Bonnie M. Vest

Diabetes self-management in a low-income population: impacts of social support and relationships with the health care system

Objectives: This article reports on results of a qualitative study of social supports and institutional resources utilized by individuals living with diabetes in a high-poverty urban setting. The goal was to examine how access to social capital among low-income populations facilitates and impedes their self-efficacy in diabetes self-management. Methods: Semi-structured interviews were conducted with 34 patients with diabetes from a safety net primary care practice in Buffalo, New York. Results: Facilitators and barriers to successful self-management were identified in three broad areas: (1) the influence of social support networks; (2) the nature of the doctor–patient relationship; and (3) the nature of patient–health care system relationship. Patients’ unmet needs were also highlighted across these three areas. Discussion: Participants identified barriers to effective diabetes self-management directly related to their low-income status, such as inadequate insurance, and mistrust of the medical system. It may be necessary for patients to activate social capital from multiple social spheres to achieve the most effective diabetes management.

Improving evidence-based primary care for chronic kidney disease: study protocol for a cluster randomized control trial for translating evidence into practice (TRANSLATE CKD)

BackgroundChronic kidney disease (CKD) and end stage renal disease (ESRD) are steadily increasing in prevalence in the United States. While there is reasonable evidence that specific activities can be implemented by primary care physicians (PCPs) to delay CKD progression and reduce mortality, CKD is under-recognized and undertreated in primary care offices, and PCPs are generally not familiar with treatment guidelines. The current study addresses the question of whether the facilitated TRANSLATE model compared to computer decision support (CDS) alone will lead to improved evidence-based care for CKD in primary care offices.Methods/DesignThis protocol consists of a cluster randomized controlled trial (CRCT) followed by a process and cost analysis. Only practices providing ambulatory primary care as their principal function, located in non-hospital settings, employing at least one primary care physician, with a minimum of 2,000 patients seen in the prior year, are eligible. The intervention will occur at the cluster level and consists of providing CKD-specific CDS versus CKD-specific CDS plus practice facilitation for all elements of the TRANSLATE model. Patient-level data will be collected from each participating practice to examine adherence to guideline-concordant care, progression of CKD and all-cause mortality. Patients are considered to meet stage three CKD criteria if at least two consecutive estimated glomerular filtration rate (eGFR) measurements at least three months apart fall below 60 ml/min. The process evaluation (cluster level) will determine through qualitative methods the fidelity of the facilitated TRANSLATE program and find the challenges and enablers of the implementation process. The cost-effectiveness analysis will compare the benefit of the intervention of CDS alone against the intervention of CDS plus TRANSLATE (practice facilitation) in relationship to overall cost per quality adjusted years of life.DiscussionThis study has three major innovations. First, this study adapts the TRANSLATE method, proven effective in diabetes care, to CKD. Second, we are creating a generalizable CDS specific to the Kidney Disease Outcome Quality Initiative (KDOQI) guidelines for CKD. Additionally, this study will evaluate the effects of CDS versus CDS with facilitation and answer key questions regarding the cost-effectiveness of a facilitated model for improving CKD outcomes. The study is testing virtual facilitation and Academic detailing making the findings generalizable to any area of the country.Trial registrationRegistered as NCT01767883 on clinicaltrials.gov NCT01767883

Citizen, Soldier, or Citizen-Soldier? Negotiating Identity in the US National Guard

This study examines the construction of US Army National Guard members’ dual identities as soldiers and civilians and posits processes, including behavioral practice, spatial displacement, and narrativity, which soldiers use to reconcile these potentially contradictory identities to develop an understanding of themselves as “citizen-soldiers.” Ethnographic evidence gathered from in-depth interviews suggests that for National Guard members who have never experienced deployment, the two identities of civilian and soldier are mostly separated. However, after experiencing deployment and reintegration, soldier and civilian identities become more intertwined and individuals must reorganize their identity according to different conceptions; integrating on a more permanent basis two different cultural modes of being. In light of the National Guard’s increased participation in deployments post-9/11, this reorganization of identity is contributing to a shift in the meaning of “citizen-soldiery” in the current US context.

Chronic Kidney Disease Guideline Implementation in Primary Care: A Qualitative Report from the TRANSLATE CKD Study

Background: Primary care physicians (PCPs) are optimally situated to identify and manage early stage chronic kidney disease (CKD). Nonetheless, studies have documented suboptimal PCP understanding, awareness, and management of early CKD. The TRANSLATE CKD study is an ongoing national, mixed-methods, cluster randomized control trial that examines the implementation of evidence-based guidelines for CKD into primary care practice. Methods: As part of the mixed-methods process evaluation, semistructured interviews were conducted by phone with 27 providers participating in the study. Interviews were audio-taped and transcribed. Thematic content analysis was used to identify themes. Themes were categorized according to the 4 domains of Normalization Process Theory (NPT). Results: Identified themes illuminated the complex work undertaken to manage CKD in primary care practices. Barriers to guideline implementation were identified in each of the 4 NPT domains, including (1) lack of knowledge and understanding around CKD (coherence), (2) difficulties engaging providers and patients in CKD management (cognitive participation), (3) limited time and competing demands (collective action), and (4) challenges obtaining and using data to monitor progress (reflexive monitoring). Conclusions: Addressing the barriers to implementation with concrete interventions at the levels at which they occur, informed by NPT, will ultimately improve the quality of CKD patient care.

Living with diabetes on Buffalo, New York’s culturally diverse West Side

Objectives: This study explores the perceptions, attitudes, and beliefs that inform how people live with diabetes in a high poverty, ethnically diverse neighborhood with a growing population of refugees. The specific research objective was to examine participants’ explanations of how their diabetes began, understandings about the illness, description of symptoms, as well as physical and emotional reactions to the diagnosis. Methods: Qualitative design using semi-structured interviews. The transcripts were analyzed using an immersion–crystallization approach. Results: Thirty four individuals diagnosed with diabetes for at least 1 year participated. The sample included 14 refugees (from Somalia, Sudan, Burma, or Cuba), eight Puerto Ricans, six non-Hispanic Caucasians, six African-Americans, and two Native Americans. Three broad themes were identified across ethnic groups: (a) the diagnosis of diabetes was unexpected; (b) emotional responses to diabetes were similar to Kubler-Ross’s stages of grief; (c) patients’ understanding of diabetes focused on symptoms and diet. Conclusions: Patients were frequently stunned by the diagnosis of diabetes, and expressed emotions associated with the stages of grief including denial, anger, bargaining, depression, and acceptance. Our findings suggest that clinicians might consider addressing the patients’ emotions or grief reaction as an early priority to promote acceptance as a first step to self-management.

Marital Satisfaction, Family Support, and Pre-Deployment Resiliency Factors Related to Mental Health Outcomes for Reserve and National Guard Soldiers

ABSTRACT The purpose of this study is to examine the relationship between resiliency factors and mental health outcomes among U.S. Army Reserve and National Guard soldiers. Our results demonstrate that higher marital satisfaction is significantly associated with lower anger, depression, anxiety, and PTSD. Importantly, our results provide evidence that among the assessed resiliency factors (predeployment preparation, unit social support, marital satisfaction, and family support), marital satisfaction has the strongest evidence for promoting resiliency. Future research should develop interventions that can be provided jointly to the soldier and his partner to facilitate stronger relationships and promote improved mental health and reintegration postdeployment.

The impact of military service and traumatic brain injury on the substance use norms of Army Reserve and National Guard Soldiers and their spouses

INTRODUCTION Traumatic brain injury (TBI) and substance use are highly prevalent conditions among military populations. There is a significant body of evidence that suggests greater approval of substance use (i.e., norms) is related to increased substance use. The objective of this work is to understand the impact of TBI and military service on substance use norms of soldiers and their partners. Data are from the baseline assessment of Operation: SAFETY, an ongoing, longitudinal study of US Army Reserve/National Guard (USAR/NG) soldiers and their partners. METHODS Multiple regression models examined associations between alcohol, tobacco, illicit drug use, and non-medical use of prescription drug (NMUPD) norms within and across partners based on current military status (CMS) and TBI. RESULTS Male USAR/NG soldiers disapproved of NMUPD, illicit drug use and tobacco use. There was no relation between military status and alcohol use. Among females, there was no relation between CMS and norms. The NMUPD norms of wives were more likely to be approving if their husbands reported TBI symptoms and had separated from the military. Husbands of soldiers who separated from the military with TBI had greater approval of the use of tobacco, NMUPD, and illicit drugs. CONCLUSION Overall, there is evidence to suggest that, while generally disapproving of substance use, soldiers and partners become more accepting of use if they also experience TBI and separate from the military. Future research should examine the longitudinal influence of TBI on substance use norms and subsequent changes in substance use over time.

“Living Well with Diabetes”: Evaluation of a Pilot Program to Promote Diabetes Prevention and Self-Management in a Medically Underserved Community

A substantial disparity exists in the prevalence and effective self-management of diabetes among African Americans in the United States. Community-level programs have the potential to affect self-efficacy and may be helpful in overcoming common barriers to self-management. The Neighborhood Health Talker Program used community members trained as cultural health brokers to engage their communities in conversations about “living diabetes well.” Program evaluators used mixed methods to analyze post-conversation surveys and Health Talker field notes. These indicated an increase in diabetes-related knowledge and increased confidence among conversation participants. Conversations included discussion of barriers and facilitators to lifestyle changes and effective self-management that are frequently overlooked in a clinical setting.

Substance use and dependence among current reserve and former military members: Cross-sectional findings from the National Survey on Drug Use and Health, 2010–2014

ABSTRACT Maladjustment after leaving the military may contribute to poor health outcomes, including increased risk for substance use and dependence. The authors examined differences in substance use and dependence on the basis of military involvement in a large nationally representative sample. Data are from a subset of the 2010–2014 waves of the National Survey on Drug Use and Health (n = 5,608). The sample included men (81.9%) and women (18.1%) aged 20–49 years who had either separated/retired from the military (n = 4,862) or were a current reserve service member (n = 746). The sample was 70.8% Non-Hispanic White with a median family income between

Developing a Smoking Cessation Intervention for Low Income and Minority Women

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