Metabolic health disparities driven by financial stress: Behavioural adaptation or modification?

Financial stress has been linked to an increased risk of metabolic syndrome, yet, it remains unclear whether suboptimal sleep duration and physical inactivity are the adaptive responses to financial stress or effect modifiers in the association between financial stress and metabolic syndrome. Hence, this study aims to examine whether physical activity and sleep duration mediate or moderate the bivariate association between financial stress and metabolic syndrome. A prospective secondary analysis was conducted using data from the Wisconsin Sleep Cohort Study (N = 445, mean [SD] age = 64 [7] years). Baseline moderation effect was examined using subgroup analysis with model constraints; prospective mediation model was examined using bias-corrected bootstrap confidence intervals. Results indicate that participants with higher financial stress were less likely to meet physical activity and sleep recommendations. Baseline moderation analysis indicates that meeting current recommendations of sleep duration and physical activity attenuated the association between financial stress and metabolic syndrome. In the prospective mediation analysis, weekly physical activity levels partially mediated the relationship between financial stress and metabolic syndrome, but sleep duration did not mediate this relationship. In conclusion, the joint effect of optimal sleep duration and physical activity disassociates financial stress from the risk of metabolic syndrome. Future interventions addressing metabolic risk might achieve better outcomes if clinicians and researchers factor in the behavioral adaptation of physical inactivity in financially stressed adults (Clinical Trial Registration: NCT00005557).

Mixed Methods Study of Nurse Assessment of Patient Preferences for Engagement During Hospitalization.

BACKGROUND: Global healthcare initiatives emphasize the importance of engaging patients in their healthcare to improve patients' experience and outcomes. Assessing patient preferences for engagement is critical, as there are many ways patients can engage in their care and preferences vary across individuals. OBJECTIVE: The primary purpose of this study was to evaluate the effect of implementation of the Patient Preferences for Engagement Tool 13-Item Short Form (PPET13) during hospitalization on patient and nurse experience of engagement. Readmissions and emergency department (ED) usage within 30 days postdischarge were also examined. METHODS: The mixed methods study was conducted within two medical units in the United States between December 2018 and May 2019. Preimplementation group patients completed a demographic survey and the Patient Experience of Engagement Survey (PEES) on discharge. Implementation group patients completed the PPET13 within 24 hours of admission with their nurse and the demographic survey and PEES on discharge. A focus group with nurses who implemented the PPET13 was conducted following the implementation period. Data analysis included confirmatory factor analysis, multiple and logistic regression, and qualitative content analysis. RESULTS: There was significant improvement in PEES scores during the implementation phase. The PEES score was a significant predictor of ED visits, but not 30-day readmissions. Nurses were not always certain how to best integrate patient preferences for engagement into their care delivery and suggested integrating the PPET13 into the electronic health record to assist with streamlining the assessment and communicating preferences across the care team. DISCUSSION: Assessing patients' preferences for engagement using the PPET13 was associated with an improved experience of engagement, which was found to mediate the relationship between utilization of PPET13 and ED usage within 30 days postdischarge. Use of a patient engagement preference tool, such as the PPET13, can help inform the delivery of individualized engagement strategies to improve patient and family engagement and outcomes; however, nurses need formalized education on how to tailor their care to meet the individual engagement preferences of their patients.

Gender Differences in the Relationship Between Financial Stress and Metabolic Abnormalities.

BACKGROUND: Financial stress is associated with higher prevalence of metabolic abnormalities and cardiovascular disease, but the extent to which this association differs by type of metabolic abnormalities or gender is unclear. OBJECTIVES: The study aims were (a) to examine the association between financial stress and the prevalence of common metabolic abnormalities and (b) to test the association for gender differences. METHODS: A cross-sectional secondary analysis was conducted using data from the Retirement and Sleep Trajectories study, an ancillary study of the Wisconsin Sleep Cohort study. Composite indicator structural equation alpha modeling with a stacking approach was applied in the data analysis. RESULTS: After controlling for covariates, financial stress was positively associated with the prevalence of abdominal obesity, metabolic syndrome, and dyslipidemia, with significant gender differences. Among men, financial stress was positively associated with the prevalence of hypertriglyceridemia. Among women, financial stress was positively associated with the prevalence of prediabetes, abdominal obesity, metabolic syndrome, and dyslipidemia. CONCLUSION: Men living with financial stress are more likely to have hypertriglyceridemia, a specific metabolic abnormality and risk factor for acute cardiovascular events. However, financial stress in women is associated with a broader array of metabolic abnormalities (e.g., dyslipidemia, prediabetes, abdominal obesity, metabolic syndrome), highlighting a potential risk of multiple chronic conditions later in life.

Influence of race/ethnicity and income on the link between adverse childhood experiences and child flourishing.

BACKGROUND: The impact of early adversity increases the risk of poor outcomes across the life course. Identifying factors that protect against or contribute to deleterious life outcomes represents an important step in resilience promotion among children exposed to adversity. Informed by resilience science, we hypothesized that family resilience mediates the relationship between adverse childhood experiences (ACEs) and child flourishing, and these pathways vary by race/ethnicity and income. METHODS: We conducted a secondary data analysis using the 2016-17 National Survey of Children's Health data reported by parents/guardians for 44,686 children age 6-17 years. A moderated-mediation model estimated direct, indirect, and total effects using a probit link function and stacked group approach with weighted least square parameter estimates. RESULTS: The main variables were related in expected directions. Family resilience partially mediated the ACEs-flourishing association. Although White and socioeconomically advantaged families were more likely to maintain family resilience, their children functioned more poorly at high-risk levels relative to Black and Hispanic children and across income groups. CONCLUSION: Children suffer from cumulative adversity across race/ethnicity and income. Partial mediation of family resilience indicates that additional protective factors are needed to develop comprehensive strategies, while racial/ethnic differences underscore the importance of prevention and intervention programs that are culturally sensitive. IMPACT: The key message of the article reinforces the notion that children suffer from cumulative adversity across race/ethnicity and income, and prevention of ACEs should be the number one charge of public policy, programs, and healthcare. This is the first study to examine family resilience in the National Survey Children's Health (NSCH) data set as mediating ACEs-flourishing by race/ethnicity and family poverty level. Examining an ACEs dose-response effect using population-based data within the context of risk and protective factors can inform a public health response resulting in a greater impact on prevention efforts.

Rasch Analysis of The WURSS-21 Dimensional Validation and Assessment of Invariance.

BACKGROUND: The purpose of this study is to use Rasch analysis to explore the validity of considering self-report scores from Wisconsin Upper Respiratory Symptom Survey (WURSS-21) as a single global illness severity domain. The WURSS-21 is a widely used questionnaire instrument that assesses symptom severity and functional impact of common cold and flu-like illness. METHODS: This study applies item response theory, specifically Rasch modeling, to investigate dimensional and measurement properties of the WURSS-21, and looks at invariance over time. The data assessed represents 1167 people, each scoring the WURSS-21 once daily for up to seven consecutive days of acute upper respiratory infection (URI) illness. RESULTS: Rasch analysis supports a single domain WURSS-21 global symptom score. Assessment of differential item functioning across seven days of illness provides evidence for measurement invariance. While individual items rating physical symptoms were somewhat variable, items rating functional impairment and quality of life impact appeared quite consistent across a single domain over seven days of illness. CONCLUSION: Rasch analysis of WURSS-21 items provides evidential support for a single invariant domain. These findings support the practice of using a simply summed daily global illness severity score to represent the overall symptomatic and functional impairments arising from URI.

Impact of Work Conditions and Minority Patient Populations on Quality and Errors.

OBJECTIVES: To determine whether workplace conditions affect care quality and errors, especially in primary care clinics serving minority patients. METHODS: We conducted a 3-year assessment of work conditions and patient outcomes in 73 primary care clinics in the upper Midwest and New York City. Study participants included 287 physicians and 1204 patients with hypertension and/or diabetes. Chart audit data were contrasted between clinics with ≥30% minority patients (minority-serving clinics, or MSCs) and those with <30% (nonminority-serving clinics, or NMSCs). Physicians reported on time pressure, work control, clinical resources, and specialty referral access; managers described room availability; and chart audits determined care errors and quality. Two-level hierarchical models tested work conditions as mediators between MSC status and clinical outcomes. RESULTS: Error rates were higher in MSCs than NMSCs (29.6% vs 24.8%, P < .05). Lack of clinical resources explained 41% of the effect of MSC status on errors (P < .05). Diabetes control was poorer in MSCs than in NMSCs (53.8% controlled vs 76.1%, P < .05); lack of clinical resources explained 24% of this difference (P < .05). Room availability increased quality in both MSCs and NMSCs by 5.95% for each additional room per clinician per session. Lack of access to rooms and specialists decreased the likelihood of blood pressure control in MSCs. CONCLUSION: Work conditions such as clinical resources, examination room availability, and access to referrals are significantly associated with errors and quality, especially in MSCs.

Development and validation of PRISM: a survey tool to identify diabetes self-management barriers.

AIMS: Although most children with type 1 diabetes do not achieve optimal glycemic control, no systematic method exists to identify and address self-management barriers. This study develops and validates PRISM (Problem Recognition in Illness Self-Management), a survey-based tool for efficiently identifying self-management barriers experienced by children/adolescents with diabetes and their parents. METHODS: Adolescents 13 years and older and parents of children 8 years and older visiting for routine diabetes management (n=425) were surveyed about self-management barriers. HbA1c was abstracted from the electronic health record. To develop PRISM, exploratory and confirmatory factor analyses were used. To assess validity, the association of PRISM scores with HbA1c was examined using linear regression. RESULTS: Factor analyses of adolescent and parent data yielded well-fitting models of self-management barriers, reflecting the following domains: (1) Understanding and Organizing Care, (2) Regimen Pain and Bother, (3) Denial of Disease and Consequences, and (4) Healthcare Team, (5) Family, or (6) Peer Interactions. All models exhibited good fit, with χ(2) ratios<2.21, root mean square errors of approximation<0.09, Confirmatory Fit Indices and Tucker-Lewis Indices both >0.92, and weighted root mean square residuals<1.71. Greater PRISM barrier scores were significantly associated with higher HbA1cs. CONCLUSIONS: Our findings suggest at least six different domains exist within self-management barriers, nearly all of which are significantly related to HbA1c. PRISM could be used in clinical practice to identify each child and family's unique self-management barriers, allowing existing self-management resources to be tailored to the family's barriers, ultimately improving effectiveness of such services.

Communicating advanced cancer patients' symptoms via the Internet: a pooled analysis of two randomized trials examining caregiver preparedness, physical burden, and negative mood.

BACKGROUND: Using available communication technologies, clinicians may offer timely support to family caregivers in managing symptoms in patients with advanced cancer at home. AIM: To assess the effects of an online symptom reporting system on caregiver preparedness, physical burden, and negative mood. DESIGN: A pooled analysis of two randomized trials (NCT00214162 and NCT00365963) was conducted to compare caregiver outcomes at 6 and 12 months after intervention between two randomized, unblinded groups using General Linear Mixed Modeling. Caregivers in one group (Comprehensive Health Enhancement Support System-Only) were given access to an interactive cancer communication system, the Comprehensive Health Enhancement Support System. Those in the other group (Comprehensive Health Enhancement Support System + Clinician Report) received access to Comprehensive Health Enhancement Support System plus an online symptom reporting system called the Clinician Report. Clinicians of patients in the Comprehensive Health Enhancement Support System + Clinician Report group received e-mail alerts notifying them when a symptom distress was reported over a predetermined threshold. SETTING/PARTICIPANTS: Dyads (n = 235) of advanced-stage lung, breast, and prostate cancer patients and their adult caregivers were recruited at five outpatient oncology clinics in the United States. RESULTS: Caregivers in the Comprehensive Health Enhancement Support System + Clinician Report group reported less negative mood than those in the Comprehensive Health Enhancement Support System-Only group at both 6 months (p = 0.009) and 12 months (p = 0.004). Groups were not significantly different on caregiver preparedness or physical burden at either time point. CONCLUSIONS: This study provides new evidence that by using an online symptom reporting system, caregivers may experience less emotional distress due to the Clinician Report's timely communication of caregiving needs in symptom management to clinicians.

Gender differences in financial hardships of medical debt.

Women are more likely than men to forgo, delay, and ration medical care because of medical debt. Using 2003-04 Community Tracking Study Household Survey data, this study examined gender differences in five financial hardships associated with medical debt. Regression analyses accounting for predisposing, enabling, and need factors of health services use indicated women were less likely to report being contacted by a collection agency (b=-0.15, p<.05), using savings (b=-0.23, p<.005), or having any financial hardships associated with medical debt (b=-0.24, p<.05). There were no significant gender differences in putting off major purchases, borrowing money, and problems paying for necessities. Similarly, there were positive and negative relationships between medical debt financial hardships and income, insurance, and health status. Findings suggest that making health care affordable and equitable is critically important for both men and women. Research is needed to understand the differential impact of medical debt, especially among disadvantaged populations.

Employed family physician satisfaction and commitment to their practice, work group, and health care organization.

OBJECTIVE: Test a model of family physician job satisfaction and commitment. DATA SOURCES/STUDY SETTING: Data were collected from 1,482 family physicians in a Midwest state during 2000-2001. The sampling frame came from the membership listing of the state's family physician association, and the analyzed dataset included family physicians employed by large multispecialty group practices. STUDY DESIGN AND DATA COLLECTION: A cross-sectional survey was used to collect data about physician working conditions, job satisfaction, commitment, and demographic variables. PRINCIPAL FINDINGS: The response rate was 47 percent. Different variables predicted the different measures of satisfaction and commitment. Satisfaction with one's health care organization (HCO) was most strongly predicted by the degree to which physicians perceived that management valued and recognized them and by the extent to which physicians perceived the organization's goals to be compatible with their own. Satisfaction with one's workgroup was most strongly predicted by the social relationship with members of the workgroup; satisfaction with one's practice was most strongly predicted by relationships with patients. Commitment to one's workgroup was predicted by relationships with one's workgroup. Commitment to one's HCO was predicted by relationships with management of the HCO. CONCLUSIONS: Social relationships are stronger predictors of employed family physician satisfaction and commitment than staff support, job control, income, or time pressure.

Perceived influences on physical activity and diet in low-income adults from two rural counties.

BACKGROUND: Despite the increased use of ecological models in health behavior research, multilevel influences on health behaviors in rural, low-income people, an aggregate at high risk for sedentary behavior and inadequate diets, have been examined in few studies. OBJECTIVE: The purpose of this study was to describe influences on physical activity and diet in low-income, rural adults. METHOD: A cross-sectional survey was conducted using face-to-face interviews in a convenience sample of 137 low-income Anglo and Latino adults recruited from two rural Wisconsin counties. The survey included questions on health behaviors, self-efficacy, barriers, social support, and community environments. Self-report data on physical activity and fruit and vegetable intake were categorized into outcome variables of meets recommendation or does not meet recommendation. Latent class cluster analysis was used to identify clusters of participants with similar influences on health behaviors, and cluster membership was used as an independent variable in logistic regression of physical activity and diet outcomes. RESULTS: Fifty-two percent of participants met a recommendation for physical activity, but only 8% met their MyPyramid recommendation for fruit and vegetable intake. Participants in the moderate self-efficacy/high safety cluster were significantly more likely than those in the low self-efficacy/moderate safety cluster to meet a recommendation for physical activity (odds ratio = 2.65). For healthy diet, participants in the low barriers cluster were significantly more likely to eat more fruits and vegetables (odds ratio = 4.13) than those in the high barriers cluster. DISCUSSION: People with healthier behaviors were distinguished from those with less healthy behaviors by higher levels of intrapersonal, interpersonal, and community supports. Results support the importance of multilevel approaches to promoting healthy lifestyles in rural, low-income adults.

Separate and unequal: clinics where minority and nonminority patients receive primary care.

BACKGROUND: Few studies have examined the influence of physician workplace conditions on health care disparities. We compared 96 primary care clinics in New York, New York, and in the upper Midwest serving various proportions of minority patients to determine differences in workplace organizational characteristics. METHODS: Cross-sectional data are from surveys of 96 clinic managers, 388 primary care physicians, and 1701 of their adult patients with hypertension, diabetes mellitus, or congestive heart failure participating in the Minimizing Error, Maximizing Outcome (MEMO) study. Data from 27 clinics with at least 30% minority patients were contrasted with data from 69 clinics with less than 30% minority patients. RESULTS: Compared with clinics serving less than 30% minority patients, clinics serving at least 30% minority patients have less access to medical supplies (2.7 vs 3.4, P < .001), referral specialists (3.0 vs 3.5, P < .005) on a scale of 1 (none) to 4 (great), and examination rooms per physician (2.2 vs 2.7, P =.002) . Their patients are more frequently depressed (22.8% vs 12.1%), are more often covered by Medicaid (30.2% vs 11.4%), and report lower health literacy (3.7 vs 4.4) on a scale of 1 (low) to 5 (high) (P < .001 for all). Physicians from clinics serving higher proportions of minority populations perceive their patients as frequently speaking little or no English (27.1% vs 3.4%, P =.004), having more chronic pain (24.1% vs 12.9%, P < .001) and substance abuse problems (15.1% vs 10.1%, P =.005), and being more medically complex (53.1% vs 39.9%) and psychosocially complex (44.9% vs 28.2%) (P < .001 for both). In regression analyses, clinics with at least 30% minority patients are more likely to have chaotic work environments (odds ratio, 4.0; P =.003) and to have fewer physicians reporting high work control (0.2; P =.003) or high job satisfaction (0.4; P =.01). CONCLUSION: Clinics serving higher proportions of minority patients have more challenging workplace and organizational characteristics.

Assessment of the physician-caregiver relationship scales (PCRS).

OBJECTIVE: The physician-caregiver relationship affects patients' health outcomes, but measures of this important relationship are lacking. We develop and validate the physician-caregiver relationship scales (PCRS), incorporating three relationship domains (liking, understanding, dominance). METHODS: Videotapes of 100 children's visits were coded for verbal and nonverbal communication. Roter interaction analysis system utterance categories (personal remarks, laughter, agreements, approvals, concerns, reassurances, back channels and empathy) and summary measures (physician proportion of total talk and of number of questions) along with nonverbal measures (touch initiations, upright postures and leaning toward a participant) were used as indicators. Model fit was evaluated with confirmatory factor analysis (CFA). Validity was evaluated by associations of the PCRS with visit characteristics and global affect ratings. RESULTS: PCRS domains incorporating verbal and nonverbal indicators demonstrated good model fit (RMSEA<0.05; SRMR<0.12; TLI and CFI>0.95). Construct and predictive validity were demonstrated with PCRS domains relating to visit characteristics and affect ratings as predicted. CONCLUSIONS: CFA supported the multi-dimensional PCRS with three domains-liking, understanding and dominance. Such measures are valuable tools for investigations of physician-caregiver relationships. PRACTICE IMPLICATIONS: Models suggest specific indicators of the physician-caregiver relationship and inform interventions to improve these relationships.

Effect of gender and visit length on participation in pediatric visits.

OBJECTIVE: To examine the effect of child, physician and parent genders as well as visit length on participation. METHODS: We analyzed videotapes and sociodemographics from 100 pediatric visits. Using the Roter Interaction Analysis System, coded utterances were aggregated to reflect key visit tasks: information giving, information gathering and relationship building. Negative binomial models were used to analyze how participation was associated with participants' genders and visit length. RESULTS: After adjustment, girls did twice as much relationship building as boys (incidence rate ratio = 2.33, 95% confidence interval = 1.01-5.36) and their physicians did 34% more information gathering (1.34, 1.16-1.55). Female physicians did 29% less information giving (0.71, 0.54-0.94). Having the father accompany the child reduced child relationship building 76% (0.24, 0.08-0.69) and reduced physician information giving 14% (0.86, 0.75-0.995), compared to having mother accompany. After adjusting for participants' genders, longer visits were associated with more participation for all participants. CONCLUSION: Child participation was impacted by child gender and by the accompanying parent's gender as well as the visit length. PRACTICE IMPLICATIONS: Because gender-based patterns of participation are evident in childhood, interventions to facilitate participation might begin early in life. To improve participation, interventions might include advocating for policies to support longer visit lengths.

Enhancing survey data collection among youth and adults: use of handheld and laptop computers.

Tobacco use, alcohol and other drug use, early sexual behavior, dietary practices, physical inactivity, and activities that contribute to unintentional and intentional injuries are a significant threat to the health of young people. These behaviors have immediate and long-term consequences and contribute to diminished health, educational, and social outcomes. Research suggests that health risk behaviors exhibited during adolescence and adulthood have their origins earlier in childhood and preventive interventions are less successful after the risk behaviors have begun. Therefore, efforts to prevent health risk behaviors are best initiated in late childhood or early adolescence. However, to document the efficacy of these efforts, reliable, valid, and parent/child-friendly systems of data collection are required. Computerized data collection for research has been found to improve privacy, confidentiality, and portability over the paper-and-pencil method, which, in turn, enhances the reliability of sensitive data such as alcohol use or sexual activity. We developed programming tools for the personal computer and a handheld personal data assistant to offer a comprehensive set of user interface design elements, relational databases, and ample programming languages so that adults could answer 261 items and youth 346 items. The purpose of the article was to describe an innovative handheld computer-assisted survey interview method of collecting sensitive data with children aged 9 to 11. The method was developed as part of a large multisite, national study to prevent substance use.

Cancer prevention services and physician consensus in primary care group practices.

BACKGROUND: We conducted a randomized clinical trial of interventions to achieve physician consensus, practice changes, and patient activation designed to help primary care group practices enhance the delivery of cancer prevention and screening services. METHODS: In each of 42 primary care practices in 1991 to 1994, we studied approximately 60 patients per physician who were between the ages 53 and 64. Data sources included patient and physician questionnaires, medical record audits of consenting patients for evidence of 11 cancer prevention services during the previous 3 years, and telephone interviews with key practice personnel. RESULTS: None of the interventions was associated with significant changes in frequency of services or procedures received or provided. Increased frequencies of services overall and of specific activities were associated with HMO membership or insurance coverage for six screening procedures. Patient reports of clinic staff recommendations to have each of six screening procedures were specifically associated with higher frequencies of services (P = 0.001). CONCLUSIONS: Demonstration of intervention impact may have been limited because the rates of prevention services were significantly higher in this study than have been reported elsewhere. These results might be explained by selection biases inherent in studying patients with a regular provider, overall practice trends for changes in provision of the studied services, and the study methods.