1
|
Obeng-Nyarko CN, Ralston PA, Wickrama KKAS, Lemacks JL, Ilich JZ. Health for Hearts United Longitudinal Trial: Improving Perceived Stress and Allostatic Load Outcomes of Mid-Life and Older African American Women. HEALTH EDUCATION & BEHAVIOR 2024:10901981241263027. [PMID: 39051464 DOI: 10.1177/10901981241263027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Cardiovascular disease (CVD) continues to be the leading cause of death in the United States, with African Americans experiencing higher age-adjusted mortality compared to Whites. African American women in particular carry a high CVD burden due to more exposure to adverse personal and socioenvironmental challenges. Church-based interventions can improve health behaviors and health status of African Americans, yet few have addressed stress-related health. The purpose of this study was to determine the effectiveness of the 18-month Health for Hearts United intervention in relation to stress-related outcomes (perceived stress, allostatic load) of mid-life and older African American women (≥45 years of age; n = 152 overall sample, n = 65 clinical subsample). The results of the repeated measures analysis of variance (ANOVA) analyses showed overall significant decreases in perceived stress and allostatic load for both treatment and comparison groups over the measurement occasions (baseline and 18 months) with educational level remaining as a significant correlate over time. There was no significant interaction between treatment and time, yet there were trends in improvements for the treatment group compared to the comparison group. The findings demonstrate the potential of church-based interventions in reducing both self-reported stress and allostatic load in African American women, and highlight the need for further investigation of educational level and other possible factors influencing stress management in these settings.
Collapse
|
2
|
Woods-Giscombe CL, Gaylord S, Bradford A, Vines S, Eason K, Smith R, Addo-Mensah D, Lackey C, Dsouza V, Sheffield-Abdullah K, Day T, Green-Scott K, Chilcoat A, Peace-Coard A, Chalmers L, Evenson KR, Samuel-Hodge C, Lewis TT, Crandell J, Corbie G, Faurot K. Protocol of the HARMONY study: A culturally relevant, randomized-controlled, stress management intervention to reduce cardiometabolic risk in African American women. Contemp Clin Trials 2024; 146:107604. [PMID: 38866096 DOI: 10.1016/j.cct.2024.107604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 05/16/2024] [Accepted: 06/09/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND African American Women (AAW) are at high risk for stress-related cardiometabolic (CM) conditions including obesity, heart disease, and diabetes. Prior interventions lack attention to culturally-nuanced stress phenomena (Superwoman Schema [SWS], contextualized stress, and network stress), which are positively and significantly associated with unhealthy eating and sedentary behavior. PURPOSE The HARMONY Study is designed to test a culturally tailored mindfulness-based stress management intervention to address SWS, contextualized stress, and network stress as potential barriers to adherence to healthy exercise and eating goals. The study will help AAW build on their strengths to promote cardiometabolic health by enhancing positive reappraisal, self-regulation, and self-efficacy as protective factors against chronic stress-inducing biobehavioral morbidity and mortality risk. METHODS This two-arm, randomized-controlled trial will test the effects of two group-based, online interventions. HARMONY 1 includes culturally-tailored exercise and nutrition education. HARMONY 2 includes mindfulness-based stress reduction, exercise, and nutrition education. We aim to recruit 200 AAW ≥ 18 years old with CM risk. RESULTS Primary outcomes (actigraphy and carotenoid levels) and secondary outcomes (body composition, inflammatory markers, glucose metabolism, and stress) are being collected at baseline and 4-, 8-, and 12-months post-intervention. Intent-to-treat, data analytic approaches will be used to test group differences for the primary outcomes. DISCUSSION This study is the first to address culturally-nuanced stress phenomena in AAW (SWS, network stress, and contextualized stress) using culturally-tailored stress management, exercise, and nutrition educational approaches to reduce biobehavioral CM risk among AAW. Quantitative and qualitative results will inform the development of scalable and sustainable CM risk-reduction programming for AAW. TRIAL REGISTRATION The Multiple PIs registered the clinical trial (Identifier: NCT04705779) and reporting of summary results in ClinicalTrials.gov in accordance with the NIH Policy on the Dissemination of NIH-Funded Clinical Trial Information, within the required timelines.
Collapse
Affiliation(s)
- Cheryl L Woods-Giscombe
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America.
| | - Susan Gaylord
- Program for Integrated Medicine, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Andrew Bradford
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Sierra Vines
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Kelly Eason
- Physical Medicine Rehab, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Raven Smith
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Dorothy Addo-Mensah
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Charity Lackey
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Vinisha Dsouza
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Karen Sheffield-Abdullah
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Tomeka Day
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Kerri Green-Scott
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Aisha Chilcoat
- Physical Medicine Rehab, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Angela Peace-Coard
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - LaTonia Chalmers
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Kelly R Evenson
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Carmen Samuel-Hodge
- Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Tene T Lewis
- Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Jamie Crandell
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Giselle Corbie
- Department of Social Medicine, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Keturah Faurot
- Physical Medicine Rehab, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| |
Collapse
|
3
|
Horne CE, Abel WM, Crane PB. Fatigue, Stress, and Blood Pressure Medication Adherence by Race After Myocardial Infarction. J Nurse Pract 2023; 19:104757. [PMID: 37810177 PMCID: PMC10552602 DOI: 10.1016/j.nurpra.2023.104757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Fatigue and stress may affect medication adherence. This study explored fatigue, stress, and blood pressure (BP) medication adherence in Black and White adults (N= 152) who had experienced a myocardial infarction. Over half of the sample (55%) reported fatigue as moderate to severe. The regression model explained up to 40% of the variance (p < .001) with fatigue and race significantly predicting adherence. Black participants reported fatigue causing distress (r =.40), and White participants reported greater association of fatigue severity-related BP medication adherence (r =.49). Our findings support considering racial differences when evaluating fatigue associated with BP medication adherence.
Collapse
Affiliation(s)
- Carolyn E. Horne
- School of Nursing, The University of North Carolina, Charlotte, NC
| | - Willie M. Abel
- School of Nursing, The University of North Carolina, Charlotte, NC
| | | |
Collapse
|
4
|
Abel WM, Efird JT, Crane PB, Ferdinand KC. Self-management program and Black women with hypertension: Randomized controlled trial substudy. Res Nurs Health 2023; 46:336-347. [PMID: 36789452 PMCID: PMC10148903 DOI: 10.1002/nur.22301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/25/2023] [Accepted: 02/01/2023] [Indexed: 02/16/2023]
Abstract
The prevalence of hypertension (HTN) among Black women in the United States has increased over the past 10 years with a decline in levels of HTN awareness, treatment, and control. Higher death rates occur in Black women from HTN-related diseases when compared with women of other racial/ethnic groups. Although interventions aimed at self-care/self-management are vital to adults becoming the cornerstone of their own health and well-being, there is a paucity of research in Black women. This randomized controlled pilot trial substudy examined the influence of a Chronic Disease Self-Management Program (CDSMP) with tailored coaching versus the CDSMP alone on blood pressure (BP), weight, and scores on self-care questionnaires and medication adherence for Black women with HTN over 9 months. Eighty-three women who had completed the CDSMP were randomly assigned to coaching or no coaching. Median age was 54 years and the time since the HTN diagnosis was 9 years. Significant differences were noted in self-care maintenance and management over time with better self-care in the treatment group. Though not significant, both groups denoted a trend toward better medication adherence. Almost 60% of the participants in both groups showed improvements in their systolic and/or diastolic BP. However, there was no significant difference between the study groups' BP and weight variables. The CDSMP was effective in decreasing BP and improving medication adherence. Further research is needed to evaluate effective coaching strategies that motivate Black women with HTN toward self-care management.
Collapse
Affiliation(s)
- Willie M. Abel
- School of Nursing, The University of North Carolina, Charlotte, NC
| | - Jimmy T. Efird
- School of Medicine, Case Western Reserve University, Cleveland, OH
- VA Cooperative Studies Program Coordinating Center, Boston, MA; School of Medicine, Case Western Reserve University, Cleveland, OH
| | | | | |
Collapse
|
5
|
Woods SB, Hiefner AR, Udezi V, Slaughter G, Moore R, Arnold EM. 'They should walk with you': the perspectives of African Americans living with hypertension and their family members on disease self-management. ETHNICITY & HEALTH 2023; 28:373-398. [PMID: 35227154 DOI: 10.1080/13557858.2022.2040958] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVES African Americans are at significantly greater risk for hypertension, as well as worse hypertension-related morbidity and mortality than other racial/ethnic groups. Prior research aiming to address these health disparities has focused on improving individual patient self-management, with few studies testing family-centered interventions. We aimed to explore the perspectives of African Americans with hypertension and their family members on hypertension, self-management, and reciprocal family-hypertension impacts to inform future intervention design. DESIGN We conducted four dyadic focus groups (90-120 minutes) of African American adults with hypertension (i.e. patients) and their family members. We recruited patients (n = 23) and their family members (n = 23) from four African American-serving Christian churches over a period of three months (69.6% female, M age = 60.73 years). Patient-family member dyads were interviewed conjointly (groups ranged from 4 to 6 dyads, each) by facilitators using open-ended questions to elicit perspectives regarding contributors to hypertension, self-management strategies, family influence on self-management, and the impact of hypertension on the family. A grounded theory approach was used for analysis. RESULTS Participants' responses highlighted themes of societal risk factors and barriers (e.g. racism-related stress worsens blood pressure), influences of African American culture (e.g. culturally-informed diet practices), the patient-physician relationship (e.g. proactive communication is beneficial), family-level influences on health (e.g. family monitoring patients' health behaviors), and patient-level risk factors and self-management strategies (e.g. prayer to cope with stress). Themes reflected a hierarchical, nested, ecological structure such that themes within unique levels of participants' social systems affected, and were affected by, stress, change, or behavior in the other levels. CONCLUSIONS African American adults with hypertension and their family members described multilevel influences on hypertension and disease self-management, with a strong emphasis on the value of family support. Developing culturally appropriate, family-centered interventions to improve hypertension self-management will be an important next step.
Collapse
Affiliation(s)
- Sarah B Woods
- Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Angela R Hiefner
- Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Victoria Udezi
- Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Gabriele Slaughter
- Medical School, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rachel Moore
- Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | |
Collapse
|
6
|
Wang Q, Collet JP, Mei J, Chen G, Huang S, Yang Y, Wang W, Ding F. Complex interactive multimodal intervention to improve personalized stress management among healthcare workers in China: A knowledge translation protocol. Digit Health 2023; 9:20552076231184052. [PMID: 37545629 PMCID: PMC10399255 DOI: 10.1177/20552076231184052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 06/07/2023] [Indexed: 08/08/2023] Open
Abstract
Objectives Numerous stress management interventions have been implemented in the workplace, but few are adapted to the healthcare setting. Due to the nature of their jobs, healthcare workers (HCWs) may find it difficult to adopt recommended stress management strategies. We present the protocol for a 12-week personalized stress management intervention among HCWs to change their behavior as well as improve physiological/psychological outcomes. Methods It is a pragmatic quasi-experimental study involving stressed HCWs from two general hospitals in Wuhan, China. The intervention group will receive a complex interactive multimodal intervention, including advanced education via mobile connection, participation in a web-based social network, tailored feedback, and the support of a nurse coach, while the control group will engage in self-guided stress management. Results The primary outcome is centered on behavioral measures, namely improvements in stress management practice frequency after a 12-week intervention. The secondary outcomes are the changes in stress-related physiological indices (i.e. high frequency variability and normalized unit assessed by Holter) and psychological indicators (scores on the Perceived Stress Scale and Depression, Anxiety, Stress Scale) following 12 weeks of treatment. Conclusion The knowledge translation intervention builds on a body of work defining the role of individualized instruction and feedback intervention, as well as group intervention through WeChat social network and personalized coaching. We believe this novel intervention will help HCWs promote their stress management awareness and skills, and ultimately benefit their long-term health. Trial Registration ClinicalTrials.gov., NCT05239065. Registered 14 February 2022-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05239065.
Collapse
Affiliation(s)
- Quan Wang
- Department of Pharmacology, School of Basic Medical Sciences, Fudan University, Shanghai, China
- Nursing College, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jean-Paul Collet
- UBC Department of Pediatrics and Children's Hospital Research Institute, Vancouver, Canada
| | - Junhua Mei
- Department of Neurology, The First Hospital of Wuhan City, Wuhan, China
| | - Guohua Chen
- Department of Neurology, The First Hospital of Wuhan City, Wuhan, China
| | - Sufang Huang
- Nursing College, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuan Yang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fengfei Ding
- Department of Pharmacology, School of Basic Medical Sciences, Fudan University, Shanghai, China
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
7
|
Rahimi A, Nkombua L. Hypertensive patients’ knowledge and practices on lifestyle modification in Extension 6, Middelburg. S Afr Fam Pract (2004) 2022; 64:e1-e8. [PMID: 36073105 PMCID: PMC9459174 DOI: 10.4102/safp.v64i1.5528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 12/04/2022] Open
Abstract
Background Hypertension (HTN) is one of the most common chronic diseases affecting the majority of patients worldwide, including in South Africa. The control of HTN and prevention of complications are major challenges for patients and healthcare workers. The proper control of the disease requires a multifactorial approach consisting of medical treatment, as well as lifestyle modification, with the assistance of healthcare workers. Addressing patients’ beliefs, the practice of lifestyle and acceptance of change are some of the ways of aiding control. Methods The researchers used a cross-sectional and descriptive survey to establish the knowledge and practices of lifestyle modifications in patients with hypertension. A validated questionnaire was adopted. A total of 250 participants from the Extension 6 Clinic in Middelburg, Mpumalanga, constituted the study population. Results Most of the participants had borderline high blood pressure (37.2%) or uncontrolled high blood pressure (46%). The participants’ knowledge of HTN and its complications was not adequate. The study established that increased age and long duration of HTN were associated with high numbers of uncontrolled HTN. Most of the participants (88.8%) had difficulty exercising. Also, most of the participants (90.8%) did not have a place or facility for exercises. Fifty per cent of the participants were unable to maintain a balanced healthy diet which included fruits and vegetables. Conclusion The study explored the participants’ knowledge and practice of lifestyle modification. The participants lacked knowledge regarding the definition of HTN and the meaning of controlled HTN. To assist the patients and improve on the identified pitfalls, each consultation session should include some methods of education, and motivation for healthy behaviours and lifestyle modification. This should be extended to all the people visiting the health facilities for them to adopt a healthier diet, greater intake of vegetables and availability of fitness facilities for the community.
Collapse
Affiliation(s)
- Amir Rahimi
- Department of Family Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria.
| | | |
Collapse
|
8
|
Law MA, Wilbiks JMP, Roach SP, Best LA. Remember the past, plan for the future: How interactions between risk perception and behavior during the COVID-19 pandemic can inform future Canadian public health policy. Front Public Health 2022; 10:784955. [PMID: 36033823 PMCID: PMC9413218 DOI: 10.3389/fpubh.2022.784955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 07/11/2022] [Indexed: 01/21/2023] Open
Abstract
The ongoing COVID-19 pandemic necessitated the implementation of numerous temporary public health policies, including social distancing, masking, and movement limitations. These types of measures require most citizens to follow them to be effective at a population level. This study examined population adherence to emergency public health measures using early data collected in the Spring of 2020, when all Canadian jurisdictions were under relatively strict measures. In total, 1,369 participants completed an online questionnaire package to assess adherence, perceptions of government response, and perceptions of COVID-19 risk. Results indicated that most Canadians were pleased with the government's handling of the early phases of the pandemic and immediately engaged new public health mandates. Willingness to change behaviors was unrelated to satisfaction with the government response. Similarly, behavioral adherence was also unrelated to satisfaction with government, or personal risk perceptions; however, adherence to public health guidelines was related to elevated psychological distress. As the pandemic continues, public health officials must balance the mental health of the population with the physical health concerns posed by COVID-19 when applying public health mandates.
Collapse
Affiliation(s)
| | - Jonathan M. P. Wilbiks
- Department of Psychology, University of New Brunswick Saint John, Saint John, NB, Canada
| | | | | |
Collapse
|
9
|
Ford ND, Robbins CL, Hayes DK, Ko JY, Loustalot F. Prevalence, Treatment, and Control of Hypertension Among US Women of Reproductive Age by Race/Hispanic Origin. Am J Hypertens 2022; 35:723-730. [PMID: 35511899 PMCID: PMC10123529 DOI: 10.1093/ajh/hpac053] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/07/2022] [Accepted: 04/26/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND To explore the prevalence, pharmacologic treatment, and control of hypertension among US nonpregnant women of reproductive age by race/Hispanic origin to identify potential gaps in care. METHODS We pooled data from the 2011 to March 2020 (prepandemic) National Health and Nutrition Examination Survey cycles. Our analytic sample included 4,590 nonpregnant women aged 20-44 years who had at least 1 examiner-measured blood pressure (BP) value. We estimated prevalences and 95% confidence intervals (CIs) of hypertension, pharmacologic treatment, and control based on the 2003 Joint Committee on High Blood Pressure (JNC 7) and the 2017 American College of Cardiology and the American Heart Association (ACC/AHA) guidelines. We evaluated differences by race/Hispanic origin using Rao-Scott chi-square tests. RESULTS Applying ACC/AHA guidelines, hypertension prevalence ranged from 14.0% (95% CI: 12.0, 15.9) among Hispanic women to 30.9% (95% CI: 27.8, 34.0) among non-Hispanic Black women. Among women with hypertension, non-Hispanic Black women had the highest eligibility for pharmacological treatment (65.5%, 95% CI: 60.4, 70.5); current use was highest among White women (61.8%, 95% CI: 53.8, 69.9). BP control ranged from 5.2% (95% CI: 1.1, 9.3) among women of another or multiple non-Hispanic races to 18.6% (95% CI: 12.1, 25.0) among Hispanic women. CONCLUSIONS These findings highlight the importance of monitoring hypertension, pharmacologic treatment, and control by race/Hispanic origin and addressing barriers to equitable hypertension care among women of reproductive age.
Collapse
Affiliation(s)
- Nicole D Ford
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Cheryl L Robbins
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Donald K Hayes
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jean Y Ko
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,U.S. Public Health Service Commissioned Corps, Atlanta, Georgia, USA
| | - Fleetwood Loustalot
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,U.S. Public Health Service Commissioned Corps, Atlanta, Georgia, USA
| |
Collapse
|
10
|
WILDER ME, ZHENG Z, ZEGER SL, ELMI A, KATZ RJ, LI Y, MCCARTHY ML. Relationship Between Social Determinants of Health and Antihypertensive Medication Adherence in a Medicaid Cohort. Circ Cardiovasc Qual Outcomes 2022; 15:e008150. [PMID: 35098730 PMCID: PMC8847233 DOI: 10.1161/circoutcomes.121.008150] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Little is known about the relationship between social determinants of health (SDH) and medication adherence among Medicaid beneficiaries with hypertension. METHODS We conducted a posthoc subgroup analysis of 3044 adult Medicaid beneficiaries who enrolled in a parent prospective cohort study and had a diagnosis of hypertension based on their Medicaid claims during a 24-month period before study enrollment. We calculated the proportion of days covered by at least one antihypertensive medication during the first 12 months after study enrollment using the prescription claims data. We measured numerous SDH at the time of study enrollment and we categorized our hypertension cohort into 4 social risk groups based on their response profiles to the SDH variables. We compared the mean proportion of days covered by the different levels of the SDH factors. We modeled the odds of being covered by an antihypertensive medication daily throughout the follow-up period by social risk group, adjusted for age, sex, and disease severity using a generalized linear model. RESULTS The nonrandom sample was predominately Black (93%), female (62%) and had completed high school (77%). The mean proportion of days covered varied significantly by different SDH, such as food insecurity (49%-56%), length of time living at present place (47%-57%), smoking status (50%-56%), etc. Social risk group was a significant predictor of medication adherence. Participants in the 2 groups with the most social risks were 36% (adjusted odds ratio=0.64 [95% CI, 0.53-0.78]) and 20% (adjusted odds ratio=0.80 [95% CI, 0.70-0.93]) less adherent to their hypertension therapy compared with participants in the group with the fewest social risks. CONCLUSIONS Social risks are associated with lower antihypertensive medication adherence in the Medicaid population.
Collapse
Affiliation(s)
- Marcee E. WILDER
- Department of Emergency Medicine, The George Washington University, Medical Faculty Associates, Washington, DC
| | - Zhanonian ZHENG
- Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Scott L. ZEGER
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Angelo ELMI
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Richard J. KATZ
- Division of Cardiology, George Washington Heart and Vascular Institute, The George Washington University, Medical Faculty Associates, Washington, DC
| | - Yixuan LI
- Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Melissa L. MCCARTHY
- Department of Emergency Medicine, The George Washington University, Medical Faculty Associates, Washington, DC,Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC
| |
Collapse
|
11
|
Kalinowski J, Kaur K, Newsome-Garcia V, Langford A, Kalejaiye A, Vieira D, Izeogu C, Blanc J, Taylor J, Ogedegbe O, Spruill T. Stress interventions and hypertension in Black women. ACTA ACUST UNITED AC 2021; 17:17455065211009751. [PMID: 34254559 PMCID: PMC8280834 DOI: 10.1177/17455065211009751] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Hypertension is a risk factor for cardiovascular disease. Black women have high
rates of hypertension compared to women of other racial or ethnic groups and are
disproportionately affected by psychosocial stressors such as racial
discrimination, gender discrimination, and caregiving stress. Evidence suggests
that stress is associated with incident hypertension and hypertension risk.
Stress management is associated with improvements improved blood pressure
outcomes. The purpose of this review is to synthesize evidence on effects of
stress management interventions on blood pressure in Black women. A
comprehensive search of scientific databases was conducted. Inclusion criteria
included studies that were: (1) primary research that tested an intervention;
(2) in the English language; (3) included African-American women; (4)
incorporated stress in the intervention; (5) included blood pressure as an
outcome; and (6) were US based. Eighteen studies met inclusion criteria. Ten
(56%) studies tested meditation-based interventions, two (11%) tested coping and
affirmation interventions, and six (33%) tested lifestyle modification
interventions that included stress management content. Thirteen of the studies
were randomized controlled trials. Reductions in blood pressure were observed in
all of the meditation-based interventions, although the magnitude and
statistical significance varied. Comprehensive lifestyle interventions were also
efficacious for reducing blood pressure, although the relative contribution of
stress management versus behavior modification could not be evaluated. Coping
and affirmation interventions did not affect blood pressure. Most of the
reviewed studies included small numbers of Black women and did not stratify
results by race and gender, so effects remain unclear. This review highlights
the urgent need for studies specifically focusing on Black women. Given the
extensive disparities in cardiovascular disease morbidity and mortality, whether
stress management can lower blood pressure and improve primary and secondary
cardiovascular disease prevention among Black women is an important question for
future research.
Collapse
Affiliation(s)
- Jolaade Kalinowski
- Department of Human Development and Family Sciences, The University of Connecticut, Storrs, CT, USA
| | - Kiran Kaur
- Department of Population Health, School of Medicine, New York University, New York, NY, USA
| | | | - Aisha Langford
- Department of Population Health, School of Medicine, New York University, New York, NY, USA
| | | | - Dorice Vieira
- Department of Population Health, School of Medicine, New York University, New York, NY, USA
| | - Chigozirim Izeogu
- Department of Population Health, School of Medicine, New York University, New York, NY, USA
| | - Judite Blanc
- Department of Population Health, School of Medicine, New York University, New York, NY, USA
| | | | - Olugbenga Ogedegbe
- Department of Population Health, School of Medicine, New York University, New York, NY, USA
| | - Tanya Spruill
- Department of Population Health, School of Medicine, New York University, New York, NY, USA
| |
Collapse
|
12
|
Chang PS, Lu Y, Nguyen CM, Suh Y, Luciani M, Ofner S, Powell S. Effects of Qigong Exercise on Physical and Psychological Health among African Americans. West J Nurs Res 2021; 43:551-562. [PMID: 32942949 PMCID: PMC8159432 DOI: 10.1177/0193945920959067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Interventions are needed to address physical and psychological health in middle-aged and older African Americans (AAs). The purpose of this pilot study was to evaluate the feasibility and potential benefits of an eight-week Qigong exercise on physical ability and function, balance, frailty, depression and anxiety, and spiritual well-being in AAs using a single-group design. Fifteen AAs with a mean age of 64 years received Qigong exercise over 16 semi-weekly, one-hour sessions. The majority were female (93.3%) and college-level educated (53.3%). Repeat chair stands, physical function, and spiritual well-being improved significantly (p < .05) with effect sizes ranging from .45 to .87. Over 52% of participants showed improved depression scores, fast gait speed, and standing balance. Nearly 42% demonstrated some frailty improvement over baseline. No adverse events were reported. Qigong exercise potentially improves the physical ability and function, and spiritual well-being of AAs and needs further testing in a randomized clinical trial.
Collapse
Affiliation(s)
- Pei-Shiun Chang
- Indiana University School of Nursing; 1033 E. Third Street, Bloomington, Indiana 47405
| | - Yvonne Lu
- Indiana University School of Nursing; 600 Barnhill Dr, NU W407, Indianapolis, Indiana 46202
| | - Chi Mai Nguyen
- Indiana University School of Nursing; 1033 E. Third Street, Bloomington, Indiana 47405
| | - Youngnok Suh
- Indiana University School of Nursing; 1033 E. Third Street, Bloomington, Indiana 47405
| | - Mary Luciani
- Indiana University School of Nursing; 600 Barnhill Dr, NU W407, Indianapolis, Indiana 46202
| | - Susan Ofner
- Indiana University School of Medicine, Department of Biostatistics; 410 W. 10th Street, HITS 3000, Indianapolis, IN 46202
| | - Savannah Powell
- Indiana University School of Nursing; 1033 E. Third Street, Bloomington, Indiana 47405
| |
Collapse
|
13
|
Ibe CA, Haywood DR, Creighton C, Cao Y, Gabriel A, Zare H, Jones W, Yang M, Balamani M, Gaston M, Porter G, Woods DL, Gaskin DJ. Study protocol of a randomized controlled trial evaluating the Prime Time Sister Circles (PTSC) program's impact on hypertension among midlife African American women. BMC Public Health 2021; 21:610. [PMID: 33781228 PMCID: PMC8008559 DOI: 10.1186/s12889-021-10459-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Prime-Time Sister Circles® (PTSC) program is a multifaceted, community-based peer support intervention targeting African American women who are 40 to 75 years of age. It aims to reduce hypertension disparities observed among African American women by promoting adherence to antihypertensive therapies, including lifestyle modification and therapeutic regimens. METHODS The PTSC randomized controlled trial will evaluate the effectiveness of the PTSC Program on improved blood pressure control, healthcare utilization attributed to cardiovascular events, and healthcare costs. The study began in 2016 and will end in 2022. African American women who are 40-75 years old, have been diagnosed with hypertension, reside in Washington, D.C. or Baltimore, Maryland, and receive their care from Unity Health Care, a federally qualified health center in Washington, D.C., or Baltimore Medical System, a federally qualified health center in Baltimore, Maryland, are eligible to participate. Those randomized to the intervention group participate in the PTSC Program, which spans 13 weeks and comprises facilitator-led discussions, didactic training about hypertension management, and peer-based problem-solving concerning CVD risk factors and their amelioration. Blood pressure, weight, body mass index, waist circumference, self-reported adherence, physical activity, dietary practices, stress, and healthcare utilization data are collected at baseline, 13 weeks (end of the intervention), 9 months (months post-intervention), and 15 months (one year after the intervention). Healthcare costs will be computed at the end of the study. The study's design is reported in the present manuscript, wherein we employed the SPIRIT checklist to guide its construction. DISCUSSION Disparities in hypertension prevalence and management observed among mid-life African American women exist as a result of a confluence of structural determinants of health. Consequently, there is a need to develop, implement, and evaluate culturally appropriate and relevant interventions that are tailored to their lived experiences. The PTSC Trial aims to assess the impact of the program on participants' cardiovascular, psychosocial, and cost outcomes. Its results have implications for advancing the science of designing and implementing culturally relevant interventions for African American women. TRIAL REGISTRATION Unique identifier: NCT04371614 . Retrospectively registered on April 30, 2020.
Collapse
Affiliation(s)
- Chidinma A Ibe
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Johns Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Danielle R Haywood
- Johns Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Trachtenberg School of Public Policy and Administration, George Washington University, Washington, DC, USA
| | - Ciana Creighton
- Johns Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Mayor's Office of Policy, Executive Office of the Mayor, Washington, DC, USA
| | - Yidan Cao
- Johns Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Angel Gabriel
- Johns Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Howard University College of Medicine, Washington, DC, USA
| | - Hossein Zare
- Johns Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway Ste 441, Baltimore, MD, 21205, USA.,Department of Global Health Services and Administration, University of Maryland Global Campus, Adelphi, MD, USA
| | - Wehmah Jones
- American Institutes for Research, Washington, DC, USA
| | - Manshu Yang
- Department of Psychology, University of Rhode Island, Kingston, RI, USA
| | - Michele Balamani
- The Gaston & Porter Health Improvement Center, Inc., Washington, DC, USA.,Baraka and Associates, Largo, MD, USA
| | - Marilyn Gaston
- The Gaston & Porter Health Improvement Center, Inc., Washington, DC, USA
| | - Gayle Porter
- The Gaston & Porter Health Improvement Center, Inc., Washington, DC, USA
| | - Denise L Woods
- The Gaston & Porter Health Improvement Center, Inc., Washington, DC, USA
| | - Darrell J Gaskin
- Johns Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway Ste 441, Baltimore, MD, 21205, USA.
| |
Collapse
|
14
|
Gaskin DJ, Zare H, Jackson JW, Ibe C, Slocum J. Decomposing Race and Ethnic Differences in CVD Risk Factors for Mid-life Women. J Racial Ethn Health Disparities 2021; 8:174-185. [PMID: 32462612 DOI: 10.1007/s40615-020-00769-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/17/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study decomposes race and ethnic differences in hypertension, waist circumference, obesity and allostatic load between black non-Hispanic (BNH), Mexican American (MA), and white non-Hispanic (WNH) women. DATA This study uses 10,109 observations from The National Health and Nutrition Examination Survey from years 1999-2014 for BNH, MA women, and WNH between 40 and 75 years old. METHODOLOGY We used the Oaxaca-Blinder decomposition to explore how demographic, socioeconomic, healthcare access, and health behavior factors are associated with race and ethnic differences in blood pressure, waist circumference, body mass index (BMI), and allostatic load score (ALS). RESULTS We found that demographic factors, socioeconomic status, healthcare access, and health behaviors explained from 0 to 50% of the difference in CVD risk factors between BNH and WNH. However, these factors explain from 39 to 100% of the difference in CVD risk factors between MA and WNH. Differences in demographic, socioeconomic, access to care, and health behavior factor variables explained very little of the differences in CVD risk factors between NHB and MA women. CONCLUSION The impact of the determinants on CVD risk factors varies by race and ethnicity. Efforts to address differences in CVD risk factors should promote health equity programs and acknowledge that even race and ethnic groups that have similar demographic, SES, access to care, and health behavior factors can have different outcomes.
Collapse
Affiliation(s)
- Darrell J Gaskin
- Department of Health Policy and Management, Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway Suite 441, Baltimore, MD, 21205, USA.
| | - Hossein Zare
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, & Adjunct Associate Professor Global Health Services and Administration, University of Maryland Global Campus (UMGC), 624 N. Broadway Room 337, Baltimore, MD, 21205, USA
| | - John W Jackson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E6543, Baltimore, MD, 21205, USA
| | - Chidinma Ibe
- General Internal Medicine, Johns Hopkins University School of Medicine, 2024 East Monument Street, 2-514, Baltimore, MD, 21287, USA
| | - Jamar Slocum
- General Preventative Medicine Resident, Preventive Medicine Residency Program, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street Room WB602, Baltimore, MD, 21205, USA
| |
Collapse
|
15
|
Spikes T, Higgins M, Lewis T, Dunbar SB. The associations among illness perceptions, resilient coping, and medication adherence in young adult hypertensive black women. J Clin Hypertens (Greenwich) 2019; 21:1695-1704. [PMID: 31556484 PMCID: PMC6851441 DOI: 10.1111/jch.13712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/23/2019] [Accepted: 09/02/2019] [Indexed: 02/02/2023]
Abstract
Hypertension, a modifiable risk factor of cardiovascular disease, is largely responsible for the disproportionate morbidity and mortality in black women. Black women 20 years of age and older have a higher prevalence of HTN compared to white women (44% vs 28%). Poor adherence and non-adherence to hypertensive medications have been strongly indicated as a primary contributor to the early onset of disparity in cardiovascular disease morbidity and mortality experienced by black people. The purpose of this study was to examine medication adherence in black women relative to sociodemographic, clinical, cultural context, psychosocial, cognitive, and behavioral factors. This was a prospective, descriptive cross-sectional study of N = 85, hypertensive black women, with mean age of 39 ± 5.4 years, 18-45 years of age. Variables and measures included: sociodemographic characteristics, clinical, adverse social stressors, psychosocial, cognitive-behavioral factors, and medication adherence. Descriptive statistics, correlations, multivariate logistic regressions, and moderation analysis were tested. 81.2% (n = 69) of the sample was categorized as non-adherent. SBP was the only clinical covariate associated with HTN medication adherence. HTN illness perceptions, composite score, resilient coping, depressive symptoms, exposure to lifetime gender, and racial stressors, were not associated with HTN medication adherence. Using multivariate logistic regression, decreased SBP and lower scores on the "Consequence" dimension of the HTN illness perception scale were associated with medication adherence (χ2 = 10.53, P = .001). Adherence was associated with both the "Consequence" and "Identity" dimensions of the HTN illness perception scale indicating the need and importance for clinicians to have open and honest communication regarding HTN and its treatment in facilitating adherence.
Collapse
Affiliation(s)
- Telisa Spikes
- Nell Hodgson Woodruff School of NursingEmory UniversityAtlantaGeorgia
| | - Melinda Higgins
- Nell Hodgson Woodruff School of NursingEmory UniversityAtlantaGeorgia
- Rollins School of Public HealthEmory UniversityAtlantaGeorgia
| | - Tene’ Lewis
- Rollins School of Public HealthEmory UniversityAtlantaGeorgia
| | - Sandra B. Dunbar
- Nell Hodgson Woodruff School of NursingEmory UniversityAtlantaGeorgia
| |
Collapse
|
16
|
The relationship between chronic stress, hair cortisol and hypertension. INTERNATIONAL JOURNAL CARDIOLOGY HYPERTENSION 2019; 2:100012. [PMID: 33447745 PMCID: PMC7803047 DOI: 10.1016/j.ijchy.2019.100012] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 04/12/2019] [Accepted: 05/02/2019] [Indexed: 12/25/2022]
Abstract
Inconsistencies in studies of chronic psychosocial stress and hypertension may be explained by the use of stress markers greatly influenced by circadian rhythm and transient stressors. We assessed whether hair cortisol, a marker that captures systemic cortisol over months, was independently associated with hypertension. We measured hair cortisol and blood pressure in 75 consecutive participants in the Survey of the Health of Wisconsin, using an ELISA test. Individuals with values ≥ median (78.1 pg/mg) were considered exposed. We used approximate Bayesian logistic regression, with a prior odds ratio of 1.0–4.0, to quantify the multivariate-adjusted hair cortisol-hypertension association. Participants' average age was 46.9 years; 37.3% were male; and 25.3% were hypertensive. Hypertension prevalence was 2.23 times higher in exposed (95% CI: 1.69–3.03). This finding was unlikely explained by differential measurement errors, since we conducted blinded measurements of exposure and outcome. Sensitivity analyses showed the association was unlikely explained by an unmeasured confounder, survival bias, or reverse causality bias. Findings suggest elevated hair cortisol is a risk factor for hypertension. Although feasible, the clinical value of hair cortisol as a tool for hypertension risk stratification or for monitoring the effect of chronic psychosocial stress management interventions is still uncertain.
Collapse
|
17
|
Wang L, Chen P, Zheng C. Poor adherence is a contributor to viral breakthrough in patients with chronic hepatitis B. Infect Drug Resist 2018; 11:2179-2185. [PMID: 30519055 PMCID: PMC6233945 DOI: 10.2147/idr.s186719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective The objective of this study was to explore the risk factors of poor adherence of nucleoside analogs (NUC) treatment in chronic hepatitis B (CHB) patients and the virological changes in patients with poor adherence. Subjects and methods A total of 205 CHB patients were enrolled. The patients’ demographic data and family history were collected. NUC adherence was calculated every 12 weeks as follows: number of NUC tablets taken by the patients was divided by the number of NUC tablets prescribed. NUC adherence > 90% was defined as good adherence of NUC treatment. Results NUC adherence of male patients was significantly lower than that of female patients. Adherence among patients with previous NUC treatment was poorer than that of patients without previous NUC treatment. Multivariate analysis indicated that female gender (OR =0.367, P=0.013) was the protective factor for NUC adherence in CHB patients, while pretreatment with NUC was the risk factor for NUC adherence (OR =3.209, P=0.002). A total of six patients in the good adherence group experienced virological breakthroughs while 15 of 77 patients in the poor adherence group experienced virological breakthroughs (P=0.001). Similar trends were observed in NUC resistance. Four of the 128 patients with good adherence developed NUC resistance while nine of the 77 patients with poor adherence developed resistance (P=0.015). Multivariate analysis suggested that pretreatment with NUC (OR =3.133, P=0.031), NUC drugs (OR = 3.951, P=0.010), and adherence (OR =2.749, P=0.046) were independent risk factors associated with virological breakthroughs and that NUC drugs (OR =7.083, P=0.005) and poor adherence (OR =4.951, P=0.009) were independent risk factors for NUC resistance. Conclusion Male gender and pretreatment with NUC were risk factors associated with NUC adherence. Poor NUC adherence is more likely to induce virological breakthroughs and NUC resistance. For patients with poor NUC adherence, it is necessary to give timely education to improve treatment adherence.
Collapse
Affiliation(s)
- Liguo Wang
- Department of Infectious Diseases, First Affiliated Hospital of Xiamen University, Fujian Province, China
| | - Peng Chen
- Department of Emergency, Xinglin Hospital, First Affiliated Hospital of Xiamen University, Fujian Province, China
| | - Chao Zheng
- Department of Respiratory, First Affiliated Hospital of Xiamen University, Fujian Province, China,
| |
Collapse
|