Approaching the interpretive process as systematically as possible within a nonlinear methodology streamlines and clarifies interpretations of the interview data.

BackgroundRace influences medical decision making, but its impact on advanced heart failure therapy allocation is unknown. We sought to determine whether patient race influences allocation of advanced heart failure therapies.Methods and ResultsMembers of a national heart failure organization were randomized to clinical vignettes that varied by patient race (black or white man) and were blinded to study objectives. Participants (N=422) completed Likert scale surveys rating factors for advanced therapy allocation and think‐aloud interviews (n=44). Survey results were analyzed by least absolute shrinkage and selection operator and multivariable regression to identify factors influencing advanced therapy allocation, including interactions with vignette race and participant demographics. Interviews were analyzed using grounded theory. Surveys revealed no differences in overall racial ratings for advanced therapies. Least absolute shrinkage and selection operator regression selected no interactions between vignette race and clinical factors as important in allocation. However, interactions between participants aged ≥40 years and black vignette negatively influenced heart transplant allocation modestly (−0.58; 95% CI, −1.15 to −0.0002), with adherence and social history the most influential factors. Interviews revealed sequential decision making: forming overall impression, identifying urgency, evaluating prior care appropriateness, anticipating challenges, and evaluating trust while making recommendations. Race influenced each step: avoiding discussing race, believing photographs may contribute to racial bias, believing the black man was sicker compared with the white man, developing greater concern for trust and adherence with the black man, and ultimately offering the white man transplantation and the black man ventricular assist device implantation.ConclusionsBlack race modestly influenced decision making for heart transplant, particularly during conversations. Because advanced therapy selection meetings are conversations rather than surveys, allocation may be vulnerable to racial bias.

IMPORTANCE Racial bias is associated with the allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices. It is unknown whether gender and racial biases are associated with the allocation of advanced therapies among women. OBJECTIVE To determine whether the intersection of patient gender and race is associated with the decision-making of clinicians during the allocation of advanced heart failure therapies. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, 46 US clinicians attending a conference for an international heart transplant organization in April 2019 were interviewed on the allocation of advanced heart failure therapies. Participants were randomized to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men) to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients. Participants were interviewed about their decision-making process using the think-aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with Wilcoxon tests. EXPOSURE Randomization to clinical vignettes. MAIN OUTCOMES AND MEASURES Thematic differences in allocation of advanced therapies by patient race and gender. RESULTS Among 46 participants (24 [52%] women, 20 [43%] racial minority), participants were randomized to the vignette of a white woman (20 participants [43%]), an African American woman (20 participants [43%]), a white man (3 participants [7%]), and an African American man (3 participants [7%]). Allocation differences centered on 5 themes. First, clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Second, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared with the white woman. Fourth, there were greater concerns about adequacy of social support for the women than for the men. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were perceived to be greater concerns for the African American woman than for individuals in the other vignettes; spouses were deemed inadequate support for women. Last, participants recommended ventricular assist devices over transplantation for all racial and gender groups. Surveys revealed no statistically significant differences in allocation recommendations for African American and white women patients. (continued) Key Points Question Is bias against a patient's gender and race associated with the allocation of advanced heart failure therapies? Findings In a qualitative study of 46 health care professionals, there was more bias against women compared with men when evaluating appearance and social support, particularly among African American women. Fina...

Purpose The purpose of this study was to describe Sub-Saharan African immigrants' health-illness transition experiences associated with type 2 diabetes mellitus (T2DM) self-management. Methods A qualitative description methodology was used in this study. Face-to-face semi-structured in-depth interviews lasting 60 to 90 minutes were conducted with 10 Sub-Saharan African immigrant men and women with T2DM recruited using purposive and snowball sampling. Each interview was audio-taped, transcribed, and analyzed using qualitative content analysis. Results Participants' mean age was 60.3 years (range, 44-76 years), 5 men and 5 women; most had lived in the US for more than 10 years (70%) and with T2DM for more than 5 years (60%). Four overarching domains described the health-illness transition experiences the participants had with T2DM self-management: (1) knowledge of T2DM self-management behaviors, (2) current T2DM self-management behaviors, (3) inhibitors of T2DM self-management, and (4) facilitators of T2DM self-management. Conclusions Health professionals should be equipped with an understanding of the properties and conditions of health-illness transition. This understanding is necessary to build a foundation that facilitates healthy adaptation to the T2DM transition requiring the development and mastery of new skills consistent with gaining control of T2DM. Culturally tailored interventions need to be developed to decrease inhibitors of and encourage self-management in daily T2DM care for Sub-Saharan African immigrants with T2DM.

Purpose:The purpose of this qualitative descriptive study was to explore the socio-cultural influences and social context associated with living with type 2 diabetes among rural, migrant Latino adults. Methods:A qualitative descriptive study using grounded theory techniques was conducted. In-depth semistructured interviews were completed with ten participants (6 female and 4 male) ranging in age from 46-65 years and duration of diabetes diagnosis ranging from 1.5-40 years. Results:An over-arching meta-theme Self Management in a Social Environment emerged. Every aspect of the process of self-management, as described in the four major themes, (1) Family Cohesion, (2) Social Stigma of Disease, (3) Social Expectations/ Perception of "Illness," and (4) Disease Knowledge and Understanding, was influenced by the social context. Conclusions:The familist traditions, central to the Mexican culture, had both positive and negative consequences on diabetes management. Tailoring clinical care and developing novel education approaches, to include family and community, is central to improving the health of this population. Recognizing and acknowledging the social stigma associated with diabetes, for this population, will promote understanding and improve clinician/patient communication. The socio-cultural influences that impact diabetes management practices (e.g., include family, in particular the primary female caregiver, and establish community and home based education sessions) must be integrated into clinical practice. Future research focused on population defined health and disease self-management, novel educational interventions, and family and community interventions focusing on the concept of "social stigma of disease" is indicated to further impact the health disparities of this population. (2009) 2 The final, definitive version of this paper has been published in the Diabetes Educator, Vol. 35 (Iss 2), 2009. SAGE Publications, Inc., All rights reserved. doi: 10.1177/0145721708329545 D.WEILER & J. CRIST in DIABETES EDUCATORThe National Institutes of Health (NIH) define disparities in health as "differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States". 1 These disparities include shorter life expectancy, higher incidence and prevalence of disease states such as diabetes and cardiovascular disease, and higher infant mortality and mental disorder rates. Many factors can contribute to health disparities such as reduced access to health care, increased risk of morbidity and mortality due to occupation or hazard exposure; increased risk due to underlying biological, socioeconomic, ethnic and familial factors; influences of cultural values and level of education.1 The Latino population is one group with known health disparities, 2 especially in the area of diabetes. 3Diabetes poses a significant public health challenge in the United States. It is estimated that 1.5 million new cases are diagnosed ...

Hispanic elders use skilled home care nursing (SHCN) services less often than Anglo elders. The purpose of this study was to identify factors that influence whether disabled Mexican American elders decide to use SHCN services. The research process included reviewing the historical context in one Mexican American community, interviewing key and primary informants, presenting a report to the community and getting feedback, and assessing whether the community perceived a need for increased use of SHCN services by their disabled elders. Seven barriers to the use of SHCN services were identified: expectations of discrimination, lack of knowledge about services, expectations embedded in familism, lack of sense of prevention, lack of health insurance, preference for traditional remedies, and neglect/abuse. A community advisory committee validated the barriers identified during interviews and the need for increased use of SHCN services. Results provide new insight into the sociopolitical and cultural complexities that influence health care utilization decisions by Mexican American elders and their families and uncover traditional, oversimplified beliefs and practices by mainstream professionals and policymakers. Interventions that decrease inequities in a southern Arizona community may be transferable to other vulnerable populations in the United States and globally.

Mexican American elders have higher levels of functional impairment and chronic illness, yet they use formal home care services less than do non-Hispanic White elders. This article describes the processes by which Mexican American elders and their caregivers decide to use home care services. Interviews were conducted with Mexican American elders (n = 11) and family caregivers (n = 12) for a sample of 23 individuals. The emerging substantive grounded theory included three stages that described the process of deciding to use home care services: Taking Care of our Own, Acknowledging Options, and Becoming Empowered. The processes describe how Mexican American families eventually accept home care services while maintaining their cultural norm of taking care of elders. The theory gives voice to both elders and caregivers in this process, adds to extant knowledge, and shapes interventions to support traditional Mexican American family values such as elders' staying at home as long as possible. The theory meets nursing's goals of reducing health care disparities by improving or sustaining elders' health and functional ability, decreasing the caregiving burden, and reducing health care costs.

Caregiving burden has been shown to predict use of home care services among Anglo Americans. In a previous study, only one of two dimensions of caregiving burden predicted such use among Mexican American caregivers. Because acculturation and familism may affect burden, we conducted analyses to test three hypotheses: increased acculturation decreases familism; decreased familism increases burden; and increased burden increases use of home care services. Among 140 Mexican American family caregivers, acculturation was positively correlated with familism; familism was not significantly correlated with burden; objective burden was positively correlated with use of home care services, and objective and subjective burden significantly interacted in their effect on the use of home care services. Targeted interventions may be needed to increase use of home care services and preserve the well-being of Mexican American elders and caregivers.