The Graying of the Cool Pose: Examining Active Care Strategies Among Older African-American Men With Type 2 Diabetes Mellitus.

OBJECTIVES: The influence of masculinity norms on disparate health outcomes has been established in the literature. What is less understood are the specific ways in which African-American men "do health" by engaging in strategies promoting positive health outcomes. This article reframes what has been previously examined through a health deficit perspective by reporting the experiences and positive health maintenance strategies of older, African-American men with type 2 diabetes mellitus (diabetes). METHODS: We employed an intersectional framework to thematically analyze qualitative interviews with African-American male participants (N = 15) in our National Institute on Aging-funded study of diabetes among older adults in Baltimore. Interviews consisted of a modified version of the McGill Illness Narrative Interview, which included discussions of diabetes experiences and self-management strategies. RESULTS: The majority of African-American men in our study link their successful diabetes management to purposeful self-care activities, despite structural and personal limitations. These activities include proactively seeking diabetes education, healthy eating, medication management, and engaging in supportive relationships. DISCUSSION: Active pursuit of a healthy lifestyle often requires redefining Black manhood, defying negative gender stereotypes of what it means to be a Black male. Results are described in the context of the "Cool Pose," a framework for understanding how African-American men and boys cope with systemic racial oppression and the unachievable dominant standards of masculinity in the United States. The results suggest that this framework may be less applicable for older African-American men who promote well-being in the wake of chronic disease as they age.

"How I Can Help Me": Self-Care Priorities and Structural Pressures Among Black Older Adults With Diabetes.

BACKGROUND AND OBJECTIVES: Disparities in type 2 diabetes mellitus (diabetes) represent an ongoing public health challenge. Black older adults are at high risk of diabetes and diabetes' complications. Diet, physical activity, and medication can control these risks, yet disease rates remain elevated. Utilizing an intersectionality framework, we seek to extend understanding of the social dimensions of diabetes through an examination of the diabetes self-care process from the perspective of Black older adults. RESEARCH DESIGN AND METHODS: This project involved a thematic analysis of diabetes illness narrative interviews with Black participants (N = 41) in our National Institute on Aging-funded study of diabetes. In a narrative approach, the participant communicates the significance of actions and events. RESULTS: The findings suggest that diabetes self-care involves interconnected struggles across four domains of care: (1) multimorbidity management, (2) financial well-being, (3) family support, and (4) formal health care. DISCUSSION AND IMPLICATIONS: Black older adult self-care reflects an active process of pursuing meaningful social goals and critical health needs. An intersectional framework, however, reveals the ongoing histories of inequity that shape this process. Further intervention to address the racist policies and practices found in Black older adults' communities and clinical care is needed to make true progress on diabetes disparities.

Affective Practices of Diabetes Self-Management Among Older Adults: Cumulative Effects of Childhood Adversity.

BACKGROUND AND OBJECTIVES: A strong correlation exists between Type 2 diabetes mellitus and adverse childhood experiences. How adverse childhood experiences inform later-life diabetes management is less understood. This article examines diabetes management from the perspective of affective practice to explore the lingering impact of trauma biographies in diabetes management. RESEARCH DESIGN AND METHODS: This secondary narrative analysis of 15 in-depth interviews with community-dwelling older adults with diabetes (subsample of the Subjective Experiences of Diabetes Study) focuses on the ways their reported childhood adversity affects perceptions of and responses to diabetes self-management. RESULTS: The experiences of adversity in childhood accumulate, throughout the life course, in the affective practices informing diabetes self-management, from blood glucose testing, to food consumption, to the emotions invested in body size. We identify 3 thematic areas that emerged across participants: (a) undermining self-worth, (b) (over)eating and food as comfort, and (c) weight and body size. DISCUSSION AND IMPLICATIONS: Our findings highlight affective practices as a mechanism through which adverse events accumulate and shape well-being over the life course. This analysis also suggests the potential for (de)accumulation of affective practices to improve diabetes management. The findings support recent calls for trauma-informed clinical care.

Adaptive Physical Activity for Stroke: An Early-Stage Randomized Controlled Trial in the United States.

Background. As stroke survival improves, there is an increasing need for effective, low-cost programs to reduce deconditioning and improve mobility. Objective. To conduct a phase II trial examining whether the community-based Italian Adaptive Physical Activity exercise program for stroke survivors (APA-Stroke) is safe, effective, and feasible in the United States. Methods. In this single-blind, randomized controlled trial, 76 stroke survivors with mild to moderate hemiparesis >6 months were randomized to either APA-Stroke (N = 43) or Sittercise (N = 33). APA-Stroke is a progressive group exercise regimen tailored to hemiparesis that includes walking, strength, and balance training. Sittercise, a seated, nonprogressive aerobic upper body general exercise program, served as the control. Both interventions were 1 hour, 3 times weekly, in 5 community locations, supervised by exercise instructors. Results. A total of 76 participants aged 63.9 ± 1.2 years, mean months poststroke 61.8 ± 9.3, were included. There were no serious adverse events; completion rates were 58% for APA-Stroke, 70% for Sittercise. APA-Stroke participants improved significantly in walking speed. Sample size was inadequate to demonstrate significant between-group differences. Financial and logistical feasibility of the program has been demonstrated. Ongoing APA classes have been offered to >200 participants in county Senior Centers since study completion. Conclusion. APA-Stroke shows great promise as a low-cost, feasible intervention. It significantly increased walking speed. Safety and feasibility in the US context are demonstrated. A pivotal clinical trial is required to determine whether APA-Stroke should be considered standard of care.

The Telemedicine for Patients With Inflammatory Bowel Disease (TELE-IBD) Clinical Trial: Qualitative Assessment of Participants' Perceptions.

BACKGROUND: Inflammatory bowel disease (IBD), comprising Crohn disease and ulcerative colitis, affects 1 to 3 million people in the United States. Telemedicine has shown promise in IBD. The objective of this study, telemedicine for patients with IBD (TELE-IBD), was to compare disease activity and quality of life (QoL) in a 1-year randomized clinical trial of IBD patients receiving telemedicine versus standard care. Treatment groups experienced improvements in disease activity and QoL, but there were no significant differences between groups. Study adherence to the text-based intervention was less than 80%, the targeted goal. OBJECTIVE: To understand adherence to remote monitoring, the goal of this qualitative assessment was to obtain TELE-IBD trial participants' perceptions, including their recommendations for future monitoring. METHODS: In this study, patients attending 3 tertiary referral centers with worsening IBD symptoms in the previous 2 years were eligible for randomization to remote monitoring via SMS text messages (short message service, SMS) every other week, weekly, or standard care. Participants (n=348) were evenly enrolled in the treatment groups, and 259 (74.4%) completed the study. For this study, a purposive sample of adherent (N=15) and nonadherent (N=14) patients was drawn from the TELE-IBD trial population. Adherence was defined as the completion of 80% (278/348) or more of the weekly or every other week self-assessments. Semistructured interviews conducted by phone surveyed (1) the strengths and benefits of TELE-IBD, (2) challenges associated with using TELE-IBD, and (3) how to improve the TELE-IBD intervention. Interviews were recorded, professionally transcribed, and coded based on a priori concepts and emergent themes with the aid of ATLAS.ti, version.7 qualitative data analysis software. RESULTS: Participants' discussions centered on 3 elements of the intervention: (1) self-assessment questions, (2) action plans, and (3) educational messages. Participants also commented on text-based platform, depression and adherence, TELE-IBD system in place of office visit, and their recommendations for future TELE-IBD systems. Adherent and nonadherent participants prefer a flexible system that is personalized, including targeted education messages, and they perceive the intervention as effective in facilitating IBD self-management. CONCLUSIONS: Participants identified clear benefits to the TELE-IBD system, including obtaining a better understanding of the disease process, monitoring their symptoms, and feeling connected to their health care provider. Participants' perceptions obtained in this qualitative study will assist in improving the TELE-IBD system to be more responsive to patients with IBD.

Ascribed Meaning of Disease Control: Perspectives of Patients With Type 2 Diabetes.

BACKGROUND: Contemporary treatment of type 2 diabetes mellitus (hereafter diabetes) heavily emphasizes "diabetes control," largely defined by measurable blood glucose parameters. Little is known about how people living with the condition themselves define diabetes control within the lived experience of their disease. METHODS: As part of a qualitative study investigating the subjective construction of diabetes, 83 in-depth interviews were conducted with African American and non-Hispanic white older adults. Using content analysis, 4237 pages of narrative data were analyzed to explore how informants conceptualized diabetes control. FINDINGS: Four themes emerged from the data, describing varied understandings of diabetes control: (a) blood sugar regulation, (b) practicable treatment adherence, (c) bodily experience, and (d) degree of pharmaceutical need. Findings demonstrate that among persons with diabetes, the term diabetes control is multifaceted. CONCLUSION: While clinical guidelines have established target blood glucose parameters as the standard indicator of diabetes control, persons with diabetes conveyed varied and diverse meanings situated within personal experiences. To foster empathetic and collaborative care, health-care providers tending to this population may consider integrating the emergent themes into communicative and treatment approaches.

Understanding the Subjective Experience of Medication Adherence for Older Urban African Americans With Type 2 Diabetes and a History of Illicit Drug Addiction.

OBJECTIVE: African Americans experience high rates of type 2 diabetes mellitus (T2D). Self-management strategies, such as medication adherence, are key to mitigating negative T2D outcomes. This article addresses a gap in the literature by examining the intersections of drug abuse histories and medication adherence among urban, older African Americans with T2D. METHOD: In-depth interview data were collected as part of a larger ethnographic study examining the subjective experience of T2D among urban older adults. Two representative focal cases were selected and thematic analysis performed to illustrate how former illicit drug addicts perceive prescription medication usage. RESULTS: Narratives reveal that participants are displeased about having to take prescription drugs and are making lifestyle changes to reduce medication usage and maintain sobriety. DISCUSSION: Previous drug abuse not only complicates medication adherence but is also a significant part of how older African Americans who are former drug users frame their understanding of T2D more broadly.

Qualitative perspectives on aquatic exercise initiation and satisfaction among persons with multiple sclerosis.

PURPOSE: To identify the individual and social experiences underlying the initiation and satisfaction with aquatic exercise among persons with MS. METHODS: A convenience sample (n = 45) of persons aged ≥18 with MS who had engaged in water-based exercise within the previous six months completed a 60-90 min semi-structured telephone interview regarding their aquatic exercise experiences. RESULTS: An aquatic exercise history was not a prerequisite for the adoption of aquatic exercise. Rather, participants described aquatic exercise routines as stemming from recognition of a decline in physical function combined with encouragement and invitations to join aquatic programs. Despite regular visits, health care providers were not a common source of information regarding the feasibility of aquatic exercise. Participants' aquatic activities included MS-specific and generalized aquatics courses, with class satisfaction resting on the instructor, class "fit" and a feeling of acceptance. CONCLUSION: Communication regarding local aquatic opportunities is critical for ensuring aquatics engagement among persons with MS. Providers could play a stronger role in emphasizing the feasibility and benefits of aquatic programs. In addition, persons with MS should be encouraged to try local MS and more generalized aquatic programs in order to identify a program matching their social and physical goals. Implications for Rehabilitation Directed communication regarding aquatic opportunities is essential to prompting the initiation of aquatic exercise Both MS-specific and general aquatics classes can provide positive exercise experiences for persons with MS A history of regular exercise or aquatic experiences is not a prerequisite for the initiation of aquatic exercise among persons with MS Health care provider visits may represent missed opportunities for promoting aquatics; providers should consider the suitability of aquatics for all patients with MS, regardless of the patient's exercise history.

Diabetes and the Motivated Patient: Understanding Perlocutionary Effect in Health Communication.

Health care providers (HCP) understand the importance of keeping patients motivated but may be unaware how their words may have unintended negative effects upon their patient's lives. People with diabetes report being told by their HCP that they are "cured" or that they are praised for strides made in weight loss and/or lowered blood glucose, and interpret these messages in unexpected ways. For this paper, we focus upon one case to illustrate the depth and nuance of the patient-provider communication as it emerged within a larger interview-based ethnographic study. Audio-recorded interviews and transcriptions were analyzed discursively. Discourse analysis reveals the ways ideology affects how the patient responds to HCP's utterances and how this affects diabetes self-care. Findings indicate significant perlocutionary effects upon health outcomes, varying both positively and/or negatively. This study points to the importance of carefully considering the power of words and whenever possible knowing the patient's ideological orientation to their world. HCPs should be explicit and deliberate with their communication. Sensitization to the various ways patients hear and react to messages in a clinical setting may lead to improved health outcomes, especially for those with chronic health conditions such as diabetes mellitus.

Successful Aging Among African American Older Adults With Type 2 Diabetes.

OBJECTIVES: Rowe and Kahn's concept of successful aging remains an important model of well-being; additional research is needed, however, to identify how economically and socially disadvantaged older adults experience well-being, including the role of life events. The findings presented here help address this gap by examining the subjective construction of well-being among urban African American adults (age ≥ 50) with Type 2 diabetes. METHOD: As part of the National Institute on Aging-funded Subjective Experience of Diabetes among Urban Older Adults study, ethnographers interviewed African American older adults with diabetes (n = 41) using an adaptation of the McGill Illness Narrative Interview. Data were coded using an inductively derived codebook. Codes related to aging, disease prognosis, and "worldview" were thematically analyzed to identify constructions of well-being. RESULTS: Participants evaluate their well-being through comparisons to the past and to the illnesses of friends and family. Diabetes self-care motivates social engagement and care of others. At times, distrust of medical institutions means well-being also is established through nonadherence to suggested biomedical treatment. DISCUSSION: Hardship and illness in participants' lives frame their diabetes experience and notions of well-being. Providers need to be aware of the social, economic, and political lenses shaping diabetes self-management and subjective well-being.

Routes to government TB treatment: private providers, family support, and the process of TB treatment seeking among Ugandan women.

Tuberculosis (TB) remains a major source of morbidity and mortality in Uganda. This cross-sectional study explores Ugandan women's TB treatment-seeking processes to determine the routes to effective government TB treatment among a sample of urban, semirural, and rural women. This research focuses on women in particular as Ugandan women with tuberculosis must negotiate their treatment paths in a context where women tend to be politically and economically marginalized, with limited control of household resources and senior family members' health care decisions. The results examine the structural, social, and economic forces similarly guiding treatment seeking across the three research sites and then the specific differences among the settings. The findings suggest that the modest number of nongovernmental health care providers' diagnoses and referrals, particularly for urban and semirural participants, represents a critical barrier to biomedical TB treatment. Private providers' diagnosis delays also carry financial and physical costs, which undermine the resources available for subsequent TB treatment and participants' social and economic well-being. This study indicates that conceptualizations of the political economy of treatment seeking need to more fully acknowledge the dynamic nature of the microlevel political economic context of treatment seeking, including the domino social, economic, and health effects of structurally problematic health care systems.

Community exercise: a vital component to healthy aging.

Exercise plays a critical role in promoting healthy aging and in the management of chronic illness. In this paper, we provide an overview of the leading research regarding exercise and chronic illness, and the variables influencing exercise participation among persons with a chronic illness. We then examine the Empoli Adaptive Physical Activity (APA) program as a model program that has overcome many of the obstacles to exercise adherence. Piloted by Local Health Authority 11 in Tuscany, Italy, APA has over 2,000 participants, and it provides tailored exercise opportunities for persons with stroke, back pain, Parkinson's disease or multiple sclerosis, among others illnesses. The Empoli APA program serves as a model community exercise program and is now being replicated throughout Tuscany and in the United States.

Exercise for chronic stroke survivors: a policy perspective.

Evidence is growing on the efficacy of exercise models for improving multiple domains of physiological health and fitness in people with chronic stroke. The Adaptive Physical Activity exercise program in Italy illustrates how geographic dispersion can increase access to such programs. A partnership between local agencies of the Veterans Health Administration and Administration on Aging suggests ways to increase access to exercise programs for veterans and other citizens with chronic stroke in the United States. The use of a structure-process-outcome framework is suggested to facilitate exchange between international research teams regarding development of evolving stroke exercise models.

Community neurorehabilitation: a synthesis of current evidence and future research directions.

Over the past decade, community neurorehabilitation has emerged as a promising extension of neurological rehabilitation. The goal of community neurorehabilitation is to maximize functional ability and quality of life through multidimensional rehabilitation that occurs while the individual is living in a home versus acute or transitory care setting. Because of its multidisciplinary focus, many variations of community neurorehabilitation teams have been implemented. Critical gaps exist, however, in understanding of the influence of structural and procedural differences among programs, as well as patient level variables such as social support, on recovery. This paper examines the current evidence of the effectiveness of community neurorehabilitation through a review of the findings of systematic reviews and meta-analyses of four neurological conditions: stroke, multiple sclerosis, traumatic brain injury, and Parkinson's disease. It focuses in particular on the data regarding physical therapy and occupational therapy, which are two of the primary components of community neurorehabilitation programs.

Stroke rehabilitation in Switzerland versus the United States: a preliminary comparison.

This article compares the structure and process of rehabilitation for stroke patients at 2 internationally recognized rehabilitation hospitals, Klinik Valens ("Valens") in Switzerland and the William Donald Schaeffer Rehabilitation Hospital at Kernan ("Kernan") in the United States. Although the patient mix, structure, and process of rehabilitation were similar in many regards, there were some important differences. Most notably, on average, patients at the U.S. hospital were discharged from rehabilitation at approximately the same day poststroke that rehabilitation began in Switzerland. Patients remained in an inpatient setting an average of 40 days longer in Switzerland (for the combination of acute care and rehabilitation) and had significantly higher levels of functioning at discharge when compared to their U.S. counterparts. The authors' findings suggest that Europe may offer opportunities for rehabilitation research that would be difficult to duplicate in the United States and highlight policy-relevant questions for future studies aimed at developing efficient managed care systems for stroke survivors.