Belinda W. Nelson

Age-Specific Factors Influencing Asthma Management by Older Adults

Although many asthma patients experience their first attack after age 40, the experiences and concerns of older adults with asthma remain largely unknown. We conducted six focus groups, each consisting of participants over the age of 65 with a physician diagnosis of asthma. Semistructured questions regarding asthma education, symptoms, and management were used. A total of 46 adults participated in the six focus groups. The mean age of the participants was 72.6 years, and 43.5% were African American. The majority of participants had coexisting cardiac disease or hypertension. Major age-specific domains identified in all focus groups were atypical asthma symptoms, inability to distinguish asthma from other medical conditions, use of complementary and alternative therapies, desire for independence in asthma management, and a lack of participation in asthma education. Participants acknowledged that they did not commonly address these issues with their physicians or with family members. Optimal care will require physicians and researchers to explicitly address these issues unique to the geriatric asthmatic population.

Consideration of Shared Decision Making in Nursing: A Review of Clinicians' Perceptions and Interventions

As the number of individuals with chronic illness increases so has the need for strategies to enable nurses to engage them effectively in daily management of their conditions. Shared decision making between patients and nurses is one approach frequently discussed in the literature. This paper reviews recent studies of shared decision making and the meaning of findings for the nurse-patient relationship. Patients likely to prefer to engage in shared decision making are younger and have higher levels of education. However, there is a lack of evidence for the effect of shared decision making on patient outcomes. Further, studies are needed to examine shared decision making when the patient is a child. Nurses are professionally suited to engage their patients fully in treatment plans. More evidence for how shared decision making affects outcomes and how nurses can successfully achieve such engagement is needed.

Study protocol for Women of Color and Asthma Control: a randomized controlled trial of an asthma-management intervention for African American women.

BackgroundAmong adults in the United States, asthma prevalence is disproportionately high among African American women; this group also experiences the highest levels of asthma-linked mortality and asthma-related health care utilization. Factors linked to biological sex (e.g., hormonal fluctuations), gender roles (e.g., exposure to certain triggers) and race (e.g., inadequate access to care) all contribute to the excess asthma burden in this group, and also shape the context within which African American women manage their condition. No prior interventions for improving asthma self-management have specifically targeted this vulnerable group of asthma patients. The current study aims to evaluate the efficacy of a culturally- and gender-relevant asthma-management intervention among African American women.Methods/DesignA randomized controlled trial will be used to compare a five-session asthma-management intervention with usual care. This intervention is delivered over the telephone by a trained health educator. Intervention content is informed by the principles of self-regulation for disease management, and all program activities and materials are designed to be responsive to the specific needs of African American women. We will recruit 420 female participants who self-identify as African American, and who have seen a clinician for persistent asthma in the last year. Half of these will receive the intervention. The primary outcomes, upon which the target sample size is based, are number of asthma-related emergency department visits and overnight hospitalizations in the last 12 months. We will also assess the effect of the intervention on asthma symptoms and asthma-related quality of life. Data will be collected via telephone survey and medical record review at baseline, and 12 and 24 months from baseline.DiscussionWe seek to decrease asthma-related health care utilization and improve asthma-related quality of life in African American women with asthma, by offering them a culturally- and gender-relevant program to enhance asthma management. The results of this study will provide important information about the feasibility and value of this program in helping to address persistent racial and gender disparities in asthma outcomes.Trial RegistrationClinicalTrials.gov: NCT01117805

Reducing Disparities in Diabetes: The Alliance Model for Health Care Improvements

Individuals in specific racial and ethnic groups experience the greatest prevalence and widest disparity in outcome for both type 1 and type 2 diabetes.1 The negative long-term consequences of the disease for these individuals are also higher and can be severe, including amputation, kidney disease, cardiovascular disease, and blindness.2 Better access to and higher quality of health care leads to improved diabetes control and fewer negative outcomes for people at risk of and diagnosed with the condition, especially, in low-income communities.2,3 Particular systems problems associated with poor results for those with diabetes include failure to adequately identify high-risk people, failure to follow recommended clinical treatment guidelines, lack of adequate provider education, inadequacy of patient self-management education, and minimal coordination of care.4 Each of these has been linked to inadequate information systems, insurance and payment options, deployment of clinical personnel, and application of evidence-based strategies for change and similar other deficiencies.5 It is widely agreed that to achieve sustainable change that reduces disparities, new and improved health care policies and systems are needed.6 Achieving such change within and across health care facilities and communities requires participation by key stakeholders in the problem.7 This view posits that solutions are complex (including adaptation of evidence-based strategies to new locales) and require engagement of diverse perspectives (including those of the people who experience the day-to-day burden of the health problem). Recent evidence has shown that collaborative community-wide approaches to enhancing health care delivery can generate far-reaching policy and system changes and improvements in health status.8 To support evidence-based means to reduce inequity in health status, the Alliance to Reduce Disparities in Diabetes was launched by the Merck Company Foundation in 2009. The foundation is providing up to

Young, African American adults with asthma: what matters to them?

2 million over 5 years (2009–2013) to …

Self-management of multiple chronic conditions among African American women with asthma: a qualitative study.

BACKGROUND Asthma is a common chronic condition that shows significant health disparities among minority populations. Little research has focused on the management needs and preferences of young African American adults with asthma, a population undergoing dramatic life changes as they transition from adolescence to adulthood. OBJECTIVE To understand the experiences and perspectives of young African American adults managing their asthma. METHODS Focus groups were conducted with African American adults (n = 34) 18 to 30 years old with a physician diagnosis of asthma. Focus group sessions were audiotaped, transcribed verbatim, and coded using constant comparative analysis. RESULTS Six major domains were identified and some of the salient themes included changes in asthma management needs with the onset of adulthood, career limitations owing to asthma, childcare interference with asthma regimen adherence, and difficulties with medication cost owing to lapses in insurance coverage. Participants also reported feeling discouraged when interacting with physicians as it related to their asthma care; yet ageism and racism were not perceived. Despite poor medication regimen compliance, participants were overwhelmingly interested in participating in asthma self-management programs and had strong preferences that such programs be tailored specifically to young adults with special consideration of the cultural experience of young African Americans with asthma. CONCLUSION Young African American adults have specific barriers to optimal asthma care and distinctive ideas for self-management programs. It is important for the asthma care provider to identify and address these population- and age-specific barriers to improve asthma outcomes and decrease health care disparities.

Alliance System and Policy Change: Necessary Ingredients for Improvement in Diabetes Care and Reduction of Disparities

Abstract Objective: African American women are disproportionately burdened by asthma morbidity and mortality and may be more likely than asthma patients in general to have comorbid health conditions. This study sought to identify the self-management challenges faced by African American women with asthma and comorbidities, how they prioritize their conditions and behaviors perceived as beneficial across conditions. Methods: In-depth interviews were conducted with 25 African-American women (mean age 52 years) with persistent asthma and at least one of the following: diabetes, heart disease or arthritis. Information was elicited on women’s experiences managing asthma and concurrent health conditions. The constant-comparison analytic method was used to develop and apply a coding scheme to interview transcripts. Key themes and subthemes were identified. Results: Participants reported an average of 5.7 comorbidities. Fewer than half of the sample considered asthma their main health problem; these perceptions were influenced by beliefs about the relative controllability, predictability and severity of their health conditions. Participants reported ways in which comorbidities affected asthma management, including that asthma sometimes took a “backseat” to conditions considered more troublesome or worrisome. Mood problems, sometimes attributed to pain or functional limitations resulting from comorbidities, reduced motivation for self-management. Women described how asthma affected comorbidity management; e.g. by impeding recommended exercise. Some self-management recommendations, such as physical activity and weight control, were seen as beneficial across conditions. Conclusions: Multiple chronic conditions that include asthma may interact to complicate self-management of each condition. Additional clinical attention and self-management support may help to reduce multimorbidity-related challenges.

Engaging Faith-Based Resources to Initiate and Support Diabetes Self-Management Among African Americans A Collaboration of Informal and Formal Systems of Care

Reducing diabetes inequities requires system and policy changes based on real-life experiences of vulnerable individuals living with the condition. While introducing innovative interventions for African American, Native American, and Latino low-income people, the five community-based sites of the Alliance to Reduce Disparities in Diabetes recognized that policy changes were essential to sustain their efforts. Data regarding change efforts were collected from site leaders and examined against documents provided routinely to the National Program Office at the University of Michigan. A policy expert refined the original lists to include only confirmed policy changes, scope of change (organizational to national), and stage of accomplishment (1, beginning; 2, adoption; 3, implementation; and 4, full maintenance). Changes were again verified through site visits and telephone interviews. In 3 years, Alliance teams achieved 53 system and policy change accomplishments. Efforts were implemented at the organizational (33), citywide (13), state (5), and national (2) levels, and forces helping and hindering success were identified. Three types of changes were deemed especially significant for diabetes control: data sharing across care-providing organizations, embedding community health workers into the clinical care team, and linking clinic services with community assets and resources in support of self-management.

Food & Community: the cross-site evaluation of the W.K. Kellogg Food & Fitness community partnerships

Diabetes for Life (DFL), a project of Memphis Healthy Churches (MHC) and Common Table Health Alliance (CTHA; formerly Healthy Memphis Common Table [HMCT]), is a self-management program aimed at reducing health disparities among African Americans with type 2 Diabetes Mellitus in Memphis and Shelby County, Tennessee. This program is one of five national projects that constitute The Alliance to Reduce Disparities in Diabetes, a 5-year grant-funded initiative of The Merck Foundation. Our purpose is to describe the faith-based strategies supporting DFL made possible by linking with an established informal health system, MHC, created by Baptist Memorial Health Care. The MHC network engaged volunteer Church Health Representatives as educators and recruiters for DFL. The components of the DFL project and the effect on chronic disease management for the participants will be described. The stages of DFL recruitment and implementation from an open-access to a closed model involving six primary care practices created a formal health system. The involvement of CTHA, a regional health collaborative, created the opportunity for DFL to expand the pool of health care providers and then recognize the core of providers most engaged with DFL patients. This collaboration between MHC and HMCT led to the organization of the formal health network.

The Continuing Problem of Asthma in Very Young Children: A Community-Based Participatory Research Project

This article describes the collaborative development of the cross-site evaluation of the Food & Fitness initiative. Evaluators and community partners together created a multi-site evaluation to document similarities and unique aspects across the work in the nine participating communities. The evaluation includes measures of partner engagement, resources, processes, and outcomes of achieving systems and policy change, and impact of the work in vulnerable communities. Inherent in and critical to the evaluation is a process for providing feedback to communities and stakeholders. Pioneering ways to assess the process of achieving systems and policy change and the impact of this work on children and families, the Food & Fitness cross-site evaluation is creating a picture of the collective accomplishments of these community partnerships, which are doing innovative work related to equity around food access and the built environment.