The time is now: Fostering relationship-centered discussions about patients’ social determinants of health

Objective

This paper discusses the importance of developing best practices in communication strategies to identify and act on social determinants of health (SDOH) in care settings in ways that minimizes shame and builds patient trust in the process.

Illness beliefs and self-management in children and young people with chronic illness: a systematic review

To review the extent to which illness representations, based on Leventhal's Common Sense Model, relate to self-management in children and young people with chronic physical health conditions. A systematic literature review was carried out to identify relevant studies and each included paper was assessed for risk of bias. Fifteen papers met criteria for inclusion within the review. The majority of studies were cross-sectional, and small sample sizes for some studies made it difficult to generalise findings. The method of measuring both illness representations and outcomes varied. Timeline, identity, control and consequences beliefs were the most frequently assessed domains of illness representations included within the studies. While there is variability, there are indications that control beliefs, specifically treatment control beliefs, are more consistently and strongly associated with self-management than other representation domains. Control beliefs should be targeted for intervention in studies trying to improve adolescent self-management. In addition, the relationship between illness representations and self-management needs to be considered within both developmental and systemic contexts. It is likely that the variation in self-management will be more fully explained in future research that explores the combined effects of individual representations and the influence of wider contexts.     

Diabetes self-management in patients with low health literacy: ordering findings from literature in a health literacy framework

Objective

To review studies on the association between health literacy (HL), diabetes self-management and possible mediating variables.

Methods

We systematically searched for empirical studies in PubMed. Findings were ordered by a HL framework that outlines routes between HL, sociocognitive determinants and health actions.

Results

Of the 11 relevant studies, three reported a significant positive association between HL and specific diabetes self-management domains. Ten studies investigated the association between HL and knowledge (n = 8), beliefs (n = 2), self-efficacy (n = 3) and/or social support (n = 1). Significant associations were found between HL and knowledge (n = 6), self-efficacy (n = 1) and social support (n = 1). Of the three studies evaluating the effect of these sociocognitive variables on diabetes self-management, only one found proof for a mediating variable (social support) in the pathway between HL and self-management.

Conclusion

There is only limited evidence for a significant association between HL and diabetes self-management, and for the mediating role of sociocognitive variables in this pathway.

Practice implications

Longitudinal studies, including HL, diabetes self-management and potential mediators, are needed to substantiate possible associations between these variables. Such research is essential to enable evidence-based development of interventions to increase adequate and sustainable self-management in diabetic patients with low HL.     

Cognitive impairment no dementia and associations with health literacy,self-management skills,and functional health status

ObjectivesTo determine the prevalence of cognitive impairment no dementia (CIND) among a diverse, community-based population, and establish associations between CIND and health literacy, chronic disease self-management and functional health status.Methods863 primary care adults without dementia aged 55–74. Adjusted logistic and linear regressions were used to assess associations between CIND (None, Mild, Moderate/Severe) and outcomes.Results36 % participants exhibited CIND. It was strongly associated with limited health literacy (Newest Vital Signs: Mild [OR 3.25; 95 % CI 1.93, 5.49], Moderate/Severe [OR 6.45; 95 % CI 3.16, 13.2]; Test of Functional Health Literacy in Adults: Mild [OR 3.46; 95 % CI 2.08, 5.75], Moderate/Severe [OR 8.82; 95 % CI 4.87, 16.0]; all p’s < 0.001) and poor chronic disease self-management (Mild [B = −11.2; 95 % CI −13.5, -8.90], Moderate/Severe CI [B = −21.0; 95 % CI −23.6, −18.4]; both p’s < 0.001). Associations between CIND and functional health status were non-significant.ConclusionsCIND was prevalent in this cohort, and strongly associated with requisite skills for managing everyday health needs.Practice ImplicationsAttention to subtle declines in chronic disease self-care may assist with CIND identification and care management within this population. When CIND is observed, clinicians should also expect and address difficulties with self-management.     

Blended face-to-face and online/computer-based education approaches in chronic disease self-management: A critical interpretive synthesis

ObjectiveTo review the literature on chronic disease self-management programs that blend face-to-face and online/computer-based education design and delivery.MethodsA critical interpretive synthesis was conducted. Studies that described blended chronic disease self-management programs were reviewed. Two reviewers performed independent database searches, eligibility screening, and data extraction. Findings were synthesized using a conceptual mapping process.ResultsTwelve articles were included in the final review. Studies focused on patients with diagnoses of diabetes, asthma, and chronic obstructive pulmonary disorder. Factors influencing the design and delivery of programs focused on patient characteristics (such as disease prognosis, time since diagnosis, social determinants of health, health literacy, and proficiency with online/computer-based technologies).ConclusionsBlended learning self-management programs should consider the suitability of programs in light of health conditions and patient characteristics. Individual patient needs can be identified through clinician-driven assessments, including collaborative goal setting and the selection of pertinent educational tools.Practice ImplicationsWhen considering the design and delivery of chronic disease self-management education programs, healthcare providers should consider three factors: 1) patient characteristics, 2) learning perspectives, and 3) design technology options that best meet patient abilities, clinician expertise, and administrative capacity.     

Engagement in a diabetes self-management website: usage patterns and generalizability of program use

Background

Increased access to the Internet and the availability of efficacious eHealth interventions offer great promise for assisting adults with diabetes to change and maintain health behaviors. A key concern is whether levels of engagement in Internet programs are sufficient to promote and sustain behavior change.

Objective

This paper used automated data from an ongoing Internet-based diabetes self-management intervention study to calculate various indices of website engagement. The multimedia website involved goal setting, action planning, and self-monitoring as well as offering features such as “Ask an Expert” to enhance healthy eating, physical activity, and medication adherence. We also investigated participant characteristics associated with website engagement and the relationship between website use and 4-month behavioral and health outcomes.

Methods

We report on participants in a randomized controlled trial (RCT) who were randomized to receive (1) the website alone (n = 137) or (2) the website plus human support (n = 133) that included additional phone calls and group meetings. The website was available in English and Spanish and included features to enhance engagement and user experience. A number of engagement variables were calculated for each participant including number of log-ins, number of website components visited at least twice, number of days entering self-monitoring data, number of visits to the “Action Plan” section, and time on the website. Key outcomes included exercise, healthy eating, and medication adherence as well as body mass index (BMI) and biological variables related to cardiovascular disease risk.

Results

Of the 270 intervention participants, the average age was 60, the average BMI was 34.9 kg/m², 130 (48%) were female, and 62 (23%) self-reported Latino ethnicity. The number of participant visits to the website over 4 months ranged from 1 to 119 (mean 28 visits, median 18). Usage decreased from 70% of participants visiting at least weekly during the first 6 weeks to 47% during weeks 7 to 16. There were no significant differences between website only and website plus support conditions on most of the engagement variables. In total, 75% of participants entered self-monitoring data at least once per week. Exercise action plan pages were visited more often than medication taking and healthy eating pages (mean of 4.3 visits vs 2.8 and 2.0 respectively, P < .001). Spearman nonparametric correlations indicated few significant associations between patient characteristics and summary website engagement variables, and key factors such as ethnicity, baseline computer use, age, health literacy, and education were not related to use. Partial correlations indicated that engagement, especially in self-monitoring, was most consistently related to improvement in healthy eating (r = .20, P = .04) and reduction of dietary fat (r = -.31, P = .001). There was also a significant correlation between self-monitoring and improvement in exercise (r = .20, P = .033) but not with medication taking.

Conclusions

Participants visited the website fairly often and used all of the theoretically important sections, but engagement decreased over 4 months. Usage rates and patterns were similar for a wide range of participants, which has encouraging implications for the potential reach of online interventions.

Trial Registration

{"type":"clinical-trial","attrs":{"text":"NCT00987285","term_id":"NCT00987285"}}NCT00987285; http://clinicaltrials.gov/show/{"type":"clinical-trial","attrs":{"text":"NCT00987285","term_id":"NCT00987285"}}NCT00987285 (Archived by WebCite at http://www.webcitation.org/5vpe4RHTV)     

Patient and provider perspectives on preterm birth risk assessment and communication

ObjectiveTo describe and compare how obstetric patients and care providers view preterm birth risk assessment and communication.MethodsWe conducted eight focus groups with obstetric patients (n = 35) and 16 qualitative interviews with obstetric providers. Grounded theory was used to identify and analyze themes.ResultsPatients' knowledge about preterm birth varied greatly. Similar benefits and risks of preterm birth risk counseling were discussed by patients and providers with notable exceptions: patients cited preparedness as a benefit and providers cited maternal blame, patient alienation, and estimate uncertainty as potential risks. Most patients expressed a desire to know their personalized preterm birth risk during pregnancy. Providers differed in whether they offer universal versus selective, and quantitative versus qualitative, preterm birth risk counseling. Many providers expressed concern about discussing social and structural risk factors for preterm birth.ConclusionWhile many patients desired knowing their personalized preterm birth risk, prenatal care providers’ disclosure practices vary because of uncertainty of estimates, concerns about negative consequences and challenges of addressing systemic inequities and social determinants of health.Practice implicationsGiven the existing asymmetry of information about preterm birth risk, providers should consider patient preferences regarding and potential benefits and risks of such disclosure in their practice.     

The Quality and Outcomes Framework and self-management dialogue in primary care consultations: a qualitative study

Background

Two key elements to improve the quality of care for people with long-term conditions in primary care are improved clinical information systems to support delivery of evidence-based care, and enhanced self-management support. Although both elements are viewed as necessary, their interaction is not well understood.

Aim

To explore the use of computer-based ‘disease management’ templates and their relevance to self-management dialogue within clinical encounters.

Design and setting

Qualitative study of general practices located in three primary care trusts in the north of England.

Method

A qualitative mixed methods study was conducted that included comparative analysis of (1) observations of general practice consultations (n = 86); and (2) interviews with health professionals in general practice (n = 17).

Results

The analysis suggested that use of the computer templates reinforced a checklist approach to consultations, which included professionals working through several self-management topics framed as discrete behaviours. As a consequence, conversation tended to become focused on the maintenance of the professional-patient relationship at the expense of expansion in self-management dialogue. The computer templates also shaped how patient-initiated self-management dialogue was managed when it arose, with a shift towards discussion around medical agendas.

Conclusion

In order to enhance the management of long-term conditions in primary care, the design and implementation of clinical information systems to improve evidence-based care need to take into account their potential impact on supporting self-management.     

Interdisciplinary speed dating augments diabetes self-management education and support to improve health outcomes

ObjectiveTo determine if a novel interdisciplinary “speed-dating” clinic augments Diabetes Self-Management Education and Support (DSMES).MethodsAdult patients with diabetes attended a DSMES class. Two weeks later patients attended an interdisciplinary clinic utilizing a “speed-dating” format during which they progressed through 5 stations hosted by different healthcare disciplines at 30-minute increments: physician, pharmacist, nurse/dietitian, case manager, and psychologist. Shared decision-making was utilized to identify mutually agreeable recommendations. Change in clinical outcomes were compared for DSMES-only attenders versus Dual-attendees; utilization of emergency department and hospital services were measured 12 months before and after attending the Speed Dating clinic. This analysis represents patients attending the program during 2016.ResultsSixty-nine attended the DSMES class, 40 of whom followed-up in the “speed-dating” clinic (58% return rate). Attending the Speed Dating clinic improved A1C (p = 0.003) and LDL-C (p = 0.003) compared to the DSMES class alone. Comparatively, after attending the speed-dating clinic, patients had fewer emergency department (p = 0.366) and hospital admissions (p = 0.036), and shorter lengths of hospital stay (p = 0.030).ConclusionsThe interdisciplinary “speed-dating” approach improved diabetes outcomes beyond DSMES alone and reduced utilization of hospital services.Practice implicationsPatients should attend DSMES but also participate in an Interdisciplinary Speed Dating follow-up to further improve outcomes.     

Personal models of osteoarthritis and their relation to self-management activities and quality of life

We examined the personal models of osteoarthritis (OA) of 61 patients over 60 years of age. Models were elicited using a structured interview. Shared beliefs included perceiving OA as a serious, painful, chronic, and incurable condition that can be managed by recommended medical treatment. Considerable individual differences were found on six personal-model constructs: Symptoms, Seriousness, Cause, Control, Helpfulness of Treatment, and Negative Feelings about Treatment. The constructs of Symptoms and Seriousness were consistently related to a variety of important outcomes. For example, participants with higher scores on Symptoms and Seriousness reported higher levels of self-management (both concurrently and prospectively), reported more utilization of medical services, and experienced a poorer quality of life. The implications for the design of health-education materials and for patient-provider interactions are discussed.     

The dynamics of the relationship between diabetes incidence and low income: longitudinal results from Canada's National Population Health Survey

This paper sheds light on the dynamic relationship between people's experiences of low income and the development of type 2 diabetes (T2DM) by moving beyond the static perspective provided by cross-sectional studies to a long-term approach informed by longitudinal analyses. Methods: We analyzed data from the Canadian National Population Health Survey (NPHS) conducted by Statistics Canada from 1994 to 2007. The longitudinal sample is composed of 17,276 respondents (8046 males, 9230 females) 12 years of age or older. We further developed an algorithm to distinguish T2DM from other types of diabetes. Proportional hazard models with time-varying predictors were used to explore the dynamics of the relationship between low income and T2DM. Results: The results suggest that living in low income and experiencing persistent low income are significant precursors of developing T2DM. Being in low income in the previous cycle of T2DM onset was associated with 77% higher risk of T2DM (hazard ratio 1.77; 95% CI: 1.48–2.12). The association between low income and diabetes incidence remains significant after adjusting for age, sex, health behaviors, and psychological distress (hazard ratio 1.24; 95% CI: 1.02–1.52). Conclusion: This study contributes to the under-developed research examining longitudinally the relationship between socioeconomic status and diabetes incidence. Employing this long-term approach, this study calls attention to the primary effect of socioeconomic position on diabetes incidence that cannot be explained entirely by behavioral factors. Findings draw attention to the need to address the role played in T2DM by the inequitable distribution of the social determinants of health.     

Understanding the potential role of mobile phone-based monitoring on asthma self-management: qualitative study

BACKGROUND: National and international healthcare policy increasingly seeks technological solutions to the challenge of providing care for people with long-term conditions. Novel technologies, however, have the potential to change the dynamics of disease monitoring and self-management. We aimed to explore the opinions and concerns of people with asthma and primary care clinicians on the potential role of mobile phone monitoring technology (transmitting symptoms and peak flows, with immediate feedback of control and reminder of appropriate actions) in supporting asthma self-management. METHODS: This qualitative study recruited 48 participants (34 adults and teenagers with asthma, 14 asthma nurses and doctors) from primary care in Lothian (Central Scotland) and Kent (South East England). Thirty-nine participated in six focus groups, which included a demonstration of the technology; nine gave in-depth interviews before and after a 4-week trial of the technology. RESULTS: Participants considered that mobile phone-based monitoring systems can facilitate guided self-management although, paradoxically, may engender dependence on professional/technological support. In the early phases, as patients are learning to accept, understand and control their asthma, this support was seen as providing much-needed confidence. During the maintenance phase, when self-management predominates, patient and professionals were concerned that increased dependence may be unhelpful, although they appreciated that maintaining an on-going record could facilitate consultations. CONCLUSION: Mobile phone-based monitoring systems have the potential to support guided self-management by aiding transition from clinician-supported early phases to effective self-management during the maintenance phase. Continuing development, adoption and formal evaluation of these systems should take account of the insights provided by our data.     

Effects of a Web-based intervention for adults with chronic conditions on patient activation: online randomized controlled trial

Background

With almost one-half of Americans projected to have at least one chronic condition before 2020, a vital role of the health care system is to develop informed, engaged individuals who are effective self-managers of their health. Self-management interventions (SMIs) delivered face-to-face or by telephone (traditional SMIs) are associated with improved self-management knowledge, skills, and self-efficacy, which are expressed by the composite construct of patient activation, a predictor of health outcomes. Web-based interventions to support self-management across the spectrum of chronic diseases have the potential to reach a broader population of patients for extended periods than do traditional SMIs. However, evidence of the effectiveness of Web-based interventions on patient activation is sparse. High-quality studies featuring controlled comparisons of patients with different chronic conditions are needed to explore the interaction of Web-based interventions and patient activation.

Objective

To explore the effect of a Web-based intervention on the patient activation levels of patients with chronic health conditions, measured as attitudes toward knowledge, skills, and confidence in self-managing health.

Methods

For this 12-week study, prospective participants were selected from the patient panel of a regional health care system in the United States. The 201 eligible participants were randomly assigned to two groups. Intervention group participants had access to MyHealth Online, a patient portal featuring interactive health applications accessible via the Internet. Control participants had access to a health education website featuring various topics. Patient activation was assessed pre- and posttest using the 13-item patient activation measure. Parametric statistical models (t test, analysis of variance, analysis of covariance) were applied to draw inferences.

Results

The Web-based intervention demonstrated a positive and significant effect on the patient activation levels of participants in the intervention group. A significant difference in posttest patient activation scores was found between the two groups (F _1,123 = 4.438, P = .04, r = .196). Patients starting at the most advanced development of patient activation (stage 4) in the intervention group did not demonstrate significant change compared with participants beginning at earlier stages.

Conclusions

To our knowledge, this is the first study to measure change in patient activation when a Web-based intervention is used by patients living with different chronic conditions. Results suggest that Web-based interventions increase patient activation and have the potential to enhance the self-management capabilities of the growing population of chronically ill people. Activated patients are more likely to adhere to recommended health care practices, which in turn leads to improved health outcomes. Designing Web-based interventions to target a specific stage of patient activation may optimize their effectiveness. For Web-based interventions to reach their potential as a key component of chronic disease management, evidence is needed that this technology produces benefits for a sustained period among a diverse population.     

Predictors and effectiveness of diabetes self-management education in clinical practice

OBJECTIVE: To describe the demographic and clinical predictors of attendance at a diabetes education center (DEC) for self-management education, and to compare subsequent quality of care indicators between attendees and non-attendees. METHODS: DEC attendance in 2002 was determined from a written questionnaire completed by 781 adults with diabetes across Ontario, Canada. Predictors of attendance and quality of care indicators were defined from the questionnaire and from linkage with health care administrative data. A multivariate logistic regression model was built to find the independent predictors of attendance, while quality of care was evaluated using propensity score methods. RESULTS: 30% of survey participants reported attending a DEC in 2002. Independent predictors of attendance were shorter duration of diabetes, receiving regular primary care, receiving regular diabetes specialist care and single marital status. Attendees were more likely to receive a retinal screening examination in the following 2 years than non-attendees. CONCLUSION: Receiving regular primary care was the strongest predictor of attending a DEC, suggesting that DECs are not substitute providers of diabetes care for people without a regular physician. Increased retinal screening among DEC attendees suggests that self-management education improved their self-efficacy to ensure adequate screening was performed. PRACTICE IMPLICATIONS: The findings characterize the types of people who attend DECs, which may lead to identification and targeting of inequities in access. The findings also highlight the influence diabetes education can have on quality of care in real-world practice.     

Health literacy in rural and urban populations: A systematic review

ObjectiveThis review assessed whether health literacy differences exist between rural and urban populations and whether rurality is a determinant.MethodsEight online databases were searched using the keywords “health literacy”, “rural” and “urban”, and related terms. Peer-reviewed original research comparing health literacy levels between rural and urban populations were evaluated for strength of evidence. A narrative synthesis summarised the results of included studies.ResultsNineteen articles met inclusion criteria and were of sufficient methodological quality for data extraction. The majority of studies found that urban populations had higher health literacy than rural populations. Differences were more likely to be found in developing than developed countries. Studies that performed covariate analysis indicated that rurality may not be a significant determinant of health literacy.ConclusionEvidence suggests that rurality alone does not explain rural-urban health literacy differences and that sociodemographic factors play important roles.Practice implicationsThese findings could be used to help inform the development of evidence-based interventions specifically for rural populations, at both health policy and clinical levels; for example, by tackling healthcare access challenges. The findings also provide a lens through which to consider efforts to reduce rural-urban health outcome disparities.     

Literacy skills,language use,and online health information seeking among Hispanic adults in the United States

ObjectiveOnline health information is underutilized among Hispanics with low English proficiency in the U.S. This study examines the association between a unique measure of general English literacy, language use, and online health information seeking among Hispanic adults.MethodsData for Hispanics ages 25–65 (N = 700) come from the 2012/2014 Program for International Assessment of Adult Competencies (PIAAC). Binary logistic regression models were used to predict online health information seeking as a function of literacy skill scores (0–500 points) and primary language use (Spanish vs. other).ResultsLiteracy (Odds-Ratio = 1.012, p < 0.001) was a positive predictor, while speaking Spanish at home (Odds-Ratio = 0.352, p < 0.01) was a negative predictor of online health information seeking.ConclusionLiteracy skills and language use appear to be separate contributors of online health information seeking among Hispanic adults.Practice implicationsOnline health information providers should be aware of literacy skills and Spanish language use as barriers to online health information seeking among Hispanics, particularly those who have both limited literacy skills and predominantly Spanish language use.     

Development and validation of subscales to assess perceived support for self-management of mood or emotional problems: Results from a randomized trial

ObjectivesTo validate 2 new patient-reported measures of self-management support from health professionals for mood and emotional problems.MethodsThe sample comprised primary care patients with chronic physical conditions and co-morbid depressive symptoms enrolled in a randomized trial of telephone coaching of a depression self-care intervention (n = 120). At 6-month follow-up, patients completed 2 subscales with respect to support for self-management of their chronic physical condition(s): 1) Self-Management Information (SMInfo-Phys); and 2) Care Plan (CP-Phys) and equivalent subscales adapted to assess self-management support for mood and emotional problems: SMInfo-Mood and CP-Mood. Subscale scoring was assessed with Item Response Theory (IRT) analysis. Convergent validity of the mood subscales was assessed. The sensitivity of the mood and physical condition subscales to mental health interventions was assessed with generalized estimating equations (GEE).ResultsThe mood subscales were associated with relevant measures of perceived unmet mental health needs. Both SMInfo-Mood and CP-Mood were sensitive to the coaching intervention; CP-Mood was also sensitive to receipt of depression treatment outside the trial.ConclusionThis study provides preliminary evidence for the validity of the 2 new subscales.Practice implicationsThe subscales may be used to assess perceived health professional support for self-management of mood and emotional problems.     

The Violence Epidemic in the African American Community: A Call by the National Medical Association for Comprehensive Reform

While much progress has occurred since the civil rights act of 1964, minorities have continued to suffer disparate and discriminatory access to economic opportunities, education, housing, health care and criminal justice. The latest challenge faced by the physicians and public health providers who serve the African American community is the detrimental, and seemingly insurmountable, causes and effects of violence in impoverished communities of color. According to statistics from the Centers for Disease Control (CDC), the number one killer of black males ages 10–35 is homicide, indicating a higher rate of violence than any other group. Black females are four times more likely to be murdered by a boyfriend or girlfriend than their white counterparts, and although intimate partner violence has declined for both black and white females, black women are still disproportionately killed. In addition, anxiety and depression that can lead to suicide is on the rise among African American adolescents and adults. Through an examination of the role of racism in the perpetuation of the violent environment and an exploration of the effects of gang violence, intimate partner violence/child maltreatment and police use of excessive force, this work attempts to highlight the repercussions of violence in the African American community. The members of the National Medical Association have served the African American community since 1895 and have been advocates for the patients they serve for more than a century. This paper, while not intended to be a comprehensive literature review, has been written to reinforce the need to treat violence as a public health issue, to emphasize the effect of particular forms of violence in the African American community and to advocate for comprehensive policy reforms that can lead to the eradication of this epidemic. The community of African American physicians must play a vital role in the treatment and prevention of violence as well as advocating for our patients, family members and neighbors who suffer from the preventable effects of violence.