A Culturally Adapted, Telehealth, Community Health Worker Intervention on Blood Pressure Control among South Asian Immigrants with Type II Diabetes: Results from the DREAM Atlanta Intervention.

BACKGROUND: South Asians face a high prevalence of type II diabetes (DMII) and comorbid hypertension (HTN). Community health worker (CHW) interventions have the potential to improve chronic disease outcomes, yet few have been tailored to South Asian populations in the United States. OBJECTIVE: To test the effectiveness of an evidence-based CHW-led and culturally-tailored HTN and DMII management program for South Asian adults with diabetes and comorbid uncontrolled HTN (systolic blood pressure (SBP) > 130 mmHg or diastolic blood pressure (DBP) > 80 mmHg). DESIGN: Randomized-controlled Trial. PARTICIPANTS: South Asian adults with DMII and comorbid HTN. INTERVENTION: The Diabetes Research, Education, and Action for Minorities (DREAM) Atlanta intervention was a CHW telehealth intervention designed to improve blood pressure (BP). The treatment group received five virtual group-based health education sessions, an action plan, and follow-up calls to assess goal setting activities. The control group received only the first session. Main Measures included: feasibility, improvement in BP control, and decreases in SBP, DBP, weight, and hemoglobin A1c (HbA1c). KEY RESULTS: A total of 190 South Asian adults were randomized (97 to the treatment group and 93 to the control group); 94% of treatment group participants completed all 5 telehealth sessions. At endpoint, BP control increased 33.7% (95% CI: 22.5, 44.9, p < 0.001) in the treatment group and 16.5% (95%: 6.2, 26.8, p = 0.003) in the control group; the adjusted intervention effect was 1.8 (95% CI: 1.0, 3.2, p = 0.055). Mean weight decreased by 4.8 pounds (95% CI: -8.2, -1.4, p = 0.006) in the treatment group, and the adjusted intervention effect was -5.2 (95% CI: -9.0, -1.4, p = 0.007. The intervention had an overall retention of 95%. CONCLUSIONS: A culturally-tailored, CHW-led telehealth intervention is feasible and can improve BP control among South Asian Americans with DMII. GOV REGISTRATION: NCT04263311.

The Prevalence and Correlates of Diabetes Distress among South Asians Living in New York City (NYC): Baseline Results from a Randomized Trial.

Background: Type 2 diabetes (T2D) disproportionately affects South Asians in the United States (US). Living with T2D can be challenging due to the distress it can create for an individual. Distress associated with diabetes, commonly known as diabetes distress (DD), may lead to complications and challenges with the management of diabetes. This study aims to describe the prevalence of DD among a sample of South Asians in New York City (NYC) seeking care in community-based primary care settings and its association with sociodemographic characteristics and clinical measures. Methods: This study utilized baseline data from the Diabetes Research, Education, and Action for Minorities (DREAM) Initiative, an intervention designed to reduce hemoglobin A1C (HbA1c) among South Asians with uncontrolled T2D in NYC. DD was measured using the Diabetes Distress Scale (DDS). First, descriptive statistics were used to analyze sociodemographic variables. Chi-square tests assessed categorical variables and Wilcoxon Rank Sum tests assessed continuous variables using a Type I error rate of 0.05. Logistic regression was performed to determine if HbA1c and mental health, along with other covariates, were associated with dichotomized DDS subscales. Results: Overall, 415 participants completed the DDS at baseline. Median age was 56 years (IQR: 48-62). A total of 25.9% had high emotional burden distress, 6.6% had high physician-related distress, and 22.2% had high regimen-related distress based on subscales. In adjusted analyses, individuals with any days of poor mental health had significantly higher odds of overall distress (OR:3.7, p=0.014), emotional burden distress (OR:4.9, p<0.001), and physician-related distress (OR:5.0, p=0.002) compared to individuals with no days of poor mental health. Individuals with higher HbA1c had significantly higher odds of regimen-related distress (OR:1.31, p=0.007). Conclusions: Findings suggest that DD is prevalent among this sample of South Asians with diagnosed T2D in NYC. Screening for DD in patients with prediabetes/diabetes should be considered by providers to help provide mental and physical health services during primary care visits. Future research can also benefit from a longitudinal analysis of the impact of DD on diabetes self-management, medication adherence, and mental and physical health. Trial registration: This study uses baseline data from "Diabetes Management Intervention For South Asians" (NCT03333044), which was registered with clinicaltrials.gov on 6/11/2017.

Stakeholder Perspectives on the Impact of COVID-19 on the Implementation of a Community-Clinic Linkage Model in New York City.

Community-clinical linkage models (CCLM) have the potential to reduce health disparities, especially in underserved communities; however, the COVID-19 pandemic drastically impacted their implementation. This paper explores the impact of the pandemic on the implementation of CCLM intervention led by community health workers (CHWs) to address diabetes disparities among South Asian patients in New York City. Guided by the Consolidated Framework for Implementation Research (CFIR), 22 stakeholders were interviewed: 7 primary care providers, 7 CHWs, 5 community-based organization (CBO) representatives, and 3 research staff. Semi-structured interviews were conducted; interviews were audio-recorded and transcribed. CFIR constructs guided the identification of barriers and adaptations made across several dimensions of the study's implementation context. We also explored stakeholder-identified adaptations used to mitigate the challenges in the intervention delivery using the Model for Adaptation Design and Impact (MADI) framework. (1) Communication and engagement refers to how stakeholders communicated with participants during the intervention period, including difficulties experienced staying connected with intervention activities during the lockdown. The study team and CHWs developed simple, plain-language guides designed to enhance digital literacy. (2) Intervention/research process describes intervention characteristics and challenges stakeholders faced in implementing components of the intervention during the lockdown. CHWs modified the health curriculum materials delivered remotely to support engagement in the intervention and health promotion. (3) community and implementation context pertains to the social and economic consequences of the lockdown and their effect on intervention implementation. CHWs and CBOs enhanced efforts to provide emotional/mental health support and connected community members to resources to address social needs. Study findings articulate a repository of recommendations for the adaptation of community-delivered programs in under-served communities during a time of public health crises.

Protocol and baseline characteristics for a community health worker-led hypertension and diabetes management program for South Asians in Atlanta: The DREAM Atlanta study.

BACKGROUND: South Asians are disproportionately affected by type 2 diabetes (DMII) and comorbid hypertension (HTN). Community health worker (CHW) interventions have been shown to improve chronic disease outcomes, yet few have been tailored for South Asians. This paper describes the study protocol and baseline characteristics of an evidence-based CHW intervention to improve blood pressure (BP) control among South Asian adults with diabetes and comorbid HTN in Atlanta, GA. METHODS: A total of 195 South Asian adults were randomized to treatment and control groups, and of these 190 completed baseline surveys (97 treatment group and 93 control group). The treatment group receives five group education sessions on DMII and HTN management and two one-on-one goal setting sessions. MEASURES: Primary outcomes include feasibility, acceptability, and BP control (systolic blood pressure [SBP] <130 and diastolic blood pressure [DBP] <80). Secondary outcomes included changes in glycated hemoglobin (HbA1c), weight, diabetes self-efficacy, diet, and physical activity. BASELINE RESULTS: Of the enrolled sample, 56% are female and mean age is 56.0 (±11.7). All participants are foreign-born. Mean SBP was 139.2 ± 4.3 and mean DBP was 84.7 ± 9.5. Intervention outcomes are measured at baseline and 6-month endpoint for both study groups. CONCLUSIONS: To our knowledge, this study is the first to document the efficacy of a HTN and DMII management intervention among South Asian adults in Atlanta, GA. Future findings of the submitted protocol will fill an important gap on the translation and adaption of evidence-based interventions that have relevance to immigrant and minority populations. CLINICAL TRIALS REGISTRATION: NCT04263311.

Social influence of adult children on parental health behavior among South Asian immigrants: findings from the MASALA (Mediators of Atherosclerosis in South Asians Living in America) study.

Objectives: Examine the social influence of adult children on the cardiovascular-related health behaviors of older South Asian (SA) immigrants to inform lifestyle interventions.Design: This mixed-methods study used data from an ancillary study of social networks (2014-2018) in the Mediators of Atherosclerosis in South Asians Living in America cohort. Phase 1 was a quantitative analysis of self-reported diet and physical activity among SA adults (n = 448, mean age = 58 years, SD 8.4) who named at least one adult child to their social network. The Alternative Healthy Eating Index (AHEI) was used to measure parents' diet; higher numbers indicate a healthier diet (range 0-110). Phase 2 was a thematic content analysis of in-depth qualitative interviews from a subsample of these parents (n = 23, mean age = 55, SD 7.6).Results: Parents with an adult child in their network who consumed uncooked vegetables daily had mean parental AHEI score 1.5 points higher (adjusted p-value = 0.03) than those who had a child in the network who ate uncooked vegetables less often. When at least one adult child in their network ate fresh fruit daily compared to less frequently or when at least one child ate non-SA food daily compared to less frequently, mean parental AHEI scores were higher by 2.0 (adjusted p-value = 0.01) and 1.6 (adjusted p-value = 0.03) points respectively. Parents with an adult child in their network who exercised at least weekly were more likely to meet guideline-recommended physical activity levels than parents with children who exercised less often (76% v. 56%, adjusted p-value = 0.02). Adult children provided social support and were seen as 'role models' for healthy behavior, especially when adopting Western health behaviors.Conclusion: Positive role modeling and support from adult children were important facilitators of healthy behavior change in older SA immigrants and can inform health behavior interventions for SA adults.

Implementation of a multi-level community-clinical linkage intervention to improve glycemic control among south Asian patients with uncontrolled diabetes: study protocol of the DREAM initiative.

BACKGROUND: A number of studies have identified patient-, provider-, and community-level barriers to effective diabetes management among South Asian Americans, who have a high prevalence of type 2 diabetes. However, no multi-level, integrated community health worker (CHW) models leveraging health information technology (HIT) have been developed to mitigate disease among this population. This paper describes the protocol for a multi-level, community-clinical linkage intervention to improve glycemic control among South Asians with uncontrolled diabetes. METHODS: The study includes three components: 1) building the capacity of primary care practices (PCPs) to utilize electronic health record (EHR) registries to identify patients with uncontrolled diabetes; 2) delivery of a culturally- and linguistically-adapted CHW intervention to improve diabetes self-management; and 3) HIT-enabled linkage to culturally-relevant community resources. The CHW intervention component includes a randomized controlled trial consisting of group education sessions on diabetes management, physical activity, and diet/nutrition. South Asian individuals with type 2 diabetes are recruited from 20 PCPs throughout NYC and randomized at the individual level within each PCP site. A total of 886 individuals will be randomized into treatment or control groups; EHR data collection occurs at screening, 6-, 12-, and 18-month. We hypothesize that individuals receiving the multi-level diabetes management intervention will be 15% more likely than the control group to achieve ≥0.5% point reduction in hemoglobin A1c (HbA1c) at 6-months. Secondary outcomes include change in weight, body mass index, and LDL cholesterol; the increased use of community and social services; and increased health self-efficacy. Additionally, a cost-effectiveness analysis will focus on implementation and healthcare utilization costs to determine the incremental cost per person achieving an HbA1c change of ≥0.5%. DISCUSSION: Final outcomes will provide evidence regarding the effectiveness of a multi-level, integrated EHR-CHW intervention, implemented in small PCP settings to promote diabetes control among an underserved South Asian population. The study leverages multisectoral partnerships, including the local health department, a healthcare payer, and EHR vendors. Study findings will have important implications for the translation of integrated evidence-based strategies to other minority communities and in under-resourced primary care settings. TRIAL REGISTRATION: This study was registered with clinicaltrials.gov: NCT03333044 on November 6, 2017.

Loneliness and mental health outcomes among South Asian older adult immigrants in the United States: a cross-sectional study.

BACKGROUND: There is growing concern of mental health issues among South Asian immigrant populations, although limited disaggregated data on determinants of these issues exists. The aim of this study was to examine factors associated with mental health outcomes among South Asian older adult immigrants living in New York City (NYC). METHODS: Data were sourced from a needs assessment among self-identified South Asians aged 60+ conducted by an NYC-based frontline agency and nonprofit organization. Variables assessed included the 9-item Patient Health Questionnaire, degree of difficulty experienced due to depression, loneliness, emotional distress, as well as sociodemographic, living situation, acculturation, general health, and financial related indicators. RESULTS: Among the 682 responses, 9.4% of participants displayed symptoms of mild or moderate depression (16% of Caribbean-origin, 10% of Pakistani, 9% of Bangladeshi, and 8% of Indian participants). About a third of participants (29.9%) reported feeling lonely sometimes and 39.1% experienced any type of emotional distress. When compared to those with excellent or very good self-rated health, having fair, poor, or terrible self-rated health was associated with a greater adjusted odds ratio (AOR) of having mild or moderate depression (AOR: 8.42, 95% confidence interval [CI]: 22.09) and experiencing emotional distress (AOR: 3.03, 95% CI: 1.88-4.94). Those experiencing emotional distress were more likely to be younger (AOR: 0.97, 95% CI: 0.95-1.00) and live alone (AOR: 2.06, 95% CI: 1.21-3.53). DISCUSSION: Findings support the need for tailored mental health interventions targeting concerns, such as poor self-rated health, among South Asian older adult immigrants, as well as specific subpopulations such as Indo-Caribbeans who may be experiencing a disproportionate burden.

The DREAM Initiative: study protocol for a randomized controlled trial testing an integrated electronic health record and community health worker intervention to promote weight loss among South Asian patients at risk for diabetes.

BACKGROUND: Electronic health record (EHR)-based interventions that use registries and alerts can improve chronic disease care in primary care settings. Community health worker (CHW) interventions also have been shown to improve chronic disease outcomes, especially in minority communities. Despite their potential, these two approaches have not been tested together, including in small primary care practice (PCP) settings. This paper presents the protocol of Diabetes Research, Education, and Action for Minorities (DREAM) Initiative, a 5-year randomized controlled trial integrating both EHR and CHW approaches into a network of PCPs in New York City (NYC) in order to support weight loss efforts among South Asian patients at risk for diabetes. METHODS/DESIGN: The DREAM Initiative was funded by the National Institute of Diabetes and Digestive and Kidney Diseases (National Institutes of Health). A total of 480 individuals at risk for type 2 diabetes will be enrolled into the intervention group, and an equal number will be included in a matched control group. The EHR intervention components include the provision of technical assistance to participating PCPs regarding prediabetes-related registry reports, alerts, and order sets. The CHW intervention components entail group education sessions on diabetes prevention, including weight loss and nutrition. A mixed-methods approach will be used to evaluate the feasibility, adoption, and impact (≥ 5% weight loss) of the integrated study components. Additionally, a cost effectiveness analysis will be conducted using outcomes, implementation costs, and healthcare claims data to determine the incremental cost per person achieving 5% weight loss. DISCUSSION: This study will be the first to test the efficacy of an integrated EHR-CHW intervention within an underserved, minority population and in a practical setting via a network of small PCPs in NYC. The study's implementation is enhanced through cross-sector partnerships, including the local health department, a healthcare payer, and EHR vendors. Through use of a software platform, the study will also systematically track and monitor CHW referrals to social service organizations. Study findings, including those resulting from cost-effectiveness analyses, will have important implications for translating similar strategies to other minority communities in sustainable ways. TRIAL REGISTRATION: This study protocol has been approved and is made available on ClinicalTrials.gov by NCT03188094 as of 15 June 2017.

An Exercise Intervention for South Asian Mothers with Risk Factors for Diabetes.

PURPOSE: South Asians (Indians, Pakistanis, Bangladeshis, Sri Lankans, Nepalis, and Bhutanese) in the United States have a very high prevalence of type 2 diabetes mellitus (DM). This pilot study evaluated a culturally-tailored exercise intervention among South Asian immigrant mothers with DM risk factors. METHODS: Through an academic-community partnership, South Asian women with risk factors for DM and who had at least one child between 6-14 years were enrolled into this single-arm study. The intervention for the mothers included 16-weeks of twice weekly exercise classes, self-monitoring with activity trackers, goal-setting, and classes on healthy eating. Based on prior community-based participatory research, children were offered exercise classes during the mothers' classes. The primary efficacy outcomes were change in mothers' moderate/vigorous physical activity and body weight pre- and post-intervention (16-weeks). Program adherence, clinical, and psychosocial outcomes were measured. A qualitative process evaluation was conducted to understand participant perspectives. RESULTS: Participants' (n=30) average age was 40 (SD=5) years., 57% had a high school education or less, and all were overweight/obese.. At baseline, women were not meeting recommended physical activity guidelines. Overall, participants attended 75% of exercise classes. Compared to baseline, participants' weight decreased by 3.2 lbs. (95% CI: -5.5, -1.0) post-intervention. Among women who attended at least 80% of classes (n=17), weight change was -4.8 lbs, (95% CI: -7.7, -1.9). Change in accelerometer-measured physical activity was not significant; however exercise-related confidence increased from baseline (p-value <0.01). Women described multiple physical and psychosocial benefits from the intervention. CONCLUSION: This pilot study suggests that a culturally-tailored exercise intervention that included exercise classes for children was feasible and had physical and psychosocial benefits in South Asian mothers with risk factors for DM.