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Lachner C, Craver EC, Babulal GM, Lucas JA, Ferman TJ, White RO, Graff-Radford NR, Day GS. Disparate Dementia Risk Factors Are Associated with Cognitive Impairment and Rates of Decline in African Americans. Ann Neurol 2024; 95:518-529. [PMID: 38069571 PMCID: PMC10922775 DOI: 10.1002/ana.26847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 11/28/2023] [Accepted: 12/05/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE This study was undertaken to evaluate the frequency of modifiable dementia risk factors and their association with cognitive impairment and rate of decline in diverse participants engaged in studies of memory and aging. METHODS Modifiable dementia risk factors and their associations with cognitive impairment and cognitive decline were determined in community-dwelling African American (AA; n = 261) and non-Hispanic White (nHW; n = 193) participants who completed ≥2 visits at the Mayo Clinic Alzheimer Disease Research Center in Jacksonville, Florida. Risk factors and their associations with cognitive impairment (global Clinical Dementia Rating [CDR] ≥ 0.5) and rates of decline (CDR Sum of Boxes) in impaired participants were compared in AA and nHW participants, controlling for demographics, APOE ɛ4 status, and Area Deprivation Index. RESULTS Hypertension, hypercholesterolemia, obesity, and diabetes were overrepresented in AA participants, but were not associated with cognitive impairment. Depression was associated with increased odds of cognitive impairment in AA (odds ratio [OR] = 4.30, 95% confidence interval [CI] = 2.13-8.67) and nHW participants (OR = 2.79, 95% CI = 1.21-6.44) but uniquely associated with faster decline in AA participants (β = 1.71, 95% CI = 0.69-2.73, p = 0.001). Fewer AA participants reported antidepressant use (9/49, 18%) than nHW counterparts (57/78, 73%, p < 0.001). Vitamin B12 deficiency was also associated with an increased rate of cognitive decline in AA participants (β = 2.65, 95% CI = 0.38-4.91, p = 0.023). INTERPRETATION Modifiable dementia risk factors are common in AA and nHW participants, representing important risk mitigation targets. Depression was associated with dementia in AA and nHW participants, and with accelerated declines in cognitive function in AA participants. Optimizing depression screening and treatment may improve cognitive trajectories and outcomes in AA participants. ANN NEUROL 2024;95:518-529.
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Affiliation(s)
- Christian Lachner
- Mayo Clinic Florida, Department of Neurology; Jacksonville, FL, 32224, USA
- Mayo Clinic Florida, Department of Psychiatry & Psychology; Jacksonville, FL, 32224, USA
| | - Emily C. Craver
- Mayo Clinic Florida, Department of Quantitative Health Sciences; Jacksonville, FL, 32224, USA
| | - Ganesh M. Babulal
- Washington University in St. Louis, Department of Neurology; St. Louis, MO, 63110, USA
| | - John A. Lucas
- Mayo Clinic Florida, Department of Psychiatry & Psychology; Jacksonville, FL, 32224, USA
| | - Tanis J. Ferman
- Mayo Clinic Florida, Department of Psychiatry & Psychology; Jacksonville, FL, 32224, USA
| | - Richard O. White
- Mayo Clinic Florida, Division of Community Internal Medicine; Jacksonville, FL, 32224, USA
- Mayo Center for Health Equity and Community Engaged Research, Jacksonville, FL, 32224, USA
| | | | - Gregory S. Day
- Mayo Clinic Florida, Department of Neurology; Jacksonville, FL, 32224, USA
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Lalika M, Salinas M, Asiedu GB, Jones C, Richard M, Erickson J, Weis J, Abbenyi A, Brockman TA, Sia IG, Wieland ML, White RO, Doubeni CA, Brewer LC. Perspectives of African American Church Leaders in Response to COVID-19 Emergency Preparedness and Risk Communication Efforts Within a Community Engaged Research Partnership: COVID-19 emergency risk communication. Disaster Med Public Health Prep 2023; 17:e532. [PMID: 37830352 PMCID: PMC11017953 DOI: 10.1017/dmp.2023.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Affiliation(s)
- Mathias Lalika
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Manisha Salinas
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Jacksonville, FL, USA
| | - Gladys B. Asiedu
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Jennifer Weis
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, USA
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN, USA
| | - Adeline Abbenyi
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, USA
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN, USA
| | - Tabetha A. Brockman
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, USA
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN, USA
| | - Irene G. Sia
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, USA
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN, USA
- Division of Infectious Diseases, Mayo Clinic Department of Medicine, Rochester, MN, USA
| | - Mark L. Wieland
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN, USA
- Division of Community Internal Medicine, Mayo Clinic Department of Medicine, Rochester, MN, USA
| | - Richard O. White
- Division of Community Internal Medicine, Mayo Clinic Department of Medicine, Jacksonville, FL, USA
| | - Chyke A. Doubeni
- Department of Family and Community Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - LaPrincess C. Brewer
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN, USA
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Lalika M, Woods C, Patel A, Scott C, Lee A, Weis J, Jones C, Abbenyi A, Brockman TA, Sia IG, White RO, Doubeni CA, Brewer LC. Factors Associated With COVID-19 Vaccine Acceptance Among Patients Receiving Care at a Federally Qualified Health Center. J Prim Care Community Health 2023; 14:21501319231181881. [PMID: 37350465 PMCID: PMC10291217 DOI: 10.1177/21501319231181881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND COVID-19 vaccine hesitancy in the United States is high, with at least 63 million unvaccinated individuals to date. Socioeconomically disadvantaged populations experience lower COVID-19 vaccination rates despite facing a disproportionate COVID-19 burden. OBJECTIVE To assess the factors associated with COVID-19 vaccine acceptance among under-resourced, adult patients. METHODS Participants were patients receiving care at a Federally Qualified Health Center (FQHC) in St. Paul, Minnesota. Data were collected via multiple modes over 2 phases in 2020 (self-administered electronic survey) and 2021 (study team-administered survey by telephone, self-administered written survey) to promote diversity and inclusion for study participation. The primary outcome was COVID-19 vaccine acceptance. Using logistic regression analysis, associations between vaccine acceptance and factors including risk perception, concerns about the COVID-19 vaccine, social determinants of health (SDOH), co-morbidities, pandemic-induced hardships, and stress were assessed by adjusted odds ratios (AORs) and 95% confidence intervals (CI). RESULTS One hundred sixty-eight patients (62.5% female; mean age [SD]: 49.9 [17.4] years; 32% <$20 000 annual household income; 69% CONCLUSIONS Our study in a socioeconomically disadvantaged population suggests that risk perception is associated with an increased likelihood of vaccine acceptance, while concerns about the COVID-19 vaccine are associated with a lower likelihood of vaccine acceptance. As these factors could impact vaccine uptake, consistent, innovative, and context-specific risk communication strategies may improve vaccine coverage in this population.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Chyke A. Doubeni
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Seckin ZI, Umadat G, White RO. 71-Year-Old Man With a New Heart Murmur. Mayo Clin Proc 2022; 97:1717-1722. [PMID: 36058583 DOI: 10.1016/j.mayocp.2022.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/22/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Zeynep I Seckin
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Goyal Umadat
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Richard O White
- Advisor to residents and Consultant in Community Internal Medicine, Mayo Clinic, Jacksonville, FL.
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Adedinsewo DA, Porter IE, White RO, Hickson LJ. Racial and Ethnic Disparities in Cardiovascular Disease Risk Among Patients with Chronic Kidney Disease. Curr Cardiovasc Risk Rep 2022. [DOI: 10.1007/s12170-022-00701-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Brewer LC, Asiedu GB, Jones C, Richard M, Erickson J, Weis J, Abbenyi A, Brockman TA, Sia IG, Wieland ML, White RO, Doubeni CA. Emergency Preparedness and Risk Communication Among African American Churches: Leveraging a Community-Based Participatory Research Partnership COVID-19 Initiative. Prev Chronic Dis 2020; 17:E158. [PMID: 33301390 PMCID: PMC7769077 DOI: 10.5888/pcd17.200408] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) crisis has disproportionately affected the African American population. To mitigate the disparities, we deployed an emergency preparedness strategy within an existing community-based participatory research (CBPR) partnership among African American churches to disseminate accurate COVID-19 information. We used the Centers for Disease Control and Prevention Crisis and Emergency Risk Communication framework to conduct a needs assessment, distribute emergency preparedness manuals, and deliver COVID-19–related messaging among African American churches via electronic communication platforms. A needs assessment showed that the top 3 church emergency resource needs were financial support, food and utilities, and COVID-19 health information. During an 8-week period (April 3–May 31, 2020), we equipped 120 churches with emergency preparedness manuals and delivered 230 messages via social media (Facebook) and email. For reach, we estimated that 6,539 unique persons viewed content on the Facebook page, and for engagement, we found 1,260 interactions (eg, likes, loves, comments, shares, video views, post clicks). Emails from community communication leaders reached an estimated 12,000 church members. CBPR partnerships can be effectively leveraged to promote emergency preparedness and communicate risk among under-resourced communities during a pandemic.
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Affiliation(s)
- LaPrincess C Brewer
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.,Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota.,Mayo Clinic, 200 First St SW, Rochester, MN 55905.
| | - Gladys B Asiedu
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Jennifer Weis
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota.,Center for Clinical and Translational Science, Mayo Clinic, Rochester, Minnesota
| | - Adeline Abbenyi
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota.,Center for Clinical and Translational Science, Mayo Clinic, Rochester, Minnesota
| | - Tabetha A Brockman
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota.,Center for Clinical and Translational Science, Mayo Clinic, Rochester, Minnesota
| | - Irene G Sia
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota.,Center for Clinical and Translational Science, Mayo Clinic, Rochester, Minnesota.,Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Mark L Wieland
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota.,Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Richard O White
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota.,Division of Community Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Chyke A Doubeni
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota.,Center for Clinical and Translational Science, Mayo Clinic, Rochester, Minnesota.,Department of Family Medicine, Mayo Clinic, Rochester, Minnesota
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White RO, Chakkalakal RJ, Wallston KA, Wolff K, Gregory B, Davis D, Schlundt D, Trochez KM, Barto S, Harris LA, Bian A, Schildcrout JS, Kripalani S, Rothman RL. The Partnership to Improve Diabetes Education Trial: a Cluster Randomized Trial Addressing Health Communication in Diabetes Care. J Gen Intern Med 2020; 35:1052-1059. [PMID: 31919724 PMCID: PMC7174470 DOI: 10.1007/s11606-019-05617-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/12/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Effective type 2 diabetes care remains a challenge for patients including those receiving primary care in safety net settings. OBJECTIVE The Partnership to Improve Diabetes Education (PRIDE) trial team and leaders from a regional department of health evaluated approaches to improve care for vulnerable patients. DESIGN Cluster randomized controlled trial. PATIENTS Adults with uncontrolled type 2 diabetes seeking care across 10 unblinded, randomly assigned safety net clinics in Middle TN. INTERVENTIONS A literacy-sensitive, provider-focused, health communication intervention (PRIDE; 5 clinics) vs. standard diabetes education (5 clinics). MAIN MEASURES Participant-level primary outcome was glycemic control [A1c] at 12 months. Secondary outcomes included select health behaviors and psychosocial aspects of care at 12 and 24 months. Adjusted mixed effects regression models were used to examine the comparative effectiveness of each approach to care. KEY RESULTS Of 410 patients enrolled, 364 (89%) were included in analyses. Median age was 51 years; Black and Hispanic patients represented 18% and 25%; 96% were uninsured, and 82% had low annual income level (< $20,000); adequate health literacy was seen in 83%, but numeracy deficits were common. At 12 months, significant within-group treatment effects occurred from baseline for both PRIDE and control sites: adjusted A1c (- 0.76 [95% CI, - 1.08 to - 0.44]; P < .001 vs - 0.54 [95% CI, - 0.86 to - 0.21]; P = .001), odds of poor eating (0.53 [95% CI, 0.33-0.83]; P = .01 vs 0.42 [95% CI, 0.26-0.68]; P < .001), treatment satisfaction (3.93 [95% CI, 2.48-6.21]; P < .001 vs 3.04 [95% CI, 1.93-4.77]; P < .001), and self-efficacy (2.97 [95% CI, 1.89-4.67]; P < .001 vs 1.81 [95% CI, 1.1-2.84]; P = .01). No significant difference was observed between study arms in adjusted analyses. CONCLUSIONS Both interventions improved the participant's A1c and behavioral outcomes. PRIDE was not more effective than standard education. Further research may elucidate the added value of a focused health communication program in this setting.
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Affiliation(s)
- Richard O White
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, FL, USA.
| | - Rosette James Chakkalakal
- Department of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kenneth A Wallston
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kathleen Wolff
- School of Nursing, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Becky Gregory
- Vanderbilt Diabetes Research and Training Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dianne Davis
- Vanderbilt Diabetes Research and Training Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Karen M Trochez
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shari Barto
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura A Harris
- Mid-Cumberland Regional Office, Tennessee Department of Health , Nashville, TN, USA
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | | | - Sunil Kripalani
- Department of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Russell L Rothman
- Department of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
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Presley CA, White RO, Bian A, Schildcrout JS, Rothman RL. Factors associated with antidepressant use among low-income racially and ethnically diverse patients with type 2 diabetes. J Diabetes Complications 2019; 33:107405. [PMID: 31405797 PMCID: PMC6736726 DOI: 10.1016/j.jdiacomp.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/26/2019] [Accepted: 07/09/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Depression is common in patients with type 2 diabetes and associated with poor diabetes-related outcomes. We evaluated the factors associated with antidepressant use in a low-income, racially and ethnically diverse sample of patients with type 2 diabetes. RESEARCH DESIGN AND METHODS We performed a cross-sectional study of baseline data from participants in a cluster randomized trial evaluating a health literacy intervention for diabetes care in safety net clinics. Depressive symptoms were measured by the Center for Epidemiological Studies Depression Scale (CES-D); antidepressant use was abstracted from medication lists. Multivariable mixed effects logistic regression was used to evaluate the relationship between antidepressant use and race/ethnicity adjusting for depressive symptoms, age, gender, income, and health literacy. RESULTS Of 403 participants, 58% were non-Hispanic White, 18% were non-Hispanic Black, and 24% were Hispanic. Median age was 51 years old; 60% were female, 52% of participants had a positive screen for depression, and 18% were on antidepressants. Black and Hispanic participants were significantly less likely to be on an antidepressant compared with white participants, adjusted odds ratios 0.31(95% CI: 0.12 to 0.80) and 0.26 (95% CI: 0.10 to 0.74), respectively. CONCLUSIONS In this vulnerable population with type 2 diabetes, we found a high prevalence of depressive symptoms, and a small proportion of participants were on an antidepressant. Black and Hispanic participants were significantly less likely to be treated with an antidepressant. Our findings suggest depression may be inadequately treated in low-income, uninsured patients with type 2 diabetes, especially racial and ethnic minorities.
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Affiliation(s)
- Caroline A Presley
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Ave, Suite 450, Nashville, TN 37203, United States of America; Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, 1310 24th Avenue South, Nashville, TN 37212, United States of America.
| | - Richard O White
- Division of Community Internal Medicine, Mayo Clinic, Cannaday Building, 3 West 4500 San Pablo Road, Jacksonville, FL 32224, United States of America.
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End, Suite 1100, Nashville, TN 37203, United States of America.
| | - Jonathan S Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End, Suite 1100, Nashville, TN 37203, United States of America; Department of Anesthesiology, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN 37232, United States of America.
| | - Russell L Rothman
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Ave, Suite 450, Nashville, TN 37203, United States of America.
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Phelan SM, Burke SE, Cunningham BA, Perry SP, Hardeman RR, Dovidio JF, Herrin J, Dyrbye LN, White RO, Yeazel MW, Onyeador IN, Wittlin NM, Harden K, van Ryn M. The Effects of Racism in Medical Education on Students' Decisions to Practice in Underserved or Minority Communities. Acad Med 2019; 94:1178-1189. [PMID: 30920443 DOI: 10.1097/acm.0000000000002719] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE The purpose of this study was to examine the relationship between manifestations of racism in medical school and subsequent changes in graduating medical students' intentions to practice in underserved or minority communities, compared with their attitudes and intentions at matriculation. METHOD The authors used repeated-measures data from a longitudinal study of 3,756 students at 49 U.S. medical schools that were collected from 2010 to 2014. They conducted generalized linear mixed models to estimate whether manifestations of racism in school curricula/policies, school culture/climate, or student attitudes/behaviors predicted first- to fourth-year changes in students' intentions to practice in underserved communities or primarily with minority populations. Analyses were stratified by students' practice intentions (no/undecided/yes) at matriculation. RESULTS Students' more negative explicit racial attitudes were associated with decreased intention to practice with underserved or minority populations at graduation. Service learning experiences and a curriculum focused on improving minority health were associated with increased intention to practice in underserved communities. A curriculum focused on minority health/disparities, students' perceived skill at developing relationships with minority patients, the proportion of minority students at the school, and the perception of a tense interracial environment were all associated with increased intention to care for minority patients. CONCLUSIONS This study provides evidence that racism manifested at multiple levels in medical schools was associated with graduating students' decisions to provide care in high-need communities. Strategies to identify and eliminate structural racism and its manifestations in medical school are needed.
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Affiliation(s)
- Sean M Phelan
- S.M. Phelan is associate professor, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota. S.E. Burke is assistant professor, Department of Psychology, Syracuse University, Syracuse, New York. B.A. Cunningham is assistant professor, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota. S.P. Perry is assistant professor, Departments of Psychology and Medical Social Sciences, Institute for Policy Research, Northwestern University, Evanston, Illinois. R.R. Hardeman is assistant professor, Division of Health Policy & Management, University of Minnesota School of Public Health, Minneapolis, Minnesota. J.F. Dovidio is professor, Department of Psychology, Yale University, New Haven, Connecticut. J. Herrin is assistant professor, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut. L.N. Dyrbye is professor, Department of Medicine, Mayo Clinic, Rochester, Minnesota. R.O. White is assistant professor, Department of Community Internal Medicine, Mayo Clinic, Jacksonville, Florida. M.W. Yeazel is professor, Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota. I.N. Onyeador is postdoctoral fellow, Department of Psychology, Yale University, New Haven, Connecticut. N.M. Wittlin is a PhD candidate, Department of Psychology, Yale University, New Haven, Connecticut. K. Harden is senior program coordinator, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota. M. van Ryn is distinguished professor, School of Nursing, Oregon Health & Science University, and founder/president, Institute for Equity & Inclusion Sciences, Portland, Oregon
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Doshi RS, Gudzune KA, Dyrbye LN, Dovidio JF, Burke SE, White RO, Perry S, Yeazel M, van Ryn M, Phelan SM. Factors influencing medical student self-competence to provide weight management services. Clin Obes 2019; 9:e12288. [PMID: 30358159 PMCID: PMC6411289 DOI: 10.1111/cob.12288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 08/28/2018] [Accepted: 09/20/2018] [Indexed: 11/27/2022]
Abstract
This study aimed to identify factors associated with high obesity care self-competence among US medical students. The authors performed a cross-sectional analysis of 2014 survey data on fourth year medical students collected online as part of the Medical Student Cognitive Habits and Growth Evaluation Study (CHANGES). Independent variables included quality and quantity of interaction with patients and peers with obesity; hours of communication and partnership skills training; negative remarks against patients with obesity by supervising physicians, and witnessed discrimination against patients with obesity. The dependent variable was self-competence in providing obesity care. Of 5823 students invited to participate, 3689 (63%) responded and were included in our analyses. Most students were white (65%), half were women and 42% had high self-competence in caring for patients with obesity. Factors associated with high self-competence included increased interaction with peers with obesity (39% vs. 49%, P < 0.001) and increased partnership skills training (32% vs. 61%, P < 0.001). Increased partnership skills training and quantity of interactions with peers with obesity were associated with high student self-competence in providing obesity-related care to patients. Medical schools might consider increasing partnership skills training to improve students' preparedness and skill in performing obesity-related care.
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Affiliation(s)
- R S Doshi
- Duke University Medical Center, Department of Internal Medicine-Pediatrics, Duke University Hospital, Durham, North Carolina, USA
| | - K A Gudzune
- Department of General Internal Medicine, Johns Hopkins University School of Medicine and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
| | - L N Dyrbye
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - J F Dovidio
- Department of Psychology, Yale University, New Haven, Connecticut, USA
| | - S E Burke
- Department of Psychology, Syracuse University, Syracuse, New York, USA
| | - R O White
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - S Perry
- Department of Psychology, Northwestern University, Evanston, Illinois, USA
| | - M Yeazel
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - M van Ryn
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - S M Phelan
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
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Pullins CT, Seele PC, White RO, Willis FB, Poole K, Albertie ML, Chamie C, Allen AM, Kelly M, Penheiter S, Buras MR, Brewer LC. Health Behaviors and Preventive Healthcare Utilization Among African-American Attendees at a Faith-Based Public Health Conference: Healthy Churches 2020. J Relig Health 2018; 57:2538-2551. [PMID: 29995232 PMCID: PMC7249222 DOI: 10.1007/s10943-018-0667-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Unhealthy eating habits and physical inactivity along with lack of access to quality healthcare contribute to the marked health disparities in chronic diseases among African-Americans. Faith-based public health conferences offer a potential opportunity to improve health literacy and change health behaviors through health promotion within this population, thereby reducing health disparities. This study examined the self-reported health behaviors and preventive healthcare utilization patterns of 77 participants at a predominantly African-American faith-based public health conference, Healthy Churches 2020. A self-administered questionnaire was distributed to a sample of attendees to assess their health behaviors (diet and physical activity), preventive healthcare utilization (annual healthcare provider visits), and health-promoting activities at their places of worship. The results indicate that attendees of a faith-based public health conference have adequate preventive healthcare utilization, but suboptimal healthy behaviors. Our findings support the need for ongoing health-promoting activities with an emphasis on diet and physical activity among this population.
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Affiliation(s)
| | | | - Richard O White
- Department of Community Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Floyd B Willis
- Department of Family Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Kenneth Poole
- Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Monica L Albertie
- Clinical Studies Unit, Health Disparities, Mayo Clinic, Jacksonville, FL, USA
| | - Chara Chamie
- Research Service, Health Disparities, Mayo Clinic, Scottsdale, AZ, USA
| | - Angela M Allen
- College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Marion Kelly
- Divison of Community Relations, Mayo Clinic, Scottsdale, AZ, USA
| | - Sumedha Penheiter
- Office of Health Disparities Research, Mayo Clinic, Rochester, MN, USA
| | - Matthew R Buras
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, USA
| | - LaPrincess C Brewer
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA.
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Dyrbye LN, Burke SE, Hardeman RR, Herrin J, Wittlin NM, Yeazel M, Dovidio JF, Cunningham B, White RO, Phelan SM, Satele DV, Shanafelt TD, van Ryn M. Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians. JAMA 2018; 320:1114-1130. [PMID: 30422299 PMCID: PMC6233627 DOI: 10.1001/jama.2018.12615] [Citation(s) in RCA: 274] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Burnout among physicians is common and has been associated with medical errors and lapses in professionalism. It is unknown whether rates for symptoms of burnout among resident physicians vary by clinical specialty and if individual factors measured during medical school relate to the risk of burnout and career choice regret during residency. OBJECTIVE To explore factors associated with symptoms of burnout and career choice regret during residency. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of 4732 US resident physicians. First-year medical students were enrolled between October 2010 and January 2011 and completed the baseline questionnaire. Participants were invited to respond to 2 questionnaires; one during year 4 of medical school (January-March 2014) and the other during the second year of residency (spring of 2016). The last follow-up was on July 31, 2016. EXPOSURES Clinical specialty, demographic characteristics, educational debt, US Medical Licensing Examination Step 1 score, and reported levels of anxiety, empathy, and social support during medical school. MAIN OUTCOMES AND MEASURES Prevalence during second year of residency of reported symptoms of burnout measured by 2 single-item measures (adapted from the Maslach Burnout Inventory) and an additional item that evaluated career choice regret (defined as whether, if able to revisit career choice, the resident would choose to become a physician again). RESULTS Among 4696 resident physicians, 3588 (76.4%) completed the questionnaire during the second year of residency (median age, 29 [interquartile range, 28.0-31.0] years in 2016; 1822 [50.9%] were women). Symptoms of burnout were reported by 1615 of 3574 resident physicians (45.2%; 95% CI, 43.6% to 46.8%). Career choice regret was reported by 502 of 3571 resident physicians (14.1%; 95% CI, 12.9% to 15.2%). In a multivariable analysis, training in urology, neurology, emergency medicine, and general surgery were associated with higher relative risks (RRs) of reported symptoms of burnout (range of RRs, 1.24 to 1.48) relative to training in internal medicine. Characteristics associated with higher risk of reported symptoms of burnout included female sex (RR, 1.17 [95% CI, 1.07 to 1.28]; risk difference [RD], 7.2% [95% CI, 3.1% to 11.3%]) and higher reported levels of anxiety during medical school (RR, 1.08 per 1-point increase [95% CI, 1.06 to 1.11]; RD, 1.8% per 1-point increase [95% CI, 1.6% to 2.0%]). A higher reported level of empathy during medical school was associated with a lower risk of reported symptoms of burnout during residency (RR, 0.99 per 1-point increase [95% CI, 0.99 to 0.99]; RD, -0.5% per 1-point increase [95% CI, -0.6% to -0.3%]). Reported symptoms of burnout (RR, 3.20 [95% CI, 2.58 to 3.82]; RD, 15.0% [95% CI, 12.8% to 17.3%]) and clinical specialty (range of RRs, 1.66 to 2.60) were both significantly associated with career choice regret. CONCLUSIONS AND RELEVANCE Among US resident physicians, symptoms of burnout and career choice regret were prevalent, but varied substantially by clinical specialty. Further research is needed to better understand these differences and to address these issues.
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Affiliation(s)
| | - Sara E. Burke
- Department of Psychology, Syracuse University, Syracuse, New York
| | - Rachel R. Hardeman
- Division of Health Policy and Management, University of Minnesota, School of Public Health, Minneapolis
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Mark Yeazel
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis
| | - John F. Dovidio
- Department of Psychology, Yale University, New Haven, Connecticut
| | - Brooke Cunningham
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis
| | | | - Sean M. Phelan
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - Daniel V. Satele
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
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Phelan SM, Burke SE, Hardeman RR, White RO, Przedworski J, Dovidio JF, Perry SP, Plankey M, A Cunningham B, Finstad D, W Yeazel M, van Ryn M. Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students. J Gen Intern Med 2017; 32:1193-1201. [PMID: 28766125 PMCID: PMC5653554 DOI: 10.1007/s11606-017-4127-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/25/2017] [Accepted: 06/23/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Implicit and explicit bias among providers can influence the quality of healthcare. Efforts to address sexual orientation bias in new physicians are hampered by a lack of knowledge of school factors that influence bias among students. OBJECTIVE To determine whether medical school curriculum, role modeling, diversity climate, and contact with sexual minorities predict bias among graduating students against gay and lesbian people. DESIGN Prospective cohort study. PARTICIPANTS A sample of 4732 first-year medical students was recruited from a stratified random sample of 49 US medical schools in the fall of 2010 (81% response; 55% of eligible), of which 94.5% (4473) identified as heterosexual. Seventy-eight percent of baseline respondents (3492) completed a follow-up survey in their final semester (spring 2014). MAIN MEASURES Medical school predictors included formal curriculum, role modeling, diversity climate, and contact with sexual minorities. Outcomes were year 4 implicit and explicit bias against gay men and lesbian women, adjusted for bias at year 1. KEY RESULTS In multivariate models, lower explicit bias against gay men and lesbian women was associated with more favorable contact with LGBT faculty, residents, students, and patients, and perceived skill and preparedness for providing care to LGBT patients. Greater explicit bias against lesbian women was associated with discrimination reported by sexual minority students (b = 1.43 [0.16, 2.71]; p = 0.03). Lower implicit sexual orientation bias was associated with more frequent contact with LGBT faculty, residents, students, and patients (b = -0.04 [-0.07, -0.01); p = 0.008). Greater implicit bias was associated with more faculty role modeling of discriminatory behavior (b = 0.34 [0.11, 0.57); p = 0.004). CONCLUSIONS Medical schools may reduce bias against sexual minority patients by reducing negative role modeling, improving the diversity climate, and improving student preparedness to care for this population.
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Affiliation(s)
- Sean M Phelan
- Division of Healthcare Policy and Research, Mayo Clinic, Rochester, MN, USA.
| | - Sara E Burke
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Rachel R Hardeman
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - Richard O White
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Julia Przedworski
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - John F Dovidio
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Sylvia P Perry
- Department of Psychology, Northwestern University, Evanston, IL, USA
| | - Michael Plankey
- Division of Infectious Diseases, Department of Medicine, Georgetown University Medical School, Washington, DC, USA
| | - Brooke A Cunningham
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Deborah Finstad
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Mark W Yeazel
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Michelle van Ryn
- Division of Healthcare Policy and Research, Mayo Clinic, Rochester, MN, USA
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Pujalte GGA, Ahanogbe I, Thurston MJ, White RO, Roche-Green A. Addressing Pediatric Obesity in Clinic. Glob Pediatr Health 2017; 4:2333794X17736971. [PMID: 29119130 PMCID: PMC5665102 DOI: 10.1177/2333794x17736971] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 09/13/2017] [Indexed: 11/15/2022] Open
Abstract
There is an epidemic of pediatric obesity in the United States. In most cases, there is an excess in the amount of calories consumed, compared with the amount of calories expended. Numerous body systems are affected by pediatric obesity, with complications varying between boys and girls. Behavioral, genetic, and environmental factors affect the ability of children to avoid becoming obese. Primary care physicians should screen for obesity in children as much as possible. Associated risk factors for obesity should be uncovered. Methods of preventing obesity should be discussed routinely with children and their families. Healthy dietary habits are key, and so are family-oriented interventions, such as eating together at dinnertime. One hour of moderate to vigorous activity daily is recommended for children and adolescents. While pediatric bariatric surgery is an option, there are also numerous nonpharmacological and pharmacological measures available as management for pediatric obesity. Family-based approaches, such as reducing screen time, have been very successful. Non-weight-bearing exercises also help children and adolescents expend calories without causing injury to themselves. Family availability, activity preference, and developmental levels should all be considerations when managing pediatric obesity. Motivational interviewing may also be helpful, especially when customized for each specific patient and family. Clinicians will play an increasing role in terms of identifying, treating, and preventing pediatric obesity; measures that can be done in the clinic should be considered more and more.
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Chakkalakal RJ, Venkatraman S, White RO, Kripalani S, Rothman R, Wallston K. Validating Health Literacy and Numeracy Measures in Minority Groups. Health Lit Res Pract 2017; 1:e23-e30. [PMID: 29888342 PMCID: PMC5991606 DOI: 10.3928/24748307-20170329-01] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: Validation studies of existing health literacy or numeracy tools among racial/ethnic minorities are limited. Objective: This study assessed the validity of the Subjective Numeracy Scale (SNS), the Diabetes Numeracy Test (DNT-5), the Brief Health Literacy Screen (BHLS), and the Short Test of Functional Health Literacy in Adults (S-TOFHLA) by trait (health literacy or numeracy) and by method (subjective or objective) among non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic patients with type 2 diabetes mellitus (T2DM). Methods: We conducted a secondary analysis of baseline data from the Partnering to Improve Diabetes Education (PRIDE) study, a clustered randomized controlled trial testing the efficacy of a health communication intervention on T2DM outcomes at state Department of Health clinics in middle Tennessee. PRIDE participants with race/ethnicity data available (n = 398) were included in this study. Most patients identified as NHW (59%), 18% identified as NHB, and 23% identified as Hispanic. Pearson correlations among the 4 measures were compared for each racial/ethnic group by trait and method. The convergent validity of each measure with education was also assessed using Pearson correlation analyses. Key Results: Significant correlations were observed across all 3 subgroups for the numeracy measures (SNS and DNT-5) and the objective measures (DNT-5 and S-TOFHLA). Nonsignificant correlations were observed among Hispanic participants for the health literacy measures (BHLS and S-TOFHLA, correlation coefficient = 0.13) and among NHB and Hispanic participants for the subjective measures (SNS and BHLS, correlations coefficients = 0.15 and 0.09, respectively). A significant positive correlation was noted between education and each measure across all 3 subgroups. Conclusions: Subjective and health literacy measures demonstrate weaker correlations than objective and numeracy measures, respectively, among minority patients in this study. Our findings highlight the need to further evaluate the appropriateness of these tools for use with minority populations, particularly the BHLS for Hispanic patients. [Health Literacy Research and Practice. 2017;1(2):e23–e30.] Plain Language Summary: Few studies have tested the validity of health literacy and numeracy measures in minority groups. This study highlights racial/ethnic differences in the results of validity testing of the Subjective Numeracy Scale, the Diabetes Numeracy Test, the Brief Health Literacy Screen, and the Short Test of Functional Health Literacy in Adults among adults with type 2 diabetes.
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Affiliation(s)
- Rosette J Chakkalakal
- Division of General Internal Medicine and Public Health, Department of Internal Medicine, Vanderbilt University Medical Center
| | | | - Richard O White
- Division of Community Internal Medicine and Family Medicine, Mayo Clinic Florida
| | - Sunil Kripalani
- Division of General Internal Medicine and Public Health, Center for Health Services Research, Vanderbilt University Medical Center
| | - Russell Rothman
- Division of General Internal Medicine and Public Health, Center for Health Services Research, Vanderbilt University Medical Center
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Heerman WJ, White RO, Hotop A, Omlung K, Armstrong S, Mathieu I, Sherwood NE, Barkin SL. A Tool Kit to Enhance the Informed Consent Process for Community-Engaged Pediatric Research. IRB 2016; 38:8-14. [PMID: 29442474 PMCID: PMC5806528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- William J Heerman
- Assistant professor in the Division of General Pediatrics at Vanderbilt University Medical Center
| | - Richard O White
- Assistant professor in the Department of Community Internal Medicine at the Mayo Clinic in Jacksonville, Florida
| | - Annie Hotop
- Senior coordinator in the Division of Epidemiology & Community Health at the University of Minnesota
| | - Karen Omlung
- Community program specialist in the Division of Epidemiology & Community Health at the University of Minnesota
| | - Sharelle Armstrong
- Research assistant in the Division of General Pediatrics at Vanderbilt University Medical Center when this article was written
| | - Irène Mathieu
- Student in the School of Medicine at Vanderbilt University when this article was written
| | - Nancy E Sherwood
- Senior investigator and the director of scientific development in the Health-Partners Institute for Education and Research
| | - Shari L Barkin
- Professor in the Division of General Pediatrics at Vanderbilt University Medical Center
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White RO, Chakkalakal RJ, Presley CA, Bian A, Schildcrout JS, Wallston KA, Barto S, Kripalani S, Rothman R. Perceptions of Provider Communication Among Vulnerable Patients With Diabetes: Influences of Medical Mistrust and Health Literacy. J Health Commun 2016; 21:127-134. [PMID: 27662442 PMCID: PMC5540358 DOI: 10.1080/10810730.2016.1207116] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Patient-provider communication is modifiable and is linked to diabetes outcomes. The association of communication quality with medical mistrust is unknown. We examined these factors within the context of a low-literacy/numeracy-focused intervention to improve diabetes care, using baseline data from diverse patients enrolled in a randomized trial of a health communication intervention. Demographics, measures of health communication (Communication Assessment Tool [CAT], Interpersonal Processes of Care survey [IPC-18]), health literacy (Short Test of Functional Health Literacy in Adults), depression, medical mistrust, and glycemic control were ascertained. Adjusted proportional odds models were used to test the association of mistrust with patient-reported communication quality. The interaction effect of health literacy on mistrust and communication quality was also assessed. A total of 410 patients were analyzed. High levels of mistrust were observed. In multivariable modeling, patients with higher mistrust had lower adjusted odds of reporting a higher CAT score (adjusted odds ratio [AOR] = 0.67, 95% confidence interval [CI] [0.52, 0.86], p = .003) and higher scores on the Communication (AOR = 0.69, 95% CI [0.55, 0.88], p = .008), Decided Together (AOR = 0.74, 95% CI [0.59, 0.93], p = .02), and Interpersonal Style (AOR = 0.69, 95% CI [0.53, 0.90], p = .015) subscales of the IPC-18. We observed evidence of an interaction effect of health literacy for the association between mistrust and the Decided Together subscale of the IPC-18 such that patients with higher mistrust and lower literacy perceived worse communication relative to mistrustful patients with higher literacy. In conclusion, medical mistrust was associated with poorer communication with providers in this public health setting. Patients' health literacy level may vary the effect of mistrust on interactional aspects of communication. Providers should consider the impact of mistrust on communication with vulnerable diabetes populations and focus efforts on mitigating its influence.
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Affiliation(s)
- Richard O. White
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Rosette J. Chakkalakal
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Caroline A. Presley
- School of Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan S. Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Shari Barto
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sunil Kripalani
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Russell Rothman
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Wolff K, Chambers L, Bumol S, White RO, Gregory BP, Davis D, Rothman RL. The PRIDE (Partnership to Improve Diabetes Education) Toolkit: Development and Evaluation of Novel Literacy and Culturally Sensitive Diabetes Education Materials. Diabetes Educ 2015; 42:23-33. [PMID: 26647414 DOI: 10.1177/0145721715620019] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Patients with low literacy, low numeracy, and/or linguistic needs can experience challenges understanding diabetes information and applying concepts to their self-management. The authors designed a toolkit of education materials that are sensitive to patients' literacy and numeracy levels, language preferences, and cultural norms and that encourage shared goal setting to improve diabetes self-management and health outcomes. The Partnership to Improve Diabetes Education (PRIDE) toolkit was developed to facilitate diabetes self-management education and support. METHODS The PRIDE toolkit includes a comprehensive set of 30 interactive education modules in English and Spanish to support diabetes self-management activities. The toolkit builds upon the authors' previously validated Diabetes Literacy and Numeracy Education Toolkit (DLNET) by adding a focus on shared goal setting, addressing the needs of Spanish-speaking patients, and including a broader range of diabetes management topics. Each PRIDE module was evaluated using the Suitability Assessment of Materials (SAM) instrument to determine the material's cultural appropriateness and its sensitivity to the needs of patients with low literacy and low numeracy. Reading grade level was also assessed using the Automated Readability Index (ARI), Coleman-Liau, Flesch-Kincaid, Fry, and SMOG formulas. CONCLUSIONS The average reading grade level of the materials was 5.3 (SD 1.0), with a mean SAM of 91.2 (SD 5.4). All of the 30 modules received a "superior" score (SAM >70%) when evaluated by 2 independent raters. The PRIDE toolkit modules can be used by all members of a multidisciplinary team to assist patients with low literacy and low numeracy in managing their diabetes.
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Affiliation(s)
- Kathleen Wolff
- School of Nursing, Vanderbilt University, Nashville, TN (Ms Wolff)
| | - Laura Chambers
- Department of Epidemiology, University of Washington, Seattle, WA (Ms Chambers)
| | - Stefan Bumol
- Department of Psychology, University of Illinois, Chicago, IL (Dr Bumol)
| | - Richard O White
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, FL (Dr White)
| | | | - Dianne Davis
- Vanderbilt Diabetes Center, Nashville, TN (Ms Davis)
| | - Russell L Rothman
- Departments of Medicine and Pediatrics, Vanderbilt University, Nashville, TN (Dr Rothman)
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Affiliation(s)
- Willliam J. Heerman
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Richard O. White
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Shari L. Barkin
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee; and
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White RO, Eden S, Wallston KA, Kripalani S, Barto S, Shintani A, Rothman RL. Health communication, self-care, and treatment satisfaction among low-income diabetes patients in a public health setting. Patient Educ Couns 2015; 98:144-9. [PMID: 25468393 PMCID: PMC4282939 DOI: 10.1016/j.pec.2014.10.019] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 10/14/2014] [Accepted: 10/20/2014] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Diabetes patients with limited resources often experience suboptimal care. Less is known about the role of effective health communication (HC) in caring for low income diabetes patients. METHODS Ten health department clinics in TN participated in a trial evaluating a literacy-sensitive communication intervention. We assessed the quality of baseline HC and measured associations with diabetes outcomes. Assessments included: demographics, measures of HC, health literacy, self-care behaviors, self-efficacy, medication non-adherence, treatment satisfaction, and A1C. Unadjusted and adjusted multivariable regression models were used to test associations. RESULTS Participants (N=411) were 49.7±9.5 years, 61% female, uninsured (96%), with A1C 9.6±2.1. In unadjusted analyses, better communication, was associated with lower medication non-adherence (OR 0.40-0.68, all p<0.05), higher treatment satisfaction (OR 1.76-1.96, all p<0.01), portion size reduction (OR 1.43, p<0.05), diabetes self-efficacy (OR 1.41, p<0.05), and lower A1C (β=-0.06, p<0.01). In adjusted analyses, communication quality remained associated with lower medication non-adherence (AOR 0.39-0.68, all p<0.05), and higher treatment satisfaction (AOR 1.90-2.21, all p<0.001). CONCLUSIONS Better communication between low-income patients and providers was independently associated with lower medication non-adherence and higher treatment satisfaction. PRACTICE IMPLICATIONS Communication quality may be an important modifiable approach to improving diabetes care for vulnerable populations.
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Affiliation(s)
- Richard O White
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, USA; Department of Family Medicine, Mayo Clinic, Jacksonville, USA.
| | - Svetlana Eden
- Department of Biostatistics, Vanderbilt University, Nashville, USA
| | | | - Sunil Kripalani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, USA; Institute for Medicine and Public Health, Vanderbilt University, Nashville, USA
| | - Shari Barto
- Institute for Medicine and Public Health, Vanderbilt University, Nashville, USA
| | - Ayumi Shintani
- Department of Biostatistics, Vanderbilt University, Nashville, USA
| | - Russell L Rothman
- Department of Medicine, Vanderbilt University Medical Center, Nashville, USA; Institute for Medicine and Public Health, Vanderbilt University, Nashville, USA
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White RO, Osborn CY, Gebretsadik T, Kripalani S, Rothman RL. Health literacy, physician trust, and diabetes-related self-care activities in Hispanics with limited resources. J Health Care Poor Underserved 2014; 24:1756-68. [PMID: 24185168 DOI: 10.1353/hpu.2013.0177] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hispanics with diabetes often have deficits in health literacy (HL). We examined the association among HL, psychosocial factors, and diabetes-related self-care activities. METHODS Cross-sectional analysis of 149 patients. Data included patient demographics and validated measures of HL, physician trust, self-efficacy, acculturation, self-care behaviors, and A1c. RESULTS Participants (N=60) with limited HL were older and less educated, and had more years with diabetes compared with adequate HL participants (N=89). Limited HL participants reported greater trust in their physician, greater self-efficacy, and better diet, foot care, and medication adherence. Health literacy status was not associated with acculturation or A1c. In adjusted analyses, HL status remained associated with physician trust, and we observed a notable but nonsignificant trend between HL status and medication adherence. DISCUSSION Lower HL was associated with greater physician trust and better medication adherence. Further research is warranted to clarify the role of HL and physician trust in optimizing self-care for Hispanics.
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van Ryn M, Hardeman RR, Phelan SM, Burke SE, Przedworski J, Allen ML, Burgess DJ, Ridgeway J, White RO, Dovidio JF. Psychosocial predictors of attitudes toward physician empathy in clinical encounters among 4732 1st year medical students: a report from the CHANGES study. Patient Educ Couns 2014; 96:367-75. [PMID: 25065328 PMCID: PMC4195739 DOI: 10.1016/j.pec.2014.06.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 06/12/2014] [Accepted: 06/13/2014] [Indexed: 05/06/2023]
Abstract
OBJECTIVE Medical school curricula intended to promote empathy varies widely. Even the most effective curricula leave a significant group of students untouched. Pre-existing student factors influence their response to learning experiences. We examined the individual predictors of first semester medical students' attitudes toward the value of physician empathy in clinical encounters. METHODS First year students (n=4732) attending a stratified random sample of 49 US medical schools completed an online questionnaire that included measures of dispositional characteristics, attitudes and beliefs, self-concept and well-being. RESULTS Discomfort with uncertainty, close-mindedness, dispositional empathy, elitism, medical authoritarianism, egalitarianism, self-concept and well-being all independently predicted first year medical students' attitudes toward the benefit of physician empathy in clinical encounters. CONCLUSION Students vary on their attitude toward the value of physician empathy when they start medical school. The individual factors that predict their attitudes toward empathy may also influence their response to curricula promoting empathic care. PRACTICE IMPLICATIONS Curricula in medical school promoting empathic care may be more universally effective if students' preexisting attitudes are taken into account. Messages about the importance of physician empathy may need to be framed in ways that are consistent with the beliefs and prior world-views of medical students.
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Ciampa PJ, White RO, Perrin EM, Yin HS, Sanders LM, Gayle EA, Rothman RL. The association of acculturation and health literacy, numeracy and health-related skills in Spanish-speaking caregivers of young children. J Immigr Minor Health 2014; 15:492-8. [PMID: 22481307 DOI: 10.1007/s10903-012-9613-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Little is known about the relationship among acculturation, literacy, and health skills in Latino caregivers of young children. Latino caregivers of children < 30 months seeking primary care at four medical centers were administered measures of acculturation (SASH), functional health literacy (STOFHLA), numeracy (WRAT-3) and health-related skills (PHLAT Spanish). Child anthropomorphics and immunization status were ascertained by chart review. Caregivers (N = 184) with a median age of 27 years (IQR: 23-32) participated; 89.1% were mothers, and 97.1% had low acculturation. Lower SASH scores were significantly correlated (P < 0.01) with lower STOFHLA (ρ = 0.21), WRAT-3 (ρ = 0.25), and PHLAT Spanish scores (ρ = 0.34). SASH scores predicted PHLAT Spanish scores in a multivariable linear regression model that adjusted for the age of child, the age and gender of the caregiver, number of children in the family, the type of health insurance of the caregiver, and study site (adjusted β: 0.84, 95% CI 0.26-1.42, P = 0.005). This association was attenuated by the addition of literacy (adjusted β: 0.66, 95% CI 0.11-1.21, P = 0.02) or numeracy (adjusted β: 0.50, 95% CI -0.04-1.04, P = 0.07) into the model. There was no significant association between acculturation and up-to-date child immunizations or a weight status of overweight/obese. Lower acculturation was associated with worse health literacy and diminished ability to perform child health-related skills. Literacy and numeracy skills attenuated the association between acculturation and child health skills. These associations may help to explain some child health disparities in Latino communities.
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Affiliation(s)
- Philip J Ciampa
- Department of Internal Medicine, Vanderbilt University School of Medicine, Nashville, TN 37203-1738, USA.
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White RO, Thompson JR, Rothman RL, McDougald Scott AM, Heerman WJ, Sommer EC, Barkin SL. A health literate approach to the prevention of childhood overweight and obesity. Patient Educ Couns 2013; 93:612-618. [PMID: 24001660 PMCID: PMC3904952 DOI: 10.1016/j.pec.2013.08.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 07/24/2013] [Accepted: 08/10/2013] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To describe a systematic assessment of patient educational materials for the Growing Right Onto Wellness (GROW) trial, a childhood obesity prevention study targeting a low health literate population. METHODS Process included: (1) expert review of educational content, (2) assessment of the quality of materials including use of the Suitability Assessment of Materials (SAM) tool, and (3) material review and revision with target population. RESULTS 12 core modules were developed and assessed in an iterative process. Average readability was at the 6th grade reading level (SMOG Index 5.63 ± 0.76, and Fry graph 6.0 ± 0.85). SAM evaluation resulted in adjustments to literacy demand, layout & typography, and learning stimulation & motivation. Cognitive interviews with target population revealed additional changes incorporated to enhance participant's perception of acceptability and feasibility for behavior change. CONCLUSION The GROW modules are a collection of evidence-based materials appropriate for parents with low health literacy and their preschool aged children, that target the prevention of childhood overweight/obesity. PRACTICE IMPLICATIONS Most trials addressing the treatment or prevention of childhood obesity use written materials. Due to the ubiquitous prevalence of limited health literacy, our described methods may assist researchers in ensuring their content is both understood and actionable.
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Affiliation(s)
- Richard O White
- Department of Community Internal Medicine, Mayo Clinic, Jacksonville, USA; Department of Family Medicine, Mayo Clinic, Jacksonville, USA.
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Abstract
BACKGROUND Although deficits in health literacy and numeracy have been described among Latinos, the impact of low numeracy on diabetes outcomes has not been studied. Study objectives were (1) to establish the reliability and validity of a 15-item Spanish, diabetes-specific numeracy measure (Diabetes Numeracy Test [DNT]-15 Latino) and (2) to examine the relationship between diabetes-specific numeracy and diabetes-related outcomes among a sample of Latino adults with diabetes. METHODS Data collection included patient demographics, health literacy, general numeracy, diabetes-specific numeracy, acculturation, self-efficacy, self-care behaviors, and most recent glycosylated hemoglobin (HbA1c). RESULTS Participants (n=144) were on average 47.8 years old (SD=12.1). The majority were female (62%), uninsured (81%), and of Mexican nationality (78%) and reported low levels of acculturation (96%). The DNT-15 Latino had high internal reliability (Kruder-Richardson 20=0.78). The DNT-15 Latino demonstrated construct validity, correlating with measures of health literacy (ρ=0.291), general numeracy (ρ=0.500), education (ρ=0.361), and income (ρ=0.270) (P<0.001 for each). The DNT-15 Latino was significantly associated with acculturation but unrelated to self-efficacy, self-care behaviors, insulin use, and HbA1c. CONCLUSIONS The DNT-15 Latino is a reliable and valid measure of diabetes-specific numeracy for Latino patients with diabetes; however, additional studies are needed to further explore the association between diabetes-specific numeracy and acculturation and their impact on diabetes-related outcomes for Latinos.
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Affiliation(s)
- Richard O White
- Department of Internal Medicine, Meharry Medical College, Nashville, Tennessee 37208, USA.
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Osborn CY, Cavanaugh K, Wallston KA, Kripalani S, Elasy TA, Rothman RL, White RO. Health literacy explains racial disparities in diabetes medication adherence. J Health Commun 2011; 16 Suppl 3:268-78. [PMID: 21951257 PMCID: PMC3561717 DOI: 10.1080/10810730.2011.604388] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Although low health literacy and suboptimal medication adherence are more prevalent in racial/ethnic minority groups than Whites, little is known about the relationship between these factors in adults with diabetes, and whether health literacy or numeracy might explain racial/ethnic disparities in diabetes medication adherence. Previous work in HIV suggests health literacy mediates racial differences in adherence to antiretroviral treatment, but no study to date has explored numeracy as a mediator of the relationship between race/ethnicity and medication adherence. This study tested whether health literacy and/or numeracy were related to diabetes medication adherence, and whether either factor explained racial differences in adherence. Using path analytic models, we explored the predicted pathways between racial status, health literacy, diabetes-related numeracy, general numeracy, and adherence to diabetes medications. After adjustment for covariates, African American race was associated with poor medication adherence (r = -0.10, p < .05). Health literacy was associated with adherence (r = .12, p < .02), but diabetes-related numeracy and general numeracy were not related to adherence. Furthermore, health literacy reduced the effect of race on adherence to nonsignificance, such that African American race was no longer directly associated with lower medication adherence (r = -0.09, p = .14). Diabetes medication adherence promotion interventions should address patient health literacy limitations.
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Affiliation(s)
- Chandra Y Osborn
- Vanderbilt University Medical Center, Nashville, Tennessee 37232-8300, USA.
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Affiliation(s)
- Richard O White
- Assistant professor in the Department of Internal Medicine at Meharry Medical College, Nashville, Tenn
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White RO, DeWalt DA, Malone RM, Osborn CY, Pignone MP, Rothman RL. Leveling the field: addressing health disparities through diabetes disease management. Am J Manag Care 2010; 16:42-48. [PMID: 20148604 PMCID: PMC2914617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To examine the relationships among patient characteristics, labor inputs, and improvement in glycosylated hemoglobin (A1C) level in a successful primary care-based diabetes disease management program (DDMP). STUDY DESIGN We performed subanalyses to examine the relationships among patient characteristics, labor inputs, and improvement in A1C level within a randomized controlled trial. Control patients received usual care, while intervention patients received usual care plus a comprehensive DDMP. METHODS The primary outcome was improvement in A1C level over 12 months stratified by intervention status and patient characteristics. Process outcomes included the number of actions or contacts with patients, time spent with patients, and number of glucose medication titrations or additions. RESULTS One hundred ninety-three of 217 enrolled patients (88.9%) had complete 12-month followup data. Patients in the intervention group had significantly greater improvement in A1C level than the control group (-2.1% vs -1.2%, P = .007). In multivariate analysis, no significant differences were observed in improvement in A1C level when stratified by age, race/ethnicity, income, or insurance status, and no interaction effect was observed between any covariate and intervention status. Among intervention patients, we observed similar labor inputs regardless of age, race/ethnicity, sex, education, or whether goal A1C level was achieved. CONCLUSIONS Among intervention patients in a successful DDMP, improvement in A1C level was achieved regardless of age, race/ethnicity, sex, income, education, or insurance status. Labor inputs were similar regardless of age, race/ethnicity, sex, or education and may reflect the nondiscriminatory nature of providing algorithm-based disease management care.
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Affiliation(s)
- Richard O White
- Division of General Internal Medicine, Meharry Medical College, 1005 Dr DB Todd Jr Blvd, Nashville, TN 37208, USA.
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Abstract
OBJECTIVE Understanding the reasons and eliminating the pervasive health disparities in diabetes is a major research, clinical, and health policy goal. We examined whether health literacy, general numeracy, and diabetes-related numeracy explain the association between African American race and poor glycemic control (A1C) in patients with diabetes. RESEARCH DESIGN AND METHODS Adults with type 2 diabetes (n = 383) were enrolled in a cross-sectional study at primary care and diabetes clinics at three medical centers. Data collected included the following: self-reported race, health literacy, general numeracy, diabetes-related numeracy, A1C, and sociodemographic factors. A series of structural equation models were estimated to explore the interrelations between variables and test for mediation. RESULTS In model 1, younger age (r = -0.21, P < 0.001), insulin use (r = 0.27, P < 0.001), greater years with diabetes (r = 0.16, P < 0.01), and African American race (r = 0.12, P < 0.01) were all associated with poorer glycemic control. In model 2, diabetes-related numeracy emerged as a strong predictor of A1C (r = -0.46, P < 0.001), reducing the association between African American and poor glycemic control to nonsignificance (r = 0.10, NS). In model 3, African American race and older age were associated with lower diabetes-related numeracy; younger age, insulin use, more years with diabetes, and lower diabetes-related numeracy were associated with poor glycemic control. CONCLUSIONS Diabetes-related numeracy reduced the explanatory power of African American race, such that low diabetes-related numeracy, not African American race, was significantly related to poor glycemic control. Interventions that address numeracy could help to reduce racial disparities in diabetes.
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Abstract
Disparities in diabetes care are prevalent in the United States. This article provides an overview of these disparities and discusses both potential causes and efforts to address them to date. The authors focus the discussion on aspects relevant to the patient-provider dyad and provide practical considerations for the primary care provider's role in helping to diminish and eliminate disparities in diabetes care.
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Affiliation(s)
- Richard O White
- Division of General Internal Medicine, Department of Medicine, Meharry Medical College, in Nashville, Tenn
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