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.

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.

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.

Dementia Caregivers' Experiences and Reactions to Remote Activity Monitoring System Alerts.

Technology-based tools, including remote activity monitoring (RAM) systems, have been proposed as valuable aids for family caregivers of people with dementia. Previous analyses have shown limited effects of these systems and highlighted a number of barriers, including false alarms. We used data from an ongoing embedded mixed method randomized controlled intervention to describe patterns of alerts and their association with receipt of the RAM system and caregiver outcomes. Quantitative analyses showed a modest positive association between the number of alerts during the first month and system review score. In addition, qualitative results illustrated the importance of alert context, including utility, accuracy, and type of alert delivery. These findings highlight the relevance of early alerts to engagement with and perceived benefit from the RAM system. [Journal of Gerontological Nursing, 47(1), 13-20.].

"All I know is that there is a lot of discrimination": Older African immigrants' experiences of discrimination in the United States.

Discrimination is implicated in the disproportionate burden of disease and health disparities in racial/ethnic minorities. This qualitative descriptive study explored the experiences of discrimination and its impact on the health of older African immigrants. Semi-structured interviews were conducted with 15 participants. Three main themes and six sub-themes were identified. These included: (1) types of discrimination which were: (a) accent-based, (b) unfair treatment during routine activities, (c) experience with systems; (2) consequences of discrimination; and (3) surviving and thriving with discrimination: (a) "blind eye to it", (b) reacting to it, (c) avoiding it. These themes described common experiences of discrimination, current strategies used to deal with discrimination, and the impact of discrimination on this sample. Health care providers should be aware of discrimination experiences, how to assess for it, and identify when to refer patients to appropriate community resources that include mental health, employment, cultural groups and legal services.

Recruiting African Immigrant Women for Community-Based Cancer Prevention Studies: Lessons Learned from the AfroPap Study.

Recruitment in research can be challenging, particularly for racial/ethnic minorities and immigrants. There remains a dearth of research identifying the health and sociocultural needs of these populations related to recruitment. To describe our experiences and lessons learned in recruiting African immigrant (AI) women for the AfroPap study, a community-based study examining correlates of cervical cancer screening behaviors. We developed several recruitment strategies in collaboration with key informants and considered published recruitment methods proven effective in immigrant populations. We also evaluated the various recruitment strategies using recruitment records and study team meeting logs. We enrolled 167 AI women in the AfroPap study. We used the following recruitment strategies: (1) mobilizing African churches; (2) utilizing word of mouth through family and friends; (3) maximizing research team's cultural competence and gender concordance; (4) promoting altruism through health education; (5) ensuring confidentiality through the consenting and data collection processes; and (6) providing options for data collection. Online recruitment via WhatsApp was an effective recruitment strategy because it built on existing information sharing norms within the community. Fear of confidentiality breaches and time constraints were the most common barriers to recruitment. We were successful in recruiting a "hard-to-reach" immigrant population in a study to understand the correlates of cervical cancer screening behaviors among AI women by using a variety of recruitment strategies. For future research involving African immigrants, using the internet and social media to recruit participants is a promising strategy to consider.

A Systematic Review of Community Health Center Based Interventions for People with Diabetes.

Community health centers (CHCs) focus on serving socioeconomically disadvantaged populations with heightened chronic disease burden, making CHCs an ideal setting for implementing diabetes care programs that target vulnerable populations. We aimed to synthesize evidence concerning the effects of CHC interventions in people with diabetes. To do this, four electronic databases were searched, including PubMed, EMBASE, CINAHL, and Scopus, and hand searches of reference collections were undertaken to identify intervention trials published in English. We screened 892 unique titles and abstracts. Two reviewers then independently evaluated 221 full-text articles. We discovered 29 articles met our eligibility criteria for inclusion. We found 27 unique studies with two companion articles. Seventeen studies were randomized controlled trials and the majority had a higher proportion of female and racial/ethnic minorities in the study sample. CHC interventions often involved either one-on-one or group education sessions supplemented by a phone follow-up that were delivered by health providers, nutritionists, or community health workers. CHC interventions using education sessions combined with follow up via phone generally resulted in significant improvements in hemoglobin A1C, while sole telephone-based education studies showed no significant improvements. CHC interventions had no significant effects on physical activity in all six studies that examined the outcome. Overall, we found that CHC interventions were in general effective in improving glucose control when using face-to-face interactions in low-income, underserved, and racial and ethnic minority patients with diabetes. Evidence was limited, however, in regards to other outcomes which suggests the need for continued evaluations of CHC intervention models.

Views of regulatory authorities on standards to assure quality in online nursing education.

BACKGROUND: With the rapid growth in online education programs in nursing, quality of education through this modality is becoming of greater importance. PURPOSE: This paper aims to explore current recommendations and standards for quality in online nursing education offered by nursing regulatory, accrediting, and licensing organizations. METHOD: Individual interviews were conducted with the leaders from four accrediting, licensing and certifying organizations in nursing about their perspectives on quality standards for online education. FINDINGS: The following themes emerged from the qualitative interviews: Theme 1- Standards are not specific to online education; Theme 2-This is not up to us - Professional organizations can offer recommendations but not responsible for regulations; and Theme 3- Each institution has responsibility to provide support and evaluate the quality of online education. DISCUSSION: Schools of nursing should continue to incorporate current standards for quality in online education as the methods of delivery continue to evolve in this highly technologically-oriented world.

Achieving self-management goals among low income older adults with functional limitations.

Although self-management interventions can improve symptoms and disease among older adults, there is a dearth of literature on how self-management behaviors may improve factors related to the older adults' physical function. To fill this gap in the literature, we describe the patient-directed self-management goals in nursing visits that relate to physical function as part of a multi-component program. We analyze the self-management goals and outcomes of 367 low- income older adults with functional limitations who participated in the CAPABLE program: a program to reduce the health effects of impaired physical function in low-income older adults. We focus on the following self-management goals that participants chose with the nurses: pain management, depressive symptoms, incontinence, fall prevention, and communication with healthcare providers. The majority of participants chose pain (50%) or fall prevention (51%) as goals and partially or fully met their goals. Improvements across these areas may lead to improved physical function.

Pain, Racial Discrimination, and Depressive Symptoms among African American Women.

African American women with osteoarthritis (OA) are at high risk of experiencing pain. They report more pain than non-Hispanic White women and men of other racial/ethnic groups. This pain can limit independence and diminish their quality of life. Despite the detrimental effects that pain can have on older African American women with OA, there is a dearth of literature examining factors beyond the OA pathology that are associated with pain outcomes within this population. The purpose of this study was to examine the relationships between racial discrimination and depressive symptoms with pain intensity in African American women with OA. The sample comprised of 120 African American women, aged 50-80 years, with OA, from Texas and New Mexico. The women completed survey booklets to answer study questionnaires. We used multiple linear regression to test associations between racial discrimination, depressive symptoms, and pain intensity. We tested whether depressive symptoms mediated the relationship between racial discrimination and pain intensity by using bootstrapping. Results indicated that racial discrimination was significantly associated with pain intensity and that this relationship was mediated by depressive symptoms, even after controlling for body mass index, years of education, and length of time with OA. Both depressive symptoms and racial discrimination may be modifiable. If these modifiable factors are addressed in this population, there may be decreased pain in middle-aged and older African American women.

Ensuring safe and optimal medication use in older community residents: Collaboration between a nurse and a pharmacist.

The purpose of this retrospective review is to describe 1) a nurse-pharmacist collaboration within a home based nurse-occupational therapist-handyman program called CAPABLE and 2) potential medication problems and 3) information communicated to participants and prescribers about those problems. A chart review was performed for each participant that one CAPABLE nurse referred to the pharmacists. We identified recommendations provided by pharmacists, synthesized common questions posed to the pharmacists' and developed exemplar cases of participant encounters. Fifty-nine participants were reviewed. The median number of total medications was 11 (IQR 9-14.5). Participants were most commonly taking antihypertensives (93%), statins (66%), and supplements/vitamins (61%). Pharmacists provided 83 unique recommendations for the 59 participants. The recommendations from the pharmacist were communicated for 49 of the 59 participants (83%), by the nurse. The nurse-pharmacist collaboration identified medication-related problems and solutions aimed at improving the quality of life for home-dwelling seniors with functional limitations.

Communication between office-based primary care providers and nurses working within patients' homes: an analysis of process data from CAPABLE.

AIMS AND OBJECTIVES: To examine themes of communication between office-based primary care providers and nurses working in private residences; to assess which methods of communication elicit fruitful responses to nurses' concerns. BACKGROUND: Lack of effective communication between home health care nurses and primary care providers contributes to clinical errors, inefficient care delivery and decreased patient safety. Few studies have described best practices related to frequency, methods and reasons for communication between community-based nurses and primary care providers. DESIGN: Secondary analysis of process data from 'Community Aging in Place: Advancing Better Living for Elders (CAPABLE)'. METHODS: Independent reviewers analysed nurse documentation of communication (phone calls, letters and client coaching) initiated for 70 patients and analysed 45 letters to primary care providers to identify common concerns and recommendations raised by CAPABLE nurses. RESULTS: Primary care providers responded to 86% of phone calls, 56% of letters and 50% of client coaching efforts. Primary care providers addressed 86% of concerns communicated by phone, 34% of concerns communicated by letter and 41% of client-raised concerns. Nurses' letters addressed five key concerns: medication safety, pain, change in activities of daily living, fall safety and mental health. In letters, CAPABLE nurses recommended 58 interventions: medication change; referral to a specialist; patient education; and further diagnostic evaluation. CONCLUSIONS: Effective communication between home-based nurses and primary care providers enhances care coordination and improves outcomes for home-dwelling elders. Various methods of contact show promise for addressing specific communication needs. RELEVANCE TO CLINICAL PRACTICE: Nurses practicing within patients' homes can improve care coordination by using phone calls to address minor matters and written letters for detailed communication. Future research should explore implementation of Situation, Background, Assessment and Recommendation in home care to promote safe and efficient communication. Nurses should empower patients to address concerns directly with providers through use of devices including health passports.

Perceptions of Dementia and Dementia Care Among African Immigrants in Minnesota: Insights From Community Conversations.

OBJECTIVES: This qualitative descriptive study explored the perceptions of dementia, dementia care, and caregiving within the African immigrant community. METHODS: Six community conversations (focus groups) were held with 24 participants. Three conversations were led by project advisory board members and utilized a 12-question conversation guide. The recorded conversations were transcribed and analyzed using thematic analysis. RESULTS: Of the 24 African immigrants who participated, 52% were 55-75 years old, 67% identified as female, and 39% were married or cohabitating. Twenty percent were currently providing care to a relative with dementia and 40% had provided care to a relative with dementia in the past. Four themes were identified. These included (1) attitudes toward mental health, illnesses, and poor health, (2) community attitudes toward dementia, and dementia caregiving, (3) barriers to dementia care and caregiving, and (4) current dementia care resources in the African immigrant community. DISCUSSION: The findings show that African immigrant cultural beliefs significantly shape dementia care and caregiving attitudes, preferences, and behavioral practices. African immigrants' cultural backgrounds influence (or have the potential to influence) timely access and engagement in dementia care. And, depending on how deeply held these cultural beliefs are, they could affect dementia care and caregiving both positively and negatively. With the rapidly growing immigrant older adult population, there is a need for systemic strategies to facilitate affordable and culturally responsive dementia care for African immigrants and other minoritized older adults.

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.

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.

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.

Best Practice Recommendations for Integrating Health Equity into Pragmatic Clinical Trials for Dementia Care.

Context: Minoritized populations experience higher rates of dementia and worse health outcomes than non-Hispanic white people, but they are vastly underrepresented in pragmatic clinical trials embedded in health care systems (ePCTs). Little guidance is available to consider health equity-relevant issues in ePCTs. Objective: This report describes the development, structure, and content of a guidance document developed by the National Institute on Aging Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratory to help investigators systematically assess the integration of health equity into all aspects of ePCT design. Design: Led by a task force of IMPACT investigators, a literature review of existing frameworks for health equity considerations in clinical trials was conducted. Next, priority health equity-relevant recommendations in the domains of ePCT design were solicited from Collaboratory experts. The 50 submitted recommendations were reduced to 36 nonoverlapping best practices and categorized into 6 domains, as follows: Getting Started, Community Stakeholder Engagement, Design and Analysis, Intervention Design and Implementation, Health Care System and Participant Selection, and Selecting Outcomes. Each domain had 6 best practice recommendations consisting of a succinctly worded main sentence, with 1 to 2 explanatory sentences. The content was finalized through an iterative process of editing and revision. Conclusions: Although specifically focused on ePCTs involving dementia care, the best practices are applicable to any ePCT and can be useful to advance health equity in traditional clinical trials. This guidance document provides a first step toward promoting holistic, structured integration of health equity into the design and conduct of ePCTs as a matter of good science.

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.