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End-stage kidney disease (ESKD) is common in the U.S. There is no cure, and survival requires either dialysis or kidney transplant. Medicare provides coverage for most ESKD patients in the U.S., though non-citizens are excluded from most current policies providing standard ESKD care, especially regarding kidney transplants. Despite being eligible to be organ donors, non-citizens often have few avenues to be organ recipients—a major equity problem. Overall, transplants are cost-saving compared to dialysis, and non-citizens have comparable outcomes to the general population. We reviewed the literature regarding the vastly different policies across the U.S., with a focus on current Illinois policy, including updates regarding Illinois legislation which passed in 2014 providing non-citizens to receive coverage for transplants. Unfortunately, despite legislation providing avenues for transplants, funds were not allocated, and the bill has not had the impact that was expected when initially passed. We outline opportunities for improving current policies.

Older Black adults face a disproportionate burden of HIV prevalence, but less is known about racial disparities in age-related outcomes in HIV. We assessed the effect of HIV status and race on motor and pulmonary function, as well as how they contribute to mobility disability. Community-based study; Chicago, IL Participants were 363 community-dwelling adults age ≥ 50 years, 48% living with HIV, and 68% Black. Participants with HIV were recruited from a specialty HIV clinic, and participants without HIV (comparable on key demographic, lifestyle, and behavioral characteristics) were recruited from the community. Measures included motor function summarized by 10 motor performance measures, pulmonary function summarized by 3 measures assessed using handheld spirometry, and self-reported mobility disability. In fully adjusted linear models, HIV was associated with better motor (β = 9.35, p

Traumatic stress and posttraumatic stress disorder (PTSD) are overrepresented in urban African American communities, and associated with health risk behaviors such as tobacco use. Support and resources provided by churches may reduce trauma-related health risks. In the current study, we assessed weekly church attendance as a moderator of relations between (a) traumatic event exposure and probable PTSD, and (b) probable PTSD and tobacco use. Data were drawn from a health surveillance study conducted in seven churches located in Chicago's West Side. Participants (N = 1015) were adults from churches as well as the surrounding community. Trauma exposure was reported by 62% of participants, with 25% of those who experienced trauma reporting probable PTSD. Overall, more than one-third of participants (37.2%) reported current tobacco use. As compared with non-weekly church attendance, weekly church attendance was associated with a lower likelihood of PTSD (odds ratio [OR] = 0.41; 95% confidence interval [CI] = 0.26-0.62; p < .0001) and lower tobacco use overall (OR = 0.22; 95% CI = 0.16-0.30; p < .0001), but did not moderate the effect of trauma exposure on risk of PTSD, or the effect of PTSD on tobacco use. Findings support church attendance as a potential buffer of trauma-related stress.

Objectives Short sleep duration and poor sleep quality are more prevalent among African Americans (AAs) and may be a modifiable risk factor for cardiometabolic disorders. However, research is limited about sleep-related attitudes, beliefs, and practices among AAs. Our objective was to evaluate these practices and beliefs surrounding sleep among urban-dwelling AAs. Design Qualitative study comprised of five 90-minute focus groups using a semistructured interview guide. Setting Five churches located on the west side of Chicago. Participants Adults (N = 43) ages 25-75 years. Measurements Transcripts were voice recorded, transcribed, and then coded for content analysis using NVivo 12 Pro to capture themes in the discussions. Results Most participants (86%) reported sleeping less than the recommended 7 or more hours. The discrepancy between actual and desired sleep duration was nearly 3 hours per night. Participants reported that sleep is essential for mental and physical health. Napping and consuming caffeine were frequently reported techniques for coping with lack of sleep. Noise, physical discomfort, and stress were reported as barriers to sleep, and participants reported using TV and other electronics to cope with racing thoughts or worry. Many participants were diagnosed with or knew someone with obstructive sleep apnea, but few participants had been diagnosed with insomnia or were aware of nonpharmacologic insomnia treatments. Conclusion A cycle of stress/disruptive environment, stress, rumination at night, and coping by use of electronics and daytime napping may perpetuate sleep disparities in this community. Results suggest that sleep-related interventions should include stress reduction and environmental improvements in addition to the typical sleep hygiene–related behavioral recommendations.

Older Black adults face a disproportionate burden of HIV prevalence, but less is known about racial disparities in age-related outcomes in HIV. We assessed the effect of HIV status and race on motor and pulmonary function, as well as how they contribute to mobility disability.Community-based study; Chicago, IL METHODS: Participants were 363 community-dwelling adults age ≥ 50 years, 48% living with HIV, and 68% Black. Participants with HIV were recruited from a specialty HIV clinic, and participants without HIV (comparable on key demographic, lifestyle, and behavioral characteristics) were recruited from the community. Measures included motor function summarized by 10 motor performance measures, pulmonary function summarized by 3 measures assessed using handheld spirometry, and self-reported mobility disability.In fully adjusted linear models, HIV was associated with better motor (β = 9.35, p lt; 0.001) and pulmonary function (β = 16.34, p lt; 0.001). For pulmonary function, the effect of HIV status was moderated by race (interaction between Black race and HIV status: β = - 11.66, p = 0.02), indicating that better pulmonary function among participants with HIV was less evident among Black participants. In fully adjusted models, odds of mobility disability did not differ by race, HIV status, or pulmonary function; better motor function was associated with lower odds of mobility disability (OR = 0.91 per 1-point higher, 95% CI 0.88-0.93).Better motor and pulmonary function exhibited by participants with HIV could reflect access to medical care. Racial differences in lung function among participants with HIV indicate potential disparities in prevention or treatment of pulmonary disease or underlying risk factors.

Hypertension is a chronic condition that disproportionately affects African Americans. Managing high blood pressure (HBP) requires adherence to daily medication. However, many patients with hypertension take their HBP medication inconsistently, putting them at heightened risk of heart disease. Researchers have shown that these health risks are greater for African Americans than for Caucasians. In this article, we examine barriers and facilitators of medication adherence among urban African Americans with hypertension. We interviewed 24 African Americans with hypertension (58.5% women, average age 59.5 years) and conducted a comprehensive thematic analysis. Twenty-two barriers and 32 facilitators to medication adherence emerged. Barriers included side effects and forgetting while facilitators included reminders, routines, and social support. Using this data, we developed a diagram of theme connectedness of factors that affect medication adherence. This diagram can guide multi-level HBP intervention research that targets African Americans to promote medication adherence, prevent heart disease, and reduce ethnic and racial health disparities.

Objective To test whether a previously tested, small-changes weight loss program could be translated for use in African American churches. Methods The program consisted of 12 group sessions held weekly at a partner church. Key intervention messages were disseminated via Facebook. A single-arm pretest-posttest evaluation included assessments at baseline, program completion (3-month), and after three months with no contact (6-month). Results Participants (N = 17; 16 women, age 57.5±12.1 years, body mass index 36.5 kg/m2±5.4, hemoglobin A1c 6.3±0.5, blood pressure 132±14/82±7) attended an average of 77% (mdn=9) of treatment sessions and 94% and 100% completed the 3- and 6-month assessment visits. All participants reported they were "somewhat" or "very satisfied" with the program. There was minimal interaction with Facebook with an average of 0.5 comments and 3.9 reactions per post. Three- and six-month reductions (all p's≤.01) were observed for weight (mdn=-2.7 kg; mdn=-2.6 kg), waist circumference (mdn=-3.8cm; mdn=-5.1cm), and hemoglobin A1c (mdn=-0.5; mdn=-0.3). At 3-months, there were significant reductions in systolic (mdn=-10.7 mmHg) and diastolic blood pressure (mdn=-8.0) but not at 6 months. Conclusions This study suggests that a faith-based, faith-placed intervention utilizing a small-changes approach in African American churches may achieve sustained weight loss in parishioners with obesity.

Supplemental Digital Content is available in the text., IMPORTANCE: Studying interhospital transfer of critically ill patients with coronavirus disease 2019 pneumonia in the spring 2020 surge may help inform future pandemic management. OBJECTIVES: To compare outcomes for mechanically ventilated patients with coronavirus disease 2019 transferred to a tertiary referral center with increased surge capacity with patients admitted from the emergency department. DESIGN, SETTING, PARTICIPANTS: Observational cohort study of single center urban academic medical center ICUs. All patients admitted and discharged with coronavirus disease 2019 pneumonia who received invasive ventilation between March 17, 2020, and October 14, 2020. MAIN OUTCOME AND MEASURES: Demographic and clinical variables were obtained from the electronic medical record. Patients were classified as emergency department admits or interhospital transfers. Regression models tested the association between transfer status and survival, adjusting for demographics and presentation severity. RESULTS: In total, 298 patients with coronavirus disease 2019 pneumonia were admitted to the ICU and received mechanical ventilation. Of these, 117 were transferred from another facility and 181 were admitted through the emergency department. Patients were primarily male (64%) and Black (38%) or Hispanic (45%). Transfer patients differed from emergency department admits in having English as a preferred language (71% vs 56%; p = 0.008) and younger age (median 57 vs 61 yr; p < 0.001). There were no differences in race/ethnicity or primary payor. Transfers were more likely to receive extracorporeal membrane oxygenation (12% vs 3%; p = 0.004). Overall, 50 (43%) transferred patients and 78 (43%) emergency department admits died prior to discharge. There was no significant difference in hospital mortality or days from intubation to discharge between the two groups. CONCLUSIONS AND RELEVANCE: In a single-center retrospective cohort, no significant differences in hospital mortality or length of stay between interhospital transfers and emergency department admits were found. While more study is needed, this suggests that interhospital transfer of critically ill patients with coronavirus disease 2019 can be done safely and effectively.

African Americans experience poorer diabetes outcomes than non-Hispanic Whites. Few clinical trials of diabetes self-management interventions specifically target African Americans, perhaps due to well-documented barriers to recruitment in this population. This paper describes strategies used to successfully recruit 211 low-income African Americans from community clinics of a large, urban public hospital system to a randomized clinical trial of an 18-month diabetes self-management intervention. Diabetes-related physiological, psychosocial, and behavioral characteristics of the sample are reported. The sample was 77% female, mean age = 55, mean A1C = 8.5%, 39% low health literacy, 28.4% moderate/severe depression, and 48.3% low adherence. Participants ate a high-fat diet with low vegetable consumption. Relative to males, females had higher BMI, depression, and stress, and better glycemic control, less physical activity, and less alcohol consumption. Males consumed more daily calories, but females consumed a greater proportion of carbohydrates. Gender-specific diabetes self-management strategies may be warranted in this population.

West Side Alive (WSA) is a partnership among pastors, church members and health researchers with the goal of improving health in the churches and surrounding community in the West Side of Chicago, a highly segregated African American area of Chicago with high rates of premature mortality and social disadvantage. To inform health intervention development, WSA conducted a series of health screenings that took place in seven partner churches. Key measures included social determinants of health and healthcare access, depression and PTSD screeners, and measurement of cardiometabolic risk factors, including blood pressure, weight, cholesterol and hemoglobin A1C (A1C). A total of 1106 adults were screened, consisting of WSA church members (n = 687), members of the local community served by the church (n = 339) and 80 individuals with unknown church status. Mean age was 52.8 years, 57% were female, and 67% reported at least one social risk factor (e.g. food insecurity). Almost all participants had at least one cardiovascular risk factor (92%), including 50% with obesity, 79% with elevated blood pressure and 65% with elevated A1C. A third of participants experienced ≥ 4 potentially traumatic events and 26% screened positive for depression and/or post-traumatic stress disorder. Participants were given personalized health reports and referred to services as needed. Information from the screenings will be used to inform the design of interventions targeting the West Side community and delivered in partnership with the churches. Sharing these results helped mobilize community members to improve their own health and the health of their community.

Literature is lacking on the impact of diet quality on glycemic control in those with type 2 diabetes (T2DM), especially African Americans with T2DM. 211 African American adults with T2DM and A1c ≥ 7.0% were randomized into intervention (26 sessions) and control (2 sessions) for an 18-month randomized community-based control trial, Lifestyle Improvement Through Food and Exercise (LIFE), assessing the impact of culturally-relevant lifestyle education on glycemic control. Participants lived in low-income Chicago-area neighborhoods and had regular medical care. Diet quality was assessed via 24-hour recall and translated into the Alternative Healthy Eating Index 2010 (AHEI-2010). AHEI-2010 total scores (0-110: higher score=healthier pattern) for intervention (n=95) and control (n=92) respectively were baseline: 47.4 ± 1.1 vs. 51.2 ± 1.1, 12 months: 51.4 ± 1.0 vs. 50.5 ± 1.1, 18 months: 50.3 ± 1.2 vs. 51.6 ± 1.2. Using repeated measures ANOVA, the AHEI-2010 18 month increase from baseline was significantly higher in the intervention group, df (2, 370), F (3.18), p=0.043. A1c% decline over 18 months (intervention: 9.1 ± 0.2 to 8.5 ± 0.2; control: 8.9 ± 0.2 to 8.6 ± 0.2, p Disclosure B. Tahsin: None. K.S. Keim: None. L. Fogelfeld: None. L. Fogg: None. E. Lynch: None. Funding National Institutes of Health

BACKGROUND: African Americans suffer more than non-Hispanic whites from type 2 diabetes, but diabetes self-management education (DSME) has been less effective at improving glycemic control for African Americans. Our objective was to determine whether a novel, culturally tailored DSME intervention would result in sustained improvements in glycemic control in low-income African-American patients of public hospital clinics. RESEARCH DESIGN AND METHODS: This randomized controlled trial (n = 211) compared changes in hemoglobin A1c (A1c) at 6, 12, and 18 months between two arms: (1) Lifestyle Improvement through Food and Exercise (LIFE), a culturally tailored, 28-session community-based intervention, focused on diet and physical activity, and (2) a standard of care comparison group receiving two group DSME classes. Cluster-adjusted ANCOVA modeling was used to assess A1c changes from baseline to 6, 12, and 18 months, respectively, between arms. RESULTS: At 6 months, A1c decreased significantly more in the intervention group than the control group (− 0.76 vs − 0.21%, p = 0.03). However, by 12 and 18 months, the difference was no longer significant (12 months − 0.63 intervention vs − 0.45 control, p = 0.52). There was a decrease in A1c over 18 months in both the intervention (β = − 0.026, p = 0.003) and the comparison arm (β = − 0.018, p = 0.048) but no difference in trend (p = 0.472) between arms. The intervention group had greater improvements in nutrition knowledge (11.1 vs 6.0 point change, p = 0.002) and diet quality (4.0 vs − 0.5 point change, p = 0.018) while the comparison group had more participants with improved medication adherence (24% vs 10%, p

Background Changes in reproductive hormones during menopause are associated with accumulation of intra-abdominal adipose tissue (IAAT), a subclinical indicator of cardiometabolic disease risk. Independent of reproductive hormones, unhealthy lifestyle contributes to IAAT gain. The Women in the Southside Health and Fitness (WISHFIT) Study aims to develop a lifestyle approach to slowing IAAT accumulation as women begin the menopausal transition. Methods The primary aim is to develop and conduct a proof-of-concept test of a multi-component, multi-level behavioral intervention targeting jointly physical activity, diet, and psychological well-being. Participants attend group sessions over 2 years to experiment with healthy living through both experiential and didactic learning, cultivate a health network, and draw on community resources to sustain change. The primary endpoint is 2-year IAAT progression, assessed using computerized tomography. Behavioral targets of treatment and secondary endpoints will be evaluated at 6, 12, 18 and 24 months. Change in social networks and community support will be assessed at 2 years. Results WISHFIT recruited 71 pre- and peri-menopausal Caucasian and African American women (mean ± SD age = 47.6 ± 3.4 yrs; BMI = 33.6 ± 7.3 kg/m2; 52% African American). Baseline IAAT was 2104.1 ± 1201.3 cm3. IAAT, physical activity, BMI, and self-reported family income and resilience differed by ethnicity at baseline. Conclusions WISHFIT is a multi-component, multi-level intervention aimed at producing a sustained improvement in physical activity, diet, and psychological well-being early in the menopausal transition to slow menopause-related accumulation of IAAT. It provides a model for the process of developing a behavioral treatment to manage a chronic disease.

Background:Physical inactivity in midlife women is associated with increased intra-abdominal adipose tissue development. We describe an innovative multimethod study 1) to better understand barriers to physical activity (PA) and 2) to engage midlife women to product test physical activities and identify local community-based providers and sustainable and fun PA experiences.Methods:Formative research on PA barriers from the Chicago site Study of Women’s Health Across the Nation (SWAN) ancillary study of midlife women was used to develop a pilot testing measure. Feasibility, acceptability and sustainability of the PA activities were determined using the measure.Results:Desirable locations and/or instructors were identified. The first 2 groups identified, pilot tested, and then ranked activities for their ability to promote sustained PA. The 6 top-ranked were: circuit training, total body fitness, kickboxing, Zumba, Pilates, and pedometer. The final group pilot tested highly ranked PA in 2-week blocks, and ranked pedometer and Zumba in their top 3.Conclusion:Consensus was reached regarding activities that could be valuable in promoting sustained PA in midlife women. Choosing convenient sites and popular instructors further facilitates sustainability. Building relationships with key community partners is essential for sustainability. Community-based participant involvement in study design is a critical element in developing a healthy living intervention.

Background. Understanding diabetes-specific quality of life (DSQOL) is important to improving lives of people with type 2 diabetes mellitus (T2DM). Despite the prevalence of T2DM among African Americans, there is scant evidence about DSQOL in this population. This study aims to understand relationships between DSQOL and demographics, clinical markers, psychosocial factors, and stress in African Americans. We hypothesize that: 1) predictors of DSQOL in African Americans will be consistent with predictors identified in prior studies with non-African Americans, and 2) greater stress will independently predict poorer DSQOL. Methods. Participants were 211 low-income African Americans with uncontrolled T2DM. The two hypotheses were tested using distinct linear regression models. Results. Significant predictors of poorer DSQOL were: 1) fewer years of school, 2) fewer T2DM-related complications, 3) longer T2DM duration, and 4) more perceived stress. Implications. Findings suggest that interventions targeting stress could improve DSQOL in African Americans.

Background Factors at multiple ecological levels, including the child, family, home, medical care, and community, impact adolescent asthma outcomes. Objective This systematic review characterizes behavioral interventions at the child, family, home, medical system, and community level to improve asthma management among adolescents. Methods A systematic search of PubMed, SCOPUS, OVID, PsycINFO, CINAHL, and reference review databases was conducted from January 1, 2000, through August 10, 2014. Articles were included if the title or abstract included asthma AND intervention AND (education OR self-management OR behavioral OR technology OR trigger reduction), and the mean and/or median age of participants was between 11 and 16 years. We compared populations, intervention characteristics, study designs, outcomes, settings, and intervention levels across studies to evaluate behavioral interventions to improve asthma management for adolescents. Results Of 1230 articles identified and reviewed, 24 articles (21 unique studies) met inclusion criteria. Promising approaches to improving adherence to daily controller medications include objective monitoring of inhaled corticosteroid adherence with allergist and/or immunologist feedback on medication-taking behavior and school nurse directly observed therapy. Efficacy at increasing asthma self-management skills was demonstrated using group interactive learning in the school setting. This systematic review is not a meta-analysis, thus limiting its quantitative assessment of studies. Publication bias may also limit our findings. Conclusions Novel strategies to objectively increase controller medication adherence for adolescents include allergist and/or immunologist feedback and school nurse directly observed therapy. Schools, the most common setting across studies in this review, provide the opportunity for group interactive learning to improve asthma knowledge and self-management skills.

Black-White disparities in gait speed have been observed in studies of adults reporting HIV, consistent with work among older adults without HIV. However, it is unknown if racial differences exist among adults with HIV for other mobility-related factors. We aimed to determine if racial differences exist in mobility disability among older adults with and without HIV and assess if pulmonary and motor function contribute to mobility disability. We examined older adults age 50+ with HIV (N=177; 72% Black) and without HIV (N=191; 68% Black). Motor function summarized 10 motor performances including gait speed; pulmonary function summarized 3 measures assessed using hand-held spirometry. Mobility disability was based on self-report. In regression models adjusted for age, sex, medical conditions, and smoking, neither race nor HIV status were associated with mobility-related factors. However, in models stratified by HIV status, Blacks with HIV had worse motor (β=-4.3, p=0.04) and pulmonary function (β=-50.5

Introduction Limitations in physical function are predictive of adverse health outcomes, and screening has been recommended in clinical settings for older adults. Rarely assessed in community-based settings, physical function could provide insight for tailoring health-related community-based programs and raise awareness about this important aspect of health. This cross-sectional study seeks to demonstrate the feasibility of integrating physical function assessments into health screenings in African American churches in Chicago, Illinois, through a large health partnership and to determine the prevalence and correlates of physical function limitations among midlife (aged 40–59 years) and late-life (aged ≥60 years) participants. Methods Screenings were held in 7 churches in Spring 2018. Physical function was assessed using the Short Physical Performance Battery. Demographics, medical history, health status, and health behaviors were assessed. Age-stratified logistic regression identified independent associations with physical function limitations (Score ≤9) among midlife and late-life participants (data were analyzed in 2018–2019). Results Among 731 participants (median age=57 [IQR=51−65] years, 58% women, 97% African American), 25% of midlife and 56% of late-life participants had physical function limitations. For midlife participants, fair/poor health (OR=1.83, 95% CI=1.10, 3.05), stroke/neurologic conditions (OR=2.42, 95% CI=1.07, 5.46), and arthritis (OR=2.25, 95% CI=1.32, 3.81) were associated with higher odds of limitations. Fair/poor health (OR=1.97, 95% CI=1.11, 3.50) and stroke/neurologic conditions (OR=7.85, 95% CI=2.22, 27.74) were related to limitations among late-life participants. Conclusions Physical function screening was successfully implemented into this large-scale church-based health screening program. Physical function limitations were prevalent, particularly at midlife; this information will be used to guide future programs.

BackgroundSubstantial disparities in life expectancy exist between Chicago’s 77 defined community areas, ranging from approximately 69 to 85 years. Prior work in New York City and Boston has shown that community-level racial and economic segregation as measured by the Index of Concentration at the Extremes (ICE) is strongly related to premature mortality. This novel metric allows for the joint assessment of area-based income and racial polarisation. This study aimed to assess the relationships between racial and economic segregation and economic hardship with premature mortality in Chicago.MethodsAnnual age-adjusted premature mortality rates (deaths ResultsAverage annual premature mortality rates ranged from 94 (95% CI 61 to 133) deaths per 100 000 population age Incomerate ratio (RR)=3.06, 95% CI 2.51 to 3.73; ICERaceRR=3.07, 95% CI 2.62 to 3.58; ICEIncome+RaceRR=3.27, 95% CI 2.84 to 3.77). Similarly, compared with communities in the lowest hardship index quintile, communities in the highest quintile had significantly higher premature mortality rates (RR=2.79, 95% CI 2.18 to 3.57).ConclusionsThe strong relationships observed between ICE measures and premature mortality—particularly the combined ICE metric encompassing race and income—support the use of ICE in public health monitoring.

Objective: To examine if incident and preexisting diabetes mellitus (DM) were associated with cognitive decline among African Americans (AAs) and European Americans (EAs). Methods: Based on a prospective study of 7,740 older adults (mean age 72.3 years, 64% AA, 63% female), DM was ascertained by hypoglycemic medication use and Medicare claims during physician or hospital visits, and cognition by performance on a brief battery for executive functioning, episodic memory, and Mini-Mental State Examination (MMSE). Decline in composite and individual tests among those with incident DM, with preexisting DM, and without DM was studied using a linear mixed effects model with and without change point. Results: At baseline, 737 (15%) AAs and 269 (10%) EAs had preexisting DM. Another 721 (17%) AAs and 289 (12%) EAs had incident DM in old age. Following incident DM, cognitive decline increased by 36% among AAs and by 40% among EAs compared to those without DM. No significant difference was observed between AAs and EAs ( p = 0.64). However, cognitive decline increased by 17% among AAs with preexisting DM compared to those without DM, but no increased decline was observed among EAs with preexisting DM. In secondary analyses, faster decline in executive functioning and episodic memory was observed following incident DM. Conclusions: In old age, faster cognitive decline was present among AAs and EAs following incident DM, compared to cognitive decline prior to DM, and among those without DM. This underscores the need for stronger prevention and control of DM in old age.

This article describes formative work conducted to inform design of an intervention targeting asthma control in overweight/obese children. Using a PRECEDE-PROCEED framework and a community-based participatory research approach, investigators conducted key informant interviews and focus groups in a low-income urban community. Key informants ( N = 18) represented schools and community agencies. Focus groups were conducted with caregivers (4 groups, N = 31) and children (3 groups, N = 30). Focus group participants were low-income and African American, Puerto Rican, or Mexican. Children were age 5 to 12 years and overweight or obese with a diagnosis of asthma; caregivers had a child meeting these criteria. A range of issues competed with families’ day-to-day prioritization and management of asthma, with social limitations reported as the most important issue. Many school-level and individual-level barriers were described. Caregivers and children drew strong connections between asthma and obesity and described their need to comanage these conditions. The connection between the diseases was not as obvious for the key informants, many of whom control the services families receive. These results led to an understanding of key targets and components that are needed for a multilevel community-based intervention to be relevant and appropriate in low-income children with both asthma and obesity.

Despite growing interest in the current and potential role of medical travel in U.S. patient care, very little research has been conducted on clinician and other provider organizations' perspectives on providing international patient care. The present study sought to gain formative insights about medical travel from the providers' perspectives, by conducting structured interviews and focus groups in six hospitals from three countries catering to patients traveling from the United States. Findings highlighted the surprising role of international events and policies in the evolution of medical travel, as well as both the desire and need for more transparent quality standards.