Publications by authors named "Danielle Hessler"

107 Publications

Overcoming psychological insulin resistance: A practical guide for healthcare professionals.

Prim Care Diabetes 2021 Mar 27. Epub 2021 Mar 27.

Eli Lilly and Company, Indianapolis, IN, USA. Electronic address:

Despite the demonstrated benefits of using insulin, nearly a third of the patients with type 2 diabetes (T2D) are initially reluctant to initiate insulin therapy when it is first recommended by their healthcare provider (HCP). Several studies have documented the reasons for this phenomenon known as psychological insulin resistance (PIR) and also identified actionable strategies for HCPs to assist people with T2D to overcome their PIR. However, most strategies are based on the experiences of HCPs, rather than of patients. Based on findings from a study exploring real-world patient experience around HCP actions for mitigating PIR, we suggest that HCPs use collaborative strategies throughout the course of T2D treatment to 1) explore reasons for PIR, 2) help patients overcome PIR, and 3) follow-up regarding experience with insulin.
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http://dx.doi.org/10.1016/j.pcd.2021.03.001DOI Listing
March 2021

Development and validation of a scale to measure diabetes burnout.

J Clin Transl Endocrinol 2021 Mar 11;23:100251. Epub 2021 Feb 11.

Department of Family and Community Medicine, University of California, San Francisco, CA, USA.

Introduction: The aim of this study is to establish reliability and validity of the Diabetes Burnout Scale (DBS) among adults with type 1 diabetes (T1D).

Methods: We used a multi-stage, mixed methods approach to developing the DBS. First, the research team identified twenty-eight candidate items through a review of the literature and 117 qualitative narratives from adults living with T1D. Next, items were revised based on the expert (n = 20) and individual with T1D (n = 10) feedback. The resulting 18-item DBS measure along with validated measures of diabetes distress, depressive symptoms, and questions related to diabetes outcomes (i.e., last reported hemoglobin A1c [HbA1c] and Time-in-Range [TiR]) were completed by 1099 adults with T1D across the U.S. The sample was randomly divided into two subsets (n1 = 561, n2 = 538) for exploratory and confirmatory factor analyses (EFA/CFA) to determine the underlying structure of the DBS. Regression analyses examined the relationships of the DBS with self-reported glycemic control and socio-demographic characteristics.

Results: Based on the EFA three factors are identified and the DBS demonstrated strong internal consistency with Cronbach alphas (≥0.80). The validation and confirmatory analysis for the structure of the DBS provided consistent results with EFA. Higher burnout (overall DBS) was positively associated with diabetes distress (b = 0.74; p < 0.01) and depressive symptoms (b = 0.61; p < 0.01). Overall DBS, however was the strongest predictor for poorer HbA1c (r2 = 0.19; p < 0.01) and lower TiR (r2 = 0.17; p < 0.01) compared to diabetes distress and depressive symptoms.

Conclusion: The 12-item DBS is a reliable and valid scale to measure diabetes burnout in adults with diabetes. The results provide a weak to strong degree of association between the validated DBS scale, T1-DDS and PHQ-8. The DBS can contribute to advancement of diabetes science by measuring diabetes burnout and informing clinical interventions to improve psychosocial care in individuals with diabetes.
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http://dx.doi.org/10.1016/j.jcte.2021.100251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7898165PMC
March 2021

Salivary cytokine cluster moderates the association between caregivers perceived stress and emotional functioning in youth.

Brain Behav Immun 2021 Mar 2. Epub 2021 Mar 2.

Douglas Mental Health University Institute, Douglas Research Center, McGill University, Montreal, QC, Canada; Ludmer Centre for Neuroinformatics and Mental Health and Department of Psychiatry, Faculty of Medicine, McGill University, Montreal, QC, Canada. Electronic address:

Some individuals exposed to early life stress show evidence of enhanced systemic inflammation and are at greater risk for psychopathology. In the current study, caregivers and their offspring (0-17 years) were recruited at a pediatric clinic visit at the University of California, San Francisco (UCSF). Mothers and seven-year-old children from the Growing Up inSingaporeTowards healthy Outcomes (GUSTO) prospective birth cohort were used as a replication cohort. Caregivers perceived stress was measured to determine potential intergenerational effects on the children's functioning and inflammation levels. Children's emotional functioning in the UCSF cohort was evaluated using the Pediatric Quality of Life (PedsQL) inventory. Child emotional and behavioral functioning was measured using the Child Behavior Checklist (CBCL) in GUSTO. Saliva was collected from the children and salivary levels of IL-6, IL-1β, IL-8 and TNF-α were measured using an electrochemiluminescent cytokine multiplex panel. Child IL-6, IL-1β, IL-8 cytokine levels were clustered into low, average, and high cytokine cluster groups using hierarchical cluster analysis. We did not find that salivary cytokine clusters were significantly associated with children's emotional or behavioral function. However, cytokine clusters did significantly moderate the association between increased caregiver perceived stress and reduced child emotional functioning (UCSF cohort) and increased Attention-Deficit-Hyperactivity (ADH) problems (GUSTO cohort, uncorrected Cohen's F2 = 0.02). Using a cytokine clustering technique may be useful in identifying those children exposed to increased caregiver perceived stress that are at risk of emotional and attention deficit hyperactivity problems.
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http://dx.doi.org/10.1016/j.bbi.2021.02.025DOI Listing
March 2021

Development of the Person-Centered Contraceptive Counseling scale (PCCC), a short form of the Interpersonal Quality of Family Planning care scale.

Contraception 2021 May 27;103(5):310-315. Epub 2021 Jan 27.

Department of Family & Community Medicine, University of California, San Francisco, CA, United States.

Objective: Person-centeredness is a critical component of quality in family planning. We previously validated an 11-item Interpersonal Quality of Family Planning (IQFP) scale. We sought to create a parsimonious version of the scale in preparation for testing its appropriateness as a patient-reported outcome performance measure.

Study Design: To explore clarity and importance of each of the 11 items, we conducted English and Spanish cognitive interviews with patients who received contraceptive counseling (n = 33) at 3 publicly funded California clinics. We triangulated these results with psychometric analysis of previously collected IQFP data (n = 1097) to assess validity and reliability of selected item combinations.

Results: The 11-item IQFP scale was reduced to a 4-item scale (the Person-Centered Contraceptive Counseling scale, or PCCC) that includes items evaluating provider performance regarding respect for patients, information provision, and eliciting and honoring patient preferences for birth control. Interview participants deemed the items included in the 4-item PCCC important and clear in both English and Spanish versions of the instrument. The 4-item PCCC retained the 11-item IQFP's psychometric properties, including internal consistency (Cronbach's alpha = 0.92 vs 0.97 for the PCCC and IQFP, respectively) and a consistent single factor analysis solution (factor loadings = 0.86-0.92 and 0.81-0.91). The 4-item PCCC additionally retained the construct and predictive validity of the IQFP.

Conclusions: The 4-item PCCC is a valid and reliable as a measure of person-centered contraceptive counseling that reflects patients' perspectives on contraceptive counseling.

Implications: Person-centered measures such as the 4-item PCCC can help inform efforts to improve health care quality. Future work will investigate the validity and reliability of the 4-item PCCC as a performance measure to determine the appropriateness of its use in the quality improvement context.
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http://dx.doi.org/10.1016/j.contraception.2021.01.008DOI Listing
May 2021

Identifying Relative Changes in Social Risk Factors: An Analytic Approach.

Med Care 2021 02;59(2):e9-e15

Institute for Health Research, Kaiser Permanente Colorado.

Background: Individuals often report concurrent social risk factors such as food insecurity, unstable housing, and transportation barriers. Comparing relative changes between pairs of social risk factors may identify those that are more resistant to change.

Objective: The objective of this study was to develop a method to describe relative changes in pairs of social risk factors.

Research Design: This was a prospective cohort study.

Subjects: Participants in a randomized controlled trial of hypertension care in an Urban Indian Health Organization.

Measures: We measured 7 social risk factors (housing, transportation, food, clothing, health care, utilities, and debts) at enrollment, 6, and 12 months among 295 participants in the trial. We hypothesized that pairwise comparisons could identify social risk factors that were less likely to change over time. We used conditional odds ratios (ORs) with 95% confidence intervals (CIs) to rank each pair.

Results: Food, clothing, health care, utilities, and debts had more changes between 0 and 6 months relative to housing (OR=2.3, 3.4, 4.7, 3.5, and 3.4, respectively; all 95% CI excluded 1.0). These same social risk factors also had more changes between baseline and 6 months relative to transportation (OR=2.8, 3.4, 4.9, 4.7, and 4.1, respectively; all 95% CI excluded 1.0). Changes in housing and transportation risk factors were comparable (OR=0.7, 95% CI: 0.4-1.4). Relative changes between 6 and 12 months were similar.

Conclusions: Housing and transportation exhibited fewer relative changes than other social risk factors and might be more resistant to change. Awareness of the relationships between social risk factors can help define priorities for intervention.
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http://dx.doi.org/10.1097/MLR.0000000000001441DOI Listing
February 2021

Assessment of Social Risk Factors and Interest in Receiving Health Care-Based Social Assistance Among Adult Patients and Adult Caregivers of Pediatric Patients.

JAMA Netw Open 2020 10 1;3(10):e2021201. Epub 2020 Oct 1.

Department of Family and Community Medicine, University of California, San Francisco, San Francisco.

Importance: Health care organizations are increasingly incorporating social risk screening into patient care. Studies have reported wide variations in patients' interest in receiving health care-based assistance for identified social risks. However, no study to date has examined the factors associated with patients' interest in receiving assistance, including whether interest in receiving assistance varies based on specific patient demographic characteristics. Targeted research on this topic could improve the success of health care-based programs that offer social care services.

Objective: To identify participant characteristics associated with interest in receiving health care-based social risk assistance.

Design, Setting, And Participants: This cross-sectional study was conducted in 7 primary care clinics and 4 emergency departments in 9 US states between July 2, 2018, and February 13, 2019. A convenience sample of adult patients and adult caregivers of pediatric patients completed a screening survey that measured social risk factors and participants' interest in receiving assistance for identified social risks. Participants were randomly selected to receive 1 of 2 versions of the survey, which differed based on the order in which questions about social risks and interest in receiving assistance were presented. Multivariable logistic regression analyses were used to evaluate the associations between covariates and participants' interest in receiving assistance, stratified by social risk screening results. Data were analyzed from September 8, 2019, to July 30, 2020.

Exposures: Social risk screening questions assessed risk factors comprising housing, food, transportation, utilities, and exposure to interpersonal violence. Additional questions assessed participants' interest in receiving assistance and their perspectives on health care-based social risk screening.

Main Outcomes And Measures: Participant interest in receiving health care-based social risk assistance.

Results: A total of 1021 adult participants with complete survey responses were included in the analysis. Of those, 709 of 1004 participants (70.6%) were female, and 544 of 1007 participants (54.0%) were aged 18 to 44 years. Overall, 353 of 662 participants (53.3%) with positive screening results for 1 or more social risk factors were interested in receiving assistance, whereas 31 of 359 participants (8.6%) with negative screening results for all social risks were interested in receiving assistance. Participants with positive screening results for 1 or more social risk factors had a higher likelihood of being interested in receiving assistance if they answered the question about interest in receiving assistance before they answered the questions about social risk factors (adjusted odds ratio [aOR], 1.48; 95% CI, 1.05-2.07), had positive screening results for a higher number of social risk factors (aOR, 2.40; 95% CI, 1.68-3.42), reported lower household income levels (aOR, 7.78; 95% CI, 2.96-20.44), or self-identified as having non-Hispanic Black ancestry (aOR, 2.22; 95% CI, 1.37-3.60). Among those with negative screening results for all social risk factors, the interest in receiving assistance was higher if the participants reported lower household income levels (aOR, 12.38; 95% CI, 2.94-52.15), previous exposure to health care-based social risk screening (aOR, 2.35; 95% CI, 1.47-3.74), higher perceived appropriateness of social risk screening (aOR, 3.69; 95% CI, 1.08-12.55), or worse health status (aOR, 4.22; 95% CI, 1.09-16.31).

Conclusions And Relevance: In this study, multiple factors were associated with participants' interest in receiving social risk assistance. These findings may have implications for how and when social risk assistance is offered to patients. As the health care system's role in addressing social risk factors evolves, an understanding of patients' perspectives regarding screening and their interest in receiving assistance may be important to implementing patient-centered interventions.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.21201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568201PMC
October 2020

The early impact of the COVID-19 pandemic on adults with type 1 or type 2 diabetes: A national cohort study.

J Diabetes Complications 2020 12 7;34(12):107748. Epub 2020 Oct 7.

Department of Family & Community Medicine, University of California, San Francisco, United States of America.

Aims: To describe the effects of the COVID-19 pandemic on adults with T1D or T2D in the U.S.

Methods: Participants, recruited from the Taking Control of Your Diabetes Research Registry, were ≥19 years old and diagnosed with either T1D or T2D for ≥12 months. Participants completed an online survey on a HIPAA-protected platform.

Results: Completed surveys were received from 763 T1Ds and 619 T2Ds. Average T1D age was 53.3 (SD = 15.3); average T2D age was 64.9 (SD = 10.3). Both samples were predominantly female, non-Hispanic white and well-educated. Average self-reported HbA1c was 6.9 (SD = 1.0; 52 mmol/mol) for T1Ds and 7.1 (SD = 1.1; 54 mmol/mol) for T2Ds. About 40% of respondents reported that all of their diabetes healthcare appointments at the time were cancelled or postponed, 40% reported a switch to telehealth appointments and almost half reported lower overall satisfaction with these visits (compared to pre-pandemic). There were widespread increases in general and diabetes-related stress and social isolation, and negative effects on disease management. About 25% reported increases in highs, lows, and glucose variability in both groups.

Conclusion: There has been a substantive increase in level of diabetes-related and general life stress and social isolation due to the pandemic, with a significant impact on disease management.
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http://dx.doi.org/10.1016/j.jdiacomp.2020.107748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7539933PMC
December 2020

New insights into diabetes burnout and its distinction from diabetes distress and depressive symptoms: A qualitative study.

Diabetes Res Clin Pract 2020 Nov 16;169:108446. Epub 2020 Sep 16.

Pennsylvania State University Hershey College of Medicine, 500 University Drive, H034, Hershey, PA 17033, USA. Electronic address:

Aims: This study aimed to corroborate the main hypotetized dimensions of diabetes burnout, and its distinction from diabetes distress and depressive symptoms among adults with type 1 diabetes (T1D).

Methods: A qualitative descriptive study was employed to collect data from 31 eligible participants using semi-structured individual phone interviews. Participants were recruited through purposive sampling among a larger sample of adults with T1D in a previous study. Data was analyzed using qualitative content analysis including immersion, reduction, and interpretation.

Results: Exhaustion and detachment were frequent manifestations of diabetes burnout that often accompanied by instances during which participants experienced a loss of control over diabetes. Whereas individuals' support systems could either help or hinder diabetes burnout. Participants saw burnout as separate but closely related to distress and depressive symptoms, with some suggesting correlations among burnout, distress, and depressive symptoms, while others expressed that distress caused their burnout and depressive symptoms.

Conclusions: Diabetes burnout reflects a significant yet unexplored concept which might explain the complexities of suboptimal self-management and poor diabetes outcomes. Emerging evidence suggesting diabetes burnout as a distinct concept calls for more studies to mitigate diabetes burnout as an obstacle to optimal diabetes care.
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http://dx.doi.org/10.1016/j.diabres.2020.108446DOI Listing
November 2020

Pediatrics adverse childhood experiences and related life events screener (PEARLS) and health in a safety-net practice.

Child Abuse Negl 2020 Oct 5;108:104685. Epub 2020 Sep 5.

Center for Youth Wellness, 3450 3rd St, San Francisco, CA, 94124, United States. Electronic address:

Background: Adverse Childhood Experiences (ACEs) are associated with behavioral, mental, and clinical outcomes in children. Tools that are easy to incorporate into pediatric practice, effectively screen for adversities, and identify children at high risk for poor outcomes are lacking.

Objective: To examine the relationship between caregiver-reported child ACEs and related life events with health outcomes.

Participants And Setting: Participants (0-11 years) were recruited from the University of California San Francisco Benioff's Children Hospital Oakland Primary Care Clinic. There were 367 participants randomized.

Methods: Participants were randomized 1:1:1 to item-level (item response), aggregate-level (total number of exposures), or no screening for ACEs (control arm) with the PEdiatric ACEs and Related Life Event Screener (PEARLS). We assessed 10 ACE categories capturing abuse, neglect, and household challenges, as well as 7 additional categories. Multivariable regression models were conducted.

Results: Participants reported a median of 2 (IQR 1-5) adversities with 76 % (n = 279) reporting at least one adversity; participants in the aggregate-level screening arm, on average, disclosed 1 additional adversity compared to item-level screening (p = 0.01). Higher PEARLS scores were associated with poorer perceived child general health (adjusted B = -0.94, 95 %CI: -1.26, -0.62) and Global Executive Functioning (adjusted B = 1.99, 95 %CI: 1.51, 2.46), and greater odds of stomachaches (aOR 1.14; 95 %CI: 1.04-1.25) and asthma (aOR 1.08; 95 %CI 1.00, 1.17). Associations did not differ by screening arm.

Conclusion: In a high-risk pediatric population, ACEs and other childhood adversities remain an independent predictor of poor health. Increased efforts to screen and address early-life adversity are necessary.
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http://dx.doi.org/10.1016/j.chiabu.2020.104685DOI Listing
October 2020

Effects of In-Person Navigation to Address Family Social Needs on Child Health Care Utilization: A Randomized Clinical Trial.

JAMA Netw Open 2020 06 1;3(6):e206445. Epub 2020 Jun 1.

Center for Health and Community, University of California, San Francisco.

Importance: While many organizations endorse screening for social risk factors in clinical settings, few studies have examined the health and utilization effects of interventions to address social needs.

Objective: To compare the acute care utilization effects of a written resources handout vs an in-person navigation service intervention to address social needs.

Design, Settings, And Participants: In this secondary analysis of a randomized clinical trial, 1809 adult caregivers of pediatric patients seen in primary and urgent care clinics of 2 safety-net hospitals in northern California were recruited between October 13, 2013, and August 27, 2015. Each participating family was randomly assigned to an in-person navigator intervention vs active control to address the family's social needs. Analyses were conducted between February 28, 2018, and September 25, 2019.

Interventions: Caregivers either received written information about relevant local resources related to social needs (active control) or met with a patient navigator focused on helping them resolve social needs (navigator intervention). After an initial in-person visit, navigation services included telephone, email, and/or in-person follow-up for up to 3 months.

Main Outcome And Measures: Child emergency department visit or hospitalization within 12 months of study enrollment.

Results: Among the 1300 caregivers enrolled in the study without missing follow-up data, most spoke English (878 [67.5%]) and were women (1127 [86.7%]), with a mean (SD) age of 33.0 (9.33) years. Most children were aged 0 to 5 years (779 of 1300 [59.9%]), 723 children (55.6%) had Hispanic ethnicity, and 462 children (35.5%) were in excellent health; 840 families (64.6%) were recruited from urgent care. In total, 637 families (49.0%) were randomized to the in-person navigator group and 663 (51.0%) to the active control group. There was no difference in risk of an emergency department visit between the 2 groups. Children enrolled in the in-person navigator group had a decreased risk of hospitalization within 12 months (hazard ratio, 0.59; 05% CI, 0.38-0.94; P = .03), making them 69% less likely to be hospitalized.

Conclusions And Relevance: In this randomized clinical trial evaluating heath care utilization effects of programs designed to address social needs among families, children enrolled in the navigation group were significantly less likely to be hospitalized after the intervention but equally likely to have an emergency department visit. These findings strengthen our understanding of the effects of addressing social needs in clinical settings as part of a comprehensive strategy to improve health and reduce health care utilization.

Trial Registration: ClinicalTrials.gov Identifier: NCT01939704.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.6445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265099PMC
June 2020

Burnout, distress, and depressive symptoms in adults with type 1 diabetes.

J Diabetes Complications 2020 07 30;34(7):107608. Epub 2020 Apr 30.

Department of Family and Community Medicine, University of California, 500 Parnassus Avenue, E334, San Francisco, CA 94117, USA. Electronic address:

Introduction: We identified established scales and subscales related to the hypostatized dimensions of diabetes burnout (exhaustion, detachment, powerlessness) emerging from our preliminary qualitative studies, and examined the relationship of diabetes burnout with diabetes distress, depressive symptoms, and diabetes outcomes.

Methods: In this cross-sectional study, adults with type 1 diabetes (n = 111) completed an online survey including measures of diabetes distress, depressive symptoms, and proposed measures of diabetes burnout. Participants also answered questions related to diabetes outcomes (i.e., last reported HbA1c, missed appointments) as well as other clinical and sociodemographic characteristics. Items related to diabetes burnout were identified and analyzed in an exploratory factor analysis (EFA). The items retained through the EFA were then used in a series of regression analyses to estimate the relationships of the diabetes burnout measure with participants' background characteristics, diabetes distress, depressive symptoms, and diabetes outcomes.

Results: The EFA provided mixed results. The proposed measures of powerlessness were consistent with the original hypothesis. However, the identified measures of exhaustion and detachment did not load onto the anticipated factors. After revising the subscales based on the results of the factor analysis, the measures of diabetes burnout demonstrated strong internal consistency with Cronbach alphas (all subscales and total scale ≥0.85). Diabetes burnout was significantly associated with both depression (es = 0.70; p < .01) and diabetes distress (es = 0.80; p < .01). While measures of diabetes burnout, distress, and depressive symptoms were significant predictors of multiple diabetes outcomes, overall diabetes burnout was no longer significantly related to these outcomes after controlling for diabetes distress and depressive symptoms.

Conclusion: The results of the study provide a first step toward identifying a reliable, valid measure of diabetes burnout. Further research is needed to identify additional items to supplement/replace existing measures and to further differentiate diabetes burnout from diabetes distress and depressive symptoms.
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http://dx.doi.org/10.1016/j.jdiacomp.2020.107608DOI Listing
July 2020

Screening for Park Access during a Primary Care Social Determinants Screen.

Int J Environ Res Public Health 2020 04 17;17(8). Epub 2020 Apr 17.

UCSF Center for Health and Community, 3333 California St., Suite 465, Campus Box 0844, San Francisco, CA 94143-0844, USA.

While there is evidence that access to nature and parks benefits pediatric health, it is unclear how low-income families living in an urban center acknowledge or prioritize access to parks.

Methods: We conducted a study about access to parks by pediatric patients in a health system serving low-income families. Adult caregivers of pediatric patients completed a survey to identify and prioritize unmet social and economic needs, including access to parks. Univariate and multivariate analyses were conducted to explore associations between lack of access to parks and sociodemographic variables. We also explored the extent to which access to parks competed with other needs.

Results: The survey was completed by 890 caregivers; 151 (17%) identified "access to green spaces/parks/playgrounds" as an unmet need, compared to 397 (45%) who endorsed "running out of food before you had money or food stamps to buy more". Being at or below the poverty line doubled the odds ( Odds ratio 1.96, 95% CI 1.16-3.31) of lacking access to a park (reference group: above the poverty line), and lacking a high school degree nearly doubled the odds. Thirty-three of the 151 (22%) caregivers who identified access to parks as an unmet need prioritized it as one of three top unmet needs. Families who faced competing needs of housing, food, and employment insecurity were less likely to prioritize park access ( < 0.001).

Conclusion: Clinical interventions to increase park access would benefit from an understanding of the social and economic adversity faced by patients.
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http://dx.doi.org/10.3390/ijerph17082777DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216015PMC
April 2020

Successful Health Care Provider Strategies to Overcome Psychological Insulin Resistance in United States and Canada.

J Am Board Fam Med 2020 Mar-Apr;33(2):198-210

From the University of British Columbia, Vancouver, Canada (TT); University of California, San Francisco, CA (DH, LF); Behavioral Diabetes Institute, San Diego, CA (WHP); University of California, San Diego, CA (WHP); Eli Lilly and Company, Indianapolis, IN (BR, MP-N); Eli Lilly and Company, Canada (TI); Analysis Group, Inc., Boston, MA (UD).

Purpose: To identify specific actions and characteristics of health care providers (HCPs) in the United States and Canada that influenced patients with type 2 diabetes who were initially reluctant to begin insulin.

Methods: Patients from the United States (n = 120) and Canada (n = 74) were recruited via registry, announcements, and physician referrals to complete a 30-minute online survey based on interviews with patients and providers regarding specific HCP actions that contributed to the decision to begin insulin.

Results: The most helpful HCP actions were patient-centered approaches to improve patients' understanding of the injection process (ie, "My HCP walked me through the whole process of exactly how to take insulin" [helped moderately or a lot, United States: 79%; Canada: 83%]) and alleviate concerns ("My HCP encouraged me to contact his/her office immediately if I ran into any problems or had questions after starting insulin" [United States: 76%; Canada: 82%]). Actions that were the least helpful included referrals to other sources (ie, "HCP referred patient to a class to help learn more about insulin" [United States: 40%; Canada: 58%]).

Conclusions: The study provides valuable insight that HCPs can use to help patients overcome psychological insulin resistance, which is a critical step in the design of effective intervention protocols.
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http://dx.doi.org/10.3122/jabfm.2020.02.190157DOI Listing
April 2019

A Systematic Approach to Working With Medical Learners in Difficulty: A Faculty Development Workshop.

MedEdPORTAL 2020 01 31;16:10872. Epub 2020 Jan 31.

Associate Professor, Department of Family and Community Medicine, University of California, San Francisco, School of Medicine.

Introduction: For medical educators, applying a systematic approach to working with struggling learners (learners in difficulty) can improve faculty success and satisfaction with the remediation process. Use of the familiar SOAP diagnostic framework can ensure that faculty develop a thorough differential diagnosis and target their interventions to address underlying issues affecting learner success.

Methods: We developed a workshop to teach medical education faculty essential skills for supporting learners in difficulty. Teaching methods included didactic presentation, large-group discussion, and small-group work with role-plays. Over three 2-hour sessions, participants learned to assess a learner in difficulty, develop an initial remediation plan, and evaluate their learning system with the goal of improving support to learners in difficulty. Evaluation included pre- and postsession assessment of learner self-perceived confidence and skill with working with struggling learners, as well as brief postsession evaluation.

Results: Ninety-nine faculty participated in the Learners in Difficulty workshop over 7 years. Participants' overall rating of the workshop was 4.9 (1 = , 5 = ). Pre- and postworkshop evaluation showed a statistically significant increase in perceived self-confidence to "Meet the needs of a struggling learner," from an average of 4.4 to 7.6 on a 10-point scale (mean Δ = 3.2; 95% confidence interval, 2.6-3.8; < .001).

Discussion: This workshop provides a stepwise approach to working with learners in difficulty and assessing participants' educational systems to identify strengths and weaknesses. Evaluations indicated participants felt more confident in their ability to engage in this topic following completion of the workshop.
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http://dx.doi.org/10.15766/mep_2374-8265.10872DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7062539PMC
January 2020

Effects of In-Person Assistance vs Personalized Written Resources About Social Services on Household Social Risks and Child and Caregiver Health: A Randomized Clinical Trial.

JAMA Netw Open 2020 03 2;3(3):e200701. Epub 2020 Mar 2.

Department of Family and Community Medicine, University of California, San Francisco.

Importance: Social and economic contexts shape children's short- and long-term health. Efforts to address contextual risk factors are increasingly incorporated into pediatric health care.

Objective: To compare the effectiveness of 2 social risk-related interventions.

Design, Setting, And Participants: This randomized clinical trial included English- and/or Spanish-speaking caregiver-child dyads recruited from a pediatric urgent care clinic nested in a large, urban, safety-net hospital. Study recruitment, enrollment, and follow-up were conducted from July 18, 2016, to March 8, 2019. Data analysis was conducted from January 1, 2019, to January 20, 2020.

Interventions: Following standardized social risk assessment, caregivers were randomly assigned to receive either written information regarding relevant government and community social services resources or comparable written information plus in-person assistance and follow-up focused on service access.

Main Outcomes And Measures: Caregiver-reported number of social risk factors and child health 6 months after enrollment.

Results: Among 611 caregiver-child dyads enrolled in the study, 302 dyads were randomized to the written resources group and 309 dyads were randomized to the written resources plus in-person assistance group. The mean (SD) age of children was 6.1 (5.0) years; 483 children (79.1%) were Hispanic; and 315 children (51.6%) were girls. There were no significant differences between groups in the effects of the interventions. In post hoc secondary analyses, the number of reported social risks decreased from baseline to 6-month follow-up in both groups: caregivers who received written resources alone reported a mean (SE) of 1.28 (0.19) fewer risks at follow-up, while those receiving written resources plus in-person assistance reported 1.74 (0.21) fewer risks at follow-up (both P < .001). In both groups, there were small but statistically significant improvements from baseline to follow-up in child health (mean [SE] change: written resources, 0.37 [0.07]; written resources plus in-person assistance, 0.24 [0.07]; both P < .001).

Conclusions And Relevance: This randomized clinical trial compared 2 approaches to addressing social risks in a pediatric urgent care setting and found no statistically significant differences in the social risk and child and caregiver health effects of providing written resources at the point of care with vs without in-person longitudinal navigation services. Caregivers in both groups reported fewer social risks and improved child and caregiver health 6 months after the intervention. These findings deepen understanding of effective doses of social risk-related interventions.

Trial Registration: ClinicalTrials.gov Identifier: NCT02746393.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.0701DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7064877PMC
March 2020

When patient-reported experience does not match change in clinical outcomes: A perplexing view from the inside of a diabetes distress intervention.

J Diabetes Complications 2020 04 11;34(4):107533. Epub 2020 Jan 11.

University of California, San Francisco, San Francisco, CA, USA.

Aims: To assess between-group differences in participant experiences in a two-arm diabetes distress (DD) reduction RCT and to determine their relationship to clinical outcomes (reductions in DD and HbA1C).

Methods: For high DD adults with Type 1 diabetes and HbA1c ≥7.5% participating in T1-REDEEM, we evaluated post intervention 5-point ratings of overall program "helpfulness" and program component "helpfulness," along with open-ended feedback statements using 10 qualitative codes. We compared responses of those in OnTrack, a distressed-focused intervention, with KnowIt, an education/management intervention.

Results: Those in OnTrack reported significantly higher levels of overall program helpfulness and greater helpfulness of each component of the program, greater group support, far fewer negative experiences, and more active and meaningful group engagement than those who participated in KnowIt. Ratings of helpfulness were unrelated to reductions in DD and HbA1C in both study arms. As previously reported, these findings occurred despite significant reductions in both DD and HbA1C in both arms with no between-group differences.

Conclusions: Findings highlight the importance of addressing the personal experience of diabetes interventions in clinical care as separate, distinct outcomes. Personal experience may not always be related to changes in traditional clinical indicators.
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http://dx.doi.org/10.1016/j.jdiacomp.2020.107533DOI Listing
April 2020

Lay Health Coaching to Increase Appropriate Inhaler Use in COPD: A Randomized Controlled Trial.

Ann Fam Med 2020 01;18(1):5-14

Department of Medicine, Stanford University School of Medicine, Palo Alto, California.

Purpose: Poor adherence to medications is more prevalent for chronic obstructive pulmonary disease (COPD) than for other chronic conditions and is associated with unfavorable health outcomes. Few interventions have successfully improved adherence for COPD medications; none of these use unlicensed health care personnel. We explored the efficacy of lay health coaches to improve inhaler adherence and technique.

Methods: Within a randomized controlled trial, we recruited English- and Spanish-speaking patients with moderate to severe COPD from urban, public primary care clinics serving a low-income, predominantly African American population. Participants were randomized to receive 9 months of health coaching or usual care. Outcome measures included self-reported adherence to inhaled controller medications in the past 7 days and observed technique for all inhalers. We used generalized linear models, controlling for baseline values and clustering by site.

Results: Baseline adherence and inhaler technique were uniformly poor and did not differ by study arm. At 9 months, health-coached patients reported a greater number of days of adherence compared with usual care patients (6.4 vs 5.5 days; adjusted = .02) and were more likely to have used their controller inhalers as prescribed for 5 of the last 7 days (90% vs 69%; adjusted = .008). They were more than 3 times as likely to demonstrate perfect technique for all inhaler devices (24% vs 7%; adjusted = .01) and mastery of essential steps (40% vs 11%; adjusted <.001).

Conclusions: Health coaching may provide a scalable model that can improve care for people living with COPD.
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http://dx.doi.org/10.1370/afm.2461DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227462PMC
January 2020

Key factors for overcoming psychological insulin resistance: an examination of patient perspectives through content analysis.

BMJ Open Diabetes Res Care 2019 11;7(1):e000723. Epub 2019 Dec 11.

Eli Lilly and Company, Indianapolis, Indiana, USA.

Objective: To understand participant perceptions about insulin and identify key behaviors of healthcare professionals (HCPs) that motivated initially reluctant adults from seven countries (n=40) who had type 2 diabetes (T2D) to start insulin treatment.

Research Design And Methods: Telephone interviews were conducted with a subset of participants from an international investigation of adults with T2D who were reluctant to start insulin (EMOTION). Questions related to: (a) participants' thoughts about insulin before and after initiation; (b) reasons behind responses on the survey that were either 'not helpful at all' or 'helped a lot'; (c) actions their HCP may have taken to help start insulin treatment; and (d) advice they would give to others in a similar situation of starting insulin. Responses were coded by two independent reviewers (kappa 0.992).

Results: Starting insulin treatment was perceived as a negative experience that would be painful and would lead down a 'slippery slope' to complications. HCPs engaged in four primary behaviors that helped with insulin acceptance: (1) showed the insulin pen/needle and demonstrated the injection process; (2) explained how insulin could help with diabetes control and reduce risk of complications; (3) used collaborative communication style; and (4) offered support and willingness to answer questions so that participants would not be 'on their own'. Following initiation, most participants noted that insulin was not 'as bad as they thought' and recommended insulin to other adults with T2D.

Conclusions: Based on these themes, two actionable strategies are suggested for HCPs to help people with psychological insulin resistance: (1) demonstrate the injection process and discuss negative perceptions of insulin as well as potential benefits; (2) offer autonomy in a person-centred collaborative approach, but provide support and accessibility to address concerns. These findings help HCPs to better understand ways in which they can engage reluctant people with T2D with specific strategies.
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http://dx.doi.org/10.1136/bmjdrc-2019-000723DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6936574PMC
August 2020

CE: Original Research: Experiences of Diabetes Burnout: A Qualitative Study Among People with Type 1 Diabetes.

Am J Nurs 2019 12;119(12):22-31

Samereh Abdoli is an assistant professor in the College of Nursing, University of Tennessee, Knoxville, where Amit Vora is a clinical assistant professor in the Graduate School of Medicine. Danielle Hessler is an associate professor in the Department of Family and Community Medicine, University of California, San Francisco. Betsy Smither is a project manager at Oak Ridge Associated Universities, Oak Ridge, TN. Heather Stuckey is an associate professor in the Departments of Medicine, Public Health Science, and Humanities at Pennsylvania State University, Harrisburg. This study was supported in part by an unrestricted grant from the Beryl Institute. Contact author: Samereh Abdoli, The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

Background: People with type 1 diabetes are at increased risk for diabetes burnout, resulting in suboptimal diabetes care and quality of life. While the existence of diabetes burnout is widely acknowledged, there is no evidence-based definition, means of measurement, or interventions to address it.

Objective: This study was aimed at increasing our understanding of the lived experiences of diabetes burnout among adults with type 1 diabetes.

Methods: A qualitative descriptive study was conducted with a sample of 18 adults with type 1 diabetes who reported a current or previous experience of diabetes burnout. Data were collected using in-depth interviews and analyzed using qualitative content analysis.

Results: Four main themes were identified: mental, emotional, and physical exhaustion from having diabetes; detachment from illness identity, diabetes self-care, and support systems; contributing factors to diabetes burnout; and strategies for preventing or overcoming diabetes burnout.

Conclusion: Although exhaustion is an entry point for diabetes burnout, the findings suggest that detachment from illness identity, diabetes self-care, and support systems form a core component. Detachment may explain poor outcomes in individuals experiencing diabetes burnout.
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http://dx.doi.org/10.1097/01.NAJ.0000615776.64043.beDOI Listing
December 2019

Part II: A Qualitative Study of Social Risk Screening Acceptability in Patients and Caregivers.

Am J Prev Med 2019 12;57(6 Suppl 1):S38-S46

Department of Family & Community Medicine, University of California, San Francisco, San Francisco, California.

Introduction: This study aimed to better understand patient and caregiver perspectives on social risk screening across different healthcare settings.

Methods: As part of a mixed-methods multisite study, the authors conducted semistructured interviews with a subset of adult patients and adult caregivers of pediatric patients who had completed the Center for Medicare and Medicaid Innovation Accountable Health Communities social risk screening tool between July 2018 and February 2019. Interviews, conducted in English or Spanish, asked about reactions to screening, screening acceptability, preferences for administration, prior screening experiences that informed perspectives, and expectations for social assistance. Basic thematic analysis and constant comparative methods were used to code and develop themes.

Results: Fifty interviews were conducted across 10 study sites in 9 states, including 6 primary care clinics and 4 emergency departments. There was broad consensus among interviewees across all sites that social risk screening was acceptable. The following 4 main themes emerged: (1) participants believed screening for social risks is important; (2) participants expressed insight into the connections between social risks and overall health; (3) participants emphasized the importance of patient-centered implementation of social risk screening; and (4) participants recognized limits to the healthcare sector's capacity to address or resolve social risks.

Conclusions: Despite gaps in the availability of social risk-related interventions in healthcare settings, patient-centered social risk screening, including empathy and attention to privacy, may strengthen relationships between patients and healthcare teams.

Supplement Information: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.
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http://dx.doi.org/10.1016/j.amepre.2019.07.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6876708PMC
December 2019

Part I: A Quantitative Study of Social Risk Screening Acceptability in Patients and Caregivers.

Am J Prev Med 2019 12;57(6 Suppl 1):S25-S37

Department of Family & Community Medicine, University of California, San Francisco, San Francisco, California.

Introduction: Despite recent growth in healthcare delivery-based social risk screening, little is known about patient perspectives on these activities. This study evaluates patient and caregiver acceptability of social risk screening.

Methods: This was a cross-sectional survey of 969 adult patients and adult caregivers of pediatric patients recruited from 6 primary care clinics and 4 emergency departments across 9 states. Survey items included the Center for Medicare and Medicaid Innovation Accountable Health Communities' social risk screening tool and questions about appropriateness of screening and comfort with including social risk data in electronic health records. Logistic regressions evaluated covariate associations with acceptability measures. Data collection occurred from July 2018 to February 2019; data analyses were conducted in February‒March 2019.

Results: Screening was reported as appropriate by 79% of participants; 65% reported comfort including social risks in electronic health records. In adjusted models, higher perceived screening appropriateness was associated with previous exposure to healthcare-based social risk screening (AOR=1.82, 95% CI=1.16, 2.88), trust in clinicians (AOR=1.55, 95% CI=1.00, 2.40), and recruitment from a primary care setting (AOR=1.70, 95% CI=1.23, 2.38). Lower appropriateness was associated with previous experience of healthcare discrimination (AOR=0.66, 95% CI=0.45, 0.95). Higher comfort with electronic health record documentation was associated with previously receiving assistance with social risks in a healthcare setting (AOR=1.47, 95% CI=1.04, 2.07).

Conclusions: A strong majority of adult patients and caregivers of pediatric patients reported that social risk screening was appropriate. Most also felt comfortable including social risk data in electronic health records. Although multiple factors influenced acceptability, the effects were moderate to small. These findings suggest that lack of patient acceptability is unlikely to be a major implementation barrier.

Supplement Information: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.
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http://dx.doi.org/10.1016/j.amepre.2019.07.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336892PMC
December 2019

The importance of relationship processes for lowering BMI over time in women with type 2 diabetes in a randomized controlled trial.

Obes Res Clin Pract 2019 Nov - Dec;13(6):599-601. Epub 2019 Oct 22.

The University of California, San Francisco, CA United States.

Objective: Weight change may be affected by dyadic processes within couple relationships. The aim of this secondary data analysis was to explore trends in BMI across time, and assess whether relationship processes (i.e., relationship satisfaction, positive problem-solving), predict BMI trajectories in men and women.

Methods: Data are from 268 participants in the Diabetes Support Project, a randomized trial of behavioral intervention for individuals with type 2 diabetes (T2D) in poor glycemic control. For secondary analyses, BMI was measured at pre-treatment (baseline), 4 months (post-treatment), 8 months, and 12 months. Multiple relationship variables were measured at all time points and were modeled as predictors and correlates of change in BMI across time.

Results: In general, BMI trajectories had higher starting values (intercepts) for females than for males in the sample (b = -2.51, p < .05), and slopes trended downward from pre-treatment to 12 months (b = -.09, p <  .05). Downward trajectories of BMI were more pronounced for women with higher relationship satisfaction (b = .05, p <  .05) and higher positive problem solving skills (b = .06, p < .05) at baseline. Change in relationship processes were not correlated with change in BMI across time.

Conclusion: For women with T2D in this behavioral intervention study, relationship process scores at the beginning of treatment predicted changes in BMI over time, with better problem solving and higher relationship satisfaction at baseline related to steeper decreases in BMI across treatment. Additional research is needed to understand how improving relationship interaction prior to diabetes treatment may positively influence weight loss during treatment.
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http://dx.doi.org/10.1016/j.orcp.2019.08.003DOI Listing
July 2020

Economic costs of implementing group interventions to reduce diabetes distress in adults with type 1 diabetes mellitus in the T1-REDEEM trial.

J Diabetes Complications 2019 11 15;33(11):107416. Epub 2019 Aug 15.

Department of Medicine, University of California, San Francisco, Box 1222, San Francisco, CA 94143-1222, USA.

Aims: This study evaluated the implementation costs of two group interventions, one focused on diabetes education (KnowIt) and one focused directly on diabetes distress (OnTrack), that reduced diabetes distress and HbA1C in adults with poorly controlled type 1 diabetes (T1DM) in the T1-REDEEM trial.

Methods: Resources used to provide interventions were enumerated using activity-based micro-costing methods. Costs were assigned to resources in 2017 US dollars. US median wage and benefit rates were used to calculate costs of staff time. Cost per unit change was calculated for diabetes distress and HbA1C.

Results: For both interventions, per participant implementation costs were approximately $250 and cost per 1.0 percentage point (11 mmol/mol) change in HbA1C was $1400. Cost per unit change in diabetes distress was $364 for KnowIt and $335 for OnTrack. No statistically significant differences in costs were observed.

Conclusions: This is the first study to examine the costs of implementing interventions targeting diabetes distress in the context of T1DM. Both interventions had per participant implementation costs in the lower end of the range of previously examined diabetes self-management interventions ($219 to $5390). These inventions and their costs merit further attention because reducing diabetes distress may impact long term T1DM outcomes.

Clinical Trials Registration: ClinicalTrials.govNCT02175732.
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http://dx.doi.org/10.1016/j.jdiacomp.2019.107416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6823162PMC
November 2019

Self-management support for chronic disease in primary care: frequency of patient self-management problems and patient reported priorities, and alignment with ultimate behavior goal selection.

BMC Fam Pract 2019 08 29;20(1):120. Epub 2019 Aug 29.

Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA.

Background: To enable delivery of high quality patient-centered care, as well as to allow primary care health systems to allocate appropriate resources that align with patients' identified self-management problems (SM-Problems) and priorities (SM-Priorities), a practical, systematic method for assessing self-management needs and priorities is needed. In the current report, we present patient reported data generated from Connection to Health (CTH), to identify the frequency of patients' reported SM-Problems and SM-Priorities; and examine the degree of alignment between patient SM-Priorities and the ultimate Patient-Healthcare team member selected Behavioral Goal.

Methods: CTH, an electronic self-management support system, was embedded into the flow of existing primary care visits in 25 primary care clinics and was used to assess patient-reported SM-Problems across 12 areas, patient identified SM-Priorities, and guide the selection of a Patient-Healthcare team member selected Behavioral Goal. SM-Problems included: BMI, diet (fruits and vegetables, salt, fat, sugar sweetened beverages), physical activity, missed medications, tobacco and alcohol use, health-related distress, general life stress, and depression symptoms. Descriptive analyses documented SM-Problems and SM-Priorities, and alignment between SM-Priorities and Goal Selection, followed by mixed models adjusting for clinic.

Results: 446 participants with ≥ one chronic diseases (mean age 55.4 ± 12.6; 58.5% female) participated. On average, participants reported experiencing challenges in 7 out of the 12 SM-Problems areas; with the most frequent problems including: BMI, aspects of diet, and physical activity. Patient SM-Priorities were variable across the self-management areas. Patient- Healthcare team member Goal selection aligned well with patient SM-Priorities when patients prioritized weight loss or physical activity, but not in other self-management areas.

Conclusion: Participants reported experiencing multiple SM-Problems. While patients show great variability in their SM-Priorities, the resulting action plan goals that patients create with their healthcare team member show a lack of diversity, with a disproportionate focus on weight loss and physical activity with missed opportunities for using goal setting to create targeted patient-centered plans focused in other SM-Priority areas. Aggregated results can assist with the identification of high frequency patient SM-Problems and SM-Priority areas, and in turn inform resource allocation to meet patient needs.

Trial Registration: ClinicalTrials.gov ID: NCT01945918 .
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http://dx.doi.org/10.1186/s12875-019-1012-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714442PMC
August 2019

Development and Validation of the Client-Reported Quality of Contraceptive Counseling Scale to Measure Quality and Fulfillment of Rights in Family Planning Programs.

Stud Fam Plann 2019 06 23;50(2):137-158. Epub 2019 May 23.

We developed the Quality of Contraceptive Counseling (QCC) Scale to improve measurement of client experiences with providers in the era of rights-based service delivery. We generated scale items drawing on the previously published QCC Framework and qualitative research on women's preferences for counseling in Mexico, and refined them through cognitive interviews (n = 29) in two Mexican states. The item pool was reduced from 35 to 22 items after pilot testing using exit interviews in San Luis Potosí (n = 257). Exploratory Factor Analysis revealed three underlying dimensions (Information Exchange, Interpersonal Relationship, Disrespect and Abuse); this dimensionality was reproduced in Mexico City (n = 242) using Confirmatory Factor Analysis. Item Response Theory analyses confirmed acceptable item properties in both states, and correlation analyses established convergent, predictive, and divergent validity. The QCC Scale and subscales fill a gap in measurement tools for ensuring high quality of care and fulfillment of human rights in contraceptive services, and should be evaluated and adapted in other contexts.
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http://dx.doi.org/10.1111/sifp.12092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6618078PMC
June 2019

Correction to: Health coaching to improve self-management and quality of life for low income patients with chronic obstructive pulmonary disease (COPD): protocol for a randomized controlled trial.

BMC Pulm Med 2019 05 21;19(1):96. Epub 2019 May 21.

Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA.

In the original article [1], the authors reference their intention to use the 'Morisky Medication Adherence Scale'.
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http://dx.doi.org/10.1186/s12890-019-0859-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6528370PMC
May 2019

A Cluster Randomized Trial Comparing Strategies for Translating Self-Management Support into Primary Care Practices.

J Am Board Fam Med 2019 May-Jun;32(3):341-352

From the Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO (WPD, LMD, BTJ, DHF, MC); Department of Family and Community Medicine, University of California-San Francisco, San Francisco, CA (DMH, LF).

Introduction: Self-management support (SMS) is a key factor in diabetes care, but true SMS has not been widely adopted by primary care practices. Interactive behavior-change technology (IBCT) can provide efficient methods for adoption of SMS in primary care. Practice facilitation has been effective in assisting practices in implementing complex evidence-based interventions, such as SMS. This study was designed to study the incremental impact of practice education, the Connection to Health (CTH) IBCT tool, and practice facilitation as approaches to enhance the translation of SMS for patients with diabetes in primary care practices.

Methods: A cluster-randomized trial compared the effectiveness of 3 implementation strategies for enhancing SMS for patients with diabetes in 36 primary care practices: 1) SMS education (SMS-ED); 2) SMS-ED plus CTH availability (CTH); and 3) SMS-ED, CTH availability, plus brief practice facilitation (CTH + PF). Outcomes including hemoglobin A1c (HbA1c) levels and SMS activities were assessed at 18 months post study initiation in a random sample of patients through medical record reviews.

Results: A total of 488 patients enrolled in the CTH system (141 CTH, 347 CTH + PF). In the intent-to-treat analysis of patients with medical record reviews, HbA1c slopes did not differ between study arms (CTH vs SMS-ED: = .2243, CTH + PF vs SMS-ED: = .8601). However, patients from practices in the CTH + PF arm who used CTH showed significantly improved HbA1c trajectories over time compared with patients from SMS-ED practices ( = .0422). SMS activities were significantly increased in CTH and CTH + PF study arms compared with SMS-ED (CTH vs SMS-ED: = .0223, CTH + PF vs SMS-ED: = .0013). The impact of CTH on SMS activities was a significant mediator of the impact of the CTH and CTH + PF interventions on HbA1c.

Conclusion: An interactive behavior change technology tool such as CTH can increase primary care practice SMS activities and improve patient HbA1c levels. Even brief practice facilitation assists practices in implementing SMS.
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http://dx.doi.org/10.3122/jabfm.2019.03.180254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6599532PMC
June 2020

Practice Characteristics Associated with Better Implementation of Patient Self-Management Support.

J Am Board Fam Med 2019 May-Jun;32(3):329-340

From Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO (BTJ, DHF, LMD, RW, LC, JSH, WPD); Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA (DMH, LF).

Background: Advanced primary care models emphasize patient-centered care, including self-management support (SMS). This study aimed to promote the translation of SMS into primary care practices and reported on key baseline practice characteristics that may impact SMS implementation.

Methods: Thirty-six practices in Colorado and California participated in the study from December 2013 to March 2017. Practice administrators completed a Practice Information Form describing practice characteristics. Clinicians and staff (n = 716) completed the Practice Culture Assessment and the Patient-Centered Medical Home (PCMH) Monitor. Descriptive statistics were computed to determine practice characteristics related to culture, quality improvement, level of PCMH, and SMS implementation. Field notes and key informant interviews provided contextual details about practices. Iterative qualitative analyses identified important facilitators and barriers and change capabilities around SMS implementation.

Results: In bivariate analyses, rural locations, fewer uncontrolled patients with diabetes, higher Medicaid or uninsured populations, underserved designation, and higher level of "PCMHness" were associated with greater reported implementation of patient SMS (all < .05) at baseline. In the final multilevel model, specialty (FM vs mixed, = .0081), rural location ( = .0109), and higher percent Medicaid ( < .0001) were associated with greater SMS. Practices described key facilitators (alignment, motivation, a visible champion, supporting infrastructure, and functional quality improvement and care teams) and barriers (no shared vision, no visible champion, siloed infrastructure, competing programs, turnover, and time constraints) to improving SMS delivery.

Conclusions: Careful attention-and action-on key practice characteristics and context may create more favorable initial conditions for practice change efforts to improve SMS in primary care practices.
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http://dx.doi.org/10.3122/jabfm.2019.03.180124DOI Listing
June 2020

Bringing Social Context into Diabetes Care: Intervening on Social Risks versus Providing Contextualized Care.

Curr Diab Rep 2019 04 29;19(6):30. Epub 2019 Apr 29.

Department of Family and Community Medicine, University of California, San Francisco, Box 0900, San Francisco, CA, 94143, USA.

Purpose Of Review: Patient social and economic risk information can guide diabetes care through social risk-targeted care (directly intervening on social risk factors) or social risk-informed care (modifying or tailoring care to accommodate social risks). We review evidence supporting these approaches and highlight critical gaps in the current evidence.

Recent Findings: Literature is scarce on isolated social care interventions and the impact on glycemic control is unclear, while blended social-behavioral interventions more consistently point to reductions in HbA1c. Social risk-informed care naturally occurs at low rates, yet holds potential to improve care. Momentum is building around programs designed to intervene on social risk factors and/or to contextualize care based on social context. Future work will need to isolate the impacts of these programs, clarify the pathways through which social care programs can improve outcomes, and identify provider barriers and facilitators to using social risk information in care.
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http://dx.doi.org/10.1007/s11892-019-1149-yDOI Listing
April 2019

Toward effective interventions to reduce diabetes distress among adults with type 1 diabetes: Enhancing Emotion regulation and cognitive skills.

Patient Educ Couns 2019 08 27;102(8):1499-1505. Epub 2019 Mar 27.

Department of Medicine, University of California, San Francisco, CA, USA. Electronic address:

Objective: We tested three models to determine how improvements in emotion regulation (ER) and cognitive skills (CS) as a result of intervention operate to affect reductions in diabetes distress DD.

Methods: Change data were drawn from the baseline and 9-month T1-REDEEM trial. Adults with type 1 diabetes were recruited from several U.S. states and Toronto, Canada. A primary and two alternative structural equation models were tested to explore the directionality of effect: primary model - changes in ER and CS drive changes in DD; reverse model - changes in DD drive changes in ER and CS; and bidirectional model - changes in ER, CS and DD occur together with no directionality.

Results: All three models displayed a good fit to the data. The primary model indicated 7 significant directional pathways: improvements in ER and CS operate together to drive reductions in DD. The reverse model only indicated that reductions in DD affected changes in one CS variable; and the bidirectional model indicated only that these results were bidirectional. Reductions in all tested domains of DD occurred together.

Conclusions: Improvements in ER and CS drive reductions in DD.

Practice Implications: Interventions to reduce high DD should focus on improving ER and CS.
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http://dx.doi.org/10.1016/j.pec.2019.03.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6565487PMC
August 2019