Residential Racial Segregation and Neighborhood Adversity: Associations with Hemoglobin A1c in Adolescents with Type 1 Diabetes

Black adolescents with Type 1 Diabetes (T1D) are at increased risk for disparities in health outcomes. More research is necessary on the effects of neighborhood characteristics such as residential racial segregation (RRS) and neighborhood adversity on health. 149 Black youth with T1D were recruited from seven pediatric diabetes clinics in Detroit and Chicago to participate in a clinical trial to improve diabetes management. RRS was calculated at the census block group level based on US census data using Location Quotients. LQs represented the ratio of patients to total population in the block group compared to the same ratio in the metro area. Neighborhood adversity was assessed at the census block group level using the Neighborhood Adversity Index (NAI). Bivariate associations between RRS, NAI and HbA1c were calculated at baseline and 18-month follow-up, controlling for multiple factors including age, sex, and family income. At baseline, mean youth age =13.4 years + 1.7, mean family income = $35,276 +$27,181, and 49.7% were from single-parent households. Mean HbA1c = 11.49 ± 2.71, suggesting suboptimal control. In bivariate associations, HbA1c was significantly associated with RRS (r=.32, p=.002) and NAI (r= 0.35 p\u3c 0.001) at baseline and with RRS (r=.38, p\u3c .001) and NAI (r=.25 p=.016) at follow-up. Black adolescents with T1D residing in adverse and segregated neighborhoods are more likely to have persistently poorer glycemic control. Culturally competent physicians are vital for providing information to patients on neighborhood resources and improving glycemic outcomes

The Relationship Among Depression, Motivational Factors, and Diabetes Management In Emerging Adults with Type 1 Diabetes

Self-determination theory (SDT) posits intrinsic motivation arises from fulfilling three psychological needs – autonomy, self-efficacy, and relatedness. SDT is useful for understanding the challenges emerging adults (EA, age 18-30) living with a chronic illness, like type 1 diabetes (T1D), face including developing independence, autonomy and new relationships while parental support and involvement decrease. This places EAs at risk for sub-optimal health. Depression can further decrease motivation. The aim of this study is to test the hypothesis that depressive symptoms are associated with motivation (autonomy and self-efficacy) which are associated with diabetes management (DM) in EAs with T1D. Participants (N=52) were from a larger randomized clinical trial testing an intervention to improve DM. At study entry, EAs endorsing higher depression levels also reported statistically significantly lower self-efficacy on the Perceived Health Competency Scale (PHCS; r=-0.350, p=0.011). Self-efficacy assessed by the Diabetes Empowerment Scale (DES; r=-0.217,p=0.123) was not associated with depression, nor was autonomy assessed, using the Treatment Self-Regulation Scale (TSRQ; r=-0.157,p=0.267), although both were in the hypothesized direction. EAs reports of self-efficacy (rPHCS=0.123,p=0.206; rDES=0.055,p=0.701) and autonomy (r=0.178,p=0.206) were not correlated with DM, although responses were in the intended direction. Therefore, t in this sample, there was partial support for the hypothesis that depression reduces motivation was partially supported, but there was not enough support for the relationship between motivation and –DM link

A Social Ecological Perspective On Diabetes Care: Supporting Adolescents And Caregivers

The diabetes illness management regimen is complex and demanding, requiring daily motivation and self-control. Adolescents with diabetes face unique risks for which social support may be one protective factor. The importance of social support from family and friends is well documented in the literature. Support for the caregiver and support from the health care provider, conversely, are understudied. These four sources of social support, considered together, span the adolescent\u27s micro-, meso-, and exosystems constituting a social ecological model of social support for diabetes. The primary aim of this study was to test this model. The hypotheses were that each source of social support would independently and positively contribute to illness management when evaluated simultaneously, after controlling for adolescent and caregiver demographics and that illness management behavior would mediate the relationship between social support and diabetes health. A secondary data analysis of adolescents with chronically poorly managed diabetes was undertaken. Structural equation modeling was used to test the study hypotheses. A total of 146 adolescents and their primary caregivers participated in the study. Participants were primarily African American, low-income single-parent families. Results from the analysis did not support the model as hypothesized but did support an alternative model. In the alternative model, exosystem, but not mesosystem, support was positively associated with microsystem support. Microsystem support was directly related to adolescents\u27 illness management behavior and indirectly related to adolescents\u27 health status. Findings from this study introduce an innovative model of social support for adolescents with diabetes. Supporting the caregiver of adolescents with diabetes may have a beneficial impact on the social support environment in which adolescents perform their daily illness care. A more supportive daily care environment, in turn, may translate to better illness management and better illness health. Social support intervention may be an important strategy for medical social workers, as members of multidisciplinary medical treatment teams, treating adolescents with diabetes and their families

Technology-delivered adaptations of motivational interviewing for the prevention and management of chronic diseases: Scoping review

BACKGROUND: Motivational interviewing (MI) can increase health-promoting behaviors and decrease health-damaging behaviors. However, MI is often resource intensive, precluding its use with people with limited financial or time resources. Mobile health-based versions of MI interventions or technology-delivered adaptations of MI (TAMIs) might increase reach. OBJECTIVE: We aimed to understand the characteristics of existing TAMIs. We were particularly interested in the inclusion of people from marginalized sociodemographic groups, whether the TAMI addressed sociocontextual factors, and how behavioral and health outcomes were reported. METHODS: We employed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews to conduct our scoping review. We searched PubMed, CINAHL, and PsycInfo from January 1, 1996, to April 6, 2022, to identify studies that described interventions incorporating MI into a mobile or electronic health platform. For inclusion, the study was required to (1) describe methods/outcomes of an MI intervention, (2) feature an intervention delivered automatically via a mobile or electronic health platform, and (3) report a behavioral or health outcome. The exclusion criteria were (1) publication in a language other than English and (2) description of only in-person intervention delivery (ie, no TAMI). We charted results using Excel (Microsoft Corp). RESULTS: Thirty-four studies reported the use of TAMIs. Sample sizes ranged from 10 to 2069 participants aged 13 to 70 years. Most studies (n=27) directed interventions toward individuals engaging in behaviors that increased chronic disease risk. Most studies (n=22) oversampled individuals from marginalized sociodemographic groups, but few (n=3) were designed specifically with marginalized groups in mind. TAMIs used text messaging (n=8), web-based intervention (n=22), app + text messaging (n=1), and web-based intervention + text messaging (n=3) as delivery platforms. Of the 34 studies, 30 (88%) were randomized controlled trials reporting behavioral and health-related outcomes, 23 of which reported statistically significant improvements in targeted behaviors with TAMI use. TAMIs improved targeted health behaviors in the remaining 4 studies. Moreover, 11 (32%) studies assessed TAMI feasibility, acceptability, or satisfaction, and all rated TAMIs highly in this regard. Among 20 studies with a disproportionately high number of people from marginalized racial or ethnic groups compared with the general US population, 16 (80%) reported increased engagement in health behaviors or better health outcomes. However, no TAMIs included elements that addressed sociocontextual influences on behavior or health outcomes. CONCLUSIONS: Our findings suggest that TAMIs may improve some health promotion and disease management behaviors. However, few TAMIs were designed specifically for people from marginalized sociodemographic groups, and none included elements to help address sociocontextual challenges. Research is needed to determine how TAMIs affect individual health outcomes and how to incorporate elements that address sociocontextual factors, and to identify the best practices for implementing TAMIs into clinical practice

Implementation Science Research Examining the Integration of Evidence-Based Practices Into HIV Prevention and Clinical Care: Protocol for a Mixed-Methods Study Using the Exploration, Preparation, Implementation, and Sustainment (EPIS) Model

BACKGROUND: The Exploration, Preparation, Implementation, and Sustainment (EPIS) model is an implementation framework for studying the integration of evidence-based practices (EBPs) into real-world settings. The EPIS model conceptualizes implementation as a process starting with the earliest stages of problem recognition (Exploration) through the continued use of an EBP in a given clinical context (Sustainment). This is the first implementation science (IS) study of the integration of EBPs into adolescent HIV prevention and care settings. OBJECTIVE: This protocol (ATN 153 EPIS) is part of the Scale It Up program, a research program administered by the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN), described in this issue by Naar et al. The EPIS study is a descriptive study of the uptake of 4 EBPs within the Scale It Up program. The goal of EPIS is to understand the barriers and facilitators associated with the Preparation, Implementation, and Sustainment of EBPs into HIV prevention and clinical care settings. METHODS: The EPIS study is a convergent parallel mixed-methods IS study. Key implementation stakeholders, that is, clinical care providers and leaders, located within 13 ATN sites across the United States will complete a qualitative interview conducted by telephone and Web-based surveys at 3 key implementation stages. The Preparation assessment occurs before EBP implementation, Implementation occurs immediately after sites finish implementation activities and prepare for sustainment, and Sustainment occurs 1 year postimplementation. Assessments will examine stakeholders\u27 perceptions of the barriers and facilitators to EBP implementation within their clinical site as outlined by the EPIS framework. RESULTS: The EPIS baseline period began in June 2017 and concluded in May 2018; analysis of the baseline data is underway. To date, 153 stakeholders have completed qualitative interviews, and 91.5% (140/153) completed the quantitative survey. CONCLUSIONS: The knowledge gained from the EPIS study will strengthen the implementation and sustainment of EBPs in adolescent prevention and clinical care contexts by offering insights into the barriers and facilitators of successful EBP implementation and sustainment in real-world clinical contexts

Provider Communication Behaviors that Predict Motivation to Change in Black Adolescents with Obesity

Objective: The goal of this research was to identify communication behaviors used by weight loss counselors that mostly strongly predicted black adolescents\u27 motivational statements. Three types of motivational statements were of interest: change talk (CT; statements describing their own desires, abilities, reasons, and need for adhering to weight loss recommendations), commitment language (CML; statements about their intentions or plans for adhering), and counterchange talk (CCT; amotivational statements against change and commitment). Methods: Thirty-seven black adolescents with obesity received a single motivational interviewing session targeting weight-related behaviors. The video-recorded transcribed sessions were coded using the Minority Youth Sequential Coding for Observing Process Exchanges generating a sequential chain of communication. Data were then subjected to sequential analysis to determine causal relationships between counselor and adolescent communication. Results: Asking open-ended questions to elicit adolescent CT and emphasizing adolescents\u27 autonomy most often led to CT. Open-ended questions to elicit CML, reflecting adolescent CML, and emphasizing autonomy most often led to CML. In contrast, open-ended questions to elicit CCT, reflecting CCT, reflecting ambivalence, and neutral open-ended questions about the target behavior led to CCT. Conclusions: This study provides clinicians with insight into the most effective way to communicate with black adolescents with obesity about weight loss. Specifically, reflective statements and open questions focusing on their own desires, abilities, reasons, need, and commitment to weight loss recommendations are more likely to increase motivational statements, whereas other types of reflections and questions may be counterproductive. Finally, because adolescents have a strong need for autonomous decision making, emphasizing their autonomy may be particularly effective in evoking motivational statements

Using the Exploration-Preparation-Implementation-Sustainment (EPIS) Framework to prepare for the implementation of evidence-based practices into adolescent HIV settings.

Despite advances in evidence-based practices (EBP) to support HIV prevention and treatment, youth ages 13-24 experience significant disparities in HIV risk and outcomes. An important factor in this disparity is poor EBP implementation, yet implementation research is limited, particularly in youth-serving settings. This study used the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to guide the implementation of four Motivational Interviewing (MI) and MI-framed interventions into youth-serving HIV prevention and treatment settings. Key stakeholders (n = 153) across 13 sites completed pre-implementation interviews. Stakeholders comments identified two critical factors for effective implementation: fit with the patient population and provider receptivity, including concerns about scope of practice, buy-in, and time. Stakeholders recommended strategies for structuring training, fidelity monitoring, and facilitating implementation including engaging informal leaders, collaboratively developing the implementation strategy, and site-wide implementation. Results highlight the importance of pre-implementation contextual assessment and strategic planning for identifying provider concerns and developing responsive implementation strategies

Deep Neural Architectures for Discourse Segmentation in E-Mail Based Behavioral Interventions.

Communication science approaches to develop effective behavior interventions, such as motivational interviewing (MI), are limited by traditional qualitative coding of communication exchanges, a very resource-intensive and time-consuming process. This study focuses on the analysis of e-Coaching sessions, behavior interventions delivered via email and grounded in the principles of MI. A critical step towards automated qualitative coding of e-Coaching sessions is segmentation of emails into fragments that correspond to MI behaviors. This study frames email segmentation task as a classification problem and utilizes word and punctuation mark embeddings in conjunction with part-of-speech features to address it. We evaluated the performance of conditional random fields (CRF) as well as multi-layer perceptron (MLP), bi-directional recurrent neural network (BRNN) and convolutional recurrent neural network (CRNN) for the task of email segmentation. Our results indicate that CRNN outperforms CRF, MLP and BRNN achieving 0.989 weighted macro-averaged F1-measure and 0.825 F1-measure for new segment detection

Effective Patient-Provider Communication in Pediatric Obesity

Effective patient-provider communication, although acknowledged as a key clinical skill and linked to better outcomes for patients, providers, and society as a whole, is not a primary focus of many medical schools’ curricula. Motivational Interviewing, or MI, is a patient-centered, directive communication framework appropriate for the health care setting with an ever growing empirical evidence base. Research on MI’s causal mechanisms has previously established patient change talk (motivational statements about behavior change) to be a mediator of behavior change. Current MI research is focused on identifying which provider communication skills are responsible for evoking change talk. MI recommends three core communication skills – informing, asking, and listening. A consistent evidence base is emerging for providers’ use of reflections (an active listening strategy). Our research provides evidence that asking for and reflecting patient change talk are effective communication strategies, but cautions providers to inform judiciously. In addition, our research indicates that supporting a patient's decision making autonomy is an important strategy to promote health behaviors