Facilitators and Barriers of a Chronic Care Management Intervention Addressing Diabetes Among Mexican-Origin Adults.

BACKGROUND: Chronic care management (CCM) and community health worker (CHW) interventions hold promise for managing complex chronic conditions such as diabetes and related comorbidities. This qualitative study examines facilitators and barriers to the implementation of an expanded CCM intervention that explicitly incorporated program staff, clinic staff, CHWs, and partnerships with community-based organizations to enhance diabetes management among Mexican-origin adults. METHOD: Grounded theory was used to analyze interviews conducted in 2018 with 24 members of the CCM team, including program staff, clinic staff, and community-based program partner staff. RESULTS: Three themes emerged that characterize perceived facilitators and barriers to CCM implementation, based on analysis of interviews: (1) understanding roles and responsibilities across organizations, (2) building relationships across organizations, and (3) coordinating delivery of the model among different organizations. First, structured meetings and colocated workspaces enhanced understanding of CCM roles for each team member and across organizations. Barriers to understanding CCM roles were more common during the early stages of CCM implementation and amongst staff who did not participate in regular meetings. Second, regular meetings facilitated development of relationships across organizations to enhance implementation of the CCM model. In contrast, limited relationship building among some CCM team members served as a barrier to implementation. Third, CHWs and case review meetings fostered communication and coordination across the CCM model. CONCLUSIONS: Results suggest the importance of understanding roles and building relationships among multidisciplinary teams to ensure effective communication and coordination of care.

Improved diabetes control among low-income Mexican Americans through community-clinical interventions: results of an RCT.

INTRODUCTION: This randomized controlled trial investigated community-clinical intervention strategies for a Mexican American population who had not demonstrated control of their diabetes. We tested a control program (Salud y Vida 1.0) supporting diabetes management versus an enhanced version (Salud y Vida 2.0) for reductions in HbA1c at 12 months. RESEARCH DESIGN AND METHODS: Adults with uncontrolled diabetes (n=353) were enrolled if they had an HbA1c≥9.0% during a program or doctor's visit between 6 and 36 months of their receipt of SyV 1.0 services, were patients at one of two clinics in local counties, and had an HbA1c≥8.0% at SyV 2.0 baseline enrollment. The control and intervention arms were coordinated by community health workers and the intervention arm included the control program enhanced with medication therapy management; behavioral health services; peer-led support groups; and additional community-based lifestyle programs also open to the family. RESULTS: At 12 months, both study arms improved HbA1c (mean, (CI), Control (-0.47 (-0.74 to -0.20)) and intervention (-0.48 (-0.76 to -0.19)). The intervention group maintained HbA1c levels after month 6, whereas control group HbA1c levels slightly increased (adjusted mean from 9.83% at month 6%-9.90% at month 12). Also, HbA1c was examined by level of participant engagement. The high engagement group showed a decreasing trend over the study period, while control and lower engagement groups failed to maintain HbA1c levels at month 12. CONCLUSIONS: Improved HbA1c was found among a population that had not demonstrated diabetes management prior; however, mean HbA1c values were above clinical guideline recommendations. The randomized control trial findings provide additional evidence that extended time and intervention supports may be needed for populations experiencing inequities in social determinants of health. TRIAL REGISTRATION NUMBER: NCT04035395.

Role of Landlords in Creating Healthy Homes: Section 8 Landlord Perspectives on Healthy Housing Practices.

PURPOSE: This article presents qualitative research findings of Section 8 landlord perceptions regarding healthy housing practices to inform landlord-focused initiatives. Approach or Design: Five focus groups were conducted with landlords. SETTING: Boston, Massachusetts. PARTICIPANTS: Section 8 landlords participated in focus groups (n = 39). METHOD: Focus group transcripts were coded for key themes using a grounded theory approach. RESULTS: Landlords' primary challenges to creating a healthy housing environment included tenant behavior, financial burden, and policy enforcement; tenant safety and cost savings were seen as primary benefits. CONCLUSION: Landlords play a critical role in implementing healthy housing practices. Several opportunities exist to reduce barriers and capitalize on perceived benefits of implementing these practices, including increasing access to educational and financial resources.

Participation in Clinical Research Registries: A Focus Group Study Examining Views From Patients With Arthritis and Other Chronic Illnesses.

OBJECTIVE: Patient registries have contributed substantially to progress in clinical research in rheumatic diseases. However, not much is known about how to optimize the patient experience in such registries. We assessed patient views, motivations, and potential barriers towards participation in registry research to better understand how registries can be improved to maximize patient engagement. METHODS: Focus groups were held with 23 patients (mean ± SD age 59 ± 13 years) from the Boston area and led by a bilingual moderator trained in focus group methodology, using a semistructured moderator guide. Three separate focus groups were conducted to thematic saturation: patients with rheumatoid arthritis (RA) who had registry experience, patients with any chronic illness, and Spanish-speaking patients with RA or osteoarthritis. Patients in the latter 2 groups had no prior registry experience. Focus groups were audiotaped and transcribed. Four researchers independently analyzed transcripts using open data coding to identify themes. A normative group process was used to consolidate and refine themes. RESULTS: Seven major themes were identified, including personalization/convenience of data collection, trust and confidentiality, camaraderie, learning about yourself and your disease, altruism, material motivators, and capturing mental health and other elements of the lived experience. We observed distinct differences in the discussion content of the Spanish-speaking patients compared to the English-speaking patients. CONCLUSION: This study identified patient attitudes towards registry research among those with and without prior experience in a registry. The results provide insight into strategies for registry design to maximize patient engagement, which can lead to more robust registry data.

Phenotypic and molecular characterization of Mycobacterium tuberculosis isolates resistant to both isoniazid and ethambutol.

In performing radiometric susceptibility testing on over 2,000 patient isolates of Mycobacterium tuberculosis during the past 6 years, we found that resistance to 7.5 microg/ml ethambutol (EMB) occurred only in isolates that are also resistant to 0.4 microg/ml isoniazid (INH). Using 157 selected isolates in the present study, we performed radiometric and agar proportion susceptibility tests and DNA sequencing of genetic regions associated with resistance to these two drugs. The goal was to study the occurrence of the common mutations associated with resistance to each drug and also to determine whether any particular INH-resistance-associated mutation occurred more often in combination with any particular EMB-resistance-associated mutation. In an analysis of 128 isolates resistant to 0.4 microg/ml INH, we found that a mutation at katG Ser315 was more common in isolates also resistant to 7.5 microg/ml EMB (61 of 67=91.0%) than in isolates either susceptible to EMB or resistant to 2.5 microg/ml EMB (39 of 60=65.0%). These observations suggest that INH-resistant strains with a mutation at katG Ser315 are more likely to acquire resistance to 7.5 microg/ml EMB than are isolates with INH-resistance-associated mutations at other sites. In addition, we found that 64 of 67 (95.5%) isolates resistant to 7.5 microg/ml EMB contained a mutation in either codon 306 or codon 406 of embB. Met306Val was the most common embB mutation, present in 52 (77.6%) of the 67 isolates. Most occurrences of this mutation (49 of 52=94.2%) were found in isolates that also contained the katG Ser315Thr mutation. Finally, sequencing this region of embB appears to be sufficiently sensitive for use as a rapid screening tool for detection of high-level resistance to EMB.