Economic Adversity Transitions From Childhood to Older Adulthood Are Differentially Associated With Later-Life Physical Performance Measures in Men and Women in Middle and High-Income Sites

Objective: This study examines the relationship between economic adversity transitions from childhood to older adulthood and older adulthood physical performance among 1,998 community-dwelling older adults from five demographically diverse sites from middle and high-income countries. Method: The principal exposure variable was economic adversity transition. No adversity encompassed not experiencing poverty in both childhood and older adulthood, improved described having only experienced poverty in childhood, worsened captured having experienced poverty in older adulthood, and severe is having experienced poverty in both childhood and older adulthood. The short physical performance battery (SPPB) was used for outcome measures. Analyses of the continuous SPPB score used linear regression, while analysis of a binary outcome (SPPB < 8 vs. ≥8) used Poisson regression models with robust error variance, both adjusting for sex, education, and site location. Result: In sex-stratified models, the SPPB < 8 prevalence rate ratio (PRR) was higher for the severe (PRR: 2.80, 95% confidence interval [CI] = [1.70, 4.61]), worsened (PRR: 2.40, 95% CI = [1.41, 4.09]), and improved (PRR: 1.82, 95% CI = [1.11, 3.01]) groups, compared with those with no adversity in childhood or as adults, but only for females. Discussion: Findings from this study indicate that persistent economic adversity has a negative effect on older adult physical performance, especially among women.

Disparities in Diabetes Prevalence Among Native Hawaiians/Other Pacific Islanders and Asians in Hawai'i

Introduction

The prevalence of diabetes varies widely among racial/ethnic groups in Hawai‘i. How prevalence varies by age for Asian subgroups and Native Hawaiian/Other Pacific Islanders (NHOPIs) is understudied. We examined diabetes prevalence by age and race/ethnicity and assessed how socioeconomic status and lifestyle behaviors affected prevalence among Japanese, Filipino, Chinese, NHOPI, and white populations in Hawai‘i.

Methods

We studied 18,200 subjects aged 18 or older from the Hawai‘i Behavioral Risk Factor Surveillance System. We performed Poisson regression analyses to examine the prevalence of diabetes by race/ethnicity, age, sex, marital status, education, income, health care coverage, obesity, smoking and drinking status, physical activity, and fruit and vegetable consumption and examined the interactions of these factors with age and race/ethnicity.

Results

We found disparities in diabetes prevalence among respondents aged 35 to 44 and among Asians and NHOPIs, and disparities increased with age. NHOPIs and Filipinos had the highest prevalence of diabetes after controlling for other demographic factors and lifestyle variables. Japanese adults were less likely than NHOPIs and Filipinos to have diabetes; however, whites had the lowest prevalence. Income, physical activity, and obesity were the strongest predictors of diabetes.

Conclusion

NHOPIs and Filipinos have higher rates of diabetes compared with other races/ethnicities in Hawai‘i. More research is needed to reduce diabetes disparities among NHOPI and Filipino populations in Hawai‘i. This study also shows the importance of conducting age-specific analyses of racial/ethnic-subgroups for health disparities.

Aloha Undergraduates: Development and Application of Local & Indigenous Topics into an Undergraduate Public Health Curriculum

As public health education expands to include undergraduate students, it is important to include discussion of local public health topics and issues to provide a sense of place to the educational experience. Inclusion of Native Hawaiian and indigenous issues and perspectives is also an established priority of the University of Hawai‘i system. To address both needs, a required course was created during development of a new Bachelor of Arts (BA) public health program at the University of Hawai‘i at Mānoa to specifically focus on discussion of local and indigenous public health topics of interest. Public Health Issues in Hawai‘i is an introductory course included early in the recommended undergraduate curriculum and emphasizes the application of public health skills and principles to local issues (e.g., state-level legislative awareness and local sustainability topics). The Public Health Issues in Hawai‘i course further challenges students to recognize public health practice in their daily activities, and encourages them to become actively engaged in local community issues early in their public health educational careers. Among multiple advantages, improved awareness of local health challenges and early connections to community members and organizations have been instrumental in actively engaging local students in their education, and has also proved beneficial for students participating in required undergraduate applied learning capstone experiences and entry-level public health careers following graduation. Here we present insights into course development, articulation with broader program curricula, and successes and challenges in the past 4 years of implementation and instruction.

The Role of Collective Efficacy in Reducing Health Disparities: A Systematic Review

Many improvements in health equity are spearheaded by community collaborations working to change policy and social norms. But how can collective efficacy (CE), defined as the willingness and ability of a group to work toward a common good, be increased? Eight articles reporting on interventions aiming to reduce health disparities by improving CE were found for this systematic literature review. All studies showed improvements in CE and most found reduction in disparities, but operationalization of CE varied. Findings support a model of how CE can address health disparities, which can guide standardization of CE interventions and measures.

Patient empowerment: A critique of individualism and systematic review of patient perspectives

OBJECTIVE

The purpose of this review is two-fold: 1) to broaden conceptualization of patient empowerment by synthesizing qualitative research on patient perspectives, and 2) to examine how researcher's method and background may have affected their framing of patient empowerment, thereby shaping the results.

METHODS

A systematic search for qualitative research on patient definitions of power, powerlessness, and empowerment was completed. Articles were analyzed at three levels (theory, method, and data) as suggested by the meta-study method for qualitative synthesis.

RESULTS

The search yielded 13 articles from 11 investigator teams across 9 countries (the United Kingdom, Norway, Australia, Taiwan, New Zealand, China, Iran, Belgium and Italy). Emergent themes from patient perspectives included control, psychological coping, legitimacy, support, knowledge, and participation.

CONCLUSIONS

Despite variation in diagnosis, age, ethnicity, income and country of origin, patients share many perspectives on empowerment. Furthermore, there are indications that interview questions may have influenced findings such that structural barriers to empowerment were not deeply explored.

PRACTICE IMPLICATIONS

This review provides knowledge that can be of direct use to medical professionals who aim to increase patient empowerment (via findings on patient perspectives) and to researchers who can use the critical appraisal of past work to improve future research on this topic.

A Qualitative Study Exploring Yoga in Veterans with PTSD Symptoms

Quantitative studies of yoga have reported reduced posttraumatic stress disorder (PTSD) symptoms in veterans, but little is known about how and why veterans are attracted to and stick with a yoga practice. Guided by the Health Belief Model, this study examined veterans' perceptions of the benefits, barriers, and motivations to continue practicing trauma-sensitive yoga. Interviews were conducted with nine individuals, five of whom completed a 6-week trauma-sensitive yoga intervention designed for veterans and four who did not complete the intervention. Transcripts were analyzed for themes. The benefits identified by veterans were finding mental stillness, body awareness, and social connection. The barriers were perceptions that yoga is socially unacceptable, especially for men, and physically unchallenging. Understanding these benefits and barriers can help to make yoga more attractive to service members and veterans. For example, medical personnel can refer service members and veterans to yoga not only for PTSD symptoms, but also to address back pain and to reduce isolation. Access to male yoga instructors, especially those who are themselves service members or veterans, could be expanded, and classes could be integrated into physical activity routines required of active-duty personnel. Promotional materials can feature male service members and veterans with captions related to yoga as a way to increase resiliency, self-sufficiency, and physical and mental mission readiness. Findings from this study can help the Department of Defense and the Veterans Health Administration implement yoga as an adjunct or alternative treatment for veterans with PTSD symptoms.

Effect of the Children's Healthy Living Program on Young Child Overweight, Obesity, and Acanthosis Nigricans in the US-Affiliated Pacific Region: A Randomized Clinical Trial

IMPORTANCE

Pacific Islanders have among the highest rates of obesity and type 2 diabetes in the world. Targeting children is critical for primary prevention.

OBJECTIVES

To prevent young child overweight and obesity and to improve health in the US-Affiliated Pacific region via the Children's Healthy Living Program.

DESIGN, SETTING, AND PARTICIPANTS

In this multijurisdictional, multilevel, multicomponent community randomized clinical trial, where all evaluable children were analyzed according to the random assignment of their community, hierarchical difference-in-difference models accounted for the community randomization, community clustering with jurisdictions, and these models were adjusted for the age and sex distribution of the community. The setting was 27 communities in 5 jurisdictions (Alaska, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, and Hawaii). Participants were 4329 children (time 1) and 4042 children (time 2) aged 2 to 8 years in 27 selected communities from October 7, 2012, to October 25, 2015. Data analysis was completed in June 2018.

INTERVENTIONS

Nineteen activities addressed policy, environment, messaging, training, and 6 target behaviors (sleep time, screen time, physical activity, fruits and vegetables, water, and sugar-sweetened beverages).

MAIN OUTCOMES AND MEASURES

Primary outcomes were body size measurements. Secondary outcomes were acanthosis nigricans, sleep quality and duration, dietary intake, physical activity, and other questionnaire reponses.

RESULTS

The study included 27 communities and 8371 evaluable children (mean [SD] age, 5.4 [1.8] years; 50.9% male [n = 4264]). Data analysis included 952 children in the intervention group and 930 children in the control group aged 2 to 5 years at time 1; 825 children in the intervention group and 735 children in the control group aged 2 to 5 years at time 2; 565 children in the intervention group and 561 children in the control group aged 6 to 8 years at time 1; and 517 children in the intervention group and 560 children in the control group aged 6 to 8 years at time 2. The intervention communities showed significant improvement compared with control communities in overweight and obesity prevalence (effect size [d] = -3.95%; 95% CI, -7.47% to -0.43%), waist circumference (d = -0.71 cm; 95% CI, -1.37 to -0.05 cm), and acanthosis nigricans prevalence (d = -2.28%; 95% CI, -2.77% to -1.57%). Age and sex subgroup analysis revealed greater difference among the intervention communities in acanthosis nigricans prevalence in the group aged 2 to 5 years (-3.99%) vs the group aged 6 to 8 years (-3.40%), and the interaction was significant (d = 0.59%, P < .001), as well as the smaller difference in the group aged 2 to 5 years (-0.10%) vs the group aged 6 to 8 years (-1.07%) in screen time (d = -0.97 hour per day, P = .01).

CONCLUSIONS AND RELEVANCE

The intervention reduced the prevalence of young child overweight and obesity and acanthosis nigricans. Comprehensive, effective, and sustainable interventions are needed to improve child health in the US-Affiliated Pacific region.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01881373.

2017 Writing Contest Undergraduate Winner: Pathways to Preventable Hospitalizations for Filipino Patients with Diabetes and Heart Disease in Hawai'i

Filipinos are one of the fastest growing Asian ethnic groups in the United States, yet little is known about how to specifically address the varying health needs of the Filipino community with diabetes and heart disease. This is a problem because rates of potentially preventable hospitalizations (PPH) are high for Filipinos with these conditions. A PPH is a hospitalization that could potentially have been avoided with better access to quality primary care. Patients over 21 years of age with heart disease or diabetes and who were hospitalized at the Queen's Medical Center with a PPH were recruited to complete a face-to-face interview eliciting the patients' perspectives on key factors leading to this hospitalization (n=102). This study focused on a subset of Filipino patients (n=21). Two independent coders reviewed interviews to identify factors leading to their PPH. A majority of the Filipino respondents identified social vulnerabilities as the most common factor that led to their hospitalization, including financial challenges, limited social support, and life instability. Many respondents also noted challenges with the healthcare system as precipitating their hospitalization, including poor communication/coordination, management plan issues, and bad experience with their healthcare providers. Cultural and language barriers were also identified by Filipino patients as challenges leading to their hospitalizations. These findings emphasize the importance of considering patients' perspectives of the barriers they face inside and outside of healthcare facilities.

Developing an Undergraduate Public Health Introductory Core Course Series

The number of undergraduate public health education programs is increasing, but few publications provide examples of introductory public health courses that provide foundational knowledge and meet 2016 Council on Education in Public Health (CEPH) accreditation standards. This article presents the development and testing of a three-course, introductory series in public health at the University of Hawai‘i at Mānoa (UHM). Development was informed by best pedagogical practices in education, web review of existing programs, literature review, key informant interviews, and accreditation standards. Student mastery of required concepts, domains, and competencies is assessed through testing and class assignments. Data from course evaluations, students' exit questionnaires at graduation, and faculty feedback were used to continuously evolve and adapt the curriculum. The three-course series—including Introduction to Public Health, Public Health Issues in Hawai‘i, and Introduction to Global Health—was designed to provide incoming undergraduate public health students with a foundation in local, national, and global public health concepts and domains, while improving their skills in public health communication and information literacy. Data from class assignments, examinations, and later coursework suggest students are mastering the course materials and gaining required competencies. Data from course evaluation and exit questionnaires suggest that the students appreciate the series' approach and the challenge to apply course concepts locally and globally in subsequent courses. This foundational public health series provides a model for an introductory course series that can be implemented with existing resources by most programs, meets the new CEPH requirements, is well-received by students, and prepares students well for upper-division public health courses.

Strategies to Increase Filipino American Participation in Cardiovascular Health Promotion: A Systematic Review

Introduction

Cultural tailoring of interventions can be effective in reducing health disparities by attracting underserved populations to health promotion programs and improving their outcomes. The purpose of this systematic review was to assess what is known about increasing access to and participation in cardiovascular disease (CVD) prevention and control programs among Filipino Americans.

Methods

PubMed MEDLINE, CINAHL, and Sociologic Abstracts were searched for peer-reviewed studies and dissertations conducted in the United States from 2004 through 2016.

Results

A total of 347 articles were identified through the search, and 9 articles reporting on 7 interventions focused on CVD prevention in a Filipino American sample were included. All but one intervention used evidence-based curricula, and implementation varied across sites. All but 2 interventions used word-of-mouth advertising from friends, family, and community leaders to increase participation. The Filipino cultural values of food, social relationships, and family were prevalent aspects across interventions tailored for Filipino Americans. Aspects of spirituality and the arts were integrated into only 3 studies.

Conclusion

Given the burden of CVD in Filipino American populations, tailored interventions rooted in Filipino cultural values are vital to address this known health disparity.

Military-Tailored Yoga for Veterans with Post-traumatic Stress Disorder

Introduction

Among veterans of post-9/11 conflicts, estimates of post-traumatic stress disorder (PTSD) range from 9% shortly after returning from deployment to 31% a year after deployment. Clinical and pharmaceutically based treatments are underutilized. This could be due to concerns related to lost duty days, as well as PTSD patients' fears of stigma of having a mental health condition. Yoga has been shown to reduce PTSD symptoms in the civilian population, but few studies have tested the impact of yoga on veterans of post-9/11 conflicts. The purpose of this study is to test the impact of yoga on post-9/11 veterans diagnosed with PTSD.

Materials and Methods

Participants were 18 yr of age or older and veterans of post-9/11 conflicts. They had subthreshold or diagnostic-level PTSD related to their combat military service, as determined by a score of 30 or higher on the PTSD Checklist-Military version (PCL-M). Veterans participated in 60-min weekly yoga sessions for 6 wk taught by a Warriors at Ease-trained yoga instructor who is a, post-9/11 veteran. The yoga sessions incorporated Vinyasa-style yoga and a trauma-sensitive, military-culture informed approach advocated by two separate organizations: Warriors at Ease and Meghan's Foundation. Data were collected at baseline and again after 7 wk. The primary outcome was PCL-M score. Participants also completed the Patient Health Questionnaire, the Beck Anxiety Inventory, the Pittsburgh Sleep Quality Index, and the Mindful Attention Awareness Scale at both time points.

Results

Eighteen Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans completed the pre- and post-intervention self-report questionnaires. Age ranged from 26 to 62 yr (median = 43 yr), length of service ranged from 2 to 34 yr (median = 18.8 yr), and 13 (72.2%) had completed college. Decreased PTSD symptomatology was demonstrated in the three-symptom clusters represented in the PCL-M (i.e., hyperarousal, re-experiencing, and avoidance). In addition, the total score on the PCL-M decreased significantly, by both statistical and clinical measures. The participants also demonstrated improved mindfulness scores and reported decreased insomnia, depression, and anxiety symptoms.

Conclusion

This study demonstrates that a trauma-sensitive yoga intervention may be effective for veterans with PTSD symptoms, whether as stand-alone or adjunctive therapy. The impressive decrease in PTSD symptomatology may be due to the tailored military-specific nature of this intervention and the fact that it was led by a veteran of post-9/11 conflicts. More research is needed with a larger sample and a more diverse veteran population.

Comparing Weight Loss-Maintenance Outcomes of a Worksite-Based Lifestyle Program Delivered via DVD and Face-to-Face: A Randomized Trial

BACKGROUND

Native Hawaiians and other Pacific Islanders have high rates of overweight and obesity compared with other ethnic groups in Hawai'i. Effective weight loss and weight loss-maintenance programs are needed to address obesity and obesity-related health inequities for this group.

AIMS

Compare the effectiveness of a 9-month, worksite-based, weight loss-maintenance intervention delivered via DVD versus face-to-face in continued weight reduction and weight loss maintenance beyond the initial weight loss phase.

METHOD

We tested DVD versus face-to-face delivery of the PILI@Work Program's 9-month, weight loss-maintenance phase in Native Hawaiian-serving organizations. After completing the 3-month weight loss phase, participants ( n = 217) were randomized to receive the weight loss-maintenance phase delivered via trained peer facilitators or DVDs. Participant assessments at randomization and postintervention included weight, height, blood pressure, physical functioning, exercise frequency, and fat intake.

RESULTS

Eighty-three face-to-face participants were retained at 12 months (74.1%) compared with 73 DVD participants (69.5%). There was no significant difference between groups in weight loss or weight loss maintenance. The number of lessons attended in Phase 1 of the intervention (β = 0.358, p = .022) and baseline systolic blood pressure (β = -0.038, p = .048) predicted percent weight loss at 12 months.

DISCUSSION AND CONCLUSION

Weight loss maintenance was similar across groups. This suggests that low-cost delivery methods for worksite-based interventions targeting at-risk populations can help address obesity and obesity-related disparities. Additionally, attendance during the weight loss phase and lower baseline systolic blood pressure predicted greater percent weight loss during the weight loss-maintenance phase, suggesting that early engagement and initial physical functioning improve long-term weight loss outcomes.

The PILI@Work Program: a translation of the diabetes prevention program to Native Hawaiian-serving worksites in Hawai'i

A previously translated Diabetes Prevention Program Lifestyle Intervention (DPP-LI) was adapted for delivery as a worksite-based intervention, called PILI@Work, to address obesity disparities in Native Hawaiians/Pacific Islanders. This study examined the effectiveness of PILI@Work and factors associated with weight loss at post-intervention. Overweight/obese employees of 15 Native Hawaiian-serving organizations received the 3-month component of PILI@Work. Assessments included weight, systolic/diastolic blood pressure, physical activity and functioning, fat intake, locus of weight control, social support, and self-efficacy. Weight, systolic/diastolic blood pressure, physical functioning, physical activity frequency, fat intake, family support, and eating self-efficacy improved from pre- to post-intervention. Regression analysis indicated that worksite type, decreased diastolic blood pressure, increased physical activity, and more internalized locus of weight control were significantly associated with 3-month weight loss. PILI@Work initiated weight loss in Native Hawaiians/Pacific Islanders. DPP-LI translated to worksite settings and tailored for specific populations can be effective for addressing obesity.

The educational, racial and gender crossovers in life satisfaction: Findings from the longitudinal Health and Retirement Study

OBJECTIVE

To examine variations in life satisfaction by education, gender, and race/ethnicity over a period of eight years among middle-aged and older Americans.

METHODS

Mixed-effects models were used to analyze five waves (2006, 2008, 2010, 2012 and 2014) of longitudinal data from 16,163 participants born 1890-1953 in the U.S. Health and Retirement Study.

RESULTS

Life satisfaction was higher in older adults, and the Great Recession had great impact on life satisfaction. Crossover interactions were found by gender, education, and race/ethnicity. Higher education was associated with higher life satisfaction for both genders, with stronger effects for females. Hispanics had the higher level of life satisfaction than non-Hispanic Whites and African Americans.

DISCUSSION

Longitudinal evidence revealed disparities in life satisfaction. The racial/ethnic differences in the impact of education suggest that the economic and health returns of education vary by social group. Researchers should continue to examine reasons for these disparities.

Exploring the Potential for Technology-Based Nutrition Education Among WIC Recipients in Remote Alaska Native Communities

OBJECTIVE

Estimate media technology use in Alaska Native communities to inform the feasibility of technology-based nutrition education.

METHODS

A self-administered questionnaire was mailed to a random selection of about 50% of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) authorized representatives in remote Alaska Native communities (n = 975). Media technology use, interest in media technology-based nutrition education, and potential barriers were assessed. Chi-square tests were used to investigate associations among technology use, age, and education.

RESULTS

Technology use was common among respondents (n = 368); use was significantly more common among younger age groups and participants with a higher level of education. Smartphone (78.8%) and Facebook (95.8%) use was comparable to national averages, but having a computer at home (38.4%) was much less likely. Less than 50% of participants have Internet access at home.

CONCLUSIONS AND IMPLICATIONS

Findings shed light on new opportunities for WIC and other programs to deliver nutrition education to Alaska Native people in remote communities.

"I Need my Own Place to get Better": Patient Perspectives on the Role of Housing in Potentially Preventable Hospitalizations

OBJECTIVE

To analyze patient perspectives on the role of housing in their potentially preventable hospitalization.

METHODS

Individuals admitted with cardiovascular-or diabetes-related diagnoses (n = 90) in a major medical center in Hawai'i completed an in-person interview eliciting patient perspectives on key factors leading to hospitalization. Using the framework approach, two independent coders identified themes. This study focused on housing-related findings.

RESULTS

Overall, 23% of participants reported housing as a precipitating factor to their hospitalization, including 12 with no regular place to stay. Four housing-related themes emerged: challenges meeting basic needs, complex chronic care management difficulties, stigma and relationship with provider, and stress and other mental health issues.

DISCUSSION

Almost 25% of patients identified housing as a key factor to their hospital stay. Patient-reported themes highlight specific mechanisms by which housing challenges may lead to hospitalization. Addressing housing issues could help reduce the number and associated cost burden of preventable hospitalizations.

Characteristics of Effective Colorectal Cancer Screening Navigation Programs in Federally Qualified Health Centers: A Systematic Review

In the U.S., colorectal cancer (CRC) incidence and mortality have declined due to screening and improvements in early detection; however, racial/ethnic disparities in screening and mortality persist. Patient navigation has been shown to be effective in increasing CRC screening prevalence. This systematic review answered three questions about navigation in federally qualified community health centers (FQHCs): 1) Which navigation activities increased CRC screening prevalence? 2) What were the challenges to implementing these programs in FQHCs? 3) Which clinic protocols supported screening completion? Findings suggest that navigation services must be tailored to the specific screening test provided. Federally qualified community health centers report difficulty maintaining a current electronic medical records system and sustaining funding; they should establish excellent patient tracking systems (for follow-up and annual rescreening) and establish multiple protocols to facilitate screening completion. With the movement toward patient-centered care models, patient navigation will be integral to FQHCs and their clients.

Examining the role of a community coalition in facilitating policy and environmental changes to promote physical activity: the case of Get Fit Kaua'i

Community coalitions help to generate policy and environmental changes that address community health problems. This qualitative study examined how one community coalition, Get Fit Kaua'i, catalyzed built environment (BE) policy and infrastructure changes in a rural county in Hawai'i. The purpose was to develop a theory that explained the process by which the community coalition facilitated BE changes to support physical activity. Using a grounded theory approach, semi-structured interviews were conducted with a purposeful sample of 25 stakeholders engaged in the coalition's BE activities. The model to emerge from the coalition interviews consisted of five phases: (1) coalition formation, (2) capacity building, (3) policy development, (4) policy passage, and (5) policy implementation. Community context influenced all of these phases. Although community context limits generalizability, other community coalitions pursuing BE changes can learn from the process of the coalition under study.

Family Response to End-of-Life Education: Differences by Ethnicity and Stage of Caregiving

The authors developed and tested 5 educational booklets to improve end-of-life knowledge, attitudes, intention, and practices in a multiethnic sample of family caregivers of well, homebound, and institutionalized elders. Of 570 participants, 424 (74%) read at least 1 booklet and completed pretests and posttests. At 3-month follow-up, small improvements were seen in completion of advance directives, and significant increases were seen in proportions of caregivers with funeral or burial plans and willingness to consider hospice. The booklets had wide appeal, but end-of-life measures varied by care-giver stage and ethnicity, suggesting that these factors need to be considered in developing education interventions for family caregivers.

Pathways to potentially preventable hospitalizations for diabetes and heart failure: a qualitative analysis of patient perspectives

BACKGROUND

Potentially preventable hospitalizations (PPH) for heart failure (HF) and diabetes mellitus (DM) cost the United States over $14 billion annually. Studies about PPH typically lack patient perspectives, especially across diverse racial/ethnic groups with known PPH health disparities.

METHODS

English-speaking individuals with a HF or DM-related PPH (n = 90) at the largest hospital in Hawai'i completed an in-person interview, including open-ended questions on precipitating factors to their PPH. Using the framework approach, two independent coders identified patient-reported factors and pathways to their PPH.

RESULTS

Seventy-two percent of respondents were under 65 years, 30 % were female, 90 % had health insurance, and 66 % had previously been hospitalized for the same problem. Patients' stories identified immediate, precipitating, and underlying reasons for the admission. Underlying background factors were critical to understanding why patients had the acute problems necessitating their hospitalizations. Six, non-exclusive, underlying factors included: extreme social vulnerability (e.g., homeless, poverty, no social support, reported by 54 % of respondents); health system interaction issues (e.g., poor communication with providers, 44 %); limited health-related knowledge (42 %); behavioral health issues (e.g., substance abuse, mental illness, 36 %); denial of illness (27 %); and practical problems (e.g., too busy, 6 %). From these findings, we developed a model to understand an individual's pathways to a PPH through immediate, precipitating, and underlying factors, which could help identify potential intervention foci. We demonstrate the model's utility using five examples.

CONCLUSIONS

In a young, predominately insured population, factors well outside the traditional purview of the hospital, or even clinical medicine, critically influenced many PPH. Patient perspectives were vital to understanding this issue. Innovative partnerships and policies should address these issues, including linkages to social services and behavioral health.