Behind Closed Doors: A Thematic Analysis of Diabetes Community Health Worker Home Visit Content.

The present work studies how community health workers (CHWs) perform the role of educator and how this relates to the implementation of other CHW roles, skills, and qualities. Prior studies on this topic have relied on interviews or focus groups rather than analysis of CHW interactions. We conducted a thematic analysis of 24 transcripts of conversations occurring between CHWs and participants during home visits as part of the Mexican American Trial of Community Health Workers, a randomized controlled trial that improved clinical outcomes among low-income Mexican American adults with type 2 diabetes. Three themes describing interactions related to diabetes self-management education accounted for about half of encounter content. The other half of encounter content was dedicated to interactions not explicitly related to diabetes described by 4 subthemes. In a successful CHW intervention, focused educational content was balanced with other interactions. Interactions not explicitly related to diabetes may have provided space for the implementation of core CHW roles, skills, and qualities other than educator, particularly those related to relationship building. It is important that interventions provide CHWs with sufficient time and flexibility to develop strong relationships with participants.

The effect of the Ambulatory Integration of the Medical and Social (AIMS) model on health risk and depression.

Social needs are factors for health risk and depression that may negatively impact health outcomes and costly services use. Care management addresses social needs that can reduce health risk and depression. An exploratory study of the 5-step Ambulatory Integration of the Medical and Social Model (AIMS) was conducted to examine the effect of steps completed as part of AIMS on patients' depression and health risk outcomes at 6-months. Results reveal steps central to AIMS are significantly related to lower depression and health risk, suggesting AIMS is a valuable intervention for reducing health risk and depression.

Development of a Bidimensional Simpatía Scale for Use With Mexican American, Puerto Rican, and Cuban American Adults.

BACKGROUND: Through its influence on social interactions, simpatía may have a wide-ranging influence on Latinx health. Simpatía-which does not have a direct English translation-refers to being perceived as likeable, pleasant, and easygoing. Research to investigate the influence simpatía on Latinx health is limited, likely due to a lack of options for measuring simpatía among diverse Latinx populations. OBJECTIVES: The goal of this research was to develop a bilingual, survey-based simpatía scale for use among ethnically diverse Latinx adults in health-related settings. METHODS: Data were obtained through a telephone survey data of 1,296 Mexican American, Puerto Rican, and Cuban American adults living in the United States. Interviews were conducted in English and Spanish. Exploratory factor analysis, item response theory analysis, confirmatory factor analysis, and computation of estimates of internal consistency reliability were conducted to inform the development of the final simpatía scale. RESULTS: Results indicate that the final, nine-item, simpatía scale has high internal consistency (α = .83) and measurement invariance among Mexican American, Puerto Rican, and Cuban American adults. Two dimensions were identified, as indicated by a perceptions subscale and a behavior subscale. Cuban Americans were found to have the highest simpatía scores, followed by Puerto Ricans and Mexican Americans. DISCUSSION: Culture is often identified as a powerful potential influence on health-related behaviors, but measures are often not available to assess specific cultural traits. By developing a new tool for measuring simpatía, this research advances opportunities for understanding and promoting Latinx health.

Measuring the Elusive Construct of Personalismo among Mexican American, Puerto Rican, and Cuban American Adults.

Personalismo may have a broad influence on the well-being of U.S. Latinos by shaping social networks, and, in turn, access to information and resources. However, research on personalismo is currently constrained by the lack of a psychometrically sound measure of this cultural construct. This research used a mixed methods approach to develop a personalismo scale across three studies: a cognitive interviewing study with Mexican American adults (n=33); a cognitive interviewing study with non-Latino white, Mexican American, Puerto Rican, and Cuban American adults (n=61); and a psychometric telephone survey with Mexican American, Puerto Rican, and Cuban American adults (n=1,296). The final, 12-item scale had high internal consistency reliability and appears to be appropriate for use with Mexican American, Puerto Rican, and Cuban American adults. Significant differences emerged across Latino subgroups, with higher personalismo observed among Cuban Americans and female respondents, providing empirical evidence of cultural heterogeneity among U.S. Latino populations.

BRIGHTEN Heart intervention for depression in minority older adults: Randomized controlled trial.

OBJECTIVE: Assess the effectiveness of an interdisciplinary geriatric team intervention in decreasing symptoms of depression among urban minority older adults in primary care. Secondary outcomes included cardiometabolic syndrome and trauma. METHOD: 250 African American and Hispanic older adults with PHQ-9 scores ≥ 8 and BMI ≥ 25 were recruited from 6 underserved urban primary care clinics. Intervention arm participants received the BRIGHTEN Heart team intervention plus membership in Generations, an older adult educational activity program; comparison participants received only Generations. RESULTS: Both arms demonstrated clinically significant improvements in PHQ-9 scores at 6 months (-5 points, intervention and comparison) and 12 months (-7 points intervention, -6.5 points comparison); there was no significant difference in change scores between groups on depression or cardiometabolic syndrome at 6 months; there was a small difference in depression trajectory at 12 months (p < .001). More participants in the treatment group (70.7%) had greater than 50% reduction in PHQ-9 scores than the comparison group (56.3%; p = .036). For those with higher PTSD symptoms (PCL-C6), improvement in depression was significantly better in the intervention arm than the comparison arm, regardless of baseline PHQ-9 (p = .001). In mixed models, those with higher PTSD symptoms (ß = -0.012, p = < 0.001) in the intervention arm showed greater depression improvement than those with lower PTSD symptoms (ß = -0.004, p = .001). CONCLUSIONS: The BRIGHTEN Heart intervention may be effective in reducing depression for urban minority older adults. Further research on team care interventions and screening for PTSD symptoms in primary care is warranted. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Addressing asthma and obesity in children with community health workers: proof-of-concept intervention development.

BACKGROUND: The objective of this study was to design and test the feasibility and impact of a community health worker (CHW) intervention for comorbid asthma and obesity. METHODS: Using a proof of concept study design, we collected pre/post outcomes from a single intervention cohort of urban low-income in a single community area. A community-based participatory research approach was employed. Forty-six children and their caregivers were recruited. Children were 5-12 years old with physician-diagnosed asthma and body mass index (BMI) > 85%. Families were offered 12 home visits from CHWs that integrated asthma and obesity core curriculums. The primary asthma outcome was asthma control, measured via the Childhood Asthma Control Test (cACT). The primary obesity outcome was child body mass index (BMI). RESULTS: Families received a median of 10 out of the 12 home visits over 1 year. At 1 year, there was a significant improvement in the number of children with controlled asthma as measured via cACT (85.7% at 1 year compared to 61.9% at baseline, p = 0.01). Activity limitations and emergency utilization were reduced while inhaler technique improved (p < 0.01 for all). Child BMI z-score was reduced: mean = 1.97 (SD 0.79) at 1 year compared to mean = 2.13 (SD 0.40) at baseline, p < 0.01. No association was seen between change in child BMI and change in asthma control. Worse baseline child depression scores were associated with less improvement in asthma control (p = 0.003) and higher baseline caregiver post-traumatic stress disorder scores were associated with increased child BMI (p = 0.012). CONCLUSIONS: The CHW intervention has promise for improving asthma and weight outcomes in high-risk children with comorbid asthma and obesity; this model warrants further development and investigation.

Mexican American trial of community health workers: a randomized controlled trial of a community health worker intervention for Mexican Americans with type 2 diabetes mellitus.

OBJECTIVES: We assessed whether community health workers (CHWs) could improve glycemic control among Mexican Americans with diabetes. METHODS: We recruited 144 Mexican Americans with type 2 diabetes between January 2006 and September 2008 into the single-blinded, randomized controlled Mexican American Trial of Community Health Workers (MATCH) and followed them for 2 years. Participants were assigned to either a CHW intervention, delivering self-management training through 36 home visits over 2 years, or a bilingual control newsletter delivering the same information on the same schedule. RESULTS: Intervention participants showed significantly lower hemoglobin A1c levels than control participants at both year 1 Δ = -0.55; P = .021) and year 2 (Δ = -0.69; P = .005). We observed no effect on blood pressure control, glucose self-monitoring, or adherence to medications or diet. Intervention participants increased physical activity from a mean of 1.63 days per week at baseline to 2.64 days per week after 2 years. CONCLUSIONS: A self-management intervention delivered by CHWs resulted in sustained improvements in glycemic control over 2 years among Mexican Americans with diabetes. MATCH adds to the growing body of evidence supporting the use of CHWs to reduce diabetes-related health disparities.

Home asthma triggers: barriers to asthma control in Chicago Puerto Rican children.

We sought objectively to measure, summarize, and contextualize the asthma triggers found in the homes of urban high-risk Puerto Rican children and adolescents with asthma in Chicago. Data were from the baseline home assessments of Project CURA. Research assistants interviewed caregivers, conducted a home visual inspection, and collected saliva samples for cotinine analysis. A trigger behavior summary score was created. The housing inspected was old with multiple units and obvious structural deficiencies. Many allergic and irritant triggers were observed. Having a controller medicine or private insurance was associated with lower trigger behavior summary scores; caregiver depression, caregiver perceived stress, and child negative life events were associated with high trigger scores. The final multivariate model retained had a controller medicine, private insurance, and caregiver perceived stress. The data from this high-risk cohort identified modifiable areas where environmental interventions could reduce morbidity in Puerto Rican children and adolescents.

Recruitment, asthma characteristics, and medication behaviors in Midwestern Puerto Rican youth: data from Project CURA.

BACKGROUND: Puerto Rican children have the highest prevalence of asthma, but detailed descriptions of this population have been limited to the island of Puerto Rico and the northeastern United States. OBJECTIVE: To describe the asthma characteristics of this urban Midwest cohort of Puerto Rican youth, focusing on medication behaviors, and to test whether their asthma outcomes are associated with their demographic and psychosocial variables. METHODS: Data are from the baseline cohorts of a randomized controlled trial designed to improve medication adherence in Puerto Rican youth. Recruitment used a community-based participatory research approach. Data were collected in the home. Medications and medication technique were visually assessed, and adherence was determined using electronic medication monitors or counters. Data on asthma symptoms and morbidity, demographics, and psychosocial factors were collected. RESULTS: The recruitment of 101 participants (51 in elementary school and 50 in high school) was completed in 14 months. Despite overall high asthma severity and poor asthma control, 20% of participants had no reliever medicine in their home. Self-report of controller use was higher than actual controller medications visualized in the home. For those who had an inhaled corticosteroid medicine (only 45% of elementary school participants and 12% of high school participants), median adherence was 1.0 doses per day. Rates of depression and stress were very high among both caregivers and children. CONCLUSION: Puerto Rican youth in the Midwest bear a significant asthma burden in addition to other stressors, including depression. Visual inspection of medications and monitoring of adherence are critical for understanding asthma morbidity in this high-risk population.

The Mexican-American Trial of Community Health workers (MATCH): design and baseline characteristics of a randomized controlled trial testing a culturally tailored community diabetes self-management intervention.

OBJECTIVES: Community Health Workers (CHWs) have been recommended to reduce diabetes disparities, but few robust trials of this approach have been conducted. Limitations of prior studies include: unspecified a priori outcomes; lack of blinded outcome assessments; high participant attrition rates; and lack of attention to intervention fidelity. These limitations reflect challenges in balancing methodologic rigor with the needs of vulnerable populations. The Mexican-American Trial of Community Health workers (MATCH) was a blinded randomized controlled trial testing CHW efficacy in improving physiologic outcomes and self-management behaviors among Mexican-Americans with type 2 diabetes. This paper describes methods used to overcome limitations of prior studies. RESEARCH DESIGN AND METHODS: The primary aim was to determine if a CHW intervention would result in significant reductions in Hemoglobin A1c and rates of uncontrolled blood pressure. 144 Mexican-Americans with diabetes were randomized. The intervention consisted of self-management training delivered by CHWs over a 24-month period; the comparison population received identical information via bilingual newsletter. Blinded research assistants completed assessments at baseline, 12 months, and 24 months post-randomization. RESULTS: The MATCH cohort was characterized by low acculturation and socioeconomic status. Study participants had low rates of medication adherence and glucose monitoring. 70% had poor glycemic control with A1c levels over 7.0, and 57.3% had blood pressures worse than ADA target levels (<130/80). CONCLUSIONS: MATCH preserved community sensitivity and methodologic rigor. The study's attention to intervention fidelity, behavioral attention control, blinded outcomes assessment, and strategies to enhance participant retention can be replicated by researchers testing culturally-tailored CHW interventions.

Recruitment of Mexican American adults for an intensive diabetes intervention trial.

OBJECTIVE: Effective behavioral diabetes interventions for Mexican Americans are needed. Our study focused on efforts to recruit Mexican American adults for a trial testing a diabetes community health worker (CHW) self-management intervention. DESIGN: Behavioral randomized controlled trial, community-based participatory research approach. SETTING: Chicago. PARTICIPANTS: Mexican American adults with type 2 diabetes. OUTCOME MEASURES: Screening and randomization. METHODS: Initial eligibility criteria included Mexican heritage, treatment with oral diabetes medication, residence in designated zip codes, planned residence in the area for two years, and enrollment in a specific insurance plan. RESULTS: Recruitment through the insurer resulted in only one randomized participant. Eligibility criteria were relaxed and subsequent efforts included bilingual advertisements, presentations at churches and community events, postings in clinics, partnerships with community providers, and CHW outreach. Zip codes were expanded multiple times and insurance criteria removed. CHW outreach resulted in 53% of randomized participants. CONCLUSIONS: Despite strong ties with the target community, culturally appropriate recruitment strategies involving community representation, and a large pool of potential participants, significant challenges were encountered in recruitment for this diabetes intervention trial. Researchers identified three key barriers to participation: study intensity and duration, lack of financial incentives, and challenges in establishing trust. For future research to be successful, investigators need to recognize these barriers, offer adequate incentives to compensate for intervention intensity, and establish strong trust through community partnerships and the incorporation of community members in the recruitment process.

Pushing the envelope for cultural appropriateness: does evidence support cultural tailoring in type 2 diabetes interventions for Mexican American adults?

PURPOSE: This study explores the potential utility of a culturally tailored diabetes management intervention approach by testing associations between acculturation and diabetes-related beliefs among Mexican-American adults with type 2 diabetes. METHODS: Data from 288 Mexican-American adults with type 2 diabetes were obtained via a bilingual, telephone-administered survey. Participants were drawn from a stratified, random sample designed to obtain maximum variability in acculturation. The survey assessed diabetes-related beliefs, intervention preferences, and the following three acculturation constructs from the Hazuda acculturation and assimilation scales: Spanish use, value for preserving Mexican culture, and interaction with Mexican Americans. RESULTS: Only one outcome-preference for a program for Mexican Americans-was associated with all three acculturation variables. Spanish use was positively associated with belief in susto as a cause of diabetes, preference for expert-driven health guidance, and involvement of others in taking care of diabetes. Value for preserving Mexican culture was related to a more holistic view of health, as evidenced by an increased likelihood of consulting a curandero, use of prayer, and interest in a diabetes program with religious content. Value for cultural preservation was also related to higher suspicion of free diabetes programs. Interaction with Mexican Americans was associated with a belief that insulin causes blindness. CONCLUSION: Findings from this study suggest distinct relationships between acculturation constructs and diabetes-related beliefs and preferences, thus arguing against the use of a single acculturation construct to determine diabetes intervention design. Cultural tailoring may enhance the cultural appropriateness and ultimate effectiveness of diabetes interventions for Mexican American adults.

Interdisciplinary management of chronic disease in primary practice.

Primary care physicians are often challenged by the complex needs of patients with chronic disease. Unfortunately, many solo and small group practices lack the interdisciplinary resources essential to chronic disease management. To address this, clinicians and researchers at Rush University Medical Center, Chicago, developed the "Virtual Integrated Practice," a process that creates virtual patient care teams. Preliminary results in four practice sites using it have shown increased referrals to dietitians and improved nutritional compliance but less extensive involvement of social workers and pharmacy team members.

Virtual integrated practice: integrating teams and technology to manage chronic disease in primary care.

The use of teams in health care has generally relied on the notion that teams must physically meet and function in person in the same location, on a regular, scheduled basis, in order to maximize the value of the interdisciplinary process. This article examines the concept of creating a different kind of team in primary care, out-patient settings--one which relies upon communications technology to link together clinicians from different locations to coordinate and manage the care of patients, particularly those with chronic disease. This approach--referred to as Virtual Integrated Practice--is designed to overcome the barriers of traditional in-person teams by creating a "virtual team" with the potential to function more efficiently, productively, and satisfactorily for clinicians and patients alike.