Incorporating Black women's perspectives into long-acting reversible contraception implementation.

Objective: To study urban, predominantly Black women's expressed opinions and beliefs related to the use of contraceptives to better inform implementation strategies designed to increase the use of highly effective contraceptives among minoritized and low-income women. Design: Focus group interviews with women, in conjunction with a community-based organization providing programs for underserved women with a mission of improved women and infant health. Setting: Focus groups were conducted, and women were recruited from clinical sites in predominantly African American urban neighborhoods in a southeastern US city. Patients: Self-identified 18-35-year-old women recruited from clinical sites in the urban core of the city with an 80% African American population. Interventions: No interventions tested. Main Outcome Measures: Black women's opinions and concerns about contraception. Results: Key insights from the focus group results for healthcare providers include the following: the importance of framing discussions with patients within the context of the patients' goals; need to acknowledge and respect the support systems that women rely on for child birthing and childcare; recognition of the clinician's role as a trusted and respected source of information; and need to understand and be prepared to address much of the inaccurate and misleading information that can interfere with the patients' optimal choices for contraception. Conclusions: A critical component for applying the implementation science theory to increase the use of evidence-based practices, such as implementation of highly effective contraceptives, requires understanding women's perspectives of the factors influencing their decisions to use highly effective contraceptives. This study provides important insights into the following: the potential barriers inherent in minoritized women's concerns about contraceptives and how these insights can inform implementation strategies such as patient-centered counseling and education to overcome those barriers.

Diabetes Self-management Training in a Virtual Environment.

Diabetes self-management training (DSMT) improves diabetes health outcomes. However, low numbers of patients receive DSMT. Using virtual environments (VEs) for DSMT is an innovative approach to removing barriers for patients. The purpose of this paper is to describe the experience of health professionals and diabetes educators establishing and teaching DSMT in a VE, Diabetes LIVE© (Learning in Virtual Environments), and the implications for future use of VEs in DSMT. It was found that providing DSMT in a VE preserves real-time interaction between patients and educators. To facilitate ongoing patient learning and engagement, the DSMT curriculum was expanded beyond the core content as "Above and Beyond" topics. Using a VE for DSMT presents challenges and opportunities. Challenges include overcoming technological barriers and improving comfort levels to orient educators and patients to the functionality of the VE. Opportunities include overcoming barriers to reaching patients, particularly given the diabetes epidemic and relatively small number of diabetes educators. Using a VE also affords a simulated community for experiential learning. VEs may become powerful tools for diabetes and other health educators to reach patients. Ongoing education and support are vital to successful self-management of chronic disease.

Clinical, Psychosocial, and Demographic Factors Are Associated With Overweight and Obesity in Early Adolescent Girls With Type 1 Diabetes.

PURPOSE: The purpose of the study was to examine the differences in clinical, psychosocial, and demographic factors by sex and weight status. METHODS: Baseline data were analyzed from 318 adolescents (mean age = 12.3 ± 1.1 years, 55.0% female, 62.7% white) with type 1 diabetes (T1D) from a multisite clinical trial. Differences were examined between normal weight (body mass index ≥5th and <85th percentile) and overweight/obese (body mass index ≥85th percentile) boys and girls with T1D in clinical, psychosocial, and demographic factors. Descriptive and multiple logistic regression analyses were used. RESULTS: Overweight/obesity was prevalent (39.0%) and common in girls (42.6%) and boys (33.1%). In bivariate analyses, overweight/obese girls had parents with lower educational attainment, longer diabetes duration, and significantly worse self-management and psychosocial health as compared with normal weight girls. There were no differences between overweight/obese and normal weight girls in A1C, therapy type, race/ethnicity, or household income. No significant differences were found between normal weight and overweight/obese boys. In multivariate analysis, parental educational attainment (master or higher vs high school diploma or less) and perceived stress were significantly associated with overweight/obesity in girls. Longer duration of T1D bordered statistical significance. CONCLUSIONS: Overweight/obesity is prevalent among adolescents with T1D. Clinical, psychosocial, and demographic factors are associated with overweight/obesity in girls but not boys. Greater attention to weight status and aspects of health that are germane to adolescents with T1D is warranted.

The Value of Continuous ST-Segment Monitoring in the Emergency Department.

Practice standards for electrocardiographic monitoring recommend continuous ST-segment monitoring (C-STM) in patients presenting to the emergency department (ED) with signs and/or symptoms of acute coronary syndrome (ACS), but few studies have evaluated its use in the ED. We compared time to diagnosis and 30-day adverse events before and after implementation of C-STM. We also evaluated the diagnostic accuracy of C-STM in detecting ischemia and infarction. We prospectively studied 163 adults (preintervention: n = 78; intervention: n = 85) in a single ED and stratified them into low (n = 51), intermediate (n = 100), or high (n = 12) risk using History, ECG, Age, Risk factors, and Troponin (HEART) scores. The principal investigator monitored participants, activating C-STM on bedside monitors in the intervention phase. We used likelihood ratios (LRs) as the measure of diagnostic accuracy. Overall, 9% of participants were diagnosed with ACS. Median time to diagnosis did not differ before and after implementation of C-STM (5.55 vs. 5.98 hr; p = 0.43). In risk-stratified analyses, no significant pre-/postdifference in time to diagnosis was found in low-, intermediate-, or high-risk participants. There was no difference in the rate of 30-day adverse events before versus after C-STM implementation (11.5% vs. 10.6%; p = 0.85). The +LR and -LR of C-STM for ischemia were 24.0 (95% confidence interval [CI]: 1.4, 412.0) and 0.3 (95% CI: 0.02, 2.9), respectively, and for infarction were 13.7 (95% CI: 1.7, 112.3) and 0.7 (95% CI: 0.3, 1.5), respectively. Use of C-STM did not provide added diagnostic benefit for patients with signs and/or symptoms of myocardial ischemia in the ED.

Coping skills training in a telephone health coaching program for youth at risk for type 2 diabetes.

INTRODUCTION: The purpose of this article is to describe components of a health coaching intervention based on coping skills training delivered via telephone. This intervention was provided to urban adolescents at risk for type 2 diabetes mellitus (T2DM), reinforcing a school-based curriculum designed to promote a healthy lifestyle and prevent T2DM. METHOD: Health coaching via telephone was provided to at-risk urban youth enrolled in a study of an intervention to reduce risk for T2DM. Vignettes are used to describe the use of several coping skills in this high-risk youth population. RESULTS: A variety of vignettes illustrate how telephone health coaching reinforced lifestyle changes in students by incorporating coping skills training. DISCUSSION: Given the benefits and the challenges of the telephone health coaching intervention, several suggestions for others who plan to use a similar method are described.

Metabolic risk and health behaviors in minority youth at risk for type 2 diabetes.

OBJECTIVE: The purpose of this study was to determine the impact of sex and race/ethnicity on metabolic risk and health behaviors in minority youth. RESEARCH DESIGN AND METHODS: A total of 173 seventh graders (46% male and 54% female; 49% Hispanic and 51% African American) with BMI ≥85th percentile and a family history of diabetes were assessed with weight, height, BMI, percent body fat, and waist circumference measures. Laboratory indexes included 2-h oral glucose tolerance tests with insulin levels at 0 and 2 h, fasting A1C, and lipids. Insulin resistance was estimated by homeostasis model assessment (HOMA-IR). Youth also completed questionnaires evaluating health behaviors. RESULTS: Average BMI (31.6 ± 6.4 kg/m²) and percent body fat (39.5 ± 10.6%) were high. All participants demonstrated insulin resistance with elevated HOMA-IR values (8.5 ± 5.2). Compared with African American youth, Hispanic youth had higher triglycerides and lower HDL cholesterol despite similar BMI. Hispanic youth reported lower self-efficacy for diet, less physical activity, and higher total fat intake. Male youth had higher glucose (0 and 2 h) and reported more physical activity, more healthy food choices, and higher calcium intake than female youth. CONCLUSIONS: Screening high-risk youth for insulin resistance and lipid abnormalities is recommended. Promoting acceptable physical activities and healthy food choices may be especially important for Hispanic and female youth.

The effect of a diabetes education, coping skills training, and care intervention on physiological and psychosocial outcomes in black women with type 2 diabetes.

An 11-week culturally relevant group diabetes self-management training (DSMT), coping skills training (CST), and diabetes care intervention was compared to a 10-week usual diabetes education and diabetes care intervention on physiological and psychosocial outcomes in 109 Black women (aged 48 +/- 10 years) with type 2 diabetes in primary care (PC). Strong time effects for hemoglobin A1c improvement were seen in both groups from baseline to 3 months and remained similar at 12 and 24 months (p < .0001). Systolic blood pressure (p =.01) and low-density lipoprotein cholesterol levels (p = .05) improved in both groups from baseline to 24 months. Baseline quality of life ([QOL]; Medical Outcome Study Short Form-36) was low. Social function, role-emotional, and mental health domains increased initially in both groups then declined slightly, with less decline for the experimental group at 12 months. At 24 months, experimental group scores increased. General health (p = .002), vitality (p = .01), role-physical, and bodily pain (p = .02) domains increased in both groups over time. Perceived provider support for diet (p = .0001) and exercise (p = .0001) increased in both groups over time. Diabetes-related emotional distress decreased in the experimental compared to the control group (group x time, p = .01). Findings suggest that both methods of diabetes education combined with care can improve metabolic control, QOL, and perceptions of provider care. CST may further assist in long-term improvements in health outcomes. Behavioral interventions are needed in addition to routine diabetes care, particularly in PC.

A multifaceted school-based intervention to reduce risk for type 2 diabetes in at-risk youth.

OBJECTIVE: To evaluate the impact of a multifaceted, school-based intervention on inner city youth at high risk for type 2 diabetes mellitus (T2DM) and to determine whether the addition of coping skills training (CST) and health coaching improves outcomes. METHOD: 198 students in New Haven, CT at risk for T2DM (BMI>85th percentile and family history of diabetes) were randomized by school to an educational intervention with or without the addition of CST and health coaching. Students were enrolled from 2004 to 2007 and followed for 12 months. RESULTS: Students in both groups showed some improvement in anthropometric measures, lipids, and depressive symptoms over 12 months. BMI was not improved by the intervention. Students who received CST showed greater improvement on some indicators of metabolic risk than students who received education only. CONCLUSION: A multifaceted, school-based intervention may hold promise for reducing metabolic risk in urban, minority youth.

Correlates of depressive symptoms in urban youth at risk for type 2 diabetes mellitus.

BACKGROUND: Rates of overweight in youth have increased at an alarming rate, particularly in minority youth, and depressive symptoms may affect the ability of youth to engage in healthy lifestyle behaviors to manage weight and reduce their risk for health problems. The purpose of this study was to examine the relationships between depressive symptoms, clinical risk factors, and health behaviors and attitudes in a sample of urban youth at risk for type 2 diabetes mellitus (T2DM). METHODS: We obtained self-report questionnaire data on depressive symptoms and health attitudes and behaviors related to diet and exercise and clinical data on risk markers (eg, fasting insulin) from 198 youth from an urban setting. Seventh-grade students were eligible if they were at risk for developing T2DM because they had a body mass index (BMI) in the 85th percentile or higher and a family history of diabetes. RESULTS: Clinically significant levels of depressive symptoms were evident in approximately 21% of the sample, and Hispanic youth reported higher levels of depressive symptoms than black youth. Higher levels of depression were associated with several health behaviors and attitudes, in particular less perceived support for physical activity and poorer self-efficacy for diet. Depressive symptoms were also related to some clinical risk markers, such as higher BMI and fasting insulin levels. CONCLUSIONS: Because depressive symptoms may affect ability to engage in healthy behavior changes, evaluation and treatment of depressive symptoms should be considered in preventive interventions for youth at risk for T2DM.

Recruitment of black women with type 2 diabetes into a self-management intervention trial.

The purpose of this study was to evaluate the relationship of recruitment methods to enrollment status in Black women with type 2 diabetes screened for entry into a randomized clinical trial (RCT). Using a cross-sectional study design with convenience sampling procedures, data were collected on recruitment methods to which the women responded (N=236). Results demonstrated that the RCT had a moderate overall recruitment rate of 46% and achieved only 84% of its projected accrual goal (N=109). Chi-square analysis demonstrated that enrollment outcomes varied significantly according to recruitment methods (P=.05). Recruitment methods such as community health fairs (77.8%), private practice referrals (75.0%), participant referrals (61.5%), community clinic referrals (44.6%), community advertising and marketing (40.9%), and chart review (40.4%) demonstrated variable enrollment yields. Results confirm previous findings that indicate that Black Americans may be successfully recruited into research studies at moderate rates when traditional recruitment methods are enhanced and integrated with more culturally sensitive methods. Lessons learned are considered.

A culturally competent intervention of education and care for black women with type 2 diabetes.

This article reports on the development and pilot feasibility testing of a culturally competent intervention of education and care for black women with type 2 diabetes mellitus (T2DM). Using a one group, pretest posttest quasi-experimental design, the intervention was tested with a convenience sample of 25 community black women with T2DM. The conceptual basis, process, and content of the intervention as well as the feasibility and acceptability of study materials and methods are described. Significant improvements from baseline to 3 months were observed in measures of glycemic control, weight, body mass index, and diabetes-related emotional distress. The findings suggest that a culturally sensitive intervention of nurse practitioner diabetes care and education is beneficial for black women with T2DM, resulting in program attendance, kept appointments, improved glycemic control and weight, and decreased diabetes-related emotional distress.

The relationship of spirituality and health outcomes in Black women with type 2 diabetes.

The purpose of this pilot study was to explore the relationships between spiritual well-being emotional distress, HbA1c values, and blood pressure levels in a convenience sample of 22 Black women with type 2 diabetes. Results revealed significant inverse correlations between diastolic blood pressure (BP) and both total spiritual well-being (r=-.51, P=.02) and religious well-being (RWB) (r=-.55, P=.01). Women with higher RWB scores tended to have lower diastolic BP, as compared to their counterparts with lower RWB scores (z=2.78, P=.005). Emotional distress was positively related to systolic BP (r=.48, P=.03). These finding suggest that holistic care, addressing the spiritual and emotional dimensions, may foster improved BP levels among Black women with type 2 diabetes, thereby potentially reducing their high risk for secondary complications.