Using Community-Based Participatory Research to Identify Environmental Justice Issues in an Inner-City Community and Inform Urban Planning.

The Southeast CARE Coalition has been using community-based participatory research to examine environmental degradation in the Southeast Community, Newport News, Virginia. A survey was developed to collect assessment data. Up to 66% of respondents were concerned about environmental problems in their community. Those with health conditions were significantly more likely to identify specific environmental problems. The top 5 environmental concerns included coal dust, air quality, crime, water quality, and trash. The community-based participatory research process is building community capacity and participation, providing community input into strategic planning, and empowering community members to take control of environmental justice issues in their community.

Self-efficacy and barriers to multiple behavior change in low-income African Americans with hypertension.

Behavioral risk factors are among the preventable causes of health disparities, yet long-term change remains elusive. Many interventions are designed to increase self-efficacy, but little is known about the effect on long-term behavior change in older, low-income African Americans, especially when facing more problematic barriers. A cohort of 185 low-income African-Americans with hypertension reported barriers they encountered while undergoing a multiple behavior change trial from 2002 to 2006. The purpose of the present study was to explore the relationships between self-efficacy, barriers, and multiple behavior change over time. Higher self-efficacy seemed to be partially helpful for smoking reduction and increasing physical activity, but not for following a low-sodium diet. Addiction was indirectly associated with less reduction in smoking through lower self-efficacy. Otherwise, different barriers were associated with behavior change than were associated with self-efficacy: being "too busy" directly interfered with physical activity and "traditions" with low-sodium diet; however, they were neither the most frequently reported barriers, nor associated with lower self-efficacy. This suggests that an emphasis on self-efficacy alone may be insufficient for overcoming the most salient barriers encountered by older African Americans. Additionally, the most common perceived barriers may not necessarily be relevant to long-term behavioral outcomes.

Gender Differences in Self-Efficacy for Diabetes Self-Management Among Hispanics: The Mediating Role of Perceived Support and Depressive Symptoms.

PURPOSE: The purpose of this study is to examine the extent to which perceived support and depressive symptoms might interfere with Hispanic patients' ability to manage their diabetes and whether these effects vary by gender. METHODS: Data were collected from a cohort of 232 Hispanic men and women with type 2 diabetes mellitus (T2DM). Conditional process analysis was used to test a moderated mediation model of the time-lagged processes associating gender, diabetes support, and depressive symptoms with reported self-efficacy after 3 months. RESULTS: Increased depressive symptoms were associated with lower self-efficacy, but the conditional effects varied among men and women. The index of moderated mediation was significant, indicating that among women, the indirect effect of depressive symptoms on self-efficacy was contingent on lower levels of perceived support. Among men, increased depressive symptoms were directly associated with declines in self-efficacy and were not conditional on perceived support. CONCLUSIONS: Results of the study have important implications for gender health equity. Mental health screening and an assessment of support needs may be important for determining appropriate complementary therapies when treating Hispanic women with chronic conditions such as diabetes. Attention to possible differences in gender-specific mental health needs could lead to improved self-management, better glycemic control, and more equitable health outcomes.

Effect of a physician uncertainty reduction intervention on blood pressure in uncontrolled hypertensives--a cluster randomized trial.

BACKGROUND: Clinical inertia, provider failure to appropriately intensify treatment, is a major contributor to uncontrolled blood pressure (BP). Some clinical inertia may result from physician uncertainty over the patient's usual BP, adherence, or value of continuing efforts to control BP through lifestyle changes. OBJECTIVE: To test the hypothesis that providing physicians with uncertainty reduction tools, including 24-h ambulatory BP monitoring, electronic bottle cap monitoring, and lifestyle assessment and counseling, will lead to improved BP control. DESIGN: Cluster randomized trial with five intervention clinics (IC) and five usual care clinics (UCC). SETTING: Six public and 4 private primary care clinics. PARTICIPANTS: A total of 665 patients (63 percent African American) with uncontrolled hypertension (BP ≥140 mmHg/90 mmHg or ≥130/80 mmHg if diabetic). INTERVENTIONS: An order form for uncertainty reduction tools was placed in the IC participants' charts before each visit and results fed back to the provider. OUTCOME MEASURES: Percent with controlled BP at last visit. Secondary outcome was BP changes from baseline. RESULTS: Median follow-up time was 24 months. IC physicians intensified treatment in 81% of IC patients compared to 67% in UCC (p < 0.001); 35.0% of IC patients and 31.9% of UCC patients achieved control at the last recorded visit (p > 0.05). Multi-level mixed effects longitudinal regression modeling of SBP and DBP indicated a significant, non-linear slope difference favoring IC (p (time × group interaction) = 0.048 for SBP and p = 0.001 for DBP). The model-predicted difference attributable to intervention was -2.8 mmHg for both SBP and DBP by month 24, and -6.5 mmHg for both SBP and DBP by month 36. CONCLUSIONS: The uncertainty reduction intervention did not achieve the pre-specified dichotomous outcome, but led to lower measured BP in IC patients.

Psychosocial Contributors to Depressive Symptoms in Hispanic Patients With Type 2 Diabetes.

PURPOSE: The purpose of this study is to identify psychosocial factors associated with depressive symptoms in Hispanic patients with diabetes and explore the extent to which their effects may vary by gender and acculturation. METHODS: The authors completed a secondary analysis of data from 247 Hispanic adults with type 2 diabetes. Gender and language groups were compared using chi-square and t tests. Hierarchical multiple regression was used to examine associations of depressive symptoms with perceived support, diabetes-related distress, and social and personal factors. RESULTS: Women reported less support than men. English speakers reported more depressive symptoms than Spanish speakers. When adjusting for age, gender, and acculturation, psychosocial factors significantly associated with depressive symptoms included less support received, greater emotional burden, and less ability to socialize or pursue normal activities because of diabetes. CONCLUSIONS: Social support provided by family among less acculturated Hispanics may play an important role in reducing emotional burden and lowering the risk of comorbid depression. The quality of interpersonal relationships and the ability to continue normal activities may also be important. More acculturated Hispanic women with diabetes may be at greater risk for comorbid depression and worse health outcomes. Screening for depression and assessment of support needs is warranted for Hispanic women.

Culture and the social context of health inequalities.

There is a great deal of recent interest and debate concerning the linkages between inequality and health cross-nationally. The U.S. National Institutes of Health recommended in 2001 that any new research on health disparities should include social and cultural systems as units of analysis. Nevertheless, many public health interventions and policies continue to decontextualize risk factors from the social environment. Exposures to social and health inequalities probably vary as a consequence of different cultural contexts. To identify the processes that cause social and health inequalities, it is important to understand culture's influence. Navarro's research on political institutions and inequality illustrates the role of cultural context, although indirectly. Policies reflect cultural values because politicians typically translate their constituents' dominant values into policy. Political systems and structural inequality are institutionalized manifestations of cultural differences that intervene between dominant cultural dimensions at the societal level and health. The authors present a theoretical framework that combines constructs from sociological theory and cross-cultural psychology to identify potential pathways leading from culture and social structure to social and health inequalities. Only when all levels are taken into consideration is it possible to come up with effective, sustainable policies and interventions.

The cultural production of health inequalities: a cross-sectional, multilevel examination of 52 countries.

In a 2001 report, the U.S. National Institutes of Health called for more integration of the social sciences into health-related research, including research guided by theories and methods that take social and cultural systems into consideration. Based on a theoretical framework that integrates Hofstede's cultural dimensions with sociological theory, the authors used multilevel modeling to explore the association of culture with structural inequality and health disparities. Their results support the idea that cultural dimensions and social structure, along with economic development, may account for much of the cross-national variation in the distribution of health inequalities. Sensitivity tests also suggest that an interaction between culture and social structure may confound the relationship between income inequality and health. It is necessary to identify important cultural and social structural characteristics before we can achieve an understanding of the complex, dynamic systems that affect health, and develop culturally sensitive interventions and policies. This study takes a step toward identifying some of the relevant cultural and structural influences. More research is needed to explore the pathways leading from the sociocultural environment to health inequalities.

Social capital, income inequality, and self-rated health in 45 countries.

There has been growing interest in the relationship between the social environment and health. Among the concepts that have emerged over the past decade to examine this relationship are socio-economic inequality and social capital. Using data from the World Values Survey and the World Bank, we tested the hypothesis that self-rated health is affected by social capital and income inequality cross-nationally. The merit of our approach was that we used multilevel methods in a larger and more diverse sample of countries than used previously. Our results indicated that, for a large number of diverse countries, commonly used measures of social capital and income inequality had strong compositional effects on self-rated health, but inconsistent contextual effects, depending on the countries included. Cross-level interactions suggested that contextual measures can moderate the effect of compositional measures on self-rated health. Sensitivity tests indicated that effects varied in different subsets of countries. Future research should examine country-specific characteristics, such as differences in cultural values or norms, which may influence the relationships between social capital, income inequality, and health.

Hispanic Acculturation and Gender Differences in Support and Self-Efficacy for Managing Diabetes.

PURPOSE: The purpose of this study was to determine whether perceived support, social norms, and their association with self-efficacy varied by gender and language-based acculturation in Hispanic men and women with uncontrolled type 2 diabetes mellitus (T2DM). METHODS: A cross-sectional, secondary analysis of baseline survey data from a randomized control trial. Participants were 248 Hispanic patients from 4 community health centers who participated in a culturally targeted intervention for diabetes management. Quantitative statistical methods were used, including chi-square analyses, one-way ANOVA, and multiple regression. RESULTS: Gender and language both moderated the relationship between social factors and self-efficacy. Regardless of language, better perceived support was associated with improved self-efficacy in women but not men. Dietary norms were associated with self-efficacy in English-speaking men and women, while physical activity norms were associated with self-efficacy for Spanish-speaking women only. CONCLUSIONS: This study builds on previous research by exploring the extent to which the social context of diabetes self-management may vary in its effects depending on gender and acculturation. The findings revealed potentially important differences based on both gender and language, suggesting that interventions must be designed with these differences in mind. Diabetes-specific support from family members, especially spouses, may be especially important for Hispanic women. For both men and women, it may be effective to find creative ways of involving the family in creating healthier social norms and expectations.

Social factors and barriers to self-care adherence in Hispanic men and women with diabetes.

OBJECTIVE: To explore quantitatively the extent to which social support, social norms and barriers are associated with self-efficacy and self-care adherence in Hispanic patients with diabetes and the extent to which these differ for men and women. METHODS: Baseline survey data were collected from 248 low-SES, Hispanic men and women who were participants in a randomized controlled trial of a culturally targeted intervention for diabetes management. Student's t, Pearson correlations and multiple regression were used to analyze the data. RESULTS: Compared to men, women were less likely to receive support, faced more barriers, reported less self-efficacy and had lower levels of self-care adherence. Perceived support was consistently correlated with better self-efficacy in women but not men, even though men reported higher levels of support. CONCLUSION: The lack of adequate support seems to be a fundamental barrier for Hispanic women with diabetes. PRACTICE IMPLICATIONS: Health care providers should be sensitive to sociocultural influences in Hispanic groups that may facilitate men's self-care adherence, but could potentially hamper women's efforts. Interventions designed for Hispanics should augment women's support needs and address culture and social factors that may differentially impact the ability of men and women to manage their diabetes.