Mark L. Wieland

Current Concepts in the Management of Tuberculosis

Tuberculosis (TB) poses a serious threat to public health throughout the world but disproportionately afflicts low-income nations. Persons in close contact with a patient with active pulmonary TB and those from endemic regions of the world are at highest risk of primary infection, whereas patients with compromised immune systems are at highest risk of reactivation of latent TB infection (LTBI). Tuberculosis can affect any organ system. Clinical manifestations vary accordingly but often include fever, night sweats, and weight loss. Positive results on either a tuberculin skin test or an interferon-γ release assay in the absence of active TB establish a diagnosis of LTBI. A combination of epidemiological, clinical, radiographic, microbiological, and histopathologic features is used to establish the diagnosis of active TB. Patients with suspected active pulmonary TB should submit 3 sputum specimens for acid-fast bacilli smears and culture, with nucleic acid amplification testing performed on at least 1 specimen. For patients with LTBI, treatment with isoniazid for 9 months is preferred. Patients with active TB should be treated with multiple agents to achieve bacterial clearance, to reduce the risk of transmission, and to prevent the emergence of drug resistance. Directly observed therapy is recommended for the treatment of active TB. Health care professionals should collaborate, when possible, with local and state public health departments to care for patients with TB. Patients with drug-resistant TB or coinfection with human immunodeficiency virus should be treated in collaboration with TB specialists. Public health measures to prevent the spread of TB include appropriate respiratory isolation of patients with active pulmonary TB, contact investigation, and reduction of the LTBI burden.

Disparities in Preventive Health Services Among Somali Immigrants and Refugees

African immigrants and refugees—almost half of them from Somalia—account for one of the fastest-growing groups in the United States. There is reason to suspect that Somali-Americans may be at risk for low completion of recommended preventive health services. This study’s aim was to quantify disparities in preventive health services among Somali patients compared with non-Somali patients in an academic primary care practice in Rochester, Minn. It also examined the effect of medical interpreters, emergency department visits, and primary care visits on the completion of preventive services. Rates of pap smears, vaccinations (influenza, pneumococcus, and tetanus), lipid screening, colorectal cancer screening, and mammography were assessed in Somali and non-Somali patients during the second quarter of 2008. Data were collected regarding the utilization of medical interpreters, emergency services, and primary care services among Somali patients. Results were reported using standard descriptive statistics. Of the 91,557 patients identified in the database, 810 were Somali. Somali patients had significantly lower completion rates of colorectal cancer screening, mammography, pap smears, and influenza vaccination than non-Somali patients. Use of medical interpreters and primary care services were generally associated with higher completion rates of preventive services. There are significant discrepancies in the provision of preventive health services to Somali patients compared with that of non-Somali patients. These findings suggest the need to identify the root causes of these discrepancies so that interventions may be crafted to close the gap.

Perspectives on Physical Activity Among Immigrants and Refugees to a Small Urban Community in Minnesota

Immigrants and refugees to the United States exhibit relatively low levels of physical activity, but reasons for this disparity are poorly understood. 16 gender and age-stratified focus groups were conducted among 127 participants from heterogenous immigrant and refugee groups (Cambodian, Mexican, Somali, Sudanese) in a small Minnesota urban community. We found many similarities in perceived barriers and facilitators to physical activity between heterogeneous immigrant and refugee groups. While the benefits of physical activity were widely acknowledged, lack of familiarity and comfort with taking the first steps towards being physically active were the most significant barriers to physical activity. Participants described being motivated by social support from family, friends, and communities to be physically active. Our findings suggest that shared experiences of immigration and associated social, economic, and linguistic factors influence how physical activity is understood, conceptualized and practiced.

Perceptions of tuberculosis among immigrants and refugees at an adult education center: A community-based participatory research approach

English as a Second Language programs serve large foreign-born populations in the US with elevated risks of tuberculosis (TB), yet little is known about TB perceptions in these settings. Using a community-based participatory research approach, we elicited perceptions about TB among immigrant and refugee learners and staff at a diverse adult education center. Community partners were trained in focus groups moderation. Ten focus groups were conducted with 83 learners and staff. Multi-level, team-based qualitative analysis was conducted to develop themes that informed a model of TB perceptions among participants. Multiple challenges with TB control and prevention were identified. There were a variety of misperceptions about transmission of TB, and a lack of knowledge about latent TB. Feelings and perceptions related to TB included secrecy, shame, fear, and isolation. Barriers to TB testing include low awareness, lack of knowledge about latent TB, and the practical considerations of transportation, cost, and work schedule conflicts. Barriers to medication use include suspicion of generic medications and perceived side effects. We posit adult education centers with large immigrant and refugee populations as excellent venues for TB prevention, and propose several recommendations for conducting these programs. Content should dispel the most compelling misperceptions about TB transmission while clarifying the difference between active and latent disease. Learners should be educated about TB in the US and that it is curable. Finally, TB programs that include learners and staff in their design and implementation provide greater opportunity for overcoming previously unrecognized barriers.

Missed appointments in resident continuity clinic: patient characteristics and health care outcomes.

BACKGROUND Frequent missed patient appointments in resident continuity clinic is a well-documented problem, but whether rates of missed appointments are disproportionate to standard academic practice, what patient factors contribute to these differences, and health care outcomes of patients who frequently miss appointments are unclear. METHODS The overall population for the study was composed of patients in an academic internal medicine continuity clinic with 5 or more office visits between January 2006 and December 2008. We randomly selected 325 patients seen by resident physicians and 325 patients cared for by faculty. Multivariate linear regression was used to examine the relationship between patient factors and missed appointments. Health outcomes were compared between patients with frequent missed appointments and the remainder of the study sample, using Cox regression analysis. RESULTS Resident patients demonstrated significantly higher rates of missed appointments than faculty patients, but this difference was explained by patient factors. Factors associated with more missed appointments included use of a medical interpreter, Medicaid insurance, more frequent emergency department visits, less time impanelled in the practice, and lower proportion of office visits with the primary care provider. Patients with frequent missed appointments were less likely to be up to date with preventive health services and more likely to have poorly controlled blood pressure and diabetes. CONCLUSIONS We found that the disproportionate frequency of missed appointments in resident continuity clinic is explained by patient factors and practice discontinuity, and that patients with frequent missed appointments demonstrated worse health care outcomes.

Reaching those most in need: a scoping review of interventions to improve health care quality for disadvantaged populations with osteoarthritis.

To conduct a systematic review to identify and describe the scope and nature of the research evidence on the effectiveness of interventions to improve health care quality or reduce disparities in the care of disadvantaged populations with osteoarthritis (OA) as an example of a common chronic disease.

A focus group study of healthy eating knowledge, practices, and barriers among adult and adolescent immigrants and refugees in the United States

BackgroundImmigrants and refugees to the United States exhibit lower dietary quality than the general population, but reasons for this disparity are poorly understood. In this study, we describe the meanings of food, health and wellbeing through the reported dietary preferences, beliefs, and practices of adults and adolescents from four immigrant and refugee communities in the Midwestern United States.MethodsUsing a community based participatory research approach, we conducted a qualitative research study with 16 audio-recorded focus groups with adults and adolescents who self-identified as Mexican, Somali, Cambodian, and Sudanese. Focus group topics were eating patterns, perceptions of healthy eating in the country of origin and in the U.S., how food decisions are made and who in the family is involved in food preparation and decisions, barriers and facilitators to healthy eating, and gender and generational differences in eating practices. A team of investigators and community research partners analyzed all transcripts in full before reducing data to codes through consensus. Broader themes were created to encompass multiple codes.ResultsResults show that participants have similar perspectives about the barriers (personal, environmental, structural) and benefits of healthy eating (e.g., ‘junk food is bad’). We identified four themes consistent across all four communities: Ways of Knowing about Healthy Eating (‘Meanings;’ ‘Motivations;’ ‘Knowledge Sources’), Eating Practices (‘Family Practices;’ ‘Americanized Eating Practices’ ‘Eating What’s Easy’), Barriers (‘Taste and Cravings;’ ‘Easy Access to Junk Food;’ ‘Role of Family;’ Cultural Foods and Traditions;’ ‘Time;’ ‘Finances’), and Preferences for Intervention (‘Family Counseling;’ Community Education;’ and ‘Healthier Traditional Meals.’). Some generational (adult vs. adolescents) and gender differences were observed.ConclusionsOur study demonstrates how personal, structural, and societal/cultural factors influence meanings of food and dietary practices across immigrant and refugee populations. We conclude that cultural factors are not fixed variables that occur independently from the contexts in which they are embedded.

Screening for tuberculosis at an adult education center: results of a community-based participatory process.

OBJECTIVES We used a community-based participatory research (CBPR) approach to plan and implement free TB skin testing at an adult education center to determine the efficacy of CBPR with voluntary tuberculosis (TB) screening and the prevalence of TB infection among immigrant and refugee populations. METHODS We formed a CBPR partnership to address TB screening at an adult education center that serves a large immigrant and refugee population in Rochester, Minnesota. We conducted focus groups involving educators, health providers, and students of the education center, and used this input to implement TB education and TB skin testing among the centers students. RESULTS A total of 259 adult learners volunteered to be skin-tested in April 2009; 48 (18.5%) had positive TB skin tests. CONCLUSIONS Our results imply that TB skin testing at adult education centers that serve large foreign-born populations may be effective. Our findings also show that a participatory process may enhance the willingness of foreign-born persons to participate in TB skin-testing efforts.

Cervical Cancer Screening Adherence Among Somali Immigrants and Refugees to the United States

Somali women have lower cervical cancer screening (CCS) rates than non-Somali women in the United States. We examined clinical and administrative data associated with CCS adherence among Somali women seen at a large primary care practice over 2 years. Fifty-one percent of 310 women were adherent to CCS, and adherence was associated with more overall health care system visits. Patients saw male providers 65.8% of the time; however, only 20.4% of the CCS tests were performed by male providers. Future interventions that enhance cancer prevention, health literacy, and patient–provider gender concordance may improve rates of CCS among Somali women.

Physical activity among Somali men in Minnesota: barriers, facilitators, and recommendations.

Immigrants and refugees arrive to the United States healthier than the general population, but this advantage declines with increasing duration of residence. One factor contributing to this decline is suboptimal physical activity, but reasons for this are poorly understood. Persons from Somalia represent the largest African refugee population to the United States, yet little is known about perceptions of physical activity among Somali men. Somali members of a community-based participatory research partnership implemented three age-stratified focus groups and three semistructured interviews among 20 Somali men in Rochester, Minnesota. Team-based inductive analysis generated themes for barriers and facilitators to physical activity. Barriers to physical activity included less walking opportunities in the United States, embarrassment about exercise clothing and lack of familiarity with exercise equipment/modalities, fear of harassment, competing priorities, facility costs, transportation, and winter weather. Facilitators to physical activity included high knowledge about how to be active, success stories from others in their community as inspiration, and community cohesion. Findings may be used to derive interventions aimed to promote physical activity among Somali men in the United States.