Michael T. Quinn

The PATHWAYS Church-Based Weight Loss Program for Urban African-American Women at Risk for Diabetes

OBJECTIVE This study was carried out to test the effectiveness of PATHWAYS, a weight loss program designed specifically for urban African-American women, when administered in urban churches by trained lay facilitators. RESEARCH DESIGN AND METHODS Thirty-nine obese women were recruited from three urban African-American churches. After randomization and the collection of baseline data on weight and lifestyle practices, subjects in the experimental group (n = 19) were assigned to receive a 14-week weight loss program (PATHWAYS) conducted by trained lay volunteers; control group subjects (n = 20) were put on a waiting list to receive the program at the conclusion of the study period. RESULTS Of the 39 women enrolled, 15 experimental group subjects and 18 control group subjects were available for posttreatment data collection. After completing the program, PATHWAYS participants lost an average of 10.0 lb, and the control group subjects gained an average of 1.9 lb. Posttreatment difference in weight loss between the groups was statistically significant (P < 0.0001). Waist circumference among PATHWAYS participants decreased 2.5 inches, while waist circumference among control group subjects remained relatively the same. This difference between the groups was statistically significant (P < 0.05). CONCLUSIONS A weight loss program administered by trained lay volunteers was effective in producing significant and clinically meaningful weight loss among African-American women who often do not benefit from typical weight loss programs. Ongoing research is focusing on whether the weight loss can be maintained or enhanced through monthly reinforcement sessions.

Improving and sustaining diabetes care in community health centers with the health disparities collaboratives.

Background:In 1998, the Health Resources and Services Administration’s Bureau of Primary Health Care began the Health Disparities Collaboratives (HDC) to improve chronic disease management in community health centers (HCs) nationwide. The HDC incorporates rapid quality improvement, a chronic care model, and best practice learning sessions. Objectives:To determine whether the HDC improves diabetes care in HCs over 4 years and whether more intensive interventions enhance care further. Subjects:Chart review of 2364, 2417, and 2212 randomly selected patients with diabetes from 34 HCs in 17 states in 1998, 2000, and 2002, respectively. Measures:American Diabetes Association standards. Research Design:We performed a randomized controlled trial with an embedded prospective longitudinal study. We randomized 34 HCs that had undergone 1–2 years of the HDC. The standard-intensity arm continued the baseline HDC intervention. High-intensity arm centers received 4 additional learning sessions, provider training in behavioral change, and patient empowerment materials. To assess the impact of the HDC, we analyzed changes in clinical processes and outcomes in the standard-intensity centers. To determine the effect of more intensive interventions, we compared the standard- and high-intensity centers. Results:Between 1998 and 2002, HCs undertaking the standard HDC improved 11 diabetes processes and lowered hemoglobin A1c [−0.45%; 95% confidence interval (CI), −0.72 to −0.17] and low-density lipoprotein cholesterol (−19.7 mg/dL; 95% CI, −25.8 to −13.6). High-intensity intervention centers had greater use of angiotensin converting enzyme inhibitors [adjusted odds ratio (OR), 1.47; 95% CI, 1.07–2.01] and aspirin (OR, 2.20; 95% CI, 1.28–3.76), but lower use of dietary (OR, 0.24; 95% CI, 0.08–0.68) and exercise counseling (OR, 0.34; 95% CI, 0.15–0.75). Conclusions:Diabetes care and outcomes improved in HCs during the first 4 years of the HDC quality improvement collaborative. More intensive interventions helped marginally.

Barriers and Facilitators to Shared Decision-making Among African-Americans with Diabetes

ABSTRACTINTRODUCTIONShared decision-making (SDM) between patients and their physicians is associated with improved diabetes health outcomes. African-Americans have less SDM than Whites, which may contribute to diabetes racial disparities. To date, there has been little research on SDM among African-Americans.OBJECTIVEWe explored the barriers and facilitators to SDM among African-Americans with diabetes.METHODSQualitative research design with a phenomenological methodology using in-depth interviews (n = 24) and five focus groups (n = 27). Each interview/focus group was audio-taped and transcribed verbatim, and coding was conducted using an iterative process. Participants: We utilized a purposeful sample of African-American adult patients with diabetes. All patients had insurance and received their care at an academic medical center.RESULTSPatients identified multiple SDM barriers/facilitators, including the patient/provider power imbalance that was perceived to be exacerbated by race. Patient-related factors included health literacy, fear/denial, family experiences and self-efficacy. Reported physician-related barriers/facilitators include patient education, validating patient experiences, medical knowledge, accessibility and availability, and interpersonal skills.DISCUSSIONBarriers/facilitators of SDM exist among African-Americans with diabetes, which can be effectively addressed in the outpatient setting. Primary care physicians, particularly academic internists, may be uniquely situated to address these barriers/facilitators and train future physicians to do so as well.

Evaluation of patient centered medical home practice transformation initiatives.

Background:The patient-centered medical home (PCMH) has become a widely cited solution to the deficiencies in primary care delivery in the United States. To achieve the magnitude of change being called for in primary care, quality improvement interventions must focus on whole-system redesign, and not just isolated parts of medical practices. Methods:Investigators participating in 9 different evaluations of Patient Centered Medical Home implementation shared experiences, methodological strategies, and evaluation challenges for evaluating primary care practice redesign. Results:A year-long iterative process of sharing and reflecting on experiences produced consensus on 7 recommendations for future PCMH evaluations: (1) look critically at models being implemented and identify aspects requiring modification; (2) include embedded qualitative and quantitative data collection to detail the implementation process; (3) capture details concerning how different PCMH components interact with one another over time; (4) understand and describe how and why physician and staff roles do, or do not evolve; (5) identify the effectiveness of individual PCMH components and how they are used; (6) capture how primary care practices interface with other entities such as specialists, hospitals, and referral services; and (7) measure resources required for initiating and sustaining innovations. Conclusions:Broad-based longitudinal, mixed-methods designs that provide for shared learning among practice participants, program implementers, and evaluators are necessary to evaluate the novelty and promise of the PCMH model. All PCMH evaluations should as comprehensive as possible, and at a minimum should include a combination of brief observations and targeted qualitative interviews along with quantitative measures.

Reducing health disparities in depressive disorders outcomes between non-Hispanic Whites and ethnic minorities: a call for pragmatic strategies over the life course.

There are significant disparities in treatment process and symptomatic and functional outcomes in depressive disorders for racial and ethnic minority patients. Using a life-course perspective, the authors conducted a systematic review of the literature to identify modifiable mechanisms and effective interventions for prevention and treatment at specific points—system, community, provider, and individual patient—in health care settings. Multicomponent chronic disease management interventions have produced improvements in depression outcomes for ethnic minority populations. Case management appears to be a key component of effective interventions. Socioculturally tailored treatment and prevention interventions may be more efficacious than standard treatment programs. Future research should focus on identifying key components of case management and sociocultural tailoring that are essential for effective interventions and developing new low-cost dissemination mechanisms for treatment and preventive programs that could be tailored to racial and ethnic minorities.

Training Lay Health Educators to Conduct a Church-Based Weight-Loss Program for African American Women

PURPOSE Community-based lay health educators have been utilized in a range of settings and with a variety of health issues. However, little has been published about the specifics of training lay health educators to effectively deliver community-based programs. This paper describes the training used to prepare volunteer, church-based lay health educators to conduct a community-based weight-loss program, and the evaluation of that training. METHODS After recruitment through their respective churches, volunteer lay health educators were given structured training in how to conduct the PATHWAYS weight-loss program. Program sessions were observed to monitor program delivery, and participation rates and weight loss were evaluated. RESULTS The lay health educators were highly consistent in their delivery of the program content. Participant attendance was high and virtually all of the participants completed the program. Participant weight loss averaged 8.3 pounds, which correlated with session attendance. CONCLUSIONS Given training appropriate to the structure of the program and specific to the targeted health behavior, lay health educators can reliably and effectively administer even rather complex programs.

Increasing children's responsibility for diabetes self-care: the In Control study.

The purpose of this pilot study was to test the hypothesis that children can learn to become more independent in their own diabetes self management without compromising their metabolic control. Twenty four children (ages 8 to 12 years) with insulin- dependent diabetes mellitus (IDDM) were matched by age and race, then randomly assigned either to a 6-week, self management education program (experimental) or to receive usual care (control). A questionnaire was administered to the parents to determine the frequency with which 35 diabetes management behaviors were performed and the degree to which children assumed responsibility for these behaviors. Glycohemoglobin levels were monitored at baseline and at posttreatment, 12 weeks after baseline. At the posttreatment, children in the experimental group were found to be assuming significantly more responsibility for their diabetes self-care than were children in the control group. No decrease in the frequency with which self-care behaviors were performed was observed, and metabolic control was maintained. The results suggest that a diabetes self-management education program for children ages 8 to 12 years can be effective in facilitating children becoming more responsible for their own diabetes management.

Early Lessons From An Initiative On Chicago’s South Side To Reduce Disparities In Diabetes Care And Outcomes

Interventions to improve health outcomes among patients with diabetes, especially racial or ethnic minorities, must address the multiple factors that make this disease so pernicious. We describe an intervention on the South Side of Chicago-a largely low-income, African American community-that integrates the strengths of health systems, patients, and communities to reduce disparities in diabetes care and outcomes. We report preliminary findings, such as improved diabetes care and diabetes control, and we discuss lessons learned to date. Our initiative neatly aligns with, and can inform the implementation of, the accountable care organization-a delivery system reform in which groups of providers take responsibility for improving the health of a defined population.

Community and Family Perspectives on Addressing Overweight in Urban, African-American Youth

ObjectiveTo assess weight-related beliefs and concerns of overweight urban, African-American children, their parents, and community leaders before developing a family-based intervention to reduce childhood overweight and diabetes risk.DesignWe conducted 13 focus groups with overweight children and their parents and eight semistructured interviews with community leaders.Participants and SettingFocus group participants (N = 67) from Chicago’s South Side were recruited through flyers in community sites. Interview participants (N = 9) were recruited to sample perspectives from health, fitness, education, civics, and faith leaders.ResultsCommunity leaders felt awareness was higher for acute health conditions than for obesity. Parents were concerned about their children’s health, but felt stressed by competing priorities and constrained by lack of knowledge, parenting skills, time, and financial resources. Parents defined overweight in functional terms, whereas children relied upon physical appearances. Children perceived negative social consequences of overweight. Parents and children expressed interest in family-based interventions to improve nutrition and physical activity and offered suggestions for making programs interesting.ConclusionsThis study provides insights into the perspectives of urban, African-American overweight children, their parents, and community leaders regarding nutrition and physical activity. The specific beliefs of these respondents can become potential leverage points in interventions.

Preventing Diabetes in the Clinical Setting

OBJECTIVE: Translating lessons from clinical trials on the prevention or delay of type 2 diabetes to populations in nonstudy settings remains a challenge. The purpose of this paper is to review, from the perspective of practicing clinicians, available evidence on lifestyle interventions or medication to prevent or delay the onset of type 2 diabetes.DESIGN: A MEDLINE search identified 4 major diabetes prevention trials using lifestyle changes and 3 using prophylactic medications. We reviewed the study design, key components, and outcomes for each study, focusing on aspects of the interventions potentially adaptable to clinical settings.RESULTS: The lifestyle intervention studies set modest goals for weight loss and physical activity. Individualized counseling helped participants work toward their own goals; behavioral contracting and self-monitoring were key features, and family and social context were emphasized. Study staff made vigorous follow-up efforts for subjects having less success. Actual weight loss by participants was modest; yet, the reduction in diabetes incidence was quite significant. Prophylactic medication also reduced diabetes risk; however, lifestyle changes were more effective and are recommended as first-line strategy. Cost-effectiveness analyses have shown both lifestyle and medication interventions to be beneficial, especially as they might be implemented in practice.CONCLUSION: Strong evidence exists for the prevention or delay of type 2 diabetes through lifestyle changes. Components of these programs may be adaptable for use in clinical settings. This evidence supports broader implementation and increased reimbursement for provider services related to nutrition and physical activity to forestall morbidity from type 2 diabetes.