Laurene Tumiel-Berhalter

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.

Implementation of an asthma intervention in the inner city

BACKGROUND Despite availability of asthma self-management interventions for children, few have been implemented in community-based settings. OBJECTIVE To describe implementation of the Inner-City Asthma Intervention and factors associated with higher rates of program completion by enrollees. METHODS Descriptive analyses of data from multiple data sources. Two-tailed Pearson correlation coefficients and analyses of variance were used to calculate associations of descriptive variables with the retention rate (percentage of enrolled children who completed the core intervention and had more than 1 follow-up visit) and with the percentage who had allergy testing done. RESULTS A total of 4,174 children were enrolled at 22 sites; 2,153 (52%) completed the core intervention and had more than 1 follow-up visit. A total of 2,014 enrolled children (48%) were tested for allergies. Retention was related to type and location of site, ease of obtaining written plans, language and ethnicity of asthma counselor, and on-site allergy testing. Higher rates of allergy testing were associated with the same factors, as well as flexibility in scheduling and selective enrollment of participants. CONCLUSIONS Inner-city children with asthma can be enrolled in the Inner-City Asthma Intervention outside a controlled research setting. However, completion of all intervention components is difficult to achieve. We identify having an asthma counselor who is representative of the community, access to asthma action plans, and on-site allergy testing as factors that facilitate the implementation of this intervention in community-based settings.

Building Community Research Capacity: Process Evaluation of Community Training and Education in a Community-Based Participatory Research Program Serving a Predominately Puerto Rican Community

Background: Education and training build community research capacity and have impact on improvements of health outcomes. Objectives: This manuscript describes the training and educational approaches to building research capacity that were utilized in a community-based participatory research program serving a Puerto Rican population and identifies barriers and strategies for overcoming them. Methods: A process evaluation identified a multitiered approach to training and education that was critical to reaching the broad community. Results: This approach included four major categories providing a continuum of education and training opportunities: networking, methods training, on-the-job experience, and community education. Participation in these opportunities supported the development of a registry, the implementation of a survey, and two published manuscripts. Barriers included the lack of a formal evaluation of the education and training components, language challenges that limited involvement of ethnic groups other than Puerto Ricans, and potential biases associated with the familiarity of the data collector and the participant. The CBPR process facilitated relationship development between the university and the community and incorporated the richness of the community experience into research design. Strategies for improvement include incorporating evaluation into every training and educational opportunity and developing measures to quantify research capacity at the individual and community levels. Conclusions: Evaluating training and education in the community allows researchers to quantify the impact of CBPR on building community research capacity.

The Impact of Provider Knowledge and Attitudes Toward National Asthma Guidelines on Self-Reported Implementation of Guidelines

This study determines the impact of provider knowledge and attitude on implementation of guidelines: spirometry, peak flows, patient assessments, action plans, severity assessment, and anti-inflammatories. A self-administered survey conducted in academic family practice sites in Buffalo, NY assessed knowledge, self-reported use, and perceived usefulness. Knowledge was associated with regular use of peak flows (p = 0.048) and anti-inflammatories (p = 0.01). Positive attitude was associated with regular use of spirometry (p = 0.03), peak flows (p ≤ 0.001), patient assessments (p = 0.02), action plans (p = 0.046), anti-inflammatories (p ≤ 0.001), and severity assessment (p ≤ 0.001). Perceived usefulness is critical to implementing asthma guidelines. Interventions to improve provider adherence must address attitude.

The Impacts of “Growing Our Own” A Pilot Project to Address Health Disparities by Training Health Professionals to Become Certified Diabetes Educators in Safety Net Practices

Purpose The purpose of the study was to examine the impact of incorporating certified diabetes educator trainees into medical practices on patient diabetes outcomes. Methods This was a mixed methods practice-based evaluation study undertaken in 2 primary care practices in high-poverty neighborhoods in Buffalo, New York. The evaluation entailed a physician-referred patient cohort with pre- and postanalysis of chart review data corresponding to the American Diabetes Association’s diabetes indicators. Patient charts were reviewed at baseline and 12 months. A brief survey was administered to the providers and staff to ascertain the extent to which the certified diabetes educator trainees were perceived as useful as part of the medical practice team. Results Among 74 patients enrolled in diabetes classes, A1C levels decreased from a mean of 8.8% to 8.3%. Among a subset of patients (35%) with poorly controlled diabetes at baseline (A1C ≥ 9), there was a 15% decrease in A1C levels. Overall improvement in A1C was observed among 219 patients seen by a diabetes educator, in either a diabetes education class or a one-on-one visit. Conclusions Results suggest that having a certified diabetes educator trainee as part of the primary care practice team may advance diabetes care, as evidenced by improvements in glucose control. Responses from providers and staff suggest that the certified diabetes educator trainees were well integrated into the practices and were perceived as instrumental in educating patients to better manage their diabetes.

Knowledge and Use of Ethnomedical Treatments for Asthma Among Puerto Ricans in an Urban Community

PURPOSE Puerto Ricans have higher lifetime and current asthma prevalence than other racial and ethnic groups in the United States. A great many Hispanics use ethnomedical therapies for asthma. This study elicited participant knowledge of ethnomedical therapies, developed a typology of the therapies, and considered whether some types are used or deemed efficacious based, in part, on information source. METHODS Eligible participants were randomly selected from the medical records of an inner-city primary care clinic serving a predominantly Hispanic community in Buffalo, New York. Thirty adult Puerto Ricans who had asthma or were care-givers of children with asthma were interviewed in person using a semistructured instrument. Qualitative data analysis followed a content-driven immersion-crystallization approach. Outcome measures were ethnomedical treatments for asthma known to participants, whether these treatments were used or perceived effective, and the participant’s information source about the treatment. RESULTS Participants identified 75 ethnomedical treatments for asthma. Behavioral strategies were significantly more likely to be used or perceived effective compared with ingested and topical remedies (P <.001). Among information sources for ingested and topical remedies, those recommended by community members were significantly less likely to be used or perceived effective (P <.001) compared with other sources. CONCLUSIONS This sample of Puerto Ricans with a regular source of medical care was significantly more likely to use or perceive as effective behavioral strategies compared with ingested and topical remedies. Allopathic clinicians should ask Puerto Rican patients about their use of ethnomedical therapies for asthma to better understand their health beliefs and to integrate ethnomedical therapies with allopathic medicine.

Differences between adolescents who complete and fail to complete residential substance abuse treatment

ABSTRACT This study examined the admission characteristics associated with failure to complete residential substance abuse treatment among male adolescents. Of 160 admissions, 48 (30%) completed treatment. Having commercial health insurance (P= .005), having a family history of a substance use disorder (P= .05), and living with only one biological parent (P= .015) were admission characteristics associated with non-completion. Those reporting a history of physical or sexual abuse also appeared to be at risk for non-completion (P= .014); none of these participants completed the treatment. Interventions that improve residential substance abuse treatment retention for adolescents are needed.

Encouraging a Systems Approach for Adherence to National Asthma Guidelines

Purpose. There is a lack of information in the literature reflecting systems effects on adherence to national asthma guidelines. The purpose of this pilot study is to provide a descriptive account of the preparedness of academic primary care sites to follow national asthma guidelines related to spirometry, peak flow meters, standard history forms, severity assessment, follow-up assessment sheets, patient self-assessment sheets, and asthma action plan templates. Methods. This was a cross-sectional descriptive study. A short survey was mailed to medical directors on behalf of primary care academic clinical sites to assess the availability of guideline tools in their practices. Medical directors were also asked to rate their perception of how essential the guidelines were in the management of asthma. Results. Medical directors agreed that the guideline tools were essential in managing asthma. However, with the exceptions of peak flow meters and standard history forms, most sites were not equipped with these tools for providers to use. Conclusions. The findings highlight the importance of the practice environment on the implementation of national asthma guidelines and encourage larger studies to include an assessment of the systems in place to enable guideline adherence. By taking systems into account, interventions may be potentially much more effective in improving the quality of 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.

The Impacts of Subsidized Health Insurance on Employees’ Use of Preventive Health Services

This study presents an uncontrolled preliminary evaluation of a pilot health insurance subsidy program and addresses whether provision of subsidized insurance that required employee contribution had an impact upon preventive health utilization among small businesses and their employees. Self-report questionnaires were mailed to the employees; these included questions on use of preventive health services before and after enrollment in the subsidy program. The analysis was stratified by self-reported prior enrollment in an insurance program to compare employees with and without prior health insurance. The findings suggest significant increases in health service utilization among the previously uninsured. Regular checkups more than doubled (p < .0001), as did the number of individuals receiving regular blood work (p < .0001). Nearly twice the number of individuals filled regular prescriptions after enrollment in the subsidy program as compared with before (p < .0001). This study suggests that employees of small businesses are willing to contribute to the cost of a health insurance premium, and once insured are more likely to use preventive services. A model of shared cost responsibility is an effective way to provide affordable insurance to small-business employees, thus increasing preventive services in these populations.