Ending "domestic helicopter research"

"Helicopter research" refers to a practice where researchers from wealthier countries conduct studies in lower-income countries with little involvement of local researchers or community members. This practice also occurs domestically. In this Commentary, we outline strategies to curb domestic helicopter research and to foster equity-centered collaborations.

Community Perceptions of Health Equity: A Qualitative Study

INTRODUCTION

Notable inequities in patient experiences exist in the healthcare system. Communities with a large concentration of blacks and immigrants are often marginalized rather than centralized in the healthcare system. These inequities may fuel distrust and exacerbate adverse outcomes, thereby widening the health gap. Addressing differences in patients' experiences of care is paramount for reducing health inequities.

METHODS

In this qualitative study, we used a purposive sampling method to recruit 62 participants to conduct 10 FGs (44 participants total) and 18 key informant interviews with stakeholders across Central Brooklyn.

RESULTS

The data revealed three primary themes: Trust, Discrimination, and Social Determinants of Health (SDOHs). Each theme comprised subthemes as follows: For Trust, the subthemes included (1) confidence in the healthcare professional, (2) provider empathy, and (3) active participation in healthcare decisions. Regarding Discrimination, the subthemes involved (1) racism and identity, as well as (2) stigma related to diagnosis, disease state, and pain management. Lastly, for Social Determinants of Health, the key subtheme was the acknowledgment by providers that patients encounter competing priorities acting as barriers to care, such as housing instability and food insecurity. For the first theme, participants' interactions with the healthcare system were prompted by a necessity for medical attention, and not by trust. The participants reported that experiences of discrimination resulting from identity and stigma associated with diagnosis, disease state, and pain management amplified the disconnect between the community, the patients, and the healthcare system. This also exacerbated the poor healthcare experiences suffered by many people of color. For SDOHs, the participants identified housing, food security, and other various social factors that may undermine the effectiveness of the healthcare that patients receive.

CONCLUSIONS

Improvements in the health system, based on feedback from patients of color regarding their unique care experiences, are important initiatives in combating inequities in healthcare.

R.E.A.C.T: A framework for role modeling anti-racism in the clinical learning environment

PURPOSE

In 2020, medical schools across the U.S. were called to task by students who demanded a response to structural racism in medicine. Many medical schools made anti-racism declarations and pledged to promote more inclusive learning environments. Much of the focus was on changing the pre-clinical curriculum and less on the everyday interactions that occur in clinical settings. As medical educators, we have an obligation to reinforce statements of solidarity by role modeling behaviors that demonstrate anti-racism in clinical practice.

METHODS

This article proposes a framework that provides practical steps for role modeling anti-racism in the clinical learning environment. These steps are drawn from a review of the literature on role modeling, constructs from Social Cognitive Learning Theory, and anti-racism praxis.

RESULTS

The resulting framework uses the acronym R.E.A.C.T to describe practical steps that include Reflecting on implicit biases, Educating ourselves on historical and current forms of structural racism, Assessing the use of race in clinical practice and asking how racism is impacting a clinical interaction, Calling out behaviors that perpetuate racism, and Treating everyone with dignity and respect.

CONCLUSIONS

The R.E.A.C.T framework is of value to medical educators because it provides practical steps on role modeling anti-racism in the clinical learning environment. The framework calls medical educators not to merely passively 'react,' but to be introspective, proactive, and intentional in their response to racism. Examples are provided on how each step can be actualized and adapted for different learning environments.

Reconsidering Community-Engaged Research Through a Syndemic Theoretical Framework: Lessons from COVID-19

BACKGROUND

Community-engaged research is a well-established approach to tackling health disparities in communities of color. However, the devastation caused by coronavirus disease 2019 (COVID-19) calls for a reexamination of the practice of community-engaged research. Syndemic framework characterizes the clustering and synergistic interactions between two or more diseases amid an underlay of social and environmental threats. This framework has been used to explain the disproportionately higher rates of COVID-19 in communities of color and may have utility in guiding future community-engaged research.

OBJECTIVES

This article describes the process by which a syndemic framework was used to generate discussions on lessons learned from COVID-19 and describes the ensuing collaborative writing process that emerged from this discourse.

METHODS

This article was developed by the Community Engagement Working Group (CEWG) of the Jackson Heart Study, a community-based epidemiologic study focused on cardiovascular disease among African Americans in the Jackson, Mississippi Metropolitan Area. By drawing upon a syndemic framework and lessons from COVID-19, the CEWG identified gaps and opportunities to enhance community-engaged research.

CONCLUSIONS

Using syndemic framework as a starting point, the CEWG identified the following as aspects of community-engaged research that may warrant further consideration: 1) the need to examine multiple dimensions and assets of a community, 2) the need to view communities through an intersectionality lens, 3) the need to acknowledge the impact of historical and current trauma on the community, and 4) the need to provide support to community-engaged researchers who may be members of minoritized groups themselves and therefore, experience similar trauma.

Factors influencing decision making for kidney transplantation among Black and Latino patients on dialysis: A qualitative study applying the social ecological model

OBJECTIVES

This qualitative study explored factors that may influence decisions regarding kidney transplantation among African-American and Latino adults on dialysis.

METHODS

Qualitative interviews were audio-recorded and transcribed. Open-coding techniques were used to identify concepts, categories, and themes. The Social Ecological Model (SEM) was used to organize themes and identify potential solutions across multiple levels (individual, interpersonal, community, and policy/health system).

RESULTS

Thirty-six patients were interviewed. Their mean age was 53 SD 12 years; 50% were female; and their duration on dialysis was 4.9 SD 6 years. Five themes emerged and were organized according to the levels of the SEM: 1) Fear about the outcomes of transplantation and 2) faith in God (individual level); 3) Family dynamics and reluctance to involve family in the decision making process (interpersonal level); 4) The experiences of friends and social networks (community level); and 5) Concerns about the social and economic impact of transplantation (policy and health system).

DISCUSSION

The application of a Social Ecological model in this study helped to illuminate the complex and multilevel factors that may influence the decisions for kidney transplantation. Future studies are needed to further explore how family members, social networks, faith communities, and policies/health systems influence the decision making process.

Increased Metabolic Burden Among Blacks: A Putative Mechanism for Disparate COVID-19 Outcomes

Mounting evidence shows a disproportionate COVID-19 burden among Blacks. Early findings indicate pre-existing metabolic burden (eg, obesity, hypertension and diabetes) as key drivers of COVID-19 severity. Since Blacks exhibit higher prevalence of metabolic burden, we examined the influence of metabolic syndrome on disparate COVID-19 burden. We analyzed data from a NIH-funded study to characterize metabolic burden among Blacks in New York (Metabolic Syndrome Outcome Study). Patients (n=1035) were recruited from outpatient clinics, where clinical and self-report data were obtained. The vast majority of the sample was overweight/obese (90%); diagnosed with hypertension (93%); dyslipidemia (72%); diabetes (61%); and nearly half of them were at risk for sleep apnea (48%). Older Blacks (age≥65 years) were characterized by higher levels of metabolic burden and co-morbidities (eg, heart disease, cancer). In multivariate-adjusted regression analyses, age was a significant (p≤.001) independent predictor of hypertension (OR=1.06; 95% CI: 1.04-1.09), diabetes (OR=1.03; 95% CI: 1.02-1.04), and dyslipidemia (OR=0.98; 95% CI: 0.97-0.99), but not obesity. Our study demonstrates an overwhelmingly high prevalence of the metabolic risk factors related to COVID-19 among Blacks in New York, highlighting disparate metabolic burden among Blacks as a possible mechanism conferring the greater burden of COVID-19 infection and mortality represented in published data.

Life Without a Breast: Exploring the Experiences of Young Nigerian Women After Mastectomy for Breast Cancer

PURPOSE

The majority of women managed for breast cancer in Nigeria are relatively young, many in their forties. Mastectomy, the most common surgical treatment, raises psychosocial concerns. Understanding these concerns may help address the fears of women who refuse treatment and aid in the care of those who have had mastectomy.

METHODS

Using qualitative methods, we purposively sampled women 45 years of age and younger who underwent mastectomy for breast cancer at a Nigerian teaching hospital. One-on-one in-depth interviews were conducted using an unstructured interview guide. Data were transcribed verbatim and analyzed to identify themes and subthemes.

RESULTS

The study identified six major themes on the impact of mastectomy on psychosocial lives of women, namely decision for mastectomy, postmastectomy transition, body image changes, relationship with husband and sexual life, coping with life postmastectomy, and social support.

CONCLUSION

Our findings highlight the importance of addressing individual patient's psychosocial needs and preferences when discussing breast cancer treatment with young women. The experiences of women described in this study reveal several useful themes for planning treatment protocols and postmastectomy care.

Factors Associated With Use of a High-Volume Cancer Center by Black Women With Ovarian Cancer

OBJECTIVE

Disparities exist between population subgroups in the use of gynecologic oncologists and high-volume hospitals. The objectives of this study were to explore the experiences of black women obtaining ovarian cancer (OC) care at a high-volume center (HVC) and to identify patient-, provider-, and systems-related factors affecting their access to and use of this level of care.

MATERIALS AND METHODS

Twenty-one semistructured interviews were conducted as part of an institutional review board-approved protocol with women who self-identified as black or African American, treated for OC at a single HVC from January 2013 to May 2017. Recurring themes were identified in transcribed interviews through the process of independent and collaborative thematic content analysis.

RESULTS

Five themes were identified: (1) internal attributes contributing to black women's ability/desire to be treated at an HVC, (2) pathways to high- and low-volume centers, (3) obstacles to obtaining care, (4) potential barriers for black women interested in treatment at an HVC, and (5) suggestions for improving HVC use by black women. Study participants who successfully accessed care were comfortable navigating the health care system, understood the importance of self-advocacy, and valued the expertise of an HVC. Barriers to obtaining care at an HVC included lack of knowledge about the HVC, lack of referral, transportation difficulties, and lack of insurance coverage.

CONCLUSION

In this qualitative study, black women treated at an HVC shared attributes and experiences that helped them access care. There is a need to collaborate with black communities and establish interventions to reduce barriers, facilitate access, and disseminate information about the value of receiving care for OC at an HVC.

Understanding of cardiovascular disease risk factors among Bangladeshi immigrants in New York City

OBJECTIVES

Among all South Asians, Bangladeshis have the highest prevalence of cardiovascular disease (CVD). The purpose of our study was to compare the understanding of CVD risk factors among Bangladeshi immigrants to the general Caucasian population in the U.S.

DESIGN

We surveyed Bangladeshi immigrants in Queens, New York using a CVD risk factor knowledge instrument used in the Coronary Artery Risk Development in Young Adults (CARDIA) study to assess awareness of risk factors. Using multivariate regression modeling, we compared scores on the knowledge instrument between Bangladeshis we surveyed and Caucasians from the CARDIA study, controlling for potential confounders. We subsequently examined the frequency of mentioning each risk factor to understand what was driving the difference in the overall score.

RESULTS

The proportion of Bangladeshis scoring low on the knowledge assessment was 0.53, where as the proportion of whites scoring low in the CARDIA study was 0.32 (p value < .001). Whites were 34% more likely to score high than Bangladeshis (adjusted odds ratio [aOR] 1.34, 95% confidence interval [CI] 1.19-1.52). Bangladeshis were more likely to mention diet and cholesterol as risk factors and less likely to mention lack of exercise, being overweight, and smoking as risk factors.

CONCLUSION

Understanding of cardiovascular disease risk factors was lower among Bangladeshis than whites. This was driven by Bangladeshis having less awareness regarding how exercise and being overweight contribute to CVD. Community based interventions and community health partnerships should target these behavioral risk factors in the Bangladeshi population.

Barriers to mammography screening in Nigeria: A survey of two communities with different access to screening facilities

Delayed presentation of breast cancer is a common theme in most low- and middle-income countries. This study evaluates barriers to mammography screening in two Nigerian communities with different geographic access to screening facilities. A 35 item questionnaire was administered to women, 40 years and older, 1,169 (52.6%) in Ife Central Local Government where mammography services are offered and 1,053 (47.4%) in Iwo Local Government where there are no mammography units. Information on breast cancer screening practices and barriers to mammography screening were compared between the two communities. Most women had heard of breast cancer (Ife 94%, Iwo 97%), but few were aware of mammography (Ife 11.8%, Iwo 11.4%). Mammography uptake in Ife Central was 2.8% and 1.8% in Iwo, despite the former offering mammography services. Knowledge and practice of mammography were not statistically different between the two communities (p = 0.74, 0.1). Lack of awareness was the commonest reason cited for not having mammography in both communities. Others include lack of perceived need and cost. Awareness creation to ensure optimal utilisation of existing facilities, as well as innovative measures to address the barrier of cost, is required to improve breast cancer screening uptake in Nigeria.

Safety and feasibility of early postmastectomy discharge and home drain care in a low resource setting

BACKGROUND

Early postmastectomy discharge with a drain in place is standard practice in most developed countries. Its feasibility has not been evaluated in low resource settings like Nigeria.

METHODS

Consenting patients undergoing mastectomy were discharged on the third postoperative day and assessed as outpatients for wound complications as well as their experience at home. Wound outcomes were compared with patients who had traditional long stay.

RESULTS

Forty-five of the 58 patients who had a mastectomy during the study period participated in the early discharge program (77.6%). Of these, four patients (8.9%) had drain malfunction, seroma occurred in eight patients (17.8%), eight patients (17.8%) had wound infection, and six patients (13.3%) had flap necrosis. There was no readmission. Compared with long stay patients, postoperative stay was significantly shorter (3 vs 11 days; P < 0.01) with significant cost savings, while complication rates were not statistically different. All the patients in the early discharge group were confident operating their drains and preferred early discharge. Being around relatives, reduced cost, and fear of the hospital environment were common reasons cited for their preference.

CONCLUSION

Our results support the implementation of an early postmastectomy discharge program in a low resource setting.

Barriers to Mammography Screening in Nigeria: A Survey of Two Communities With Different Access to Screening Facilities

Purpose

Breast cancer outcomes are poor in most low- and middle-income countries. This is a result, in part, of delayed presentation. Critical to improving this gloomy picture is the promotion of breast cancer screening programs; however, designing a formidable screening program requires obtaining necessary background data. This survey evaluates breast cancer screening practices and barriers in two Nigerian communities with different geographic access to screening facilities.

Methods

We administered a 35-item questionnaire to women age 40 years and older—1,169 participants (52.6%) in the Ife Central Local Government, where mammography services are offered, and 1,053 (47.4%) in the Iwo Local Government, where there are no mammography units. Information on breast cancer screening practices and barriers to mammography screening were compared between the two communities.

Results

Most women had heard of breast cancer (Ife, 94%; Iwo, 97%), but few have had any form of breast cancer screening recommended to them—37.7% of Ife respondents and 36.6% of Iwo respondents. Few women were aware of mammography (Ife, 11.8%; Iwo, 11.4%), whereas mammography uptake was 2.8% Ife respondents and 1.8% in Iwo respondents, despite the latter offering mammography services. Awareness and practice of mammography were not statistically different between the two communities ( P = .74 and P = .1 for Ife and Iwo, respectively). Lack of awareness was the most common reason cited for not undergoing mammography in both communities. Cost was also identified as a barrier, as only 20% of respondents could afford mammography. Despite being offered at little or no cost, uptake of clinical breast examination (CBE) was poor in both communities—27.4% in Iwo and 19.7% in Ife; however, the majority were willing to participate in a routine CBE-based breast cancer screening program.

Conclusion

Access without awareness and community mobilization does not guarantee use of breast cancer screening services. Given the above findings, a comprehensive breast health program that incorporates awareness creation, routine CBE-based screening, and selective mammography is currently underway in a selected Nigerian community.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

No COIs from the author

Understanding the Breast Cancer Experience of Women in East Africa: A Qualitative Study

Background: Breast cancer is one of the leading causes of premature death in women in East Africa. The majority of patients are diagnosed with advanced cancers (stage III and IV) which results in more cancer deaths. Even after a diagnosis of breast cancer, many patients do not complete their treatment. The reasons why delays in diagnosis and treatment occur are multilevel, involving a combination of both patient related factors, such as sociocultural reasons like stigma or fatalism, or the use of alternative medicine. Financial factors play a big role as many patients have to pay out of pocket for their health expenditure. System related factors such as a lack of resources for the diagnosis or treatment, lack of health worker knowledge leading to misdiagnosis with inappropriate treatment and poor referral pathways, also contribute to delays in care. Aim: To understand the experience of breast cancer patients in East Africa, to determine the facilitators and barriers to diagnosis, treatment and follow-up of breast cancer. Methods: 28 patients in Kenya and Tanzania who had completed at least a year of initial treatment were invited to participate in the study. A qualitative exploratory study was done using semistructured, in-depth interviews. Grounded theory was then used to analyze and develop themes that emerged from these narratives. Results: For these patients who had completed at least a year of treatment, the cost of treatment and expenses incurred was a major concern. Family disintegration emerged as a significant theme following cancer diagnosis. There was a prevalence of stigma around breast cancer and patients would not disclose their status to others in the community for fear of being ridiculed, pitied or isolated. A number of patients used alternative medicine resulting in delays in treatment. Family support, support groups and spirituality played a major role in facilitating the completion of initial care and in reducing psychological morbidity. System factors such as poor referral pathways, and inappropriate treatment emerged as minor themes. Conclusion: The sociocultural aspects of breast cancer need to be addressed to ensure comprehensive management of breast cancer patients and completion of treatment. As programs in the region, mainly run by governments, aim to improve the financial access to treatment, it would be critical to include efforts aimed at stigma reduction and interventions focusing on the sociocultural reintegration of these patients.

Impact of Depression and Demoralization on Blood Pressure Control in African Americans with Hypertension: Findings from the TRIUMPH Trial

BACKGROUND

African Americans develop hypertension earlier and have worse cardiovascular outcomes than Caucasians. Accumulating evidence suggests that psychological distress may play a role in the observed racial differences in hypertension. Several studies have investigated the relationship between depression and hypertension while little is still known about the role of demoralization.

METHODS

Using data from the Trial Using Motivational Interviewing, Positive Affect, and Self-affirmation in African Americans with Hypertension (TRIUMPH), logistic regression models were used to estimate differences in blood pressure control at 12 months among participants with demoralization, depression, and both conditions.

RESULTS

Our logistic models showed that reported psychosocial symptoms significantly differed in predicting success in blood pressure control at 12 months. Contrast analyses showed that, after adjusting for sociodemographic, clinical, and psychosocial variables, demoralized patients were less likely to achieve blood pressure control than participants without affective conditions (p = 0.020). Similar results emerged for patients with depression (p = 0.042) and both conditions (p = 0.022).

CONCLUSIONS

Depression can be extremely debilitating and has serious health consequence. Our findings confirm this result and show that, even though depression and demoralization share common features, they are two distinct clinical phenomena with similar negative impact on blood pressure control in African Americans.

Community-Based, Preclinical Patient Navigation for Colorectal Cancer Screening Among Older Black Men Recruited From Barbershops: The MISTER B Trial

OBJECTIVES

To test the effectiveness of a preclinical, telephone-based patient navigation intervention to encourage colorectal cancer (CRC) screening among older Black men.

METHODS

We conducted a 3-parallel-arm, randomized trial among 731 self-identified Black men recruited at barbershops between 2010 and 2013 in New York City. Participants had to be aged 50 years or older, not be up-to-date on CRC screening, have uncontrolled high blood pressure, and have a working telephone. We randomized participants to 1 of 3 groups: (1) patient navigation by a community health worker for CRC screening (PN), (2) motivational interviewing for blood pressure control by a trained counselor (MINT), or (3) both interventions (PLUS). We assessed CRC screening completion at 6-month follow-up.

RESULTS

Intent-to-treat analysis revealed that participants in the navigation interventions were significantly more likely than those in the MINT-only group to be screened for CRC during the 6-month study period (17.5% of participants in PN, 17.8% in PLUS, 8.4% in MINT; P < .01).

CONCLUSIONS

Telephone-based preclinical patient navigation has the potential to be effective for older Black men. Our results indicate the importance of community-based health interventions for improving health among minority men.

Trouble in transit: Organizational barriers to workers' health

BACKGROUND

Valuable insights on the health and behavior of transit workers can be obtained from qualitative research that considers the social environment, which affects job performance and determines levels of perceived stress.

METHODS

Using a grounded theory approach, semi-structured interviews were conducted with American transit workers (n = 32). Recorded interviews were transcribed and analyzed using a constant comparative method.

RESULTS

Participants described categories related to entrenched organizational practices, particularly managements' leadership style, which created an atmosphere of distrust. High demanding work schedules, as a result of technological advances, were discussed in relation to diminished breaks, fatigue, and unhealthy diets. Transit workers also attributed increased work demands and irregular working hours to compromised time with family and friends.

CONCLUSIONS

The described barriers to positive health behaviors and social support underscore the need for interventions that ensure adequate breaks and recovery between shifts and increase safety for transit passengers. Am. J. Ind. Med. 60:350-367, 2017. © 2017 Wiley Periodicals, Inc.

Live with the Disease Like You Used to Before You Knew You Were Infected: A Qualitative Study Among 10-Year Survivors Living with HIV in Haiti

In 2003, the Haitian Study Group on Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), a nonprofit organization, began administering antiretroviral therapy (ART) to its patients. This practice transformed HIV from a fatal disease to a more manageable chronic condition. However, relatively few studies focus on the experiences of survivors. This study provided a unique opportunity to interview patients who survived at least 10 years after being treated with ART at GHESKIO. The goal of the study was to elicit from patients their perspectives on what enabled them to survive with AIDS. Grounded Theory, a qualitative research method was used to guide data collection, coding, and analysis. Individual interviews were conducted, audio-taped, transcribed and analyzed in Creole, and translated into English. Data saturation was reached at 25 participants. Of which, 64% were women, the mean age was 49, range of 43-55 years, 24% were married, 44% had not completed elementary school, and 72% had no income, the remaining participants had incomes ranging from $1000 to $5000 annually. Qualitative analysis resulted in 681 codes, which were grouped into six categories: being spiritually grounded, having supportive interactions with providers, caring for children, setting personal goals, persevering and living life as usual, and maintaining strict medication adherence practices. The overarching theory was that having a reason to live despite one's circumstances and living life as usual enabled one to survive. Having a strong spiritual foundation coupled with supportive family and providers motivated participants to live and adhere to their ART. As the number of patients who are living longer with HIV in Haiti increases, results from this study will be important in helping tailor interventions that enhance their overall quality of life.

Evaluation of HeartSmarts, a Faith-Based Cardiovascular Health Education Program

In order to effectively address cardiovascular disease among African Americans, evidence-based health information must be disseminated within a context aligned with the values and beliefs of the population. Faith-based organizations play a critical role in meeting the religious and spiritual needs of many African Americans. Additionally, faith-based organizations can be effective in health promotion. A manual was created by incorporating biblical scriptures relating to health messages drawn from existing health manuals oriented toward African Americans. Lay health educators active in their churches participated in a 12-week training to learn the basics of cardiovascular disease and methods for delivering the program to their congregations' members. After the completion of the training, these lay health educators recruited participants from their respective churches and administered their own 12-week HeartSmarts program. Measurements of participants' systolic and diastolic blood pressure (mmHg), height (in.), weight (lbs.), and waist circumference (in.) were taken, and cardiovascular disease knowledge assessments (based on 20 open-ended questions) were administered at the start and end of the 12-week programs. Fourteen predominantly African American churches in NYC participated. Of the 221 participants, 199 completed the program. There were significant reductions in pretest and posttest total participant averages for systolic BP (4.48 mmHg, p < 0.001), diastolic BP (3.38 mmHg, p < 0.001), weight (3lbs., p = 0.001), and BMI (0.46, p = 0.001). Cardiovascular disease health assessment scores had an average increase of 12.74 correct responses (p < 0.001). The HeartSmarts program may be an effective ecumenical and cultural model for disseminating health messages and reducing cardiovascular risk among African Americans.

Developing a Breast Cancer Screening Program in Nigeria: Evaluating Current Practices, Perceptions, and Possible Barriers

Purpose

In low- and middle-income countries like Nigeria, women present with advanced breast cancer at an earlier age. Given the limited resources, development of screening programs that parallel resource capabilities of low- and middle-income countries is imperative. The objective of this study was to evaluate the perceptions, practices, and barriers regarding clinical breast examination (CBE) screening in a low-income community in Nigeria.

Materials and Methods

A cross-sectional survey of women age 40 years or older in Ife, Nigeria, using multistaged sampling was performed. Information on sociodemographics, knowledge of breast cancer, screening practices, and willingness to participate in CBE screening was obtained using an interviewer-administered questionnaire.

Results

A total of 1,169 women whose ages ranged from 40 to 86 years (mean age, 47.7 years; standard deviation, 8.79 years) were interviewed. The majority of women (94%) knew about breast cancer, whereas 27.5% knew someone who had had breast cancer, the majority of whom (64.5%) had died of the disease. Of the 36% of women who had breast screening recommended to them, only 19.7% had an actual CBE. Of these, only 6% had it in the last year. The majority of women (65.4%) were willing to have regular CBEs and did not care about the sex of the examiner in most instances. Lack of perceived need was the reason cited by women unwilling to participate.

Conclusion

The majority of women were aware of breast cancer and knew it as a fatal disease. With the relatively encouraging number of those willing to be examined, a carefully designed CBE program coupled with advocacy to correct uneducated beliefs seems promising.

The ripple effect: why promoting female leadership in global health matters

Leadership positions in global health are greatly skewed toward men; the imbalance is more pronounced in low- and middle-income countries (LMICs). The under-representation of women in leadership is a threat to gender equality, and also impacts the improvement of women's health outcomes globally. In this perspectives piece, we assert that the promotion and retention of women in global health leadership has a ripple effect that can achieve improvement in global health outcomes. We present pragmatic, actionable solutions to promote and retain female global health leaders in this field.

Experiences of patients undergoing dialysis who are from ethnic and racial minorities

BACKGROUND

Approximately 500,000 people in the United States are affected by end-stage kidney disease (ESKD), 53% of whom are Black or Latino. ESKD significantly impacts psychosocial health and quality of life. However, few studies address the psychosocial aspects of ESKD, especially among black and Latino adults. This study sought to understand the psychosocial context of living with ESKD among black and Latino adults who reside in a medically underserved community.

STUDY DESIGN

A qualitative study.

SETTING AND PARTICIPANTS

Participants were recruited from a dialysis centre in East New York, Brooklyn, a medically underserved community.

METHODOLOGY

Descriptive phenomenology was used as a qualitative approach for capturing the experiences of patients who received dialysis in this community.

ANALYTICAL APPROACH

Open-ended interviews were audio-taped, transcribed, coded and analysed using standard qualitative techniques.

RESULTS

Data saturation was achieved at 36 participants. The following five themes emerged: the transition to dialysis is abrupt and unexpected; denial is often an initial response; dialysis is the new normal and in order to survive one must forget the past and press forward; dialysis changes everything and impacts the entire family; strength was often found in faith and family.

LIMITATIONS

This study was conducted in one setting and may need to be expanded to other sites to capture the experiences of patients cared for in other settings.

CONCLUSION

These findings have practical implications for informing patient-centered models of care that are more responsive to the psychosocial needs of patients with ESKD living in medically underserved communities.

Community Perspectives in Medicine: Elective for First-Year Medical Students

INTRODUCTION

Recently, stories depicting social injustices and inequities have gripped the US, leading to protests and other demonstrations of student activism. In response to current events, students at Weill Cornell Medical College identified the need for more diversity inclusion components in the newly developed medical school curriculum. Thus, we developed a student-initiated, student-run elective, Community Perspectives in Medicine, which provides a forum for first-year medical students to interact, and have open discussions, with members of communities most impacted by social and health inequities.

METHODS

During five weekly 2-hour sessions, representatives of different community-based organizations (CBOs) speak with 15 first-year medical students. Invited CBOs represent diverse populations, including LGBT, chronic illness, disabilities, religion, and immigrant health. For each session's first hour, a second-year student facilitates a semistructured interview of the CBO guests focusing on health disparities within their community, challenges experienced with the medical system, and what they wish doctors did differently. Students are encouraged to ask questions, often resulting in a rich dialogue. The session's second part is a debriefing by the student facilitator over a relaxed dinner (without CBO guests).

RESULTS

Fourteen of the16 enrolled students attended all five sessions and completed the course evaluation. Satisfaction with the course was high, as 93% of students enrolled rated the course as excellent. The course format, content, and diversity of speakers were rated as excellent by 79%, 86%, and 93%, respectively. Similarly, 71% of students believed there to be excellent applicability to medical practice, and 100% of students thought the timing during first year was excellent.

DISCUSSION

We emphasize the importance of a partnership between CBOs and medical students, thus increasing students' cultural awareness as well as formally involving traditionally disenfranchised communities in medical education. Our project's unique format of safe-space discussion forums and session debriefings enhances critical thinking. Though used with multiple CBOs as an elective, our model can be easily adapted for one session on a specific health disparity.

A qualitative study of factors underlying decision making for joint replacement among African Americans and Latinos with osteoarthritis

To support patients in making decisions that align with their unique cultural beliefs, an understanding of factors underlying patient preferences is needed. We sought to identify psychosocial factors that influenced decision making among African-American and Hispanic patients referred for knee or hip arthroplasty. Thirty-six participants deciding on surgery were interviewed. Responses were audio-taped, transcribed, and read. Codes were assigned to the raw data and then clustered into categories that were analyzed to yield overarching themes. This process was repeated independently by two corroborators. Six categories described the mental calculations made in patients' decision-making processes: 1) self-assessment of fit for surgery based on age and comorbidity, 2) research and development of mental report cards of their surgeons, 3) reliving of social network experiences, 4) reliance on faith and spirituality for guidance, 5) acknowledgment of fear and anxiety, and 6) setting expectations for recovery. This study advanced the understanding of how decisions about joint replacement are constructed and identified cultural levers that can be targeted for intervention. Developing culturally tailored health information that addresses some of our findings and disseminating messages through social networks may reduce the underutilization of joint replacement among racial and ethnic minority populations.

Racial and Ethnic Disparities in Utilization Rate, Hospital Volume, and Perioperative Outcomes After Total Knee Arthroplasty

BACKGROUND

Previous studies of racial disparities in total joint replacement, particularly total knee arthroplasty, in the U.S. have predominantly focused on disparities between blacks and whites and were limited to Medicare patients or veterans, populations that are not representative of the entire U.S.

POPULATION

We sought to study racial disparities in the utilization of total knee arthroplasty, the use of high-volume hospitals, and total knee arthroplasty outcomes, including mortality and complications, using all-payer databases.

METHODS

We analyzed data from 8 years and 8 racially diverse states in the State Inpatient Databases (SID). Patient race was categorized according to the SID as white, black, Hispanic, Asian, Native American, and mixed race. Both crude and adjusted racial and/or ethnic disparities were evaluated.

RESULTS

In comparison with whites (4.65 per 1000 population per year), black (3.90), Hispanic (3.71), Asian (3.89), Native American (4.40), and mixed-race (3.69) populations had lower rates of total knee arthroplasty utilization (p < 0.0001). After risk adjustment, the rate of total knee arthroplasty utilization was significantly lower for blacks (odds ratio [OR] = 0.87 [95% confidence interval (CI), 0.85 to 0.89]; p < 0.0001), Hispanics (OR = 0.76 [95% CI, 0.68 to 0.83]; p < 0.0001), Asians (OR = 0.83 [95% CI, 0.78 to 0.89]; p < 0.0001), Native Americans (OR = 0.87 [95% CI, 0.81 to 0.93]; p < 0.0001), and mixed race (OR = 0.84 [95% CI, 0.79 to 0.90]; p < 0.0001) compared with the rate for whites. Lower rates of total knee arthroplasty utilization for blacks, Hispanics, and mixed-race groups became worse over the years. Patients from minority groups were less likely to undergo total knee arthroplasty in high-volume hospitals than were whites. Moreover, the rates of mortality were significantly higher for blacks (OR = 1.52 [95% CI, 1.17 to 1.97]; p = 0.0017), Native Americans (OR = 6.52 [95% CI, 4.63 to 9.17]; p < 0.0001), and mixed-race patients (OR = 4.35 [95% CI, 3.24 to 5.84]; p < 0.0001). Blacks (OR = 1.08 [95% CI, 1.01 to 1.15]; p = 0.01) and mixed-race patients (OR = 1.17 [95% CI, 1.001 to 1.36]; p = 0.04) had higher rates of complications than whites.

CONCLUSIONS

Minorities had lower rates of total knee arthroplasty utilization but higher rates of adverse health outcomes associated with the procedure, even after adjusting for patient-related and health-care system-related characteristics. Utilization rates were based on overall population as the proportion of the population with osteoarthritis requiring arthroplasty is unknown. Future studies that consider specific patient-level information with psychosocial and behavioral factors are needed.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

"It's Like Backing up Science with Scripture": Lessons Learned from the Implementation of HeartSmarts, a Faith-Based Cardiovascular Disease Health Education Program

African-Americans are disproportionately impacted by cardiovascular disease (CVD). Faith-based institutions provide a non-traditional route for health education targeted at African-Americans. This paper describes HeartSmarts, a faith-based CVD education program. Evidence-based literature was used to develop a curriculum, which was tailored by integrating biblical scripture representing aspects of health behaviors. Eighteen church peer-educators were recruited to participate in a 12-week training. They then disseminated the faith-based curriculum to members of their congregations. There were 199 participants of which 137 provided feedback via open-ended surveys indicating that HeartSmarts was well accepted and effective for disseminating CVD health messages while engaging spirituality.

Demographic and Behavioral Factors Linked to Obesity Among Inner-City Latino New Yorkers in the Bronx Community

New York City (NYC) Latinos are disproportionately affected by obesity. However, little information is available on demographic and behavioral factors linked to body mass index (BMI) in this population. A community-based survey was conducted in the inner-city Bronx community of NYC to evaluate these factors among Latino New Yorkers. 738 Latinos completed the survey. 241 (32.7 %) participants were obese (BMI > 30 kg/m(2)) and 302 (41 %) individuals were overweight (BMI 25-30 kg/m(2)). Adjusted regression analyses show that Latinos who are overweight or obese were found at greater odds of being men, residing in the US for >10 years, in early stages 1-3 of change of physical activity behavior, and at lower odds of being young adults aged <35 years or with college education. Analysis of factors associated stages of change (SOC) revealed that subjects in these preliminary SOC related to physical activity were at greater odds of speaking Spanish alone, in the same SOC with respect to diet, and at lower odds of living >10 years in the US. With respect to diet, subjects in preliminary stages were at greater odds of being young adults <35 years of age or in early SOC of physical activity and at lower odds of low income <20  dollars per year. The survey shows that Latino New-Yorkers in the Bronx with high prevalence of overweight status and obesity have unique demographic, socio-economic, behavioral and cultural factors that can be linked to excessive body weight.

Abstract 262: The Predictive Ability of a 30-Day Heart Failure Readmission Model Improves with Multi-level Analysis

Background: Although readmission occurs following 25% of heart failure hospitalizations, identifying patients at greatest risk has been challenging. To date, prediction models have offered only modest discriminatory power (C-Statistic: 0.58-0.65). Their limitations underscore the need for novel approaches to risk prediction.

Hypothesis: Multi-level analysis and the inclusion of population-level factors will improve the predictive ability of our 30-day HF readmission model.

Methods: We studied patients with a principal diagnosis of HF who were discharged home from an academic hospital in 2013-2014. Index hospitalizations and 30-day readmissions were identified by query of the electronic medical record. Variables of analysis included demographics, HF characteristics, comorbidities, echocardiographic (echo) parameters and clinical indices. Heart failure with preserved ejection fraction (HFpEF) was defined as LVEF ≥ 50 on echo. Conventional logistic regression models were first used to examine the association between patient characteristics and 30-day readmissions. Next, multi-level modeling was used wherein hierarchical clustering techniques identified key drivers of readmission. The final predictive model incorporated these findings.

Results: Of the 821 patients admitted with HF, 242 (29.5%) were readmitted within 30 days. HFpEF (p = .008), LVEF (p= .03) and NYHA classification (p=.002) were associated with early readmission, as were end stage renal disease (p=.04) and gastrointestinal bleeding (p =.02). In addition, serum sodium (p =.02), creatinine (p =.03) and hemoglobin (p =.002) were also associated with readmission. The initial multivariable logistic regression model based on patient characteristics was significant (p=.01) with 66% convergence. This model found ventricular tachycardia (VT) (OR = 3.47 CI 1.49-8.08) and HFpEF (OR =1.49 CI 1.01-2.22) to be associated with readmission. As expected, NYHA Class II (OR = 0.28 CI 0.09-0.834) and Hemoglobin (OR = 0.89 CI 0.80-0.98) were inversely associated with readmission. Multi-level analysis revealed that beyond the characteristics of the individuals alone, patients with HFpEF represented a significant sub-population that was driving readmissions. The final model incorporated this nested sub-group and was found to have an improved convergence of 73% (p =.02). In this model, the association of HFpEF and readmission increased in magnitude (OR = 3.43 CI 1.39-8.45), whereas factors including VT, NYHA Class II, and hemoglobin were no longer significant.

Conclusion: Multi-level analysis increased the predictive ability of our 30-day HF readmission model (c stat 0.66 to 0.73) by accounting for both individual and population-level characteristics. HFpEF emerged as a key driver of readmission and its inclusion in the model led to a more accurate and clinically meaningful tool for our clinicians and medical center.

Results from the Trial Using Motivational Interviewing, Positive Affect, and Self-Affirmation in African Americans with Hypertension (TRIUMPH)

OBJECTIVE

Our objective was to determine the effectiveness of combining positive affect and self-affirmation strategies with motivational interviewing in achieving blood pressure control among hypertensive African Americans (AA) compared with AA hypertensives in an education-only control group.

DESIGN

Randomized trial.

SETTING

Ambulatory practices in the South Bronx and Harlem, New York City.

PARTICIPANTS

African American adults with uncontrolled hypertension.

INTERVENTIONS

Participants were randomized to a positive affect and self-affirmation intervention or an education control group. The positive affect and self-affirmation intervention involved having participants think about things that made them happy and that reminded them of their core values on a daily basis. These strategies were reinforced every two months through motivational interviewing. The control arm received a workbook of strategies on blood pressure control. All participants were called every two months for one year.

MAIN OUTCOMES

Blood pressure control rate.

RESULTS

A total of 238 participants were randomized. The average age was 56 ± 11 years, approximately 70% were female, 80% were not married, and up to 70% had completed high school. There was no difference in control rates between the intervention and the control group. However, at one year, female participants were more likely to be controlled. Participants with high depressive symptoms or high perceived stress at baseline were less likely to be controlled.

CONCLUSIONS

While this study did not demonstrate an intervention effect, it does provide important insight into the psychosocial factors that may underlie blood pressure control in African Americans. Implications for future behavioral intervention trials are discussed.

Do patient race and sex change surgeon recommendations for TKA?

BACKGROUND

Prior investigations have suggested that physician-related factors may contribute to differential use of TKA among women and ethnic minorities. We sought to evaluate the effect of surgeon bias on recommendations for TKA.

QUESTIONS/PURPOSE

Using an experimental approach with standardized patient scenarios, we sought to evaluate surgeon recommendations regarding TKA, specifically to determine whether recommendations for TKA are influenced by (1) patient race, and (2) patient sex.

METHODS

We developed four computerized scenarios for all combinations of race (white or black) and sex (male or female) for otherwise similar patients with end-stage knee osteoarthritis. Patients gave an orthopaedic history of 2 years worsening pain with decreased functional status and failure of oral antiinflammatory medications and corticosteroid intraarticular injections. Orthopaedic surgeons attending the 2012 annual meetings of the New York State Society of Orthopaedic Surgeons and American Association of Hip and Knee Surgeons were recruited for the study. Surgeons passing an open recruitment table at each meeting were asked to participate. Of the 1111 surgeons in attendance at either meeting, 113 (10.2%) participated in the study. All participants viewed the "control" patient's story (white male) and were randomized to view one of the three "experimental" scenarios (white female, black male, black female). After viewing each scenario, the participants were anonymously asked whether they would recommend TKA. An a priori power analysis showed that 112 participants were needed to detect a 15% difference in the likelihood of recommending surgery for white versus nonwhite patients in the test scenarios evaluated with 90% power at a level of significance of 0.05.

RESULTS

Of the 39 surgeons who viewed the white male plus black female scenario, there were 33 (85%) concordant responses (TKA offered to both patients) and six discordant responses (TKA offered to only one of the patients), with no effect of patient race and sex (p = 0.99). Of the 37 surgeons who viewed the white male plus black male scenario, there were 33 (89%) concordant responses and four discordant responses, with no effect of patient race (p = 0.32). Of the 37 surgeons who viewed the white male plus white female scenario, there were 30 (77%) concordant responses and seven discordant responses, with no effect of patient sex (p = 0.71).

CONCLUSION

After orthopaedic surgeons viewed video scenarios of patients with end-stage knee osteoarthritis, patient race and sex were not associated with a different likelihood of a surgical recommendation. Our findings support the notion that patient race and sex may be less influential on decision making when there are strong clinical data to support a decision. Physician bias may have a greater effect on decision making in situations where the indications for surgery are less clear.

"Looking out for each other": a qualitative study on the role of social network interactions in asthma management among adult Latino patients presenting to an emergency department

OBJECTIVE

The objective of this study was to identify the types of interactions between asthma patients and their social networks such as close family and friends that influence the management of asthma.

METHODS

Participants were Latino adults presenting for a repeat visit to the emergency department for asthma treatment. Qualitative interviews were conducted with 76 participants. They were asked to describe the experiences of their social networks that have asthma and how interactions with these individuals influenced their own asthma management. Responses were transcribed and analyzed using Grounded Theory as a qualitative analytic approach. Responses were assigned codes; similar codes were grouped into concepts and then categorized to form overarching themes.

RESULTS

Four themes emerged: (1) Perceptions of severity of asthma may be based on the experiences of social networks; (2) Economic factors may contribute to the sharing and borrowing of asthma medications between patients and their social networks; (3) Economic factors may contribute to using home remedies instead of prescribed medications; (4) Social network members may be unaware of the factors that trigger asthma and therefore, contribute to asthma exacerbations.

CONCLUSION

This study identified important social network interactions that may impact asthma management in Latino adults. These results can be used to broaden the current focus of asthma self-management programs to incorporate discussions on the role of social networks. A focus on social network interactions addresses the social epidemiology of asthma and advances our understanding of root causes that may underlie the high prevalence of asthma in many Latino communities.

Characteristics of asthmatic patients with and without repeat emergency department visits at an inner city hospital

Abstract Objective: The objective of this study was to document the frequency and clinical characteristics associated with repeat emergency department (ED) visits for asthma in an inner city population with a high burden of asthma.

METHODS

During an ED visit for asthma in an inner city hospital ('index visit'), patients completed a valid survey addressing disease and behavioral factors. Hospital records were reviewed for information about ED visits and hospitalizations for asthma during the 12 months before and the 90 days after the index visit.

RESULTS

One hundred and ninety-two patients were enrolled; the mean age was 42 years, 69% were women, 36% were black, 54% were Latino, 69% had Medicaid, and 17% were uninsured. 100 patients (52%) were treated and released from the ED, 88 patients (46%) were hospitalized, and 4 patients (2%) left against medical advice. During the subsequent 90 days, 64 patients (33%) had at least one repeat ED visit for asthma and 27 (14%) were hospitalized for asthma. In a multivariate model, more past ED visits (OR 1.7, 95% CI 1.4, 2.1; p < 0.0001) and male gender (OR 2.5, 95% CI 1.2, 5.4; p = 0.02) remained associated with having a repeat ED visit. Most patients had the first repeat ED visit within 30 days and 18 returned within only 7 days. Among all patients with a repeat visit, those who were not hospitalized for the index visit were more likely to have a repeat visit within 7 days (37%) compared to those who were hospitalized (17%) (p = 0.05 in multivariate analysis).

CONCLUSIONS

Repeat ED visits were prevalent among inner city asthma patients and most occurred shortly after the index visit. The strongest predictors of repeat visits were male gender and more ED visits in the 12 months before the index visit.

Telephone-delivered behavioral intervention among blacks with sleep apnea and metabolic syndrome: study protocol for a randomized controlled trial

Background

Lack of adherence to recommended treatment for obstructive sleep apnea remains an ongoing public health challenge. Despite evidence that continuous positive airway pressure (CPAP) is effective and improves overall quality of life, adherence with the use of CPAP in certain racial/ethnic groups, especially blacks, is suboptimal. Evidence indicates that the incidence and prevalence of obstructive sleep apnea are higher among blacks, relative to whites, and blacks are less likely to adhere to recommended treatment compared with other racial/ethnic groups.

Methods

Using a two-arm randomized controlled design, this study will evaluate the effectiveness of a culturally and linguistically tailored telephone-delivered intervention to promote adherence to physician-recommended sleep apnea assessment and treatment among blacks with metabolic syndrome, versus an attention-control arm. The intervention is designed to foster adherence to recommended sleep apnea care using the stages-of-change model. The intervention will be delivered entirely over the telephone. Participants in the intervention arm will receive 10 phone calls to address challenges and barriers to recommended care. Outcomes will be assessed at baseline, and at 6- and 12-months post-randomization.

Discussion

This tailored behavioral intervention will improve adherence to sleep apnea assessment and treatment among blacks with metabolic syndrome. We expect to demonstrate that this intervention modality is feasible in terms of time and cost and can be replicated in populations with similar racial/ethnic backgrounds.

Trial registration

The study is registered at clinicaltrials.gov NCT01946659 (February 2013)

"I am proud of myself, just the way I am" (Mwen fyé de tét mwen, jan mwen ye ya): a qualitative study among young Haitian women seeking care for sexually transmitted infections (STIs) in Haiti

Haitian women are twice as likely as men to have HIV/AIDs. Factors underlying the feminization of HIV are complex. Self-esteem is an important correlate of sexual behavior. However, its meaning and impact on health behaviors may be influenced by cultural factors. This qualitative study took place in Haiti 4 months after the 2010 earthquake and examines the meaning of self-esteem among young Haitian women seeking treatment for a recurrent sexually transmitted infection (STI). The meaning of self-esteem was derived from a sense of gratitude and was rooted in their ability to provide for family. This may have led to behaviors such as not using condoms or having sex with partners in concurrent relationships. This article highlights the resilience and resourcefulness of Haitian women, provides insight into how women with apparent positive self-images were led to make choices that placed them at high risk for contracting HIV, and concludes with recommendations for future interventions.

Mediators and moderators of behavior change in patients with chronic cardiopulmonary disease: the impact of positive affect and self-affirmation

Among patients with chronic cardiopulmonary disease, increasing healthy behaviors improves outcomes, but such behavior changes are difficult for patients to make and sustain over time. This study aims to demonstrate how positive affect and self-affirmation improve health behaviors compared with a patient education control group. The patient education (PE control) patients completed a behavioral contract, promising to increase their physical activity or their medication adherence and received an educational guide. In addition to the contract and guide, the positive affect/self-affirmation intervention (PA intervention) patients also learned to use positive affect and self-affirmation to facilitate behavior change. Follow-up was identical. In 756 patients, enrolled in three randomized trials, the PA intervention resulted in increased positive affect and more success in behavior change than the PE control (p < .01). Behavior-specific self-efficacy also predicted success (p < .01). Induction of positive affect played a critical role in buffering against the adverse behavioral consequences of stress. Patients who experienced either negative psychosocial changes (p < .05) or interval negative life events (p < .05) fared better with the PA intervention than without it. The PA intervention increased self-efficacy and promoted success in behavior change by buffering stress.

"Es como uno bomba de tiempo [It's like a time bomb]": A Qualitative Analysis of Perceptions of Diabetes Among First-Degree Relatives of Latino Patients With Diabetes

Background. The South Bronx, a largely Latino community, has become an epicenter of the diabetes epidemic in New York City. In this community, nondiabetic first-degree relatives of people with diabetes are prime targets for intervention. Therefore, the objective of this study was to explore the knowledge of diabetes and attitudes toward health behavior modification of Latino adults who are first-degree relatives of people with diabetes. Methods. Participants were recruited from three settings in the South Bronx (a community-based organization, a faith-based organization, and a taxi station). The Common Sense Model was used to develop focus-group items. This model provides a framework for exploring illness representations along five domains: identity, cause, consequences, timeline, and perceptions of curability. Responses were transcribed verbatim, and data analysis proceeded in the following order: data immersion, assignment of codes, grouping of key concepts to form categories, and construction of higher-order themes. Results. Of the 115 potential participants identified, 53 were found to be eligible, and 23 of these participated in the focus group. Of these, 20 were Dominicans, 2 were Puerto Ricans, and 1 was Salvadorian. The mean age was 46.39 years, 35% were women, 61% were married, and 26% had less than a high school education. Qualitative analyses resulted in 547 codes that were grouped into 52 concepts, from which 9 categories and 4 overarching themes emerged. The dominant themes were 1) family, genetics, and culture play a major role in the etiology of diabetes; 2) being Latino and having a first-degree relative with diabetes makes getting diabetes inevitable, and, like a time bomb exploding, it is destined to happen; 3) once one develops diabetes, the physical and emotional consequences are devastating and destructive; and 4) diabetes can be "cured" through healthy eating and with insulin. Conclusions.In this study, first-degree relatives of patients with diabetes were knowledgeable about the risks and consequences of diabetes. However, some participants felt that being Latino and having a first-degree relative with diabetes made one destined to have diabetes. Addressing this misperception through culturally tailored interventions has implications for diabetes prevention and may help to stem the diabetes epidemic in Latino communities.

Excessive daytime sleepiness and adherence to antihypertensive medications among Blacks: analysis of the counseling African Americans to control hypertension (CAATCH) trial

BACKGROUND

Excessive daytime sleepiness (EDS) often occurs as a result of insufficient sleep, sleep apnea, illicit substance use, and other medical and psychiatric conditions. This study tested the hypothesis that blacks exhibiting EDS would have poorer self-reported adherence to hypertensive medication using cross-sectional data from the Counseling African-Americans to Control Hypertension (CAATCH) trial.

METHODS

A total of 1,058 hypertensive blacks (average age 57±12 years) participated in CAATCH, a randomized controlled trial evaluating the effectiveness of a multilevel intervention for participants who receive care from community health centers in New York City. Data analyzed in this study included baseline sociodemographics, medical history, EDS, and medication adherence. We used the Epworth Sleepiness Scale, with a cutoff score of ≥10, to define EDS. Medication adherence was measured using an abbreviated Morisky Medication Adherence scale, with a score >0 indicating nonadherence.

RESULTS

Of the sample, 71% were female, 72% received at least a high school education, 51% reported a history of smoking, and 33% had a history of alcohol consumption. Overall, 27% of the participants exhibited EDS, and 44% of those who exhibited EDS were classified as adherent to prescribed antihypertensive medications. Multivariable logistic regression analysis, adjusting for effects of age, body mass index, sex, education, and smoking and drinking history indicated that participants who exhibited EDS were more than twice as likely to be nonadherent (odds ratio 2.28, 95% confidence interval 1.42-3.67, P<0.001).

CONCLUSION

Analysis of the CAATCH data showed a high prevalence of EDS among hypertensive blacks. EDS is a significant predictor of nonadherence to prescribed medications for hypertension. These findings point to a modifiable variable that can be targeted in future interventions focusing on medication adherence.

Incorporating the principles of the patient-centered medical home into a student-run free clinic

As the health care delivery landscape changes, medical schools must develop creative strategies for preparing future physicians to provide quality care in this new environment. Despite the growing prominence of the patient-centered medical home (PCMH) as an effective model for health care delivery, few medical schools have integrated formal education on the PCMH into their curricula. Incorporating the PCMH model into medical school curricula is important to ensure that students have a comprehensive understanding of the different models of health care delivery and can operate effectively as physicians. The authors provide a detailed description of the process by which the Weill Cornell Community Clinic (WCCC), a student-run free clinic, has integrated PCMH principles into a service-learning initiative. The authors assessed patient demographics, diagnoses, and satisfaction along with student satisfaction. During the year after a PCMH model was adopted, 112 students and 19 licensed physicians volunteered their time. A review of the 174 patients seen from July 2011 to June 2012 found that the most common medical reasons for visits included management of hypertension, hyperlipidemia, diabetes, gastrointestinal conditions, arthritis, anxiety, and depression. During the year after the adoption of the PCMH model, 87% were very or extremely satisfied with their care, and 96% of the patients would recommend the WCCC to others. Students who participate in the WCCC gain hands-on experience in coordinating care, providing continuity of care, addressing issues of accessibility, and developing quality and safety metrics. The WCCC experience provides an integrative model that links service-learning with education on health care delivery in a primary care setting. The authors propose that adoption of this approach by other student-run clinics provides a substantial opportunity to improve medical education nationwide and better prepare future physicians to practice within this new model of health care delivery.

Knowledge of the health consequences of obesity among overweight/obese Black and Hispanic adults

OBJECTIVE

To measure knowledge of the health consequences of obesity among overweight/obese Black and Hispanic adults and examine the relationship to prior weight loss.

METHODS

Knowledge of the health consequences of obesity was assessed among 410 Black and Hispanic adults with BMI ≥ 25 kg/m2 enrolled in a behavior change weight loss study. The relationship between obesity risk knowledge and previous weight loss was also examined.

RESULTS

The majority of participants were knowledgeable of the risk of hypertension (94%), diabetes (96%), high cholesterol (91%), joint pains/arthritis (89%) and sleep apnea (89%) associated with obesity. Among post-menopausal age women, 53% were aware of the increased risk of breast cancer. There was no significant relationship between obesity risk knowledge and previous weight loss of 10 pounds or more (OR = 1.075, 95% CI: [0.808, 1.430]).

CONCLUSIONS

We found that knowledge of the health consequences of obesity was high, except for knowledge of the risk of breast cancer. Obesity risk knowledge was not associated with past weight loss.

PRACTICE IMPLICATIONS

Further health education is needed regarding the increased risk of breast cancer associated with obesity. Our data suggest that knowledge of the health consequences of obesity is not associated with weight loss success.

Ethical considerations for conducting health disparities research in community health centers: a social-ecological perspective

Community health centers (CHCs) provide optimal research settings. They serve a high-risk, medically underserved population in the greatest need of intervention. Low socioeconomic status renders this population particularly vulnerable to research misconduct. Traditional principles of research ethics are often applied to participants only. The social-ecological model offers a comprehensive framework for applying these principles across multiple levels (participants, providers, organizations, communities, and policy). Our experience with the Trial Using Motivational Interviewing, Positive Affect and Self-Affirmation in African-Americans with Hypertension, a randomized trial conducted in CHCs, led us to propose a new platform for discussing research ethics; examine the social, community, and political factors surrounding research conducted in CHCs; and recommend how future research should be conducted in such settings.

A novel community-based study to address disparities in hypertension and colorectal cancer: a study protocol for a randomized control trial

BACKGROUND

Black men have the greatest burden of premature death and disability from hypertension (HTN) in the United States, and the highest incidence and mortality from colorectal cancer (CRC). While several clinical trials have reported beneficial effects of lifestyle changes on blood pressure (BP) reduction, and improved CRC screening with patient navigation (PN), the effectiveness of these approaches in community-based settings remains understudied, particularly among Black men.

METHODS/DESIGN

MISTER B is a two-parallel-arm randomized controlled trial that will compare the effect of a motivational interviewing tailored lifestyle intervention (MINT) versus a culturally targeted PN intervention on improvement of BP and CRC screening among black men aged ≥50 with uncontrolled HTN who are eligible for CRC screening. Approximately 480 self-identified black men will be randomly assigned to one of the two study conditions. This innovative research design allows each intervention to serve as the control for the other. Specifically, the MINT arm is the control condition for the PN arm, and vice-versa. This novel, simultaneous testing of two community-based interventions in a randomized fashion is an economical and yet rigorous strategy that also enhances the acceptability of the project. Participants will be recruited during scheduled screening events at barbershops in New York City. Trained research assistants will conduct the lifestyle intervention, while trained community health workers will deliver the PN intervention. The primary outcomes will be 1) within-patient change in systolic and diastolic BP from baseline to six months and 2) CRC screening rates at six months.

DISCUSSION

This innovative study will provide a unique opportunity to test two interventions for two health disparities simultaneously in community-based settings. Our study is one of the first to test culturally targeted patient navigation for CRC screening among black men in barbershops. Thus, our study has the potential to improve the reach of hypertension control and cancer prevention efforts within a high-risk population that is under-represented in primary care settings.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01092078.

Attitudes and beliefs regarding cardiovascular risk factors among Bangladeshi immigrants in the US

The US has increasingly growing Bangladeshi population, a South Asian sub-ethnic group with a high prevalence of cardiovascular disease (CVD). We conducted a qualitative study using individual in-depth interviews to explore attitudes towards and difficulties with modifying CVD related behaviors among a Bangladeshi cohort. We interviewed 55 patients before reaching data saturation. Bangladeshis discussed the meaning of health and heart disease in the context of how disease can potentially impact their ability to care for their family. Behavioral and psychological factors were discussed as the causes of CVD. Internal forces and external forces were brought up to explain difficulties addressing the causes of CVD. Bangladeshi individuals in our study were aware of CVD, but felt unable to address behavioral risk factors. They cite a combination of internal and external factors as barriers to lifestyle modification. Interventions to address these barriers must simultaneously addressing self-efficacy and work-life balance.

The Trial Using Motivational Interviewing and Positive Affect and Self-Affirmation in African-Americans with Hypertension (TRIUMPH): from theory to clinical trial implementation

This paper describes the application of a translational research model in developing The Trial Using Motivational Interviewing and Positive Affect and Self-Affirmation in African-Americans with Hypertension (TRIUMPH), a theoretically-based, randomized controlled trial. TRIUMPH targets blood pressure control among African-Americans with hypertension in a community health center and public hospital setting. TRIUMPH applies positive affect, self-affirmation, and motivational interviewing as strategies to increase medication adherence and blood pressure control. A total of 220 participants were recruited in TRIUMPH and are currently being followed. This paper provides a detailed description of the theoretical framework and study design of TRIUMPH and concludes with a critical reflection of the lessons learned in the process of implementing a health behavior intervention in a community-based setting. TRIUMPH provides a model for incorporating the translational science research paradigm to conducting pragmatic behavioral trials in a real-world setting in a vulnerable population. Lessons learned through interactions with our community partners reinforce the value of community engagement in research.

Translating basic behavioral and social science research to clinical application: the EVOLVE mixed methods approach

OBJECTIVE

To describe a mixed-methods approach to develop and test a basic behavioral science-informed intervention to motivate behavior change in 3 high-risk clinical populations. Our theoretically derived intervention comprised a combination of positive affect and self-affirmation (PA/SA), which we applied to 3 clinical chronic disease populations.

METHOD

We employed a sequential mixed methods model (EVOLVE) to design and test the PA/SA intervention in order to increase physical activity in people with coronary artery disease (post-percutaneous coronary intervention [PCI]) or asthma (ASM) and to improve medication adherence in African Americans with hypertension (HTN). In an initial qualitative phase, we explored participant values and beliefs. We next pilot tested and refined the intervention and then conducted 3 randomized controlled trials with parallel study design. Participants were randomized to combined PA/SA versus an informational control and were followed bimonthly for 12 months, assessing for health behaviors and interval medical events.

RESULTS

Over 4.5 years, we enrolled 1,056 participants. Changes were sequentially made to the intervention during the qualitative and pilot phases. The 3 randomized controlled trials enrolled 242 participants who had undergone PCI, 258 with ASM, and 256 with HTN (n = 756). Overall, 45.1% of PA/SA participants versus 33.6% of informational control participants achieved successful behavior change (p = .001). In multivariate analysis, PA/SA intervention remained a significant predictor of achieving behavior change (p < .002, odds ratio = 1.66), 95% CI [1.22, 2.27], controlling for baseline negative affect, comorbidity, gender, race/ethnicity, medical events, smoking, and age.

CONCLUSIONS

The EVOLVE method is a means by which basic behavioral science research can be translated into efficacious interventions for chronic disease populations.

Knowledge, perceptions, and experiences of Dominicans with diabetes

Dominicans, one of the fastest growing Hispanic subgroups in New York City (NYC), have a high rate of diabetes. A qualitative study exploring Dominicans' knowledge, perceptions, and experiences in managing their diabetes was conducted. There were a total of 40 participants who were Spanish speaking Dominicans, 40-74 years of age, diagnosed with diabetes and NYC residents. Four focus groups were conducted in Spanish, which were recorded and then transcribed into English. Content analysis was used to analyze the text of the focus groups. Different themes emerged from the data, with apparent gaps in diabetes knowledge and of awareness of risk for diabetes complications.

A randomized controlled trial of positive-affect intervention and medication adherence in hypertensive African Americans

BACKGROUND

Poor adherence explains poor blood pressure (BP) control; however African Americans suffer worse hypertension-related outcomes.

METHODS

This randomized controlled trial evaluated whether a patient education intervention enhanced with positive-affect induction and self-affirmation (PA) was more effective than patient education (PE) alone in improving medication adherence and BP reduction among 256 hypertensive African Americans followed up in 2 primary care practices. Patients in both groups received a culturally tailored hypertension self-management workbook, a behavioral contract, and bimonthly telephone calls designed to help them overcome barriers to medication adherence. Also, patients in the PA group received small gifts and bimonthly telephone calls to help them incorporate positive thoughts into their daily routine and foster self-affirmation. The main outcome measures were medication adherence (assessed with electronic pill monitors) and within-patient change in BP from baseline to 12 months.

RESULTS

The baseline characteristics were similar in both groups: the mean BP was 137/82 mm Hg; 36% of the patients had diabetes; 11% had stroke; and 3% had chronic kidney disease. Based on the intention-to-treat principle, medication adherence at 12 months was higher in the PA group than in the PE group (42% vs 36%, respectively; P =.049). The within-group reduction in systolic BP (2.14 mm Hg vs 2.18 mm Hg; P = .98) and diastolic BP (-1.59 mm Hg vs -0.78 mm Hg; P = .45) for the PA group and PE group, respectively, was not significant.

CONCLUSIONS

A PE intervention enhanced with PA led to significantly higher medication adherence compared with PE alone in hypertensive African Americans. Future studies should assess the cost-effectiveness of integrating such interventions into primary care. Trial Registration clinicaltrials.gov Identifier: NCT00227175.

Associations between posttraumatic stress disorder and hemoglobin A1(C) in low-income minority patients with diabetes

OBJECTIVE

Posttraumatic Stress Disorder (PTSD) is prevalent among low-income minorities and is associated with poorer health. However, the association between PTSD and hemoglobin A1(C) (A1(C)) among patients with diabetes has not been fully described. The objective of this cross-sectional study was to evaluate associations between PTSD and A1(C) among low-income minorities with diabetes.

METHOD

Adults with diabetes were recruited from a network of primary care clinics. Data were obtained from surveys and electronic medical records. Lifetime PTSD symptoms were assessed using the Structured Clinical Interview-DSM-IV and depressive symptoms with the Patient Health Questionnaire-9. A1(C) was obtained from chart review.

RESULTS

Of 103 adults analyzed, 12% had lifetime full PTSD and 12% had subthreshold PTSD. On backward stepwise logistic regression, patients with any PTSD symptoms were significantly more likely to have an A1(C) >7% compared to patients without symptoms (OR(adj) 2.98, 95% CI 1.04-8.52, P=.04). An A1(C) >7% also was associated with an interaction between PTSD symptoms and longer diabetes duration (P<.05).

CONCLUSION

In this cohort of low-income minorities with diabetes, lifetime PTSD symptoms were significantly associated with an A1(C) >7%.

Shared decision-making in the primary care treatment of late-life major depression: a needed new intervention?

OBJECTIVE

We suggest that clinicians consider models of shared decision-making (SDM) for their potential ability to improve the treatment of major depression in the primary care setting and overcome limitations of collaborative care and other interventions.

METHODS

We explore the characteristics and techniques of patient-clinician SDM, with particular emphasis on this model's relevance to the unique treatment concerns of depressed older adults.

RESULTS

We describe a SDM intervention to engage older adults in depression treatment in the primary care sector.

CONCLUSIONS

It is timely to examine SDM models for elderly depressed primary care patients given their potential ability to improve treatment adherence and clinical outcomes.