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.