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. Author manuscript; available in PMC: 2016 Nov 1.
Published in final edited form as: Public Health Nurs. 2015 Mar 2;32(6):625–633. doi: 10.1111/phn.12190

Improving Physical Activity in Hispanics with Diabetes and their Families

Jie Hu 1, Debra C Wallace 1, Karen A Amirehsani 1, Thomas P McCoy 1, Sheryl L Coley 1, Kimberly D Wiseman 1, Zulema A Silva 1, Christina R Hussami 1
PMCID: PMC4558404  NIHMSID: NIHMS660858  PMID: 25731967

Abstract

Objective

This study examined changes in physical activity among Hispanics with diabetes and their families who received an 8-week diabetes self-management intervention.

Design

A quasi-experimental design was used to conduct a secondary analysis of physical activity data from two intervention studies that used the same protocols and measures.

Sample

A total of 65 patients and 66 family members participated in the studies.

Measures

Physical activity was measured with the International Physical Activity Questionnaire (IPAQ) and pedometers. Self-report of physical activity was collected pre- and postintervention, and pedometer data for the 8 weeks of the intervention period.

Intervention

The interventions consisted of 8 weeks of educational sessions.

Results

IPAQ walking Metabolic Equivalent of Task (MET) minutes per week significantly increased for patients (p < 0.001) and family members (p < 0.001) from pre- to post-intervention as did moderate activity MET-minutes/week for family members (p = 0.004). Based on pedometer steps, the percentage of sedentary patients declined from 38% to 17% over the intervention record; differences in pedometer steps over time were not significant for patients (p = 0.803) or family members (p = 0.144).

Conclusions

Pedometers are a cost effective and user-friendly method of measuring physical activity. Pedometers can also serve as a motivator to help increase physical activity among Hispanics with diabetes and their family members.

Keywords: Physical activity, pedometer, Intervention, Hispanics and family members

Background

Physical activity (PA) is an essential element of type 2 diabetes (T2DM) self-management (Duvivier et al., 2013; Van Dijk, Tummers, Stehouwer, Hartgens, & Van Loon, 2012; Weinstock et al., 2011). Increased PA has been linked to improvements in body weight, body fat, cardiorespiratory fitness, waist circumference, HDL cholesterol, hs-CRP and HbA1c levels, and mental health status (Balducci et al., 2012; Ho, Dhaliwal, Hills, & Pal, 2012; Lincoln, Shepherd, Johnson, & Castaneda-Sceppa, 2011). PA among persons with T2DM has also been shown to reduce postprandial glucose elevations and glucose variability independent of changes in physical fitness or adiposity (Mikus, Oberlin, Libla, Boyle, & Thyfault, 2012) and to improve insulin sensitivity and action (Larsen, Anderson, Ekblom, & Nyström, 2012; Nelson et al., 2013). Current PA guidelines recommend 150 minutes/week of moderate-intensity aerobic activity, in addition to twice weekly muscle strengthening activities for all adults (Centers for Disease Control and Prevention, 2014), with encouragement to break PA into shorter periods of time, such as 10 minute increments, if needed to achieve these goals.

National U.S. data indicate that Hispanic men and women are more likely to be inactive or less physically active than non-Hispanic White and Black men and women2 (Janssen, Carson, Lee, Katzmarzyk, & Blair, 2013). Additionally, they suffer higher rates of T2DM and obesity than non-Hispanic Whites (US Department of Health and Human Services, 2014). Given the high rates of inactivity, obesity and diabetes among Hispanics, interventions are needed to increase physical activity. Previous studies have used a variety of methods to measure physical activity such as pedometers and steps per day, activity duration and intensity, and Metabolic Equivalent of Task (MET) minutes calculated from the International Physical Activity Questionnaire (IPAQ) and other self-report measures. Walking is the most common daily activity of adults, and pedometers are an inexpensive and widely used strategy for lay persons to track their steps. However, pedometers have not been widely used as an intervention strategy for improving PA among Hispanic adults (Ainsworth et al., 2013; Coffman, Ferguson, Steinman, Talbot, & Dunbar-Jacob, 2013; Trudnak, Lloyd, Westhoff, & Corvin, 2011); prior PA studies with Hispanics have used pedometers as a measure for only 7 days, a limited amount of time (Ainsworth et al., 2013; Coffman et al., 2013; Drieling, Goldman Rosas, Ma, & Stafford, 2014). This analysis used both pedometers and self-report to assess changes in physical activity among Hispanics with diabetes and their family members over an 8-week period. The research hypothesis was that an eight-week family-based diabetes self-management intervention would show a significant improvement in physical activity, measured with pedometer and self-report, for both participants and their family members.

Methods

Design

A quasi-experimental design was used to examine the effects of an 8–week, family-based intervention program for Hispanic adults with type 2 diabetes and their family members using a secondary analysis of physical activity data from two intervention studies that used the same protocols and measures. Data on physical activity for this analysis were collected at pre and post intervention for both participants with type 2 diabetes and their family members in the two intervention studies.

Sample

A total of 131 participants (65 patients and 66 family members) completed the study. Participants were recruited for the two studies in two rural counties with limited health access. Both counties had a Federally Qualified Health Center, low income charity clinic or Health Department, and a small general hospital (one with 94 beds and one with 145 beds). Per capita income in the two counties was $21,384 and $22,624 (lower than the US rate of $27,915), the unemployment rate was 10% (higher than the national average), and the population was 6.4%-10.4% Hispanic (US Census Bureau, 2012).

Participants were recruited through flyers distributed by clinics and physician office staff, face-to-face waiting room conversations with study research assistants, announcements, postings at church meetings and through word of mouth. Criteria for inclusion of patients with diabetes were a) self-identification as Hispanic, b) age 18 years or older, c) self-report of a medical diagnosis of T2DM, and d) an adult family member willing to participate. Inclusion criteria for family members were a) residence in the patient's household and b) age 18 years or older. Both patients and family members had to be able to speak either Spanish or English. Those who were pregnant, were diagnosed with type 1 diabetes, reported prior (past year) or current participation in other diabetes self-management intervention programs, or were cognitively impaired were excluded.

Bilingual and bicultural team members were available to recruit, consent, and enroll persons. Potential participants met with team members in private rooms at study sites and made an appointment for a family session. At this initial session with each family dyad, the study purpose, format of the intervention and requirements of participants were shared, and informed consent and baseline data were collected from each participant. The university IRB approved conduct of the studies.

Intervention

The two eight-week family-based interventions were rooted in social cognitive theory and used a modified version of a diabetes program based on the National Diabetes Education Program and National Standards for Diabetes Self-Management Education (www.ndep.nih.gov). The eight modules were designed to increase diabetes knowledge, overcome barriers to self-management, and foster lifestyle behavioral changes through family support and development of self-efficacy. All study materials were administered to participants in their choice of Spanish or English. All participants received a total of $120 grocery gift cards or cash incentive for completing the eight-week intervention and were provided a new lifestyle pedometer to retain for personal use. All content was tailored to low-literacy participants and integrated cultural beliefs and values. Details on the intervention, data collection and the measures used in the studies have been published elsewhere (Hu, Wallace, McCoy, & Amirehsani, 2014).

Measures

The International Physical Activity Questionnaire (IPAQ) was used to measure self-reported physical activity. This short 9-item IPAQ form assesses the time over 7-day periods that respondents reported walking, moderate activity, and sedentary activity. The questionnaire was completed by each participant before and after the intervention. Walking Metabolic Equivalent of Task-min/week was estimated as 3.3×walking minutes×walking days; moderate activity MET-min/week as 4.0×moderate intensity activity minutes×moderate activity days; and vigorous MET-min/week as 8.0×vigorous activity minutes×vigorous activity days. Total physical activity MET-min/week was estimated as the total walking, moderate, and vigorous MET-min/week. Reliability and validity for the IPAQ have been established in studies conducted in 12 countries and for patients with T2DM (Centers for Disease Control and Prevention, 2010).

Omron HJ-112 pedometers were used to measure 7-day step counts for each participant. The Omron pedometer has a 7-day memory and clock that automatically resets to zero at midnight each day, and it retains data on aerobic and daily step counts and walking distance. It is valid within the recommended 3% of steps walked, as confirmed in previous research (Holbrook, Barreira, & Kang, 2009; Zhu & Lee, 2010). Pedometers were given to participants at the first group meeting with instructions for use, correct wearing site, and use of ‘clips’ to attach to clothing. The instructions included a reminder to wear the pedometer each day from the time when participants woke up until they went to bed at night for 7 consecutive days. In addition, participants were asked to bring the pedometers to each of the eight weekly intervention sessions. Steps were collected each week over the 8-week intervention period by study staff and recorded on separate data sheets for each participant. All participants were encouraged to look over the number of steps recorded each week to monitor their progress. Demographic data were also collected on all participants.

Analytic Strategy

Descriptive statistics including frequencies and percentages were used to summarize categorical measures, and means (M), standard deviations (SD), medians, minimums, and maximums were used to summarize continuous measures. Analyses were performed separately for patients and family members.

To investigate the research hypothesis, repeated measures analyses were conducted using mixed-effects modeling to account for follow-up time and correlations among repeated observations for subjects using random effects. Because continuous measures were right skewed, Gamma mixed-effects regression with a log link function was performed. Gamma regression has been previously used to model skewed physical activity outcomes and in particular, METs estimated from the IPAQ (Lee, Xiang, & Hirayama, 2010). Values of zero were recoded as 0.1 for this modeling (zeroes were not prevalent except for vigorous activities). Vigorous activities were dichotomized into any vigorous activity or none and similarly analyzed using mixed-effects logistic regression.

Pedometer steps were collected each week of the intervention period from both participants and family members. The first day of the first week and the last day of the last week were excluded from the analysis because less than a full day may have occurred on those days. Steps per day were calculated using total steps in a week divided by number of days of pedometer use for each participant. Modeling was performed, again using a repeated measures Gamma regression approach with covariance pattern modeling (Fitzmaurice, Laird, & Ware, 2004).

Multivariable regression models were estimated in the analyses using gender, study period, age at pre-intervention, body mass index (BMI) at pre-intervention, and years having diabetes at pre-intervention as covariates previously identified in research on physical activity using a simultaneous regression approach (Polit, 2010). These adjusted models controlled for the effects of these covariates while estimating the change in physical activity to investigate the research hypothesis. Sensitivity analyses for missing data were conducted using multiple imputation with 20 imputations, and similar conclusions were found for all analyses. Analyses were performed in SAS v9.3 (SAS®, 2014) and (STATA, 2013) v13 (STATA®). A two-sided p-value < 0.05 was considered statistically significant.

Results

Characteristics of the 131 study participants (65 patients, 66 family members) are shown in Table 1. The average age of patients was 50.1 years ± 12.6 (range = 19 to 80), and 63% were female. The average age of family members was 40.4 years ± 13.6 (range = 18 to 71), and 70% were female. About three-fourths (77%) of patients and 73% of family members reported that they were from Mexico. Only one patient and four family members reported being originally from the U.S.; most others (21%) reported being from other South American or Central American countries.

Table 1.

Patient and Family member characteristics (N = 131)

N (%) or Mean ± SD [Median, (Min, Max)]
Characteristic Patients (n = 65) Family Members (n = 66)
Age (years) 50.1 ± 12.6 [48, (19, 80)] 40.4 ± 13.6 [40.5, (18, 71)]
Gender
    Female 41 (63) 46 (70)
    Male 24 (37) 20 (30)
Country of Origin
    United States 1 (2) 4 (6)
    Mexico 50 (77) 48 (73)
    Other 14 (22) 14 (21)
Parent has diabetes 32 (49) 36 (55)
Years having diabetes 7.8 ± 7.7 [7, [0.3, 42]) 0.7 ± 2.2 [0, (0, 15)]
Body mass index (kg/m2) 32.5 ± 6.0 [32.1, (22.6, 47.7)] 32.2 ± 5.9 [32.0, (21.9, 49.2)]
    Underweight (<18.5 kg/m2) 0 0
    Normal (18.5-24.9 kg/m2) 5 (8) 8 (12)
    Overweight (25-29.9 kg/m2) 21 (32) 18 (27)
    Obese (≥30 kg/m2) 39 (60) 40 (61)
No. days from Pre- to Post-intervention 76.0 ± 17.8 [77, (35, 110)] 74.9 ± 18.5 [77, (35, 110)]
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The average number of years with diabetes for patients was 7.8 ± 7.7 (range = 0.3 to 42 years); almost half (49%) had a parent with diabetes. More than half (55%) of family members had a parent with diabetes. Sixty percent of patients with diabetes were obese based on their BMI, and 61% of family members were obese.

Descriptive statistics for IPAQ scores at pre- and post-intervention and pedometer steps per day for each week are shown in Table 2. Most IPAQ scores on average (and in median levels) improved from pre- to post-intervention, except possibly for MET-min/week for vigorous activities. Only 25% of patients and 33% of family members were engaging in any vigorous physical activity (e.g., aerobics, fast bicycling) post-intervention.

Table 2.

Descriptive statistics for Physical activity outcomes (N = 131)

Mean ± SD [Median] or N (%)
Measure Patients (n = 65) Family Members (n = 66)
    International Physical Activity Questionnaire (IPAQ)
            Walking MET-min/week at T1 1113.1 ± 2013.9 [346.5] 1237.2 ± 2482.9 [392.0]
            Walking MET-min/week at T2 1550.6 ± 2372.2 [643.5] 2415.2 ± 3501.7 [476.2]
            Moderate MET-min/week at T1 3431.0 ± 4314.9 [1440.0] 3384.3 ± 4140.8 [1440.0]
            Moderate MET-min/week at T2 3336.2 ± 3785.0 [1560.0] 4549.4 ± 4176.5 [3600.0]
            Vigorous MET-min/week at T1 1867.8 ± 4432.3 [0.0] 2503.7 ± 6077.5 [0.0]
            Vigorous MET-min/week at T2 2262.2 ± 4781.7 [0.0] 3330.4 ± 6184.4 [0.0]
        Any vigorous activities at T1 (MET-min/week>0) 18 (28) 20 (30)
        Any vigorous activities at T2 (MET-min/week>0) 16 (25) 22 (33)
            Total MET-min/week at T1 6113.7 ± 6427.8 [3906.0] 6779.5 ± 8841.9 [3835.2]
            Total MET-min/week at T2 6987.4 ± 7796.6 [4105.5] 9590.7 ± 10446.2 [6673.5]
            Total Kilocalories/week at T1 8277.1 ± 8675.6 [5132.1] 8729.1 ± 10632.3 [5323.4]
            Total Kilocalories/week at T2 9583.8 ± 10492.9 [6338.3] 13097.1 ± 15009.3 [8587.5]
    Pedometer steps per day
Week 1 4939.7 ± 3702.2 [4571.7] 5373.2 ± 3462.7 [5228.3]
            Week 2 4510.0 ± 3193.4 [4087.7] 4971.2 ± 3206.1 [5344.0]
            Week 3 5012.1 ± 3483.7 [4740.7] 5080.7 ± 2834.8 [4500.5]
            Week 4 5129.8 ± 3508.3 [4250.6] 5230.7 ± 3350.2 [4456.4]
            Week 5 5000.1 ± 3361.6 [4960.4] 4370.2 ± 2882.8 [4049.1]
            Week 6 5105.2 ± 3128.0 [4861.7] 4840.7 ± 3369.7 [4532.8]
            Week 7 5031.9 ± 3521.7 [4363.4] 4451.9 ± 2899.0 [3780.5]
            Week 8 5949.5 ± 3572.6 [5614.2] 4141.7 ± 3165.7 [3988.6]
            Successful use for at least 5 of 7 days: Week 1 32 (49) 29 (44)
            Successful use for at least 5 of 7 days: Week 2 40 (62) 27 (41)
            Successful use for at least 5 of 7 days: Week 3 48 (74) 30 (45)
            Successful use for at least 5 of 7 days: Week 4 42 (65) 32 (48)
            Successful use for at least 5 of 7 days: Week 5 33 (51) 33 (50)
            Successful use for at least 5 of 7 days: Week 6 31 (48) 27 (41)
            Successful use for at least 5 of 7 days: Week 7 37 (57) 31 (47)
Successful use for at least 5 of 7 days: Week 8 17 (26) 16 (24)
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In any given week, 26% to 74% of patients successfully used pedometers for at least 5 of 7 days. Among family members, 24% to 50% successfully used pedometers on at least 5 of 7 days. Reasons for failure to use pedometers included forgetting to wear the pedometer, pedometer not working correctly, pedometers causing too much trouble to wear, and pedometer lost. These reasons are similar to those noted in previous reports (Coffman et al., 2013; Ling & Smith, 2010; Zoellner et al., 2009).

Intervention effects on IPAQ measures are shown in Table 3. After taking into account covariates and repeated measures, there were significant increases in mean estimated walking MET-min/week for patients (Exp(b) = 1.088, p < 0.001) and for family members (Exp(b) = 1.092; p < 0.001). Family members also showed significant increases in mean moderate activity MET-min/week over time (Exp(b) = 1.053; p = 0.004). Changes in other IPAQ physical activity outcomes were not statistically significant for patients or family members.

Table 3.

Repeated measures regression results of IPAQ measures (N = 131)1

Exp(b)2 (95% CI for Exp(b)) P-value
Measure Patients (n = 65) Family Members (n = 66)
Walking MET-min/week 1.088 (1.049, 1.127) <0.001 1.092 (1.049, 1.137) <0.001
Moderate MET-min/week 0.986 (0.956, 1.107) 0.360 1.053 (1.018, 1.091) 0.004
Any vigorous activities3 0.977 (0.906, 1.054) 0.550 1.047 (0.959, 1.143) 0.303
    Total MET-min/week 0.999 (0.971, 1.027) 0.925 1.024 (0.997, 1.053) 0.083
Total Kilocalories/week 0.998 (0.971, 1.027) 0.908 1.024 (0.996, 1.052) 0.090
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Notes.

1

Gamma mixed-effects regression except for logistic mixed-effects regression for any vigorous activities

2

Estimated adjusted linear trend after exponentiation and adjusting for: gender, study period, age at pre-intervention, BMI at pre-intervention, years with DM at pre-intervention, and repeated measures

3

Exp(b) is adjusted odds ratio (AOR) for >0 MET-min/week vs. 0 for adjusted linear trend.

The 14% mean increase in total MET-min/week and the 16% mean increase in total kilocalories/week found in patients from T1 to T2 were also clinically significant. The increase was even greater among family members; they shared a 41% mean increase in total MET-min/week and a 50% mean increase in total kilocalories/week.

Results from repeated measures analysis of weekly pedometer steps per day are depicted in Figure 1. There were no significant increases in patients’ pedometer steps per day over time (p = 0.803), after adjusting for covariates and repeated measures. Increases in average pedometer steps per day for family members were also not significant over time (overall 7 df test p = 0.144).

Figure 1.

Figure 1

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Repeated measures Gamma regression modeling results for pedometer steps per day

Figure 2 depicts the changes in categories of pedometer-determined PA based on Tudor-Locke and Bassett, Jr. (2004). The percentage of sedentary patients (those who had <5,000 steps) declined over the intervention period, from 38% in week 1 to 17% in week 8. The percentage of low active patients (5,000 to 7,499 steps) also declined, from 17% to 12%. Changes in time spent in other PA categories were mixed or amounts of time remained steady for patients. Twenty-six percent of family members were categorized as sedentary at week 1 according to their steps; this figure peaked at 36% in weeks 6-7 but dropped to 24% in week 8.

Figure 2.

Figure 2

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Pedometer-determined physical activity for patients and family members (N = 131)

Discussion

This analysis examined PA among Hispanics with T2DM and their family members using both repeated measures of self-report and pedometers over a period of eight weeks. There was a significant a greater increase in estimated walking MET-min/week for both patients and family members. Additionally, family members had a significant increase in moderate MET-min/week. These findings are especially important given that more than 60% of the patients with diabetes and 61% of the family members were obese and most likely deconditioned and not accustomed to exercise; thus, they possibly found engaging in PA for 8 weeks challenging. The finding that family members showed a greater increase in moderate types of PA than patients might have to do with the fact that they were on average 10 years younger than the patients and most did not have T2DM or its sequelae.

Findings from the pedometers indicated that there was an increase (though not significant) in the weekly number of steps per day among the patient group, but not among family members. This finding was in contrast to the self-reported PA using the IPAQ. One possible explanation for the difference might be that the IPAQ assesses bouts of time, which may last from a few minutes to a longer duration; in contrast, a pedometer measures total steps per day (Yates et al., 2013). Thus, a participant may report engaging in 30 minutes of walking or moderate-intensive PA, but then be sedentary for the remainder of the day. In addition, there may be differences in how individuals define sedentary, moderate, and vigorous PA based on cultural and gender differences (Drieling et al., 2014; Kohlbry & Nies, 2009). Another explanation for the differences between the IPAQ and pedometer findings in the current study may be that some participants, particularly family members, did not consistently wear the pedometers, as some thought their pedometers were not counting correctly and others reported that wearing a pedometer was inconvenient; some simply forgot to wear it. In addition, Drieling et al. (2014) found gender differences in PA among Hispanics, with men being more active than women. Also, Casper, Harrolle, and Kelley (2013) found significant gender differences in self-reported PA among a sample of Latino men and women with men engaging in higher energy related PA at work or by playing sports whereas women were more apt to report activities such as light-intensity housework or walking and taking children to the playground. In our study, 63% of patients and 70% of family members were female, and this might contribute to the lack of significant changes in physical activity measured with pedometers.

Level of PA assessed based upon step categories indicated that the majority of participants in our study were sedentary or were low in activity. This is similar to the findings of other studies of Hispanics. In a study by Drieling et al. (2014) of low-income, obese Latino immigrants (N = 207) who wore pedometers for 7 days, 40.9% of the women and 25% of the men had fewer than 5,000 steps per day, with men walking 40% more steps than women. Ainsworth et al. (2013) reported similar results in a study of 139 women; 61% were found to be sedentary and 28.1% low active. Our intervention clearly had more impact on patient steps per day than on family member steps, Additionally, patients maintained at least 5 days of pedometer use per week more often than family members.

The increase in steps per day over time was much greater in the present study than in two other studies of Latinos using pedometers. One study (Trudnak et al., 2011) reported only an 8% increase, and activity logs used in the studies approximated the pedometer readings.

Limitations of this study include the homogeneity of the sample with low levels of education and income limiting analyses of the effects of differences in socioeconomic variables on level of PA. Social desirability may have had an impact on self-reported physical activity in the study. Missing data due to participants’ forgetting to wear the pedometer, the pedometer not working correctly, or a lost pedometer may have confounded the findings. Convenience sampling also limits the generalizability of the findings, and finally, the short duration of the intervention (eight weeks) made it difficult to examine sustained improvements in physical activity.

Despite its limitations, the study showed that the intervention increased physical activity among participants and that pedometers are a cost effective and user friendly method of measuring PA among Hispanics with diabetes and their family members (Weinstock et al., 2011). As in most previous studies, most increases were not statistically significant. However, the differences after the intervention were clinically relevant. Even a 10% increase in MET-min/week or steps per day can change the trajectory of diabetes sequelae, maintain functionality of patients, and maintain their quality of life. Our intervention improved PA more than two-fold in many cases.

Strategies to improve sustainable levels of adequate PA among Hispanics with T2DM and family members are critically important. Primary care providers (nurse practitioners) and public health nurses could provide advice to Hispanics with T2DM on pedometer use to achieve recommended levels of PA and improve their health status. Pedometer purchases could be obtained through partnerships with health systems or nonprofit organizations as a community engagement and potential cost cutting strategy. Pedometers could serve as low-literacy and culturally acceptable motivator to help increase PA in Hispanics with diabetes (Coffman et al., 2013; Martyn-Nemeth, Vitale, & Cowger, 2010). Personal engagement and goal achievement have been shown to be positively related to diabetes management.

Formal diabetes educational programs can incorporate pedometers as a strategy to improve diabetes self-management outcomes for Hispanic Americans. The pedometers provide clients and participants a mechanism to show progress, activity and self-management. These can be used as a daily or weekly reminder of the need for physical activity to alleviate long term consequences of diabetes and achieve short term glucose control.

Acknowledgements

The project described was supported by Grant P20MD002289 from the National Institute for Minority Health and Health Disparities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute for Minority Health and Health Disparities or the National Institutes of Health. Appreciation is extended to our community partners for assisting with the study logistics.

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