Do Low Income Youth of Color See "The Bigger Picture" When Discussing Type 2 Diabetes: A Qualitative Evaluation of a Public Health Literacy Campaign.

As Type 2 diabetes spikes among minority and low-income youth, there is an urgent need to tackle the drivers of this preventable disease. The Bigger Picture (TBP) is a counter-marketing campaign using youth-created, spoken-word public service announcements (PSAs) to reframe the epidemic as a socio-environmental phenomenon requiring communal action, civic engagement and norm change. METHODS:We examined whether and how TBP PSAs advance health literacy among low-income, minority youth. We showed nine PSAs, asking individuals open-ended questions via questionnaire, then facilitating a focus group to reflect upon the PSAs. RESULTS:Questionnaire responses revealed a balance between individual vs. public health literacy. Some focused on individual responsibility and behaviors, while others described socio-environmental forces underlying risk. The focus group generated a preponderance of public health literacy responses, emphasizing future action. Striking sociopolitical themes emerged, reflecting tensions minority and low-income youth experience, such as entrapment vs. liberation. CONCLUSION:Our findings speak to the structural barriers and complexities underlying diabetes risk, and the ability of spoken word medium to make these challenges visible and motivate action. PRACTICE IMPLICATIONS:Delivering TBP content to promote interactive reflection has potential to change behavioral norms and build capacity to confront the social, economic and structural factors that influence behaviors

Efficiency, Efficacy, and Power in the Implementation of a Medication Adherence Aid.

Nonadherence to medication regimens is common, with approximately 50% of patients not taking their medications as prescribed. The Universal Medication Schedule (UMS) is a set of standardized, evidence-based, and patient-centered instructions for pill-form medications that has demonstrated improvements in adherence by promoting patient comprehension. An urban, publicly funded, integrated health care system attempted to adopt UMS labeling but had limited success at its largest pilot site, which was a safety-net health care system's outpatient pharmacy. To assess barriers to implementation, we engaged pharmacists at this site in group interviews. We thematically analyzed transcripts by integrating sociological work on standardization with grounded theory methodologies. In addition to lacking technological infrastructure, tensions among efficiency, efficacy, and effectiveness, and tension between individual/biomedical versus population health perspectives emerged as barriers to implementation. Additionally, we discovered that hierarchies of professional power impeded uptake. For successful implementation of evidence-based practices for vulnerable populations in resource-poor settings, efforts must anticipate and reconcile the tensions among conflicting demands, professional hierarchies, and divergent orientations to patient care. [HLRP: Health Literacy Research and Practice. 2018;2(3):e128-e131.]

Heterogeneity of diabetes outcomes among asians and pacific islanders in the US: the diabetes study of northern california (DISTANCE).

ObjectiveEthnic minorities with diabetes typically have lower rates of cardiovascular outcomes and higher rates of end-stage renal disease (ESRD) compared with whites. Diabetes outcomes among Asian and Pacific Islander subgroups have not been disaggregated.Research design and methodsWe performed a prospective cohort study (1996-2006) of patients enrolled in the Kaiser Permanente Northern California Diabetes Registry. There were 64,211 diabetic patients, including whites (n = 40,286), blacks (n = 8,668), Latinos (n = 7,763), Filipinos (n = 3,572), Chinese (n = 1,823), Japanese (n = 951), Pacific Islanders (n = 593), and South Asians (n = 555), enrolled in the registry. We calculated incidence rates (means ± SD; 7.2 ± 3.3 years follow-up) and created Cox proportional hazards models adjusted for age, educational attainment, English proficiency, neighborhood deprivation, BMI, smoking, alcohol use, exercise, medication adherence, type and duration of diabetes, HbA(1c), hypertension, estimated glomerular filtration rate, albuminuria, and LDL cholesterol. Incidence of myocardial infarction (MI), congestive heart failure, stroke, ESRD, and lower-extremity amputation (LEA) were age and sex adjusted.ResultsPacific Islander women had the highest incidence of MI, whereas other ethnicities had significantly lower rates of MI than whites. Most nonwhite groups had higher rates of ESRD than whites. Asians had ~60% lower incidence of LEA compared with whites, African Americans, or Pacific Islanders. Incidence rates in Chinese, Japanese, and Filipinos were similar for most complications. For the three macrovascular complications, Pacific Islanders and South Asians had rates similar to whites.ConclusionsIncidence of complications varied dramatically among the Asian subgroups and highlights the value of a more nuanced ethnic stratification for public health surveillance and etiologic research

CARING FOR PATIENTS WITH DIABETES IN SAFETY NET HOSPITALS AND HEALTH SYSTEMS

Safety net hospital systems provide health care to a high volume of underserved patients, including uninsured and low-income patients, racial/ethnic minorities, and those with chronic conditions. To assess the effects of programs designed to improve care for the undeserved, the National Public Health and Hospital Institute interviewed administrators about available programs and services and collected information on patient demographics, health care utilization, and clinical outcomes related to diabetes management. Services range from availability of special diabetes clinics to American Diabetes Association–certified classes. Compared with other health care providers, safety net hospital systems provide comparably high quality of care to patients with diabetes, despite serving higher volumes of underserved patients. However, even with programs and services designed to improve access to care for the underserved, disparities in quality of care and patient outcomes persist as a result of demographic risk factors, most notably, lack of insurance.https://www.commonwealthfund.org/Content/Publications/Fund-Reports/2005/Jun/Caring-for-Patients-with-Diabetes-in-Safety-Net-Hospitals-and-Health-Systems.asp

Obesity and the food environment: income and ethnicity differences among people with diabetes: the Diabetes Study of Northern California (DISTANCE).

ObjectiveIt is unknown whether any association between neighborhood food environment and obesity varies according to individual income and/or race/ethnicity. The objectives of this study were to test whether there was an association between food environments and obesity among adults with diabetes and whether this relationship differed according to individual income or race/ethnicity.Research design and methodsSubjects (n = 16,057) were participants in the Diabetes Study of Northern California survey. Kernel density estimation was used to create a food environment score for each individual's residence address that reflected the mix of healthful and unhealthful food vendors nearby. Logistic regression models estimated the association between the modeled food environment and obesity, controlling for confounders, and testing for interactions between food environment and race/ethnicity and income.ResultsThe authors found that more healthful food environments were associated with lower obesity in the highest income groups (incomes 301-600% and >600% of U.S. poverty line) among whites, Latinos, and Asians. The association was negative, but smaller and not statistically significant, among high-income blacks. On the contrary, a more healthful food environment was associated with higher obesity among participants in the lowest-income group (<100% poverty threshold), which was statistically significant for black participants in this income category.ConclusionsThese findings suggest that the availability of healthful food environments may have different health implications when financial resources are severely constrained

Getting Under the Skin of Clinical Inertia in Insulin Initiation: The Translating Research Into Action for Diabetes (TRIAD) Insulin Starts Project

Purpose The purpose of this cross-sectional study is to explore primary care providers’ (PCPs) perceptions about barriers to initiating insulin among patients. Studies suggest that many patients with poorly controlled type 2 diabetes do not receive insulin initiation by PCPs. Methods As part of the Translating Research Into Action for Diabetes study, the authors conducted structured interviews in health systems in Indiana, New Jersey, and California, asking PCPs about the importance of insulin initiation and factors affecting this decision. The authors calculated proportions choosing each multiple-choice response option and listed the most frequently offered open-ended response categories. Results Among 83 PCPs, 45% were women; 60% were white; and they averaged 13.4 years in practice. Four-fifths of PCPs endorsed guideline-concordant glycemic targets, but 54% individualized targets based on patient age, life expectancy, medical comorbidities, self-management capacity, and willingness. Most (64%) reported that many patients were resistant to new oral or insulin therapies due to fears about the therapy and what it meant about their disease progression. Two-thirds (64%) cited patient resistance as a barrier to insulin initiation, and 43% cited problems with patient self-management, including cognitive or mental health issues, dexterity, or ability to adhere. Eighty percent felt that patient nonadherence would dissuade them from initiating insulin at least some of the time. Conclusions PCPs perceived that patient resistance and poor self- management skills were significant barriers to initiating insulin. Future studies should investigate whether systems-level interventions to improve patient-provider communication about insulin and enhance providers’ perceptions of patient self-management capacity can increase guideline-concordant, patient-centered insulin initiation

Hypoglycemia is More Common Among Type 2 Diabetes Patients with Limited Health Literacy: The Diabetes Study of Northern California (DISTANCE)

Little is known about the frequency of significant hypoglycemic events in actual practice. Limited health literacy (HL) is common among patients with type 2 diabetes, may impede diabetes self-management, and thus HL could increase the risk of hypoglycemia. To determine the proportion of ambulatory, pharmacologically-treated patients with type 2 diabetes reporting ≥1 significant hypoglycemic events in the prior 12 months, and evaluate whether HL is associated with hypoglycemia. Cross-sectional analysis in an observational cohort, the Diabetes Study of Northern California (DISTANCE). The subjects comprised 14,357 adults with pharmacologically-treated, type 2 diabetes who are seen at Kaiser Permanente Northern California (KPNC), a non-profit, integrated health care delivery system. Patient-reported frequency of significant hypoglycemia (losing consciousness or requiring outside assistance); patient-reported health literacy. At least one significant hypoglycemic episode in the prior 12 months was reported by 11% of patients, with the highest risk for those on insulin (59%). Patients commonly reported limited health literacy: 53% reported problems learning about health, 40% needed help reading health materials, and 32% were not confident filling out medical forms by themselves. After adjustment, problems learning (OR 1.4, CI 1.1-1.7), needing help reading (OR 1.3, CI 1.1-1.6), and lack of confidence with forms (OR 1.3, CI 1.1-1.6) were independently associated with significant hypoglycemia. Significant hypoglycemia was a frequent complication in this cohort of type 2 diabetes patients using anti-hyperglycemic therapies; those reporting limited HL were especially vulnerable. Efforts to reduce hypoglycemia and promote patient safety may require self-management support that is appropriate for those with limited HL, and consider more vigilant surveillance, conservative glycemic targets or avoidance of the most hypoglycemia-inducing medications

Caring for Patients with Diabetes at Safety Net Hospitals and Health Systems: What the Patients Say about Their Care

In 2002, with support from The Commonwealth Fund, the National Public Health and Hospital Institute (NPHHI) created a consortium of safety net hospital systems to work together to address common concerns regarding the care of patients with diabetes. As part of that project, NPHHI conducted a survey of patients with diabetes who received at least some of their care from four Consortium hospital systems: Cambridge Health Alliance; Community Health Network of San Francisco/San Francisco General Hospital; Cook County Bureau of Health Services; and LSU/Medical Center of Louisiana at New Orleans. Patients were surveyed on multiple domains of care, including overall satisfaction, access to important diabetes-related services, self-management, health status, and communication with their health care providers. This effort, known as the Consortium for Quality Improvement in Safety Net Hospitals and Health Systems, was the first initiative of its kind to bring a group of safety net hospital systems together to examine quality of care provided for diabetes patients. The work of the Consortium underscores the critical role that safety net hospital systems play in delivering high quality diabetes care to a patient population that is primarily low income, ethnically and racially diverse, and that has high rates of literacy problems. The study signals the need for comprehensive programs to support the care of vulnerable patients with chronic conditions and highlights areas for improved communication between providers and patients. Project outcomes can be summarized around several major findings: Although Consortium members care for large numbers of patients with diabetes who are?racially and ethnically diverse, low income or uninsured, and often with limited English?or literacy proficiency, the study found few significant differences among racial groups?regarding assessment of health status and access to care. Despite programs at safety net hospitals to increase access to care for patients, uninsured patients continue to report poorer control of their diabetes and disparities in access to care. Compared with patients with any insurance coverage, fewer uninsured patients reported having a primary care provider and more reported skipping medications due to cost Up to one-third of the patients at Consortium hospital systems reported having languages other than English as their primary language, and one-quarter reported having health literacy problems. Patients commonly reported problems understanding basic instructions involved in diabetes management. Safety net hospital systems are continually challenged to provide culturally and linguistically appropriate services for their diverse populations. Appropriate provider-patient communication becomes a particularly salient issue for patients with chronic illnesses like diabetes that require self-management and understanding of providers\u27 instructions. More research is necessary to understand the cultural and linguistic needs of various patient populations and to design targeted programs that address these needs in the context of comprehensive care management. The NPHHI study revealed the importance of providing comprehensive care that draws on relevant health professionals in the management of chronic illness. Diabetes teams should be expanded to include health care professionals and social workers able to address the variety of factors that affect diabetes care for low-income and minority patients. Much more work is necessary to develop comprehensive, tailored diabetes management programs that take into account literacy, language, and co-morbidities. The study identified several key areas for improvement in care for patients with diabetes in safety net hospitals, specifically around patient-provider communication. In general, survey respondents reported few problems with the care they received and their communication with providers, but not consistently across race and ethnicity. A sizable group of patients (one-quarter or more) reported having difficulty understanding their providers\u27 use of medical terminology, identified a need for improved communication, or noted the providers\u27 failure to take into account the patient\u27s religion or culture. Although patients generally identified few problems with the care they received, a remarkably high proportion of survey respondents indicated they were in fair or poor health and/or had pain that interfered with their ability to exercise. In part, this is a reflection of the experiences of patient populations in safety net hospital systems, who tend to suffer from co-morbidities such as heart disease and depression