[Show abstract][Hide abstract] ABSTRACT: Introduction:
Blood pressure measurement in clinical care settings seldom follows the protocol recommended by national guidelines, potentially leading to overestimates or underestimates of blood pressure control. We evaluated blood pressure measurement methods as a source of bias in determining blood pressure control among community-dwelling adults with diabetes.
In a community-based trial of patients with diabetes, we measured both "clinical blood pressure" (clinical BP) (taken by a community nurse or medical assistant instructed to "take the participant's blood pressure like you do in your own clinic") and "research blood pressure" (research BP) (research staff followed a guideline-concordant protocol). Each participant had both types of blood pressure assessment on the same day over the course of 2 hours.
The 227 participants had a mean age of 59 years; 86% were black and 74% were women. The mean clinical BP was 5 mm Hg higher than the mean research BP for systolic blood pressure (P < .001) and 2 mm Hg higher for diastolic blood pressure (P < .001). The proportion of participants whose clinical BP was 130/80 mm Hg or higher was 8 percentage points higher than the proportion whose research BP was 130/80 mm Hg or higher (P < .001), and the proportion whose clinical BP was 140/90 mm Hg or higher was 10 percentage points higher than the proportion whose research BP was 140/90 mm Hg or higher (P < .001). Among those aged 65 years or older, the proportion whose clinical BP was 130/80 mm Hg or higher was 10 percentage points higher than proportion whose research BP was 130/80 mm Hg or higher, and the proportion whose clinical BP was 140/90 mm Hg or higher was 14 percentage points higher than the proportion whose research BP was 140/90 mm Hg or higher. Whites and smokers had the greatest risk for having a clinical BP 5 mm Hg or more higher than their research BP.
Measurement biases in clinical settings may be a component of observed poor blood pressure control rates in real-world settings.
Preview · Article · Jan 2016 · Preventing chronic disease
[Show abstract][Hide abstract] ABSTRACT: African American women are one of the least active demographic groups in the US, with only 36% meeting the national physical activity recommendations in comparison to 46% of White women. Physical activity begins to decline in African American women in adolescence and continues to decline into young adulthood. Yet, few interventions have been developed to promote physical activity in African American women during this critical period of life. The purpose of this article was to evaluate the acceptability and feasibility of a culturally-relevant Internet-enhanced physical activity pilot intervention for overweight/obese African American college females and to examine psychosocial and behavioral characteristics associated with intervention adherence and completion.
A 6-month single group pre-posttest design was used. Participants (n = 27) accessed a culturally-relevant Social Cognitive Theory-based physical activity promotion website while engaging in a minimum of four moderate-intensity physical activity sessions each week. Acceptability and feasibility of the intervention was assessed by participant retention and a consumer satisfaction survey completed by participants.
Fifty-six percent of participants (n = 15) completed the intervention. Study completers were more physically active at baseline (P = 0.05) and had greater social support for exercise from family members (P = 0.04). Sixty percent of study completers (n = 9) reported the website as "enjoyable" or "very enjoyable" to use and 60% (n = 9) reported increased motivation from participation in the physical activity program. Moreover, 87% (n = 13) reported they would recommend the website to a friend.
Results provide some preliminary support for the acceptability and feasibility of an Internet-enhanced physical activity program for overweight/obese African American women, while highlighting important limitations of the approach. Successful promotion of physical activity in college aged African American women as they emerge into adulthood may result in the development of life-long healthy physical activity patterns which may ultimately reduce physical activity-related health disparities in this high risk underserved population. Future studies with larger samples are needed to further explore the use of Internet-based programs to promote physical activity in this population.
Full-text · Article · Dec 2015 · BMC Research Notes
[Show abstract][Hide abstract] ABSTRACT: Obesity rates are disproportionately high among Latinas living in the United States. Few community-based weight management studies have focused on Latina immigrants living in emerging Latino communities. The purpose of this study was to develop and pilot test a theory-based, promotora-delivered, peer support weight loss intervention for Latina immigrants to be administered in a community setting. We employed participatory methods to develop an 8-week program grounded in self-determination theory. Overweight Latina immigrants were recruited to participate in a quasi-experimental pilot study. Data collected pre and post-intervention included height, weight, fasting lipids, glucose, dietary practices, physical activity and depressive symptoms.
Twenty-two women completed the intervention. Mean age was 36, mean time in the U.S. was 12 years; the majority was from Mexico. Mean BMI was 33; 68% had a family history of diabetes. The intervention resulted in statistically significant weight loss (mean 2.1 kg, SD 2.6, p < 0.001); mean change in weight remained significant when compared with that of a historical control group (-2.1 kg vs 1.10 kg, p < 0.01) but was attenuated at 6 months. Levels of moderate physical activity increased significantly (p < 0.05) and dietary practices improved (p < 0.01) and remained significant at 6 months. Notably, depressive symptoms also improved (p = <0.001).
This theory-based, promotora-delivered intervention resulted in significant weight loss among a sample of Latina immigrants at 8 weeks. Future studies are needed to test the impact of an extended peer support intervention on long-term weight management.
National Clinical Trials: NCT02344212. Registered 21 January 2015.
[Show abstract][Hide abstract] ABSTRACT: Low-income, African-American smokers are less likely to have resources to aid in quitting smoking. Narrative communication may provide an enhancement to traditional smoking cessation interventions like NRT, medications, or behavioral treatments for this audience. After extensive pilot testing of stories and personal experiences with smoking cessation from African-Americans from a low-income community, we conducted a randomized control trial using stories to augment routine inpatient treatment among African-Americans at an urban Southern hospital (N = 300).
Differences in smoking cessation outcomes between the intervention (stories DVD + routine clinical treatment) and control (routine clinical treatment) arms were compared using self-report and carbon monoxide measurement at 6-months. Compared to control, individuals who viewed the intervention stories DVD reported greater intentions to quit. Although continuous quitting marginally favored the intervention, our main result did not reach statistical significance (p = 0.16).
Narrative communication via storytelling to promote smoking cessation among African-Americans in the South is one method to communicate smoking cessation. Results suggest this may not be sufficient as a stand-alone augmentation of routine clinical treatment for continuous smoking cessation. Smoking cessation efforts need to continually assess different means of communicating to smokers about quitting.
Clinical Trials Registration: The ClinicalTrials.gov Identifier is NCT00101491. This trial was registered January 10, 2005
[Show abstract][Hide abstract] ABSTRACT: We qualitatively assessed patients' perceptions of discrimination and patient satisfaction in the health care setting specific to interactions with nonphysician health care staff.
We conducted 12 focus-group interviews with African American and European American participants, stratified by race and gender, from June to November 2008. We used a topic guide to facilitate discussion and identify factors contributing to perceived discrimination and analyzed transcripts for relevant themes using a codebook.
We enrolled 92 participants: 55 African Americans and 37 European Americans, all of whom reported perceived discrimination and lower patient satisfaction as a result of interactions with nonphysician health care staff. Perceived discrimination was associated with 2 main characteristics: insurance or socioeconomic status and race. Both verbal and nonverbal communication style on the part of nonphysician health care staff were related to individuals' perceptions of how they were treated.
The behaviors of nonphysician health care staff in the clinical setting can potentially contribute to patients' perceptions of discrimination and lowered patient satisfaction. Future interventions to reduce health care discrimination should include a focus on staff cultural competence and customer service skills. (Am J Public Health. Published online ahead of print August 13, 2015: e1-e7. doi:10.2105/AJPH.2015.302721).
No preview · Article · Aug 2015 · American Journal of Public Health
[Show abstract][Hide abstract] ABSTRACT: Latinas in the US report high levels of physical inactivity and are disproportionally burdened by related health conditions (eg, type 2 diabetes, obesity), highlighting the need for innovative strategies to reduce these disparities. A 1-month single-arm pretest-posttest design was utilized to assess the feasibility and acceptability of a culturally and linguistically adapted Internet-based physical activity intervention for Spanish-speaking Latinas. The intervention was based on the Social Cognitive Theory and the Transtheoretical Model. Changes in physical activity and related psychosocial variables were measured at baseline and the end of the 1-month intervention. The sample included 24 Latina adults (mean age, 35.17 ± 11.22 years). Most (83.3%) were born outside the continental US. Intent-to-treat analyses showed a significant increase (P = .001) in self-reported moderate- to vigorous-intensity physical activity from a median of 12.5 min/wk at baseline to 67.5 min/wk at the 1-month assessment. Participants reported significant increases in self-efficacy as well as cognitive and behavioral processes of change. Nearly half of the participants (45.8%) reported advancing at least one stage of change during the course of the 1-month intervention. Findings support the feasibility and acceptability of using interactive Internet-based technology to promote physical activity among Latinas in Alabama.
No preview · Article · Jun 2015 · Computers, informatics, nursing: CIN
[Show abstract][Hide abstract] ABSTRACT: In rural communities, high rates of diabetes and its complications are compounded by limited access to health care and scarce community resources. We systematically reviewed the evidence for the impact of diabetes self-management education interventions designed for patients living in rural areas on glycemic control and other diabetes outcomes. Fifteen studies met inclusion criteria. Ten were randomized controlled trials. Intervention strategies included in-person diabetes (n = 9) and telehealth (n = 6) interventions. Four studies demonstrated between group differences for biologic outcomes, four studies demonstrated changes in behavior, and three studies demonstrated changes in knowledge. Intervention dose was associated with improved A1c or weight loss in two studies and session attendance in one study. Interventions that included collaborative goal-setting were associated with improved metabolic outcomes and self-efficacy. Telehealth and face-to-face diabetes interventions are both promising strategies for rural communities. Effective interventions included collaborative goal-setting. Intervention dose was linked to better outcomes and higher attendance.
No preview · Article · Jun 2015 · Current Diabetes Reports
[Show abstract][Hide abstract] ABSTRACT: Community health worker (CHW) interventions have potential to improve diabetes outcomes and reduce health disparities. However, few studies have explored patient perspectives of peer-delivered diabetes programs. The purpose of this qualitative study is to investigate possible benefits as well as risks of CHW-delivered peer support for diabetes from the perspectives of African American women living with type 2 diabetes in Jefferson County, Alabama. Four ninety-minute focus groups were conducted by a trained moderator with a written guide to facilitate discussion on the topic of CHWs and diabetes management. Participants were recruited from the diabetes education database at a safety-net hospital. Two independent reviewers performed content analysis to identify major themes using a combined deductive-inductive approach. There were 25 participants. Mean years with diabetes was 11.2 (range 6 months to 42 years). Participants were knowledgeable about methods for self-management but reported limited resources and stress as major barriers. Preferred CHW roles included liaison to the healthcare system and easily accessible information source. Participants preferred that the CHW be knowledgeable and have personal experience managing their own diabetes or assisting a family member with diabetes. Concerns regarding the CHW-model were possible breaches of confidentiality and privacy. The self-management strategies and barriers to management identified by participants were reflected in their preferred CHW roles and traits. These results suggest that African American women with diabetes in Alabama would support peer-led diabetes education that is community-based and socially and emotionally supportive.
No preview · Article · Mar 2015 · Journal of Community Health
[Show abstract][Hide abstract] ABSTRACT: Background:
Latinos are the fastest growing minority group in the Southeastern USA. Latinos living in the USA have a higher prevalence of obesity, metabolic diseases, and physical inactivity compared to non-Latino Whites, particularly Latina women. The objective of this study is to assess the patterns of physical activity (PA) in overweight Latina immigrants in Alabama using a self-report and an accelerometer.
Participants included foreign-born Latina women age ≥19 years with BMI ≥25 kg/m(2). The Global Physical Activity Questionnaire was used to assess self-reported physical activity. Accelerometers were used as an objective measure of physical activity.
Among 44 overweight/obese Latina immigrants (mean age 36.6 years and BMI 33.3 kg/m(2)), 36.4 % met PA recommendations by self-report while only 20.5 % met recommendations according to the accelerometer. Self-report sedentary activity was underestimated (186 min/day self-report vs. 575 min/day accelerometer) while moderate activity was overestimated (34 min/day self-report vs. 15 min/day accelerometer). While the number of years living in the USA was positively associated with vigorous activity (r=0.32, p= 0.03), the number of years living in Alabama tended to be positively associated with sedentary activity and negatively associated with moderate activity.
Latina immigrants living in Alabama overestimated the amount of time spent in moderate PA and underestimated time spent in sedentary activity.
[Show abstract][Hide abstract] ABSTRACT: Community Health Worker interventions offer a promising strategy for improving diabetes self-management and health outcomes, with evidence to support its effectiveness, particularly in underserved communities. However, there is limited evidence on how to most effectively integrate CHW programs with primary care efforts. Mobile health technology (mHealth) can connect CHWs to members of the health care team, creating synergy through the bidirectional exchange of information. This project represents a partnership between an academic institution, a safety net health system, and a local community based organization of African American Churches. Our overarching goal was to develop an effective model for the integration of a community health worker (CHW) delivered peer support program with primary care-based efforts to improve glycemic control and health outcomes. We employed an iterative, user-centered approach to develop an mHealth tool that allows for the effective and secure exchange of information between CHWs and the primary care team, allowing patients to benefit from coordinated efforts. Five CHWs and three health care providers were trained to use the system and provide real time feedback to the study team. To date, satisfaction with the system is high. We have enrolled 120 low-income African American patients with diabetes into an ongoing randomized controlled trial designed to demonstrate feasibility and provide an estimate of the intervention’s effectiveness. In this presentation we will describe development of the mHealth communication system in terms of both the process and the content. The integration of mHealth technology into CHW programs is innovative, advancing the science of developing and delivering sustainable community-based interventions.
[Show abstract][Hide abstract] ABSTRACT: Background: African Americans are disproportionately affected by the diabetes epidemic; they suffer greater diabetes-related complications and face more problems with diabetes self-management than non-Hispanic whites. Increasingly, the community health worker (CHW) model has been implemented in an effort to improve health outcomes in underserved populations. While diabetes CHW interventions in the literature have been successful, the majority of CHWs as well as the participants have been women. Further research is needed regarding men’s perceptions of how community-based interventions to promote diabetes self-management might best be implemented. The purpose of this qualitative study is to explore how African American men living with type 2 diabetes perceive the role and duties of the community health worker in the context of a community-delivered diabetes management program.
Methods: Four ninety-minute focus groups were guided by a trained moderator with a written guide to facilitate discussion on the topic of community health workers (CHWs) and diabetes management. Participants were recruited from the diabetes education database at Cooper Green Mercy Hospital in Birmingham, AL. Two independent reviewers performed content analysis to identify major themes using an iterative, combined deductive and inductive approach.
Results: There were 25 male participants. Mean years living with diabetes was 9.6 (range 1-20). Participants demonstrated knowledge of self-management strategies and identified various hardships including emotional and physical manifestations of diabetes, dietary restrictions and non-adherence, and institutional frustrations with the medical system that contributed to self-management barriers. Participants preferred CHWs be knowledgeable with a shared experience. Their preferred CHW duties were to educate, hold support groups, help track daily activities, and help find resources. Potential concerns regarding CHWs included cultural competency and confidentiality. The participants also discussed the importance of family-focused support dynamics.
Conclusions: Participants identified critical self-management strategies but endure hardships that present barriers to achieving these methods. Many of the strategies and barriers to self-management that participants identified mirrored their preferred CHW duties and traits. Results from this study suggest that African American men in Alabama would participate in and benefit from a community-delivered diabetes management program.
[Show abstract][Hide abstract] ABSTRACT: Objectives: Research and interventions have been directed at physicians in order to attempt to address perceived racial/ethnic discrimination in medical care and potentially provide more equitable care across the US population. However, little is known about the contributions of other ancillary medical staff (e.g., nurses, medical assistants, and receptionists) to perceived discrimination in medical care.
Methods: We conducted focus group interviews with African-American (AA) and European-American (EA) participants stratified by race and gender who interacted with the Alabama health care system in the previous 12 months. We utilized a focus group topic guide, based on Social Cognitive Theory, in order to probe for personal, behavioral, and environmental factors that contribute to perceived discrimination in health care. Group interviews were audio recorded. Two investigators independently analyzed the transcribed focus group interviews for relevant themes.
Results: 29 AA women (mean age and standard deviation, 47±10 years), 24 AA men (53±11 years), 18 EA women (54±15 years), and 19 EA men (39±13 years) participated in 12 focus groups. We identified several main themes related to perceptions of staff bias including communication and personal attitudes/behaviors. Communication included both verbal and non-verbal forms of communication. For example, “It’s the way they talk to you…they can talk to you like you’re below average, you know, just the tone of the voice.” Personal attitudes/behavior themes were identified with words such as “personable”, “respectful”, and “takes their time.” Some focus group response examples included, “I mean, [they] look at you, like, up and down, like you ain’t nothing,” and “they’re kind to somebody right before you, and they’re not to you. They’re short-spoken to you.”
Conclusions: The behaviors of ancillary staff in the health care setting can potentially contribute to patients’ perceptions of discrimination. Future efforts to reduce health care discrimination interventions should include a focus on staff’s cultural competence and customer service skills.
[Show abstract][Hide abstract] ABSTRACT: Purpose: Trust in your physician has been previously linked to better glycemic control. We examined the relationship between general trust in physicians and diabetic outcomes as measured through blood pressure and glycemic control (HbA1c).
Methods: This is a secondary data analysis using cross-sectional data from a community-based trial. Patients were mostly African Americans with diabetes living in southern, rural Alabama. Face-to-face interviews by trained interviewer assessed general trust in physicians using a previously validated instrument (TMP-11). HbA1c and blood pressure were measured at baseline using a standardized protocol. Categorical variables were compared using chi square tests. Continuous variables were compared using bivariate linear regression. Multivariable analyses included general linear regression models adjusted for gender, income, education, insulin use, medication adherence, number of ambulatory visits, perceived discrimination, and depressive symptoms.
Results: 418 patients provided information for the trust scale (6 were missing). Mean age was 59, 75% were female and 87% were African American. High Trust (TMP > 30) was associated with older age, less perceived discrimination, and lower medication adherence. In bivariate analyses, HbA1c (p=0.26) and mean blood pressure (p=0.64) showed no significant association with provider trust.
Discussion: General trust in physicians was not associated with change in glycemic control or blood pressure at follow-up in unadjusted analyses. Though it did not reach statistical significance, higher general trust was associated with higher systolic blood pressure. Future research should further explore these relationships.
[Show abstract][Hide abstract] ABSTRACT: Background: Diabetes Connect is a small-randomized control trial designed to test a 6 month community-based peer support intervention that is integrated into primary care efforts for low-income African American patients with type 2 diabetes in Jefferson County, Alabama. The study is a collaboration between a university, a local safety-net health system, and a community-based organization (CBO) of 10 African American Churches. This paper describes the recruitment activities employed in the study along with lessons learned.
Methods: Potential participants with type 2 diabetes were identified from the health system database. Patients were sent letters inviting them to recruitment events near their homes. An average of 144 letter invitations was sent for each event. Study staff also made phone calls to personally invite the patients. An average of 120 calls was made per event date. Of those who were called, 58% did not answer or were disconnected numbers, 27% declined, and 15% accepted the invitation. All potential participants received a 5-hour diabetes education program; events were held at local churches or at the local safety-net health system. Following the class, eligible individuals were invited to participate in the study. Food was provided at the class and all potential participants received a $15 gift card. Individuals who qualified for the study and completed the baseline questionnaire received an additional $15.
Results: There were 18 recruitment events. Fourteen were hosted by local churches and 4 were held at diabetes education classes. On average, 8% of those who the study team attempted to contact by phone attended recruitment events, making up 39% of total attendees. The other 61% of attendees had either received a letter invitation, were referred to diabetes education class by their health care provider, or both. All were consented and screened for participation in the study. Of the 239 patients who attended the events, 120 met inclusion criteria and were enrolled into the study. A mean of 13 (range 1 to 23) patients was screened and a mean of 6 (range 1 to 15) was enrolled at each event.
Conclusions: For this study, recruitment strategies included letters followed by personal phone calls, provision of education to all interested individuals, classes at trusted community locations with food provided, and small incentives for all potential participants. Recruitment in underserved communities can be enhanced by strong community partnerships, a flexible, iterative approach that acknowledges and attempts to address participants’ potential barriers to participation.