Opportunities, Challenges, and Strategies for Engaging Family in Diabetes and Hypertension Management: A Qualitative Study.

Family engagement may improve disease management, yet little is known about this topic as it relates to underrepresented minorities who receive care in low-resource primary care settings. This study aimed to explore family engagement in diabetes and hypertension management at an Urban Indian Health Organization to identify opportunities and challenges, and inform care strategies. We employed semi-structured interviews, genograms, eco-maps, and timelines, among 23 English- and Spanish-speaking American Indian and Latino adults with a dual diagnosis of type 2 diabetes and hypertension and 13 family members. Using thematic analysis, we found that family support is not always available, patients have difficulty sharing medical information, and family often live far away. Conversely, opportunities to leverage included a desire for increased engagement, motivation from the younger generation, prevention within the family, outreach to family members with the same conditions, and learning from elders and ancestors. Implications for programs, clinical care, and research are discussed.

The Illness Experience of Undocumented Immigrants With End-stage Renal Disease.

Importance: The exclusion of undocumented immigrants from Medicare coverage for hemodialysis based on a diagnosis of end-stage renal disease (ESRD) requires physicians in some states to manage chronic illness in this population using emergent-only hemodialysis. Emergent-only dialysis is expensive and burdensome for patients. Objective: To understand the illness experience of undocumented immigrants with ESRD who lack access to scheduled hemodialysis. Design, Setting, and Participants: A qualitative, semistructured, interview study was conducted in a Colorado safety-net hospital from July 1 to December 31, 2015, with 20 undocumented immigrants (hereinafter referred to as undocumented patients) with ESRD and no access to scheduled hemodialysis. Demographic information was collected from the participants' medical records. The interviews were audiorecorded, translated, and then transcribed verbatim. The interviews were analyzed using inductive qualitative theme analysis by 4 research team members from March 1 to June 30, 2016. Main Outcomes and Measures: Themes and subthemes from semistructured interviews. Results: All 20 undocumented patients included in the study (10 men and 10 women; mean [SD] age, 51.4 [13.8] years) had been in the United States for at least 5 years preceding their diagnosis with ESRD. They described the following 4 main themes: (1) a distressing symptom burden and unpredictable access to emergent-only hemodialysis, (2) death anxiety associated with weekly episodes of life-threatening illness, (3) family and social consequences of accommodating emergent-only hemodialysis, and (4) perceptions of the health care system. Conclusions and Relevance: Undocumented patients with ESRD experience debilitating, potentially life-threatening physical symptoms and psychosocial distress resulting from emergent-only hemodialysis. States excluding undocumented immigrants with ESRD from scheduled dialysis should reconsider their policies.

Facing the challenge of a changing system: training child welfare workers in a privatized environment.

The state of Kansas' implementation of a privatized child welfare system is arguably an ambitious shift in child welfare service delivery. In an attempt to drastically improve services to vulnerable families, privatization resulted in intended and unintended consequences for the child welfare workforce. Some of these consequences, including the influx of inexperienced new workers, high worker turnover, and managing relationships with multiple partners, are issues that affect training needs of child welfare professionals. The following paper offers one approach to addressing these needs as well as identifying the challenges involved in training in a privatized environment.