and provided tissue and saliva or blood specimens. An eight-item language-based Bidimensional Acculturation Scale (BAS) was used to classify MA women as English-dominant (n=88), bilingual (n=221), or Spanish-dominant (n=179). The BAS is highly correlated with nativity and time in the US, however language use/exposure was focal for this study since it is the single strongest predictor of acculturation. Chi-square tests, ANOVA, and regression models to test for trend were used to assess variation in the risk factor profile by level of acculturation. Summary of Results: Age at diagnosis was generally low; the lowest was among MA-bilingual women (48.9 = 12.0 years) and highest among Mexican women (53.7 = 12.7 years). Considering a gradient of increasing acculturation from Mexican (lowest) to MA-English dominant (highest) women, there were clear trends for decreasing rates of breastfeeding (80.2 to 35.2%; p-trend Conclusion: Our results show that heterogeneity in BC risk factor patterns by level of acculturation is present. Given the recent data supporting distinct correlations between specific risk factors and BC subtypes, it will be essential to consider level of acculturation and country of residence when assessing the prevalence of these subtypes. The trends observed in risk factor profiles by level of acculturation in the ELLA Study could provide important explanations for differences in disease patterns between groups. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):PR-5.
• Bondy, M. L., Brewster, A. M., Carvajal, S. C., Cruz, G., Martinez, M. E., Nodora, J., Thompson-carino, P. A., Wertheim, B. C., Wilkinson, A. V., & Zenuk, R. L. (2010). Abstract 2806: Factors that influence screening mammography among African American and Mexican American women with breast cancer: Findings from the ELLA Binational Breast Cancer Study. Cancer Research, 70(8_Supplement), 2806-2806. doi:10.1158/1538-7445.am10-2806
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  Proceedings: AACR 101st Annual Meeting 2010‐‐ Apr 17‐21, 2010; Washington, DC Screening mammography is associated with early detection of breast cancer (BC) and reduced BC mortality. To understand factors that influence screening mammography receipt in minority women with unrecognized risk factors for BC, this study examined BC screening behaviors among women with BC. Due to the BC survival disparities observed in African American (AA) and Mexican American (MA) women compared to whites, AA and MA women living in Texas and Arizona who were participants of the ELLA Binational Breast Cancer Study were selected for this study based on a diagnosis of BC. Data on socioeconomic status (SES), reproductive history, family history, insurance status, acculturation, and breast health history were collected via questionnaires and medical record abstraction. 601 women aged 40 years or older at time of BC diagnosis were included in this study, including 270 AA, 151 MA women classified as high-acculturation (MA-HA) and 180 MA women classified as low-acculturation (MA-LA). Logistic regression analysis was used to assess differences in mammography receipt in the last five years prior to BC diagnosis stratified by race/ethnicity and acculturation and for all groups combined. MA women in this study suffer a larger disparity than AA women with regards to screening mammography. Despite high rates of screening mammography among AA and MA women, 62% of BC was self-detected in the study population. AA women (OR=1.0) and MA-HA (OR=0.91; 95% CI: 0.57-1.48) women were more than twice as likely to receive screening mammography compared to MA-LA (OR=0.38; 95% CI: 0.25-0.59), adjusted for age. After adjusting for age, education, and insurance, there was no significant difference in screening mammography receipt between these three groups. Women who had a known family history of BC were more than twice as likely to receive screening mammography than women who had unknown or no family history (OR=2.02; 95% CI: 1.19-3.55). However, although AA and MA-HA women were twice as likely as MA-LA to report a family history of BC (20% vs. 23% vs. 12%, respectively), recognized family history did not account for the differences in screening mammography use between these groups. Thus, the differences observed in screening mammography receipt by race/ethnicity and acculturation among AA, MA-HA, and MA-LA are likely explained by SES variables, including education and insurance. Due to the large proportion of AA and MA women who reported self-detecting their BC, women must be educated about the importance of breast awareness and prompt reporting of findings to a health professional after noticing breast changes. In addition, cancer screening programs targeting underserved women should provide culturally appropriate messages about the importance of knowing their family history and the benefits of screening mammography. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 2806.
• Carvajal, S. C., & Young, R. S. (2009). Culturally based substance abuse treatment for American Indians/Alaska Natives and Latinos. Journal of ethnicity in substance abuse, 8(3), 207-22.
• Carvajal, S. C., Estrada, B. D., & Estrada, A. L. (2007). Longitudinal Prediction of Unprotected Sex in Predominantly Latino Male IDUs1. Journal of Applied Biobehavioral Research, 10(3), 133-148. doi:10.1111/j.1751-9861.2005.tb00008.x
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  This longitudinal study with male, predominantly Latino, injection drug users (IDUs) was undertaken to test a model of determinants of unprotected sex guided by the theory of planned behavior (TPB). Structural equation modeling (SEM) was used to test each theory-based predictor and the overall model's efficacy in predicting current and escalation of unprotected sex in a community sample (n = 371). The hypothesized model fit the data well—with intention and self-efficacy directly predicting risk behavior. In the observed model, the theory-based factors were significantly related to T1 and T2 unprotected sex outcomes, though the effects on the latter were mediated by T1 unprotected sex. The findings are generally congruent with postulates of the theory of planned behavior; however, greater predictive efficacy of future behavior may be achieved by considering psychosocial and other factors related to Latino male IDUs' sexual behaviors.
• Carvajal, S. C., Orduna, M., Romero, A. J., & Valle, F. (2007). Adolescent bicultural stress and its impact on mental well-being among Latinos, Asian Americans, and European Americans.. Journal of Community Psychology, 35(4), 519-534. doi:10.1002/jcop.20162
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  The perception of bicultural stress, stress due to discrimination/prejudice, immigration, and acculturation, was investigated in relation to mental well-being in a sample of urban Latino (n = 304), European American (n = 215), and Asian American (n = 131) 8th grade students. Bicultural stress was reported by all ethnic groups and was significantly associated with more depressive symptoms and less optimism (only for females), after accounting for ethnicity, socioeconomic status, gender, and age. Latino and Asian American youth were more likely to report more stressors, although after controlling for sociodemographic variables the differences predominantly remained only between Asian Americans and European Americans. Lower socioeconomic status, male gender, and not speaking English also were associated with more stress. The negative impact of bicultural stress on adolescent depressive symptoms and optimism indicates the need for mental health researchers and service providers to consider the cultural context of stress for adolescents. © 2007 Wiley Periodicals, Inc. J Comm Psychol 35: 519–534, 2007.
• Carvajal, S. C., Romero, A. J., Martinez, D. E., Martinez, D. E., Romero, A. J., & Carvajal, S. C. (2007). Bicultural Stress and Adolescent Risk Behaviors in a Community Sample of Latinos and Non-Latino Whites. Ethnicity & Health, 12(5), 443-463. doi:https://doi.org/10.1080/13557850701616854
• Romero, A. J., Martinez, D., & Carvajal, S. C. (2007). Bicultural stress and adolescent risk behaviors in a community sample of Latinos and non-Latino European Americans. Ethnicity & health, 12(5), 443-63.
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  The study examined the relation between adolescent risk behaviors and bicultural stress due to discrimination, immigration, and acculturation factors. We hypothesized bicultural stress would be related to increased risk behavior and depressive symptoms independent of socioeconomic status, ethnic self-identification, and acculturation.
• Romero, A. J., Martinez, D., & Carvajal, S. C. (2007). Bicultural stress and adolescent risk behaviors in a community sample of Latinos and non-Latino European Americans. Ethnicity and Health, 12(Issue 5). doi:10.1080/13557850701616854
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  Objectives. The study examined the relation between adolescent risk behaviors and bicultural stress due to discrimination, immigration, and acculturation factors. We hypothesized bicultural stress would be related to increased risk behavior and depressive symptoms independent of socioeconomic status, ethnic self-identification, and acculturation. Design. Middle school student participants (n=519; median age 14) completed a self-report questionnaire on their risk behaviors, psychosocial antecedents, and socio-demographic factors. Latino (304) and non-Latino European American (215) students were surveyed through a large, urban, West Coast US school district. Results. More bicultural stress was significantly related to reports of all risk behaviors (i.e. smoking, drinking, drug use, and violence) and depressive symptoms. Further, bicultural stress was a robust explanatory variable across sub-groups, and appears largely independent from depressive symptoms. Conclusion. The hypotheses were supported. Bicultural stress appears to be an important underlying factor for health disparities among US adolescents. Future research may consider promoting well-being in majority, as well as minority adolescents, through targeting sources of bicultural stressors or examining ways to moderate their effects on adolescent risk behaviors. © 2007 Taylor & Francis.
• Carvajal, S. C., & Granillo, T. M. (2006). A prospective test of distal and proximal determinants of smoking initiation in early adolescents. Addictive Behaviors, 31(Issue 4). doi:10.1016/j.addbeh.2005.05.047
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  This study tests a broad array of determinants of utility for developing smoking preventive interventions using a population-based cohort of early adolescents. Multivariable logistic regressions using never-smokers at baseline (N = 1137; age 11-14) showed a model of distal determinants was more predictive of initiation within the approximate 10 month follow up period than one of proximal determinants. When all determinants were simultaneously considered, lesser academic achievement and fewer environmental impediments to smoking most strongly predicted initiation. The findings are consistent with some current smoking prevention programs, however such programs may be further potent by using theory-based social development approaches and through reducing tobacco availability or social contexts where youth can smoke without another adult knowing. © 2005 Elsevier Ltd. All rights reserved.
• Carvajal, S. C., & Granillo, T. M. (2006). A prospective test of distal and proximal determinants of smoking initiation in early adolescents. Addictive behaviors, 31(4), 649-60.
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  This study tests a broad array of determinants of utility for developing smoking preventive interventions using a population-based cohort of early adolescents. Multivariable logistic regressions using never-smokers at baseline (N=1137; age 11-14) showed a model of distal determinants was more predictive of initiation within the approximate 10 month follow up period than one of proximal determinants. When all determinants were simultaneously considered, lesser academic achievement and fewer environmental impediments to smoking most strongly predicted initiation. The findings are consistent with some current smoking prevention programs, however such programs may be further potent by using theory-based social development approaches and through reducing tobacco availability or social contexts where youth can smoke without another adult knowing.
• Granillo, T., Jones-Rodriguez, G., & Carvajal, S. C. (2005). Prevalence of eating disorders in Latina adolescents: Associations with substance use and other correlates. Journal of Adolescent Health, 36(Issue 3). doi:10.1016/j.jadohealth.2004.01.015
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  Purpose: To estimate the occurrence and correlates of anorexia nervosa and bulimia nervosa-related symptoms in a Latina sample of U.S. adolescents. Method: Approximately 1866 Latinas ranging in age from 11-20 years old are included in this study. These adolescents are a sub-sample from the National Longitudinal Survey on Adolescent Health. Along with self-reports of eating disorder-related variables, we measured related biological, contextual, behavioral, and psychosocial correlates, including use of various substances. Conclusion: Chi-square analysis showed the prevalence in all Latina sub-groups was relatively consistent with the U.S. trends. Latinas of higher socioeconomic status were more at risk for eating disorders. Body dissatisfaction, negative affectivity, substance use, and low self-esteem were all positively correlated with eating disorder symptoms. These results suggest screening and treatment services are needed across groups of Latina adolescents. © 2005 Society for Adolescent Medicine. All rights reserved.
• Granillo, T., Jones-Rodriguez, G., & Carvajal, S. C. (2005). Prevalence of eating disorders in Latina adolescents: associations with substance use and other correlates. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 36(3), 214-20.
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  To estimate the occurrence and correlates of anorexia nervosa and bulimia nervosa-related symptoms in a Latina sample of U.S. adolescents.
• Gritz, E. R., Tripp, M. K., James, A. S., Carvajal, S. C., Harrist, R. B., Mueller, N. H., Chamberlain, R. M., & Parcel, G. S. (2005). An intervention for parents to promote preschool children's sun protection: Effects of Sun Protection is Fun!. Preventive Medicine, 41(Issue 2). doi:10.1016/j.ypmed.2005.01.007
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  Background. Young children are an important focus of sun-protection efforts, but there has been relatively little study of sun-protection interventions developed for preschool-aged children and their parents. This paper reports on the evaluation of Sun Protection is Fun! (S.P.F.), designed to improve parents' practices and psychosocial outcomes related to protecting preschool children from sun exposure. Methods. A group-randomized trial was conducted in 20 preschools to evaluate the S.P.F. parent intervention that included a video, newsletters, and handbooks. A separate, on-site intervention for preschool staff aimed to create a preschool climate that encouraged parents' sun protection for their children. Cross-sectional samples of parents completed surveys at baseline (n = 384), 12 months (n = 640), and 24 months (n = 694). Results. S.P.F. demonstrated significant effects on parents' sun-avoidance strategies at 12 months (P
• Gritz, E. R., Tripp, M. K., James, A. S., Carvajal, S. C., Harrist, R. B., Mueller, N. H., Chamberlain, R. M., & Parcel, G. S. (2005). An intervention for parents to promote preschool children's sun protection: effects of Sun Protection is Fun!. Preventive medicine, 41(2), 357-66.
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  Young children are an important focus of sun-protection efforts, but there has been relatively little study of sun-protection interventions developed for preschool-aged children and their parents. This paper reports on the evaluation of Sun Protection is Fun! (S.P.F.), designed to improve parents' practices and psychosocial outcomes related to protecting preschool children from sun exposure.
• Carvajal, S. C., Coyle, K. K., Downing, R. A., Hanson, C. E., & Pederson, L. L. (2004). Theory-Based Determinants of Youth Smoking: A Multiple Influence Approach1. Journal of Applied Social Psychology, 34(1), 59-84. doi:10.1111/j.1559-1816.2004.tb02537.x
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  This study tested a broad array of determinants of smoking grounded in general social psychological theories, as well as personality and social development theories. Using data from 2,004 middle school students, all proximal and distal determinants significantly predicted smoking in the hypothesized direction. Further, hierarchical logistic regressions showed that intention to smoke, positive and negative attitudes toward smoking, impediments to smoking, self-efficacy to resist smoking, parent norms, and academic success most strongly predicted current smoking. Hierarchical linear regressions suggested that parental relatedness, maladaptive coping strategies, depression, and low academic aspirations most strongly predicted susceptibility to smoking for those who had not yet smoked a cigarette. Global expectancies were the strongest predictor of susceptibility in low socioeconomic status students. These findings may guide the development of future theorybased interventions that produce the greatest reductions in youth smoking.
• Tripp, M. K., Carvajal, S. C., McCormick, L. K., Mueller, N. H., Hu, S. H., Parcel, G. S., & Gritz, E. R. (2003). Validity and reliability of the Parental Sun Protection Scales. Health Education Research, 18(Issue 1). doi:10.1093/her/18.1.58
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  Skin cancer is the most common cancer diagnosed in the US and its incidence continues to rise. Epidemiological studies have shown that excessive sun exposure received during childhood may increase the risk of developing skin cancer later in life. Yet, there are few published reports on the development of reliable and valid theory-based scales that assess the factors associated with parental sun-protection practices to reduce sun exposure in preschool children. To fill this gap, the Parental Sun Protection Scales were developed and validated. Two series of confirmatory factor analytic models were employed to test the factor structure of the scales and to examine the interrelationships among the proposed psychosocial factors. Sunscreen-use and sun-avoidance behavioral models were tested in a sample of 384 parents. The results provided a basis for the reliable and valid measurement of psychosocial factors related to parental sun-protection practices. These scales may be useful in more fully understanding the determinants of sunprotection behaviors and in evaluating intervention programs designed to improve such behaviors.
• Tripp, M. K., Carvajal, S. C., McCormick, L. K., Mueller, N. H., Hu, S. H., Parcel, G. S., & Gritz, E. R. (2003). Validity and reliability of the parental sun protection scales. Health education research, 18(1), 58-73.
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  Skin cancer is the most common cancer diagnosed in the US and its incidence continues to rise. Epidemiological studies have shown that excessive sun exposure received during childhood may increase the risk of developing skin cancer later in life. Yet, there are few published reports on the development of reliable and valid theory-based scales that assess the factors associated with parental sun-protection practices to reduce sun exposure in preschool children. To fill this gap, the Parental Sun Protection Scales were developed and validated. Two series of confirmatory factor analytic models were employed to test the factor structure of the scales and to examine the inter-relationships among the proposed psychosocial factors. Sunscreen-use and sun-avoidance behavioral models were tested in a sample of 384 parents. The results provided a basis for the reliable and valid measurement of psychosocial factors related to parental sun-protection practices. These scales may be useful in more fully understanding the determinants of sun-protection behaviors and in evaluating intervention programs designed to improve such behaviors.
• Carvajal, S. C., Evans, R. I., Nash, S. G., & Getz, J. G. (2002). Global positive expectancies of the self and adolescents' substance use avoidance: Testing a social influence mediational model. Journal of Personality, 70(Issue 3). doi:10.1111/1467-6494.05010
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  Grounded in theories of global positive expectancies and social influences of behavior, this investigation posited a model in which global positive expectancies are related to substance use as mediated by attitudes, subjective norms, self-efficacy, and intentions. Using a cohort sample (n = 525), structural equation modeling was employed to test the hypothesized predictions of future substance use. The findings suggest that, relative to adolescents with lower global positive expectancies, adolescents with higher global positive expectancies use substances less frequently over time because of their protective attitudinal and control-oriented perceptions towards that behavior. Additionally, results from the current investigation also extend prior findings on the factor structure of global positive expectancies, suggesting these expectancies can be viewed as a second-order factor representing optimism and two components of hope - agency and pathways.
• Carvajal, S. C., Evans, R. I., Nash, S. G., & Getz, J. G. (2002). Global positive expectancies of the self and adolescents' substance use avoidance: testing a social influence mediational model. Journal of personality, 70(3), 421-42.
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  Grounded in theories of global positive expectancies and social influences of behavior, this investigation posited a model in which global positive expectancies are related to substance use as mediated by attitudes, subjective norms, self-efficacy, and intentions. Using a cohort sample (n = 525), structural equation modeling was employed to test the hypothesized predictions of future substance use. The findings suggest that, relative to adolescents with lower global positive expectancies, adolescents with higher global positive expectancies use substances less frequently over time because of their protective attitudinal and control-oriented perceptions towards that behavior. Additionally, results from the current investigation also extend prior findings on the factor structure of global positive expectancies, suggesting these expectancies can be viewed as a second-order factor representing optimism and two components of hope-agency and pathways.
• Carvajal, S. C., Hanson, C. E., Romero, A. J., & Coyle, K. K. (2002). Behavioural risk factors and protective factors in adolescents: A comparison of Latinos and non-Latino Whites. Ethnicity and Health, 7(Issue 3). doi:10.1080/1355785022000042015
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  Objectives. This study investigated differences in behavioural health protective and risk factors in US Latino and non-Latino White adolescents as well as differences among Latinos with different levels of acculturation using a bicultural acculturation model. The bicultural model is consistent with current understanding of cultural change processes; however it has infrequently been applied to understand adolescent health outcomes. The outcomes included risk and health behaviours as well as mental health factors consistent with Jessor's framework for describing adolescents' health status. Design. Participants included 1119 students randomly selected from all middle schools of a Northern California district. Respondents completed project staff administered self-reports surveys in their schools that included assessments of health behaviours, mental health, and socio-cultural variables - including acculturation level. Results. Latinos were at higher risk than non-Latino Whites in the following areas: academic orientation, physical activity, and sunscreen use. Boys and those of lower social class were more likely to report use of various substances and violence. Among Latinos, those in the marginalised acculturation group - those with less attachments and adaptations to Latino and other cultures, showed less desirable mental health outcomes than the bicultural group. Conclusion. These results extend prior research by assessing the health needs of early adolescent youth. The study found important differences within Latinos using a bicultural acculturation model. The use of a bicultural acculturation model, or cultural orientation approach more generally, may have especial utility for addressing health issues wherever minority populations interact with a dominant society.
• Carvajal, S. C., Hanson, C. E., Romero, A. J., & Coyle, K. K. (2002). Behavioural risk factors and protective factors in adolescents: a comparison of Latinos and non-Latino whites. Ethnicity & health, 7(3), 181-93.
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  This study investigated differences in behavioural health protective and risk factors in US Latino and non-Latino White adolescents as well as differences among Latinos with different levels of acculturation using a bicultural acculturation model. The bicultural model is consistent with current understanding of cultural change processes; however it has infrequently been applied to understand adolescent health outcomes. The outcomes included risk and health behaviours as well as mental health factors consistent with Jessor's framework for describing adolescents' health status.
• Basen-Engquist, K., Coyle, K. K., Parcel, G. S., Kirby, D., Banspach, S. W., Carvajal, S. C., & Baumler, E. (2001). Schoolwide effects of a multicomponent HIV, STD, and pregnancy prevention program for high school students. Health Education and Behavior, 28(Issue 2). doi:10.1177/109019810102800204
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  Few studies have tested schoolwide interventions to reduce sexual risk behavior, and none have demonstrated significant schoolwide effects. This study evaluates the schoolwide effects of Safer Choices, a multicomponent, behavioral theory-based HIV, STD, and pregnancy prevention program, on risk behavior, school climate, and psychosocial variables. Twenty urban high schools were randomized, and cross-sectional samples of classes were surveyed at baseline, the end of intervention (19 months after baseline), and 31 months after baseline. At 19 months, the program had a positive effect on the frequency of sex without a condom. At 31 months, students in Safer Choices schools reported having sexual intercourse without a condom with fewer partners. The program positively affected psychosocial variables and school climate for HIV/STD and pregnancy prevention. The program did not influence the prevalence of recent sexual intercourse. Schoolwide changes in condom use demonstrated that a school-based program can reduce the sexual risk behavior of adolescents.
• Basen-Engquist, K., Coyle, K. K., Parcel, G. S., Kirby, D., Banspach, S. W., Carvajal, S. C., & Baumler, E. (2001). Schoolwide effects of a multicomponent HIV, STD, and pregnancy prevention program for high school students. Health education & behavior : the official publication of the Society for Public Health Education, 28(2), 166-85.
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  Few studies have tested schoolwide interventions to reduce sexual risk behavior, and none have demonstrated significant schoolwide effects. This study evaluates the schoolwide effects of Safer Choices, a multicomponent, behavioral theory-based HIV, STD, and pregnancy prevention program, on risk behavior, school climate, and psychosocial variables. Twenty urban high schools were randomized, and cross-sectional samples of classes were surveyed at baseline, the end of intervention (19 months after baseline), and 31 months afterbaseline. At 19 months, the program had a positive effect on the frequency of sex without a condom. At 31 months, students in Safer Choices schools reported having sexual intercourse without a condom with fewer partners. The program positively affected psychosocial variables and school climate for HIV/STD and pregnancy prevention. The program did not influence the prevalence of recent sexual intercourse. Schoolwide changes in condomuse demonstrated that aschool-based program can reduce the sexual risk behavior of adolescents.
• Carvajal, S. C., Baumler, E., Harrist, R. B., & Parcel, G. S. (2001). Multilevel Models and Unbiased Tests for Group Based Interventions: Examples from the Safer Choices Study. Multivariate behavioral research, 36(2), 185-205.
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  For many large-scale behavioral interventions, random assignment to intervention condition occurs at the group level. Data analytic models that ignore potential non-independence of observations provide inefficient parameter estimates and often produce biased test statistics. For studies in which individuals are randomized by groups to treatment condition, multilevel models (MLMs) provide a flexible approach to statistically evaluating program effects. This article presents an explanation of the need for MLM's for such nested designs and uses data from the Safer Choices study to illustrate the application of MLMs for both continuous and dichotomous outcomes. When designing studies, researchers who are considering group-randomized interventions should also consider the features of the multilevel analytic models they might employ.
• Carvajal, S. C., Baumler, E., Harrist, R. B., & Parcel, G. S. (2001). Multilevel models and unbiased tests for group based interventions: Examples from the safer choices study. Multivariate Behavioral Research, 36(Issue 2). doi:10.1207/s15327906mbr3602_03
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  For many large-scale behavioral interventions, random assignment to intervention condition occurs at the group level. Data analytic models that ignore potential non-independence of observations provide inefficient parameter estimates and often produce biased test statistics. For studies in which individuals are randomized by groups to treatment condition, multilevel models (MLMs) provide a flexible approach to statistically evaluating program effects. This article presents an explanation of the need for MLM's for such nested designs and uses data from the Safer Choices study to illustrate the application of MLMs for both continuous and dichotomous outcomes. When designing studies, researchers who are considering group-randomized interventions should also consider the features of the multilevel analytic models they might employ.
• Coyle, K., Basen-Engquist, K., Kirby, D., Parcel, G., Banspach, S., Collins, J., Baumler, E., Carvajal, S., & Harrist, R. (2001). Safer choices: Reducing teen pregnancy, HIV, and STDs. Public Health Reports, 116(Issue 1). doi:10.1093/phr/116.s1.82
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  Objectives. This study evaluated the long-term effectiveness of Safer Choices, a theory-based, multi-component educational program designed to reduce sexual risk behaviors and increase protective behaviors in preventing HIV, other STDs, and pregnancy among high school students. Methods. The study used a randomized controlled trial involving 20 high schools in California and Texas. A cohort of 3869 ninth-grade students was tracked for 31 months from fall semester 1993 (baseline) to spring semester 1996 (31-month follow-up). Data were collected using self-report surveys administered by trained data collectors. Response rate at 31-month follow-up was 79%. Results. Safer Choices had its greatest effect on measures involving condom use. The program reduced the frequency of intercourse without a condom during the three months prior to the survey, reduced the number of sexual partners with whom students had intercourse without a condom, and increased use of condoms and other protection against pregnancy at last intercourse. Safer Choices also improved 7 of 13 psychosocial variables, many related to condom use, but did not have a significant effect upon rates of sexual initiation. Conclusions. The Safer Choices program was effective in reducing important risk behaviors for HIV, other STDs, and pregnancy and in enhancing most psychosocial determinants of such behavior.
• Coyle, K., Basen-Engquist, K., Kirby, D., Parcel, G., Banspach, S., Collins, J., Baumler, E., Carvajal, S., & Harrist, R. (2001). Safer choices: reducing teen pregnancy, HIV, and STDs. Public health reports (Washington, D.C. : 1974), 116 Suppl 1, 82-93.
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  This study evaluated the long-term effectiveness of Safer Choices, a theory-based, multi-component educational program designed to reduce sexual risk behaviors and increase protective behaviors in preventing HIV, other STDs, and pregnancy among high school students.
• Carvajal, S. C., Wiatrek, D. E., Evans, R. I., Knee, C. R., & Nash, S. G. (2000). Psychosocial determinants of the onset and escalation of smoking: Cross- sectional and prospective findings in multiethnic middle school samples. Journal of Adolescent Health, 27(Issue 4). doi:10.1016/s1054-139x(00)00124-5
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  Purpose: To investigate a broad range of social influence-related and global determinants of smoking to aid in the design of comprehensive multiethnic interventions by testing the most important factors of initiation and escalation of smoking across various subgroups. Methods: Cross-sectional (N = 2546) and cohort (N = 736) samples of multiethnic middle school students near a large Southwestern metropolis were surveyed through self-report questionnaires. The confidential questionnaires included information on demographics, risk factors, and smoking behavior and were administered in class by trained data collectors. Multivariable logistic regression analysis was used to examine the statistical significance and strength of the factors. Results: Those lower in self-esteem and higher in social assertiveness appeared to be most at risk for the onset of smoking, whereas those low in optimism appeared to be the most at risk for the escalation of smoking. Attitudes, friends' norms, parents' norms, perceived behavioral control, and perceived prevalence were consistent predictors of all smoking status outcomes. Conclusions: The behavioral-specific determinants of smoking appear to be important predictors of smoking status outcomes in all demographic subgroups. The relationships of the global determinants were more dependent on the smoking outcome variable and subgroup examined. The findings may serve to help facilitate the targeting of comprehensive interventions aimed at reducing adolescent smoking in multiethnic and ethnic group-specific populations. (C) Society for Adolescent Medicine, 2000.
• Carvajal, S. C., Wiatrek, D. E., Evans, R. I., Knee, C. R., & Nash, S. G. (2000). Psychosocial determinants of the onset and escalation of smoking: cross-sectional and prospective findings in multiethnic middle school samples. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 27(4), 255-65.
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  To investigate a broad range of social influence-related and global determinants of smoking to aid in the design of comprehensive multiethnic interventions by testing the most important factors of initiation and escalation of smoking across various subgroups.
• Koval, J. J., Pederson, L. L., Mills, C. A., McGrady, G. A., & Carvajal, S. C. (2000). Models of the relationship of stress, depression, and other psychosocial factors to smoking behavior: A comparison of a cohort of students in Grades 6 and 8. Preventive Medicine, 30(Issue 6). doi:10.1006/pmed.2000.0671
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  Background. Six specific hypotheses regarding putative mechanisms by which stressful life events might lead to initiation of smoking among adolescents were proposed and tested on a Grade 6 cohort of students in Scarborough, Ontario, Canada. In addition, the data were used to determine the set of risk factors for initiation of smoking most pertinent to the experience of the cohort. Methods. The same relationships were examined for the 1,543 students when they were in Grade 8 and compared to the earlier Grade 6 results. The hypotheses include the effects of personal resources (coping, selfesteem, social support, and mastery), social conformity, rebelliousness, attitudes, smoking environment factors, and gender differences. Results. The hypotheses were not unequivocally supported, except for the hypotheses about attitudes and smoking environment as well as gender effects. Males and females differ with regard to the variables and interrelationships in both years and in the final models developed. In Grade 6, there are more smoking environment items for males than for females. By Grade 8, male smoking is influenced by mastery, social conformity, and rebelliousness, while for females environmental smoking and rebelliousness are important. Conclusion. Male and female students differ in how stress, depression, and smoking are related in the presence of psychosocial factors. (C) 2000 American Health Foundation and Academic Press.
• Koval, J. J., Pederson, L. L., Mills, C. A., McGrady, G. A., & Carvajal, S. C. (2000). Models of the relationship of stress, depression, and other psychosocial factors to smoking behavior: a comparison of a cohort of students in grades 6 and 8. Preventive medicine, 30(6), 463-77.
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  Six specific hypotheses regarding putative mechanisms by which stressful life events might lead to initiation of smoking among adolescents were proposed and tested on a Grade 6 cohort of students in Scarborough, Ontario, Canada. In addition, the data were used to determine the set of risk factors for initiation of smoking most pertinent to the experience of the cohort.
• Vanoss Marín, B., Coyle, K. K., Gómez, C. A., Carvajal, S. C., & Kirby, D. B. (2000). Older boyfriends and girlfriends increase risk of sexual initiation in young adolescents. Journal of Adolescent Health, 27(Issue 6). doi:10.1016/s1054-139x(00)00097-5
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  Purpose: To explore the prevalence and impact of older boyfriends or girlfriends on sexual behavior in sixth graders (mean age 11.5 years). Methods: Students in 19 ethnically diverse middle schools in an urban area were surveyed (n = 2829, response rate 68%). Instrument measured demographics, age of oldest boyfriend or girlfriend, unwanted sexual advances, peer norms, and sexual behavior. Students with older, same-age, or no boyfriend or girlfriend were compared on demographic and psychosocial variables using analysis of variance. Separate multivariate logistic regressions for both boys and girls were used to predict sexual behavior from demographics, psychosocial variables, and age categories of boyfriend or girlfriend. Results: One-half of the respondents (56%) had never had a serious boyfriend or girlfriend, 35% reported that their oldest boyfriend or girlfriend was
• Vanoss Marín, B., Coyle, K. K., Gómez, C. A., Carvajal, S. C., & Kirby, D. B. (2000). Older boyfriends and girlfriends increase risk of sexual initiation in young adolescents. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 27(6), 409-18.
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  To explore the prevalence and impact of older boyfriends or girlfriends on sexual behavior in sixth graders (mean age 11.5 years).
• Carvajal, S. C., Parcel, G. S., Banspach, S. W., Basen-Engquist, K., Coyle, K. K., Kirby, D., & Chan, W. (1999). Psychosocial predictors of delay of first sexual intercourse by adolescents. Health Psychology, 18(Issue 5). doi:10.1037/0278-6133.18.5.443
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  This investigation predicted adolescents' delay of intercourse onset from attitudes, social norms, and self-efficacy about refraining from sexual intercourse. Age, gender, ethnicity, and parental education were also examined as predictors and moderators of the relationships among the 3 psychosocial determinants and onset. The participants (N = 827), part of a cohort initially surveyed in the 9th grade, reported at baseline that they had never engaged in intercourse. The multivariable proportional hazards regression model suggested that adolescents with more positive attitudinal and normative beliefs, as well as those with a parent who graduated from college, were less likely to engage in intercourse in the follow-up period (up to approximately 2 years). Interventions that include an objective to delay onset may benefit from addressing psychosocial determinants, especially attitudes and norms about sexual intercourse. This study predicted adolescent's delay of intercourse onset from attitudes, social norms, and self-efficacy about refraining from sexual intercourse. Age, gender, ethnicity, and parental education were also examined as predictors and moderators of the relationships among the three psychosocial determinants and onset. The longitudinal data for the study were obtained from 827 participants in the US who were part of a cohort initially surveyed in the 9th grade. These participants reported at baseline that they had never engaged in intercourse. Utilizing the multivariable proportional hazards regression model, findings suggested that adolescents with more positive attitudinal and normative beliefs were less likely to engage in intercourse in the follow-up period (up to approximately 2 years). This was also the case for those students with a parent who graduated from college. Attitudes and norms were the most robust predictors of intercourse. In addition, a relatively modest increase in either scale was predictive of a 30% reduction in the onset of future intercourse in the most conservative analytic model. Interventions that include an objective to delay onset may benefit from addressing psychosocial determinants, especially attitudes and norms about sexual intercourse.
• Carvajal, S. C., Parcel, G. S., Banspach, S. W., Basen-Engquist, K., Coyle, K. K., Kirby, D., & Chan, W. (1999). Psychosocial predictors of delay of first sexual intercourse by adolescents. Health psychology : official journal of the Division of Health Psychology, American Psychological Association, 18(5), 443-52.
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  This investigation predicted adolescents' delay of intercourse onset from attitudes, social norms, and self-efficacy about refraining from sexual intercourse. Age, gender, ethnicity, and parental education were also examined as predictors and moderators of the relationships among the 3 psychosocial determinants and onset. The participants (N = 827), part of a cohort initially surveyed in the 9th grade, reported at baseline that they had never engaged in intercourse. The multivariable proportional hazards regression model suggested that adolescents with more positive attitudinal and normative beliefs, as well as those with a parent who graduated from college, were less likely to engage in intercourse in the follow-up period (up to approximately 2 years). Interventions that include an objective to delay onset may benefit from addressing psychosocial determinants, especially attitudes and norms about sexual intercourse.
• Weller, N. F., Tortolero, S. R., Kelder, S. H., Grunbaum, J. A., Carvajal, S. C., & Gingiss, P. M. (1999). Health risk behaviors of Texas students attending dropout prevention/recovery schools in 1997. Journal of School Health, 69(Issue 1). doi:10.1111/j.1746-1561.1999.tb02338.x
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  This study determined prevalence of health risk behaviors of 9th through 12th grade students attending dropout prevention/recovery alternative schools in Texas in 1997. Participants were 470 youth whose health risk behaviors were assessed using the Youth Risk Behavior Survey in an anonymous, self-administered format. Behaviors measured included frequence of weapon-carrying and fighting, suicide-related behaviors, substance use, and sexual behaviors. A substantial percentage of alternative school students reported participating in behaviors that placed them at acute or chronic health risk. Differences in the prevalence of risk behaviors were noted by gender, racial/ethnic, and age subgroups. In addition, alternative school students frequently engaged in multiple risk behaviors. These findings suggest a need for comprehensive school-based health education/intervention programs to reduce the prevalence of risk behaviors in populations of alternative school students.
• Weller, N. F., Tortolero, S. R., Kelder, S. H., Grunbaum, J. A., Carvajal, S. C., & Gingiss, P. M. (1999). Health risk behaviors of Texas students attending dropout prevention/recovery schools in 1997. The Journal of school health, 69(1), 22-8.
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  This study determined prevalence of health risk behaviors of 9th through 12th grade students attending dropout prevention/recovery alternative schools in Texas in 1997. Participants were 470 youth whose health risk behaviors were assessed using the Youth Risk Behavior Survey in an anonymous, self-administered format. Behaviors measured included frequency of weapon-carrying and fighting, suicide-related behaviors, substance use, and sexual behaviors. A substantial percentage of alternative school students reported participating in behaviors that placed them at acute or chronic health risk. Differences in the prevalence of risk behaviors were noted by gender, racial/ethnic, and age subgroups. In addition, alternative school students frequently engaged in multiple risk behaviors. These findings suggest a need for comprehensive school-based health education/intervention programs to reduce the prevalence of risk behaviors in populations of alternative school students.
• Carvajal, S. C., Clair, S. D., Evans, R. I., & Nash, S. G. (1998). Relating Optimism, Hope, and Self-Esteem to Social Influences in Deterring Substance Use in Adolescents. Journal of Social and Clinical Psychology, 17(4), 443-465. doi:10.1521/jscp.1998.17.4.443
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  Although there is a long history of research examining relationships between intrapersonal factors and adolescent substance use, such relationships have not always been clearly delineated. The present study focused on three factors generally associated with physical and mental well being: dispositional optimism, hope, and self-esteem. These constructs were examined in relation to a social influence model as applied to the deterrence of substance use. A cross-sectional study was undertaken employing adolescents (n = 1,985) representative of a multi-racial/ethnic population. The results suggest that optimism, hope, and self-esteem are determinants of avoiding substance use, with the effects of these variables being mediated by attitudes, perceived norms, and perceived behavioral control. Additionally, the structural equation modeling analysis suggests a more general protective dimension predominantly accounts for the relationships between the personality factors and the mediators of avoiding substance use. ...
• Carvajal, S. C., Evans, R. I., & Garner, R. L. (1998). Dispositionai Optimism as a Protective Factor in Resisting HIV Exposure in Sexually Active Inner‐City Minority Adolescents1. Journal of Applied Social Psychology, 28(23), 2196-2211. doi:10.1111/j.1559-1816.1998.tb01367.x
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  Recent investigations have explored dispositional optimism as a determinant of various health-related behaviors though such research has been infrequently conducted in populations where pessimism would be expected to be prevalent. The present study examines optimism and unsafe sexual behavior in 230 sexually active inner-city minority adolescents. Findings suggest that dispositional optimism is a protective factor regarding adolescents intentions to avoid engaging in unsafe sex. Further the benefits of optimism appear to be explained by those who are more optimistic having higher levels of perceived condom use self-efficacy and stronger negative expectancies toward unsafe sex. Future interventions may need to address optimism in concert with behavioral-specific determinants to increase the probability of reducing unsafe sexual behavior in high-risk populations. (authors)
• Carvajal, S., Evans, R., Evans, R., Nash, S., & Carvajal, T. (1998). Risk factors for injury in the career female dancer: An epidemiologic study of a broadway sample of performers. Medical Problems of Performing Artists, 13(3).
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  Eighty-nine female professional theatrical dancers from 18 Broadway productions participated in an anonymous survey requesting information about their injuries and potential risk factors. Dancers with a greater body mass index were at lower risk for injury, and those dancers who began instruction at a later age were at higher risk for injury. Though additional research may help clarify the precise reasons for these risk factors, health professionals involved in dance medicine should consider these findings when coordinating prevention efforts.
• Evans, R. W., Evans, R. I., & Carvajal, S. (1998). Survey of injuries among West End performers. Occupational and Environmental Medicine, 55(Issue 9). doi:10.1136/oem.55.9.585
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  Objectives - To obtain more information about injuries of West End performers. Methods - A retrospective survey of 269 performers appearing in 20 West End productions (12 dramas and eight musicals). Results - In current productions, 46% of all performers sustained at least one injury for an average of 0.87 injuries per performer. Lower extremity injuries were the most common for dancers (52.2% of injuries) and actors (43.2%) with neck and back injuries the second most common. Sprains and strains were the most common diagnoses. 61% of performers thought that their injuries were preventable. Most performers consulted non-physician healthcare providers. Factors significantly influencing the risk of injuries for performers include female sex, a history of previous injuries, missed performances due to previous injuries, more physically demanding roles, and performing on raked (angled) stages. Conclusion - West End performers commonly sustain injuries. Although primary prevention of most theatrical injuries is not possible, modification of raked stages may reduce the incidence. This study may be helpful to the growing number of healthcare providers who practice performing arts medicine and may stimulate additional concern and research in the medical and theatrical communities about the performance injuries of professionals, amateurs, and theatrical students worldwide.
• Evans, R. W., Evans, R. I., & Carvajal, S. (1998). Survey of injuries among West End performers. Occupational and environmental medicine, 55(9), 585-93.
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  To obtain more information about injuries of West End performers.
• Carvajal, S. C., Photiades, J. R., Evans, R. I., & Nash, S. G. (1997). Relating a social influence model to the role of acculturation in substance use among Latino adolescents. Journal of Applied Social Psychology, 27(Issue 18). doi:10.1111/j.1559-1816.1997.tb01616.x
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  This study examined determinants of substance use derived from the theory of planned behavior as influenced by acculturation. Latino adolescents (n = 448) completed measures of attitudes, subjective norms, perceived behavioral control, intentions toward substance use, and 2 acculturation components. The degree to which Latino adolescents were exposed to as well as use Spanish was unrelated to determinants of future substance use, whereas the degree to which they interact with non-Latino peers exerted a protective effect regarding future substance use. However, both acculturation components influenced the extent social influence determinants predicted future substance use. Intervention strategies may need to consider acculturation in order to effectively direct resources toward those psychosocial determinants of substance use of greatest relevance to Latino populations.
• Evans, R. W., Evans, R. I., & Carvajal, S. (1996). A survey of injuries among broadway performers: Types of injuries, treatments, and perceptions of performers. Medical Problems of Performing Artists, 11(Issue 1).
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  A retrospective survey was performed of 168 dancers and 151 actors appearing in 10 Broadway productions and 13 Broadway touring companies. In current productions, lower extremity injuries were the most common for the dancers (56.8% of the injuries) and the actors (37.8%). A majority of the performers consulted nonphysician health care providers. Strains/sprains were the most common diagnoses for all the performers. Worker's compensation claims were not field for most injuries. The performers cited a variety of hazards of stages and sets. The results of this first survey of injuries among Broadway performers may be useful for physicians who practice performing arts medicine. The study may also help to stimulate additional concern and research in the medical and theatrical communities about injuries and their prevention involving other professional, amateur, and student performers.
• Evans, R. W., Evans, R. I., Carvajal, S., & Perry, S. (1996). A survey of injuries among Broadway performers. American journal of public health, 86(1), 77-80.
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  To obtain more information about injuries of Broadway performers, 313 performers appearing in 23 Broadway companies were surveyed. The percentage of performers injured was 55.5%, with a mean of 1.08 injuries performer. Lower extremity injuries were the most common. Sixty-two percent of performers believed that their injuries were preventable. As this study reports factors that significantly increase the risk of injury for dancers and actors, it may help to heighten concern with reducing the incidence of injuries to professional performers, theatrical students, and nonprofessionals worldwide.
• Evans, R. W., Evans, R. I., Carvajal, S., & Perry, S. (1996). A survey of injuries among broadway performers. American Journal of Public Health, 86(Issue 1). doi:10.2105/ajph.86.1.77
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  To obtain more information about injuries of Broadway performers, 313 performers appearing in 23 Broadway companies were surveyed. The percentage of performers injured was 55.5%, with a mean of 1.08 injuries per performer. Lower extremity injuries were the most common. Sixty-two percent of performers believed that their injuries were preventable. As this study reports factors that significantly increase the risk of injury for dancers and actors, it may help to heighten concern with reducing the incidence of injuries to professional performers, theatrical students, and nonprofessionals world-wide.

Presentations

• Beamer, P., Yubeta, A., Varela, J., Wolf, A. M., Carvajal, S. C., Spitz, R., Ingram, M., Griffin, S., Billheimer, D. D., Cortez, I., Quijada, C., Fimbres, J., & Sandoval, F. (2021). Multisector Engagement for Addressing Emerging Environmental Exposures. ISES. Virtual: ISES.
• Coulter, K., Velasco, M., Wilkinson-Lee, A. M., Ingram, M., Lohr, A. M., Coronado, G., Espinoza, C., Monge, S., Esparza, M., Figueroa, C., Itule-Klasen, L., Bowen, M., & Carvajal, S. C. (2021, October). Adaptation of Unidos during covid-19: The role of CHWs and implications for practice. American Public Health Association Annual Meeting and Expo. Denver, CO: American Public Health Association.
• Duenas, K., Crocker, R. M., Torres, E., Ingram, M., Torres, R., Vasquez, L., del Villar, L., Castro, I., Guernsey De Zapien, J. E., & Carvajal, S. C. (2021). La vida en la frontera: Exploring sources of resilience and stress in a rural Arizona-Mexico border community. American Public Health Association Annual Meeting and Expo.
• Marrone, N. L., Ingram, M., Wong, A. A., Piper, R., Colina, S., Carvajal, S. C., & Coco, L. (2021). Prioritizing community in research decision-making through partnership. American Public Health Association Annual Meeting and Expo.
• Carvajal, S. C., Coulter, K., Wilkinson-Lee, A. M., Ingram, M., Doubleday, K., & Lohr, A. (2020, fall). Linking individual needs to community and clinical services (LINKS): Outcomes of a community-based intervention. APHA 2020 VIRTUAL Annual Meeting.
• Coulter, K., Doubleday, K., Carvajal, S. C., Ingram, M., Wilkinson-Lee, A. M., Lohr, A. M., Redondo-Martinez, F., Coronado, G., Espinoza, C., & Velasco, M. (2020, Fall). Links: A community health worker led community-clinical linkage intervention addressing emotional wellbeing. American Public Health Association Annual Meeting. Virtual: APHA.
• David, C., Krupp, K., Ingram, M., Lohr, A. M., Doubleday, K., Aceves, B., Espinoza, C., Redondo-Martinez, F., Coronado, G., & Carvajal, S. C. (2020, Fall). Impact of community health worker (CHW) delivered links intervention on depression symptoms among Latinos living in the US-Mexico border region. American Public Health Association Annual Meeting. Virtual: APHA.
• Lohr, A. M., Doubleday, K., Ingram, M., Wilkinson-Lee, A. M., Coulter, K., & Carvajal, S. C. (2020, Fall). Linking individual needs to community and clinical services (LINKS): Outcomes of a community-based intervention. American Journal of Public Health Annual Meeting.
• Muniz, F., Carlos, K., Hunter, A., Fox, M. J., Nuno, V. L., Carvajal, S. C., & Yuan, N. P. (2020, Oct). Mixed methods evaluation of a culturally-grounded after-school program on an urban-based American Indian reservation. APHA. Virtual.
• Beamer, P., Ingram, M., Carvajal, S. C., Bell, M. L., Griffin, S., Lee, A. A., Wertheim, B., Wolf, A. M., Parra, K. L., Lopez-Galvez, N. I., Wagoner, R. S., Cortez, I., Sandoval, F., & Lothrop, N. Z. (2019, Summer). The Feasibility of Identifying and Quantifying Worker Exposures to Volatile Organic Chemicals in Beauty Salons and Auto Shops in the Southwestern USA. International. Society of Exposure Science ConferenceInternational. Society of Exposure Science.
• Beamer, P., Ingram, M., Carvajal, S. C., Bell, M. L., Griffin, S., Lee, A. A., Wertheim, B., Wolf, A. M., Parra, K. L., Lopez-Galvez, N. I., Wagoner, R. S., Cortez, I., Sandoval, F., & Lothrop, N. Z. (2019, Summer). The Feasibility of Identifying and Quantifying Worker Exposures to Volatile Organic Chemicals in Beauty Salons and Auto Shops in the Southwestern USA. Research to Action GranteesNIH/NIEHS.
• Carvajal, S. C., Ingram, M., Coulter, K. M., Lohr, A. M., Wilkinson-Lee, A. M., Ochoa, M., & Espinoza, C. (2019, Fall). Participant Perspectives on a Community-Clinical Linkage Intervention to Reduce Chronic Disease Risk and Promote Well-being. American Public Health Association Annual Meeting. Pittsburgh, PA: APHA.
• Carvajal, S. C., Lohr, A. M., Espinoza, C., Ingram, M., & Coulter, K. M. (2019, Fall). Examining the Associations between Community Health Worker-Rated Health and Depressive Symptomology in Latino Adults. American Public Health Association Annual Meeting. Pittsburgh, PA: APHA.
• Redondo, F., Carvajal, S. C., Ingram, M., Coulter, K. M., David, C., Velasco, M., Lohr, A. M., Wilkinson-Lee, A. M., & Coronado, G. (2019, Fall). Community Health Workers’ and their Supervisors’ Perceptions on a Community-Clinical Linkage Intervention to Reduce Chronic Disease Risk and Promote Well-being. American Public Health Association. Pittsburgh, PA: APHA.
• Carvajal, S. C. (2018, March). Health inequities and resilience in Latinx populations: Concepts, trends and prevention research from the Arizona-Sonora region. Invited Scholar, AAHB's Annual Scientific Meeting “An Equity Approach to Health Behavior Innovation". Portland OR: American Academy of Health Behavior.
• Carvajal, S. C. (2018, November). Six co-authored oral or poster presentations at 2018 APHA in San Diego, CA. American Public Health Association. San Diego.
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  Formative Research for a Health Communication Framing Intervention to Reduce High-Risk Alcohol Consumption in Hispanic Men. Luis Valdez, PhD, MPH, University of Massachusetts - Amherst, Amherst, MA, David O. Garcia, PhD, University of Arizona, Mel and Enid Zuckerman College of Public Health, Tucson, AZ, Scott Carvajal, PhD, MPH, CHW-facilitated social support in fostering emotional wellness and chronic disease self-management. Maia Ingram, MPH, University of Arizona, Tucson, AZ, Cynthia Espinoza, Yuma County Health Department, Gloria Coronado, Yuma County Public Health Services District, Yuma, AZ, Martha Ochoa, Arizona Community Health Worker Association, Tucson, AZ, Maria Velasco, BA, El Rio Community Health Center, Tucson, AZ, Abby Lohr, MPH, University of Arizona, Tucson and Scott Carvajal, PhD, MPH, Latino representation in bullying and depression research. Karen Lutrick, MS1, Velia Nuno, PhD, MSW1, Sheri Bauman, PhD1 and Scott Carvajal, PhD, MPH2, University of Arizona, TucsonMechanisms for race and gender disparities in cognitive decline: A systematic review. Rachel Peterson, MPH, MA1, Mindy Fain, MD2, John Ehiri, PhD, MPH, MSc3, Emily Butler, PhD1 and Scott Carvajal, PhD, MPH4, University of Arizona, Tucson, AZYPAR Photovoice Findings: Factors that Influence Adolescent Substance Use on the U.S.-Mexico Border. Elizabeth Salerno Valdez, MPH1, Samantha Sabo, DrPH2, Josephine Korchmaros, Ph.D.1, David O. Garcia, PhD3, Nathan Stupiansky, PhD4 and Scott Carvajal, PhD, MPH5Using Youth Participatory Action Research and Photovoice to Examine Adolescent Substance Use on the U.S.-Mexico Border. Alejandro Duarte1, Elizabeth S. Valdez, MPH2, Samantha Sabo, DrPH3, David O. Garcia, PhD4, Josephine Korchmaros, Ph.D.2 and Scott Carvajal, PhD, MPH5,
• Carvajal, S. C. (2018, November). Social Justice Education and Health Promotion Challenges and Opportunities (Invited Forum Lead). University of New Mexico Health Sciences Center. Albuquerque, NM.
• Carvajal, S. C. (2018, October). Health inequities and resilience in Latino populations: trends and prevention research from the Arizona Prevention Research Center. Colorado School of Public Health (Invited Scholarly Presentation). Aurora, CO.
• Carvajal, S. C., Carvajal, S. C., Carvajal, S. C., Colina, S., Colina, S., Colina, S., Piper, R., Piper, R., Piper, R., Coco, L. S., Coco, L. S., Coco, L. S., Ingram, M., Ingram, M., Ingram, M., Wong, A. A., Wong, A. A., Wong, A. A., Marrone, N. L., , Marrone, N. L., et al. (2018, November 15). Community-based Hearing Loss Education and Support Groups for Older Hispanic/Latinx Adults. The Gerontological Society of America 2018 Annual Scientific Meeting. John B. Hynes Veterans Memorial Convention Center in Boston, Massachusetts: The Gerontological Society of America.
• Carvajal, S. C., Korchmaros, J. D., Stupiansky, N. W., Garcia, D. O., Sabo, S., & Valdez, E. (2018, November). Using youth participatory action research and photovoice to examine adolescent substance use on the U.S.-Mexico border. Paper presented at the American Public Health Association annual conference. San Diego, CA: American Public Health Association.
• Carvajal, S. C., Stupiansky, N. W., Garcia, D. O., Korchmaros, J. D., Sabo, S., & Valdez, E. (2018, November). YPAR photovoice findings: Factors that influence adolescent substance use on the U.S.-Mexico border. Paper presented at the American Public Health Association annual conference. San Diego, CA: American Public Health Association.
• Carvajal (lead), S. C. (2017, August). Health behavior changes in Latino US-Mexico border residing adults participating in chronic disease preventive interventions .. 31st annual conference of the European Health Psychology Society, Padova, Italy. August 29 –September 2 2017..
• Carvajal (lead), S. C. (2017, Fall). Impacts of two community health worker-led chronic disease preventive interventions on health behavior changes in US-Mexico border residing adults. 145th APHA Annual Meeting & Expo. Atlanta, GA November 3 – November 8, 2017..
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  Carvajal, S., Huang, S., Bell, M., Denman, C., de Zapien, J., Cornejo, E., Chang, J., Staten, LK., & Rosales, R. Impacts of two community health worker-led chronic disease preventive interventions on health behavior changes in US-Mexico border residing adults145th APHA Annual Meeting & Expo. Atlanta, GA November 3 – November 8, 2017.
• Carvajal (lead), S. C. (2017, Fall). The Role of Community Health Workers in Institutional and Community Policy Change in Arizona.. Improving Population Health: Now, Across People’s Lives and Across Generations to Come. Austin TX. October 2 - 4, 2017.
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  Carvajal, S. Ingram, M., Sabo, S., Piper, R., & Reinschmidt, K. The Role of Community Health Workers in Institutional and Community Policy Change in Arizona. Improving Population Health: Now, Across People’s Lives and Across Generations to Come. Austin TX. October 2 - 4, 2017.
• Carvajal, S. C., & Reinschmidt (lead), K. (2017, Spring). Community-clinic linkages to improve emotional well-being among patients with or at risk for chronic disease: Piloting tools for community-based CHWs. 145th APHA Annual Meeting & Expo. Atlanta, GA November 3 – November 8, 2017..
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  Reinschmidt, K.M., Sbarra, D.A., Lohr, A., Ingram, M. & Carvajal, S. Community-clinic linkages to improve emotional well-being among patients with or at risk for chronic disease: Piloting tools for community-based CHWs. 145th APHA Annual Meeting & Expo. Atlanta, GA November 3 – November 8, 2017.
• Gerald, L. B., Carvajal, S. C., Billheimer, D. D., Fisher, J., Gerald, J. K., & Lowe, A. (2017, May). Among children with asthma, greater acculturation is associated with having a medical home. American Thoracic Society International Conference. Washington, DC: American Thoracic Society.
• Gerald, L. B., Stefan, N., Bryson, D., Carvajal, S. C., Moore, M. A., Clemens, C. J., Billheimer, D. D., Fisher, J., Brown, M., & Gerald, J. K. (2017, May). Supervised Medicine in Schools: The SAMS Study. American Thoracic Society International Conference. Washington, DC: American Thoracic Society.
• Reinschmidt, K. M., Ingram, M., Morales, S., Sabo, S. J., Carvajal, S. C., Reinschmidt, K. M., Ingram, M., Morales, S., Sabo, S. J., & Carvajal, S. C. (2016, November). Documenting Community Health Worker Roles and Integration in Community Health Centers in Southern Arizona: Contributions to Evidence-based and Locally Relevant CHW Integration.. 144th APHA Annual Meeting & Expo. Denver, CO: APHA.
• Adamovich, S. L., Carvajal, S. C., Ingram, M., De Zapien, J. G., Harris, F. P., Colina, S., & Sanchez, D. (2015, March). Community-based participatory research on hearing loss in a border/low-resource community. American Auditory Society Scientific & Technology Meeting. Scottsdale, Arizona: American Auditory Society.
• Ingram, M., Murrieta, L., de Zapien, J. G., Herman, P., & Carvajal, S. C. (2015, Fall). Community Health Worker-driven participatory action research method to improve behavioral health services for farm workers in a primary care setting. American Public Health Association Annual Meeting. Chicago, IL: APHA.
• Ingram, M., Schachter, K. A., Murrieta, L., De Zapien, J. G., Herman, P., & Carvajal, S. C. (2015, Fall). Engaging the Mexican American farmworker community in improving the delivery of mental health services. American Public Health Association Annual Meeting. Chicago, IL: APHA.
• Sabo, S. J., Ingram, M., Dreifuss, H., Soto, Y., Carvajal, S. C., & Redondo, F. (2015, Fall). Impact of Community Health Workers (CHW) in the Primary Health Care Setting. American Public Health Association. Chicago, IL: APHA - Medical Care Section.
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  Since the 1960s, Community Health Workers (CHWs) have been characterized as community leaders who share the language, socioeconomic status and life experiences of the community members they serve and are recognized as a promising strategy to address glaring health inequities. Testimony the CHW effectiveness is their inclusion in the Affordable Care Act as distinct members of the health care team and the Centers for Medicaid and Medicare services recent guidance that allows for reimbursement of preventive services offered by unlicensed professionals such as CHWs. Objective: In response to such historical shifts in healthcare policy, and in partnership with local and state health departments and CHW professional associations, the Arizona Prevention Research Center (AzPRC) aimed to characterize the CHW workforce and assess the attitudes, barriers and impact of the utilization of CHWs among primary care providers and health plans. Methods: A series of quantitative and qualitative surveys and interviews engaged a large national sample of CHWs (N=1600) and a local sample of primary health care providers and health plans (N=150). Results: Approximately 28% (439) of CHWs surveyed nationally work in a clinical setting. Locally, health care providers reported CHW impact on the quality of care for high cost and high-risk patients, including improved access to care and health outcomes. CHWs improved provider efficiency through health systems navigation, health education and social support. Conclusions: CHWs are an effective member of the primary health care team and improve access to care and management of chronic conditions among high-risk high cost populations.

Poster Presentations

• Beamer, P., Carvajal, S. C., Ingram, M., Griffin, S., Billheimer, D. D., Wolf, A. M., Cortez, I., Torbzadeh, E., Parra, K., Lee, A., Lopez-Galvez, N., Wagoner, R., Honan, J., Sandoval, F., Quijada, C., Lothrop, N., & Fimbres, J. (2021). Mixed Models to Assess Auto Repair Shop Worker Exposures to VOCs and Inform a Community Health Worker Intervention. ISES. Virtual: ISES.
• Skobic, I., Carvajal, S. C., Gates, M., Haynes, P. L., Yuan, N. P., Yuan, N. P., Gates, M., Haynes, P. L., Skobic, I., & Carvajal, S. C. (2019, November). Stigma and willingness to seek mental health treatment among college students: Exploring potential moderators of a complex association. American Public Health Association 2019 Annual Meeting & Expo. Philadelphia, PA.
• Carvajal, S. C., Ingram, M., Sbarra, D. A., Lohr, A. M., & Reinschmidt, K. M. (2017, Fall). Community-clinic linkages to improve emotional well-being among patients with or at risk for chronic disease: Piloting tools for community-based CHWs. American Public Health Association Annual Meeting. Atlanta, Georgia: APHA.
• Reinschmidt, K. M., Ingram, M., Morales, S., Sabo, S. J., Blackburn, J., Murietta, L., David, C., & Carvajal, S. C. (2016, May). Taking a CBPR Approach to Documenting CHW Roles and Integration into Community Health Centers in Southern Arizona.. First Annual El Rio / The Wright Center Virtual Health Research Fair: “Community-Oriented Primary Care. ”. Tucson, AZ: El Rio Community Health Center.
• Sanchez, A., Marrone, N. L., Ingram, M., Sanchez, D., Colina, S., De Zapien, J. G., Adamovich, S. L., Carvajal, S. C., Sanchez, A., Marrone, N. L., Ingram, M., Sanchez, D., Colina, S., De Zapien, J. G., Adamovich, S. L., & Carvajal, S. C. (2016, October). Family Perspectives on Hearing and Communication Among Mexican American Older Adults. World Congress of Audiology. Vancouver, Canada.
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  Sanchez, A., Marrone, N., Ingram, M., Sánchez, D.,Wong, A., Colina, S., de Zapien, J., Adamovich, S., &Carvajal, S. (September 2016) Family perspectives onhearing and communication among Mexican-Americanolder adults. Poster presented at the 33rd World Congressof Audiology. Vancouver, British Columbia, Canada.

Others

• Contreras, R., Molina, P., Ramos, V., Elias, M., Garcia, A., Harris, E., Hardesty, E., Nisbet, K., Felix, E., Albelais, P., Collier, E., Maya, M., Carvajal, S. C., Guernsey de Zapien, J., Duenas, K., Moore-Monroy, M. J., Gonzalez, L., Sanchez, B. O., & Emrick, G. (2025, January).

  Community Assessment Report for Proyecto Juntos

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  Proyecto Juntos/ Project Together Community Engaged Assessment Report on access to mental and behavioral health services in Cochise, Santa Cruz, Graham and Greenlee counties.
• Carvajal, S. C., Emerick, g., Guernsey De Zapien, J. E., Gonzalez, L., Sanchez, B., Duenas, K., & Moore-Monroy, M. J. (2024, 2024-3-16). Proyecto Juntos Qualitative Research Workshop Series.
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  Series of workshops to build community health workers on qualitative data collection methods, analysis, and interpretation. Sessions included: River of Life, Digital Stories and storytelling, qualitative analysis, data interpretation and prioritization and SWOT analysis.
• Derksen, D. J., Aguirre, A., Hernandez, M., Carvajal, S. C., Moreno, F., Kennedy, L., & Moore-Monroy, M. J. (2022, september). Daniel Dawes Book Signing, Presentation on the Political Determinants of Health.