Information Visualizations to Facilitate HIV-related Patient-provider Communication in New York City (Info Viz: HIV-NYC)

Health Communication Clinical Trial

Official title:

Information Visualizations to Facilitate HIV-related Patient-provider Communication in New York City (Info Viz: HIV-NYC)

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT04102540
• Other study ID #: AAAS4611
• Secondary ID: 1K99NR017829-01A
• Status: Completed
• Phase: N/A
• Start date: October 7, 2019
• Est. completion date: July 29, 2020

Study information

• Verified date: August 2021
• Source: Columbia University
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

To complete the study aims, a mixed methods study that includes a single group pretest-posttest study design will be used to pilot test the infographic intervention. In-depth interviews will be completed with a selection of participants to explore participant perceptions of HIV-related communication using infographics. Data will be collected from participants through baseline (at enrollment) and follow up assessments at 3- and 6-month follow up visits). Follow up interviews will be conducted with members of the clinical team to ascertain their perspectives on the clinical utility of infographics.

Description:

Latinos are the largest and fastest growing minority group in the US, and they are disproportionately affected by HIV. In 2014, almost 25% of new cases of HIV infections were among Latinos although they only represent 17% of the US population. Additionally, Latinos have a faster rate of progression from HIV to AIDS, higher rates of HIV-related deaths, and marked delay in the diagnosis of infections. Approximately 42% of HIV diagnoses among Latinos in the US are in persons born abroad. In absolute numbers, new HIV diagnoses among foreign-born individuals in the US were the highest among Caribbean-born persons, which may partially be attributed to high rates of bidirectional travel. It is, therefore, critical that HIV prevention and treatment activities incorporate factors associated with Latino immigrant and transnational groups. In Washington Heights, New York City, understanding these factors related with bi-directional travel to the Dominican Republic (DR) is warranted, as the Latino population of Washington Heights is largely comprised of Dominicans. Many factors contribute to the health disparities experienced by Latinos, of which low health literacy and literacy in general are potential contributors. Health literacy, or "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions," is an established concern affecting vulnerable communities globally. Not surprisingly, Spanish-speaking, less educated, and/or foreign-born Latinos have lower health literacy than those born in the US. Low health literacy can lead to worse health outcomes, less use of services, and poorer knowledge of illness. Also, patients with limited health literacy are likely to have low numeracy which affects interpretations of medication quantities, time between doses, and time between appointments, among other quantitative knowledge relating to effective management of HIV. Infographics are emerging technologies to help teach complex health concepts to patients with low health literacy. When effectively designed, infographics (information visualizations) contain a depth and breadth of information and lead to improved understanding of concepts. By carefully selecting the design and included content, simple images can convey large amounts of information in a visually appealing and comprehensible way. Methodically constructed infographics have been shown to improve communication about health behaviors and health risks and minimize comprehension differences between individuals with high and low health literacy. They can also help improve information exchange amidst culture and language differences by using images familiar to patients to explain complicated processes as well as augment attention span and recall of learned material. Furthermore, rigorously designed and evaluated infographics can help mitigate health disparities by helping clinicians provide the information that people need for effective health management in an understandable way. During preliminary studies, the investigators developed a set of infographics designed to facilitate HIV-related clinician-patient communication during clinic visits. Initial infographics were designed by persons living with HIV (PLWH) in the Dominican Republic and are now being tested for feasibility and usability among a cohort in the DR. In this study, the investigators propose to assess the feasibility of using the infographic intervention in a clinic that specializes in HIV care in Washington Heights to improve clinical communication and subsequently, patient outcomes. Additionally, the investigators will collect information about acculturation and bi-directional travel to more thoroughly assess how these factors relate to HIV infection among Hispanic/Latino populations living in the US.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 32
• Est. completion date: July 29, 2020
• Est. primary completion date: July 29, 2020
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Adult = 18 years of age
• Living with HIV and has a detectable viral load
• Self-identifies as Hispanic/Latino
• Plan to receive care at the same clinic for the next 6 months

Exclusion Criteria:

• Does not meet inclusion criteria
• Not able to understand study procedures or provide informed consent

Related Conditions & MeSH terms

• Health Communication

Intervention

Other:
• Infographic intervention
Information visualizations (infographics) will be used to teach participants about HIV during study visits immediately following their normal clinic visits.

Locations

Country	Name	City	State
United States	Comprehensive HIV Program of NewYork-Presbyterian Hospital	New York	New York

Sponsors (2)

Lead Sponsor	Collaborator
Columbia University	National Institute of Nursing Research (NINR)

Country where clinical trial is conducted

United States, 

References & Publications (61)

Ancker JS, Senathirajah Y, Kukafka R, Starren JB. Design features of graphs in health risk communication: a systematic review. J Am Med Inform Assoc. 2006 Nov-Dec;13(6):608-18. Epub 2006 Aug 23. Review. — View Citation

Arcia A, Suero-Tejeda N, Bales ME, Merrill JA, Yoon S, Woollen J, Bakken S. Sometimes more is more: iterative participatory design of infographics for engagement of community members with varying levels of health literacy. J Am Med Inform Assoc. 2016 Jan;23(1):174-83. doi: 10.1093/jamia/ocv079. Epub 2015 Jul 13. — View Citation

Berkhof M, van Rijssen HJ, Schellart AJ, Anema JR, van der Beek AJ. Effective training strategies for teaching communication skills to physicians: an overview of systematic reviews. Patient Educ Couns. 2011 Aug;84(2):152-62. doi: 10.1016/j.pec.2010.06.010. Epub 2010 Jul 29. Review. — View Citation

Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011 Jul 19;155(2):97-107. doi: 10.7326/0003-4819-155-2-201107190-00005. Review. — View Citation

Bowen DJ, Kreuter M, Spring B, Cofta-Woerpel L, Linnan L, Weiner D, Bakken S, Kaplan CP, Squiers L, Fabrizio C, Fernandez M. How we design feasibility studies. Am J Prev Med. 2009 May;36(5):452-7. doi: 10.1016/j.amepre.2009.02.002. — View Citation

Brown A, Hugo Lopez M. Mapping the Latino Population, By State, County and City. Washington DC2013.

Centers for Disease Control and Prevention. HIV in the United States: At a Glance. 2015; https://www.cdc.gov/hiv/statistics/overview/ataglance.html. Accessed June, 2017.

Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, Hakim JG, Kumwenda J, Grinsztejn B, Pilotto JH, Godbole SV, Mehendale S, Chariyalertsak S, Santos BR, Mayer KH, Hoffman IF, Eshleman SH, Piwowar-Manning E, Wang L, Makhema J, Mills LA, de Bruyn G, Sanne I, Eron J, Gallant J, Havlir D, Swindells S, Ribaudo H, Elharrar V, Burns D, Taha TE, Nielsen-Saines K, Celentano D, Essex M, Fleming TR; HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011 Aug 11;365(6):493-505. doi: 10.1056/NEJMoa1105243. Epub 2011 Jul 18. — View Citation

Cuellar I, Arnold B, Maldonado RJHjobs. Acculturation rating scale for Mexican Americans-II: A revision of the original ARSMA scale. 1995;17(3):275-304.

Cuellar I, Bastida E, Braccio SM. Residency in the United States, subjective well-being, and depression in an older Mexican-origin sample. J Aging Health. 2004;16(4):447-66. — View Citation

Dang BN, Westbrook RA, Hartman CM, Giordano TP. Retaining HIV Patients in Care: The Role of Initial Patient Care Experiences. AIDS Behav. 2016 Oct;20(10):2477-2487. doi: 10.1007/s10461-016-1340-y. — View Citation

Dickens A, Utley-Smith Q, Stott G, Relf M. Evaluation of communication techniques used by HIV specialty providers caring for patients with low health literary in an outpatient HIV clinical setting. Journal of Nursing Education & Practice. 2013;3(7)

Dowse R, Ramela T, Browne SH. An illustrated leaflet containing antiretroviral information targeted for low-literate readers: development and evaluation. Patient Educ Couns. 2011 Dec;85(3):508-15. doi: 10.1016/j.pec.2011.01.013. Epub 2011 Feb 8. — View Citation

Garcia-Retamero R, Dhami MK. Pictures speak louder than numbers: on communicating medical risks to immigrants with limited non-native language proficiency. Health Expect. 2011 Mar;14 Suppl 1:46-57. doi: 10.1111/j.1369-7625.2011.00670.x. — View Citation

Garcia-Retamero R, Galesic M. Communicating treatment risk reduction to people with low numeracy skills: a cross-cultural comparison. Am J Public Health. 2009 Dec;99(12):2196-202. doi: 10.2105/AJPH.2009.160234. Epub 2009 Oct 15. — View Citation

Garcia-Retamero R, Okan Y, Cokely ET. Using visual aids to improve communication of risks about health: a review. ScientificWorldJournal. 2012;2012:562637. doi: 10.1100/2012/562637. Epub 2012 May 2. Review. — View Citation

Gill MJ, Krentz HB. Unappreciated epidemiology: the churn effect in a regional HIV care programme. Int J STD AIDS. 2009 Aug;20(8):540-4. doi: 10.1258/ijsa.2008.008422. — View Citation

Gioia DA, Corley KG, Hamilton AL. Seeking qualitative rigor in inductive research: Notes on the Gioia methodology. Organizational research methods. 2013;16(1):15-31.

Glanz K, Rimer BK, Viswanath K. Health behavior and health education: theory, research, and practice. Fourth ed: John Wiley & Sons; 2008.

Gonzalez JS, Hendriksen ES, Collins EM, Durán RE, Safren SA. Latinos and HIV/AIDS: examining factors related to disparity and identifying opportunities for psychosocial intervention research. AIDS Behav. 2009 Jun;13(3):582-602. doi: 10.1007/s10461-008-9402-4. Epub 2008 May 23. — View Citation

Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004 Feb;24(2):105-12. Review. — View Citation

Henao-Martínez AF, Castillo-Mancilla JR. The Hispanic HIV Epidemic. Curr Infect Dis Rep. 2013 Feb;15(1):46-51. doi: 10.1007/s11908-012-0306-0. — View Citation

Hertzog MA. Considerations in determining sample size for pilot studies. Res Nurs Health. 2008 Apr;31(2):180-91. doi: 10.1002/nur.20247. Review. — View Citation

Houts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns. 2006 May;61(2):173-90. Epub 2005 Aug 24. Review. Erratum in: Patient Educ Couns. 2006 Dec;64(1-3):393-4. — View Citation

Kalichman SC, Rompa D. Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS. J Acquir Immune Defic Syndr. 2000 Dec 1;25(4):337-44. — View Citation

Kallio H, Pietilä AM, Johnson M, Kangasniemi M. Systematic methodological review: developing a framework for a qualitative semi-structured interview guide. J Adv Nurs. 2016 Dec;72(12):2954-2965. doi: 10.1111/jan.13031. Epub 2016 Jun 23. Review. — View Citation

Kasper J, van de Roemer A, Pöttgen J, Rahn A, Backhus I, Bay Y, Köpke S, Heesen C. A new graphical format to communicate treatment effects to patients-A web-based randomized controlled trial. Health Expect. 2017 Aug;20(4):797-804. doi: 10.1111/hex.12522. Epub 2016 Dec 16. — View Citation

Katz MG, Jacobson TA, Veledar E, Kripalani S. Patient literacy and question-asking behavior during the medical encounter: a mixed-methods analysis. J Gen Intern Med. 2007 Jun;22(6):782-6. Epub 2007 Apr 12. — View Citation

Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978 Feb;88(2):251-8. — View Citation

Knobel H, Alonso J, Casado JL, Collazos J, González J, Ruiz I, Kindelan JM, Carmona A, Juega J, Ocampo A; GEEMA Study Group. Validation of a simplified medication adherence questionnaire in a large cohort of HIV-infected patients: the GEEMA Study. AIDS. 2002 Mar 8;16(4):605-13. — View Citation

Koskan A, Friedman D, Messias D. Health literacy among Hispanics: a systematic research review (1992-2008). Hispanic Health Care International. 2010;8:65-76.

Laws MB, Lee Y, Rogers WH, Beach MC, Saha S, Korthuis PT, Sharp V, Cohn J, Moore R, Wilson IB. Provider-patient communication about adherence to anti-retroviral regimens differs by patient race and ethnicity. AIDS Behav. 2014 Jul;18(7):1279-87. doi: 10.1007/s10461-014-0697-z. — View Citation

Lee SY, Stucky BD, Lee JY, Rozier RG, Bender DE. Short Assessment of Health Literacy-Spanish and English: a comparable test of health literacy for Spanish and English speakers. Health Serv Res. 2010 Aug;45(4):1105-20. doi: 10.1111/j.1475-6773.2010.01119.x. Epub 2010 May 24. — View Citation

Lescano CM, Brown LK, Raffaelli M, Lima LA. Cultural factors and family-based HIV prevention intervention for Latino youth. J Pediatr Psychol. 2009 Nov-Dec;34(10):1041-52. doi: 10.1093/jpepsy/jsn146. Epub 2009 Jan 30. Review. — View Citation

McCaffery KJ, Dixon A, Hayen A, Jansen J, Smith S, Simpson JM. The influence of graphic display format on the interpretations of quantitative risk information among adults with lower education and literacy: a randomized experimental study. Med Decis Making. 2012 Jul-Aug;32(4):532-44. doi: 10.1177/0272989X11424926. Epub 2011 Nov 10. — View Citation

McGuire WJ. McGuire's classic input-output framework for constructing persuasive messages. Public communication campaigns. 2013;4:133-145.

McMahon T, Ward PR. HIV among immigrants living in high-income countries: a realist review of evidence to guide targeted approaches to behavioural HIV prevention. Syst Rev. 2012 Nov 20;1:56. doi: 10.1186/2046-4053-1-56. Review. — View Citation

McSweeney JC, Allan JD, Mayo K. Exploring the use of explanatory models in nursing research and practice. Image J Nurs Sch. 1997;29(3):243-8. — View Citation

Moore JO, Boyer EW, Safren S, Robbins GK, Boudreaux ED, Rosen R, Barton B, Moss F. Designing interventions to overcome poor numeracy and improve medication adherence in chronic illness, including HIV/AIDS. J Med Toxicol. 2011 Jun;7(2):133-8. doi: 10.1007/s13181-011-0149-3. — View Citation

Nash D, Katyal M, Brinkhof MW, Keiser O, May M, Hughes R, Dabis F, Wood R, Sprinz E, Schechter M, Egger M; ART-LINC Collaboration of IeDEA. Long-term immunologic response to antiretroviral therapy in low-income countries: a collaborative analysis of prospective studies. AIDS. 2008 Nov 12;22(17):2291-302. doi: 10.1097/QAD.0b013e3283121ca9. — View Citation

Nwosu C, Balaova J. Immigrants from the Dominican Republic in the United States. 2014; https://www.migrationpolicy.org/article/immigrants-dominican-republic-united-states. Accessed May, 2019.

Osborn CY, Paasche-Orlow MK, Davis TC, Wolf MS. Health literacy: an overlooked factor in understanding HIV health disparities. Am J Prev Med. 2007 Nov;33(5):374-8. — View Citation

Osborn CY, Weiss BD, Davis TC, Skripkauskas S, Rodrigue C, Bass PF, Wolf MS. Measuring adult literacy in health care: performance of the newest vital sign. Am J Health Behav. 2007 Sep-Oct;31 Suppl 1:S36-46. — View Citation

Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR. The prevalence of limited health literacy. J Gen Intern Med. 2005 Feb;20(2):175-84. — View Citation

Passel J, Cohn D, Lopez M. Hispanics account for more than half of nation's growth in past decade. Washington DC: Pew Hispanic Center;2011.

Prosser AT, Tang T, Hall HI. HIV in persons born outside the United States, 2007-2010. JAMA. 2012 Aug 8;308(6):601-7. doi: 10.1001/jama.2012.9046. — View Citation

Ritter PL, Lorig K. The English and Spanish Self-Efficacy to Manage Chronic Disease Scale measures were validated using multiple studies. J Clin Epidemiol. 2014 Nov;67(11):1265-73. doi: 10.1016/j.jclinepi.2014.06.009. Epub 2014 Aug 3. — View Citation

Saint-Jean G, Dévieux J, Malow R, Tammara H, Carney K. Substance Abuse, Acculturation, and HIV Risk among Caribbean-Born Immigrants in the United States. J Int Assoc Physicians AIDS Care (Chic). 2011 Sep-Oct;10(5):326-32. doi: 10.1177/1545109711401749. Epub 2011 Apr 21. — View Citation

Sandelowski M. Sample size in qualitative research. Res Nurs Health. 1995 Apr;18(2):179-83. — View Citation

Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000 Aug;23(4):334-40. Review. — View Citation

Schnall R, Liu J, Cho H, Hirshfield S, Siegel K, Olender S. A Health-Related Quality-of-Life Measure for Use in Patients with HIV: A Validation Study. AIDS Patient Care STDS. 2017 Feb;31(2):43-48. doi: 10.1089/apc.2016.0252. Epub 2017 Jan 4. — View Citation

Sentell TL, Halpin HA. Importance of adult literacy in understanding health disparities. J Gen Intern Med. 2006 Aug;21(8):862-6. — View Citation

Shedlin MG, Drucker E, Decena CU, Hoffman S, Bhattacharya G, Beckford S, Barreras R. Immigration and HIV/AIDS in the New York Metropolitan Area. J Urban Health. 2006 Jan;83(1):43-58. Review. — View Citation

Street RL Jr, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Educ Couns. 2009 Mar;74(3):295-301. doi: 10.1016/j.pec.2008.11.015. Epub 2009 Jan 15. Review. — View Citation

Toren KG, Buskin SE, Dombrowski JC, Cassels SL, Golden MR. Time From HIV Diagnosis to Viral Load Suppression: 2007-2013. Sex Transm Dis. 2016 Jan;43(1):34-40. doi: 10.1097/OLQ.0000000000000376. — View Citation

Vega WA, Rodriguez MA, Gruskin E. Health disparities in the Latino population. Epidemiol Rev. 2009;31:99-112. doi: 10.1093/epirev/mxp008. Epub 2009 Aug 27. Review. — View Citation

Wawrzyniak AJ, Ownby RL, McCoy K, Waldrop-Valverde D. Health literacy: impact on the health of HIV-infected individuals. Curr HIV/AIDS Rep. 2013 Dec;10(4):295-304. doi: 10.1007/s11904-013-0178-4. Review. — View Citation

White MD, Marsh EE. Content analysis: A flexible methodology. Library trends. 2006;55(1):22-45.

Wiewel EW, Torian LV, Hanna DB, Bocour A, Shepard CW. Foreign-Born Persons Diagnosed with HIV: Where are They From and Where Were They Infected? AIDS Behav. 2015 May;19(5):890-8. doi: 10.1007/s10461-014-0954-1. — View Citation

Xia Q, Braunstein SL, Wiewel EW, Hadler JL, Torian LV. Persistent Racial Disparities in HIV Infection in the USA: HIV Prevalence Matters. J Racial Ethn Health Disparities. 2017 Feb;4(1):87-93. doi: 10.1007/s40615-015-0205-9. Epub 2016 Jan 8. — View Citation

Zikmund-Fisher BJ, Witteman HO, Dickson M, Fuhrel-Forbis A, Kahn VC, Exe NL, Valerio M, Holtzman LG, Scherer LD, Fagerlin A. Blocks, ovals, or people? Icon type affects risk perceptions and recall of pictographs. Med Decis Making. 2014 May;34(4):443-53. doi: 10.1177/0272989X13511706. Epub 2013 Nov 18. — View Citation

* Note: There are 61 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Mean CD4 Count	Mean Cluster of Differentiation 4 (CD4) count at each time point.	Baseline, 3-, and 6-months
Primary	Mean Viral Load	Mean viral load at each time point	Baseline, 3-, and 6-months
Secondary	Mean Score on HIV-related Knowledge Assessment	14 questions pertaining to HIV-related knowledge were developed according to the information that will be included in the intervention. Participants will receive one point for each correct answer and then the scores for each question will be summed to obtain a final score. Therefore, the minimum score will be 0 and maximum score will be 14 where the scores closer to 14 indicate patients have more HIV-related knowledge.	Baseline, 3-, and 6-months
Secondary	Mean Score on Satisfaction With Care Scale	7 questions on patients' satisfaction with health care provider and the health care center adapted from previously validated instruments were included.; Each question response from included questions has a different score range: Question 1: 1 - 7 Question 2: 1 - 10 Question 3: 1 - 7 Question 4: 1 - 5 Question 5: 1 - 7 Question 6: 1 - 7 Question 7: 1 - 5; Total scores range from 7 - 48, which is calculated from the lowest and highest possible scores on each of the included questions. Higher scores indicating more satisfaction with care.	Baseline, 3-, and 6-months
Secondary	Mean Score on the SEMCD Scale	The Self-Efficacy for Managing Chronic Disease (SEMCD) scale is a 6-item questionnaire that measures confidence in one's ability to manage fatigue, pain, emotional distress, and other symptoms using self-management techniques. Each item is scored from a minimum value of 1 which indicates "not at all confident" to a maximum score of 10, which indicates "completely confident." Final scores are calculated as the mean of the 6 questions ranging from 1(minimum) to 10 (maximum), where higher scores indicate higher self-efficacy (better outcome).	Baseline, 3-, and 6-months
Secondary	Number of Participants Who Are Adherent to Their Medications	Adherence will be measured with the validated simplified medication adherence questionnaire (SMAQ)-6 scale, a 6-item questionnaire. A person is considered "non-adherent" if there is a "yes" answer for any of items 1,2,3, and 5. Additionally, if they answer that they have missed more than two doses of their medication in the past week (item 4) or if they have gone more than two days without taking their medication in the past 3 months (item 6), they are also considered "non-adherent."	Baseline, 3-, and 6-months
Secondary	Number of Participants Who Reported Each of the 5 General Health Categories	Participants rated their general health as "excellent," "very good," "good," "more or less," or "bad."	Baseline, 3-, and 6-months
Secondary	Mean Score on Current Health Status	Current health status will be assessed with one question from the Health Status Assessment which asks participants to rate their current health by providing a number on a scale from 0 - 100 where 0=death or worst possible health and 100=perfect or best possible health.	Baseline, 3-, and 6-months
Secondary	Number of Participants With Likely Low vs. Adequate Health Literacy According to SAHL-S&E Measurement	Health literacy will be assessed using the short assessment of health literacy- Spanish. Scores range from 0 - 18 and a score above a 15 indicates that participants are likely to have adequate health literacy.	Baseline visit only
Secondary	Number of Participants With Likely Limited, Possibly Limited, or Adequate Health Literacy According to NVS Measurement	A second measure of health literacy, the Newest Vital Sign (NVS) will also be administered. Scores on this scale range from 0-6 where a score of 0-1 suggests high likelihood of limited literacy, a score of 2-3 indicates the possibility of limited literacy, and a score of 4-6 almost always indicates adequate literacy.	Baseline visit only
Secondary	Number of Participants in Each Acculturation Category Presented in the Brief ARSMA	The Brief Acculturation Rating Scale for Mexican Americans-II (Brief ARSMA)12 item instrument that assesses level of acculturation that has been used in Mexican Americans as well as other Latino subgroups, including Dominicans. Scores are calculated by summing the scores and dividing by 12 to get a mean acculturation. Higher scores indicate greater acculturation.	Baseline visit only
Secondary	Percent of Participants Who Complete an In-depth Qualitative Interview	Participants will be invited to participate in an in-depth qualitative interview regarding their experiences. The number who participate will be reported as a percent of the total who are enrolled.	6 months after baseline