Latinx Health Disparities Research During COVID-19: Challenges and Innovations.

BACKGROUND: The Center for Latino Health Research Opportunities (CLaRO) supports and facilitates research addressing substance abuse, violence/trauma, and HIV/AIDS among diverse and underserved Latinx populations. CLaRO runs a pilot awards program for early-stage investigators conducting Latinx health disparities research. This pilot awards program was impacted by the COVID-19 pandemic, necessitating innovative responses for research continuity.
PURPOSE: The purpose of this commentary is to describe the challenges and innovative research methods developed in response to COVID-19 to continue Latinx health disparities research in the context of COVID-19. METHODS/
RESULTS: This commentary provides a brief description of each CLaRO pilot project, the challenges introduced by COVID-19, and innovative research methods to continue Latinx health disparities research during and beyond COVID-19.
CONCLUSIONS: Despite the challenges COVID-19 presents to the continuity of health disparities research, it also presents unprecedented opportunities to innovate. Such innovation is essential for solving persistent scientific, public health, and clinical challenges underlying current and emerging health disparities. © Society of Behavioral Medicine 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

The purpose of this commentary is to describe the challenges COVID-19 has introduced to Latinx health disparities research, in addition to the usual challenges of this work. The Center for Latino Health Research Opportunities (CLaRO) supports and facilitates research addressing the SAVA syndemic (substance abuse, violence/trauma, and HIV/AIDS) [1] among Latinx communities. CLaRO’s pilot awards program supports Latinx health disparities research, much of which occurs within Miami-Dade county, which has a large, diverse Latinx population, substantial poverty, high substance use, high HIV prevalence and incidence, and trauma/violence [2]. Conducting Latinx health disparities research in this context requires consideration of the roles of economic deprivation, stigma, and fear of deportation, among other culturally specific barriers to participation, as well as emerging challenges related to COVID-19.

In the face of these challenges, we optimized CLaRO-funded Latinx health disparities research (see Table 1) to protect participant and research staff physical safety, adhere to human subjects protections, address cultural factors related to engaging Latinx populations in research, and capture emerging COVID-19-related health disparities. This resulted in innovative approaches to conducting research with Latinx populations that may enhance future health disparities research, even after the COVID-19 crisis subsides.

Table 1.

Summary of projects and responses to COVID-19

Project	Summary	Challenges and innovations
Mobile Intervention Prototypes	Creating intervention prototypes for a mobile application to prevent drug use, sexual risk behaviors, and depression among Latinx adolescents	➢ Remote recruitment via phone, email, and word of mouth ➢ Informed consent and assent via videoconferencing ➢ Adolescents provide feedback on intervention prototypes via videoconference focus groups. ➢ Online survey to accompany focus groups, completed via REDCap
Feasibility and Acceptability of the Family Acceptance Project (FAP)	Assessing the feasibility and acceptability of FAP, a family intervention to affirm LGBT children, after adaptation for Latinx families.	➢ FAP, designed as a home-based intervention, transitioned to a videoconferencing format, creating the opportunity to reach Latinx families across Florida and the USA. ➢ COVID-19 prompted college-aged Latinx youth to move in with their families, potentially exacerbating stressors (e.g., minority stress) that may be addressed in the intervention.
DÍMELO	Evaluating Latino men who have sex with men’s use of HIV-prevention and behavioral health services via longitudinal cohort study	➢ COVID-19 likely impacted key variables (e.g., sexual behavior, mental health, substance use, use of HIV-prevention, and behavioral health services). ➢ Developed Pandemic Stress Index to assess these impacts, protecting the scientific integrity of the project and potentially contributing to knowledge about Latinx health disparities
Happy Older Latinos are Active (HOLA)	Pilot testing program to reduce cardiometabolic risk and improve psychosocial functioning/health-related quality of life in older Latinos with HIV via group walks, activity scheduling, and social support.	➢ Met by phone during group walk time to motivate physical activity and activity scheduling, modeling personalismo, and emphasizing confianza ➢ Data collection by phone (unable to collect biological/physiological outcomes) ➢ Highlighted “digital divide” affecting older Latinos (e.g., participants using “flip phones”)
PROGRESO-II	Developing and pretesting an intervention to promote Latina seasonal farmworkers’ pre-exposure prophylaxis use	➢ Study photos purchased online; unable to create new photographs for intervention due to social distancing
		➢ Established feasibility of moving intervention, PROGRESO-II, online
		➢ Community meetings moved to online platform

Delivering Interventions to Address Latinx Health Disparities Remotely

To protect research participants’ and research staff’s physical safety and comply with COVID-19 policies, all studies discontinued in-person visits. Although challenging for intervention studies (e.g., group walks for social support and physical activation with older Latinx adults living with HIV and home-based family interventions for Latinx families with an LGBTQ child), we were able to transition to technology-assisted interventions. Continuing the group walk intervention while adhering to social distancing guidelines required that the community health care worker ask participants to complete an individual walk during the group walk time and conduct phone check-ins to facilitate social connection. There were challenges engaging older Latinx adults in the study remotely, with many having limitations to online communications (e.g., owning “flip phones”), suggesting the need for continued innovations to ensure that older Latinx populations are not left behind by technology-delivered interventions. In another example, the Family Acceptance Project was intended to be adapted and delivered at home to Latinx families with an LGBTQ child. COVID-19 precluded this option, which facilitated opening the pilot study to statewide and national recruitment of Latinx families.

Although there were downsides with remote interventions (e.g., less personal contact and technology access), we also observed benefits. For instance, remote delivery extended the reach of interventions that address Latinx health disparities to those who may be least likely to engage in-person (e.g., due to transportation barriers, confidentiality concerns, and time constraints). Remote delivery of interventions could also facilitate delivery to populations with disproportionate barriers to in-person participation, including rural populations where local expertise and services may not be available, as well as individuals with fewer socioeconomic resources, for whom traveling to in-person services may be particularly challenging due to transportation costs or extended work hours. In other cases, remote delivery may facilitate overcoming stigma related to accessing health services (e.g., mental health stigma) or being seen as affiliated with a stigmatized group (e.g., sexual minorities) through an enhanced sense of privacy or confidentiality.

Collecting Data Remotely

We also developed data collection strategies that adhered to human subjects protection guidelines in the context of social distancing practices, the relevance of which may continue beyond the immediate impacts of COVID-19. All studies continued without substantial disruptions due to the integration of technology-assisted data collection. Only one study experienced insurmountable barriers to collecting biological/physiological data; however, as remote data collection procedures evolve, methods for collecting these data remotely could emerge.

Two studies highlighted innovative methods for group-based remote data collection. The first involved recruitment and delivery of adolescent focus groups, which transitioned from in-person to videoconferencing. Another, which involved community meetings to develop an intervention promoting Latina seasonal farmworkers’ access to pre-exposure prophylaxis also transitioned to an online platform and, in this context, developed plans for remote intervention delivery. Transitions from in-person to remote required increasing participant and staff comfort with technology. Comfort was achieved through training staff in technology, encouraging staff to use the same rapport building skills in a remote context, being clear about recording practices (i.e., voice and/or face) and contexts in which video needed to be on, and discussing how to manage personal privacy while participating from home. Through these transitions, we learned that even focus groups and group-based data collection is feasible via remote modalities with Latinx populations.

Another component of this transition was remote recruitment. CLaRO emphasizes community partnerships for all aspects of research, including recruitment. Although community events and organizations that have historically supported our recruitment efforts (e.g., pride events to reach Latinx LGBTQ individuals) were closed or canceled, we leveraged our community partnerships to remotely recruit through these partnerships. Culturally tailored recruitment materials designed to be posted in community venues were converted to electronic format, facilitating community partners’ remote distribution (e.g., social media, email, press releases, and word of mouth). Additionally, recruitment was enhanced by attending online community town hall meetings.

The shift to remote modalities required enhanced privacy and confidentiality protections and, in some cases, obtaining consent/assent remotely. We learned about the feasibility of obtaining consent/assent remotely, alternative options for delivering participant incentives (e.g., direct cash transfers), and the importance of ongoing consultation with human subjects staff to maintain awareness of changes to protocols in a rapidly changing research environment.

Engaging Latinx Participants in Research by Addressing Cultural Factors

As with in-person research, it is crucial to consider Latinx communities’ cultural contexts to develop culturally congruent recruitment and retention plans. Latinx cultural values, such as personalismo (i.e., valuing and building interpersonal relationships, and relational warmth), familismo (i.e., dedication, commitment, and loyalty to family), confianza (trust and familiarity), and simpatía (i.e., maintaining politeness and kindness even in the face of adversity) may be important factors to consider when conducting research with Latinx communities. Moving to a remote platform requires consideration of how to maintain a focus on and integration of cultural factors to engage Latinx communities to ensure representation and inclusion in research. Research staff can be trained to communicate these cultural values via remote modalities to build staff comfort and participant engagement (e.g., phone check-ins and specialized training in rapport building via phone, text message, and video). With many of our staff being members of the Latinx community in South Florida, we were able to address these cultural values by having continuous interactions via phone. This enabled us to maintain a personal connection (i.e., personalismo) with socially isolated participants and counteract loneliness during COVID-19.

Documenting Emerging Health Disparities

Simultaneous to the challenges of conducting research during COVID-19 is the reality that COVID-19 is disproportionately impacting Latinx and Black communities [3, 4], creating new health disparities and exacerbating existing disparities. We innovated by developing new measures and incorporating qualitative inquiry to document the impacts of COVID-19 on new and existing Latinx health disparities. For example, the Pandemic Stress Index was developed to assess the behavioral and psychosocial impacts of COVID-19 on Latinx sexual minority men [5]. This measure is now being used across numerous studies and available in six languages, promoting scientific rigor and facilitating data synthesis to assess the degree to which Latinx and other populations may be differentially impacted by COVID-19. CLaRO researchers have also developed other COVID-19 measures to promote health disparities research (https://elcentro.sonhs.miami.edu/research/measures-library/covid-19/index.html).

In summary, despite the challenges COVID-19 presents to health disparities research, it also presents unprecedented opportunities to innovate. Innovative research is exactly what is needed to solve persistent scientific, public health, and clinical challenges related to ongoing and emerging health disparities. We hope the examples presented here provide a launching point for other investigators to meet COVID-19 with innovation, supporting the goals of achieving health equity for those who are most impacted by past, present, and future health crises.