Clinical Journal of the American Society of Nephrology
Background and objectivesCoronavirus disease 2019 (COVID-19) disrupted medical care across health... more Background and objectivesCoronavirus disease 2019 (COVID-19) disrupted medical care across health care settings for older patients with advanced CKD. Understanding how shared decision making for kidney treatment decisions was influenced by the uncertainty of an evolving pandemic can provide insights for supporting shared decision making through the current and future public health crises.Design, setting, participants, & measurementsWe performed thematic and narrative analyses of semistructured interviews with patients (CKD stages 4 and 5, age 70+), care partners, and clinicians from Boston, Portland (Maine), San Diego, and Chicago from August to December 2020.ResultsWe interviewed 76 participants (39 patients, 17 care partners, and 20 clinicians). Among patient participants, 13 (33%) patients identified as Black, and seven (18%) had initiated dialysis. Four themes with corresponding subthemes emerged related to treatment decision making and the COVID-19 pandemic: (1) adapting to cha...
RATIONALE & OBJECTIVE Older adults with advanced chronic kidney disease (CKD) face difficult ... more RATIONALE & OBJECTIVE Older adults with advanced chronic kidney disease (CKD) face difficult decisions about dialysis initiation. Although shared decision-making (SDM) can help align patient preferences and values with treatment options, the extent to which older CKD patients experience SDM remains unknown. STUDY DESIGN A cross-sectional analysis of patient surveys examining decisional readiness, treatment options education, carepartner support, and SDM. SETTING & PARTICIPANTS Adults ages 70 years and older with non-dialysis advanced CKD from Boston, Chicago, San Diego, and Portland (Maine). PREDICTORS Decisional readiness factors, treatment options education, and carepartner support. OUTCOMES Primary: SDM measured by the SDM-Q-9 instrument, with higher scores reflecting greater SDM. Exploratory: Factors associated with SDM. ANALYTICAL APPROACH We used multivariable linear regression models to examine the associations between SDM and predictors, controlling for demographic and health factors. RESULTS Among 350 participants, mean age was 78 ± 6 years, 58% were male, 13% identified as Black, and 48% had diabetes. Mean SDM-Q-9 score was 52 ± 28. SDM item agreement ranged from 41% of participants agreeing that "My doctor and I selected a treatment option together" to 73% agreeing that "My doctor told me that there are different options for treating my medical condition." In multivariable analysis adjusted for demographics, lower eGFR and diabetes, being "well informed" and "very well informed" about kidney treatment options, having higher decisional certainty, and attendance at a kidney treatment options class were independently associated with higher SDM-Q-9 scores. LIMITATIONS The cross-sectional study design limits the ability to make temporal associations between SDM and the predictors. CONCLUSION Many older CKD patients do not experience SDM when making dialysis decisions, emphasizing the need for greater access to and delivery of education for individuals with advanced CKD.
Background We investigate the relationships among political preferences, risk for COVID-19 compli... more Background We investigate the relationships among political preferences, risk for COVID-19 complications, and complying with preventative behaviors, such as social distancing, quarantine, and vaccination, as they remain incompletely understood. Since those with underlying health conditions have the highest mortality risk, prevention strategies targeting them and their caretakers effectively can save lives. Understanding caretakers’ adherence is also crucial as their behavior affects the probability of transmission and quality of care, but is understudied. Examining the degree to which adherence to prevention measures within these populations is affected by their health status vs. voting preference, a key predictor of preventative behavior in the U. S, is imperative to improve targeted public health messaging. Knowledge of these associations could inform targeted COVID-19 campaigns to improve adherence for those at risk for severe consequences. Methods We conducted a nationally-repre...
Although research suggests neighborhood-level factors influence youth well-being, few studies inc... more Although research suggests neighborhood-level factors influence youth well-being, few studies include youth when creating interventions to address these factors. We describe our three-step process of collaborating with youth in low-income communities to develop an intervention focused on civic engagement as a means to address neighborhood-level problems impacting their well-being. In the first step, we analyzed qualitative interviews from a project in which youth shared perceptions about their neighborhoods (e.g., interpersonal relations with neighbors and institutions). Three major themes were identified: pride in youth's communities, desire for change, and perceptions of power and responsibility. Based on these themes, we completed the second step: developing a civic engagement and leadership program, called LEAP, aimed at helping youth take an active role in addressing neighborhood problems. In the third step, we collaborated with youth who completed a pilot version of the civic program and provided feedback to finalize it for large-scale testing. While discussing our process, we highlight the importance of including youth voices when developing programs that affect them. Furthermore, we note the need for more research exploring whether civic engagement serves as a mechanism for encouraging youth involvement in addressing neighborhood-level health disparities and identifying potential psychological costs of such involvement.
Nonpharmaceutical interventions such as stay-at-home orders continue to be the main policy respon... more Nonpharmaceutical interventions such as stay-at-home orders continue to be the main policy response to the COVID-19 pandemic in countries with limited or slow vaccine rollout. Often, nonpharmaceutical interventions are managed or implemented at the subnational level, yet little information exists on within-country variation in nonpharmaceutical intervention policies. We focused on Latin America, a COVID-19 epicenter, and collected and analyzed daily subnational data on public health measures in Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico, and Peru to compare within- and across-country nonpharmaceutical interventions. We showed high heterogeneity in the adoption of these interventions at the subnational level in Brazil and Mexico; consistent national guidelines with subnational heterogeneity in Argentina and Colombia; and homogeneous policies guided by centralized national policies in Bolivia, Chile, and Peru. Our results point to the role of subnational policies and governments in responding to health crises. We found that subnational responses cannot replace coordinated national policy. Our findings imply that governments should focus on evidence-based national policies while coordinating with subnational governments to tailor local responses to changing local conditions.
Journal of Racial and Ethnic Health Disparities, 2021
Shared decision-making (SDM) is recommended for prostate cancer screening, but little is known ab... more Shared decision-making (SDM) is recommended for prostate cancer screening, but little is known about how this process is perceived by patients and providers. SDM is especially important for African American men, who are at high risk for the disease. To evaluate agreement in SDM ratings among patients, providers, and objective observers. African American men ages 45–70 were recruited from primary care practices to participate in a study evaluating a decision aid (DA). Immediately after using the DA, patients proceeded to primary care appointments. Afterwards, patients and physicians completed surveys assessing perceptions about SDM. Clinical visits were also audio-recorded and coded to assess SDM. Mean scores on SDM measures among patients were 73.2 (SD = 27.5, 95% CI 55.71–90.62), 83.1 among physicians (SD = 7.8 95% CI 78.14–88.06), and 67.1 among objective raters (SD = 36.8 95% CI 43.72–90.45). Among patient-provider dyads, mean agreement was 49.9%. Patients, physicians, and objective observers perceived SDM differently. Understanding discordant experiences of SDM is vital for improving clinical guidance about SDM especially among African Americans who have historically faced healthcare discrimination and mistrust. DAs, particularly for African American men, should incorporate strategies to empower patients to advocate for their communication needs and preferences. Clinical trials identifier number: NCT02787434
Background: COVID-19 has disproportionately impacted low-income communities and communities of co... more Background: COVID-19 has disproportionately impacted low-income communities and communities of color. Widespread uptake of COVID-19 vaccines is necessary to prevent ongoing community transmission. Little is known about the acceptability of COVID-19 vaccines among immigrant communities, many of which have been disproportionately impacted by the pandemic. Our goal was to gauge COVID-19 vaccine intentions among Brazilian immigrant women living in the U.S. Methods: We conducted an online survey in Portuguese and English among a convenience sample of Brazilian immigrant women ages 18 years and older. Women were recruited through online advertisements by community-based organizations and social media groups to complete a survey that assessed intention to get a COVID-19 vaccine, attitudes toward vaccines, and perceptions about the pandemic.Results: Of the total sample (N=364), most (70.9%) indicated they would take a COVID-19 vaccine. In bivariate analyses, vaccine intentions were signific...
BACKGROUND Petitions for involuntary commitment of people living with a substance use disorder (S... more BACKGROUND Petitions for involuntary commitment of people living with a substance use disorder (SUD) have almost doubled since 2011 in Massachusetts through the policy Section 35. However, the efficacy of this controversial policy remains unclear, and clinicians differ on whether it ought to be used. This study examines how clinicians decide whether to use Section 35 and their experiences of moral distress, the negative feeling that occurs when a clinician is required to pursue a treatment option against their moral judgement due to institutional constraints, associated with its use. METHODS Qualitative semi-structured interviews with clinicians in Massachusetts were conducted between December 2019 and February 2020 and continued until thematic saturation. Thematic and narrative analysis was conducted with recorded and transcribed interviews. RESULTS Among 21 clinicians, most (77%) experienced some or high moral distress when utilizing Section 35 for involuntary commitment, with clinicians working in emergency departments experiencing less distress than those working in SUD clinics. Clinicians with low moral distress referenced successful patient anecdotes and held an abstinence-based view of SUD, while clinicians with high moral distress were concerned by systemic treatment failures and understood SUD through a nuanced and harm reduction-oriented view. Clinicians across professional settings were concerned by the involvement of law enforcement and criminal justice settings in the Section 35 process. Clinicians employed a variety of strategies to cope with moral distress, including team-based decision-making and viewing the petition as a last resort. Barriers to utilizing Section 35 included restrictive court hours and lack of post-section aftercare services. CONCLUSION Widespread distress associated with use of involuntary commitment and inconsistent approaches to its use highlight the need for better care coordination and guidance on best practices for utilization of this policy.
IntroductionTo present an analysis of the Brazilian health system and subnational (state) variati... more IntroductionTo present an analysis of the Brazilian health system and subnational (state) variation in response to the COVID-19 pandemic, based on 10 non-pharmaceutical interventions (NPIs).Materials and methodsWe collected daily information on implementation of 10 NPI designed to inform the public of health risks and promote distancing and mask use at the national level for eight countries across the Americas. We then analyse the adoption of the 10 policies across Brazil’s 27 states over time, individually and using a composite index. We draw on this index to assess the timeliness and rigour of NPI implementation across the country, from the date of the first case, 26 February 2020. We also compile Google data on population mobility by state to describe changes in mobility throughout the COVID-19 pandemic.ResultsBrazil’s national NPI response was the least stringent among countries analysed. In the absence of a unified federal response to the pandemic, Brazilian state policy implem...
Rationale & Objective Although kidney biopsy is a useful tool, nephrologists’ approach toward... more Rationale & Objective Although kidney biopsy is a useful tool, nephrologists’ approach toward biopsies is inconsistent for reasons incompletely understood, including lack of established clinical guidelines. We examined contemporary clinical decision-making patterns among nephrologists to perform native kidney biopsy. Study Design Qualitative study using semistructured interviews. Setting & Participants Purposive sampling was used to select nephrologists from different regions in the United States. Semistructured interviews were continued until thematic saturation. Analytical Approach A modified grounded theory was used to identify dominant themes reflecting the nephrologists’ decision-making styles about kidney biopsy. Results Twenty nephrologists were interviewed: 16 (80%) were from academic centers, 3 (15%) performed their own biopsies, and 7 (35%) had been in practice for less than 10 years. The median time of practice was 14 years. We found substantial variability among the nephrologists in their attitude toward using kidney biopsy, which reflected individual differences in weighing the risks and benefits of the procedure for an individual patient. Five overarching themes were identified: operator comfort with biopsy and availability of interventional radiologist, exposure to biopsy during training and years of experience, concerns about the invasiveness of biopsy and inflicting harm, perception of evidence base and limited treatment options, and patient characteristics and preference. Limitations Generalizability was limited because the nephrologists sampled may not have been broadly representative. Conclusions Multiple factors influence nephrologists’ decision to pursue kidney biopsy, with substantial variability among nephrologists that can have meaningful clinical implications. This suggests the need to establish consensus guidelines to make biopsy practice more standardized.
RATIONALE & OBJECTIVE Education programs are needed for people with advanced chronic kidney d... more RATIONALE & OBJECTIVE Education programs are needed for people with advanced chronic kidney disease (CKD) to understand kidney failure treatment options and participate in shared decision-making (SDM). Little is known about the content and accessibility of current education programs, and whether they support SDM. STUDY DESIGN Stakeholder-engaged, mixed-methods design incorporating qualitative observations and interviews, and a quantitative content analysis of slide presentations. SETTING & PARTICIPANTS 4 sites in Boston, Chicago, Portland (Maine), and San Diego. ANALYTICAL APPROACH Thematic analysis based on the Ottawa Framework (observations and interviews) and descriptive statistical analysis (slide presentations). RESULTS Data were collected from observations of 9 education sessions, 5 semi-structured interviews with educators, and 133 educational slide presentations. Sites offered group classes or one-on-one sessions. Development, quality, and accuracy of educational materials varied widely. Educators emphasized dialysis (often in-center hemodialysis), with little mention of conservative management. Educators reported patients were often referred too late to education sessions and that some patients become overwhelmed if they learn of the implications of kidney failure in a group setting. Commonly, sessions were general and did not provide opportunities for tailored information most supportive of SDM. Few nephrologists were involved in education sessions or aware of the educational content. Content gaps included prognosis, decision support, mental health and cognition, advanced care planning, cost, and diet. Slide presentations used did not consistently reflect best practices related to health literacy. LIMITATIONS Findings may not be broadly generalizable. CONCLUSION Education sessions focused on kidney failure options do not consistently follow best practices related to health literacy or for supporting shared decision-making. To facilitate SDM, establishing expectations for kidney failure treatment options should be clearly defined and integrated into the clinical workflow. Addressing content gaps, health literacy, and communication with nephrologists are necessary steps for improving patient education in the setting of advanced CKD.
BackgroundMexican state governments’ actions are essential to control the COVID-19 pandemic withi... more BackgroundMexican state governments’ actions are essential to control the COVID-19 pandemic within the country. However, the type, rigor and pace of implementation of public policies have varied considerably between states. Little is known about the subnational (state) variation policy response to the COVID-19 pandemic in Mexico.Material and methodsWe collected daily information on public policies designed to inform the public, as well as to promote distancing, and mask use. The policies analyzed were: School Closure, Workplace Closure, Cancellation of Public Events, Restrictions on Gatherings, Stay at Home Order, Public Transit Suspensions, Information Campaigns, Internal Travel Controls, International Travel Controls, Use of Face Masks We use these data to create a composite index to evaluate the adoption of these policies in the 32 states. We then assess the timeliness and rigor of the policies across the country, from the date of the first case, February 27, 2020.ResultsThe nati...
Understanding reasons for COVID-19 vaccine hesitancy is necessary to ensure maximum uptake, neede... more Understanding reasons for COVID-19 vaccine hesitancy is necessary to ensure maximum uptake, needed for herd immunity. We conducted a cross-sectional online survey between May 29-June 20, 2020 among a national sample of U.S. adults ages 18 years and over to assess cognitive, attitudinal and normative beliefs associated with not intending to get a COVID-19 vaccine. Of 1,219 respondents, 17.7% said that they would not get a vaccine and 24.2% were unsure. In multivariable analyses controlled for gender, age, income, education, religious affiliation, health insurance coverage, and political party affiliation, those who reported that they were unwilling be vaccinated (versus those who were willing) were less likely to agree that vaccines are safe/effective (Relative Risk Ratio (RRR): 0.45, 95% confidence interval (CI): 0.31, 0.66), that everyone has a responsibility to be vaccinated (RRR: 0.39, 95% CI: 0.30, 0.52), that public authorities should be able to mandate vaccination (RRR: 0.75, 95% CI: 0.58, 0.98), and that if everyone else were vaccinated they would not need a vaccine (RRR: 1.36, 95% CI: 1.04, 1.78). Our results suggest that health messages should emphasize the safety and efficacy of vaccines, as well as the fact that vaccinating oneself is important, even if the level of uptake in the community is high.
Clinicians in the United States today regularly face dilemmas about health disparities. Many pati... more Clinicians in the United States today regularly face dilemmas about health disparities. Many patients and families cannot afford the medical care that doctors recommend. These problems are most stark when the medical care that is needed is lifesaving and expensive and involves scarce resources. Transplants are the best example of this. The most ethically disturbing situations occur when an undocumented immigrant child needs a transplant. We present such a case and analyze the ethical, legal, and policy issues that arise.
Background By 2040, one out of three older adults in the USA are expected to belong to a racial/e... more Background By 2040, one out of three older adults in the USA are expected to belong to a racial/ethnic minority group. This population has an increased risk of mental and physical disability with significant barriers to access care. Community-based organizations (CBOs) often provide programming to serve minority and immigrant elders. Limited resources and other barriers such as lack of trained staff make it difficult to implement evidence-based interventions (EBIs) in CBOs for long-term adoption. Yet little is known about what factors can facilitate adoption of EBIs in CBOs serving minority elders. Methods Positive-Minds–Strong Bodies (PM-SB), an evidence-based intervention offered in four languages, aims to reduce mental and physical disability for minority and immigrant elders through the efforts of community health workers and exercise trainers. The intervention consists of cognitive behavior therapy and exercise training sessions delivered over 6 months. During a recent clinical...
Journal of immigrant and minority health, Jan 30, 2018
Immigrants are ineligible for federally-funded Medicaid in the U.S. until at least 5 years after ... more Immigrants are ineligible for federally-funded Medicaid in the U.S. until at least 5 years after arrival. There is little information on where they receive care in light of this restriction. Using Blinder-Oaxaca decomposition, this study examines whether the setting in which older recent immigrants receive care (i.e., health clinic, emergency room or doctor's office) explains delays in care. Among older adults with a usual source of care, 13.5% of recent immigrants had not seen a health professional in the past year compared to 8.6% of non-recent immigrants and 6.3% of native-born. Approximately 23% of these differences is attributable to recent immigrants' tendency to receive care in clinics and community health centers. Even when older recent immigrants manage to find a usual source of care, it is of lower quality than that received by their non-recent immigrant and native-born counterparts.
Clinical Journal of the American Society of Nephrology
Background and objectivesCoronavirus disease 2019 (COVID-19) disrupted medical care across health... more Background and objectivesCoronavirus disease 2019 (COVID-19) disrupted medical care across health care settings for older patients with advanced CKD. Understanding how shared decision making for kidney treatment decisions was influenced by the uncertainty of an evolving pandemic can provide insights for supporting shared decision making through the current and future public health crises.Design, setting, participants, & measurementsWe performed thematic and narrative analyses of semistructured interviews with patients (CKD stages 4 and 5, age 70+), care partners, and clinicians from Boston, Portland (Maine), San Diego, and Chicago from August to December 2020.ResultsWe interviewed 76 participants (39 patients, 17 care partners, and 20 clinicians). Among patient participants, 13 (33%) patients identified as Black, and seven (18%) had initiated dialysis. Four themes with corresponding subthemes emerged related to treatment decision making and the COVID-19 pandemic: (1) adapting to cha...
RATIONALE & OBJECTIVE Older adults with advanced chronic kidney disease (CKD) face difficult ... more RATIONALE & OBJECTIVE Older adults with advanced chronic kidney disease (CKD) face difficult decisions about dialysis initiation. Although shared decision-making (SDM) can help align patient preferences and values with treatment options, the extent to which older CKD patients experience SDM remains unknown. STUDY DESIGN A cross-sectional analysis of patient surveys examining decisional readiness, treatment options education, carepartner support, and SDM. SETTING & PARTICIPANTS Adults ages 70 years and older with non-dialysis advanced CKD from Boston, Chicago, San Diego, and Portland (Maine). PREDICTORS Decisional readiness factors, treatment options education, and carepartner support. OUTCOMES Primary: SDM measured by the SDM-Q-9 instrument, with higher scores reflecting greater SDM. Exploratory: Factors associated with SDM. ANALYTICAL APPROACH We used multivariable linear regression models to examine the associations between SDM and predictors, controlling for demographic and health factors. RESULTS Among 350 participants, mean age was 78 ± 6 years, 58% were male, 13% identified as Black, and 48% had diabetes. Mean SDM-Q-9 score was 52 ± 28. SDM item agreement ranged from 41% of participants agreeing that "My doctor and I selected a treatment option together" to 73% agreeing that "My doctor told me that there are different options for treating my medical condition." In multivariable analysis adjusted for demographics, lower eGFR and diabetes, being "well informed" and "very well informed" about kidney treatment options, having higher decisional certainty, and attendance at a kidney treatment options class were independently associated with higher SDM-Q-9 scores. LIMITATIONS The cross-sectional study design limits the ability to make temporal associations between SDM and the predictors. CONCLUSION Many older CKD patients do not experience SDM when making dialysis decisions, emphasizing the need for greater access to and delivery of education for individuals with advanced CKD.
Background We investigate the relationships among political preferences, risk for COVID-19 compli... more Background We investigate the relationships among political preferences, risk for COVID-19 complications, and complying with preventative behaviors, such as social distancing, quarantine, and vaccination, as they remain incompletely understood. Since those with underlying health conditions have the highest mortality risk, prevention strategies targeting them and their caretakers effectively can save lives. Understanding caretakers’ adherence is also crucial as their behavior affects the probability of transmission and quality of care, but is understudied. Examining the degree to which adherence to prevention measures within these populations is affected by their health status vs. voting preference, a key predictor of preventative behavior in the U. S, is imperative to improve targeted public health messaging. Knowledge of these associations could inform targeted COVID-19 campaigns to improve adherence for those at risk for severe consequences. Methods We conducted a nationally-repre...
Although research suggests neighborhood-level factors influence youth well-being, few studies inc... more Although research suggests neighborhood-level factors influence youth well-being, few studies include youth when creating interventions to address these factors. We describe our three-step process of collaborating with youth in low-income communities to develop an intervention focused on civic engagement as a means to address neighborhood-level problems impacting their well-being. In the first step, we analyzed qualitative interviews from a project in which youth shared perceptions about their neighborhoods (e.g., interpersonal relations with neighbors and institutions). Three major themes were identified: pride in youth's communities, desire for change, and perceptions of power and responsibility. Based on these themes, we completed the second step: developing a civic engagement and leadership program, called LEAP, aimed at helping youth take an active role in addressing neighborhood problems. In the third step, we collaborated with youth who completed a pilot version of the civic program and provided feedback to finalize it for large-scale testing. While discussing our process, we highlight the importance of including youth voices when developing programs that affect them. Furthermore, we note the need for more research exploring whether civic engagement serves as a mechanism for encouraging youth involvement in addressing neighborhood-level health disparities and identifying potential psychological costs of such involvement.
Nonpharmaceutical interventions such as stay-at-home orders continue to be the main policy respon... more Nonpharmaceutical interventions such as stay-at-home orders continue to be the main policy response to the COVID-19 pandemic in countries with limited or slow vaccine rollout. Often, nonpharmaceutical interventions are managed or implemented at the subnational level, yet little information exists on within-country variation in nonpharmaceutical intervention policies. We focused on Latin America, a COVID-19 epicenter, and collected and analyzed daily subnational data on public health measures in Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico, and Peru to compare within- and across-country nonpharmaceutical interventions. We showed high heterogeneity in the adoption of these interventions at the subnational level in Brazil and Mexico; consistent national guidelines with subnational heterogeneity in Argentina and Colombia; and homogeneous policies guided by centralized national policies in Bolivia, Chile, and Peru. Our results point to the role of subnational policies and governments in responding to health crises. We found that subnational responses cannot replace coordinated national policy. Our findings imply that governments should focus on evidence-based national policies while coordinating with subnational governments to tailor local responses to changing local conditions.
Journal of Racial and Ethnic Health Disparities, 2021
Shared decision-making (SDM) is recommended for prostate cancer screening, but little is known ab... more Shared decision-making (SDM) is recommended for prostate cancer screening, but little is known about how this process is perceived by patients and providers. SDM is especially important for African American men, who are at high risk for the disease. To evaluate agreement in SDM ratings among patients, providers, and objective observers. African American men ages 45–70 were recruited from primary care practices to participate in a study evaluating a decision aid (DA). Immediately after using the DA, patients proceeded to primary care appointments. Afterwards, patients and physicians completed surveys assessing perceptions about SDM. Clinical visits were also audio-recorded and coded to assess SDM. Mean scores on SDM measures among patients were 73.2 (SD = 27.5, 95% CI 55.71–90.62), 83.1 among physicians (SD = 7.8 95% CI 78.14–88.06), and 67.1 among objective raters (SD = 36.8 95% CI 43.72–90.45). Among patient-provider dyads, mean agreement was 49.9%. Patients, physicians, and objective observers perceived SDM differently. Understanding discordant experiences of SDM is vital for improving clinical guidance about SDM especially among African Americans who have historically faced healthcare discrimination and mistrust. DAs, particularly for African American men, should incorporate strategies to empower patients to advocate for their communication needs and preferences. Clinical trials identifier number: NCT02787434
Background: COVID-19 has disproportionately impacted low-income communities and communities of co... more Background: COVID-19 has disproportionately impacted low-income communities and communities of color. Widespread uptake of COVID-19 vaccines is necessary to prevent ongoing community transmission. Little is known about the acceptability of COVID-19 vaccines among immigrant communities, many of which have been disproportionately impacted by the pandemic. Our goal was to gauge COVID-19 vaccine intentions among Brazilian immigrant women living in the U.S. Methods: We conducted an online survey in Portuguese and English among a convenience sample of Brazilian immigrant women ages 18 years and older. Women were recruited through online advertisements by community-based organizations and social media groups to complete a survey that assessed intention to get a COVID-19 vaccine, attitudes toward vaccines, and perceptions about the pandemic.Results: Of the total sample (N=364), most (70.9%) indicated they would take a COVID-19 vaccine. In bivariate analyses, vaccine intentions were signific...
BACKGROUND Petitions for involuntary commitment of people living with a substance use disorder (S... more BACKGROUND Petitions for involuntary commitment of people living with a substance use disorder (SUD) have almost doubled since 2011 in Massachusetts through the policy Section 35. However, the efficacy of this controversial policy remains unclear, and clinicians differ on whether it ought to be used. This study examines how clinicians decide whether to use Section 35 and their experiences of moral distress, the negative feeling that occurs when a clinician is required to pursue a treatment option against their moral judgement due to institutional constraints, associated with its use. METHODS Qualitative semi-structured interviews with clinicians in Massachusetts were conducted between December 2019 and February 2020 and continued until thematic saturation. Thematic and narrative analysis was conducted with recorded and transcribed interviews. RESULTS Among 21 clinicians, most (77%) experienced some or high moral distress when utilizing Section 35 for involuntary commitment, with clinicians working in emergency departments experiencing less distress than those working in SUD clinics. Clinicians with low moral distress referenced successful patient anecdotes and held an abstinence-based view of SUD, while clinicians with high moral distress were concerned by systemic treatment failures and understood SUD through a nuanced and harm reduction-oriented view. Clinicians across professional settings were concerned by the involvement of law enforcement and criminal justice settings in the Section 35 process. Clinicians employed a variety of strategies to cope with moral distress, including team-based decision-making and viewing the petition as a last resort. Barriers to utilizing Section 35 included restrictive court hours and lack of post-section aftercare services. CONCLUSION Widespread distress associated with use of involuntary commitment and inconsistent approaches to its use highlight the need for better care coordination and guidance on best practices for utilization of this policy.
IntroductionTo present an analysis of the Brazilian health system and subnational (state) variati... more IntroductionTo present an analysis of the Brazilian health system and subnational (state) variation in response to the COVID-19 pandemic, based on 10 non-pharmaceutical interventions (NPIs).Materials and methodsWe collected daily information on implementation of 10 NPI designed to inform the public of health risks and promote distancing and mask use at the national level for eight countries across the Americas. We then analyse the adoption of the 10 policies across Brazil’s 27 states over time, individually and using a composite index. We draw on this index to assess the timeliness and rigour of NPI implementation across the country, from the date of the first case, 26 February 2020. We also compile Google data on population mobility by state to describe changes in mobility throughout the COVID-19 pandemic.ResultsBrazil’s national NPI response was the least stringent among countries analysed. In the absence of a unified federal response to the pandemic, Brazilian state policy implem...
Rationale & Objective Although kidney biopsy is a useful tool, nephrologists’ approach toward... more Rationale & Objective Although kidney biopsy is a useful tool, nephrologists’ approach toward biopsies is inconsistent for reasons incompletely understood, including lack of established clinical guidelines. We examined contemporary clinical decision-making patterns among nephrologists to perform native kidney biopsy. Study Design Qualitative study using semistructured interviews. Setting & Participants Purposive sampling was used to select nephrologists from different regions in the United States. Semistructured interviews were continued until thematic saturation. Analytical Approach A modified grounded theory was used to identify dominant themes reflecting the nephrologists’ decision-making styles about kidney biopsy. Results Twenty nephrologists were interviewed: 16 (80%) were from academic centers, 3 (15%) performed their own biopsies, and 7 (35%) had been in practice for less than 10 years. The median time of practice was 14 years. We found substantial variability among the nephrologists in their attitude toward using kidney biopsy, which reflected individual differences in weighing the risks and benefits of the procedure for an individual patient. Five overarching themes were identified: operator comfort with biopsy and availability of interventional radiologist, exposure to biopsy during training and years of experience, concerns about the invasiveness of biopsy and inflicting harm, perception of evidence base and limited treatment options, and patient characteristics and preference. Limitations Generalizability was limited because the nephrologists sampled may not have been broadly representative. Conclusions Multiple factors influence nephrologists’ decision to pursue kidney biopsy, with substantial variability among nephrologists that can have meaningful clinical implications. This suggests the need to establish consensus guidelines to make biopsy practice more standardized.
RATIONALE & OBJECTIVE Education programs are needed for people with advanced chronic kidney d... more RATIONALE & OBJECTIVE Education programs are needed for people with advanced chronic kidney disease (CKD) to understand kidney failure treatment options and participate in shared decision-making (SDM). Little is known about the content and accessibility of current education programs, and whether they support SDM. STUDY DESIGN Stakeholder-engaged, mixed-methods design incorporating qualitative observations and interviews, and a quantitative content analysis of slide presentations. SETTING & PARTICIPANTS 4 sites in Boston, Chicago, Portland (Maine), and San Diego. ANALYTICAL APPROACH Thematic analysis based on the Ottawa Framework (observations and interviews) and descriptive statistical analysis (slide presentations). RESULTS Data were collected from observations of 9 education sessions, 5 semi-structured interviews with educators, and 133 educational slide presentations. Sites offered group classes or one-on-one sessions. Development, quality, and accuracy of educational materials varied widely. Educators emphasized dialysis (often in-center hemodialysis), with little mention of conservative management. Educators reported patients were often referred too late to education sessions and that some patients become overwhelmed if they learn of the implications of kidney failure in a group setting. Commonly, sessions were general and did not provide opportunities for tailored information most supportive of SDM. Few nephrologists were involved in education sessions or aware of the educational content. Content gaps included prognosis, decision support, mental health and cognition, advanced care planning, cost, and diet. Slide presentations used did not consistently reflect best practices related to health literacy. LIMITATIONS Findings may not be broadly generalizable. CONCLUSION Education sessions focused on kidney failure options do not consistently follow best practices related to health literacy or for supporting shared decision-making. To facilitate SDM, establishing expectations for kidney failure treatment options should be clearly defined and integrated into the clinical workflow. Addressing content gaps, health literacy, and communication with nephrologists are necessary steps for improving patient education in the setting of advanced CKD.
BackgroundMexican state governments’ actions are essential to control the COVID-19 pandemic withi... more BackgroundMexican state governments’ actions are essential to control the COVID-19 pandemic within the country. However, the type, rigor and pace of implementation of public policies have varied considerably between states. Little is known about the subnational (state) variation policy response to the COVID-19 pandemic in Mexico.Material and methodsWe collected daily information on public policies designed to inform the public, as well as to promote distancing, and mask use. The policies analyzed were: School Closure, Workplace Closure, Cancellation of Public Events, Restrictions on Gatherings, Stay at Home Order, Public Transit Suspensions, Information Campaigns, Internal Travel Controls, International Travel Controls, Use of Face Masks We use these data to create a composite index to evaluate the adoption of these policies in the 32 states. We then assess the timeliness and rigor of the policies across the country, from the date of the first case, February 27, 2020.ResultsThe nati...
Understanding reasons for COVID-19 vaccine hesitancy is necessary to ensure maximum uptake, neede... more Understanding reasons for COVID-19 vaccine hesitancy is necessary to ensure maximum uptake, needed for herd immunity. We conducted a cross-sectional online survey between May 29-June 20, 2020 among a national sample of U.S. adults ages 18 years and over to assess cognitive, attitudinal and normative beliefs associated with not intending to get a COVID-19 vaccine. Of 1,219 respondents, 17.7% said that they would not get a vaccine and 24.2% were unsure. In multivariable analyses controlled for gender, age, income, education, religious affiliation, health insurance coverage, and political party affiliation, those who reported that they were unwilling be vaccinated (versus those who were willing) were less likely to agree that vaccines are safe/effective (Relative Risk Ratio (RRR): 0.45, 95% confidence interval (CI): 0.31, 0.66), that everyone has a responsibility to be vaccinated (RRR: 0.39, 95% CI: 0.30, 0.52), that public authorities should be able to mandate vaccination (RRR: 0.75, 95% CI: 0.58, 0.98), and that if everyone else were vaccinated they would not need a vaccine (RRR: 1.36, 95% CI: 1.04, 1.78). Our results suggest that health messages should emphasize the safety and efficacy of vaccines, as well as the fact that vaccinating oneself is important, even if the level of uptake in the community is high.
Clinicians in the United States today regularly face dilemmas about health disparities. Many pati... more Clinicians in the United States today regularly face dilemmas about health disparities. Many patients and families cannot afford the medical care that doctors recommend. These problems are most stark when the medical care that is needed is lifesaving and expensive and involves scarce resources. Transplants are the best example of this. The most ethically disturbing situations occur when an undocumented immigrant child needs a transplant. We present such a case and analyze the ethical, legal, and policy issues that arise.
Background By 2040, one out of three older adults in the USA are expected to belong to a racial/e... more Background By 2040, one out of three older adults in the USA are expected to belong to a racial/ethnic minority group. This population has an increased risk of mental and physical disability with significant barriers to access care. Community-based organizations (CBOs) often provide programming to serve minority and immigrant elders. Limited resources and other barriers such as lack of trained staff make it difficult to implement evidence-based interventions (EBIs) in CBOs for long-term adoption. Yet little is known about what factors can facilitate adoption of EBIs in CBOs serving minority elders. Methods Positive-Minds–Strong Bodies (PM-SB), an evidence-based intervention offered in four languages, aims to reduce mental and physical disability for minority and immigrant elders through the efforts of community health workers and exercise trainers. The intervention consists of cognitive behavior therapy and exercise training sessions delivered over 6 months. During a recent clinical...
Journal of immigrant and minority health, Jan 30, 2018
Immigrants are ineligible for federally-funded Medicaid in the U.S. until at least 5 years after ... more Immigrants are ineligible for federally-funded Medicaid in the U.S. until at least 5 years after arrival. There is little information on where they receive care in light of this restriction. Using Blinder-Oaxaca decomposition, this study examines whether the setting in which older recent immigrants receive care (i.e., health clinic, emergency room or doctor's office) explains delays in care. Among older adults with a usual source of care, 13.5% of recent immigrants had not seen a health professional in the past year compared to 8.6% of non-recent immigrants and 6.3% of native-born. Approximately 23% of these differences is attributable to recent immigrants' tendency to receive care in clinics and community health centers. Even when older recent immigrants manage to find a usual source of care, it is of lower quality than that received by their non-recent immigrant and native-born counterparts.
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Papers by Thalia Porteny