Introduction
In 2021, the Centers for Disease Control and Prevention officially recognized racism as a public health issue, calling for “confront[ing] the systems and policies that have resulted in intergenerational injustice and given rise to racial and ethnic health inequities [1].” Linguistic exclusion, or restricted inclusion and access to information, services (e.g., healthcare providers), and resources based on language, contributes to persistent health inequities affecting communities of color and immigrant communities [Reference Cheng, Chen and Cunningham2–Reference Yan, Hwang, Ng, Chu, Tsoh and Nguyen5]. The COVID-19 pandemic exposed the impact of linguistic exclusion in access to COVID-19 information, testing, and vaccines [Reference Washburn, LeBrón and Reyes6]. Linguistic exclusion continues to be a powerful and persistent way in which institutions perpetuate racial inequities for linguistically marginalized communities. Furthermore, language and culture are interconnected, so culturally appropriate support requires linguistic support. This article is grounded in an understanding that a diversity of languages and lexicons spoken across populations, regions, and neighborhoods is a strength. This article aims to establish a framework for incorporating language justice into community-engaged public health and health services research, drawing on the experience of an academic Center focused on addressing inequities in cardiometabolic conditions. The following sections outline the importance of integrating antiracism, language justice, and community-based participatory research (CBPR) approaches.
Antiracism
Racialization processes and linguistic exclusion go hand-in-hand. Society-at-large uses racialization processes to construct and reconstruct racial categories, meanings, and differences to justify unequal social statuses within racial hierarchies [Reference Almaguer7–Reference LeBrón, Ruiz Malagon and Viruell-Fuentes9]. Racialization processes often involve policy and institutional practices [Reference Almaguer7–Reference LeBrón, Ruiz Malagon and Viruell-Fuentes9]. In the United States (US), racial inequities in social, economic, and health outcomes derive from societal, institutional, and cultural systems rooted in white supremacist and capitalistic foundations designed to construct and assert privilege to those racialized as white and to justify the exclusion and/or exploitation of those socially constructed as nonwhite (e.g., Black, Indigenous, and people of color) [Reference Almaguer7–Reference LeBrón, Ruiz Malagon and Viruell-Fuentes9].
The establishment and growth of the US as a formal nation state involved several interconnected racialization processes. This includes, for example, the enslavement and genocide of Indigenous peoples, and accordingly myriad Indigenous knowledge, practices, and languages [Reference Reséndez10]. Additionally, African peoples experienced their forced removal and subsequent loss of their mother tongues and connection to their homelands as they were forced to build the bedrock of the emerging American economy and were grouped together across languages to intentionally stymie communication and reduce the possibility of escape and revolt [Reference Eltis and Richardson11–Reference Gyasi13]. Moreover, the conquest of territories in which Indigenous and mestizo Latiné (a gender-neutral term to refer to people of Latin American origin or descent) peoples have called home for generations (e.g., regions now known as parts of Texas, California, and Puerto Rico) has contributed to their contested and/or second-class citizenship and loss of the diaspora’s connection to their native tongues [Reference Almaguer7,Reference Meléndez-Badillo14]. Similarly, the kingdom of Hawai’i was overthrown and illegally annexed by the US as a strategic military location and fertile land for sugar plantations; immigrant labor was imported and exploited from several other countries to suppress wages and prevent laborer revolt [Reference Kapono15]. The collective displacement of Native Hawaiians nearly erased “Ōlelo Hawai”i, their native tongue, still considered a critically endangered language [Reference Kehaulani Goo16].
These racialization processes are not historical artifacts; their influence on linguistic exclusion and language justice endures today. The fact that as a nation, we in the US take for granted English as the dominant language ignores these historical efforts to destroy native languages. The US does not have an official language, but there is a long history of racial injustice in stripping communities of their native languages through boarding schools designed to assimilate Indigenous children, English-only public school mandates, and punishments for speaking native languages or Black English lexicons instead of “proper” English [Reference Gyasi13,17–Reference Piccard19]. Providing conditions for in-language communication would ensure clarity and full participation for communities who have experienced restricted access to their native languages through racialization processes described above, and also for supporting limited English proficient communities who have more recently migrated and/or experience linguistic isolation.
Racialization processes are dynamic across place and time, so research to address racial health inequities requires an antiracism framework. Our approach heeds calls for scholarship that moves away from simply studying racism and its implications towards practicing antiracism and seeking antiracist transformations of institutional-level factors linked with racial injustices [Reference Adkins-Jackson, Chantarat, Bailey and Ponce20–Reference Michener and LeBrón22]. Antiracism is grounded in critical reflections on positionalities and local socio-political contexts to appropriately address health inequities [Reference Came and Griffith23]. Colorblind or race-neutral efforts by institutions or institutional actors are not grounded in antiracism and accordingly stand to maintain the status quo [Reference Kendi24]. Antiracism efforts include those who are directly affected by racism, those who benefit from racial privilege, and institutional actors who can help effect systems-level change. Language justice must be supported by those who directly benefit, as well as those willing to engage in critical self-reflection to leverage power structures for structural or institutional change [Reference Came and Griffith23].
Language justice
Language justice is the human right that everyone holds to express themselves through the language with which they are most comfortable, to understand, be understood, and to authentically participate [Reference Ghanbarpour, Noguez Mercado and Palotai25]. Importantly, language justice goes beyond language access (where the goal is understanding), towards full participation as the basis of power [Reference Ghanbarpour, Noguez Mercado and Palotai25]. With these histories of language erasure, stigmatization, and marginalization, language justice is an antiracist praxis. When practiced, language justice ensures that people participate in the language they feel most comfortable. Community-based organizations and initiatives are leaders in promoting language justice (e.g., leadership by, hiring of, and authentic engagement of communities fluent in non-English languages). Studies document enduring connections between language and health outcomes, with persons with limited English proficiency experiencing barriers to health care access (e.g., navigating health care systems, screenings) and quality of health care (e.g., communication barriers, treatment errors) and adverse health outcomes such as glycemic control and uncontrolled hypertension [Reference Gulati and Hur26–Reference Kim, Kim, Paasche-Orlow, Rose and Hanchate33].
Public health and health services researchers and funders have made progress in advancing the implementation of Culturally and Linguistically Appropriate Services (CLAS) standards in healthcare settings, such as mandating professional interpretation services for patients in federally-supported healthcare settings. Additionally, public health agencies recognize the importance of language justice in public communications and research related to population safety and well-being and for community partnerships (i.e., building relationships, planning interventions, evaluating community health) [34–Reference Morán-Acereto36]. Relatedly, the Department of Justice has an updated Language Access Plan to reassess and improve language access for individuals seeking or using governmental services [37]. However, public health and health services research have made little progress in enabling linguistically excluded communities to actively participate in research activities and decision-making processes that advance health promotion and health equity. Additionally, National Institutes of Health-funded Clinical and Translational Science hubs document institutional barriers to language inclusion [Reference Sprague Martinez, Araujo Brinkerhoff and Howard38]. Language justice also has implications for the accuracy and representativeness of research findings, especially in areas of high linguistic and cultural diversity. For example, the coauthors are part of a research center in California that reaches a multilingual population of over 13 million residents (Table 1); research conducted only in English would exclude just over a third of residents (4.5M people) in our two counties and limit the relevance of study findings.
Population characteristics, Los Angeles County and Orange County, California, 2023
Source: U.S. Census, American Community Survey Data Population Estimates for July 1, 2023 (one-year estimates).
Community-based participatory research
Predominant approaches to research have inherent power imbalances, but CBPR creates conditions for community and academic partners to share equal power throughout the research process [Reference Israel, Eng, Schulz and Parker39–Reference Balazs and Morello-Frosch41]. CBPR centers community priorities and knowledge coproduction, and often works across the translational research spectrum to ensure that research informs action (e.g., programs, policies, practices) [Reference Shelton, Adsul, Moise and Griffith42]. CBPR has often focused on health inequities affecting communities of color, recently growing to reflect on CBPR processes through the lens of antiracism praxis [Reference Fleming, Cacari Stone and Creary43]. Yet, little research has examined language justice through the lens of authentically engaging diverse communities in research processes. This manuscript critically reflects on facilitators and barriers to and recommendations for deep transformations of longstanding institutional structures to promote language justice in equitable community engagement and decision-making processes in CBPR for health equity.
UC END DISPARITIES: language justice practices and critical reflections as antiracism practice
The UCLA-UCI Center for Eliminating Cardiometabolic Disparities in Multi-Ethnic Populations (UC END DISPARITIES) is part of a NIMHD-funded national consortium of health researchers and community partners focused on prevention and management of chronic conditions, specifically cardiometabolic conditions that disproportionately affect communities of color in our catchment area. Recognizing the diversity of these communities, we actively reflect upon and incorporate language justice as an antiracist practice in the implementation of the Center’s community engagement strategies (Table 2). Through a language justice framework, we describe and critically analyze our experience confronting and navigating institutional practices and processes whose status quo impedes authentic community collaboration and inclusivity. We discuss our experience embedding language justice strategies in partnership with community experts and provide best practices to improve processes and suggestions for institutional changes to increase inclusivity, improve diversity in research, and promote health equity.
Language use across the UC END DISPARITIES center
* During recruitment, a monolingual Spanish-speaker considered joining the CAB (in which case meetings would provide live interpretation). In the end, their bilingual colleague decided to be their organizational representative because of personal interest in the Center, not language ability.
Methods
Setting
The Center’s catchment area includes 4853.1 square miles in two southern California counties [44,45] so the majority of Center activities are remote, with annual in-person meetings alternating between counties.
Dataset and analysis
Data that inform this critical analysis of facilitators, barriers, and recommendations to strengthen language justice are from two sources: (1) notes from the Center’s Community Engagement Core (CEC)’s bi-weekly meetings (involving 4 faculty, 2–5 staff, 2 community consultants connected with academic institutions) and (2) reflective discussions amongst CEC members and coauthors. The CEC collaborates with other Center members (e.g., administrative core, investigator development core, R01 intervention research projects) and affiliates (language justice practitioners) and works to incorporate reflective practices into these relationships. We conducted a thematic analysis, identifying areas in which we have confronted language injustices and sought to practice language justice. Within these, we analyzed the benefits and challenges to language justice. Reflective analyses and discussions amongst coauthors illuminated the critical reflections and lessons learned.
Results
We present three areas of practice of the Center’s antiracism intervention to weave language justice into the Center’s activities: team composition, mini-grants, and community-academic meetings. Within each area of practice, we discuss facilitators, barriers, and lessons learned regarding institutional reform to incorporate language justice throughout our community-engaged research (Tables 3 and 4). In each practice area, we highlight Center- and institution-level factors.
Benefits and challenges of language justice innovations
Recommended practices for language justice
Team composition
Some members of our team are bilingual and bicultural, reflecting antiracism praxis and bringing important lived experiences and cultural context to this work. We firmly believe that bilingual staff should not have to carry additional interpretation/translation roles unless explicitly incorporated into their job description with adequate compensation and recognition for this labor. Professional translators/interpreters are trained to translate complex terms and use best practices (e.g., collaborative translation and back-translation to ensure clarity and retention of original concepts and emotions), plus they are often deeply connected and familiar with local contexts. Relying on bilingual staff/students circumvents these processes, with the potential risk of inadequate compensation and exclusion from other professional opportunities for growth.
Reflecting our language justice principles and the reality that English and Spanish (and regional dialects) are the most commonly used languages locally (Table 1), we collaborate with professional interpreters/translators (English/Spanish) who bring lived experience and reflexive practices to inform language justice efforts. We have dedicated funding for language justice in our Community Engagement Core and Administrative Core (AC) budgets, including the recent establishment of a standing contract for professionally trained interpreters/translators (English/Spanish). This team of professionals provide simultaneous interpretation so that all participants can engage in real-time discussions. In Tables 2 and 3, we describe recommendations for language justice strategies, including engaging at least two professional interpreters for simultaneous interpretation (to allow for breaks), and the importance of meeting with interpreters/translators in advance to review meeting materials, technical terms or concepts, and connect key issues with lived experience and practice-based knowledge. Additionally, our region boasts other languages (e.g., Arabic, Cantonese, Korean, Mandarin, Russian, Samoan, Tongan, Vietnamese) and one of our Center R01 projects includes Vietnamese families, so a wider range of interpretation/translation services is important for engaging grassroots organizations and communities, especially those with the highest rates of limited English proficiency (Table 1). These practices operate within a context of English language dominance in US institutions of higher education and research, as evidenced by nonlanguage-specific courses, university-wide communications, and administrative processes that are all in English. Institutional challenges related to incorporating language justice into our antiracism approach include needing to educate about and advocate for bilingual, bicultural experiences and skills as pay factors for staff and having sufficient funding to support the incorporation of language justice into Center and research activities (above and beyond traditional budgets that may not incorporate language justice).
Mini-grant processes
The CEC, with support from a Center-wide Community Advisory Board, awards two annual Community Catalyst grants ($20,000) to build capacity and/or support community- and faith-based organization-led activities to promote cardiometabolic well-being among affected communities in Los Angeles and Orange Counties. Grant applications and technical assistance webinars are designed to be short and are professionally interpreted/translated into Spanish to be inclusive of organizations without a strong research or grant-writing infrastructure but have strong connections with historically and contemporarily marginalized communities. We received one grant application in Spanish, which two biliterate CEC members (native Spanish speakers) reviewed and scored in language (Spanish); it was professionally translated into English so other grant review process members could read it.
We recognize several institutional challenges related to integrating language justice into the mini-grant process. First, awardees need to navigate the English-only paperwork from our universities and the external funder. Our multilingual application process is currently on hold due to the potential legal ramifications of translating contractual and financial documents that require institutional-level changes. Second, the pre-award process was onerous for a mini-grant, including technically complex and legalistic paperwork for users with nonlegal backgrounds. This underscores the importance of addressing language justice through a structural racism lens (e.g., across institutions), and the need for expertise and buy-in at multiple levels (e.g., Center leadership, university administrators, funders).
Centering community in collaborative meetings
Our Center has bi-annual convenings (1 in-person, 1 virtual) that include community and academic partners, trainees, and staff to share information and enhance coordination of activities. In these meetings, we work to increase English/Spanish language access. With virtual meetings (e.g., Zoom), interpreters provide simultaneous interpretation through specific audio channels. At the beginning of the 2024 in-person retreat, professional interpreters explained language justice and how to use the interpretation equipment. Interpreters highlighted the importance of collective practices for language justice, such as avoiding acronyms and speaking clearly at a slow-to-moderate pace to enable Spanish interpretations that often involve 20%–25% additional words. Interpreters introduced several hand signs to alert speakers to slow down or to speak up. Because this was a brief presentation at the beginning of the agenda, late attendees and presenters missed this critical information, which resulted in confusion and awkwardness. Following this retreat, professional interpreters created a short video on language justice with reminders to speak slowly and clearly, which they shared with attendees ahead of the subsequent virtual retreat.
One challenge with both in-person and virtual meetings was that only some attendees would utilize the interpretation equipment to facilitate simultaneous interpretation: wearing interpretation headsets in-person or choosing a specific language channel (e.g., English, Spanish) on Zoom. This meant that if a participant spoke in Spanish, the conversation would need to shift to consecutive interpretation (alternating between Spanish and English), which is time consuming. Additional challenges included a tightly scheduled agenda and content filled with jargon or densely packed information that can be difficult to access for nonacademics and/or those with limited English proficiency. Even when asked to slow down, speakers would often speak quickly, perhaps out of habit, making it difficult for interpreters to match their pace.
These challenges of integrating language justice into bilingual community-academic spaces point to several insights and areas of future intervention. First, learning and practicing language justice is relatively new for many Center members and takes time and practice to unlearn dense, fast-paced, and jargon-filled communication practices. Second, reducing time pressures can facilitate language justice. For example, short presentation times (e.g., 10 minutes) and limited audience participation opportunities may contribute to efforts to speak quickly, sharing a lot of content in a short time. A more inclusive design would commit to less content and more discussion time (vs. covering more topics). Relatedly, language justice needs to happen at every level (e.g., agenda planning, activity guidelines) and should not be restricted to the responsibilities of the CEC or professional interpreters. To address these areas for growth, professional interpretation collaborators have offered to hold a workshop for Center members to understand how to better communicate with a broad audience, which would make it easier to translate from English into other languages. Further, language justice goes beyond language access to provide the full array of preferred languages reflected by the communities with whom the Center engages, allowing authentic participation. While many elements of centering language justice in collaborative meetings are the responsibility of the Center, language justice in wider collaborative settings is facilitated or hampered by broader institutional (e.g., university, funder) cultures that value (or not) communicating across languages and positionalities (e.g., community, academic) and designing priorities and agendas that are rooted in building relationships, fostering open dialogue and working towards collective impact (vs. packing a lot of content and/or speaking at communities).
Discussion
We close with recommendations to promote language justice for antiracist research to advance health equity, including dedicating needed time and processes to learn about and practice language justice; integrating language justice throughout research processes; adequately funding language justice within research budgets and compensation structures; equitably engaging bilingual, bicultural staff and language justice practitioners; and creating processes for incorporating language justice into written and verbal research and collaborative activities. The following sections elaborate on these recommendations, including the institutional changes needed to support these recommendations.
First, foundational to language justice as an antiracism praxis, academic institutions, funders, academic centers, and research teams should critically reflect on who benefits from current and historical racial hierarchies and how to transform racial hierarchies. This exercise is not abstract; instead, it is rooted in lived experiences and concrete examples. In academia, this process involves reflecting on the historical origins of US higher education, which was created by and for cisgender white, wealthy men; the historical and contemporary expression of white dominant culture within academia and research; and institutional- and individual-level barriers to transforming higher education and research to practice antiracism (e.g., perceptions of who might “lose” power if we transformed the status quo) [Reference Garcia46,Reference Stewart and Valian47]. Such reflections are often ongoing and iterative; involve individual, group, and institutional reflection and dialogue; necessitate connecting individual lived experiences and positionalities with the racial injustices of our time and institution-level strategies to promote racial equity; and are designed to identify pivot points and commitments to multi-level transformations (e.g., individual, academic, Center, institutional) to promote racial equity and address barriers to language justice.
Second, aligning with equity frameworks, language justice requires deep engagement and participation by everyone in all phases of research and is not an afterthought or restricted to community-facing strategies. This necessitates engaging multilingual and multicultural staff and partnering with practitioners who understand best practices for language justice in research and collaborative activities. Building a critical mass of public health and healthcare professionals of color with a diverse array of language abilities and lived experiences is important for building research capacity for language justice. Language justice should not be considered optional (e.g., only for those not fluent in English), nor is language justice the sole responsibility of professional interpreters/translators or bilingual staff. Language justice begins with a consistent use of plain language, explaining complex phenomena in tangible ways that make information more accessible to the public and across disciplines, and helping to facilitate interpretation/translation into additional languages.
Third, language justice is a collective commitment that takes time to practice in teams and collaborative spaces. Language justice requires a shift from dominant fast-paced research strategies, early integration into the process (vs. after an activity is designed), providing guidance (e.g., avoid acronyms, define terms, speak at reasonable pace), and building in time to professionally translate written materials in advance of presentations or material distribution. Meetings or other collaborative activities warrant spaciousness for everyone to have the opportunity to participate. Cultural norms can impact language in many ways, including respectful silence or deferral to other speakers according to social factors such as age (e.g., when elders are speaking) or education (e.g., when doctoras are speaking), which could be misinterpreted as having nothing to say. Furthermore, language justice is a new practice for many researchers, so teams should have time and grace to practice applying language justice. Antiracism involves moving away from fast-paced and/or unreasonable timelines and tightly-scheduled agendas (e.g., capitalistic, white supremacist culture). Language justice is an important component of antiracism approaches that invite higher quality communication and collaboration across languages and lived experiences. In health equity scholarship, investments in language justice hold promising potential to deepen connections, relationship building, analysis of structural and social drivers of health inequities, and envisioning and implementing antiracism interventions.
Fourth, language justice requires institutional investments, including adequately compensating bilingual staff (versus adding this on top of their responsibilities), ensuring paperwork and processes are available in language and in plain language, and training staff and collaborators in inclusive language practices [48,49]. Research budgets should support language justice to engage communities (i.e., equitable compensation, sufficient interpretation/translation budget), and funders should set policies mandating language justice to be planned and practiced and adequately fund language justice. We emphasize the need to build a multilingual and multicultural workforce and partner with professional interpretation/translation teams, rather than settling for imperfect technologies that make errors and miss important cultural nuances, tones, or idioms. Policies that mandate, fund, and sustain bilingual, bicultural university staff – with institutional funding separate from research grants – are an important starting place for institutional change to foster language justice. The growth of artificial intelligence (AI) systems has been an important tool for supporting language translation in real time, often in the context of limited or no interpretation services. However, we caution against reliance on AI alone for translation and interpretation services given that language is often locally, culturally, and historically specific. AI-based translations may not be sensitive to these nuances, especially for languages that are less common or that may not have a standardized written form [Reference Chhabria52–Reference Myers54]. Language reflects the evolution of rich and complicated social, economic, and political histories and cultures, but generative AI tools lack this nuance because they are trained on internet data dominated by a limited number of languages. This risks widening existing inequities, further endangering less-common languages or languages without a standardized written form, and creates potential legal or privacy risks due to inaccuracies and external vendor access to data [Reference Chhabria52 –Reference Myers54].
Implications for research
To integrate language justice into academic Centers informed by the principles of CBPR, deeper transformations of research and decision-making processes are critical. Our experience points to the centrality of center leadership and institutions (e.g., universities, funders) committing to personnel, cultural, and bureaucratic transformations to promote language justice. While institutional change may seem daunting, it is important to recall that institutions are led by individuals who have the power to prioritize and commit to institutional transformations. The consequences of not addressing language justice are many, including perpetuating racist structures in public health research and practice and failure to engage in equitable relationships across community and academic partners. The pandemic illuminated the consequences of linguistic exclusion in communicating about urgent COVID-19 updates and resources [Reference Washburn, LeBrón and Reyes6]. Without a commitment to language justice in research, we risk worsening health inequities over time and maintaining inequities in community-academic structures and processes. Applying language justice to academic Centers informed by the principles of CBPR enables community-academic collaborations to move closer to authentic community participation and ownership [Reference Gonzalez55].
Strengths-based approaches and systems and policy change within academic institutions are critical to equitably integrate communities into research, build multiracial/ethnic coalitions that equitably engage linguistically excluded communities, and promote health equity in research. The changing political climate is likely to further harm linguistically excluded communities. We continue to query how to apply language justice within our Center and build more accessible research infrastructure. California Senate Bill (SB) 1078 was a promising example of a systems change approach to language justice [Reference Min56]. If it had passed, SB1078 would have created an Office of Language Access, focused on implementing federal and state language access laws by building the multilingual capacity of California Health and Human Services programs (e.g., Medi-Cal, social services, emergency medical services, state hospital systems) to ensure that residents with limited English proficiency have in-language access to resources [Reference Min56]. Universities and academic Centers could model a similar approach to improving language access to educational, public health, and health services information; education; research; and collaborative research opportunities. For example, federal guidelines for protecting research participants require in-language consent forms when studies include participants with limited English proficiency; likewise, community-academic partnerships and mini-grant mechanisms to support community-driven strategies should be available in-language. Moreover, university post-award grants management units would benefit from multilingual, multicultural staff trained to understand and support community-academic collaborations. Academic Centers can think collectively about how to incorporate language justice Center-wide, such as supporting research in plain language with multilingual materials. Funders and academic Centers should press researchers to justify the exclusion of limited English proficient participants and/or cite this limitation of the generalizability of their findings. Consequences of upstream institutional failures to address language injustices and lack of a critical mass of public health and healthcare professionals of color include potentially irrelevant research and ineffective application or utilization of public health and health services resources [Reference AuYoung, Afflalo and Ramos Cruz57].
Conclusions
Language justice is not optional. Language justice is critical for ensuring that everyone can communicate, understand, be understood, participate, and access accurate information in a timely manner. As a component of antiracism praxis, incorporating language justice into academic Centers focused on health equity necessitates the buy-in, leadership, and support of all community and academic partners, Center leadership, universities, and funders. Academic Centers have much to learn about language justice from communities, language justice practitioners, and multicultural and multilingual students, staff and faculty in universities who are reflecting on and applying language justice.
Acknowledgements
The authors would like to thank our community collaborators, from members of the UC END DISPARITIES Community Action Board to our community grant reviewers, for their important insights and ideas that continue to move our Center forward in the pursuit of equity. Thank you, gracias, cám ơn, fa’afetai, 謝謝, malo, 감사합니다, شكرا, Спасибо, kommol. The authors also wish to thank language justice practitioners and leaders who model, innovate on, and accompany organizations and institutions in strengthening language justice. We also thank Lluvia Cardenas for her language justice support.
Author contributions
All authors contributed to the conception and design, analysis and interpretation of the data, drafting of the manuscript, or critical revision for important intellectual content. AMWL and MAY designed the study. AMWL, MAY, and YMCL drafted the manuscript. AMWL, MAY, and YMCL collected and analyzed the data. AMWL, YMCL, MG, JM, PP, ALV, MAF, AKA, KL, DHS, BBA, KN, AFB, SPT, and MAY reviewed and edited the manuscript.
Funding statement
This work was supported by the UCLA-UCI Center for Eliminating Cardiometabolic Disparities in Multi-Ethnic Populations (NIH/NIMHD P50-MD017366) and the NIMHD Loan Repayment Program. The content of this manuscript is the responsibility of the authors and does not necessarily represent the official views of the funders.
Competing interests
No conflicts of interest to declare.
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