COVID-19 Prevention and Mitigation Decision-Making Processes While Navigating Chronic Disease Care: Perspectives of Black Adults with Heart Failure and Diabetes.

BACKGROUND: Heart failure and diabetes are comorbidities that disproportionately contribute to high morbidity and mortality among Blacks. Further compounding the racial and ethnic disparities in COVID-19 health outcomes, Blacks with cardiometabolic diseases are at high risk of experiencing serious complications or mortality from COVID-19. This study aimed to assess how Blacks with heart failure and diabetes navigated chronic care management during the COVID-19 pandemic. METHODS: A mixed methods study including in-depth interviews and surveys with adults diagnosed with heart failure and diabetes (n = 17) was conducted in 2021-2022. Verbatim transcripts were analyzed using a thematic analysis approach. RESULTS: Participants reported that while the pandemic initially caused delays in access to health services, shifts to telemedicine allowed for continued care despite preferences for in-person appointments. Various sources of information were used in different ways to make decisions on how to best reduce health risks due to COVID-19, but individuals and institutions affiliated with science and medicine, or who promoted information from these sources, were considered to be the most trusted sources of information among those who relied on outside guidance when making health-related decisions. Individuals' self-awareness of their own high-risk status and perceived control over their exposure levels to the virus informed what COVID-19 prevention and mitigation strategies people used. CONCLUSION: Information backed by scientific data was an important health communication tool that alongside other factors, such as fear of mortality due to COVID-19, encouraged individuals to get vaccinated and adopt other COVID-19 prevention and mitigation behaviors.

Association of collaborative care intervention features with depression and metabolic outcomes in the INDEPENDENT study: A mixed methods study.

AIMS: The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) trial tested a collaborative care model including electronic clinical decision support (CDS) for treating diabetes and depression in India. We aimed to assess which features of this clinically and cost-effective intervention were associated with improvements in diabetes and depression measures. METHODS: Post-hoc analysis of the INDEPENDENT trial data (189 intervention participants) was conducted to determine each intervention feature's effect: 1. Collaborative case reviews between expert psychiatrists and the care team; 2. Patient care-coordinator contacts; and 3. Clinicians' CDS prompt modifications. Primary outcome was baseline-to-12-months improvements in diabetes control, blood pressure, cholesterol, and depression. Implementer interviews revealed barriers and facilitators of intervention success. Joint displays integrated mixed methods' results. RESULTS: High baseline HbA1c≥ 74.9 mmol/mol (9%) was associated with 5.72 fewer care-coordinator contacts than those with better baseline HbA1c (76.8 mmol/mol, 9.18%, p < 0.001). Prompt modification proportions varied from 38.3% (diabetes) to 1.3% (LDL). Interviews found that providers' and participants' visit frequencies were preference dependent. Qualitative data elucidated patient-level factors that influenced number of clinical contacts and prompt modifications explaining their lack of association with clinical outcomes. CONCLUSION: Our mixed methods approach underlines the importance of the complementarity of different intervention features. Qualitative findings further illuminate reasons for variations in fidelity from the core model.

Understanding Barriers and Facilitators to Integrated HIV and Hypertension Care in South Africa.

Background The burden of hypertension among people with HIV is high, particularly in low-and middle-income countries, yet gaps in hypertension screening and care in these settings persist. The objective of this study was to identify facilitators of and barriers to hypertension screening, treatment, and management among people with HIV seeking treatment in primary care clinics in Johannesburg, South Africa. Methods Using a cross-sectional study design, data were collected via interviews (n = 53) with people with HIV and hypertension and clinic managers and focus group discussions (n = 9) with clinic staff. A qualitative framework analysis approach guided by the Theoretical Domains Framework was used to identify and compare determinants of hypertension care across different stakeholder groups. Results Data from clinic staff and managers generated three themes characterizing facilitators of and barriers to the adoption and implementation of hypertension screening and treatment: 1) clinics have limited structural and operational capacity to support the implementation of integrated care models, 2) education and training on chronic care guidelines is inconsistent and often lacking across clinics, and 3) clinicians have the goal of enhancing chronic care within their clinics but first need to advocate for health system characteristics that will sustainably support integrated care. Patient data generated three themes characterizing existing facilitators of and barriers to clinic attendance and chronic disease self-management: 1) the threat of hypertension-related morbidity and mortality as a motivator for lifestyle change, 2) the emotional toll of clinic's logistical, staff, and resource challenges, and 3) hypertension self-management as a patchwork of informational and support sources. The main barriers to hypertension screening, treatment, and management were related to environmental resources and context (i.e., lack of enabling resources and siloed flow of clinic operations) the patients' knowledge and emotions (i.e., lack of awareness about hypertension risk, fear, and frustration). Clinical actors and patients differed in perceived need to prioritize HIV versus hypertension care. Conclusions The convergence of multi-stakeholder data regarding barriers to hypertension screening, treatment, and management highlight key areas for improvement, where tailored implementation strategies may address challenges recognized by each stakeholder group.

Attitudes and beliefs about sleep health among a racially and ethnically diverse sample of overweight/obese adults.

OBJECTIVES: To identify and compare how sleep-related attitudes and beliefs vary among racially and ethnically diverse adults with risk factors for cardio-metabolic disease. METHODS: This exploratory qualitative study used online focus group discussions (N = 4 groups among 17 individuals) to collect information about sleep attitudes, beliefs, and practices following participation in the Mindfulness Intervention to Improve Sleep and Reduce Diabetes Risk Among a Diverse Sample in Atlanta (MINDS) study. A rapid analyses approach was used to identify shared themes related to attitudes and beliefs about sleep health and sleep practices across participants. RESULTS: Participants on average were 31years old, 88% female, and identified as Black/African American (52.9%), White (17.7%), Asian (11.8%), and Hispanic (17.7%). Three themes related to attitudes and beliefs about sleep health were identified: prioritization of sleep to improve one's overall health, re-evaluating sleep needs, and interpersonal barriers to sleep. For Black/African American participants prioritizing sleep was coupled with a want to minimize stress as a long-term health promotion strategy, whereas individuals of other races/ethnicities were more focused on the immediate benefits of getting sufficient sleep. Individuals had reappraised their sleep needs and worked to improve their sleep hygiene accordingly, yet still experienced barriers to sleep. The most common barrier to sleep was sharing a sleep environment with someone who had conflicting sleep routines and practices. CONCLUSION: The results of this study suggest perceived benefits of and barriers to sleep vary by race/ethnicity, thus future interventions should be culturally tailored to enhance effectiveness.

LMIC Research Centers' Experiences Hosting U.S. and LMIC Trainees: Evaluation of the Fogarty Global Health Fellows and Scholars Program, 2012 to 2020.

In this mixed-methods study, we explore themes that emerged from a survey assessing the programmatic experiences of mentors and administrators at institutions in low- and middle-income countries (LMICs) hosting trainees supported by the Fogarty International Center's Global Health Program for Fellows and Scholars. A total of 89 of 170 potential respondents representing 31 countries completed the survey (response rate, 52.4%). There was agreement among respondents that their institutions received sufficient funds to support trainees and had the capacity to manage operational and financial aspects of the program. A majority also agreed that both LMIC and U.S. trainees were beneficial to the host institutions, and that trainee projects were relevant to the needs of the host country. Respondents felt that program benefits to LMIC trainees could be improved by increasing the research consumables budget, increasing the flexibility of program timelines, and increasing engagement between LMIC and U.S. trainees and institutions. Respondents indicated that both U.S. and LMIC trainees behaved professionally (including demonstrating respectful and ethical behavior) and took appropriate initiative to conduct their research projects. Findings from this study will help inform innovations to similar training initiatives that will enhance sustainability and improve program performance, and will be responsive to local needs.

Feasibility, appropriateness, and acceptability of a mobile mindfulness meditation intervention to improve sleep quality among a racially/ethnically diverse population.

OBJECTIVES: To evaluate the acceptability, appropriateness, and feasibility of using a mindfulness meditation mobile application to improve sleep quality among a diverse group of adults. METHODS: This explanatory qualitative study used online focus group discussions (N = 4 groups with 17 individuals) to collect information about user experiences with a mindfulness meditation mobile application (Headspace) among participants enrolled in the MINDS study. A rapid analyses approach was used to descriptively compare motivators of app use, barriers and facilitators to app use, and perceived tailoring needs across participants. RESULTS: Participants on average were 30 years old, 88% female, and identified as Black/African American (52.9%), White (29.4%), Asian (11.8%), and Hispanic (17.6%). All participants felt the app was acceptable and appreciated the ability to personalize their app experience. Individuals with ≥50% intervention adherence (daily use for 30 days) reported being motivated to use the app because it helped them to fall asleep faster, while the remainder of participants used the app to relax throughout the day and faced external barriers to app use (eg, lack of time) and difficulty with app navigation. Only those participants who used the app exclusively in the evenings reported falling asleep faster and staying asleep. Suggestions for tailoring the app differed by race and age. Only Black/African American participants preferred using an instructor based on their race and gender. CONCLUSION: Using a mobile meditation app to enhance sleep quality is acceptable and feasible, but additional tailoring for Black/African American individuals may improve uptake in this population.

A realist process evaluation of the INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) randomized controlled trial in India.

Aims: We aimed to determine what key resources, mechanisms, and contextual factors are necessary to integrate depression and diabetes treatment into low-resource settings. Methods: A realist evaluation framework was employed to conduct a comparative case study. Data were collected through document review, key informant interviews (n = 4), activity logs, and interviews with implementing health care providers (n = 11) to test and refine program theories for collaborative care. Results: Efforts to enhance patient care coordination (i.e., adapting clinics' patient flow and resources, on-going trainings, and on-site support for care coordinators) improved implementation of depression treatment by usual care diabetes physicians. Clinician's avoidance of the term depression was identified as a barrier to mental health counseling and treatment. Conclusions: The variations in organizational features and processes linked to implementation activities across two clinics provided an opportunity to examine how and why different contextual factors help or hinder the implementation process. Findings from this study demonstrate that successful implementation of an integrated depression and diabetes care model is feasible in a low-resource setting, while the revised program theories provide an explanatory framework of coordinated care implementation processes that can inform future efforts to disseminate and scale this care model.

Collaborative Quality Improvement Strategy in Secondary Prevention of Cardiovascular Disease in India: Findings from a Multi-Stakeholder, Qualitative Study using Consolidated Framework for Implementation Research (CFIR).

Background: Cardiovascular disease (CVD) is highly prevalent in India, and little is known about the perception of patients and providers about a package of collaborative quality improvement (C-QIP) strategies consisting of provider-focused electronic health records-decision support system (EHR-DSS), non-physician health workers (NPHW), and patient-facing text messages to enhance the CVD care. Objective: To explore the barriers and enablers of the C-QIP strategy from the perspective of providers, health administrators, patients, and care givers in India. Methods: We conducted a qualitative study using the consolidated framework for implementation research (CFIR) to understand the challenges and facilitators of implementing C-QIP strategy to enhance CVD care in the Indian context. A diverse sample of 38 physicians, 14 non-physician health workers (nurses, pharmacists), 4 health administrators, and 16 patients and their caregivers participated in semi-structured interviews. All interviews were audio-recorded, transcribed, translated, anonymised, and coded using MAXQDA software. We used the framework method and CFIR domains to analyze the qualitative data. Results: Barriers perceived from providers' and health administrators' perspectives in providing quality CVD care were high patient volume, physician burnout, lack of robust communication or referral system, paucity of electronic health records, lack of patient counsellors, polypharmacy, poor patient adherence to medications, and lack of financial incentives. Low health literacy, high cost of treatment, misinformation bias, and difficulty in maintaining lifestyle changes were barriers from patients' perspectives. The CFIR identified key enablers for the implementation of C-QIP such as standardized treatment protocol, reduced medication errors, improved physician-patient relationships, and enhanced patient self-care through trained and supported NPHW. Barriers included: heterogenous healthcare settings, diverse patient groups and comorbidities, associated costs of care and interoperability, confidentiality, and data privacy issues around the use of EHR-DSS. Conclusion: Strategies to enhance CVD care must be low-cost, culturally acceptable, and integrated into existing care pathways.

Effects of a lifestyle intervention on depression and anxiety among adults at risk for diabetes in India: A secondary analysis of the Kerala Diabetes Prevention Program.

The impact of lifestyle interventions on diabetes and mental health conditions have been documented among people with diabetes. However, the mental health benefits of lifestyle interventions designed for diabetes prevention have not been systematically investigated among people at high risk of diabetes, particularly in low- and middle-income countries. We examined the effects of a 12-month peer support lifestyle intervention designed for diabetes prevention on depression and anxiety symptomology in the sample population of the Kerala Diabetes Prevention Program. Mixed-effects linear regression models were used to examine the effect of the intervention on depression and anxiety scores at 12 and 24 months in the total sample of 1007 adults at risk for diabetes and among those with mild-severe depressive or anxiety symptoms at baseline (n = 326 for depression; n = 203 for anxiety). Among all participants, the intervention group had a significantly higher reduction of depressive symptoms as compared to the control group at 12 months (mean diff score = -0.51; 95% CI: -0.95, -0.07; P = 0.02). This effect was not sustained at 24 months. There were no significant intervention effects for anxiety. Among those with mild-severe symptoms at baseline, the intervention group had a significantly higher reduction of depressive symptoms (mean diff score = -1.55; 95% CI -2.50, -0.6; P = 0.001) and anxiety symptoms (mean diff score = -1.64; 95% CI -2.76, -0.52; P = 0.004) at 12 months. The effect was sustained at 24 months for depression, but not anxiety. Lifestyle interventions designed for prevention of diabetes might improve depressive and anxiety symptoms in the short-term, particularly among those with mild-severe symptoms.

Effect of a collaborative care model on anxiety symptoms among patients with depression and diabetes in India: The INDEPENDENT randomized clinical trial.

OBJECTIVE: We assessed the impact of a collaborative care intervention on anxiety symptoms among participants in India with comorbid depression, poorly controlled diabetes, and moderate to severe anxiety symptoms. METHOD: We analyzed data from a randomized controlled trial conducted at four diabetes clinics in India. Participants received either collaborative care or usual care. We included only participants who scored ⩾10 on the Generalized Anxiety Disorder-7 (GAD-7) at baseline. We estimated the effect of the intervention on clinically significant reduction in anxiety symptoms; we considered several potential baseline moderators and mediation by anti-depressant use. RESULTS: One hundred and seventy-two participants scored 10 or above on the GAD-7 at baseline. Collaborative care participants were more likely than control participants to achieve a clinically significant reduction in anxiety symptoms at 6 and 12 months (65.7% vs. 41.4% at 12 months, p = 0.002); these differences were not sustained at 18 or 24 months. There was little evidence of moderation by participant characteristics at baseline, and effects were not mediated by anti-depressant use. CONCLUSIONS: Collaborative care for the treatment of depression and type 2 diabetes can lead to clinically significant reductions in anxiety symptoms among patients with anxiety. Effects were notable during the active intervention period but not over the year post-intervention.

The relationship between common mental disorders and incident diabetes among participants in the Kerala Diabetes Prevention Program (K-DPP).

This study aims to describe the prevalence of depression and anxiety among a population sample of people at high risk for type 2 diabetes in Kerala, India, and examine the relationship between depressive symptoms, anxiety, and incident Type 2 Diabetes Mellitus (T2DM) over a two-year period. We used data from the Kerala Diabetes Prevention Program, a cluster-randomized controlled trial for diabetes prevention among 1007 high-risk individuals. The prevalence of depression and anxiety were estimated using the 9-item Patient Health Questionnaire and the Generalized Anxiety Disorder 7-item scale, respectively. We calculated proportions for depression and anxiety and performed generalized estimating equations (GEE) to examine the relationship between baseline mental health status and incident T2DM. The prevalence of depression and anxiety at baseline were 7.5% and 5.5%, respectively. Compared with those reporting none/low symptoms, the odds ratio for incident diabetes was 1.07 (95% CI 0.54-2.12) for participants with moderate to severe depression and 0.73 (95% CI 0.23-2.28) for participants with moderate to severe anxiety, after adjusting for potential confounders. Our findings suggest that the prevalence of depression and anxiety were higher than those previously reported in the general population in India. However, among this sample of community-based adults at high risk of developing T2DM, the presence of moderate to severe depression and/or anxiety symptoms was not significantly associated with the risk of developing T2DM. Trial registration: Australia and New Zealand Clinical Trials Registry ACTRN12611000262909. Registered 10 March 2011.

Are the PHQ-9 and GAD-7 Suitable for Use in India? A Psychometric Analysis.

BACKGROUND: Cross-cultural evidence on the factorial structure and invariance of the PHQ-9 and the GAD-7 is lacking for South Asia. Recommendations on the use of unit-weighted scores of these scales (the sum of items' scores) are not well-founded. This study aims to address these contextual and methodological gaps using data from a rural Indian population. METHODS: The study surveyed 1,209 participants of the Kerala Diabetes Prevention Program aged 30-60 years (n at risk of diabetes = 1,007 and n with diabetes = 202). 1,007 participants were surveyed over 2 years using the PHQ-9 and the GAD-7. Bifactor-(S - 1) modeling and multigroup confirmatory factor analysis were used. RESULTS: Factor analysis supported the existence of a somatic and cognitive/affective subcomponent for both scales, but less explicitly for the GAD-7. Hierarchical omega values were 0.72 for the PHQ-9 and 0.76 for the GAD-7. Both scales showed full scalar invariance and full or partial residual invariance across age, gender, education, status of diabetes and over time. Effect sizes between categories measured by unit-weighted scores versus latent means followed a similar trend but were systematically higher for the latent means. For both disorders, female gender and lower education were associated with higher symptom severity scores, which corresponds with regional and global trends. CONCLUSIONS: For both scales, psychometric properties were comparable to studies in western settings. Distinct clinical profiles (somatic-cognitive) were supported for depression, and to a lesser extent for anxiety. Unit-weighted scores of the full scales should be used with caution, while scoring subscales is not recommended. The stability of these scales supports their use and allows for meaningful comparison across tested subgroups. CLINICAL TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry: ACTRN12611000262909http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336603&isReview=true.

Factors that facilitate patient activation in the self-management of diabetes and depression among participants enrolled in an integrated chronic care model in India.

BACKGROUND: The aim of this study was to identify factors that influence patients' motivation and ability to self-manage their diabetes and depressive symptoms. METHODS: From 2016 to 17, in-depth interviews were conducted with 62 patients receiving the INDEPENDENT care model across two clinics in India. Using a realist evaluation approach, a hypothesized program theory for patient activation was tested and refined. FINDINGS: The refined theory demonstrates that motivation, education, and engagement cumulatively contribute to patient activation. CONCLUSION: The results indicate that positive and sustained patient-provider relationships drive patient motivation and enhance implementation of the care model.

Adaptations and patient responses to behavioral intervention components in a depression-focused chronic disease care model implemented in India.

Integrated care models offer one approach to treat patients with chronic multimorbidity. However, because these models consist of multiple components designed to provide individualized care, they should be adapted to best meet the needs of patients in diverse settings. This paper presents qualitative and quantitative data from a realist process evaluation embedded in the INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study to uncover what worked, for whom, how, and in what circumstances. We aimed to examine adaptations made to a care coordinator-led behavioral intervention, and how patients responded to adaptations, through a secondary analysis of these data. A purposive sample of 62 patients and 3 care coordinators were recruited based on their involvement with the INDEPENDENT care model across two clinics. Patients were interviewed and surveyed about their experiences in the care model and care coordinators were interviewed about their experiences implementing intervention components. Interview data were coded for reported modifications in intervention content, tools, and delivery; then, these adaptations were categorized by how they served to enhance implementation in the Indian context. Adaptations made in the delivery of this care model served two functions: (a) to improve health promotion communication between care coordinators and patients and (b) to improve patient engagement. Patients' expressed needs were consistent with what care coordinators perceived. Patients were satisfied with adaptations designed to improve intervention fit for local contexts. Study findings demonstrate that adapting components of an integrated care model can enhance patient satisfaction and engagement with behavioral interventions.