Racial Disparities in End-Stage Kidney Disease Outcomes among Asians and Native Hawaiians and Other Pacific Islanders across Geographic Residence.

INTRODUCTION: While Asian and Native Hawaiian and other Pacific Islander (NHOPI) patients have a high prevalence of kidney disease risk factors, there are sparse data examining their end-stage kidney disease (ESKD) outcomes. As Hawaii has high representation of Asian and NHOPI individuals, we compared their ESKD outcomes based on residence in the mainland USA versus Hawaii/Pacific Islands (PIs). MATERIALS AND METHODS: Using United States Renal Data System data, we examined the impact of geographic residence in the mainland versus Hawaii/PIs on race-mortality associations among incident ESKD patients transitioning to dialysis over January 1, 2000-December 31, 2016 using Cox regression. We examined likelihood of post-dialysis kidney transplantation using Cox models and cumulative incidence curves. RESULTS: Compared with White patients in the mainland, Asian and NHOPI patients in the mainland had lower mortality: adjusted HRs (95% CIs) 0.67 (0.66-0.67) and 0.72 (0.70-0.73), respectively. When examining Asian and NHOPI patients in Hawaii/PIs, survival benefit was attenuated in Asian and diminished to the null in NHOPI patients (ref: mainland White patients). Cumulative incidence curves comparing Asian, NHOPI, and White patients showed Asian and NHOPI patients in the mainland had the highest likelihood of transplantation, whereas NHOPI and Asian patients in Hawaii/PIs had the lowest likelihood. CONCLUSION: In the mainland, Asian and NHOPI patients had lower mortality versus White patients, whereas in Hawaii/PIs, this survival benefit was diminished in Asian and mitigated in NHOPI patients. NHOPI and Asian patients in Hawaii/PIs had less transplantation versus those in the mainland. Further research is needed to uncover factors contributing to differential ESKD outcomes among Asian and NHOPI patients across geographic residence.

Knowledge Gaps, Challenges, and Opportunities in Health and Prevention Research for Asian Americans, Native Hawaiians, and Pacific Islanders: A Report From the 2021 National Institutes of Health Workshop.

Asian Americans (AsA), Native Hawaiians, and Pacific Islanders (NHPI) comprise 7.7% of the U.S. population, and AsA have had the fastest growth rate since 2010. Yet the National Institutes of Health (NIH) has invested only 0.17% of its budget on AsA and NHPI research between 1992 and 2018. More than 40 ethnic subgroups are included within AsA and NHPI (with no majority subpopulation), which are highly diverse culturally, demographically, linguistically, and socioeconomically. However, data for these groups are often aggregated, masking critical health disparities and their drivers. To address these issues, in March 2021, the National Heart, Lung, and Blood Institute, in partnership with 8 other NIH institutes, convened a multidisciplinary workshop to review current research, knowledge gaps, opportunities, barriers, and approaches for prevention research for AsA and NHPI populations. The workshop covered 5 domains: 1) sociocultural, environmental, psychological health, and lifestyle dimensions; 2) metabolic disorders; 3) cardiovascular and lung diseases; 4) cancer; and 5) cognitive function and healthy aging. Two recurring themes emerged: Very limited data on the epidemiology, risk factors, and outcomes for most conditions are available, and most existing data are not disaggregated by subgroup, masking variation in risk factors, disease occurrence, and trajectories. Leveraging the vast phenotypic differences among AsA and NHPI groups was identified as a key opportunity to yield novel clues into etiologic and prognostic factors to inform prevention efforts and intervention strategies. Promising approaches for future research include developing collaborations with community partners, investing in infrastructure support for cohort studies, enhancing existing data sources to enable data disaggregation, and incorporating novel technology for objective measurement. Research on AsA and NHPI subgroups is urgently needed to eliminate disparities and promote health equity in these populations.

Racial/Ethnic Differences in Early Detection and Screening for Chronic Kidney Disease Among Adults in Hawaii: A 10-Year Population Health Study.

INTRODUCTION: Native Hawaiian and Asian American populations are the most understudied racial/ethnic groups in chronic kidney disease (CKD) research. The objective of our study was to describe sociodemographic and comorbidity risk factors of chronic kidney disease among 2,944 community-dwelling Native Hawaiian, Filipino, Chinese, Japanese, and non-Hispanic white participants who attended the National Kidney Foundation of Hawaii Kidney Early Detection Screening program during 2006-2017. METHODS: We used multivariable logistic regression models to examine the association between age, sex, race/ethnicity, and the major risk factors for CKD (diabetes, hypertension, cardiovascular disease, hypercholesterolemia, overweight and obesity, and smoking) with elevated urine albumin to creatinine ratio (ACR) among adults aged 18 or older in 5 racial/ethnic groups in Hawaii: Native Hawaiian, Filipino, Chinese, Japanese, and non-Hispanic white. RESULTS: In the age- and sex-adjusted model, Native Hawaiian participants were significantly more likely than non-Hispanic white participants to have an ACR of 30.0 mg/g or more (odds ratio [OR] = 1.50; 95% CI, 1.15-1.95; P = .003). In the model that adjusted for CKD risk factors, the difference between Native Hawaiian and non-Hispanic white participants became nonsignificant (OR = 1.27; 95% CI, 0.96-1.69; P = .09]). The higher prevalence of chronic conditions among Native Hawaiians partially explained their higher risk of having an elevated ACR. Filipinos had significantly higher odds than non-Hispanic whites of elevated ACR in the age- and sex-adjusted model (OR = 1.44; 95% CI, 1.14-1.84; P = .003) and after adjustment for CKD risk factors (OR = 1.36; 95% CI, 1.06-1.74; P = .01). CONCLUSION: Culturally targeted interventions are needed to improve health outcomes among Native Hawaiians and Asian Americans, particularly Filipinos, with CKD. Such interventions should focus on early kidney disease management so that disease progression can be delayed.

Asian Americans & chronic kidney disease in a nationally representative cohort.

BACKGROUND: There is a paucity of specific data on early stages of chronic kidney disease (CKD) among Asian Americans (AAs). The objective of this study was to examine the independent association of Asian race/ethnicity and socio-demographic and co-morbidity factors with markers of early kidney damage, ascertained by ACR levels, as well as kidney dysfunction, ascertained by eGFR levels in a large cross-sectional sample of AAs enrolled in the National Health and Nutrition Examination Survey (NHANES). METHODS: Secondary data analyses of the NHANES 2011-2014 data of a nationally representative sample of 5907 participants 18 years and older, US citizens, and of Asian and White race. NHANES data included race (Asian vs. White), as well as other socio-demographic information and comorbidities. Urine albumin-to-creatinine ratio (ACR) categories and estimated glomerular filtration rate (eGFR) were used as indicators for CKD. Descriptive analyses using frequencies, means (standard deviations), and chi-square tests was first conducted, then multivariable logistic regression serial adjustment models were used to examine the associations between race/ethnicity, other socio-demographic factors (age, sex, education), and co-morbidities (obesity, diabetes, hypertension) with elevated ACR levels (A2 & A3 - CKD Stages 3 and 4-5, respectively) as well as reduced eGFR (G3a-G5 and G3b -G5 - CKD Stage 3-5). RESULTS: AAs were more likely than White participants to have ACR levels > 300 mg/g (A3) (adjusted OR (aOR) (95% CI) 2.77 (1.55, 4.97), p = 0.001). In contrast, adjusted analyses demonstrated that AAs were less likely to have eGFR levels < 60 ml/min/1.73 m2 (G3a-G5) (aOR (95% CI) 0.50 (0.35, 0.72), p < .001). CONCLUSIONS: This is one of the first large U.S. population-based studies of AAs that has shown a comparatively higher risk of elevated ACR > 300 mg/g levels (A3) but lower risk of having eGFR levels < 60 ml/min/1.732 m2 (G3a-G5). The findings support the need to address the gaps in knowledge regarding disparities in risk of early stage CKD among AAs.

Colorectal cancer screening prevalence and predictors among Asian American subgroups using Medical Expenditure Panel Survey National Data.

BACKGROUND: Asian American (AA) ethnic subgroups are diverse in socio-economic status, years in the United States, English proficiency, and cultures with different health seeking behaviors and health care access. Fifty-two percent of AAs age ≥50 years had colorectal cancer screening (CRCS) in 2013, compared with 61% of non-Hispanic whites. We hypothesized that CRCS prevalence among AA ethnicities is heterogeneous and that the reasons related to CRCS among AA subgroups are associated with demographic characteristics, acculturation, health care access, and health attitudes. METHODS: Medical Expenditure Panel Survey data for 2009-2014 compared CRCS status among whites (n = 28,834), Asian Indians (n = 466), Chinese (n = 652), and Filipinos (n = 788). Multivariate logistic regression examined ethnic differences and correlates of CRCS accounting for complex sampling design. RESULTS: Whites had the highest prevalence of screening (62.3%), followed by Filipinos (55.0%), Chinese (50.9%), and Asian Indians (48.6%). Older age, having health insurance, and having a usual care provider predicted CRCS across all ethnicities. Different demographic, health care access, and health attitude predictors within each ethnic group were related to CRCS. CONCLUSION: This study contributes to the literature on influences of differential CRCS prevalence among AA subgroups. CRCS promotion should be tailored according to attitudes and structural barriers affecting screening behavior of specific ethnic subgroups to truly serve the health needs of the diverse AA population. Cancer 2018;124:1543-51. © 2018 American Cancer Society.

Asian and native Hawaiian family caregiver satisfaction with palliative care services in nursing homes.

AIM: The aim of this study was to gauge Asian and native Hawaiian family satisfaction with palliative care services in two nursing homes in Hawaii, US. METHODS: This is a mixed-method study using a convergent design. Nine nursing home family caregivers who had received palliative care services took part. They completed a Famcare-2 satisfaction survey and participated in a 1-hour interview. Descriptive analyses and directed content analysis were completed and results were compared. RESULTS: The Famcare-2 results indicated that family caregivers were satisfied with palliative care services. The interviews provided in-depth information on the major areas discussed in the survey-management of patient physical symptoms and comfort, information, family support, and patient psychological care. CONCLUSIONS: There is a need to address family caregiver and interdisciplinary nursing home staff communication based on culturally appropriate approaches for palliative as well as end of-life care services among Asians and native Hawaiians.

Racial and Ethnic Differences in Chronic Kidney Disease and Its Risk Factors among Asian-Americans and Pacific Islanders in Hawaii.

BACKGROUND: Several studies suggest that Asian-American and Native Hawaiian and Other Pacific Islander (NHOPI) racial/ethnic groups have a heightened risk of chronic kidney disease (CKD), but provide limited inference due to the aggregation of these groups into a single racial/ethnic category. We thus examined the association of granularly defined racial/ethnic groups with specific CKD indicators among a diverse group of participants from the National Kidney Foundation of Hawaii's Kidney Early Detection Screening (KEDS) Program. METHODS: Among 1,243 participants enrolled in 19 KEDS screening events over 2006-2009, we examined the association between Asian-American and NHOPI groups and specific CKD indicators, defined as self-reported CKD, microalbuminuria, and macroalbuminuria, using multivariable logistic regression. We then examined associations of race/ethnicity with various CKD risk factors. RESULTS: The most predominant racial/ethnic groups were White (22.0%), Multiracial (18.9%), Japanese (19.2%), Filipino (13.4%), NHOPI (8.4%), and Chinese (4.5%) participants. NHOPI and Chinese participants had a higher risk of microalbuminuria (adjusted ORs [aORs] [95% CIs] 2.48 [1.25-4.91] and 2.37 [1.07-5.27], respectively), while point estimates for all other minority groups suggested higher risk (reference: Whites). NHOPI participants also had a higher risk of macroalbuminuria and self-reported CKD. While most minorities had a higher risk of diabetes and hypertension, NHOPI and Multiracial participants had a higher risk of obesity, whereas the East Asian groups had a lower risk. CONCLUSIONS: In this community-based cohort, compared with Whites, Asian-Americans had a higher risk of early CKD indicators, whereas NHOPIs had a higher risk of more severe CKD indicators. Further studies are needed to elucidate the distinct pathways leading to CKD across diverse racial/ethnic groups in Hawaii.

Evidence-based practice strategies for faculty professional development in clinical translational research at Institutional Development Award (IDeA) state institutions in the Mountain West.

The Mountain West Clinical Translational Research - Infrastructure Network (MW CTR-IN), established in 2013, is a research network of 13 university partners located among seven Institutional Development Award (IDeA) states targeting health disparities. This is an enormous undertaking because of the size of the infrastructure network (encompassing a third of the US landmass and spanning four time zones in predominantly rural and underserved areas, with populations that have major health disparities issues). In this paper, we apply the barriers, strategies, and metrics to an adapted educational conceptual model by Fink (2013). Applying this model, we used four tailored approaches across this regional infrastructure network to: (1) assess individual faculty specific needs, (2) reach out and engage with faculty, (3) provide customized services to meet the situational needs of faculty, and (4) utilize a "closed communication feedback loop" between Professional Development (PD) core and MW CTR-IN faculty within the context of their home institutional environment. Summary statement results from participating faculty show that these approaches were positive. Grounded in best educational practice approaches, we have an opportunity to refine and build from this sound foundation with implications for future use in other CTR-IN networks and institutions in the IDeA states.

Living Well With Kidney Disease and Effective Symptom Management: Consensus Conference Proceedings.

Chronic kidney disease (CKD) confers a high burden of uremic symptoms that may be underrecognized, underdiagnosed, and undertreated. Unpleasant symptoms, such as CKD-associated pruritus and emotional/psychological distress, often occur within symptom clusters, and treating 1 symptom may potentially alleviate other symptoms in that cluster. The Living Well with Kidney Disease and Effective Symptom Management Consensus Conference convened health experts and leaders of kidney advocacy groups and kidney networks worldwide to discuss the effects of unpleasant symptoms related to CKD on the health and well-being of those affected, and to consider strategies for optimal symptom management. Optimizing symptom management is a cornerstone of conservative and preservative management which aim to prevent or delay dialysis initiation. In persons with kidney dysfunction requiring dialysis (KDRD), incremental transition to dialysis and home dialysis modalities offer personalized approaches. KDRD is proposed as the preferred term given the negative connotations of "failure" as a kidney descriptor, and the success stories in CKD journeys. Engaging persons with CKD to identify and prioritize their personal values and individual needs must be central to ensure their active participation in CKD management, including KDRD. Person-centered communication and care are required to ensure diversity, equity, and inclusion; education/awareness that considers the health literacy of persons with CKD; and shared decision-making among the person with CKD, care partners, and providers. By putting the needs of people with CKD, including effective symptom management, at the center of their treatment, CKD can be optimally treated in a way that aligns with their goals.

Benefits, barriers, and intentions/desires of nurses related to distance learning in rural island communities.

BACKGROUND: This study assessed distance learning needs among nurses on the Neighbor Islands in Hawaii. METHODS: An exploratory study was conducted using a descriptive qualitative design. Of the 37 nurses who completed the study, 7 were nurse administrators and 30 were staff nurses. There were 18 focus groups of nurses recruited from six public hospitals on the Neighbor Islands. RESULTS: Three major themes related to distance learning emerged in this study: benefits, barriers, and intentions/desires. Each major theme had several linkages to categories and subcategories. CONCLUSION: Overall findings were as follows: (1) cost was mentioned more often in three major thematic areas (benefit, barriers, and intentions/desires); (2) the need to revisit and address current curriculum approaches and practices in distance learning programs was identified; and (3) strong recommendations were made for programs and organizational support for distance learning in hospital settings. These findings have implications for nursing research, education, and practice.

Barriers to Access to Care in Hispanics With Type 2 Diabetes: A Systematic Review.

INTRODUCTION: Type 2 diabetes (T2D) is a major cause of death in the United States. Hispanics living in America suffer disproportionally with diabetes and is the fifth cause of death for them. A systematic review was conducted that highlighted barriers to access to care for Hispanics with T2D during the early years of the Affordable Care Act. METHOD: PubMed and CINAHL databases were searched (2010-2015) using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. From 84 studies, seven qualitative/mixed methods studies were reviewed based on inclusion/exclusion criteria. Barriers were placed into three categories set a priori. RESULTS: All study samples were from different states, representing barriers across the United States. Persistent barriers were self (100%), provider (100%), and environment (71%). Covariates (culture and genetics), individual resources (cost factors, time, and social support), lack of providers or providers specializing in T2D, and environmental factors (lack of diabetes education, nutrition, and exercise programs) were found to affect Hispanics with T2D access to care. CONCLUSION: Cost factors, time, lack of social support, providers, and relevant programs remain prevalent barriers. As the Hispanic population increases and changes in the health care system are evolving, additional barriers to access to care are likely to emerge and must be explored.

Provider adherence to clinical guidelines related to lipid-lowering medications.

The objective of this study was to determine whether health care providers at the Department of Veterans Affairs Medical Center (VAMC) in Salem, Virginia were adherent to lipid-lowering medication guidelines over a 5-year period. Five hundred randomly chosen electronic medical records of veterans with diabetes, congestive heart failure, and/or coronary artery disease were examined for the use of HMG-CoA reductase inhibitors as part of a larger study on patient-provider adherence to cardiovascular risk-reduction guidelines. Study findings indicated that health care providers prescribed HMG-CoA reductase inhibitors to patients at high risk per evidence-based guidelines. Provider adherence to guidelines rose each year of the study, which coincided with the Department of Veterans Affairs Medical Center efforts to educate health care providers about the evidence-based guidelines, utilization of computer-generated reminders, open access appointment scheduling, and increased collaboration with patients.

Advance care planning among Asian Americans and Native Hawaiians receiving haemodialysis.

AIM: To explore the attitudes about death and dying, advance care planning (ACP), and completion of ACP among Asian Americans (AAs) and Native Hawaiians (NHs) receiving haemodialysis. This study was a descriptive, cross-sectional survey design. METHOD: A convenience sample of 50 participants aged 30-82 years was recruited from four outpatient dialysis centers in Honolulu, Hawaii and interviewed face-to-face using a 43-item end-of-life community survey. A majority of participants perceived dying as an important part of life and were comfortable talking about death, but expressed concerns and fears about end-of-life issues. Aspects of ACP, such as planning a funeral service, getting finances in order, and completing the will were important. While most participants' attitudes about ACP were positive, less than half (40%) had completed ACP. Most participants preferred initiating end-of-life conversations with family. CONCLUSIONS: The main conclusions drawn from this study are that there is a need for ACP and secondly that AAs and NHs would prefer to discuss ACP with family members rather than health or legal professionals. Findings from this preliminary study build on the need to use a theoretical framework in which to develop sound instruments and effective interventions to promote ACP completion among AAs and NHs receiving haemodialysis.

Filipino American grandparent caregivers' roles, acculturation, and perceived health status.

The purpose of this exploratory study was to describe the relationships between roles, acculturation, and perceived health status among 47 FA grandparent caregivers who were providing extensive caregiving to their grandchildren. Role satisfaction was significantly related to perceived health status. Role occupancy was significantly related to years lived in the U.S. and employment. Role integration and role stress were significantly related to gender and income. Acculturation was significantly related to role involvement, years lived in the U.S., language spoken, and education. The findings of this health disparities research study will lead to more contextual work in this area of study.

Themes in the literature related to cardiovascular disease risk reduction.

PURPOSE: This article aimed to identify themes in the literature related to patient-healthcare provider beliefs, barriers to adherence, and interventions pertaining to cardiovascular disease risk reduction. METHODS: Twenty quantitative and qualitative primary research studies including 2 meta-analyses published between 1995 and 2008 were analyzed for themes and practice implications to synthesize existing research on cardiovascular disease risk reduction. Databases searched included EBSCO, CINAHL, MEDLINE, ScienceDirect, HealthSource, and PsychLit using the search terms patient- provider adherence, adherence and shared decision making, adherence and decision support, patient- provider goal setting, and cardiovascular disease risk reduction. RESULTS: The emergent themes found in this literature review included (1) complex medication regimens; (2) risk perception, quality of life, and competing priorities; (3) motivation for change; (4) provider clinical inertia; and (5) goal setting, feedback, and reminders. Studies reporting the highest rates of adherence to cardiovascular disease risk reduction recommendations incorporated patient-provider goal setting and decision support, self-management techniques, and personalized printed communication. IMPLICATIONS FOR PRACTICE: Goal setting in cardiovascular disease risk reduction is a relatively unexplored area and is an important component of shared decision making and adherence to cardiovascular disease health recommendations. The following review will address the 5 themes identified in more detail and provide a basis for improved clinical practice.

A Systematic Review of Barriers to Access-to-Care in Hispanics With Type 2 Diabetes.

INTRODUCTION: A systematic review was conducted to highlight current barriers to access-to-care for Hispanics with type 2 diabetes (T2D). METHOD: PubMed and CINAHL databases (2010-2015) using PRISMA guidelines. 84 studies were identified, 12 quantitative studies were selected for review remained based on inclusion/exclusion criteria. There were five research questions: (1) What samples/settings were included? (2) What theories guided each study? (3) What were the study aims and (4) designs? (5) What barriers of access-to-care were identified? Barriers were placed into three categories set a priori. RESULTS: The word "barrier" was in one study aim. Barriers of self (92%), provider (50%), and environment (25%) were identified. Self-care behaviors (diet and exercise), individual resources (cost factors), lack of providers specializing in T2D, and environmental factors affect Hispanics with T2D access-to-care. DISCUSSION: These barriers to access underscore current importance to Hispanics with T2D. A follow-up review should be conducted as new barriers are expected to emerge.

Nutrition and Diet as It Relates to Health and Well-Being of Native Hawaiian Kupuna (Elders): A Systematic Literature Review.

PURPOSE: The key to improving the health and well-being of Native Hawaiians is to understand the historical events that have caused change to their diet and nutrition, and identify the connection between food, life, and the land. The purpose of this article is to (a) present a review of the literature addressing nutrition and diet as it relates to health and well-being of Native Hawaiian kupuna (elders) and (b) identify limitations and gaps to promote future research. DESIGN: This systematic literature review focused on 29 studies. FINDINGS: Native Hawaiians have the highest body mass index levels, highest daily energy (kilocalorie) intake, and lowest multivitamin use. They have the highest prevalence of diabetes and hypertension compared with Whites. Traditional Hawaiian diet programs and family support were beneficial to improving health and well-being. CONCLUSION: Future research of traditional Hawaiian diet programs and revitalization of the culture may lead to improving the health and well-being of Native Hawaiians.

Culturally Competent Palliative and Hospice Care Training for Ethnically Diverse Staff in Long-Term Care Facilities.

Between 2013 and 2030, older adults 65 years and older of racial/ethnic populations in the U.S. is projected to increase by 123% in comparison to the Whites (Non-Hispanics). To meet this demand, training of ethnically diverse health staff in long-term care facilities in palliative and hospice care is imperative. The purpose of this study was to evaluate a palliative and hospice care training of staff in two nursing homes in Hawaii - (a) to evaluate knowledge and confidence over three time periods, and (b) to compare staff and family caregiver satisfaction at end of program. The educational frameworks were based on cultural and communication theories. Fifty-two ethnically diverse staff, a majority being Asian (89%), participated in a 10-week module training and one 4 hour communication skills workshop. Staff evaluation included knowledge and confidence surveys, pre- and post-test knowledge tests, and FAMCARE-2 satisfaction instrument. There were nine Asian (89%) and Pacific Islander (11%) family caregivers who completed the FAMCARE-2 satisfaction instrument. The overall staff knowledge and confidence results were promising. The staff rated overall satisfaction of palliative care services lower than the family caregivers. Implications for future research, practice, and education with palliative and hospice care training of ethnically diverse nursing home staff is to include patient and family caregiver satisfaction of palliative and hospice care services, evaluation of effectiveness of cross-cultural communication theories in palliative and hospice care staff training, and support from administration for mentorship and development of these services in long term care facilities.

Logic models used to enhance critical thinking.

Over time, various methods have been used to stimulate critical thinking in undergraduate nursing students, and although many have been successful in helping students integrate the essential knowledge, experiences, and clinical reasoning that support practice, it is also useful to explore new methods. Faculty at the University of Hawaii at Manoa, School of Nursing and Dental Hygiene have taken an innovative approach of using logic models to further enhance critical thinking. This article presents an application of varying experiences and methods of using logic models to support the development of critical thinking and reasoning skills in nursing students. The processes in which logic models are used in the curriculum are described. The models are used to connect concepts from concrete to abstract levels in diverse and often nonlinear diagrams, guided discourse, and written assignments. The specific instructional methods used include concept mapping, concept papers, conceptual linking, and substruction.