"There's no kind of respect here" A qualitative study of racism and access to maternal health care among Romani women in the Balkans

<p>Abstract</p> <p>Introduction</p> <p>Roma, the largest minority group in Europe, face widespread racism and health disadvantage. Using qualitative data from Serbia and Macedonia, our objective was to develop a conceptual framework showing how three levels of racism--personal, internalized, and institutional--affect access to maternal health care among Romani women.</p> <p>Methods</p> <p>Eight focus groups of Romani women aged 14-44 (n = 71), as well as in-depth semi-structured interviews with gynecologists (n = 8) and key informants from NGOs and state institutions (n = 11) were conducted on maternal health care seeking, experiences during care, and perceived health care discrimination. Transcripts were coded, and analyzed using a grounded theory approach. Themes were categorized into domains.</p> <p>Results</p> <p>Twenty-two emergent themes identified barriers that reflected how racism affects access to maternal health care. The domains into which the themes were classified were perceptions and interactions with health system, psychological factors, social environment and resources, lack of health system accountability, financial needs, and exclusion from education.</p> <p>Conclusions</p> <p>The experiences of Romani women demonstrate psychosocial and structural pathways by which racism and discrimination affect access to prenatal and maternity care. Interventions to address maternal health inequalities should target barriers within all three levels of racism.</p

Race/Ethnicity, Educational Attainment, and Pregnancy Complications in New York City Women with Pre-existing Diabetes

Background: More women are entering pregnancy with pre-existing diabetes. Disease severity, glycaemic control, and predictors of pregnancy complications may differ by race/ethnicity or educational attainment, leading to differences in adverse pregnancy outcomes. Methods: We used linked New York City hospital record and birth certificate data for 6291 singleton births among women with pre-existing diabetes between 1995 and 2003. We defined maternal race/ethnicity as non-Hispanic white, non-Hispanic black, Hispanic, South Asian, and East Asian, and education level as 12 years. Our outcomes were pre-eclampsia, preterm birth (PTB) (<37 weeks gestation and categorised as spontaneous or medically indicated), as well as small-for-gestational age (SGA) and large-for-gestational age (LGA). Using multivariable binomial regression, we estimated the risk ratios for pre-eclampsia, SGA, and LGA. We used multivariable multinomial regression to estimate odds ratios (OR) for PTB. Results: Compared with non-Hispanic white women with pre-existing diabetes, non-Hispanic black and Hispanic women with pre-existing diabetes had a 1.50-fold increased risk of pre-eclampsia compared with non-Hispanic whites with pre-existing diabetes, after full adjustment. Non-Hispanic black and Hispanic women with pre-existing diabetes had adjusted ORs of 1.72 [adj. 95% confidence interval (CI) 1.38, 2.15] and 1.65 [adj.95% CI 1.32, 2.05], respectively, for medically indicated PTB. South Asian women with pre-existing diabetes had the highest risk for having an SGA infant [adj. OR: 2.29; adj. 95% CI 1.73, 3.03]. East Asian ethnicity was not associated with these pregnancy complications. Conclusions: Non-Hispanic black, Hispanic, and South Asian women with pre-existing diabetes may benefit from targeted interventions to improve pregnancy outcomes

Structural Inference in Transition Measurement Error Models for Longitudinal Data

We propose a new class of models, transition measurement error models, to study the effects of covariates and the past responses on the current response in longitudinal studies when one of the covariates is measured with error. We show that the response variable conditional on the error-prone covariate follows a complex transition mixed effects model. The naive model obtained by ignoring the measurement error correctly specifies the transition part of the model, but misspecifies the covariate effect structure and ignores the random effects. We next study the asymptotic bias in naive estimator obtained by ignoring the measurement error for both continuous and discrete outcomes. We show that the naive estimator of the regression coefficient of the error-prone covariate is attenuated, while the naive estimators of the regression coefficients of the past responses are generally inflated. We then develop a structural modeling approach for parameter estimation using the maximum likelihood estimation method. In view of the multidimensional integration required by full maximum likelihood estimation, an EM algorithm is developed to calculate maximum likelihood estimators, in which Monte Carlo simulations are used to evaluate the conditional expectations in the E-step. We evaluate the performance of the proposed method through a simulation study and apply it to a longitudinal social support study for elderly women with heart disease. An additional simulation study shows that the Bayesian information criterion (BIC) performs well in choosing the correct transition orders of the models.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/66146/1/j.1541-0420.2005.00446.x.pd

Progression of Symptoms and Functioning Among Female Cardiac Patients With and Without Diabetes

Objective: To determine if older women with both heart disease and diabetes experience worse physical and psychosocial functioning and higher symptom burden over an 18-month period compared with those with heart disease alone. Methods: Data from older women with heart disease (>=60 years, n = 1008, 18% with diabetes) were used to assess the impact of diabetes on physical functioning (Sickness Impact Profile [SIP]-Physical and Six-Minute Walk test [6MWT]), psychosocial functioning (SIP-Psychosocial and depressive symptoms), and physical symptom burden (cardiac and general) at baseline and 4, 12, and 18 months later. Generalized estimating equation models compared trends in outcomes over time between groups with and without diabetes. Results: Across all four time points, women with heart disease and diabetes had greater functional impairment, as indicated by higher SIP scores, than those without diabetes (43%-71% higher SIP-Physical scores and 32%-65% higher SIP-Pyschosocial scores; all p<=-0.002). 6MWT distance was 17%-30% less in the diabetes group across time points (all p<=-0.002). Depressive symptoms were 27%-39% higher in the diabetes group (all p-<-0.03) except at month 4. Women with diabetes scored 15%-29% higher on a physical symptom index across time points (all p-<-0.05) than those without diabetes; no significant differences were observed in cardiac symptoms until month 18 (diabetes group 29% higher, p = 0.02). Subgroups with and without diabetes in this sample experienced significantly different trends over time in SIP-Physical scores (p = 0.02) and 6MWT distance (p = 0.05), such that the disadvantage of the diabetes group at baseline was greater 18 months later. Conclusions: Women with comorbid diabetes and heart disease are vulnerable to poor health-related quality of life, particularly in terms of physical functioning and symptoms, and require special efforts from clinical care providers to ameliorate a potential downward trend in these outcomes over time.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90452/1/jwh-2E2010-2E2123.pd

The influence of dyadic symptom distress on threat appraisals and self-efficacy in advanced cancer and caregiving

Physical and psychological symptoms experienced by patients with advanced cancer influence their wellbeing; how patient and family caregivers' symptom distress influence each other's wellbeing is less understood. This study examined the influence of patient and caregiver symptom distress on their threat appraisals and self-efficacy to cope with cancer

Meaning‐based coping, chronic conditions and quality of life in advanced cancer & caregiving

ObjectiveThis study examined the relationship between the number of co‐existing health problems (patient comorbidities and caregiver chronic conditions) and quality of life (QOL) among patients with advanced cancer and their caregivers and assessed the mediating and moderating role of meaning‐based coping on that relationship.MethodsData came from patients with advanced cancers (breast, colorectal, lung, and prostate) and their family caregivers (N = 484 dyads). Study hypotheses were examined with structural equation modeling using the actor‐partner interdependence mediation model. Bootstrapping and model constraints were used to test indirect effects suggested by the mediation models. An interaction term was added to the standard actor‐partner interdependence model to test for moderation effects.ResultsMore patient comorbidities were associated with lower patient QOL. More caregiver chronic conditions were associated with lower patient and caregiver QOL. Patient comorbidities and caregiver chronic conditions had a negative influence on caregiver meaning‐based coping but no significant influence on patient meaning based coping. Caregiver meaning‐based coping mediated relationships between patient comorbidities and caregiver health conditions and patient and caregiver QOL. No significant moderating effects were observed.ConclusionsDespite the severity of advanced cancer for patients and caregivers, the co‐existing health problems of one member of the dyad have the potential to directly or indirectly affect the wellbeing of the other. Future research should consider how the number of patient comorbidities and caregiver chronic conditions, as well as the ability of patients and caregivers to manage those conditions, influences their meaning‐based coping and wellbeing. Copyright © 2016 John Wiley & Sons, Ltd.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138410/1/pon4146_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/138410/2/pon4146.pd

Feasibility of an interactive voice response system for monitoring depressive symptoms in a lower-middle income Latin American country

Abstract Background Innovative, scalable solutions are needed to address the vast unmet need for mental health care in low- and middle-income countries (LMICs). Methods We conducted a feasibility study of a 14-week automated telephonic interactive voice response (IVR) depression self-care service among Bolivian primary care patients with at least moderately severe depressive symptoms. We analyzed IVR call completion rates, the reliability and validity of IVR-collected data, and participant satisfaction. Results Of the 32 participants, the majority were women (78 % or 25/32) and non-indigenous (75 % or 24/32). Participants had moderate depressive symptoms at baseline (PHQ-8 score mean 13.3, SD = 3.5) and reported good or fair general health status (88 % or 28/32). Fifty-four percent of weekly IVR calls (approximately 7 out of 13 active call-weeks) were completed. Neither PHQ-8 scores nor IVR call completion differed significantly by ethnicity, education, self-reported depression diagnosis, self-reported overall health, number of chronic conditions, or health literacy. The reliability for IVR-collected PHQ-8 scores was good (Cronbach’s alpha = 0.83). Virtually every participant (97 %) was “mostly” or “very” satisfied with the program. Many described the program as beneficial for their mood and self-care, albeit limited by some technological difficulties and the lack of human interaction. Conclusion Findings suggest that IVR could feasibly be used to provide monitoring and self-care education to depressed patients in Bolivia. An expanded stepped-care service offering contact with lay health workers for more depressed individuals and expanded mHealth content may foster greater patient engagement and enhance its therapeutic value while remaining cost-effective. Trial registration ISRCTN ISRCTN 18403214. Registered 14 September 2016. Retrospectively registeredhttp://deepblue.lib.umich.edu/bitstream/2027.42/134641/1/13033_2016_Article_93.pd

Adaptation reconceptualized: "retrofitting" ongoing organizational activities with essential elements of evidence-based interventions

http://deepblue.lib.umich.edu/bitstream/2027.42/134544/1/13012_2015_Article_948.pd

The Influence of Setting on Care Coordination for Childhood Asthma

Asthma affects 7.1 million children in the United States, disproportionately burdening African American and Latino children. Barriers to asthma control include insufficient patient education and fragmented care. Care coordination represents a compelling approach to improve quality of care and address disparities in asthma. The sites of The Merck Childhood Asthma Network Care Coordination Programs implemented different models of care coordination to suit specific settings—school district, clinic or health care system, and community—and organizational structures. A variety of qualitative data sources were analyzed to determine the role setting played in the manifestation of care coordination at each site. There were inherent strengths and challenges of implementing care coordination in each of the settings, and each site used unique strategies to deliver their programs. The relationship between the lead implementing unit and entities that provided (1) access to the priority population and (2) clinical services to program participants played a critical role in the structure of the programs. The level of support and infrastructure provided by these entities to the lead implementing unit influenced how participants were identified and how asthma care coordinators were integrated into the clinical care team.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/113262/1/MCAN_Settings_Manuscript_20150708.docxhttp://deepblue.lib.umich.edu/bitstream/2027.42/113262/3/MCAN_Settings_Manuscript_20150708.pdfDescription of MCAN_Settings_Manuscript_20150708.docx : Main ArticleDescription of MCAN_Settings_Manuscript_20150708.pdf : Main Article with Title Page and Abstrac