Rosette J. Chakkalakal

Perceptions of Provider Communication Among Vulnerable Patients With Diabetes: Influences of Medical Mistrust and Health Literacy

Patient–provider communication is modifiable and is linked to diabetes outcomes. The association of communication quality with medical mistrust is unknown. We examined these factors within the context of a low-literacy/numeracy-focused intervention to improve diabetes care, using baseline data from diverse patients enrolled in a randomized trial of a health communication intervention. Demographics, measures of health communication (Communication Assessment Tool [CAT], Interpersonal Processes of Care survey [IPC-18]), health literacy (Short Test of Functional Health Literacy in Adults), depression, medical mistrust, and glycemic control were ascertained. Adjusted proportional odds models were used to test the association of mistrust with patient-reported communication quality. The interaction effect of health literacy on mistrust and communication quality was also assessed. A total of 410 patients were analyzed. High levels of mistrust were observed. In multivariable modeling, patients with higher mistrust had lower adjusted odds of reporting a higher CAT score (adjusted odds ratio [AOR] = 0.67, 95% confidence interval [CI] [0.52, 0.86], p = .003) and higher scores on the Communication (AOR = 0.69, 95% CI [0.55, 0.88], p = .008), Decided Together (AOR = 0.74, 95% CI [0.59, 0.93], p = .02), and Interpersonal Style (AOR = 0.69, 95% CI [0.53, 0.90], p = .015) subscales of the IPC-18. We observed evidence of an interaction effect of health literacy for the association between mistrust and the Decided Together subscale of the IPC-18 such that patients with higher mistrust and lower literacy perceived worse communication relative to mistrustful patients with higher literacy. In conclusion, medical mistrust was associated with poorer communication with providers in this public health setting. Patients’ health literacy level may vary the effect of mistrust on interactional aspects of communication. Providers should consider the impact of mistrust on communication with vulnerable diabetes populations and focus efforts on mitigating its influence.

Disparities in Using Technology to Access Health Information: Race Versus Health Literacy

Leveraging computers and mobile devices to understand one’s health, support self-management, and interact with providers is associated with favorable diabetes outcomes (1,2). However, not everyone uses these technologies, potentially limiting broad benefit. We examined whether patient race and health literacy (HL) status are associated with technology use. We analyzed data from a cross-sectional study of adults (age ≥18 years) with type 2 diabetes from a federally qualified health center in Nashville, TN. Research assistants worked with clinic personnel to recruit eligible patients arriving for appointments. Research assistants conducted in-person interviews to collect self-reported information on demographics and technology access and use (Table 1), administered the Short Test of Functional Health Literacy in Adults (3), and reviewed medical charts. All participants received a point-of-care (POC) A1C test on the day of participation (4). Only 38% had a chart-reviewed A1C that same day (with POC, ρ = 0.87, P < 0.001), requiring use of POC. We …

Implementing clinical guidelines in low-income settings: A review of literature

The use of clinical guidelines has been shown to confer benefits for care delivery in high-income settings, but little is known about their implementation in low-income settings. We conducted a systematic literature review on the implementation of World Health Organisation (WHO) clinical guidelines for hospital care in low-income settings. We searched Medline, Global Health and Scopus for articles describing the implementation of clinical guidelines issued by the WHO for hospitals in low-income countries. Each article in the final sample was reviewed independently by two reviewers who harmonised their findings to identify key factors affecting the implementation process, which were grouped into thematic categories through negotiated consensus among project team members. Seventeen studies met the inclusion criteria. Factors affecting the guideline implementation process in low-income countries were (1) degree of support from facility management and Ministry of Health, (2) credibility and acceptability of clinical guidelines from the perspective of health care providers, (3) efforts to adapt clinical guidelines to local circumstances and (4) use of guides and checklists for implementation. These four factors consistently emerged in our review and should be considered when designing future strategies to implement clinical guidelines in low-income countries.

“I just wish that everything is in one place”: facilitators and barriers to continuity of care among HIV-positive, postpartum women with a non-communicable disease in South Africa

ABSTRACT HIV and non-communicable diseases (NCD) are co-epidemics in South Africa. Comorbid individuals must engage in lifelong care. Postpartum HIV-positive women in South Africa are at high risk of dropping out of HIV care. We explored healthcare utilization among postpartum women requiring chronic management of HIV and NCD. From August – December 2016, we enrolled 25 women in Soweto, South Africa, and conducted one-time interviews. All participants were adult (≥18 years), HIV-positive, postpartum, and diagnosed with a NCD that required further evaluation after delivery. We developed a conceptual model that describes how maternal factors, interaction with environments, and social networks influence follow up engagement. Barriers to follow-up included separate visit days, increased time commitment, transportation and logistics, unfamiliar clinic environments, and disrespectful staff. Factors facilitating patient engagement included social support and partner disclosure. Women were more likely to turn to friends and family for advice regarding HIV or the NCD, rather than a clinic. Women prioritized infant care after delivery, suggesting that baby care may be an entry point for improving maternal care after delivery. Our results support advocating for better integration of services at the primary care level as a method to improve continuity of care for both women and children.

Socioeconomic Status and Care Metrics for Women Diagnosed With Gestational Diabetes Mellitus

IN BRIEF Appropriate management of hyperglycemia can significantly attenuate perinatal risks associated with a diagnosis of gestational diabetes mellitus (GDM). This article reports on a study evaluating the independent associations of maternal income and education with select measures of GDM management. This exploratory study demonstrates notable socioeconomic differences in select measures of GDM management. Additional studies are needed to determine the reasons for these differences and whether they exist in broader populations.

Variation in the relationship between gestational diabetes diagnosis and total gestational weight gain by race/ethnicity

Prior research suggests that women diagnosed and treated for gestational diabetes mellitus (GDM) gain less total gestational weight than normoglycemic women. Our study finds that race/ethnicity modifies this association. Relative to normoglycemic women, non-Hispanic white women with GDM gain less weight but non-Hispanic black and Hispanic women gain more weight.

Capsule Commentary on Pilla et al., Predictors of Insulin Initiation in Patients with Type 2 Diabetes: an Analysis of the Look AHEAD Randomized Trial

T his study by Pilla et al. 1 identifies sociodemographic and clinical predictors of insulin initiation among participants enrolled in the Look AHEAD (Action for Health in Diabetes) trial. Nearly 28% of study participants not using insulin at baseline were found to have initiated insulin for management of type 2 diabetes during a median follow-up of 8 years. Using Cox proportional hazards models, the investigators found that insulin initiation was inversely associated with older age and Black or Hispanic race/ethnicity and positively associated with hemoglobin A1C, current smoking, body mass index, hypertension, the presence of macrovascular and microvascular complications, number of antihyperglycemic drugs, family history of diabetes, and care at a hospital-affiliated medical clinic. The decision to intensify type 2 diabetes treatment, especially via insulin initiation, requires Ba patient-centered approach, including assessment of efficacy, hypoglycemia risk, impact on weight, side effects, costs, and patient preferences^. Thus, insulin initiation may be appropriate for some but not all patients. Pilla et al. are unable to explain the extent towhich the differences they identified in insulin initiation may be explained by appropriateness of insulin initiation because their analysis did not account for all of the factors included in the decision-making process. In particular, hypoglycemic risk may play a critical role in the decision to initiate insulin given increased recognition of the significant negative impact of hypoglycemia on long-term outcomes of patients with type 2 diabetes but it was not addressed in this study. As stated by the authors, the racial/ethnic differences in insulin initiation identified in this study are especially noteworthy and deserve further evaluation. Discerning between differences and disparities in treatment by race/ethnicity requires knowledge of treatment appropriateness, patient attitudes and preferences for the treatment, and clinical outcomes of the treatment across racial/ethnic groups. Clarifying if the racial/ethnic variation identified in this study represents differences or disparities would greatly inform efforts to ensure equitable treatment of type 2 diabetes for all patients.

Validating Health Literacy and Numeracy Measures in Minority Groups

Background: Validation studies of existing health literacy or numeracy tools among racial/ethnic minorities are limited. Objective: This study assessed the validity of the Subjective Numeracy Scale (SNS), the Diabetes Numeracy Test (DNT-5), the Brief Health Literacy Screen (BHLS), and the Short Test of Functional Health Literacy in Adults (S-TOFHLA) by trait (health literacy or numeracy) and by method (subjective or objective) among non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic patients with type 2 diabetes mellitus (T2DM). Methods: We conducted a secondary analysis of baseline data from the Partnering to Improve Diabetes Education (PRIDE) study, a clustered randomized controlled trial testing the efficacy of a health communication intervention on T2DM outcomes at state Department of Health clinics in middle Tennessee. PRIDE participants with race/ethnicity data available (n = 398) were included in this study. Most patients identified as NHW (59%), 18% identified as NHB, and 23% identified as Hispanic. Pearson correlations among the 4 measures were compared for each racial/ethnic group by trait and method. The convergent validity of each measure with education was also assessed using Pearson correlation analyses. Key Results: Significant correlations were observed across all 3 subgroups for the numeracy measures (SNS and DNT-5) and the objective measures (DNT-5 and S-TOFHLA). Nonsignificant correlations were observed among Hispanic participants for the health literacy measures (BHLS and S-TOFHLA, correlation coefficient = 0.13) and among NHB and Hispanic participants for the subjective measures (SNS and BHLS, correlations coefficients = 0.15 and 0.09, respectively). A significant positive correlation was noted between education and each measure across all 3 subgroups. Conclusions: Subjective and health literacy measures demonstrate weaker correlations than objective and numeracy measures, respectively, among minority patients in this study. Our findings highlight the need to further evaluate the appropriateness of these tools for use with minority populations, particularly the BHLS for Hispanic patients. [Health Literacy Research and Practice. 2017;1(2):e23–e30.] Plain Language Summary: Few studies have tested the validity of health literacy and numeracy measures in minority groups. This study highlights racial/ethnic differences in the results of validity testing of the Subjective Numeracy Scale, the Diabetes Numeracy Test, the Brief Health Literacy Screen, and the Short Test of Functional Health Literacy in Adults among adults with type 2 diabetes.