"Not Alone Anymore": The Experiences of Adults With Diabetes in New York's Medicaid Health Home Program.

BACKGROUND: New York State Medicaid's Health Home program is an example of a natural experiment that could affect individuals with diabetes. While evaluations of interventions such as the Health Home program are generally based solely on clinical and administrative data and rarely examine patients' experience, patients may add to the understanding of the intervention's implementation and mechanisms of impact. OBJECTIVE: The objective of this study was to qualitatively examine the health and nonmedical challenges faced by Medicaid-insured patients with diabetes and their experiences with the services provided by New York's Health Homes to address these challenges. RESEARCH DESIGN: We performed 10 focus groups and 23 individual interviews using a guide developed in collaboration with a stakeholder board. We performed a thematic analysis to identify cross-cutting themes. SUBJECTS: A total of 63 Medicaid-insured individuals with diabetes, 31 of whom were enrolled in New York's Health Home program. RESULTS: While participants were not generally familiar with the term "Health Home," they described and appreciated services consistent with Health Home enrollment delivered by care managers. Services addressed challenges in access to care, especially by facilitating and reminding participants about appointments, and nonmedical needs, such as transportation, housing, and help at home. Participants valued their personal relationships with care managers and the psychosocial support they provided. CONCLUSIONS: From the perspective of its enrollees, the Health Home program primarily addressed access to care, but also addressed material and psychosocial needs. These findings have implications for Health Home entities and for research assessing their impact.

Outcomes of a Weight Loss Intervention to Prevent Diabetes Among Low-Income Residents of East Harlem, New York.

There is a need for diabetes prevention efforts targeting vulnerable populations. Our community-academic partnership, the East Harlem Partnership for Diabetes Prevention, conducted a randomized controlled trial to study the impact of peer led diabetes prevention workshops on weight and diabetes risk among an economically and racially diverse population in East Harlem, New York. We recruited overweight/obese adults from more than 50 community sites and conducted oral glucose tolerance testing and completed other clinical assessments and a health and lifestyle survey. We randomized prediabetic participants to intervention or delayed intervention groups. Intervention participants attended eight 90-minute peer-led workshop sessions at community sites. Participants in both groups returned for follow-up assessments 6 months after randomization. The main outcomes were the proportion of participants who achieved 5% weight loss, percentage weight loss, and change in the probability of developing diabetes over the next 7.5 years according to the San Antonio Diabetes Prediction Model. We enrolled 402 participants who were mainly female (85%), Latino (73%) or Black (23%), foreign born (64%), and non-English speaking (58%). At 6 months, the intervention group lost a greater percentage of their baseline weight, had significantly lower rise in HbA1c (glycated hemoglobin), decreased risk of diabetes, larger decreases in fat and fiber intake, improved confidence in nutrition label reading, and decrease in sedentary behavior as compared with the control group. Thus, in partnership with community stakeholders, we created an effective low-resource program that was less intensive than previously studied programs by incorporating strategies to engage and affect our priority population.

Perspectives of Urban Corner Store Owners and Managers on Community Health Problems and Solutions.

INTRODUCTION: Urban corner store interventions have been implemented to improve access to and promote purchase of healthy foods. However, the perspectives of store owners and managers, who deliver and shape these interventions in collaboration with nonprofit, government, and academic partners, have been largely overlooked. We sought to explore the views of store owners and managers on the role of their stores in the community and their beliefs about health problems and solutions in the community. METHODS: During 2013 and 2014, we conducted semistructured, in-depth interviews in Philadelphia, Pennsylvania, and Camden, New Jersey, with 23 corner store owners/managers who participated in the Healthy Corner Store Initiative spearheaded by The Food Trust, a nonprofit organization focused on food access in low-income communities. We oversampled high-performing store owners. RESULTS: Store owners/managers reported that their stores served multiple roles, including providing a convenient source of goods, acting as a community hub, supporting community members, working with neighborhood schools, and improving health. Owners/managers described many challenging aspects of running a small store, including obtaining high-quality produce at a good price and in small quantities. Store owners/managers believed that obesity, diabetes, high cholesterol, and poor diet are major problems in their communities. Some owners/managers engaged with customers to discuss healthy behaviors. CONCLUSION: Our findings suggest that store owners and managers are crucial partners for healthy eating interventions. Corner store owners/managers interact with community members daily, are aware of community health issues, and are community providers of access to food. Corner store initiatives can be used to implement innovative programs to further develop the untapped potential of store owners/managers.

Food insecurity, coping strategies and glucose control in low-income patients with diabetes.

OBJECTIVE: To examine the relationship between food insecurity and coping strategies (actions taken to manage economic stress) hypothesized to worsen glucose control in patients with diabetes. DESIGN: Using a cross-sectional telephone survey and clinical data, we compared food-insecure and food-secure individuals in their use of coping strategies. Using logistic regression models, we then examined the association between poor glucose control (glycated Hb, HbA1c≥8·0 %), food insecurity and coping strategies. SETTING: An urban medical centre, between June and December 2013. SUBJECTS: Four hundred and seven adults likely to be low income (receiving Medicaid or uninsured and/or residing in a zip code with >30 % of the population below the federal poverty level) with type 2 diabetes. RESULTS: Of respondents, 40·5 % were food insecure. A significantly higher percentage of the food-insecure group reported use of most examined coping strategies, including foregone medical care, participation in the Supplemental Nutrition Assistance Program (SNAP)) and use of emergency food programmes. Food insecurity was associated with poor glucose control (OR=2·23; 95 % CI 1·22, 4·10); coping strategies that were more common among the food insecure were not associated with poor glucose control. Among the food insecure, receipt of SNAP was associated with lower risk of poor glucose control (OR=0·27; 95 % CI 0·09, 0·80). CONCLUSIONS: While food insecurity was associated with poor glucose control, most examined coping strategies did not explain this relationship. However, receipt of SNAP among food-insecure individuals was associated with better diabetes control, suggesting that such programmes may play a role in improving health.

Food insecurity, neighborhood food access, and food assistance in Philadelphia.

An estimated 17.6 million American households were food insecure in 2012, meaning they were unable to obtain enough food for an active and healthy life. Programs to augment local access to healthy foods are increasingly widespread, with unclear effects on food security. At the same time, the US government has recently enacted major cuts to federal food assistance programs. In this study, we examined the association between food insecurity (skipping or reducing meal size because of budget), neighborhood food access (self-reported access to fruits and vegetables and quality of grocery stores), and receipt of food assistance using the 2008, 2010, and 2012 waves of the Southeastern Pennsylvania Household Health Survey. Of 11,599 respondents, 16.7% reported food insecurity; 79.4% of the food insecure found it easy or very easy to find fruits and vegetables, and 60.6% reported excellent or good quality neighborhood grocery stores. In our regression models adjusting for individual- and neighborhood-level covariates, compared to those who reported very difficult access to fruits and vegetables, those who reported difficult, easy or very easy access were less likely to report food insecurity (OR 0.62: 95% CI 0.43-0.90, 0.33: 95% CI 0.23-0.47, and 0.28: 95% CI 0.20-0.40). Compared to those who reported poor stores, those who reported fair, good, and excellent quality stores were also less likely to report food insecurity (OR 0.81: 95% CI 0.60-1.08, 0.58: 95% CI 0.43-0.78, and 0.43: 95% CI 0.31-0.59). Compared to individuals not receiving food assistance, those receiving Supplemental Nutrition Assistance Program (SNAP) benefits were significantly more likely to be food insecure (OR 1.36: 95% CI 1.11-1.67), while those receiving benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (OR 1.17: 95% CI 0.77-1.78) and those receiving both SNAP and WIC (OR 0.84: 95% CI 0.61-1.17) did not have significantly different odds of food insecurity. In conclusion, better neighborhood food access is associated with lower risk of food insecurity. However, most food insecure individuals reported good access. Improving diet in communities with high rates of food insecurity likely requires not only improved access but also greater affordability.