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1.  Baseline Predictors of Missed Visits in the Look AHEAD Study 
Obesity (Silver Spring, Md.)  2014;22(1):131-140.
Objective
To identify baseline attributes associated with consecutively missed data collection visits during the first 48 months of Look AHEAD—a randomized, controlled trial in 5145 overweight/obese adults with type 2 diabetes designed to determine the long-term health benefits of weight loss achieved by lifestyle change.
Design and Methods
The analyzed sample consisted of 5016 participants who were alive at month 48 and enrolled at Look AHEAD sites. Demographic, baseline behavior, psychosocial factors, and treatment randomization were included as predictors of missed consecutive visits in proportional hazard models.
Results
In multivariate Cox proportional hazard models, baseline attributes of participants who missed consecutive visits (n=222) included: younger age ( Hazard Ratio [HR] 1.18 per 5 years younger; 95% Confidence Interval 1.05, 1.30), higher depression score (HR 1.04; 1.01, 1.06), non-married status (HR 1.37; 1.04, 1.82), never self-weighing prior to enrollment (HR 2.01; 1.25, 3.23), and randomization to minimal vs. intensive lifestyle intervention (HR 1.46; 1.11, 1.91).
Conclusions
Younger age, symptoms of depression, non-married status, never self-weighing, and randomization to minimal intervention were associated with a higher likelihood of missing consecutive data collection visits, even in a high-retention trial like Look AHEAD. Whether modifications to screening or retention efforts targeted to these attributes might enhance long-term retention in behavioral trials requires further investigation.
doi:10.1002/oby.20613
PMCID: PMC3943994  PMID: 23996977
randomized clinical trials; behavioral trial; retention; obesity
2.  Problem Solving Interventions for Diabetes Self-management and Control: A Systematic Review of the Literature 
Aims
Problem solving is deemed a core skill for patient diabetes self-management education. The purpose of this systematic review is to examine the published literature on the effect of problem-solving interventions on diabetes self-management and disease control.
Data Sources
We searched PubMed and PsychINFO electronic databases for English language articles published between November 2006 and September 2012. Reference lists from included studies were reviewed to capture additional studies.
Study Selection
Studies reporting problem-solving intervention or problem solving as an intervention component for diabetes self-management training and disease control were included. Twenty-four studies met inclusion criteria.
Data Extraction
Study design, sample characteristics, measures, and results were reviewed.
Data Synthesis
Sixteen intervention studies (11 adult, 5 children/adolescents) were randomized controlled trials, and 8 intervention studies (6 adult, 2 children/adolescents) were quasi-experimental designs.
Conclusions
Studies varied greatly in their approaches to problem-solving use in patient education. To date, 36% of adult problem-solving interventions and 42% of children/adolescent problem-solving interventions have demonstrated significant improvement in HbA1c, while psychosocial outcomes have been more promising. The next phase of problem-solving intervention research should employ intervention characteristics found to have sufficient potency and intensity to reach therapeutic levels needed to demonstrate change.
doi:10.1016/j.diabres.2012.12.016
PMCID: PMC3633671  PMID: 23312614
3.  Effectiveness of Educational and Social Worker Interventions to Activate Patients’ Discussion and Pursuit of Preemptive Living Donor Kidney Transplantation: A Randomized Controlled Trial 
Background
Many patients with chronic kidney disease (CKD) have difficulties becoming actively engaged in the pursuit of pre-emptive living donor kidney transplantation.
Study Design
The Talking About Live Kidney Donation (TALK) study was a randomized controlled trial of the effectiveness of educational and social worker interventions designed to encourage early discussions and active pursuit of pre-emptive LKT among patients with progressive CKD.
Setting & Participants
We recruited participants with progressive CKD from academically affiliated nephrology practices in Baltimore, Maryland.
Intervention
Participants randomly received 1) “Usual Care” (routine care with their nephrologists), 2) “TALK Education” intervention (video and booklet), or the 3) “TALK Social Worker” intervention (video and booklet plus patient and family social worker visits).
Outcomes
We followed participants for 6 months to assess their self-reported achievement of behaviors reflecting their discussions about LKT and/or pursuit of LKT (discussions with family; discussions with physicians; initiating recipient evaluation; completing recipient evaluation; identifying a potential living donor).
Measurements
We assessed outcomes via questionnaire at 1, 3, and 6-month follow up.
Results
Participants receiving Usual Care with their nephrologists (n=44), TALK Education (n=43), and the TALK Social Worker (n=43) were similar at baseline. TALK Study interventions improved participants’ LKT discussion and pursuit behaviors, with the Social Worker leading to greater patient activation (participants’ predicted probability (95% confidence interval) of achieving LKT discussions, evaluations, or donor identification over 6 months in Usual Care, TALK Education, and TALK Social Worker groups: 30% (20%–46%), 42% (33% –54%), and 58% (41% –83%), respectively (p=0.03).
Limitations
Our population was well educated and mostly insured, potentially limiting generalizability of our findings.
Conclusions
TALK interventions improved discussion and active pursuit of LKT among patients with progressive CKD and may improve their utilization of pre-emptive LKT.
doi:10.1053/j.ajkd.2012.08.039
PMCID: PMC3710736  PMID: 23089512
4.  Metabolic Syndrome Risk Profiles Among African American Adolescents 
Diabetes Care  2013;36(2):436-442.
OBJECTIVE
Although African American adolescents have the highest prevalence of obesity, they have the lowest prevalence of metabolic syndrome across all definitions used in previous research. To address this paradox, we sought to develop a model of the metabolic syndrome specific to African American adolescents.
RESEARCH DESIGN AND METHODS
Data from the National Health and Nutrition Examination Survey (2003–2010) of 822 nonpregnant, nondiabetic, African American adolescents (45% girls; aged 12 to 17 years) who underwent physical examinations and fasted at least 8 h were analyzed. We conducted a confirmatory factor analysis to model metabolic syndrome and then used latent profile analysis to identify metabolic syndrome risk groups among African American adolescents. We compared the risk groups on probability of prediabetes.
RESULTS
The best-fitting metabolic syndrome model consisted of waist circumference, fasting insulin, HDL, and systolic blood pressure. We identified three metabolic syndrome risk groups: low, moderate, and high risk (19% boys; 16% girls). Thirty-five percent of both boys and girls in the high-risk groups had prediabetes, a significantly higher prevalence compared with boys and girls in the low-risk groups. Among adolescents with BMI higher than the 85th percentile, 48 and 36% of boys and girls, respectively, were in the high-risk group.
CONCLUSIONS
Our findings provide a plausible model of the metabolic syndrome specific to African American adolescents. Based on this model, approximately 19 and 16% of African American boys and girls, respectively, are at high risk for having the metabolic syndrome.
doi:10.2337/dc12-0828
PMCID: PMC3554320  PMID: 23093663
5.  Evaluation of the Effectiveness of a Problem-Solving Intervention Addressing Barriers to Cardiovascular Disease Prevention Behaviors in 3 Underserved Populations: Colorado, North Carolina, West Virginia, 2009 
Introduction
In low-income and underserved populations, financial hardship and multiple competing roles and responsibilities lead to difficulties in lifestyle change for cardiovascular disease (CVD) prevention. To improve CVD prevention behaviors, we adapted, pilot-tested, and evaluated a problem-solving intervention designed to address barriers to lifestyle change.
Methods
The sample consisted of 81 participants from 3 underserved populations, including 28 Hispanic or non-Hispanic white women in a western community (site 1), 31 African-American women in a semirural southern community (site 2), and 22 adults in an Appalachian community (site 3). Incorporating focus group findings, we assessed a standardized intervention involving 6-to-8 week group sessions devoted to problem-solving in the fall of 2009.
Results
Most sessions were attended by 76.5% of participants, demonstrating participant adoption and engagement. The intervention resulted in significant improvement in problem-solving skills (P < .001) and perceived stress (P < .05). Diet, physical activity, and weight remained stable, although 72% of individuals reported maintenance or increase in daily fruit and vegetable intake, and 67% reported maintenance or increase in daily physical activity.
Conclusion
Study results suggest the intervention was acceptable to rural, underserved populations and effective in training them in problem-solving skills and stress management for CVD risk reduction.
doi:10.5888/pcd11.130249
PMCID: PMC3944947  PMID: 24602586
6.  Feasibility and Acceptability of the TALK Social Worker Intervention to Improve Live Kidney Transplantation 
Health and Social Work  2012;37(4):234-249.
Live kidney transplantation (LKT) is underused by patients with end-stage renal disease. Easily implementable and effective interventions to improve patients' early consideration of LKT are needed. The Talking About Live Kidney Donation (TALK) social worker intervention (SWI) improved consideration and pursuit of LKT among patients with progressive chronic kidney disease in a recent randomized controlled trial: Patients and their families were invited to meet twice with a social worker to discuss their self-identified barriers to seeking LKT and to identify solutions to barriers. The authors audio recorded and transcribed all social worker visits to assess implementation of the TALK SWI and its acceptability to patients and families. The study social worker adhered to the TALK SWI protocol more than 90 percent of the time. Patients and families discussed medical (for example, long-term risks of transplant), psychological (for example, patients' denial of the severity of their disease), and economic (for example, impact of donation on family finances) concerns regarding LKT. Most patients and families felt that the intervention was helpful. Consistently high adherence to the TALK SWI protocol and acceptability of the intervention among patients and families suggest that the TALK SWI can be feasibly implemented in clinical practice.
doi:10.1093/hsw/hls034
PMCID: PMC3954101  PMID: 23301437
clinical interventions; clinical social work; health disparities; transplants
7.  Facilitators and barriers to hypertension self-management in urban African Americans: perspectives of patients and family members 
Introduction
We aimed to inform the design of behavioral interventions by identifying patients’ and their family members’ perceived facilitators and barriers to hypertension self-management.
Materials and methods
We conducted focus groups of African American patients with hypertension and their family members to elicit their views about factors influencing patients’ hypertension self-management. We recruited African American patients with hypertension (n = 18) and their family members (n = 12) from an urban, community-based clinical practice in Baltimore, Maryland. We conducted four separate 90-minute focus groups among patients with controlled (one group) and uncontrolled (one group) hypertension, as well as their family members (two groups). Trained moderators used open-ended questions to assess participants’ perceptions regarding patient, family, clinic, and community-level factors influencing patients’ effective hypertension self-management.
Results
Patient participants identified several facilitators (including family members’ support and positive relationships with doctors) and barriers (including competing health priorities, lack of knowledge about hypertension, and poor access to community resources) that influence their hypertension self-management. Family members also identified several facilitators (including their participation in patients’ doctor’s visits and discussions with patients’ doctors outside of visits) and barriers (including their own limited health knowledge and patients’ lack of motivation to sustain hypertension self-management behaviors) that affect their efforts to support patients’ hypertension self-management.
Conclusion
African American patients with hypertension and their family members reported numerous patient, family, clinic, and community-level facilitators and barriers to patients’ hypertension self-management. Patients’ and their family members’ views may help guide efforts to tailor behavioral interventions designed to improve hypertension self-management behaviors and hypertension control in minority populations.
doi:10.2147/PPA.S46517
PMCID: PMC3743518  PMID: 23966772
hypertension; patient perspective; qualitative research; health disparities
8.  5-Step Methodology for Evaluation and Adaptation of Print Patient Health Information to Meet the <5th Grade Readability Criterion 
Medical Care  2012;50(4):294-301.
Background
In the setting of declining U.S. literacy, new policies include use of clear communication and low literacy accessibility practices with all patients. Reliable methods for adapting health information to meet such criteria remain a pressing need.
Objectives
To report method validation (Study 1) and method replication (Study 2) procedures and outcomes for a 5-step method for evaluating and adapting print health information to meet the current low literacy criterion of <5th grade readability.
Materials
Sets of 18 and 11 publicly-disseminated patient education documents developed by a university-affiliated medical center.
Measures
Three low-literacy criteria were strategically targeted for efficient, systematic evaluation and text modification to meet a <5th grade reading level: sentence length <15 words, writing in active voice, and use of common words with multisyllabic words (>2–3 syllables) minimized or avoided. Inter-rater reliability for the document evaluations was determined.
Results
Training in the methodology resulted in inter-rater reliability of 0.99–1.00 in Study 1 and 0.98–1.00 in Study 2. Original documents met none of the targeted low literacy criteria. In Study 1, following low-literacy adaptation, mean reading grade level decreased from 10.4±1.8 to 3.8±0.6 (p<0.0001), with consistent achievement of criteria for words per sentence, passive voice, and syllables per word. Study 2 demonstrated similar achievement of all target criteria, with a resulting decrease in mean reading grade level from 11.0±1.8 to 4.6±0.3 (p < 0.0001).
Conclusions
The 5-step methodology proved teachable and efficient. Targeting a limited set of modifiable criteria was effective and reliable in achieving <5th grade readability.
doi:10.1097/MLR.0b013e318249d6c8
PMCID: PMC3318988  PMID: 22354210
9.  Effect of Problem-Solving-Based Diabetes Self-Management Training on Diabetes Control in a Low Income Patient Sample 
Background
Lower socioeconomic status is associated with excess disease burden from diabetes. Diabetes self-management support interventions are needed that are effective in engaging lower income patients, addressing competing life priorities and barriers to self-care, and facilitating behavior change.
Objective
To pilot test feasibility, acceptability, and effect on disease control of a problem-based diabetes self-management training adapted for low literacy and accessibility.
Design
Two-arm randomized controlled trial powered to detect a 0.50% change in A1C at follow-up with a 2-sided alpha of 0.05 in a pooled analysis.
Participants
Fifty-six urban African-American patients with type 2 diabetes and suboptimal blood sugar, blood pressure, or cholesterol control recruited from a diabetes registry within a university-affiliated managed care organization.
Interventions
A group, problem-based diabetes self-management training designed for delivery in an intensive and a condensed program format. Three intensive and three condensed program groups were conducted during the trial.
Main Measures
Clinical (A1C, systolic blood pressure [SBP], diastolic blood pressure [DBP], LDL and HDL cholesterol) and behavioral (knowledge, problem solving, self-management behavior) data were measured at baseline, post-intervention, and 3 months post-intervention (corresponding with 6–9 months following baseline).
Results
Adoption of both programs was high (>85% attendance rates, 95% retention). At 3 months post-intervention, the between-group difference in A1C change was −0.72% (p = 0.02), in favor of the intensive program. A1C reduction was partially mediated by problem-solving skill at follow-up (ß = −0.13, p = 0.04). Intensive program patients demonstrated within-group improvements in knowledge (p < 0.001), problem-solving (p = 0.01), and self-management behaviors (p = 0.04). Among the subsets of patients with suboptimal blood pressure or lipids at baseline, the intensive program yielded clinically significant individual improvements in SBP, DBP, and LDL cholesterol. Patient satisfaction and usability ratings were high for both programs.
Conclusions
A literacy-adapted, intensive, problem-solving-based diabetes self-management training was effective for key clinical and behavioral outcomes in a lower income patient sample.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1689-6) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-011-1689-6
PMCID: PMC3157525  PMID: 21445680
diabetes; self-management; problem-solving; training
10.  Barriers to and Facilitators of Postpartum Follow-Up Care in Women with Recent Gestational Diabetes Mellitus: A Qualitative Study 
Journal of Women's Health  2011;20(2):239-245.
Abstract
Objectives
Women with a history of gestational diabetes mellitus (GDM) have an increased risk of developing type 2 diabetes (T2DM) but often do not return for follow-up care. We explored barriers to and facilitators of postpartum follow-up care in women with recent GDM.
Methods
We conducted 22 semistructured interviews, 13 in person and 9 by telephone, that were audiotaped and transcribed. Two investigators independently coded transcripts. We identified categories of themes and subthemes. Atlas.ti qualitative software (Berlin, Germany) was used to assist data analysis and management.
Results
Mean age was 31.5 years (standard deviation) [SD] 4.5), 63% were nonwhite, mean body mass index (BMI) was 25.9 kg/m2 (SD 6.2), and 82% attended a postpartum visit. We identified four general themes that illustrated barriers and six that illustrated facilitators to postpartum follow-up care. Feelings of emotional stress due to adjusting to a new baby and the fear of receiving a diabetes diagnosis at the visit were identified as key barriers; child care availability and desire for a checkup were among the key facilitators to care.
Conclusions
Women with recent GDM report multiple barriers and facilitators of postpartum follow-up care. Our results will inform the development of interventions to improve care for these women to reduce subsequent diabetes risk.
doi:10.1089/jwh.2010.2233
PMCID: PMC3064871  PMID: 21265645
11.  Protocol of a Randomized Controlled Trial of Culturally Sensitive Interventions to Improve African Americans' and Non-African Americans' Early, Shared, and Informed Consideration of Live Kidney Transplantation: The talking about Live Kidney Donation (TALK) study 
BMC Nephrology  2011;12:34.
Background
Live kidney transplantation (LKT) is underutilized, particularly among ethnic/racial minorities. The effectiveness of culturally sensitive educational and behavioral interventions to encourage patients' early, shared (with family and health care providers) and informed consideration of LKT and ameliorate disparities in consideration of LKT is unknown.
Methods/Design
We report the protocol of the Talking About Live Kidney Donation (TALK) Study, a two-phase study utilizing qualitative and quantitative research methods to design and test culturally sensitive interventions to improve patients' shared and informed consideration of LKT. Study Phase 1 involved the evidence-based development of culturally sensitive written and audiovisual educational materials as well as a social worker intervention to encourage patients' engagement in shared and informed consideration of LKT. In Study Phase 2, we are currently conducting a randomized controlled trial in which participants with progressing chronic kidney disease receive: 1) usual care by their nephrologists, 2) usual care plus the educational materials, or 3) usual care plus the educational materials and the social worker intervention. The primary outcome of the randomized controlled trial will include patients' self-reported rates of consideration of LKT (including family discussions of LKT, patient-physician discussions of LKT, and identification of an LKT donor). We will also assess differences in rates of consideration of LKT among African Americans and non-African Americans.
Discussion
The TALK Study rigorously developed and is currently testing the effectiveness of culturally sensitive interventions to improve patients' and families' consideration of LKT. Results from TALK will provide needed evidence on ways to enhance consideration of this optimal treatment for patients with end stage renal disease.
Trial Registration
ClinicalTrials.gov number, NCT00932334
doi:10.1186/1471-2369-12-34
PMCID: PMC3150247  PMID: 21736762
12.  Intensive Meditation for Refractory Pain and Symptoms 
Abstract
Objective
The objective of this study was to assess patient interest in intensive meditation training for chronic symptoms.
Design and setting
This was a cross-sectional anonymous survey among six chronic disease clinics in Baltimore including Chronic Kidney Disease, Crohn's Disease, Headache, Renal Transplant Recipients, General Rheumatology, and lupus clinic.
Subjects
Subjects were 1119 consecutive patients registering for their appointments at these clinics.
Outcome measures
Outcome measures were 6-month pain, global symptomatology, four-item perceived stress scale, use of complementary and alternative medicine (CAM) therapies, and attitudes toward use of meditation for managing symptoms. We then gave a scripted description of an intensive, 10-day meditation training retreat. Patient interest in attending such a retreat was assessed.
Results
Seventy-seven percent (77%) of patients approached completed the survey. Fifty-three percent (53%) of patients reported moderate to severe pain over the past 6 months. Eighty percent (80%) reported use of some CAM therapy in the past. Thirty-five percent (35%) thought that learning meditation would improve their health, and 49% thought it would reduce stress. Overall, 39% reported interest in attending the intensive 10-day meditation retreat. Among those reporting moderate to severe pain or stress, the percentages were higher (48% and 59%). In a univariate analysis, higher education, nonworking/disabled status, female gender, higher stress, higher pain, higher symptomatology, and any CAM use were all associated with a greater odds of being moderately to very interested in an intensive 10-day meditation retreat. A multivariate model that included prior use of CAM therapies as predictors of interest in the program fit the data significantly better than a model not including CAM therapies (p = 0.0013).
Conclusions
Over 50% of patients followed in chronic disease clinics complain of moderate to severe pain. Patients with persistent pain or stress are more likely to be interested in intensive meditation.
doi:10.1089/acm.2009.0372
PMCID: PMC3110811  PMID: 20569029
13.  Cranial Volume, Mild Cognitive Deficits, and Functional Limitations Associated with Diabetes in a Community Sample 
Diabetes is associated with dementia in older adults, but it remains unclear whether nondemented adults with type 2 diabetes show subtle abnormalities across cognition, neuroanatomy, and everyday functioning. Using the Aging, Brain Imaging, and Cognition study sample of 301 community-dwelling, middle-aged and older adults, we conducted a secondary analysis on 28 participants with and 150 participants without diabetes. We analyzed brain magnetic resonance imaging data, cognitive test performance, and informant ratings of personal and instrumental activities of daily living (PADL/IADL). Relative to controls, participants with diabetes had lower brain-to-intracranial volume ratios (69.3 ± 4.5% vs. 71.7 ± 4.6%; p < .02), and performed more poorly on measures of working memory, processing speed, fluency, and crystallized intelligence (all p <.05). Decrements in working memory and processing speed were associated with IADL limitations (p < .01). Nondemented adults with diabetes exhibit neuroanatomic and cognitive abnormalities. Their cognitive deficits correlate with everyday functional limitations.
doi:10.1093/arclin/acp091
PMCID: PMC2809552  PMID: 19942595
Diabetes; Endocrine disorders; Cognition; Neuropsychological testing; MRI; Function; Behavior
14.  How to improve medical education website design 
BMC Medical Education  2010;10:30.
Background
The Internet provides a means of disseminating medical education curricula, allowing institutions to share educational resources. Much of what is published online is poorly planned, does not meet learners' needs, or is out of date.
Discussion
Applying principles of curriculum development, adult learning theory and educational website design may result in improved online educational resources. Key steps in developing and implementing an education website include: 1) Follow established principles of curriculum development; 2) Perform a needs assessment and repeat the needs assessment regularly after curriculum implementation; 3) Include in the needs assessment targeted learners, educators, institutions, and society; 4) Use principles of adult learning and behavioral theory when developing content and website function; 5) Design the website and curriculum to demonstrate educational effectiveness at an individual and programmatic level; 6) Include a mechanism for sustaining website operations and updating content over a long period of time.
Summary
Interactive, online education programs are effective for medical training, but require planning, implementation, and maintenance that follow established principles of curriculum development, adult learning, and behavioral theory.
doi:10.1186/1472-6920-10-30
PMCID: PMC2868857  PMID: 20409344
15.  Development and Pilot Evaluation of Literacy-Adapted Diabetes and CVD Education in Urban, Diabetic African Americans 
Journal of General Internal Medicine  2008;23(9):1491-1494.
Background
Despite prevalent low literacy nationally, empirical research on the development and testing of literacy-adapted patient education remains limited.
Objective
To describe procedures for developing and evaluating usability and acceptability of an adapted diabetes and CVD patient education.
Design
Materials adaptation for literacy demand and behavioral activation criteria, and pre-/post-test intervention evaluation design.
Participants
Pilot sample of 30 urban African-American adults with type 2 diabetes with Below Average literacy (n = 15) and Average literacy (n = 15).
Measurements
Wide Range Achievement Test (WRAT-3, Reading), assessment of diabetes and CVD knowledge, and patient rating scale.
Results
Reading grade levels were: >12th, 30%; 10th–12th, 20%; 7th–9th, 10%; 4th–6th grade, 10%; and ≤3rd grade or unable to complete WRAT-3, 30%. Education materials were modified to a reading level of ≤4th grade. Knowledge improved for Below Average (2.7 to 4.7, p = 0.005) and Average (3.8 to 5.7, p = 0.002) literacy groups, with up to a ten-fold increase, at post-education, in the number of participants responding correctly to some content items. The print materials and class received maximum usability and acceptability ratings from patients.
Conclusions
Development of patient education meeting very low literacy criteria was feasible, effective for knowledge acquisition, and highly acceptable irrespective of literacy level.
doi:10.1007/s11606-008-0679-9
PMCID: PMC2518002  PMID: 18521688
16.  Associations of Patient Health-Related Problem Solving with Disease Control, Emergency Department Visits, and Hospitalizations in HIV and Diabetes Clinic Samples 
Background
Patient problem solving and decision making are recognized as essential to effective self-management across multiple chronic diseases. However, a health-related problem-solving instrument that demonstrates sensitivity to disease control parameters in multiple diseases has not been established.
Objectives
To determine, in two disease samples, internal consistency and associations with disease control of the Health Problem-Solving Scale (HPSS), a 50-item measure with 7 subscales assessing effective and ineffective problem-solving approaches, learning from past experiences, and motivation/orientation.
Design
Cross-sectional study.
Participants
Outpatients from university-affiliated medical center HIV (N = 111) and diabetes mellitus (DM, N = 78) clinics.
Measurements
HPSS, CD4, hemoglobin A1c (HbA1c), and number of hospitalizations in the previous year and Emergency Department (ED) visits in the previous 6 months.
Results
Administration time for the HPSS ranged from 5 to 10 minutes. Cronbach’s alpha for the total HPSS was 0.86 and 0.89 for HIV and DM, respectively. Higher total scores (better problem solving) were associated with higher CD4 and fewer hospitalizations in HIV and lower HbA1c and fewer ED visits in DM. Health Problem-Solving Scale subscales representing negative problem-solving approaches were consistently associated with more hospitalizations (HIV, DM) and ED visits (DM).
Conclusions
The HPSS may identify problem-solving difficulties with disease self-management and assess effectiveness of interventions targeting patient decision making in self-care.
doi:10.1007/s11606-006-0091-2
PMCID: PMC1852911  PMID: 17443373
problem solving; decision making; chronic disease; disease control; measure development; minority populations
17.  Associations of Patient Health-Related Problem Solving with Disease Control, Emergency Department Visits, and Hospitalizations in HIV and Diabetes Clinic Samples 
Background
Patient problem solving and decision making are recognized as essential to effective self-management across multiple chronic diseases. However, a health-related problem-solving instrument that demonstrates sensitivity to disease control parameters in multiple diseases has not been established.
Objectives
To determine, in two disease samples, internal consistency and associations with disease control of the Health Problem-Solving Scale (HPSS), a 50-item measure with 7 subscales assessing effective and ineffective problem-solving approaches, learning from past experiences, and motivation/orientation.
Design
Cross-sectional study.
Participants
Outpatients from university-affiliated medical center HIV (N = 111) and diabetes mellitus (DM, N = 78) clinics.
Measurements
HPSS, CD4, hemoglobin A1c (HbA1c), and number of hospitalizations in the previous year and Emergency Department (ED) visits in the previous 6 months.
Results
Administration time for the HPSS ranged from 5 to 10 minutes. Cronbach’s alpha for the total HPSS was 0.86 and 0.89 for HIV and DM, respectively. Higher total scores (better problem solving) were associated with higher CD4 and fewer hospitalizations in HIV and lower HbA1c and fewer ED visits in DM. Health Problem-Solving Scale subscales representing negative problem-solving approaches were consistently associated with more hospitalizations (HIV, DM) and ED visits (DM).
Conclusions
The HPSS may identify problem-solving difficulties with disease self-management and assess effectiveness of interventions targeting patient decision making in self-care.
doi:10.1007/s11606-006-0091-2
PMCID: PMC1852911  PMID: 17443373
problem solving; decision making; chronic disease; disease control; measure development; minority populations
18.  Health-related Quality of Life in Urban African Americans with Type 2 Diabetes 
OBJECTIVE
To examine the association of socioeconomic barriers, familial barriers, and clinical variables with health-related quality of life (HRQL).
METHODS
A cross-sectional study was conducted of 186 African Americans with type 2 diabetes recruited from 2 primary care clinics in East Baltimore, Maryland. Physical functioning, social functioning, mental health, and general health were measured using the Medical Outcomes Study 36-item short form. Socioeconomic (money, housing, street crime) and familial (family problems, caretaker responsibilities) barriers were assessed by standardized interview. Insulin use, comorbid disease, and measured abnormalities in body mass index, hemoglobin A1c (HbA1c), blood pressure, lipids, and renal function were investigated.
RESULTS
Mean HRQL scores were: physical functioning, 61 ± 29; social functioning, 76 ± 26; mental health, 69 ± 21; and general health, 48 ± 21. Linear regression analyses revealed that each barrier to care was significantly associated with lower scores in 1 or more HRQL domain. As number of socioeconomic and familial barriers increased from 0 to 5, HRQL scores decreased by 18 for social functioning, 21 for general health, 23 for physical functioning, and 28 for mental health (all P for trend <.01). Clinical variables significantly associated with reduced HRQL were obesity, impaired renal function, insulin use, and comorbid disease. Blood pressure, lipids, and HbA1c were not significantly associated with HRQL.
CONCLUSIONS
An independent, graded relationship was found between socioeconomic and familial barriers to care and HRQL. This relationship was at least as strong as the association between HRQL and the clinical variables more likely to be perceived by participants as causing symptomatic distress or impacting lifestyle.
doi:10.1046/j.1525-1497.2002.11002.x
PMCID: PMC1495053  PMID: 12133154
health status; chronic illness; socioeconomic factors; urban health

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