Getting to the root: Examining within and between home health agency inequities in functional improvement.

OBJECTIVE: To quantify racial, ethnic, and income-based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs). DATA SOURCES: 2016-2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data. DATA COLLECTION/EXTRACTION METHODS: Not Applicable. STUDY DESIGN: We use multinomial-logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five-category outcome: (1) any functional improvement, (2) no functional improvement, (3) death while a patient, (4) transfer to an inpatient setting, and (5) continuing HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins. PRINCIPAL FINDINGS: Of the 3+ million Medicare beneficiaries with a HH start-of-care assessment in 2016, 77% experienced functional improvement at discharge, 8% were discharged without functional improvement, 0.6% died, 2% were transferred to an inpatient setting, and 12% continued using HH. Adjusting for individual-level characteristics, Black, Hispanic, American Indian/Alaska Native (AIAN), and low-income HH patients were all more likely to be discharged without functional improvement (1.3 pp [95% CI: 1.1, 1.5], 1.5 pp [95% CI: 0.8, 2.1], 1.2 pp [95% CI: 0.6, 1.8], 0.7 pp [95% CI:0.5, 0.8], respectively) compared to White and higher income patients. After including HHA fixed effects, the differences for Black, Hispanic, and AIAN HH patients were mitigated. However, income-based disparities persisted within HHAs. Black-White, Hispanic-White, and AIAN-White disparities were largely driven by between-HHA differences, whereas income-based disparities were mostly due to within-HHA differences, and Asian American/Pacific Islander patients did not experience any observable disparities. CONCLUSIONS: Both within- and between-HHA differences contribute to the overall disparities in functional improvement. Mitigating functional improvement inequities will require a diverse set of culturally appropriate and socially conscious interventions. Improving the quality of HHAs that serve more marginalized patients and incentivizing improved equity within HHAs are approaches that are imperative for ameliorating outcomes.

Racial Differences in Nursing Home Quality of Life Among Residents Living With Alzheimer's Disease and Related Dementias.

ObjectivesAmong nursing home (NH) residents with Alzheimer's disease (AD) and AD-related dementias (AD/ADRD), racial/ethnic disparities in quality of care exist. However, little is known about quality of life (QoL). This study examines racial/ethnic differences in self-reported QoL among NH residents with AD/ADRD. Methods: Validated, in-person QoL surveys from 12,562 long-stay NH residents with AD/ADRD in Minnesota (2012-2015) were linked to Minimum Data Set assessments and facility characteristics. Hierarchical linear models assessed disparities in resident-reported mean QoL score (range, 0-100 points), adjusting for case-mix and facility factors. Results: Compared to White residents, racially/ethnically minoritized residents reported significantly lower total mean QoL scores (75.53 points vs. 80.34 points, p < .001). After adjustment for resident- and facility-level characteristics, significant racial/ethnic differences remained, with large disparities in food enjoyment, attention from staff, and engagement domains. Discussion: Policy changes and practice guidelines are needed to address racial/ethnic disparities in QoL of NH residents with AD/ADRD.

Older Black Americans' Perspectives on Structural Racism-Resilience as a Form of Resistance.

PURPOSE: The purpose of this study was to develop a deep understanding of the lived experiences of structural racism and discrimination among older Black Americans' and their perceptions of structural racism across their lives. We also considered individual and community resilience capacity and response in the face of systemic racism. METHODS: In-depth interviews were conducted with Black community-dwelling adults aged 55 and older in and around Baltimore City. The interview guide used nine contexts to explore perceptions and experiences with structural racism over the life course. Two researchers used reflexive thematic analysis to code and analyze the data. RESULTS: Participants endorsed structural racism to varying degrees across contexts of education, employment, neighborhood, healthcare, and income/wealth. Participants who denied structural racism placed blame for Black underachievement on factors such as personal and community deficiencies, unsafe neighborhoods, and institutional indifference. There was broad agreement about the existence of structural racism within the domains of policing and violence but participants were largely ambivalent about other domains such as environment, media, and civics. Resilience factors that helped individuals to resist and rebound from racism emerged as an unexpected and important theme. CONCLUSIONS: We used Public Health Critical Race Praxis and the Cells to Society frameworks to contextualize these findings. Due to the ubiquitous nature of racism, individuals may not fully appreciate the impact of structural racism and its impact on Black well-being. This ordinariness of racism is harmful but may simultaneously contribute to resilience within Baltimore's Black community.

The Person Beneath the Hair: Hair Discrimination, Health, and Well-Being.

Discrimination toward black hair is pervasive in today's society. Hair discrimination is negative bias manifested toward black natural or textured hair styles typically worn by persons of African descent. This commentary discusses the potential effects of hair discrimination on the health and well-being of persons of African descent. Specifically, it explores the mental and physical health implications of hair discrimination and situates it within the broader context of social determinants of health. The Creating a Respectful and Open World for Natural Hair Act has been recently passed in the United States House of Representatives, but more work is needed to eliminate hair discrimination and its negative effects.

It's More Than Language: Cultural Adaptation of a Proven Dementia Care Intervention for Hispanic/Latino Caregivers.

Although Hispanic/Latino older adults are at disproportionate and increased risk for Alzheimer's disease and related dementias, few evidence-based supportive care interventions are specifically developed for or adapted for this population. Adapting a supportive care intervention requires more than Spanish language translation; it necessitates an understanding of cultural nuances and care preferences of Hispanic/Latino families and staff who implement the intervention. This article describes the cultural adaptation of the Adult Day Service Plus intervention for delivery by staff to Hispanic/Latino caregivers, which was guided by the cultural adaptation process model. Also, using the Framework for Reporting Adaptations and Modifications-Enhanced, we discuss (a) when modifications were made, (b) who determined the modifications needed, (c) what aspects of the intervention were modified, (d) the relationship to fidelity and how fidelity was maintained, and (e) reasons for modifications. Modifications to the delivery and content were changed to reflect the values and norms of both the Hispanic/Latino staff and the caregivers they serve. As supportive interventions for caregivers are developed and implemented into real-world settings, inclusion of cultural elements may enhance research participation among Hispanic/Latino provider sites, people living with dementia, and their caregivers. Cultural adaptation is an essential consideration when developing, adapting, and implementing previously tested evidence-based interventions. Cultural adaptation offers an important lens by which to identify contextual factors that influence successful adoption to assure equity in the reach of evidence-based programs.

Simultaneously Developing Interventions for Low-/Middle-Income and High-Income Settings: Considerations and Opportunities.

Most older adults reside in low- and middle-income countries (LMICs) but most research dollars spent on interventions to improve the lives of older adults are awarded to researchers in high-income countries (HICs). One approach to improve the implementation of evidence-based innovations for older adults in LMICs is designing interventions that are relevant to LMICs and HICs simultaneously. We propose that researchers in HICs could partner with stakeholders in an LMIC throughout the intervention design process to better position their intervention for the implementation in that LMIC. We provide an example study from an adaptation of the Resources for Enhancing Caregiver Health II in Vietnam, which did not use this strategy but may have benefited from this strategy. We then turn to several considerations that are important for researchers to contemplate when incorporating this strategy. Finally, we explore incentives for creating interventions that are relevant to both HICs and LMICs for funders, intervention designers, and intervention receivers. Although this is not the only strategy to bring interventions to LMICs, it may represent another tool in researchers' toolboxes to help expedite the implementation of efficacious interventions in LMICs.

Depressive Symptoms in Older African Immigrants with Mobility Limitations: A Descriptive Study.

OBJECTIVES: Before, during, and after their immigration to the United States, immigrants face stressful life circumstances that may render them at risk for depressive symptoms. However, there is a dearth of research on the mental health of African immigrants. We performed secondary data analyses of two studies in the Baltimore-Washington area to describe and identify correlates of depressive symptoms in older African immigrants. METHODS: Chi square tests, one-way ANOVAs, and linear regressions were used to describe and examine associations between depressive symptoms and immigrant-related risk factors. RESULTS: This sample included 148 participants who had a mean age of 62 (SD ± 8.2). Clinical depressive symptoms were present in 8.1% of participants, and trouble falling asleep for more than half of the days was the most prevalent symptom (20%). Levels of education, income, and migration reasons differed significantly from clinical depressive symptoms, but these were not significantly associated with more depressive symptoms after controlling for covariates. CONCLUSIONS: Longitudinal designs may further elucidate incidence, correlates, and long-term effects of depressive symptoms within this population. CLINICAL IMPLICATIONS: Knowledge of depressive symptom burden and risk factors can inform timely assessment, referral, and treatment of depressive symptoms and other mental health outcomes in older African immigrants.

Gender differences in psychosocial characteristics and diabetes self-management among inner-city African Americans.

AIMS: To characterize differences in psychosocial variables between inner-city African American men and women with type 2 diabetes, and to test if the relationships between psychosocial variables and diabetes self-management behaviours differ by gender. DESIGN: Secondary analysis. METHODS: We used baseline data from participants enrolled in the Prevention through Lifestyle Intervention and Numeracy 4 Success-Diabetes study (N = 37). Differences in psychosocial variables between genders were compared using chi-square tests. A two-way analysis of variance was then used to compare self-management scores by different psychosocial characteristics and gender. RESULTS: There was no statistically significant difference in psychosocial characteristics between genders. High diabetes knowledge and self-efficacy were associated with better self-management behaviours in African American women but not in men. In contrast, high numeracy was associated with better diabetes self-management only in men. Low depression, high health literacy, and high social support were associated with better self-management practices in both genders.

Capturing the value and core concepts of the Clinical Research Nurse.

Background: As nurses, we identify our profession as a caring one, but how does this identity translate from a conceptual definition, to real-world practice for the Clinical Research Nurse? Aim: To offer a novel, four-point conceptual model that encapsulates the Clinical Research Nurse's intrinsic value, active leadership, and direct contribution to high quality, person-centered, safe care, addressing current misperceptions of research nursing. Methods: This paper describes the provision of 'care', safely delivered by the Clinical Research Nurse through a four-point conceptual model and case-driven example. Discussion: Clinical research nursing is conceptualized within the domains of Care and Trust, Role, Impact, and Integration. The case example demonstrates real-world application of these domains and the expertise required to balance the complexities of clinical needs and research demands in a healthcare environment. Conclusions: This paper offers a mechanism for understanding the importance of the Clinical Research Nurse and their role in maintaining safety and a high-level view of the care arena. These reflections are considered with an international application for the role.

The Immigrant Memory Collaborative: A Community-University Partnership to Assess African Immigrant Families' Experiences with Dementia.

Research suggests a disparity in the prevalence of dementia, with Black older adults having double the risk compared to their White counterparts. African immigrants are a fast-growing segment of the U.S. Black population, but the dementia care needs and resources of this population are not fully understood. In this paper, we describe the process of working collaboratively with a community partner and project advisory board to conduct a culturally informed project. Specifically, we describe the process of developing culturally informed instruments to collect data on dementia care needs and resources among African immigrants. Working together with a diverse project advisory board, a guide was developed and used to conduct community conversations about experiences with dementia/memory loss. Transcripts from six conversations with 24 total participants were transcribed and analyzed thematically by two independent coders in Nvivo. These qualitative findings were used to inform the development of a survey for quantitative data collection that is currently ongoing. Themes (e.g., cultural attitudes, challenges, and current resources) from the community conversations that informed the survey are described briefly. Despite the challenges of conducting research during a global pandemic, having trusting relationships with a partnering community organization and project advisory board facilitated the successful development of instruments to conduct preliminary dementia care research in an underserved population. We anticipate that survey results will inform interventions that increase education, outreach, and access to dementia care and caregiving resources for this population. It may serve as a model for community-university partnerships for similar public health efforts in dementia as well as other chronic disease contexts.

Exploring the Experiences of Co-morbid Pain and Depression in Older African American Women and Their Preferred Management Strategies.

The intersection of race, gender, and age places older African American women at an increased risk for untreated physical pain and depression that can significantly diminish their quality of life. The objectives of this study were to (1) explore older African American women's perceptions of pain and depressive symptoms and how these symptoms influence each other, and (2) explore effective pain and depression alleviation strategies used by the women. We conducted five focus groups with older African American women (N = 18). We used deductive coding to analyze focus group transcripts and qualitative description to summarize themes. We identified five major themes: (1) Spiritual Suffering from Linked Pain and Depression, (2) Lack of Understanding from Healthcare Providers, (3) Push Through and Live Through, (4) Medications Not Worth the Risk and, (5) Strategies for Pain and Depression. This study offers insight into the experiences of pain and depression in older African American women, and alleviation strategies they perceive as effective. These qualitative findings may be used to inform interventions for older African American women who experience pain and depressive symptoms.

Acculturation and Cardiovascular Risk Screening among African Immigrants: The African Immigrant Health Study.

Acculturation and immigration-related factors may impact preventive, routine cardiovascular risk (CV) screening among African immigrants. We examined the associations between length of stay, percent of life spent in the U.S. (proxy for acculturation), and CV screening. Outcomes were recent screening for hypertension, diabetes, and dyslipidemia. Multivariable logistic regression analyses were used to examine these relationships. Among 437 African immigrants, 60% were males, mean age was 47 years, 61% had lived in the U.S. for ≥10 years, mean length of stay was 15 years, and 81% were employed. Only 67% were insured. In the 12 months prior, 85% had screened for hypertension, 45% for diabetes, and 63% for dyslipidemia. African immigrants with a ≥10-year length of U.S. stay had 2.20 (95%Confidence Intervals: 1.31−3.67), and those with >25% years of life spent in the U.S. had 3.62 (95%CI: 1.96−6.68) higher odds of dyslipidemia screening compared to those with a <10-year length of stay and ≤25% years of life spent in the U.S., respectively. Overall, screening for CV risk higher in African immigrants who have lived longer (≥10 years) in the U.S. Recent African immigrants may experience challenges in accessing healthcare. Health policies targeting recent and uninsured African immigrants may improve access to CV screening services.

Where to Retire? Experiences of Older African Immigrants in the United States.

Doubling in size since the 1970s, the aging needs of the African immigrant population are not fully understood. This qualitative study examined experiences of aging and retirement planning for African immigrant older adults in the United States (U.S.). Specifically, it explored the factors, processes, and ultimate decision of where these older adults planned to retire. Secondary analysis of semi-structured interviews with 15 older African immigrants in the Baltimore-Washington Metropolitan area was conducted. Data was analyzed using thematic analyses in NVivo. The majority of participants were women, with a mean age of 64. Three overarching themes with ten sub-themes were identified. The themes included: (1) cultural identity, which indicated the participant's comfort with the U.S. society and culture; (2) decision making, meaning factors that impact participants' choice of retirement location; and (3) decision made, meaning the final choice of where participants would like to retire. Age-friendliness for immigrant older adults in the U.S. is complex and it includes traditional domains such as physical and sociocultural environment (e.g., housing, transportation, and income). However, immigrant age-friendliness also needs to include wider contextual aspects such as political climate of their country of origin, immigrant status, family responsibilities, and acculturation in the U.S. More research is needed to better understand and facilitate age-friendly environments and transnational aging of immigrant older adults.

Prevalence of functional limitations among foreign and US-born Black older adults: 2010-2016 National Health Interview Surveys.

OBJECTIVE: To determine whether the prevalence of functional limitations in United States (US) born differs from that of foreign-born Black older adults. DESIGN: We performed a cross-sectional analysis of data from 14,438 US-born and 1583 foreign-born Black older adults (≥50 years) in the 2010-2016 National Health Interview Surveys (NHIS). Functional limitations were defined by upper and lower extremity limitations, and global functional limitations. Generalized linear modeling using a Poisson distribution and logarithmic link function was used to compare the predicted probabilities of functional limitations in both groups. RESULTS: The mean age (SE) of US-born Blacks was 63.56 (0.12) years and foreign-born Blacks was 62.06 (0.32). The majority (92%) of foreign-born Blacks had resided in the US for ≥10 years. US-born older adults were more likely to have upper (46% vs. 29%, p < .001) and lower (61% vs. 40%, p < .001) extremity limitations than foreign-born Blacks. The prevalence of lower extremity limitations was 22% less in foreign-born Blacks compared to US-born Blacks after adjusting for sociodemographic and health profiles (Prevalence Ratio [PR]: 0.78, 95% CI:0.73-0.84). The adjusted prevalence of upper extremity limitations in foreign-born Blacks was 27% (PR: 0.73, 95% CI: [0.68-0.79]), compared to US-born Black older adults. And that of global functional limitations was 22% less (PR: 0.78, 95% CI [0.73-0.83]) in foreign-born compared to US-born Blacks. CONCLUSION: Compared to their US-born counterparts, foreign-born Black older adults had a markedly lower prevalence of upper and lower extremity functional limitations. Future comparative studies should examine reasons for this apparent health advantage among foreign-born adults to inform social and medical interventions to prevent functional decline in Black older adults in the US.

Social determinants of hypertension and diabetes among African immigrants: the African immigrants health study.

OBJECTIVE: To examine the association between social determinants of health, hypertension, and diabetes among African immigrants. METHODS: The African Immigrant Health Study was a cross-sectional study of the health of African immigrants in the Baltimore-Washington Metropolitan Area. The outcomes of interest were self-reported diagnoses of hypertension and diabetes. Logistic regression was used to examine the relationship between educational status, employment, income, social support, health insurance, and self-reported diagnoses of hypertension and diabetes, adjusting for age, sex, and length of stay in the U.S. RESULTS: A total of 465 participants with mean (±SD) age 47 (±11.5) years were included. Sixty percent were women, 64% had a college degree or higher, 83% were employed, 67% had health insurance, and 70% were married/cohabitating. Over half (60%) of the participants had lived in the United States for ≥ 10 years, and 84% were overweight/obese. The overall prevalence of hypertension and diabetes was 32% and 13%, respectively. The odds of diabetes was higher (aOR: 5.00, 95% CI: 2.13, 11.11) among those who were unemployed than among those who were employed, and the odds of hypertension was higher among those who had health insurance (aOR:1.73, 95% CI: 1.00, 3.00) than among those who did not. CONCLUSIONS: Among African immigrants, those who were unemployed had a higher likelihood of a self-reported diagnosis of diabetes than those who were employed. Also, people who had health insurance were more likely to self-report a diagnosis of hypertension. Additional studies are needed to further understand the influence of social determinants of health on hypertension and diabetes to develop health policies and interventions to improve the cardiovascular health of African immigrants.

Longer Residence in the United States is Associated With More Physical Function Limitations in African Immigrant Older Adults.

Acculturation and racial discrimination have been independently associated with physical function limitations in immigrant and United States (U.S.)-born populations. This study examined the relationships among acculturation, racial discrimination, and physical function limitations in N = 165 African immigrant older adults using multiple linear regression. The mean age was 62 years (SD = 8 years), and 61% were female. Older adults who resided in the United States for 10 years or more had more physical function limitations compared with those who resided here for less than 10 years (b = -2.62, 95% confidence interval [CI] = [-5.01, -0.23]). Compared to lower discrimination, those with high discrimination had more physical function limitations (b = -2.51, 95% CI = [-4.91, -0.17]), but this was no longer significant after controlling for length of residence and acculturation strategy. Residing in the United States for more than 10 years is associated with poorer physical function. Longitudinal studies with large, diverse samples of African immigrants are needed to confirm these associations.

Exploring Challenges and Strategies in Partnering With Community-Based Organizations to Advance Intervention Development and Implementation With Older Adults.

Minoritized older adults face multiple health inequities and disparities, but are less likely to benefit from evidence-based health care interventions. With the increasing diversity of the U.S. aging population, there is a great promise for gerontology researchers to partner with racial/ethnic minority organizations and underrepresented communities to develop and implement evidence-based health interventions. Community-Based Participatory Research and Implementation Science offer guidance and strategies for researchers to develop and sustain community partnerships. However, researchers partnering with community organizations continue to face challenges in these collaborations, study outcomes, and sustainability. This may be especially true for those junior in their career trajectory or new to community-engaged research. The purpose of this forum article is to detail critical challenges that can affect gerontology researcher-community partnerships and relationships from the perspective of researchers. Seven challenges (pre- or mid-intervention design, implementation, and postimplementation phases) described within the Equity-focused Implementation Research for health programs framework are identified and discussed. Potential solutions are also presented. Planning for potential obstacles of the researcher-community partnerships can inform innovative solutions that will facilitate successful partnerships, thereby promoting the advancement of collaborative research between academic institutions and community organizations to improve older adult health outcomes.

Evidence for Action: Addressing Systemic Racism Across Long-Term Services and Supports.

Long-term services and supports (LTSS), including care received at home and in residential settings such as nursing homes, are highly racially segregated; Black, Indigenous, and persons of color (BIPOC) users have less access to quality care and report poorer quality of life compared to their White counterparts. Systemic racism lies at the root of these disparities, manifesting via racially segregated care, low Medicaid reimbursement, and lack of livable wages for staff, along with other policies and processes that exacerbate disparities. We reviewed Medicaid reimbursement, pay-for-performance, public reporting of quality of care, and culture change in nursing homes and integrated home- and community-based service (HCBS) programs as possible mechanisms for addressing racial and ethnic disparities. We developed a set of recommendations for LTSS based on existing evidence, including (1) increase Medicaid and Medicare reimbursement rates, especially for providers serving high proportions of Medicaid-eligible and BIPOC older adults; (2) reconsider the design of pay-for-performance programs as they relate to providers who serve underserved groups; (3) include culturally sensitive measures, such as quality of life, in public reporting of quality of care, and develop and report health equity measures in outcomes of care for BIPOC individuals; (4) implement culture change so services are more person-centered and homelike, alongside improvements in staff wages and benefits in high-proportion BIPOC nursing homes; (5) expand access to Medicaid-waivered HCBS services; (6) adopt culturally appropriate HCBS practices, with special attention to family caregivers; (7) and increase promotion of integrated HCBS programs that can be targeted to BIPOC consumers, and implement models that value community health workers. Multipronged solutions may help diminish the role of systemic racism in existing racial disparities in LTSS, and these recommendations provide steps for action that are needed to reimagine how long-term care is delivered, especially for BIPOC populations.

Strategies for Providing Culturally Sensitive Care to Diverse Populations.

ABSTRACT: Nurses are called to care for patients and families from many backgrounds and cultural groups. This article discusses the key strategies of cultural humility, conscientious practice, and establishing trust that promotes cultural sensitivity as well as congruence with Christian values. When implemented, these strategies can facilitate the provision of quality, culturally sensitive patient care that conforms to a biblical worldview.

Remote activity monitoring for family caregivers of persons living with dementia: a mixed methods, randomized controlled evaluation.

BACKGROUND: The goal of the present study was to determine whether a remote activity monitoring (RAM) system benefited caregivers who aided relatives with Alzheimer's disease or related dementias (ADRD) living at home. We hypothesized that over 18 months, families randomly assigned to receive RAM technology in the home of the person with ADRD would experience statistically significant (p < .05): 1) improvements in caregiver self-efficacy and sense of competence when managing their relative's dementia; and 2) reductions in caregiver distress (e.g., burden, role captivity, and depression). METHODS: An embedded mixed methods design was utilized, where 179 dementia caregivers were randomly assigned to receive RAM or not. Caregivers were surveyed bi-annually over an 18-month period to collect quantitative and qualitative data on RAM's effects. Semi-structured interviews with 30 caregivers were completed following the 18-month data collection period to explore more in-depth how and why RAM was perceived as helpful or not. RESULTS: Growth curve models showed no direct or moderation effect of RAM on dementia caregiver outcomes. The qualitative data revealed a complex utilization process of RAM influenced by the care environment/context as well as the temporal progression of ADRD and the caregiving trajectory. CONCLUSIONS: The findings suggest the need for developing more effective mechanisms to match appropriate technologies with the heterogeneous needs and care contexts of people living with ADRD and their caregivers. A triadic approach that incorporates professional care management alongside passive monitoring systems such as RAM may also enhance potential benefits. TRIAL REGISTRATION: ClinicalTrials.gov NCT03665909 , retrospectively registered on 11 Sept 2018.