A Culturally Tailored Community Health Worker Intervention Leads to Improvement in Patient-Centered Outcomes for Immigrant Patients With Type 2 Diabetes

Task-sharing with community health workers to treat hypertension: a scoping review

Many studies have implemented and evaluated task-sharing interventions with community health workers (CHWs) to manage hypertension. To identify gaps in research, we conducted a scoping review. We searched original articles published in PubMed and EMBASE between 2010 and 2022 and found 122 articles meeting our inclusion criteria. Only seven articles were from low-income countries (LICs), most of which were qualitative studies or mixed methods studies. In the identified 122 articles, CHWs often performed health education (61.3%) and measured blood pressure (60.4%). Whereas CHWs carried out pharmacological treatment in only three studies. Participant homes (75.0%) were the most common setting for receiving interventions. Our study identified specific needs for future research, specifically, studies in LICs that are experimental in design and that collect relevant qualitative information, and studies in which CHWs do advanced task. In addition, publications of CHW studies should provide a more comprehensive list of intervention features.

Tailoring HIV Care for Black Populations: A Pilot Feasibility Prospective Cohort Study

BACKGROUND

Research has shown that integrating community health workers (CHWs) into the formal health care system can improve outcomes for people living with HIV, yet there is limited literature exploring this framework among marginalized minority populations.

OBJECTIVE

Herein, we discuss the feasibility of a clinic-embedded CHW strategy to improve antiretroviral therapy adherence among Black people living with HIV in Miami-Dade County, Florida, a designated priority region for the US Department of Health and Human Services' Ending the HIV Epidemic Initiative.

METHODS

From December 2022 to September 2023, three CHWs were trained and integrated into the hospital workflow to provide support as members of the clinical team. Ten Black adults with an HIV viral load over 200 copies/mL were enrolled to received 3 months of CHW support focused on navigating the health system and addressing poor social determinants of health. Intervention feasibility was based on 4 criteria: recruitment rate, demographic composition, study fidelity, and qualitative feedback on CHW perceptions.

RESULTS

Participants were recruited at a rate of 5.7 participants per month, with the sample evenly distributed between men and women. Retention was moderately strong, with 7 (70%) of the 10 participants attending more than 75% of CHW sessions. Qualitative feedback reflected CHW perceptions on clinical interactions and intervention length.

CONCLUSIONS

Outcomes indicate that a clinic-integrated CHW approach is a feasible and acceptable methodology to address adverse social determinants and improve HIV treatment adherence. By offering targeted social and clinical support, CHWs may be a promising solution to achieve sustained viral suppression and care engagement for Black people living with HIV.

Health and Social Care Outcomes in the Community: Review of Religious Considerations in Interventions with Muslim-Minorities in Australia, Canada, UK, and the USA

The aims of this integrative review included examining the intervention characteristics, religious tailoring, and behavioural outcomes of health and social care interventions with Muslim-minorities in Australia, Canada, UK, and the USA. Nineteen articles were included, and each showed some level of improved health and social care outcomes associated with interventions that were religiously tailored to Islamic teachings, and when notions of health were extended to physical, psychological, spiritual and social domains. Future studies should measure levels of religiosity to understand whether religiously tailored interventions produce a significant intervention effect when compared to non-religiously tailored interventions with Muslims.

Lay advisor interventions for hypertension outcomes: A Systematic Review, Meta-analysis and a RE-AIM evaluation

Introduction

Lay advisor interventions improve hypertension outcomes; however, the added benefits and relevant factors for their widespread implementation into health systems are unknown. We performed a systematic review to: (1) summarize the benefits of adding lay advisors to interventions on hypertension outcomes, and (2) summarize factors associated with successful implementation in health systems using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

Methods

We systematically searched several databases, including Ovid MEDLINE, CINAHL, PsycINFO from January 1981 to May 2023. All study designs of interventions delivered solely by lay advisors for adults with hypertension were eligible. If both arms received the lay advisor intervention, the study arm with lower intensity was assigned as the low-intensity intervention.

Results

We included 41 articles, of which 22 were RCTs, from 7,267 screened citations. Studies predominantly included socially disadvantaged populations. Meta-analysis (9 RCTs; n = 4,220) of eligible lay advisor interventions reporting outcomes showed improved systolic blood pressure (BP) [-3.72 mm Hg (CI -6.1 to -1.3; I2 88%)], and diastolic BP [-1.7 mm Hg (CI -1 to -0.9; I2 7%)] compared to control group. Pooled effect from six RCTs (n = 3,277) comparing high-intensity with low-intensity lay advisor interventions showed improved systolic BP of -3.6 mm Hg (CI -6.7 to -0.5; I2 82.7%) and improved diastolic BP of -2.1 mm Hg (CI -3.7 to -0.4; I2 70.9%) with high-intensity interventions. No significant difference in pooled odds of hypertension control was noted between lay advisor intervention and control groups, or between high-intensity and low-intensity intervention groups. Most studies used multicomponent interventions with no stepped care elements or reporting of efficacious components. Indicators of external validity (adoption, implementation, maintenance) were infrequently reported.

Discussion

Lay advisor interventions improve hypertension outcomes, with high intensity interventions having a greater impact. Further studies need to identify successful intervention and implementation factors of multicomponent interventions for stepped upscaling within healthcare system settings as well as factors used to help sustain interventions.

Role of cultural brokering in advancing holistic primary care for diabetes and obesity: a participatory qualitative study

OBJECTIVES

Diabetes and obesity care for ethnocultural migrant communities is hampered by a lack of understanding of premigration and postmigration stressors and their impact on social and clinical determinants of health within unique cultural contexts. We sought to understand the role of cultural brokering in primary healthcare to enhance chronic disease care for ethnocultural migrant communities.

DESIGN AND SETTING

Participatory qualitative descriptive-interpretive study with the Multicultural Health Brokers Cooperative in a Canadian urban centre. Cultural brokers are linguistic and culturally diverse community health workers who bridge cultural distance, support relationships and understanding between providers and patients to improve care outcomes. From 2019 to 2021, we met 16 times to collaborate on research design, analysis and writing.

PARTICIPANTS

Purposive sampling of 10 cultural brokers representing eight different major local ethnocultural communities. Data include 10 in-depth interviews and two observation sessions analysed deductively and inductively to collaboratively construct themes.

RESULTS

Findings highlight six thematic domains illustrating how cultural brokering enhances holistic primary healthcare. Through family-based relational supports and a trauma-informed care, brokering supports provider-patient interactions. This is achieved through brokers' (1) embeddedness in community relationships with deep knowledge of culture and life realities of ethnocultural immigrant populations; (2) holistic, contextual knowledge; (3) navigation and support of access to care; (4) cultural interpretation to support health assessment and communication; (5) addressing psychosocial needs and social determinants of health and (6) dedication to follow-up and at-home management practices.

CONCLUSIONS

Cultural brokers can be key partners in the primary care team to support people living with diabetes and/or obesity from ethnocultural immigrant and refugee communities. They enhance and support provider-patient relationships and communication and respond to the complex psychosocial and economic barriers to improve health. Consideration of how to better enable and expand cultural brokering to support chronic disease management in primary care is warranted.

Effectiveness of a Community Health Worker-Driven Intervention in Improving the Quality of Life of Caregivers of Children With Disability in Rural Karnataka, India

Purpose To assess the effectiveness of a community-health-worker (CHW)-driven intervention in improving the quality of life (QOL) of caregivers of children with disability in rural Karnataka, India. Methodology A community-based quasi-experimental study with cluster randomization on the village level was done. CHWs provided structured health education and training for the intervention arm. Pre- and post-intervention, the QOL and Zarit burden scores were compared between and within the two arms. Results From baseline, the physical domain score improved from 49.66 to 53.88 (p < 0.001). The Zarit burden scores decreased from 33.27 to 28.89 (p < 0.001). On comparing the post-test QOL scores between the two arms, the physical domain scores increased from 51.68 to 56.08 (p = 0.025). The Zarit burden scores also significantly decreased from 31.50 to 26.28. Conclusion The intervention by the CHWs on the caregivers has significant improvements in the physical domain of QOL and a reduction in caregiver burden.

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

Culturally Tailored Dietary Interventions for Improving Glycaemic Control and Preventing Complications in South Asians with Type 2 Diabetes: Success and Future Implications

Glycaemic control is the basis of type 2 diabetes mellitus (T2DM) management and is crucial for preventing diabetes microvascular and macrovascular complications. The South Asian population is at higher risk of T2DM and resultant cardiovascular disease, peripheral vascular disease and death compared to Caucasians. Effective diabetes care has been deemed challenging in this population, but little is known about the usefulness of lifestyle interventions in improving glycaemic control and reducing complications. This narrative review aims to explore the efficacy of lifestyle interventions targeted to South Asians with T2DM in inducing clinically relevant improvements in HbA1c levels at such levels that reduce the risk of diabetes complications. A search of the literature using six databases (MEDLINE (EBSCOhost), PubMed, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials and Scopus) identified dietary-based, physical-activity-based and education-based interventions that aimed to manage T2DM in South Asians. Results showed that dietary and physical activity interventions (duration 3-12 months) have been effective in generating a clinically relevant decrease in HbA1c levels (≥0.5%) in South Asians with T2DM and could potentially assist in reducing diabetes complications. Education-based interventions produced small effects on glycaemic control. These outcomes support the development of comparable longer-term randomised clinical trials combining dietary and physical activity interventions with the aim to provide further evidence on specific interventions that can lower complications and ensure effective diabetes care in a high-risk population.

Promoting Physical Activity Among Immigrant Asian Americans: Results from Four Community Health Worker Studies

Racial/ethnic minorities have demonstrated lower rates of physical activity (PA) than non-Hispanic Whites. This study examined outcomes in PA measures after participation in a community health worker (CHW) intervention. We performed a secondary data analysis from four randomized controlled trials utilizing CHWs (n = 842) in New York City (Bangladeshi-diabetes management, Filipino-hypertension management, and Korean and Asian Indian-diabetes prevention). Outcomes included total weekly PA, PA self-efficacy, PA barriers, and PA social interaction. Each measure was examined at baseline and study endpoint. Generalized estimating equation models were fitted to assess the repeated measures over time, while accounting for study group and socio-demographic factors. Moderate PA, recommended PA, and self-efficacy increased significantly among treatment group participants. PA social interaction increased significantly among Filipinos and Asian Indians. In adjusted regression analysis, time x group interaction was significant for all PA outcomes except for PA barriers. Culturally-adapted lifestyle interventions may potentially improve PA-related outcomes in Asian immigrant communities. Trial registration at ClinicalTrials.gov includes: NCT03530579 (RICE Project), NCT02041598 (DREAM Project), and NCT03100812 (AsPIRE).

Integrating Community Health Workers into Community-Based Primary Care Practice Settings to Improve Blood Pressure Control Among South Asian Immigrants in New York City: Results from a Randomized Control Trial

BACKGROUND

Blood pressure (BP) control is suboptimal in minority communities, including Asian populations. We evaluate the feasibility, adoption, and effectiveness of an integrated CHW-led health coaching and practice-level intervention to improve hypertension control among South Asian patients in New York City, Project IMPACT (Integrating Million Hearts for Provider and Community Transformation). The primary outcome was BP control, and secondary outcomes were systolic BP and diastolic BP at 6-month follow-up.

METHODS

A randomized-controlled trial took place within community-based primary care practices that primarily serve South Asian patients in New York City between 2017 and 2019. A total of 303 South Asian patients aged 18-85 with diagnosed hypertension and uncontrolled BP (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg) within the previous 6 months at 14 clinic sites consented to participate. After completing 1 education session, individuals were randomized into treatment (n=159) or control (n=144) groups. Treatment participants received 4 additional group education sessions and individualized health coaching over a 6-month period. A mixed effect generalized linear model with a logit link function was used to assess intervention effectiveness for controlled hypertension (Yes/No), adjusting for practice level random effect, age, sex, baseline systolic BP, and days between BP measurements.

RESULTS

Among the total enrolled population, mean age was 56.8±11.2 years, and 54.1% were women. At 6 months among individuals with follow-up BP data (treatment, n=154; control, n=137), 68.2% of the treatment group and 41.6% of the control group had controlled BP (P<0.001). In final adjusted analysis, treatment group participants had 3.7 [95% CI, 2.1-6.5] times the odds of achieving BP control at follow-up compared with the control group.

CONCLUSIONS

A CHW-led health coaching intervention was effective in achieving BP control among South Asian Americans in New York City primary care practices. Findings can guide translation and dissemination of this model across other communities experiencing hypertension disparities.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03159533.

Evaluation of a Synchronous, Online Diabetes Nutrition Education Program for American Indians and Alaska Natives With Type 2 Diabetes: Facilitators and Participants' Experiences

OBJECTIVE

To explore the overall experiences of key players involved in a culturally adapted, online, synchronous diabetes nutrition education program across 5 reservation tribal and intertribal urban Indian clinics.

METHODS

A multimethods design, including postclass surveys with Likert-scale and short-answer questions, was completed after each of the 5 classes. Participants (n = 54) and class facilitators/coordinators (n = 10) completed postclass surveys (n = 189 and 58, respectively). A subset of participants (n = 24) and all class facilitators/coordinators (n = 10) engaged in online focus groups after the conclusion of program implementation. Qualitative thematic methods and frequency distributions were used to analyze the data.

RESULTS

Most participants reported that the classes were enjoyable (94%), culturally respectful (77%), and easily accessed online (68%). Qualitative themes included (1) class satisfaction, (2) class improvements, (3) preference for class facilitator, and (4) recommendations to improve recruitment and retention.

CONCLUSIONS AND IMPLICATIONS

These findings will guide program modifications to provide improved diabetes nutrition education for American Indians and Alaska Natives adults with type 2 diabetes.

Development of a multi-component tobacco cessation training package utilizing multiple approaches of intervention development for health care providers and patients attending non-communicable disease clinics of Punjab, India

Background

Providing patients with personalized tobacco cessation counseling that is culturally sensitive, and disease-specific from healthcare providers (HCPs) as part of their routine consultations is an approach that could be incorporated, using existing healthcare systems such as the Non-Communicable Disease (NCD) clinics. This paper describes the development of a multi-component culturally tailored, patient-centric, disease-specific tobacco cessation package utilizing multiple approaches of intervention development for healthcare providers and patients attending these clinics in Punjab, India, along with a proposed framework for implementation.

Methods

The proposed intervention package was developed in 6 stages. These included a review of literature for identifying successful cessation interventions for ethnic minority groups, co-production of the package with all stakeholders involved via a series of consultative meetings and workshops, understanding contextual factors of the state and 'factor-in' these in the package, pre-test of the package among HCPs and tobacco users using in-depth interviews, micro detailing and expansion of the package by drawing on existing theories of the Cascade Model and Trans-Theoretical Model and developing an evolving analysis plan through real-world implementation at two pilot districts by undertaking a randomized controlled trial, assessing implementer's experiences using a mixed-method with a primary focus on qualitative and economic evaluation of intervention package.

Results

A multi-component package consisting of a booklet (for HCPs), disease-specific pamphlets and short text messages (for patients; bilingual), and an implementation framework was developed using the 6-step process. A major finding from the in-depth interviews was the need for a specific capacity-building training program on tobacco cessation. Therefore, using this as an opportunity, we trained the in-service human resource and associated program managers at the state and district-level training workshops. Based on the feedback, training objectives were set and supported with copies of intervention package components. In addition, the role and function of each stakeholder were defined in the proposed framework.

Conclusion

Consideration of tobacco users' socio-cultural and patient-centric approach makes a robust strategy while developing and implementing an intervention providing an enlarged scope to improve care services for diversified socio-cultural communities.

Challenges in Access to Support Resources for Diabetic Patients: A Qualitative Study in Deprived Areas of Iran

OBJECTIVES

This study aimed to identify the perceptions of challenges in access to diabetes-related support resources among patients with type 2 diabetes and their family caregivers.

METHODS

This qualitative study was conducted with 18 patients with type 2 diabetes and nine of their family caregivers, using the conventional content analysis method, in 2020 in Lorestan Province, Iran. The participants were selected through purposive sampling and the process continued until the data was saturated. Thirty semi-structured interviews, carried out from February to April 2020, were used to collect the data; they were analyzed using Graneheim and Lundman's content analysis (2004).

RESULTS

The study showed two main categories of structural challenges (subcategories: shortage of skilled professionals and defects in executive processes) and destructive inefficiencies (subcategories: service bottlenecks, uncertain support, and irresponsibility of medical team), indicating the dimensions of the participants' perceptions of barriers to support.

DISCUSSION

The findings of the study showed that barriers relating to the structure and function of healthcare organizations were among the most important challenges perceived by patients with diabetes when pursuing their care. However, there may be other barriers that have not been addressed due to the lack of support resources in deprived areas and the lack of awareness of patients.

Needs assessment and planning for a clinic-community-based implementation program for hypertension control among blacks in New York City: a protocol paper

BACKGROUND

Hypertension (HTN) control among Blacks in the USA has become a major public health challenge. Barriers to HTN control exist at multiple levels including patient, physician, and the health system. Patients also encounter significant community-level barriers, such as poor linkage to social services that impact health (unstable housing, food access, transportation). We describe a multi-component needs assessment to inform the development, implementation, and evaluation of a program to improve HTN management within a large healthcare system in New York City (NYC).

METHODS

Guided by the Community-Based Participatory Research (CBPR) and Consolidated Framework for Implementation Research (CFIR) frameworks, data will be collected from four main sources: (1) quantitative surveys with health systems leadership, providers, and staff and with community-based organizations (CBOs) and faith-based organizations (FBOs); (2) qualitative interviews and focus groups with health systems leadership, providers, and staff and with CBOs and FBOs; (3) NYC Community Health Survey (CHS); and (4) New York University (NYU) Health system Epic Electronic Health Record (EHR) system. The data sources will allow for triangulation and synthesis of findings.

DISCUSSION

Findings from this comprehensive needs assessment will inform the development of a clinic-community-based practice facilitation program utilizing three multi-level evidence-based interventions (nurse case management, remote blood pressure (BP) monitoring, and social determinants of health (SDoH) support) integrated as a community-clinic linkage model for improved HTN control in Black patients. Integration of stakeholders' priorities, perspectives, and practices into the development of the program will improve adoption, sustainability, and the potential for scale-up.

TRIAL REGISTRATION

NCT05208450; registered on January 26, 2022.

Protocol and baseline characteristics for a community health worker-led hypertension and diabetes management program for South Asians in Atlanta: The DREAM Atlanta study

BACKGROUND

South Asians are disproportionately affected by type 2 diabetes (DMII) and comorbid hypertension (HTN). Community health worker (CHW) interventions have been shown to improve chronic disease outcomes, yet few have been tailored for South Asians. This paper describes the study protocol and baseline characteristics of an evidence-based CHW intervention to improve blood pressure (BP) control among South Asian adults with diabetes and comorbid HTN in Atlanta, GA.

METHODS

A total of 195 South Asian adults were randomized to treatment and control groups, and of these 190 completed baseline surveys (97 treatment group and 93 control group). The treatment group receives five group education sessions on DMII and HTN management and two one-on-one goal setting sessions.

MEASURES

Primary outcomes include feasibility, acceptability, and BP control (systolic blood pressure [SBP] <130 and diastolic blood pressure [DBP] <80). Secondary outcomes included changes in glycated hemoglobin (HbA1c), weight, diabetes self-efficacy, diet, and physical activity.

BASELINE RESULTS

Of the enrolled sample, 56% are female and mean age is 56.0 (±11.7). All participants are foreign-born. Mean SBP was 139.2 ± 4.3 and mean DBP was 84.7 ± 9.5. Intervention outcomes are measured at baseline and 6-month endpoint for both study groups.

CONCLUSIONS

To our knowledge, this study is the first to document the efficacy of a HTN and DMII management intervention among South Asian adults in Atlanta, GA. Future findings of the submitted protocol will fill an important gap on the translation and adaption of evidence-based interventions that have relevance to immigrant and minority populations.

CLINICAL TRIALS REGISTRATION

NCT04263311.

Cancer Screening Program Delivered by Community Health Workers for Chinese Married Immigrant Women in Korea

This quasi-experimental study used a cancer prevention program delivered by community health workers (CHWs) as an intervention to improve health literacy and increase screening uptake. The intervention group was educated by trained CHWs and received information about the nearby hospitals. After education, participants received telephone counseling once a month for 6 months. In the intervention group, CHWs met the participants individually and delivered the CD-ROM containing conversation scenarios with voice during the cancer screening test. The control group was provided educational materials related to breast and cervical cancers and a booklet containing information on mammography and Pap test. This study assessed the difference in mammography and Pap tests between the intervention and control groups. The results showed that the participants’ knowledge improved, and the rate of cancer screening tests did not decrease in the intervention group. Therefore, it is necessary to develop and apply various programs that train CHWs and apply them to immigrant women to promote health-related behaviors under the health system that they are not familiar with while living in another country.

Burden of cardiovascular risk factors and disease in five Asian groups in Catalonia: a disaggregated, population-based analysis of 121 000 first-generation Asian immigrants

AIMS

To evaluate the burden of cardiovascular risk factors and disease (CVD) among five Asian groups living in Catalonia (Spain): Indian, Pakistani, Bangladeshi, Filipino, and Chinese.

METHODS AND RESULTS

Retrospective cohort study using the Catalan Health Surveillance System database including 42 488 Pakistanis, 40 745 Chinese, 21 705 Indians, 9544 Filipinos, and 6907 Bangladeshis; and 5.3 million native individuals ('locals'). We estimated the age-adjusted prevalence (as of 31 December 2019) and incidence (during 2019) of diabetes, hypertension, hyperlipidaemia, obesity, tobacco use, coronary heart disease (CHD), cerebrovascular disease, atrial fibrillation, and heart failure (HF). Bangladeshis had the highest prevalence of diabetes (17.4% men, 22.6% women) followed by Pakistanis. Bangladeshis also had the highest prevalence of hyperlipidaemia (23.6% men, 18.3% women), hypertension among women (24%), and incident tobacco use among men. Pakistani women had the highest prevalence of obesity (28%). For CHD, Bangladeshi men had the highest prevalence (7.3%), followed by Pakistanis (6.3%); and Pakistanis had the highest prevalence among women (3.2%). For HF, the prevalence in Pakistani and Bangladeshi women was more than twice that of locals. Indians had the lowest prevalence of diabetes across South Asians, and of CHD across South Asian men, while the prevalence of CHD among Indian women was twice that of local women (2.6% vs. 1.3%). Filipinos had the highest prevalence of hypertension among men (21.8%). Chinese men and women had the lowest prevalence of risk factors and CVD.

CONCLUSIONS

In Catalonia, preventive interventions adapted to the risk profile of different Asian immigrant groups are needed, particularly for Bangladeshis and Pakistanis.

The Individual Nutrition Education Needs among Patients with Type 2 Diabetes at the Public Health Centers in Padang, Indonesia: A Cross-Sectional Study

Background: The Indonesian Public Health Care (PHC) of Management Nutrition Therapy (MNT) guidelines describe that individual nutrition education is aimed to improve quality of MNT services. The guidelines were originally developed for non-communicable diseases (NCDs), not specially for type 2 diabetes mellitus (T2DM) purposes. The reluctance of patients with T2DM to attend individual nutrition education is a common public health care issue in Padang (Indonesia). Methods: The presented cross-sectional study aimed to determine the individual nutrition education needs among people with T2DM. A set questionnaire was distributed to 11 PHC selected from 11 districts in Padang and 179 patients with T2DM were recruited and interviewed. Results: Among the 179 patients with T2DM, 76.5% were females and housewives (49.2%), a slight majority (57.8%) were ≤58 years old and 45.9% had graduated from primary school. The highest numbers of patients with T2DM were in PHC Andalas (20.7%). Some 74.9% (134) of the people with T2DM routinely attended individual nutrition education classes for less than 30 min (60.3%). Patients with T2DM followed individual nutrition education at a PHC every 1–2 months (59.8%), and a majority of the individual nutrition education was given by a medical doctor (57.5%). In contrast, 42.3% of patients with T2DM did not attend individual nutrition education due to a lack of recommendation from a medical doctor and their reluctance (33.3%). Although a majority of patients with T2DM (62.6%) were satisfied with their individual nutrition education, (20.4% of patients with T2DM recommended the availability of booklets during individual nutrition education that can be read at home. Patients with T2DM needed individual nutrition education (88.8%) and the majority (25.1%) requested individual nutrition education topics about diabetes food recommendation. Even though patients with T2DM followed health professionals’ advice (78.2%), however, their HbA1c (76.5%) wasnot reduced. Patients with T2DM agreed that individual nutrition education can increase their knowledge (51.9%), unfortunately, they still have difficulty to control their blood glucose (5.6%). Conclusions: According to the patients with the T2DM perspective stated above, it is crucial to develop the tool kits and educate patients with T2DM following the Diabetes Nutrition Education (DNE) curriculum to improve glycemic control.

Evaluation of a Diabetes Prevention Intervention for Korean American immigrants at Risk for Diabetes

Purpose

Despite the small but growing number of studies documenting the increasing prevalence of diabetes among Korean Americans, no culturally adapted interventions have been developed for Korean Americans at risk for diabetes. We evaluate the efficacy of a culturally tailored lifestyle intervention among Korean American immigrants at risk for diabetes in New York City (NYC).

Methods

Korean Americans at risk for diabetes were recruited into a culturally adapted, community health worker (CHW) intervention in NYC. Treatment group participants received 6 group sessions and 10 follow-up phone calls from CHWs over the 6-month period. Control participants received only the first session. Study outcomes included changes in weight, body mass index (BMI), blood pressure, physical activity (PA) and PA behaviors, nutrition behaviors, and diabetes knowledge. Paired t-tests and chi-square tests assessed group differences for each group for each outcome measure.

Results

The treatment group reported significant positive changes in recommended weekly PA, PA self-efficacy, PA barriers, nutrition self-efficacy, diabetes knowledge, weight, BMI, and systolic blood pressure compared with control participants. Generalized estimated equations models for repeated measures assessed change across time while adjusting for study arm, time point, and the interaction between study arm and time point. The intervention effect was significant for weekly moderate and vigorous PA, recommended weekly PA, PA self-efficacy, and diabetes knowledge.

Conclusions

Results suggest that a culturally adapted lifestyle intervention for Korean American immigrants at risk for diabetes have the potential to improve behaviors associated with cardiovascular disease outcomes and diabetes prevention. Further research among Korean Americans is warranted.

All in the Family: A Qualitative Study of the Early Experiences of Adults with Younger Onset Type 2 Diabetes

OBJECTIVE

Adults with type 2 diabetes diagnosed at a younger age are at increased risk for poor outcomes. We examined life stage-related facilitators and barriers to early self-management among younger adults with newly diagnosed type 2 diabetes.

RESEARCH DESIGN AND METHODS

We conducted 6 focus groups that each met twice between November 2017 and May 2018. Participants (n = 41) were aged 21 to 44 years and diagnosed with type 2 diabetes during the prior 2 years. Transcripts were coded using thematic analysis and themes were mapped to the Capability-Opportunity-Motivation-Behavior framework.

RESULTS

Participants were 38.4 (±5.8) years old; 10 self-identified as Latinx, 12 as Black, 12 as White, and 7 as multiple or other races. We identified 9 themes that fell into 2 categories: (1) the impact of having an adult family member with diabetes, and (2) the role of nonadult children. Family members with diabetes served as both positive and negative role models, and, for some, personal familiarity with the disease made adjusting to the diagnosis easier. Children facilitated their parents' self-management by supporting self-management activities and motivating their parents to remain healthy. However, the stress and time demands resulting from parental responsibilities and the tendency to prioritize children's needs were perceived as barriers to self-management.

CONCLUSIONS

Our results highlight how the life position of younger-onset individuals with type 2 diabetes influences their early experiences. Proactively addressing perceived barriers to and facilitators of self-management in the context of family history and parenthood may aid in efforts to support these high-risk, younger patients.

A culturally adapted, social support-based, diabetes group visit model for Bangladeshi adults in the USA: a feasibility study

BACKGROUND

Interventions focused on weight loss can prevent, delay, and improve management of type 2 diabetes (T2D). However, implementation of these programs is challenging in diverse populations. South Asians have higher risk for T2D, yet to date, there have been limited programs for this community in the USA. The aim of this project was to develop and test the feasibility of a tailored group visit model for Bangladeshis with type 2 diabetes (T2D) or prediabetes based in primary care.

DESIGN

Mixed-methods single-arm feasibility study.

SETTING

An academic health center-based primary care clinic in Atlanta, Georgia.

PARTICIPANTS

Bangladeshi adults > 18 years old with T2D or prediabetes METHODS: In conjunction with a community-academic board, we conducted focus groups to tailor an existing evidence-based curriculum to a culturally acceptable intervention. Fourteen participants enrolled in the 16-week program focusing on healthy diet, exercise, and weight loss. The primary feasibility outcomes were number of sessions attended and participant satisfaction with the intervention. Weight, blood pressure, cholesterol, and HbA1C were measured at beginning and end of study. Participants were asked to evaluate each session on level of satisfaction. One tailed paired t tests were used to test significance of pre-post changes in outcomes.

RESULTS

Key themes from the formative focus groups (n = 50) were closely tied to sociocultural beliefs and included: dietary patterns, physical activity perceptions, and healthcare access concerns. In the intervention, 10 of 14 participants had baseline and follow-up data. Participant attendance averaged 50%. Statistically significant reductions in mean weight (- 2%, 95%CI: - 3.1, 0.2 kg), systolic/diastolic blood pressure (- 12.7 mmHg [95%CI: - 23.2, - 2.2]/- 3.7 mmHg [95%CI: - 7.6, - 0.1], respectively), and triglycerides (- 62.6 mg/dl, 95%CI: - 123.1, - 2.0) were noted. Overall, participants reported high levels of satisfaction with the program.

CONCLUSION

A lifestyle program based in primary care is feasible and acceptable for Bangladeshi immigrants. Larger studies testing the effectiveness of group programs, in primary care, to improve cardiometabolic factors are important.

TRIALS REGISTRATION

ClinicalTrials.gov ; NCT03861546 . Registered 28 February 2019.

Implementation of a multi-level community-clinical linkage intervention to improve glycemic control among south Asian patients with uncontrolled diabetes: study protocol of the DREAM initiative

BACKGROUND

A number of studies have identified patient-, provider-, and community-level barriers to effective diabetes management among South Asian Americans, who have a high prevalence of type 2 diabetes. However, no multi-level, integrated community health worker (CHW) models leveraging health information technology (HIT) have been developed to mitigate disease among this population. This paper describes the protocol for a multi-level, community-clinical linkage intervention to improve glycemic control among South Asians with uncontrolled diabetes.

METHODS

The study includes three components: 1) building the capacity of primary care practices (PCPs) to utilize electronic health record (EHR) registries to identify patients with uncontrolled diabetes; 2) delivery of a culturally- and linguistically-adapted CHW intervention to improve diabetes self-management; and 3) HIT-enabled linkage to culturally-relevant community resources. The CHW intervention component includes a randomized controlled trial consisting of group education sessions on diabetes management, physical activity, and diet/nutrition. South Asian individuals with type 2 diabetes are recruited from 20 PCPs throughout NYC and randomized at the individual level within each PCP site. A total of 886 individuals will be randomized into treatment or control groups; EHR data collection occurs at screening, 6-, 12-, and 18-month. We hypothesize that individuals receiving the multi-level diabetes management intervention will be 15% more likely than the control group to achieve ≥0.5% point reduction in hemoglobin A1c (HbA1c) at 6-months. Secondary outcomes include change in weight, body mass index, and LDL cholesterol; the increased use of community and social services; and increased health self-efficacy. Additionally, a cost-effectiveness analysis will focus on implementation and healthcare utilization costs to determine the incremental cost per person achieving an HbA1c change of ≥0.5%.

DISCUSSION

Final outcomes will provide evidence regarding the effectiveness of a multi-level, integrated EHR-CHW intervention, implemented in small PCP settings to promote diabetes control among an underserved South Asian population. The study leverages multisectoral partnerships, including the local health department, a healthcare payer, and EHR vendors. Study findings will have important implications for the translation of integrated evidence-based strategies to other minority communities and in under-resourced primary care settings.

TRIAL REGISTRATION

This study was registered with clinicaltrials.gov: NCT03333044 on November 6, 2017.

Asian American mental health during COVID-19: A call for task-sharing interventions

In the age of COVID-19, the Asian American community is facing a number of unique risks and barriers to mental health care. Mounting challenges—including language barriers, unemployment, racialized trauma, and anti-Asian violence—threaten the health and wellness of these communities. Yet, structural obstacles prevent Asian Americans from accessing care within the professionalized behavioral health workforce. Leveraging the resources of Asian American peer networks, collectives, and community-based organizations through a task-sharing program presents an attractive alternative for mental health care provision. Investing in task-sharing approaches to care would both address access barriers and build capacity within the Asian American community.

Culturally tailored interventions for ethnic minorities: A scoping review

AIM

This scoping review identifies strengths and weakness of culturally tailored interventions for ethnic minorities' care in the United States. It reviews recently published studies to improve understanding of these interventions for future research and practice.

DESIGN

Scoping review.

METHODS

By searching five electronic databases-CINAHL, PubMed, Ovid, Scopus and Web of Science, this review located 58 empirical studies published between 2015-2019. This review was guided by the PRISMA statements.

RESULTS

The review identified four weaknesses and five strengths of culturally tailored interventions. Weaknesses included unclear guidelines, low attention and retention rates, failure to measure processes and inadequate training for healthcare providers. The intervention strengths were culturally respectful and patient-centred care, healthy lifestyle promotion, increased family and community supports, technology use for efficient and timely care and increased knowledge of disease by participants.

A Community Health Worker-Led Intervention to Improve Blood Pressure Control in an Immigrant Community With Comorbid Diabetes: Data From Two Randomized, Controlled Trials Conducted in 2011-2019

Evidence-based strategies addressing comorbid hypertension and diabetes are needed among minority communities. We analyzed the outcome of blood pressure (BP) control using pooled data from two community health worker interventions in New York City conducted between 2011 and 2019, focusing on participants with comorbid hypertension and diabetes. The adjusted odds of controlled BP (< 140/90 mmHg) for the treatment group were significant compared with the control group (odds ratio = 1.4; 95% confidence interval = 1.1, 1.8). The interventions demonstrated clinically meaningful reductions in BP among participants with comorbid hypertension and diabetes.

Development and evaluation of self-care intervention to improve self-care practices among people living with type 2 diabetes mellitus: a mixed-methods study protocol

INTRODUCTION

The management of diabetes mellitus (DM) depends on medication adherence, self-care and regular follow-up to prevent complications and premature mortality. This study aims to develop and implement the behavioural change theory and model based diabetes self-care intervention package to improve self-care practices among people living with type 2 DM.

METHODS AND ANALYSIS

An exploratory sequential mixed-method study design wherein, quantitative follows qualitative will be used to develop, implement and evaluate the effect of diabetes self-care intervention package among people living with type 2 diabetes. The qualitative research method will be used to identify barriers and facilitators for self-care practices among people living with type 2 DM and will also provide the basis for the development of the diabetes self-care intervention package. The quasi-experimental with control study design will be used to evaluate the developed intervention package among 220 randomly selected people living with type 2 diabetes in both intervention and control arms. Baseline, follow-ups and endline data will be collected using same prevalidated and structured questionnaire for each self-care activity. Difference-in-difference analysis will be used to measure for changes in the proportion of people living with type 2 DM doing different component of self-care practices, preintervention and postintervention in both arms.

ETHICS AND DISSEMINATION

Permission for conducting the study has been taken from Institutional Ethical Committee of PGIMER, Chandigarh (Ref no. NK/4538/PhD/226, Dated 18.08.18). The findings of the trial will be disseminated through publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

CTRI/2018/10/016108; Pre-results.

Lifestyle Interventions for Diabetes Prevention in South Asians: Current Evidence and Opportunities

PURPOSE OF REVIEW

This review summarizes the burden of diabetes in South Asian populations and reviews recent evidence for diabetes prevention through lifestyle modification among South Asians worldwide. We indicate important gaps in the current literature and point to opportunities for additional research in this area.

RECENT FINDINGS

Randomized, controlled, efficacy studies and implementation research show that lifestyle intervention can be an effective, cost-effective, and feasible method for reducing diabetes risk, improving cardiometabolic health, and improving lifestyle behaviors in South Asian populations, a population at high diabetes risk and elevated rates of diabetes risk factors. Additional research is needed to address diabetes risk reduction in normal-weight South Asians and individuals with impaired fasting glucose; improve community-level implementation, individual uptake, and dissemination of proven programs; and assess long-term outcomes of interventions.

Cardiovascular Disease Risk Factors Among Immigrant and US-Born Adults in New York City

OBJECTIVES

Immigrant adults tend to have better health than native-born adults despite lower incomes, but the health advantage decreases with length of residence. To determine whether immigrant adults have a health advantage over US-born adults in New York City, we compared cardiovascular disease (CVD) risk factors among both groups.

METHODS

Using data from the New York City Health and Nutrition Examination Survey 2013-2014, we assessed health insurance coverage, health behaviors, and health conditions, comparing adults ages ≥20 born in the 50 states or the District of Columbia (US-born) with adults born in a US territory or outside the United States (immigrants, following the National Health and Nutrition Examination Survey) and comparing US-born adults with (1) adults who immigrated recently (≤10 years) and (2) adults who immigrated earlier (>10 years).

RESULTS

For immigrant adults, the mean time since arrival in the United States was 21.8 years. Immigrant adults were significantly more likely than US-born adults to lack health insurance (22% vs 12%), report fair or poor health (26% vs 17%), have hypertension (30% vs 23%), and have diabetes (20% vs 11%) but significantly less likely to smoke (18% vs 27%) (all P < .05). Comparable proportions of immigrant adults and US-born adults were overweight or obese (67% vs 63%) and reported CVD (both 7%). Immigrant adults who arrived recently were less likely than immigrant adults who arrived earlier to have diabetes or high cholesterol but did not differ overall from US-born adults.

CONCLUSIONS

Our findings may help guide prevention programs and policy efforts to ensure that immigrant adults remain healthy.

Lifestyle interventions for type 2 diabetes management among migrants and ethnic minorities living in industrialized countries: a systematic review and meta-analyses

The objective of this systematic review was to determine the effectiveness of lifestyle interventions to improve the management of type 2 diabetes mellitus (T2DM) among migrants and ethnic minorities. Major searched databases included MEDLINE (via PubMed), EMBASE (via Ovid) and CINAHL. The selection of studies and data extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In the meta-analysis, significant heterogeneity was detected among the studies (I2 >50%), and hence a random effects model was used. Subgroup analyses were performed to compare the effect of lifestyle interventions according to intervention approaches (peer-led vs community health workers (CHWs)-led). A total of 17 studies were included in this review which used interventions delivered by CHWs or peer supporters or combination of both. The majority of the studies assessed effectiveness of key primary (hemoglobin (HbA1c), lipids, fasting plasma glucose) and secondary outcomes (weight, body mass index, blood pressure, physical activity, alcohol consumption, tobacco smoking, food habits and healthcare utilization). Meta-analyses showed lifestyle interventions were associated with a small but statistically significant reduction in HbA1c level (-0.18%; 95% CI -0.32% to -0.04%, p=0.031). In subgroup analyses, the peer-led interventions showed relatively better HbA1c improvement than CHW-led interventions, but the difference was not statistically significant (p=0.379). Seven studies presented intervention costs, which ranged from US$131 to US$461 per participant per year. We conclude that lifestyle interventions using either CHWs or peer supporters or a combination of both have shown modest effectiveness for T2DM management among migrants of different background and origin and ethnic minorities. The evidence base is promising in terms of developing culturally appropriate, clinically sound and cost-effective intervention approaches to respond to the growing and diverse migrants and ethnic minorities affected by diabetes worldwide.

Opportunities for and Perceptions of Integrating Community Health Workers Via the Affordable Care Act: Medicaid Health Homes

CONTEXT

The Affordable Care Act created opportunities for innovative, cost-saving measures to improve health care access. Community health workers (CHWs) are frontline public health workers who have a close understanding of the communities they serve. States that expanded Medicaid coverage could also create Medicaid Health Homes (MHHs)-virtual health care networks-to coordinate care for people with chronic conditions. New York was the second state to implement MHHs and gave the option to include CHWs as part of the health care team.

OBJECTIVE

To understand the perceptions of MHH administrators regarding CHW engagement in MHHs, as well as the facilitators and barriers to adoption in MHHs that are unknown.

DESIGN, SETTING, AND PARTICIPANTS

Semistructured qualitative interviews (n = 18) were conducted with MHH administrators throughout New York State guided by the Diffusion of Innovations (DOI) framework. Qualitative thematic analysis was used to explore the domains and themes.

RESULTS

Most MHH administrators believed that CHWs fit within MHHs. The DOI constructs of compatibility and complexity and the Consolidated Framework for Implementation Research construct of external policies helped explain CHW integration. CHWs were compatible with MHHs by enrolling patients, helping coordinate patient care, and providing social support. The complexities of CHW integration into MHHs included barriers to CHW integration, no direct reimbursement for their services, lack of clarity for CHW roles and responsibilities, and no explicit external policy for their use in MHHs.

CONCLUSIONS

CHWs can, and have, been integrated into the relatively novel Health Home system. While some barriers have prevented their integration into all MHHs, lessons learned could provide guidance for CHW integration into other health care systems in the United States.

Opportunities for Interventions That Address Socioeconomic Barriers to Type 2 Diabetes Management: Patient Perspectives

PURPOSE

The purpose of the study was to explore patient perspectives on socioeconomic barriers related to diabetes self-management and interventions to address these barriers.

METHODS

Focus groups (n = 8) were conducted with a diverse sample of adults with type 2 diabetes (T2D; n = 53). Researchers used a semistructured moderator guide; focus groups were audio recorded and transcribed verbatim. Researchers employed the constant comparison method for qualitative content analysis and utilized Atlas.ti (Version 8.1.1) to digitalize the analytic process.

RESULTS

Findings revealed 3 primary themes: (1) Existing food and nutrition resources are insufficient to support healthy eating for diabetes; (2) healthy eating is critical for diabetes management, but socioeconomic circumstances make doing so challenging; and (3) participants supported several broad categories of preferred intervention strategies. First, they endorsed lifestyle intervention informed by socioeconomic status (SES; eg, focusing on food resource management, sensitive health coaching and nutritional counseling). Next, they expressed enthusiasm for group-based learning opportunities, such as cooking classes and support groups with similar SES peers. Finally, they suggested healthy food access resources.

CONCLUSIONS

Participant suggestions should be incorporated into intervention development. Ultimately, these interventional strategies should be tested and refined to help improve health for individuals with type 2 diabetes.

Refugee and Migrant Health Literacy Interventions in High-Income Countries: A Systematic Review

Health literacy is a key determinant of health in refugee and migrant populations living in in high-income countries (HICs). We conducted a systematic review of randomized-controlled trials (RCTs) to characterize the scope, methodology, and outcomes of research on interventions aimed at improving health literacy among these vulnerable populations. We searched EMBASE, MEDLINE, PsycINFO, CINAHL, and Web of Science databases to identify RCTs of health literacy intervenions in our target population published between 1997 and 2018. The search yielded 23 RCTs (n = 5625 participants). Study demographics, health literacy topics, interventions, and outcome measures were heterogeneous but demonstrated overall positive results. Only two studies used a common health literacy measure. Few RCTs have been conducted to investigate interventions for improving the health literacy of refugees and migrants in HICs. The heterogeniety of health literacy outcome measures used impeded a robust comparison of intervention efficacy.

Outcomes of Culturally Tailored Dietary Intervention in the North African and Bangladeshi Diabetic Patients in Italy

Immigrants show higher adjusted diabetes prevalence than Italians, especially among South-East Asians followed by North and Sub-Saharan Africans. Diabetes progression is influenced by food behaviors, and diet control is a critical aspect in disease management. Food habits have many cultural and symbolic implications. Guidelines recommend that every patient should receive appropriate self-management education according to cultural and socioeconomic characteristics. This study aims to test whether a customized diet and transcultural mediator’s support can improve immigrants’ food habits. A pre-post quali-quantitative study was conducted among 20–79-year-old Bangladeshi and North African diabetic immigrants. The INMP transcultural mediator, an expert in the social and health care field, actively participates in clinical activity by decoding linguistic and cultural needs expressed by the foreigner patient. Five culturally tailored dietary profiles were designed according to international diabetes guidelines and adjusted to traditional food habits. Data were collected with two different semi-structured questionnaires. Changes in food consumption were assessed through McNemar’s test, while paired Wilcoxon Signed-Rank test was used to analyze pre and post intervention. Fifty-five patients were enrolled. At follow-up, cereals, meat, and potatoes intake significantly improved, and the number of adequate dietary habits for each patient increased significantly. Transcultural mediator support was 90% positively evaluated. Adherence to dietary control is favorably influenced by a transcultural intervention, which is based on clinical and socio-cultural criteria, in compliance with patient’s lifestyles.

Alzheimer's Disease and its Related Dementias among Asian Americans, Native Hawaiians, and Pacific Islanders: A Scoping Review

BACKGROUND

The Asian American, Native Hawaiian, and Pacific Islander (AANHPI) aging population is rapidly growing and the burden of Alzheimer's disease and its related dementias (ADRD) will likely mirror this demographic growth. AANHPIs face significant barriers in obtaining timely ADRD diagnosis and services; yet little is known about ADRD in this population.

OBJECTIVE

The study objective is to conduct a systematic review on the published literature on ADRD among AANHPIs to identify gaps and priorities to inform future research and action plans.

METHODS

The systematic review was conducted following the PRISMA Protocol for Systematic Reviews. Co-author (TR), an experienced Medical Librarian, searched PubMed, EMBASE, PsycINFO, Cochrane Central of Clinical Trials, Ageline, and Web of Science for peer-reviewed articles describing ADRD among AANHPIs. The search was not limited by language or publication date. Each citation was reviewed by two trained independent reviewers. Conflicts were resolved through consensus.

RESULTS

The title/abstract and full texts of 1,447 unique articles were screened for inclusion, yielding 168 articles for analysis. Major research topics included prevalence, risk factors, comorbidities, interventions and outreach, knowledge and attitudes, caregiving, and detection tools. A limited number of studies reported on national data, on NHPI communities generally, and on efficacy of interventions targeting AANHPI communities.

CONCLUSION

To our knowledge, this is the first systematic review on ADRD among AANHPI populations. Our review provides a first step in mapping the extant literature on ADRD among this underserved and under-researched population and will serve as a guide for future research, policy, and intervention.

Improving type 2 diabetes mellitus glycaemic control through lifestyle modification implementing diet intervention: a systematic review and meta-analysis

PURPOSE

Type 2 diabetes mellitus represents a significant health problem. Many studies have reported that intensive nutritional intervention by itself or in addition to medications is the best method to improve glycaemic control in type 2 diabetes mellitus. However, in clinical practice, dietary education is not implemented as an integral part in the management of type 2 diabetes mellitus. The purpose of this systematic review and meta-analysis is to analyse the scientific evidence concerning the role of nutritional intervention in the glycaemic control of type 2 diabetes mellitus.

METHODS

We searched Pubmed, Scopus, Cochrane Library and Web of Science databases from inception till May 2019 for randomised controlled trials (RCTs) that include dietary interventions in the management of patients with type 2 diabetes mellitus.

RESULTS

A total of 28 studies were included. Our results demonstrated that lifestyle interventions significantly lowered glycosylated haemoglobin (HbA_1c) levels compared to the usual care for patients with type 2 diabetes mellitus, overall weighted mean difference, WMD = - 0.51 (- 0.67, - 0.35). Strategies combining individualized and group-based activities were the most effective, WMD = - 0.95 (- 1.24, - 0.66). Most of stratified analyses did not totally resolve heterogeneity, but improvement in HbA_1c levels has been consistently observed.

CONCLUSIONS

The available evidence from RCTs shows that lifestyle intervention is more effective than the standard care regarding the glycaemic control of type 2 diabetic patients, particularly when there is a weight loss. It is time to translate this evidence to the primary health care practice. The protocol of the present systematic review was registered in PROSPERO, registration number CRD42018090469.

The DREAM Initiative: study protocol for a randomized controlled trial testing an integrated electronic health record and community health worker intervention to promote weight loss among South Asian patients at risk for diabetes

BACKGROUND

Electronic health record (EHR)-based interventions that use registries and alerts can improve chronic disease care in primary care settings. Community health worker (CHW) interventions also have been shown to improve chronic disease outcomes, especially in minority communities. Despite their potential, these two approaches have not been tested together, including in small primary care practice (PCP) settings. This paper presents the protocol of Diabetes Research, Education, and Action for Minorities (DREAM) Initiative, a 5-year randomized controlled trial integrating both EHR and CHW approaches into a network of PCPs in New York City (NYC) in order to support weight loss efforts among South Asian patients at risk for diabetes.

METHODS/DESIGN

The DREAM Initiative was funded by the National Institute of Diabetes and Digestive and Kidney Diseases (National Institutes of Health). A total of 480 individuals at risk for type 2 diabetes will be enrolled into the intervention group, and an equal number will be included in a matched control group. The EHR intervention components include the provision of technical assistance to participating PCPs regarding prediabetes-related registry reports, alerts, and order sets. The CHW intervention components entail group education sessions on diabetes prevention, including weight loss and nutrition. A mixed-methods approach will be used to evaluate the feasibility, adoption, and impact (≥ 5% weight loss) of the integrated study components. Additionally, a cost effectiveness analysis will be conducted using outcomes, implementation costs, and healthcare claims data to determine the incremental cost per person achieving 5% weight loss.

DISCUSSION

This study will be the first to test the efficacy of an integrated EHR-CHW intervention within an underserved, minority population and in a practical setting via a network of small PCPs in NYC. The study's implementation is enhanced through cross-sector partnerships, including the local health department, a healthcare payer, and EHR vendors. Through use of a software platform, the study will also systematically track and monitor CHW referrals to social service organizations. Study findings, including those resulting from cost-effectiveness analyses, will have important implications for translating similar strategies to other minority communities in sustainable ways.

TRIAL REGISTRATION

This study protocol has been approved and is made available on ClinicalTrials.gov by NCT03188094 as of 15 June 2017.

The Impact of a Community-Based Food Education Program on Nutrition-Related Knowledge in Middle-Aged and Older Patients with Type 2 Diabetes: Results of a Pilot Randomized Controlled Trial

The purpose of this study was to evaluate the impact of a community-based food education program on nutrition-related knowledge in middle-aged and older patients with type 2 diabetes (T2D). Participants (n = 36; 65.9 ± 6.0 years old) were recruited in primary health care to a 9-month community-based lifestyle intervention program for patients with T2D and randomly assigned to an exercise program (control group; n = 16) or an exercise program plus a food education program (experimental group; n = 20). Nutrition-related knowledge was assessed through a modified version of the General Nutrition Knowledge Questionnaire. The increase in total nutrition-related knowledge score and sources of nutrients area score was significantly higher in the experimental group compared to the control group. No significant changes in nutrition-related knowledge were found between groups in dietary recommendations and diet-disease relationship areas, although improvements were observed. This community-based food education program, with the use of easy to implement strategies (short-duration lectures and dual-task problem solving activities during exercise), had a positive and encouraging impact on nutrition-related knowledge in middle-aged and older patients with T2D.

A Culturally Adapted Diabetes Prevention Intervention in the New York City Sikh Asian Indian Community Leads to Improvements in Health Behaviors and Outcomes

INTRODUCTION

Sikh Asian Indians are an underserved, minority group demonstrating high rates of diabetes. Community health workers (CHWs) are effective in addressing health disparities by reaching socially and linguistically isolated populations. There are no culturally-adapted programs for diabetes prevention among Sikh Asian Indians, thus, this study tests the efficacy of a culturally-tailored CHW intervention to improve diabetes prevention-related outcomes among Sikh Asian Indians at-risk for diabetes.

METHODS

A quasi-experimental two-arm intervention among Sikh Asian Indian adults at-risk for diabetes and living in New York City (n=160) was conducted in 2013-2014. The treatment group received six monthly CHW group education sessions and ten follow-up phone calls; the control group received the first session. Main outcomes included weight, body mass index (BMI), blood pressure (BP), physical activity (PA), diet, and health self-efficacy.

RESULTS

Positive and significant changes in weight, BMI, and diabetes prevention-related indicators were seen among both study groups. However, only treatment group participants showed significant changes over time for weight, BMI, PA self-efficacy, and health-related self-efficacy. Significant between-group differences were seen in adjusted analyses for weight, BMI, systolic BP, total weekly PA, PA self-efficacy, PA social interaction, portion control, barriers to healthy eating, and health self-efficacy. At 6-months, treatment participants were more likely to lose ≥5% and ≥7% of their weight compared to control participants (p=0.071, and p=0.015, respectively).

CONCLUSIONS

Findings demonstrate that a culturally-adapted CHW diabetes prevention program in the Sikh community is efficacious, adding to the growing literature on CHWs' capacity to address health inequity among underserved populations.

A community health worker intervention to improve blood pressure among Filipino Americans with hypertension: A randomized controlled trial

Behavioral interventions utilizing community health workers (CHWs) have demonstrated effectiveness in improving hypertension disparities in ethnic minority populations in the United States, but few have focused on Asian Americans. We assessed the efficacy of a CHW intervention to improve hypertension management among Filipino Americans with uncontrolled blood pressure (BP) in New York City (NYC) from 2011 to 2013. A total of 240 Filipino American individuals (112 in the treatment group and 128 in the control group) with uncontrolled hypertension (SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg) were recruited from community-based settings in NYC. Using a community-based participatory research approach, treatment participants received 4 educational workshops and 4 one-on-one visits with CHWs over a 4-month period, while control group participants received 1 educational workshop. Main outcome measures included BP control, changes in SBP and DBP, and changes in appointment keeping at 8-months. At 8-months, BP was controlled among a significantly greater percentage of treatment group participants (83.3%) compared to the control group (42.7%). The adjusted odds of controlled BP for the treatment group was 3.2 times the odds of the control group (P < 0.001). Both groups showed decreases in SBP and DBP, with greater decreases among treatment participants. Significant between-group differences were also demonstrated in adjusted analyses (P < 0.001). Individuals in the treatment group showed significant changes in appointment keeping. In conclusion, a community-based intervention delivered by CHWs can help improve BP and related factors among Filipino Americans with hypertension in NYC.

Hypoglycemia Among Patients with Type 2 Diabetes: Epidemiology, Risk Factors, and Prevention Strategies

PURPOSE OF REVIEW

Hypoglycemia is the most common and often treatment-limiting serious adverse effect of diabetes therapy. Despite being potentially preventable, hypoglycemia in type 2 diabetes incurs substantial personal and societal burden. We review the epidemiology of hypoglycemia in type 2 diabetes, discuss key risk factors, and introduce potential prevention strategies.

RECENT FINDINGS

Reported rates of hypoglycemia in type 2 diabetes vary widely as there is marked heterogeneity in how hypoglycemia is defined, measured, and reported. In randomized controlled trials, rates of severe hypoglycemia ranged from 0.7 to 12 per 100 person-years. In observational studies, hospitalizations or emergency department visits for hypoglycemia were experienced by 0.2 (patients treated without insulin or sulfonylurea) to 2.0 (insulin or sulfonylurea users) per 100 person-years. Patient-reported hypoglycemia is much more common. Over the course of 6 months, 1-4% non-insulin users reported need for medical attention for hypoglycemia; 1-17%, need for any assistance; and 46-58%, any hypoglycemia symptoms. Similarly, over a 12-month period, 4-17% of insulin-treated patients reported needing assistance and 37-64% experienced any hypoglycemic symptoms. Hypoglycemia is most common among older patients with multiple or advanced comorbidities, patients with long diabetes duration, or patients with a prior history of hypoglycemia. Insulin and sulfonylurea use, food insecurity, and fasting also increase hypoglycemia risk. Clinical decision support tools may help identify at-risk patients. Prospective trials of efforts to reduce hypoglycemia risk are needed, and there is emerging evidence supporting multidisciplinary interventions including treatment de-intensification, use of diabetes technologies, diabetes self-management, and social support. Hypoglycemia among patients with type 2 diabetes is common. Patient-centered multidisciplinary care may help proactively identify at-risk patients and address the multiplicity of factors contributing to hypoglycemia occurrence.