The Role of Family in Diabetes Management for Mexican American Adults

Introduction: The purpose of this study was to characterize how family influences diabetes self-management in Mexican American adults. Methods: Data were analyzed from previously collected data that included 34 semi-structured interviews with Hispanic adults with diabetes and six focus groups with 37 adults with diabetes and family members. Themes related to family and diabetes management were identified and analyzed using a modified template approach. Results: Family-related facilitators to T2DM self-management were (1) provides support, (2) provides motivation, and (3) desire to protect family from diabetes. Family-related challenges were (1) lack of support, (2) family responsibilities, and (3) stress related to family. Diabetes education was shared with family members. Family member perspectives on T2DM included (1) not knowing how to help, (2) effect on emotional wellbeing, (3) diabetes affects the whole family, and (4) family provides support. Conclusion: Most participants with T2DM felt supported by family, but many desired more social support and support surrounding dietary changes from family. Many felt family did not understand what living with diabetes meant for them. Most family members wished to learn more about how to help. Future interventions should include family members and teach them supportive strategies to support beneficial diabetes self-management behaviors.

Barriers and facilitators to smartwatch-based prehabilitation participation among frail surgery patients: a qualitative study

BACKGROUND

For older, frail adults, exercise before surgery through prehabilitation (prehab) may hasten return recovery and reduce postoperative complications. We developed a smartwatch-based prehab program (BeFitMe) for older adults that encourages and tracks at-home exercise. The objective of this study was to assess patient perceptions about facilitators and barriers to prehab generally and to using a smartwatch prehab program among older adult thoracic surgery patients to optimize future program implementation.

METHODS

We recruited patients, aged ≥50 years who had or were having surgery and were screened for frailty (Fried's Frailty Phenotype) at a thoracic surgery clinic at a single academic institution. Semi-structured interviews were conducted by telephone after obtaining informed consent. Participants were given a description of the BeFitMe program. The interview questions were informed by The Five "Rights" of Clinical Decision-Making framework (Information, Person, Time, Channel, and Format) and sought to identify the factors perceived to influence smartwatch prehab program participation. Interview transcripts were transcribed and independently coded to identify themes in for each of the Five "Rights" domains.

RESULTS

A total of 29 interviews were conducted. Participants were 52% men (n = 15), 48% Black (n = 14), and 59% pre-frail (n = 11) or frail (n = 6) with a mean age of 68 ± 9 years. Eleven total themes emerged. Facilitator themes included the importance of providers (right person) clearly explaining the significance of prehab (right information) during the preoperative visit (right time); providing written instructions and exercise prescriptions; and providing a preprogrammed and set-up (right format) Apple Watch (right channel). Barrier themes included pre-existing conditions and disinterest in exercise and/or technology. Participants provided suggestions to overcome the technology barrier, which included individualized training and support on usage and responsibilities.

CONCLUSIONS

This study reports the perceived facilitators and barriers to a smartwatch-based prehab program for pre-frail and frail thoracic surgery patients. The future BeFitMe implementation protocol must ensure surgical providers emphasize the beneficial impact of participating in prehab before surgery and provide a written prehab prescription; must include a thorough guide on smartwatch use along with the preprogrammed device to be successful. The findings are relevant to other smartwatch-based interventions for older adults.

Costs and Health Care Utilization Analysis of Medical Group Visits for Adults With Type 2 Diabetes in Community Health Centers

OBJECTIVE

We evaluated the economic impact of group visits (GVs) in adults with uncontrolled diabetes in community health centers (CHCs) in the United States.

RESEARCH DESIGN AND METHODS

In this prospective controlled trial, we implemented 6 monthly GV sessions in 5 CHCs and compared intervention patients (n=49) to control patients (n=72) receiving usual care within the same CHCs. We conducted patient chart reviews to obtain health care utilization data for the prior 6 months at baseline, 6 months (during the GV implementation), and 12 months (after the implementation). We also collected monthly logs of CHC expenses and staff time spent on activities related to GVs. Per-patient total costs included CHCs' expenses and costs associated with staff time and patients' health care use. For group comparison, we used the Wilcoxon rank-sum test and the bootstrapping method that was to bootstrap generalized estimating equation models.

RESULTS

The GV group had fewer 6-month hospitalizations (mean: GV: 0.06 vs. control: 0.24, rate: 6.1% vs. 19.4%) ( P ≤ 0.04) and similar emergency department visits at 12 months than the control group. Implementing GV incurred $1770 per-patient. The intervention cost $1597 more than the control at 6 months ($3021 vs. $1424) but saved $1855 at 12 months ($857 vs. $2712) ( P =0.002).

CONCLUSIONS

The diabetes GV care model reduced hospitalizations and had cost savings at 12 months, while it improved patients' diabetes-related quality of life and glucose control. Future studies should assess its lifetime cost-effectiveness through a randomized controlled trial.

Elements of Integrated Behavioral Health Associated with Primary Care Provider Confidence in Managing Depression at Community Health Centers

BACKGROUND

Depression is most often treated by primary care providers (PCPs), but low self-efficacy in caring for depression may impede adequate management. We aimed to identify which elements of integrated behavioral health (BH) were associated with greater confidence among PCPs in identifying and managing depression.

DESIGN

Mailed cross-sectional surveys in 2016.

PARTICIPANTS

BH leaders and PCPs caring for adult patients at community health centers (CHCs) in 10 midwestern states.

MAIN MEASURES

Survey items asked about depression screening, systems to support care, availability and integration of BH, and PCP attitudes and experiences. PCPs rated their confidence in diagnosing, assessing severity, providing counseling, and prescribing medication for depression on a 5-point scale. An overall confidence score was calculated (range 4 (low) to 20 (high)). Multilevel linear mixed models were used to identify factors associated with confidence.

KEY RESULTS

Response rates were 60% (N=77/128) and 52% (N=538/1039) for BH leaders and PCPs, respectively. Mean overall confidence score was 15.25±2.36. Confidence was higher among PCPs who were satisfied with the accuracy of depression screening (0.38, p=0.01), worked at CHCs with depression tracking systems (0.48, p=0.045), had access to patients' BH treatment plans (1.59, p=0.002), and cared for more patients with depression (0.29, p=0.003). PCPs who reported their CHC had a sufficient number of psychiatrists were more confident diagnosing depression (0.20, p=0.02) and assessing severity (0.24, p=0.03). Confidence in prescribing was lower at CHCs with more patients living below poverty (-0.66, p<0.001). Confidence in diagnosing was lower at CHCs with more Black/African American patients (-0.20, p=0.03).

CONCLUSIONS

PCPs who had access to BH treatment plans, a system for tracking patients with depression, screening protocols, and a sufficient number of psychiatrists were more confident identifying and managing depression. Efforts are needed to address disparities and support PCPs caring for vulnerable patients with depression.

Integration of primary care and behavioral health services in midwestern community health centers: A mixed methods study

INTRODUCTION

Integrating behavioral health (BH) and primary care is an important strategy to improve health behaviors, mental health, and substance misuse, particularly at community health centers (CHCs) where disease burden is high and access to mental health services is low. Components of different integrated BH models are often combined in practice. It is unknown which components distinguish developing versus established integrated BH programs.

METHOD

A survey was mailed to 128 CHCs in 10 Midwestern states in 2016. Generalized estimating equation models were used to assess associations between program characteristics and stage of integration implementation (precontemplation, contemplation, preparation, action, or maintenance). Content analysis of open-ended responses identified integration barriers.

RESULTS

Response rate was 60% (N = 77). Most CHCs had colocated BH and primary care services, warm hand-offs from primary care to BH clinicians, shared scheduling and electronic health record (EHR) systems, and depression and substance use disorder screening. Thirty-two CHCs (42%) indicated they had completed integration and were focused on quality improvement (maintenance). Being in the maintenance stage was associated with having a psychologist on staff (odds ratio [OR] = 7.16, 95% confidence interval [CI] [2.76, 18.55]), a system for tracking referrals (OR = 3.42, 95% CI [1.03, 11.36]), a registry (OR = 2.71, 95% CI [1.86, 3.94]), PCMH designation (OR = 2.82, 95% CI [1.48, 5.37]), and a lower proportion of Black/African American patients (OR = .82, 95% CI [.75, .89]). The most common barriers to integration were difficulty recruiting and retaining BH clinicians and inadequate reimbursement.

DISCUSSION

CHCs have implemented many foundational components of integrated BH. Future work should address barriers to integration and racial disparities in access to integrated BH. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Impact of diabetes group visits on patient clinical and self-reported outcomes in community health centers

BACKGROUND

Diabetes group visits (GVs) are a promising way to deliver high quality care but have been understudied in community health centers (CHCs), across multiple sites, or with a focus on patient-centered outcomes.

METHODS

We trained staff and healthcare providers from six CHCs across five Midwestern states to implement a 6-month GV program at their sites. We assessed the impact of diabetes GVs on patient clinical and self-reported outcomes and processes of care compared to patients receiving usual care at these sites during the same period using a prospective controlled study design.

RESULTS

CHCs enrolled 51 adult patients with diabetes with glycosylated hemoglobin (A1C) ≥ 8% for the GV intervention and conducted chart review of 72 patients receiving usual care. We analyzed A1C at baseline, 6, and 12 months, low-density lipoproteins (LDL), blood pressure, and patient-reported outcomes. GV patients had a larger decrease in A1C from baseline to 6 months (-1.04%, 95% CI: -1.64, -0.44) and 12 months (-1.76, 95% CI: -2.44, -1.07) compared to usual care; there was no change in blood pressure or LDL. GV patients had higher odds of receiving a flu vaccination, foot exam, eye exam, and lipid panel in the past year compared to usual care but not a dental exam, urine microalbumin test, or blood pressure check. For GV patients, diabetes distress decreased, diabetes-related quality of life improved, and self-reported frequency of healthy eating and checking blood sugar increased from baseline to 6 months, but there was no change in exercise or medication adherence.

CONCLUSIONS

A diabetes GV intervention improved blood glucose levels, self-care behaviors, diabetes distress, and processes of care among adults with elevated A1Cs compared to patients receiving usual care. Future studies are needed to assess the sustainability of clinical improvements and costs of the GV model in CHCs.

Adapting in-person diabetes group visits to a virtual setting across federally qualified health centers

Diabetes group visits (GVs) have been shown to improve glycemic control, enrich patient self-care, and decrease healthcare utilization among patients with type 2 diabetes mellitus (T2DM). While telehealth has become routine, virtual GVs remain understudied, especially in federally qualified health centers (FQHCs). We conducted a 5-year cluster randomized trial with a waitlist control group to test the impact of diabetes GVs on patients' outcomes in Midwestern FQHCs. Due to COVID-19, the 6 waitlisted FQHCs adapted to virtual GVs. FQHC staff were provided training and support to implement virtual GVs. The GV intervention included 6 monthly 1-1.5-h long education sessions and appointments with a primary care provider. We measured staff perspectives and satisfaction via GV session logs, monthly webinars, and staff surveys and interviews. Adaptations for implementation of virtual GV included: additional staff training, video conferencing platform use, decreased session length and group size, and adjusting study materials, activities, and provider appointments. Sites enrolled a total of 48 adults with T2DM for virtual GVs. Most FQHCs were urban and all FQHCs predominantly had patients on public insurance. Patients attended 2.1 ± 2.2 GVs across sites on average. Thirty-four patients (71%) attended one or more virtual GVs. The average GV lasted 79.4 min. Barriers to virtual GVs included patient technology issues and access, patient recruitment and enrollment, and limited staff availability. Virtual GV facilitators included providing tablets, internet access from the clinic, and technical support. Staff reported spending on average 4.9 h/week planning and implementing GVs (SD = 5.9). On average, 6 staff from each FQHC participated in GV training and 1.2 staff reported past GV experience. All staff had worked at least 1 year at their FQHC and most reported multiple years of experience caring for patients with T2DM. Staff-perceived virtual GV benefits included: empowered patients to manage their diabetes, provided patients with social support and frequent contact with providers, improved relationships with patients, increased team collaboration, and better patient engagement and care-coordination. Future studies and health centers can incorporate these findings to implement virtual diabetes GVs and promote accessible diabetes care.

Patient and Clinician Satisfaction With Diabetes Group Visits in Community Health Centers

Diabetes group visits (GVs) have been shown to improve glycemic control and quality of care. However, little is known about the patient and clinician experience. We trained staff to conduct a 6-month GV intervention at six community health centers (CHCs) for adults with uncontrolled diabetes. Patient satisfaction was analyzed using postintervention surveys. Clinician satisfaction was analyzed through pre and posttraining surveys and 1:1 semistructured interviews. Twenty-seven staff and clinicians were trained. Fifty-one adult patients were enrolled and 90% reported high satisfaction with the program. Patients enjoyed longer visits with peer support and felt better equipped to manage barriers to diabetes control. 88% of staff reported that they enjoyed taking part in the program and noted improved team morale, professional development, and increased interdisciplinary collaboration. Perceived challenges of GVs included time investment for a new program, integration into workflow, and staff turnover. Patient and staff satisfaction was high across multiple domains. Staff noted many benefits but reported challenges with patient recruitment and retention as well as the time needed to implement GVs.

Addiction Treatment Capacity in Health Centers: The Role of Medicaid Reimbursement and Targeted Grant Funding

OBJECTIVE

Expanding access to addiction screening and treatment in primary care, particularly in underserved communities, is a key part of the fight against the opioid epidemic. This study explored correlates of addiction treatment capacity in federally qualified health centers participating in the Midwest Clinicians' Network (MWCN).

METHODS

Two surveys were fielded to 132 MWCN health centers: the Health Center Survey and the Behavioral Health and Diabetes Provider Survey. A total of 77 centers and 515 primary care clinicians, respectively, responded to the surveys. Data were combined with data from the 2016 Uniform Data System and information about receipt of targeted Health Resources and Services Administration (HRSA) grant funding for addiction treatment capacity. Multivariable models examined associations between Medicaid reimbursement for addiction services, HRSA targeted grant funding, and different types of on-site addiction treatment capacity: psychiatrist and certified addiction counselor staffing, addiction counseling services, and medication-assisted treatment (MAT) for opioid addiction.

RESULTS

Health centers that received Medicaid behavioral health reimbursement were five times as likely as those that did not to offer addiction counseling and to employ certified addiction counselors. Health centers that received targeted HRSA funding for addiction services were more than 20 times as likely as those that did not to provide MAT and more than three times as likely to employ psychiatrists. Training needs and privacy protections on data related to addiction treatment were cited as barriers to building addiction treatment capacity.

CONCLUSIONS

Medicaid funding and targeted grant funding were associated with addiction treatment capacity in health centers.

National physician survey on glycemic goals and medical decision making for patients with type 2 diabetes

To describe how patient characteristics influence physician decision-making about glycemic goals for Type 2 diabetes.2016 survey of 357 US physicians. The survey included two vignettes, representing a healthy patient and an unhealthy patient, adapted from a past survey of international experts and a factorial design vignette that varied age, heart disease history, and hypoglycemia history. Survey results were weighted to provide national estimates.Over half (57.6%) of physicians recommended a goal HbA1c <7.0% for most of their patients. For the healthy patient vignette, physicians recommended a goal similar to that of international experts (<6.66% (95% Confidence Interval (CI), 6.61-6.71%) vs <6.5% (Interquartile range (IQR), 6.5-6.8%)). For the unhealthy patient, physicians recommended a lower goal than international experts (<7.38% (CI, 7.30-7.46) vs <8.0% (IQR, 7.5-8.0%)). In the factorial vignette, physicians varied HbA1c goals by 0.35%, 0.06%, and 0.28% based on age, heart disease history, and hypoglycemia risk, respectively. The goal HbA1c range between the 55-year-old with no heart disease or hypoglycemic events and the 75-year-old with heart disease and hypoglycemic events was 0.65%.Despite guidelines that recommend HbA1c goals ranging from <6.5% to <8.5%, US physicians seem to be anchored on HbA1c goals around <7.0%.

Using photovoice to promote diabetes self-management in Latino patients

Innovative, patient-centered interventions that employ novel educational methods are needed to address the burden of diabetes in the growing Latino population. Objective of this study was to assess the acceptability, feasibility, and perceived utility of photovoice in a diabetes self-management intervention for Latinos. Thirty-seven adults with diabetes attended a church-based self-management education program that included a photovoice exercise where participants were asked to take photographs to illustrate their successes and challenges in diabetes management. Participants discussed their photographs in the group classes and evaluated the exercise in an exit survey. Photographs and discussion notes were analyzed for prevalent themes. We measured participant participation in the photovoice activity, content of photographs, themes of the discussions that were prompted by the photographs in class, and participants' satisfaction with the photovoice exercise. Of the 37 participants, 70% took photos and 65% shared them in class. Photos depicted family, social gatherings, diet, exercise, the neighborhood, diabetes supplies and medications, and home life. Almost all the group discussions involved aspects of social support, including giving advice, empathizing, or providing motivation for self-care to one another. Eighty-six percent reported learning how to better manage their diabetes from others' photos; 93% noted sharing photos made them feel connected to the group. In a diabetes self-management education program, photovoice was well received by Latino adults and provided a vehicle to receive and provide social support in self-care. This trial was registered at clinicaltrials.gov with identifier NCT01288300.

Organizational Factors Influencing the Early Implementation Process of Diabetes Group Visits by Five Midwestern Community Health Centers: A Multisite Case Study Analysis

The objective was to identify facilitators and challenges of implementing diabetes group visits in 5 Midwestern community health center (CHC) settings that care for diverse patient populations. Interview data were collected from July to August 2015. An interview guide was developed to explore health center teams' initial experiences with diabetes group visit implementation. Interviews were conducted with 14 individuals who participated in a training prior to diabetes group visit implementation. Four levels of coding (open, in vivo, categorical, and thematic) were used to identify characteristics of group visit implementation in 5 CHCs. A semi-structured model encouraged interprofessional teamwork across all CHC teams. Self-appointed or chosen team champions were the "pulse" or central driving force of implementation. A designated time in the clinic for patients to receive education and psychosocial support enhanced engagement in diabetes self-management. Early buy-in from upper leadership was critical to securing fiscal and human resources as unexpected needs emerged during group visit implementation. Time commitment of clinic staff and providers for ongoing operations, socioeconomic challenges of patients, staff turnover, and billing were reported as challenges in the initial implementation process. This study acknowledges the influence of administrative and sociocultural factors on successful implementation of diabetes group visits. Future research should further explore how these factors influence successful adoption of diabetes group visits in health centers across the United States and the impact of group visit implementation on staff and patient outcomes.

Unmet Respite Needs of Children With Medical Technology Dependence

Children with medical technology dependency (MTD) require a medical device to compensate for a vital body function and substantial nursing care. As such, they require constant high-level supervision. Respite care provides caregivers with a temporary break, and is associated with reduced stress; however, there are often barriers. The study utilizes mixed methodology with the National Survey of Children with Special Health Care Needs (NS-CSHCN) and semistructured interviews with state-wide care coordinators to understand the gap for respite care services. Fifty-nine percent of parents who needed respite care received none. Parents of older children with MTD were more likely to report respite needs. Care coordinators described that home health shortages created barriers to respite care utilization, and the lack of respite care can lead to hospital readmission. Although respite care is a vital resource to support families of children with MTD, it is infrequently available, which can have severe consequences.

A Novel Lay Health Worker Training to Help Women Engage in Postabortion Contraception and Well-Woman Care

Young women, low-income women, and women of color make up a disproportionate share of abortion patients and experience higher rates of unintended pregnancy, maternal morbidity and mortality, and infant mortality. Furthermore, these individuals are also less likely to have access to preventive gynecologic care. Whereas lay health worker interventions have been developed to help link individuals to care in other fields, the use of such interventions to link individuals to preventive care after abortion is novel. This article describes a training protocol and curriculum that provided nonmedically trained individuals with knowledge, skills, and competency to conduct a behavioral theory–based counseling intervention to help individuals achieve self-identified goals regarding obtaining postabortion reproductive health care and contraception. When piloted with 60 patients presenting for abortion who lacked a regular health care provider and desired to delay pregnancy for at least 6 months, participants found the lay health worker skills and the counseling session highly acceptable. Specifically, participants reported feeling comfortable speaking to lay health workers about contraception and reproductive health care. These findings indicate that lay health worker interventions may present an important opportunity to help individuals address their postabortion preventive and contraceptive health care needs.

Gastric Ischemia and Cecal Necrosis: A Simultaneous Presentation of Two Rare Entities

A 65-year-old woman presented with right lower quadrant (RLQ) abdominal pain of three days duration. During her hospitalization, she underwent computed tomography (CT) of the abdomen, duplex ultrasound of the abdomen, esophagogastroduodenoscopy (EGD), and colonoscopy as part of a diagnostic workup. The workup identified high-grade obstructions of the celiac artery (CA), superior mesenteric artery (SMA), atypical appearing gastric ulcers, and a diffusely ulcerated cecum, which created a mass-like appearance. The patient developed cecal perforation despite mesenteric vessel stenting and ultimately required right hemicolectomy for definitive management. This case report represents a rare presentation of simultaneous gastric ischemia and cecal ischemia with necrosis in a patient with underlying peripheral vascular disease.

The Development and Validation of a Modesty Measure for Diverse Muslim Populations

This paper reports on the multi-phase development of an English-language modesty measure for use among Muslim populations. The process yielded a 10-item measure that has high levels of internal consistency reliability (Cronbach's α of 0.83), and has acceptable discriminant and predictive validity. Specifically although our modesty measure for Muslim women was found to be significantly correlated with measures of positive and negative religious (Islamic) coping, it was not significantly correlated with religious practice-based religiosity (discriminant validity). Further logistic modeling revealed higher modesty levels positively associated with forgoing mammography because of concerns about lack of same-sex providers (predictive validity).

Patient expectations of hypertension and diabetes medication: Excessive focus on short-term benefits

Objectives:

The objectives of this study are to assess patient perspectives on their perceived benefits of hypertension and diabetes medications and determine associations between perceived benefits and demographics, adherence, and disease control.

Methods:

We interviewed 60 adults with type 2 diabetes and hypertension on oral medications. Participants were asked what benefits they expected from taking their medications. Transcripts were analyzed using a modified template approach. Benefits were categorized into short-term, long-term, or misconceptions (e.g. “medications cure diabetes”). Associations between perceived benefits and demographics, adherence, hemoglobin A1c, and blood pressure were analyzed.

Results:

In general, participants had relatively high self-reported medication adherence and well-controlled disease. All participants identified benefits of their hypertension medications; however, only 85% identified benefits of their diabetes medications. Half described only short-term benefits (e.g. lower blood sugar) (48%); almost one-third described both short- and long-term benefits (e.g. prevent complications) (30% and 28%, respectively). In multivariate analysis, participants with higher comorbidity were more likely to name long-term benefits of hypertension medications (odds ratio 13.3 (1.8–97.8), p = 0.01).

Discussion:

Participants perceived short-term benefits of hypertension and diabetes medications more often than long-term benefits; participants with higher comorbidity identified more long-term benefits. Further studies are warranted to determine whether additional education on long-term benefits may improve adherence.

Development and Testing of the Provider and Staff Perceptions of Integrated Care (PSPIC) Survey

This article discusses development and testing of the Provider and Staff Perceptions of Integrated Care Survey, a 21-item questionnaire, informed by Singer and colleagues' seven-construct framework. Questionnaires were sent to 2,936 providers and staff at 100 federally qualified health centers and other safety net clinics in 10 Midwestern U.S. states; 332 were ineligible, leaving 2,604 potential participants. Following 4 mailings, 781 (30%) responded from 97 health centers. Item analyses, exploratory factor analysis, and confirmatory factor analysis were undertaken. Exploratory factor analysis suggests four latent factors: Teams and Care Continuity, Patient Centeredness, Coordination with External Providers, and Coordination with Community Resources. Confirmatory factor analysis confirmed these factor groupings. For the total sample, Cronbach's alpha exceeded 0.7 for each latent factor. Descriptive responses to each of the 21 Provider and Staff Perceptions of Integrated Care questions appear to have potential in identifying areas that providers and staff recognize as care integration strengths, and areas that may warrant improvement.

Physician perspectives on de-intensifying diabetes medications

Guidelines for diabetes care recommend that physicians select individualized glycemic goals based on life expectancy, diabetes duration, comorbidity, and resources/support. When patients have stable hemoglobin A1C (HbA1C) levels, guidelines lack recommendations on when diabetes medications should be de-intensified.To understand physicians' perspectives on de-intensifying diabetes medications in patients with type 2 diabetes.Cross-sectional survey, (February-June, 2015).Academic medical center and suburban integrated health system.Primary care and endocrinology physicians.Physicians' self-reported: awareness, agreement, and frequency of individualizing HbA1C goals; practice of de-intensifying diabetes medications; HbA1C values at which physicians de-intensify diabetes medications; and other patient factors physicians consider when de-intensifying diabetes medications.Response rate was 73% (156/213). Most physicians (78%) responded they were familiar with recommendations to individualize HbA1C goals. For patients with stable HbA1C levels, 80% of physicians reported they had initiated conversations about stopping medications; however, physicians differed in predefined HbA1C levels used to initiate conversations (HbA1C < 5.7%: 14%; HbA1C < 6.0%: 31%; HbA1C < 6.5%: 22%; individualized level: 21%). In multiple logistic regression, women physicians (odds ratio [OR] 3.0; confidence interval [CI] 1.1-8.2; P = 0.03) and physicians practicing fewer than 20 years (OR 2.8; CI 1.01-7.7; P = 0.048) were more likely to report de-intensifying diabetes medications.Individualizing glycemic goals and de-intensifying treatments are concepts well accepted by physicians in our sample. However, physicians vary considerably in reporting how they carry out recommendations to individualize and may be missing opportunities to stop or taper diabetes medications based on patients' individualized glycemic goals.

A motivational interviewing-based counseling intervention to increase postabortion uptake of contraception: A pilot randomized controlled trial

OBJECTIVE

To determine if a counseling intervention using the principles of motivational interviewing (MI) would impact uptake of long-acting reversible contraception (LARC) after abortion.

METHODS

We conducted a pilot randomized controlled trial comparing an MI-based contraception counseling intervention to only non-standardized counseling. Sixty women 15-29 years-old were randomized.

PRIMARY OUTCOME

uptake of LARC within four weeks of abortion.

SECONDARY OUTCOMES

uptake of any effective contraceptive, contraceptive use three months after abortion and satisfaction with counseling. Bivariate analysis was used to compare outcomes.

RESULTS

In the intervention arm, 65.5% of participants received a long-acting method within four weeks compared to 32.3% in the control arm (p=0.01). Three months after the abortion, differences in LARC use endured (60.0% vs. 30.8%, p=0.05). Uptake and use of any effective method were not statistically different. More women in the intervention arm reported satisfaction with their counseling than women in the control arm (92.0% vs. 65.4%, p=0.04).

CONCLUSION

Twice as many women in the MI-based contraception counseling intervention initiated and continued to use LARC compared to women who received only non-standardized counseling.

PRACTICE IMPLICATIONS

A contraception counseling session using the principles and skills of motivational interviewing has the potential to impact LARC use after abortion.

A Novel Strategy to Increase Identification of African-Born People With Chronic Hepatitis B Virus Infection in the Chicago Metropolitan Area, 2012-2014

INTRODUCTION

Most research on hepatitis B virus (HBV) infection in the United States is limited to Asian populations, despite an equally high prevalence among African immigrants. The purpose of this study was to determine testing and detection rates of HBV infection among African-born people residing in the Chicago metropolitan area.

METHODS

A hepatitis education and prevention program was developed in collaboration with academic, clinical, and community partners for immigrant and refugee populations at risk for HBV infection. Community health workers implemented chain referral sampling, a novel strategy for recruiting hard-to-reach participants, targeting African-born participants. Participants were tested in both clinical and nonclinical settings. To assess infection status, blood samples were obtained for hepatitis B surface antigen (HBsAg), core antibody, and surface antibody testing. Demographic information was collected on age, sex, health insurance status, country of origin, and years residing in the United States. Participants were notified of testing results, and HBsAg-positive participants were referred for follow-up medical care.

RESULTS

Of 1,000 African-born people who received education, 445 (45%) agreed to participate in HBV screening. There were 386 (87%) participants tested in clinical and 59 (13%) tested in nonclinical sites. Compared with participants who were tested in clinical settings, participants tested in nonclinical settings were older, were less likely to have health insurance, and had lived in the United States longer (P < .005 for each). Of these, most were from the Democratic Republic of the Congo (14%), Nigeria (13%), Ghana (11%), Somalia (11%), or Ethiopia (10%). There were 35 (8%) HBsAg-positive people, 37% had evidence of past infection, and 29% were immune.

CONCLUSIONS

Chain referral sampling identified many at-risk African-born people with chronic HBV infection. The large proportion of HBsAg-positive people in this sample reinforces the need for health promotion programs that are culturally appropriate and community-driven.

Religious beliefs and mammography intention: findings from a qualitative study of a diverse group of American Muslim women

OBJECTIVE

Studies suggest that American Muslim women underutilize mammography. While religion has a strong influence upon Muslim health behaviors, scant research has examined how religion-related beliefs inform Muslim women's intention for mammography. Our study identifies and examines such beliefs.

METHODS

Muslim women aged 40 years and older sampled from mosques participated in focus groups and individual interviews. Drawing upon the theory of planned behavior, interviews elicited salient behavioral, normative, and control beliefs regarding mammography and the influence of Islam upon screening intention.

RESULTS

Fifty women participated in 6 focus groups and 19 in semistructured interviews, with near-equal numbers of African American, South Asian, and Arab Muslims. Forty-two percent of participants had not had a mammogram within the past 2 years. Across differences in race/ethnicity and mammography status, women voiced four religion-related salient beliefs that inform mammography intention: (1) the perceived duty to care for one's health, (2) religious practices as methods of disease prevention, (3) fatalistic notions about health, and (4) comfort with gender concordant health care.

CONCLUSIONS

Religious beliefs influence decisions to pursue mammography across the ethnic/racial diversity of Muslim women. Notions about duty to God and the stewardship of one's body appear to enhance mammography intention. Theocentric notions of cure and illness and varied views regarding personal agency also inform decisional frames that impact mammography intention. Given the salience of religion among our participants, religiously tailored messages in interventions have the potential to enhance cancer screening.

Design and Evaluation of a Workplace Intervention to Promote Organ Donation

Background

A number of efforts have been made to improve rates of deceased organ donation. However, few have been specifically designed for implementation in the workplace.

Objectives

To design and evaluate a workplace intervention to increase documentation of intention to be posthumous organ donors, communication of donation intention to families, and family members' documentation of their donation intentions.

Methods

The study was a randomized controlled trial of corporate employees. Within each corporation, worksites were randomized to a control condition or 1 of 2 educational interventions. Measures included baseline and 1-month postintervention measures of stage of organ donation intention, stage of family notification, and family members' organ donation intention.

Results

Across 12 corporations, 40 worksites with a total of 754 participants were randomized. At 1-month follow-up, 495 participants (66%) completed a posttreatment questionnaire. The percentage of participants who signed organ donor cards increased in the 2 intervention groups (29%, P < .001, and 31%, P < .002) but not in the control group (17%, P = .454). The percentage who discussed their donation intentions with family members increased significantly across all 3 arms (39%-47%, P < .001). The mean percentage of participants' family members who signed organ donor cards increased by 14% in the control group ( P = .016) and by 17% in the 2 intervention groups ( P < .001).

Conclusions

Educational interventions in the corporate workplace setting can be effective in increasing organ donation intention, family notification, and recruitment of family members as potential organ donors.

How information about the time requirements and legacy effects of treatments influence decision-making in patients with diabetes and hypertension

OBJECTIVE

When deciding about diabetes treatments, patients are typically uninformed about how much time is required before (time requirements), or for how long treatments change outcomes (legacy effects). However, patients may be motivated to adopt treatments with time-related treatment information. We explored whether this information alters a patients' likelihood of starting medications.

RESEARCH DESIGN AND METHODS

We conducted semistructured interviews with 60 adults with type 2 diabetes for <10 years and hypertension on oral medications. We measured change in likelihood of starting medications after receiving time requirement (diabetes, 10 years; hypertension, 3 years) and legacy effect (diabetes, 10 additional years; hypertension, none) information. Responses were analyzed for themes about time-related treatment information.

RESULTS

At baseline, 70% of participants reported being very likely to start a recommended medication. Nearly half (40%) were less likely to start a diabetes medication after being informed of time requirements; but after being informed of legacy effects, 32% reported being more likely. Fewer participants changed likelihoods of starting antihypertensives with time-related information. Many participants expressed that medications' benefits were important to them regardless of time-related information. Participants considered time requirements for diabetes medications too long and compared them to their life expectancy. Many participants were interested in legacy effects of diabetes medications because they looked forward to discontinuing medications, although some expressed doubt that benefits could persist after stopping medications.

CONCLUSIONS

While prolonged time requirements may dissuade patients from adopting treatments, the promise of legacy effects may motivate patients to commit to diabetes treatments.

First Year Open Enrollment Findings: Health Insurance Coverage for Asian Americans and the Role of Navigators

The health insurance coverage established by the Patient Protection and Affordable Care Act has created an opportunity to reduce racial/ethnic disparities in healthcare. It is expected that of the 24 million individuals projected to join, nearly one-half will be non-white and one-fourth will speak a language other than English at home. Asian Americans are one of the fastest growing racial/ethnic groups in the USA. The majority are foreign born and experience limited English proficiency. The role of navigators has been shown to increase enrollment rates of public insurance programs. They are trusted for their shared traditions and sense of community. By conducting culturally-targeted outreach, Cambodian, Chinese, Vietnamese, Korean, and Laotian community-based organizations were able to reach individuals for whom the percentage of uninsured is disproportionately high. They enrolled eligible Asians immigrants in coverage despite language barriers and limited health knowledge. Through a collaborative network, a community-level intervention was implemented that was associated with increases in first year marketplace enrollment and greater likelihood of obtaining a primary care physician. Preventable illnesses, lost productivity, and inadequate healthcare are major hardships in immigrant communities that bear similar burdens to society. Bringing primary care to the underserved helps to contain these costs.

Family interventions to improve diabetes outcomes for adults

Diabetes self-care is a critical aspect of disease management for adults with diabetes. Since family members can play a vital role in a patient's disease management, involving them in self-care interventions may positively influence patients' diabetes outcomes. We systematically reviewed family-based interventions for adults with diabetes published from 1994 to 2014 and assessed their impact on patients' diabetes outcomes and the extent of family involvement. We found 26 studies describing family-based diabetes interventions for adults. Interventions were conducted across a range of patient populations and settings. The degree of family involvement varied across studies. We found evidence for improvement in patients' self-efficacy, perceived social support, diabetes knowledge, and diabetes self-care across the studies. Owing to the heterogeneity of the study designs, types of interventions, reporting of outcomes, and family involvement, it is difficult to determine how family participation in diabetes interventions may affect patients' clinical outcomes. Future studies should clearly describe the role of family in the intervention, assess quality and extent of family participation, and compare patient outcomes with and without family involvement.

Motivational interviewing to improve postabortion contraceptive uptake by young women: development and feasibility of a counseling intervention

OBJECTIVE

The objective was to develop and test a postabortal contraception counseling intervention using motivational interviewing (MI) and to determine the feasibility, impact and patient acceptability of the intervention when integrated into an urban academic abortion clinic.

STUDY DESIGN

A single-session postabortal contraception counseling intervention for young women aged 15-24 years incorporating principles, skills and style of MI was developed. Medical and social work professionals were trained to deliver the intervention, their competency was assessed, and the intervention was integrated into the clinical setting. Feasibility was determined by assessing ability to approach and recruit participants, ability to complete the full intervention without interruption and participant satisfaction with the counseling.

RESULTS

We approached 90% of eligible patients and 71% agreed to participate (n=20). All participants received the full counseling intervention. The median duration of the intervention was 29 min. Immediately after the intervention and at the 1-month follow-up contact, 95% and 77% of participants reported that the session was helpful, respectively.

CONCLUSIONS

MI counseling can be tailored to the abortion setting. It is feasible to train professionals to use MI principles, skills and style and to implement an MI-based contraception counseling intervention in an urban academic abortion clinic. The sessions are acceptable to participants.

IMPLICATIONS

The use of motivational interviewing in contraception counseling may be an appropriate and effective strategy for increasing use of contraception after abortion. This study demonstrates that this patient-centered, directive and collaborative approach can be developed into a counseling intervention that can be integrated into an abortion clinic.

Development of small molecule non-peptide formyl peptide receptor (FPR) ligands and molecular modeling of their recognition

Formyl peptide receptors (FPRs) are G protein-coupled receptors (GPCRs) expressed on a variety of cell types. These receptors play an important role in the regulation of inflammatory reactions and sensing cellular damage. They have also been implicated in the pathogenesis of various diseases, including neurodegenerative diseases, cataract formation, and atherogenesis. Thus, FPR ligands, both agonists and antagonists, may represent novel therapeutics for modulating host defense and innate immunity. A variety of molecules have been identified as receptor subtype-selective and mixed FPR agonists with potential therapeutic value during last decade. This review describes our efforts along with recent advances in the identification, optimization, biological evaluation, and structure-activity relationship (SAR) analysis of small molecule non-peptide FPR agonists and antagonists, including chiral molecules. Questions regarding the interaction at the molecular level of benzimidazoles, pyrazolones, pyridazin-3(2H)-ones, N-phenylureas and other derivatives with FPR1 and FPR2 are discussed. Application of computational models for virtual screening and design of FPR ligands is also considered.

Community health center provider and staff's Spanish language ability and cultural awareness

Many community health center providers and staff care for Latinos with diabetes, but their Spanish language ability and awareness of Latino culture are unknown. We surveyed 512 Midwestern health center providers and staff who managed Latino patients with diabetes. Few respondents had high Spanish language (13%) or cultural awareness scores (22%). Of respondents who self-reported 76-100% of their patients were Latino, 48% had moderate/low Spanish language and 49% had moderate/low cultural competency scores. Among these respondents, 3% lacked access to interpreters and 27% had neither received cultural competency training nor had access to training. Among all respondents, Spanish skills and Latino cultural awareness were low. Respondents who saw a significant number of Latinos had good access to interpretation services but not cultural competency training. Improved Spanish-language skills and increased access to cultural competency training and Latino cultural knowledge are needed to provide linguistically and culturally tailored care to Latino patients.

Integrating diabetes self-management interventions for mexican-americans into the catholic church setting

Churches provide an innovative and underutilized setting for diabetes self-management programs for Latinos. This study sought to formulate a conceptual framework for designing church-based programs that are tailored to the needs of the Latino community and that utilize church strengths and resources. To inform this model, we conducted six focus groups with mostly Mexican-American Catholic adults with diabetes and their family members (N = 37) and found that participants were interested in church-based diabetes programs that emphasized information sharing, skills building, and social networking. Our model demonstrates that many of these requested components can be integrated into the current structure and function of the church. However, additional mechanisms to facilitate access to medical care may be necessary to support community members' diabetes care.

Combating Obesity at Community Health Centers (COACH): a quality improvement collaborative for weight management programs

Community health centers (CHCs) seek effective strategies to address obesity. MidWest Clinicians' Network partnered with [an academic medical center] to test feasibility of a weight management quality improvement (QI) collaborative. MidWest Clinicians' Network members expressed interest in an obesity QI program. This pilot study aimed to determine whether the QI model can be feasibly implemented with limited resources at CHCs to improve weight management programs. Five health centers with weight management programs enrolled with CHC staff as primary study participants; this study did not attempt to measure patient outcomes. Participants attended learning sessions and monthly conference calls to build QI skills and share best practices. Tailored coaching addressed local needs. Topics rated most valuable were patient recruitment/retention strategies, QI techniques, evidence-based weight management, motivational interviewing. Challenges included garnering provider support, high staff turnover, and difficulty tracking patient-level data. This paper reports practical lessons about implementing a weight management QI collaborative in CHCs.

Spiritual and religious beliefs and practices and social support's relationship to diabetes self-care activities in African Americans

PURPOSE

The purpose of this study is to investigate the relationship among spiritual and religious beliefs and practices, social support, and diabetes self-care activities in African Americans with type 2 diabetes, hypothesizing that there would be a positive association.

METHOD

This cohort study used a cross-sectional design that focused on baseline data from a larger randomized control trial. Diabetes self-care activities (summary of diabetes self-care activities) and sociodemographic characteristics were assessed, in addition to spiritual and religious beliefs and practices and social support based on the systems of belief inventory subscales I (beliefs and practices) and II (social support).

RESULTS

There were 132 participants: most were women, middle-aged, obese, single, high school educated, and not employed. Based on Pearson correlation matrices, there were significant relationships between spiritual and religious beliefs and practices and general diet. Additional significant relationships were found for social support with general diet, specific diet, and foot care. Based on multiple linear regression, social support was a significant predictor for general diet, specific diet, and foot care. Sex was a significant predictor for specific diet, and income was a significant predictor for blood glucose testing.

CONCLUSIONS

The findings of this study highlight the importance of spiritual and religious beliefs and practices and social support in diabetes self-care activities. Future research should focus on determining how providers integrate patients' beliefs and practices and social support into clinical practice and include those in behavior change interventions.

Undergoing transformation to the patient centered medical home in safety net health centers: perspectives from the front lines

OBJECTIVES

Safety net health centers (SNHCs), which include federally qualified health centers (FQHCs) provide primary care for underserved, minority and low income patients. SNHCs across the country are in the process of adopting the patient centered medical home (PCMH) model, based on promising early implementation data from demonstration projects. However, previous demonstration projects have not focused on the safety net and we know little about PCMH transformation in SNHCs.

DESIGN

This qualitative study characterizes early PCMH adoption experiences at SNHCs.

SETTING AND PARTICIPANTS

We interviewed 98 staff (administrators, providers, and clinical staff) at 20 of 65 SNHCs, from five states, who were participating in the first of a five-year PCMH collaborative, the Safety Net Medical Home Initiative.

MAIN MEASURES

We conducted 30-45 minute, semi-structured telephone interviews. Interview questions addressed benefits anticipated, obstacles encountered, and lessons learned in transition to PCMH.

RESULTS

Anticipated benefits for participating in the PCMH included improved staff satisfaction and patient care and outcomes. Obstacles included staff resistance and lack of financial support for PCMH functions. Lessons learned included involving a range of staff, anticipating resistance, and using data as frequent feedback.

CONCLUSIONS

SNHCs encounter unique challenges to PCMH implementation, including staff turnover and providing care for patients with complex needs. Staff resistance and turnover may be ameliorated through improved health care delivery strategies associated with the PCMH. Creating predictable and continuous funding streams may be more fundamental challenges to PCMH transformation.

Patient trust in physicians and shared decision-making among African-Americans with diabetes

This study explores patient trust in physicians and its relationship to shared decision-making (SDM) among African-Americans with diabetes (types 1 and 2). We conducted a series of focus groups (n = 27) and in-depth interviews (n = 24). Topic guides were developed utilizing theoretical constructs. Each interview was audiotaped and transcribed verbatim. Each transcript was independently coded by two randomly assigned members of the research team; codes and themes were identified in an iterative fashion utilizing Atlas.ti software. The mean age of study participants was 62 years and 85% were female. We found that (1) race as a social construct has the potential to influence key domains of patient trust (interpersonal/relationship aspects and medical skills/technical competence), (2) the relationship between patient trust and shared decision-making is bidirectional in nature, and (3) enhancing patient trust may potentially increase or decrease SDM among African-Americans with diabetes. Mistrust of physicians among African-Americans with diabetes may partially be addressed through (1) patient education efforts, (2) physician training in interpersonal skills and cultural competence, and (3) physician efforts to engage patients in SDM. To help enhance patient outcomes among African-Americans with diabetes, physicians might consider incorporating strategies to simultaneously engender their patients' trust and encourage shared decision-making.

"One Can Learn From Other People's Experiences": Latino adults' preferences for peer-based diabetes interventions

PURPOSE

To assess Latino adults' preferences for peer-based diabetes self-management interventions and the acceptability of the church setting for these interventions.

METHODS

The authors partnered with 2 predominantly Mexican American churches in Chicago and conducted 6 focus groups with 37 adults who had diabetes or had a family member with diabetes. They assessed participant preferences regarding group education and telephone-based one-to-one peer diabetes self-management interventions. Systematic qualitative methods were used to identify the types of programming preferred by participants in the church setting.

RESULTS

Participants had a mean (SD) age of 53 (11) years. All participants were Latino, and more than half were born in Mexico (60%). Most participants were female (78%), had finished high school (65%), and had health insurance (57%). Sixty-five percent reported having a diagnosis of diabetes. Many participants believed the group-based and telephone-based one-to-one peer support programs could provide opportunities to share diabetes knowledge. Yet, the majority stated the group education model would offer more opportunity for social interaction and access to people with a range of diabetes experience. Participants noted many concerns regarding the one-to-one intervention, mostly involving the impersonal nature of telephone calls and the inability to form a trusting bond with the telephone partner. However, the telephone-based intervention could be a supplement to the group educational sessions. Participants also stated the church would be a familiar and trusted setting for peer-based diabetes interventions.

CONCLUSIONS

Church-based Latinos with diabetes and their family members were interested in peer-based diabetes self-management interventions; however, they preferred group-based to telephone-based one-to-one peer programs.

Early lessons from an initiative on Chicago's South Side to reduce disparities in diabetes care and outcomes

Interventions to improve health outcomes among patients with diabetes, especially racial or ethnic minorities, must address the multiple factors that make this disease so pernicious. We describe an intervention on the South Side of Chicago-a largely low-income, African American community-that integrates the strengths of health systems, patients, and communities to reduce disparities in diabetes care and outcomes. We report preliminary findings, such as improved diabetes care and diabetes control, and we discuss lessons learned to date. Our initiative neatly aligns with, and can inform the implementation of, the accountable care organization-a delivery system reform in which groups of providers take responsibility for improving the health of a defined population.

Patient-centered medical home characteristics and staff morale in safety net clinics

BACKGROUND

We sought to determine whether perceived patient-centered medical home (PCMH) characteristics are associated with staff morale, job satisfaction, and burnout in safety net clinics.

METHODS

Self-administered survey among 391 providers and 382 clinical staff across 65 safety net clinics in 5 states in 2010. The following 5 subscales measured respondents' perceptions of PCMH characteristics on a scale of 0 to 100 (0 indicates worst and 100 indicates best): access to care and communication with patients, communication with other providers, tracking data, care management, and quality improvement. The PCMH subscale scores were averaged to create a total PCMH score.

RESULTS

Six hundred three persons (78.0%) responded. In multivariate generalized estimating equation models, a 10% increase in the quality improvement subscale score was associated with higher morale (provider odds ratio [OR], 2.64; 95% CI, 1.47-4.75; staff OR, 3.62; 95% CI, 1.84-7.09), greater job satisfaction (provider OR, 2.45; 95% CI, 1.42-4.23; staff OR, 2.55; 95% CI 1.42-4.57), and freedom from burnout (staff OR, 2.32; 95% CI, 1.31-4.12). The total PCMH score was associated with higher staff morale (OR, 2.63; 95% CI, 1.47-4.71) and with lower provider freedom from burnout (OR, 0.48; 95% CI, 0.30-0.77). A separate work environment covariate correlated highly with the quality improvement subscale score and the total PCMH score, and PCMH characteristics had attenuated associations with morale and job satisfaction when included in models.

CONCLUSIONS

Providers and staff who perceived more PCMH characteristics in their clinics were more likely to have higher morale, but the providers had less freedom from burnout. Among the PCMH subscales, the quality improvement subscale score particularly correlated with higher morale, greater job satisfaction, and freedom from burnout.

Development of a safety net medical home scale for clinics

BACKGROUND

Existing tools to measure patient-centered medical home (PCMH) adoption are not designed for research evaluation in safety-net clinics.

OBJECTIVE

Develop a scale to measure PCMH adoption in safety-net clinics.

RESEARCH DESIGN

Cross-sectional survey.

SUBJECTS

Sixty-five clinics in five states.

MAIN MEASURES

Fifty-two-item Safety Net Medical Home Scale (SNMHS). The total score ranges from 0 (worst) to 100 (best) and is an average of multiple subscales (0-100): Access and Communication, Patient Tracking and Registry, Care Management, Test and Referral Tracking, Quality Improvement, and External Coordination. The scale was tested for internal consistency reliability and tested for convergent validity using The Assessment of Chronic Illness Care (ACIC) and the Patient-Centered Medical Home Assessment (PCMH-A). The scale was applied to centers in the sample. In addition, linear regression models were used to measure the association between clinic characteristics and medical home adoption.

RESULTS

The SNMHS had high internal consistency reliability (Cronbach's alpha = 0.84). The SNMHS score correlated moderately with the ACIC score (r = 0.64, p < 0.0001) and the PCMH-A (r = 0.56, p < 0.001). The mean SNMHS score was 61 ± SD 13. Among the subscales, External Coordination (66 ± 16) and Access and Communication (65 ± 14) had the highest mean scores, while Quality Improvement (55 ± 17) and Care Management (55 ± 16) had lower mean scores. Clinic characteristics positively associated with total SNMHS score were having more providers (β 15.8 95% CI 8.1-23.4 >8 provider FTEs compared to <4 FTEs) and participation in financial incentive programs (β 8.4 95% 1.6-15.3).

CONCLUSION

The SNMHS demonstrated reliability and convergent validity for measuring PCMH adoption in safety-net clinics. Some clinics have significant PCMH adoption. However, room for improvement exists in most domains, especially for clinics with fewer providers.

Reach-out: a family-based diabetes prevention program for African American youth

OBJECTIVE

To pilot test and assess the feasibility of a culturally grounded approach to adolescent overweight and diabetes prevention.

STUDY DESIGN

Reach-Out, a family-based nutrition and exercise program for overweight African American youth aged 9 to 12 years and their families, is led by lay health leaders and conducted in a community setting on Chicago's south side (Illinois). Age-appropriate interactive sessions focus on skills building, problem solving, and setting goals during 14 weekly sessions, with monthly meetings thereafter. Pre-post comparisons were made for 29 families (62 subjects) using physical (body mass index [BMI], blood pressure, waist circumference), biochemical (glucose, insulin, lipid levels) and behavioral data. Statistical analyses included mixed-effects linear models and logistic regression.

RESULTS

Children's mean BMI z score fell from 2.46 at baseline to 2.38 at 14 weeks and 2.39 at 1 year (p=.02), while parents' BMI remained stable. Children reported increased walking (p=0.07) and exhibited a corresponding rise in mean serum high-density lipoprotein cholesterol from 49.4 to 54.2 (p<.001). Qualitative assessment showed that participants enjoyed the program but felt the program could be improved by making the sessions even more interactive.

CONCLUSION

A community-based program for overweight minority youth and families can successfully address overweight, with the potential to decrease diabetes risk in youth.

Power-up: a collaborative after-school program to prevent obesity in African American children

BACKGROUND

Schools represent a key potential venue for addressing childhood obesity.

OBJECTIVE

To assess the feasibility of Power-Up, an after-school program to decrease obesity risk among African American children, using community-based participatory research (CBPR) principles.

METHODS

Teachers led 14 weekly nutrition and physical activity sessions during afterschool care at the Woodlawn Community School on Chicago's South Side. Forty African American children ages 5 to 12 participated; their 28 parents discussed similar topics weekly at pickup time, and families practiced relevant skills at home. Pre- and post-intervention anthropometrics, blood pressure, dietary measures, and health knowledge and beliefs for children and parents were compared in univariate analysis.

RESULTS

At baseline, 26% of children were overweight; 28% were obese. Post-intervention, mean body mass index (BMI) z scores decreased from 1.05 to 0.81 (p<.0001). Changes were more pronounced for overweight (-0.206 z-score units) than for obese children (-0.062 z-score units; p=.01). Girls decreased their combined prevalence of overweight/obesity from 52% to 46%; prevalence across these categories did not change for boys. The prevalence of healthful attitudes rose, including plans to "eat more foods that are good for you" (77% to 90%; p=.027) and "planning to try some new sports" (80% to 88%; p=.007).

CONCLUSION

Children in the Power-Up program reduced mean BMI z scores significantly. The after-school venue proved feasible. The use of CBPR principles helped to integrate Power-Up into school activities and contributed to likelihood of sustainability. Engaging parents effectively in the afterschool time frame proved challenging; additional strategies to engage parents are under development. Plans are underway to evaluate this intervention through a randomized study.

Overweight in Latino preschoolers: do parental health beliefs matter?

OBJECTIVE

To characterize the knowledge, attitudes, and beliefs (KAB) regarding childhood obesity among parents of Latino preschoolers.

METHODS

Three hundred sixty-nine Mexican immigrant parents of children ages 2-5 were interviewed. Children were weighed and measured.

RESULTS

Parents underestimated their own child's weight status and had high levels of perceived control over their children's eating and activity behaviors. Parents of overweight (>95%ile-for-age-and-sex BMI) versus nonoverweight (<95%ile BMI) children did not differ in their beliefs about ideal child body size.

CONCLUSION

Latino parents of overweight children did not differ from parents of nonoverweight children with respect to their KAB about childhood obesity.

Race and shared decision-making: perspectives of African-Americans with diabetes

Shared decision-making (SDM) is an important component of patient-centered healthcare and is positively associated with improved health outcomes (e.g. diabetes and hypertension control). In shared decision-making, patients and physicians engage in bidirectional dialogue about patients' symptoms and treatment options, and select treatment plans that address patient preferences. Existing research shows that African-Americans experience SDM less often than whites, a fact which may contribute to racial disparities in diabetes outcomes. Yet little is known about the reasons for racial disparities in shared decision-making. We explored patient perceptions of how race may influence SDM between African-American patients and their physicians. We conducted in-depth interviews (n=24) and five focus groups (n=27) among a purposeful sample of African-American diabetes patients aged over 21 years, at an urban academic medical center in Chicago. Each interview/focus group was audio-taped, transcribed verbatim and imported into Atlas.ti software. Coding was conducted iteratively; each transcription was independently coded by two research team members. Although there was heterogeneity in patients' perceptions about the influence of race on SDM, in each of the SDM domains (information-sharing, deliberation/physician recommendations, and decision-making), participants identified a range of race-related issues that may influence SDM. Participants identified physician bias/discrimination and/or cultural discordance as issues that may influence physician-related SDM behaviors (e.g. less likely to share information such as test results and more likely to be domineering with African-American patients). They identified mistrust of white physicians, negative attitudes and internalized racism as patient-related issues that may influence African-American patients' SDM behaviors (e.g. less forthcoming with physicians about health information, more deference to physicians, less likely to adhere to treatment regimens). This study suggests that race-related patient and physician-related barriers may serve as significant barriers to shared decision-making between African-American patients and their physicians. Finding innovative ways to address such communication barriers is an important area of future research.

Barriers and facilitators to shared decision-making among African-Americans with diabetes

INTRODUCTION

Shared decision-making (SDM) between patients and their physicians is associated with improved diabetes health outcomes. African-Americans have less SDM than Whites, which may contribute to diabetes racial disparities. To date, there has been little research on SDM among African-Americans.

OBJECTIVE

We explored the barriers and facilitators to SDM among African-Americans with diabetes.

METHODS

Qualitative research design with a phenomenological methodology using in-depth interviews (n = 24) and five focus groups (n = 27). Each interview/focus group was audio-taped and transcribed verbatim, and coding was conducted using an iterative process.

PARTICIPANTS

We utilized a purposeful sample of African-American adult patients with diabetes. All patients had insurance and received their care at an academic medical center.

RESULTS

Patients identified multiple SDM barriers/facilitators, including the patient/provider power imbalance that was perceived to be exacerbated by race. Patient-related factors included health literacy, fear/denial, family experiences and self-efficacy. Reported physician-related barriers/facilitators include patient education, validating patient experiences, medical knowledge, accessibility and availability, and interpersonal skills.

DISCUSSION

Barriers/facilitators of SDM exist among African-Americans with diabetes, which can be effectively addressed in the outpatient setting. Primary care physicians, particularly academic internists, may be uniquely situated to address these barriers/facilitators and train future physicians to do so as well.

How is shared decision-making defined among African-Americans with diabetes?

OBJECTIVE

This study investigates how shared decision-making (SDM) is defined by African-American patients with diabetes, and compares patients' conceptualization of SDM with the Charles model.

METHODS

We utilized race-concordant interviewers/moderators to conduct in-depth interviews and focus groups among a purposeful sample of African-American patients with diabetes. Each interview/focus group was audio-taped, transcribed verbatim and imported into Atlas.ti software. Coding was done using an iterative process and each transcription was independently coded by two members of the research team.

RESULTS

Although the conceptual domains were similar, patient definitions of what it means to "share" in the decision-making process differed significantly from the Charles model of SDM. Patients stressed the value of being able to "tell their story and be heard" by physicians, emphasized the importance of information sharing rather than decision-making sharing, and included an acceptable role for non-adherence as a mechanism to express control and act on treatment preferences.

CONCLUSION

Current instruments may not accurately measure decision-making preferences of African-American patients with diabetes.

PRACTICE IMPLICATIONS

Future research should develop instruments to effectively measure decision-making preferences within this population. Emphasizing information-sharing that validates patients' experiences may be particularly meaningful to African-Americans with diabetes.

Predicting changes in staff morale and burnout at community health centers participating in the health disparities collaboratives

OBJECTIVE

To identify predictors of changes in staff morale and burnout associated with participation in a quality improvement (QI) initiative at community health centers (HCs).

DATA SOURCES

Surveys of staff at 145 HCs participating in the Health Disparities Collaboratives (HDC) program in 2004. DATA COLLECTION AND STUDY DESIGN: Self-administered questionnaire data collected from 622 HC staff (68 percent response rate) were analyzed to identify predictors of reported change in staff morale and burnout. Predictive categories included outcomes of the QI initiative, levels of HDC integration, institutional support, the use of incentives, and demographic characteristics of respondents and centers.

PRINCIPAL FINDINGS

Perceived improvements in staff morale and reduced likelihood of staff burnout were associated with receiving personal recognition, career promotion, and skill development opportunities. Similar outcomes were associated with sufficient funding and personnel, fair distribution of work, effective training of new hires, and consistent provider participation.

CONCLUSIONS

Having sufficient personnel available to administer the HDC was found to be the strongest predictor of team member satisfaction. However, a number of low-cost, reasonably modifiable, organizational and leadership characteristics were also identified, which may facilitate improvements in staff morale and reduce the likelihood of staff burnout at HCs participating in the HDC.

Provider perceptions of limited health literacy in community health centers

OBJECTIVE

To examine techniques used by community health center (HC) providers to care for patients with limited health literacy (LHL).

METHODS

Survey mailed to 803 HC providers in 10 Midwestern states. Response rate was 47.5%. Associations between variables were examined using generalized estimating equations (GEE) models to account for clustering of respondents within HCs.

RESULTS

The average provider estimates of LHL prevalence among English- and Spanish-speaking patients were 41+/-24% (mean+/-S.D.) and 48+/-30%, respectively. Those with training in health literacy were more likely to have patients repeat instructions back to check understanding (OR=2.05 and p=0.04) and were more likely to give out health education materials designed for patients with LHL (OR=2.80 and p=0.0002). Providers differed by type in encouraging patients to bring friends or family members to appointments (p=0.02).

CONCLUSION

Providers estimate LHL to be highly prevalent in their HCs, and use various techniques to assist patients.

PRACTICE IMPLICATIONS

Training in health literacy is associated with increased usage of evidence-based techniques to assist patients with LHL. Providers at all levels would likely benefit from LHL training. Most providers believe providing health education materials designed specifically for patients with LHL would be very helpful.

Reducing health disparities in depressive disorders outcomes between non-Hispanic Whites and ethnic minorities: a call for pragmatic strategies over the life course

There are significant disparities in treatment process and symptomatic and functional outcomes in depressive disorders for racial and ethnic minority patients. Using a life-course perspective, the authors conducted a systematic review of the literature to identify modifiable mechanisms and effective interventions for prevention and treatment at specific points -- system, community, provider, and individual patient -- in health care settings. Multicomponent chronic disease management interventions have produced improvements in depression outcomes for ethnic minority populations. Case management appears to be a key component of effective interventions. Socioculturally tailored treatment and prevention interventions may be more efficacious than standard treatment programs. Future research should focus on identifying key components of case management and sociocultural tailoring that are essential for effective interventions and developing new low-cost dissemination mechanisms for treatment and preventive programs that could be tailored to racial and ethnic minorities.

The Clinical, Psychosocial, and Socioeconomic Concerns of Urban Youth Living With Diabetes

OBJECTIVE

Young people with chronic diseases face the challenge of moving from the pediatric to the adult health care environment, in addition to the normal hurdles of young adulthood. To most effectively help them through this process, we must first understand their perspective.

DESIGN

Qualitative study of the social and emotional impact of having diabetes.

SAMPLE

Young adults (n=23), aged 19-26, who had been living with diabetes for a median of 12 years (range 4-19) were contacted; all but one were from underserved ethnic minorities.

MEASUREMENTS

Semistructured telephone interviews were conducted, transcribed, and coded.

RESULTS

Having diabetes profoundly affected the life choices and expectations of these young people; their feelings and attitudes evolved over time. Financial and insurance concerns were key, because managing diabetes care on one's own as an adult was a major challenge. Most young people reported that family, friends, and coworkers were sources of support, but that disclosure of their diabetes was problematic.

CONCLUSIONS

Offering emotional and practical support to young adults coping with diabetes is key to ensuring adequate medical management as they move into the adult system and assume full responsibility for their health.