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This study sought to understand the perceptions of Ghanaian immigrants of the health status and health trajectory of their community. We conducted focus groups and interviews with 63 primarily Ghanaian immigrants living in New York City. Nearly all participants observed that Ghanaians are generally healthy when they arrive in the US, but that their health declines over time. Participants identified four causes of this perceived deterioration: changes in health behaviors, increased stress, environmental exposures, and barriers to health care. Participants see themselves as being at risk for many health problems resulting from changes in lifestyle that follow immigration. Although some vulnerabilities are unique to their experience as immigrants, many of the risk factors they described are the same as those that affect other residents in the communities in which they live.

CONCLUSIONS: Despite significant infrastructure and resource differences between SIPs and FQHCs, the contextual factors that influenced the facilitator's change process and the strategies used to address those factors were remarkably similar. The findings emphasize that facilitators require multidisciplinary skills to support sustainable practice improvement in the context of varying complex health care delivery settings.

BackgroundHealthyHearts NYC (HHNYC) will evaluate the effectiveness of practice facilitation as a quality improvement strategy for implementing the Million Hearts’ ABCS treatment guidelines for reducing cardiovascular disease (CVD) among high-risk patients who receive care in primary care practices in New York City. ABCS refers to (A) aspirin in high-risk individuals; (B) blood pressure control; (C) cholesterol management; and (S) smoking cessation. The long-term goal is to create a robust infrastructure for implementing and disseminating evidence-based practice guidelines (EBPG) in primary care practices.Methods/designWe are using a stepped-wedge cluster randomized controlled trial design to evaluate the implementation process and the impact of practice facilitation (PF) versus usual care on ABCS outcomes in 250 small primary care practices. Randomization is at the practice site level, all of which begin as part of the control condition. The intervention consists of one year of PF that includes a combination of one-on-one onsite visits and shared learning across practice sites. PFs will focus on helping sites implement evidence-based components of patient-centered medical home (PCMH) and the chronic care model (CCM), which include decision support, provider feedback, self-management tools and resources, and linkages to community-based services.DiscussionWe hypothesize that practice facilitation will result in superior clinical outcomes compared to usual care; that the effects of practice facilitation will be mediated by greater adoption of system changes in accord with PCMH and CCM; and that there will be increased adaptive reserve and change capacity.Trial registration NCT02646488

With the increased understanding of the relationship between stress and disease, the role of stress in explaining persistent disparities in health outcomes has received growing attention. One body of research has focused on allostatic load--the "wear and tear" that results from chronic or excessive activation of the stress response. Other research has looked at the link between stress and health behaviors. In this study, we conducted 7 focus groups with a total of 56 people to understand how people living in Highbridge, South Bronx, New York, a low income community with poor health outcomes, perceive stress and its relationship to health. Focus group participants described a direct causal pathway between stress and poor health as well as an indirect pathway through health behaviors, including uncontrolled eating, sleep deprivation, substance abuse, smoking, violence and aggression, and withdrawal and inactivity. Participants articulated a number of theories about why stress leads to these unhealthy behaviors, including self-medication, adaptive behavior, discounting the future, depletion of willpower, and competing priorities. Their nuanced understanding of the link between stress and health elucidates the mechanisms and pathways by which stress may result in disparities in health outcomes and create challenges in changing health behaviors in poor communities like the South Bronx.