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Dean YE, Motawea KR, Shebl MA, Elawady SS, Nuhu K, Abuzuaiter B, Awayda K, Fouad AM, Tanas Y, Batista R, Elsayed A, Hassan NAIF, El‐Sakka AA, Hasan W, Husain R, Lois A, Arora A, Arora A, Ayad E, Elbahaie MA, Shah J, Shady A, Chaudhuri D, Aiash H. Adherence to antihypertensives in the United States: A comparative meta-analysis of 23 million patients. J Clin Hypertens (Greenwich) 2024; 26:303-313. [PMID: 38488773 PMCID: PMC11007819 DOI: 10.1111/jch.14788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/08/2024] [Accepted: 02/11/2024] [Indexed: 04/12/2024]
Abstract
Adherence to antihypertensives is crucial for control of blood pressure. This study analyzed factors and interventions that could affect adherence to antihypertensives in the US. PubMed, Scopus, Web of Science, and Embase were searched on January 21, 2022 and December 25, 2023 for studies on the adherence to antihypertensives in the US. Nineteen studies and 23 545 747 patients were included in the analysis, which showed that adherence to antihypertensives was the highest among Whites (OR: 1.47, 95% CI 1.34-1.61 compared to African Americans). Employment status and sex were associated with insignificant differences in adherence rates. In contrast, marital status yielded a significant difference where unmarried patients demonstrated low adherence rates compared to married ones (OR: 0.8, 95% CI 0.67-0.95). On analysis of comorbidities, diabetic patients reported lower adherence to antihypertensives (OR: 0.95, 95% CI 0.92-0.97); furthermore, patients who did not have Alzheimer showed higher adherence rates. Different BMIs did not significantly affect the adherence rates. Patients without insurance reported significantly lower adherence rates than insured patients (OR: 3.93, 95% CI 3.43-4.51). Polypill users had higher adherence rates compared with the free-dose combination (OR: 1.21, 95% CI 1.2-1.21), while telepharmacy did not prove to be as effective. Lower adherence rates were seen among African Americans, uninsured, or younger patients. Accordingly, interventions such as fixed-dose combinations should be targeted at susceptible groups. Obesity and overweight did not affect the adherence to antihypertensives.
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Affiliation(s)
- Yomna E. Dean
- Faculty of MedicineAlexandria UniversityAlexandriaEgypt
| | | | | | | | | | | | | | | | - Yousef Tanas
- Faculty of MedicineAlexandria UniversityAlexandriaEgypt
| | | | - Ahmed Elsayed
- Faculty of MedicineSuez Canal UniversityIsmailiaEgypt
| | | | | | - Walaa Hasan
- Faculty of MedicineSuez Canal UniversityIsmailiaEgypt
| | | | - Amanda Lois
- Medical University of South CarolinaCharlestonUSA
| | | | | | | | | | | | - Amr Shady
- SUNY Upstate Medical UniversitySyracuseUSA
| | | | - Hani Aiash
- SUNY Upstate Medical UniversitySyracuseUSA
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Booker JM, Cabeza de Baca T, Treviño-Alvarez AM, Stinson EJ, Votruba SB, Chang DC, Engel SG, Krakoff J, Gluck ME. Dietary Adherence Is Associated with Perceived Stress, Anhedonia, and Food Insecurity Independent of Adiposity. Nutrients 2024; 16:526. [PMID: 38398850 PMCID: PMC10892668 DOI: 10.3390/nu16040526] [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: 01/11/2024] [Revised: 02/07/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
We examined whether perceived stress, anhedonia, and food insecurity were associated with dietary adherence during a 6-week intervention. Sixty participants (23 m; 53 ± 14 y) completed psychosocial measures and were provided with full meals. Individuals with obesity were randomized to a weight-maintaining energy needs (WMENs) (n = 18; BMI 33 ± 4) or a 35% calorie-reduced diet (n = 19; BMI 38 ± 9); normal-weight individuals (n = 23; BMI 23 ± 2) were assigned to a WMENs diet. Adherence scores were determined via weekly assessments and daily ecological momentary assessments (EMAs) of real-time behavior in a natural environment. Perceived stress and anhedonia were associated with % body fat (all r-values > 0.25, all p-values < 0.05), but food insecurity and adherence were not. Higher perceived stress (r = -0.31, p = 0.02), anhedonia (r = -0.34, p = 0.01), and food insecurity (r = -0.27, p = 0.04) were associated with lower adherence scores, even after adjusting for age, sex, and % body fat. In all adjusted models, % body fat was not associated with adherence. Higher measures of stress, anhedonia, and food insecurity predicted lower adherence independently of body fat, indicating that psychosocial factors are important targets for successful adherence to dietary interventions, regardless of body size.
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Affiliation(s)
- Jetaun M. Booker
- Obesity and Diabetes Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ 85016, USA; (J.M.B.); (A.M.T.-A.); (E.J.S.); (S.B.V.); (D.C.C.); (J.K.); (M.E.G.)
| | - Tomás Cabeza de Baca
- Obesity and Diabetes Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ 85016, USA; (J.M.B.); (A.M.T.-A.); (E.J.S.); (S.B.V.); (D.C.C.); (J.K.); (M.E.G.)
| | - Andrés M. Treviño-Alvarez
- Obesity and Diabetes Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ 85016, USA; (J.M.B.); (A.M.T.-A.); (E.J.S.); (S.B.V.); (D.C.C.); (J.K.); (M.E.G.)
| | - Emma J. Stinson
- Obesity and Diabetes Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ 85016, USA; (J.M.B.); (A.M.T.-A.); (E.J.S.); (S.B.V.); (D.C.C.); (J.K.); (M.E.G.)
| | - Susanne B. Votruba
- Obesity and Diabetes Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ 85016, USA; (J.M.B.); (A.M.T.-A.); (E.J.S.); (S.B.V.); (D.C.C.); (J.K.); (M.E.G.)
| | - Douglas C. Chang
- Obesity and Diabetes Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ 85016, USA; (J.M.B.); (A.M.T.-A.); (E.J.S.); (S.B.V.); (D.C.C.); (J.K.); (M.E.G.)
| | | | - Jonathan Krakoff
- Obesity and Diabetes Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ 85016, USA; (J.M.B.); (A.M.T.-A.); (E.J.S.); (S.B.V.); (D.C.C.); (J.K.); (M.E.G.)
| | - Marci E. Gluck
- Obesity and Diabetes Clinical Research Section, Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ 85016, USA; (J.M.B.); (A.M.T.-A.); (E.J.S.); (S.B.V.); (D.C.C.); (J.K.); (M.E.G.)
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Sutton AL, He J, Bottinor W, Hong S, Mitchell K, Hines AL. Examining hypertension risk among Black and White breast cancer survivors. Cancer Med 2024; 13:e6929. [PMID: 38214087 PMCID: PMC10905221 DOI: 10.1002/cam4.6929] [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: 08/16/2023] [Revised: 12/12/2023] [Accepted: 12/28/2023] [Indexed: 01/13/2024] Open
Abstract
PURPOSE Breast cancer survivors are at increased risk of cardiovascular dysfunction following their diagnosis; however, hypertension remains underexplored within this context. This retrospective cohort study examined the incidence of hypertension in breast cancer survivors and the association of race with hypertension risk among them. METHODS Data for this study were abstracted from the electronic health records of women diagnosed with Stages I-III breast cancer. Incident hypertension diagnosis was identified through International Classification of Diseases codes. Bivariate associations were tested using Student's t-test and chi-squared test of independence. Bivariable Cox regression analysis was used to determine demographic and clinical factors that may have been associated with the development of hypertension. RESULTS A total of 664 women were included. Most women were 50 years of age or younger (52.0%), White (33.0% Black), and received a mastectomy (80.6%). Overall, 45.5% of the cohort developed hypertension. The 1-year hypertension-free survival estimates were 47% (95% confidence interval [CI], 41-54) in Black women and 73% (95% CI, 69-77) in White women (p < 0.0001). Besides race, statistically significant predictors of hypertension included: age greater than 50 (vs. ≤50) (adjusted Hazard Ratio [HR]: 1.40; 95% CI, 1.09-1.80) and residing in a non-metropolitan area (vs. metropolitan) (adjusted HR: 1.60; 95% CI, 1.19-2.16). CONCLUSIONS This study suggests that breast cancer survivors who are older, Black, or residing in non-metropolitan areas may benefit from added surveillance and hypertension prevention strategies during treatment. Future studies are needed to identify contributors to the observed racial and geographic disparities.
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Affiliation(s)
- Arnethea L. Sutton
- Department of Kinesiology and Health SciencesVirginia Commonwealth UniversityRichmondVirginiaUSA
- VCU Massey Comprehensive Cancer CenterRichmondVirginiaUSA
| | - Jian He
- VCU Massey Comprehensive Cancer CenterRichmondVirginiaUSA
| | - Wendy Bottinor
- Division of Cardiology, Department of Internal MedicineVCU School of MedicineRichmondVirginiaUSA
| | - Susan Hong
- Division of Hematology/Oncology, Department of Internal MedicineVCU School of MedicineRichmondVirginiaUSA
| | | | - Anika L. Hines
- Department of Health Behavior and PolicyVCU School of MedicineRichmondVirginiaUSA
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Hines AL, Albert MA, Blair JP, Crews DC, Cooper LA, Long DL, Carson AP. Neighborhood Factors, Individual Stressors, and Cardiovascular Health Among Black and White Adults in the US: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. JAMA Netw Open 2023; 6:e2336207. [PMID: 37773494 PMCID: PMC10543067 DOI: 10.1001/jamanetworkopen.2023.36207] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/23/2023] [Indexed: 10/01/2023] Open
Abstract
Importance Chronic stress has been posited to contribute to racial disparities in cardiovascular health. Investigation of whether neighborhood- and individual-level stressors mediate this disparity is needed. Objective To examine whether racial differences in ideal cardiovascular health (ICH) are attenuated by experiences with neighborhood- and individual-level stressors within a racially and geographically diverse population sample. Design, Setting, and Participants This cross-sectional study examined data from 7720 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study who completed the second in-home visit (2013-2016). The REGARDS study is a population-based, longitudinal study of 30 239 non-Hispanic Black and non-Hispanic White adults aged 45 years or older at baseline (2003-2007). Data for the present study were analyzed from June to July 2021 and in March 2022. Exposures Neighborhood physical environment (eg, excessive noise, violence; scored from 7-28, with higher scores indicating more problems), neighborhood safety (scored as very safe, safe, or not safe), neighborhood social cohesion (eg, shared values; scored from 5-25, with higher scores indicating higher cohesion), perceived stress (eg, coping; scored from 0-16, with higher scores indicating greater perceived stress), and the experience of discrimination (yes or no). Main Outcomes and Measures Ideal cardiovascular health (ICH), measured as a composite of 4 health behaviors (cigarette smoking, diet, physical activity, body mass index) and 3 health factors (blood pressure, cholesterol, and glucose levels). Results The sample included 7720 participants (mean [SD] age, 71.9 [8.3] years; 4390 women [56.9%]; 2074 Black participants [26.9%]; and 5646 White participants [73.1%]). Black participants compared with White participants reported higher perceived stress (mean [SD] score, 3.2 [2.8] vs 2.8 [2.7]) and more often reported discrimination (77.0% vs 24.0%). Black participants also reported poorer neighborhood physical environment (mean [SD] score, 11.2 [3.8] vs 9.8 [2.9]) and social cohesion (mean [SD] score, 15.5 [2.0] vs 15.7 [1.9]) and more often reported their neighborhoods were unsafe (54.7% vs 24.3%). The odds of having a high total ICH score (ie, closer to ideal) were lower for Black adults compared with White adults, both overall (adjusted odds ratio [AOR], 0.53; 95% CI, 0.45-0.61) and by gender (men: AOR, 0.73 [95% CI, 0.57-0.93]; women: AOR, 0.45 [95% CI, 0.37-0.54]). In mediation analyses, the racial disparity in total ICH score was attenuated by neighborhood physical environment (5.14%), neighborhood safety (6.27%), neighborhood social cohesion (1.41%), and discrimination (11.01%). In stratified analyses, the factors that most attenuated the racial disparity in total ICH scores were neighborhood safety among men (12.32%) and discrimination among women (14.37%). Perceived stress did not attenuate the racial disparity in total ICH scores. Conclusions and Relevance In this cross-sectional study of Black and White US adults aged 45 years and older, neighborhood-level factors, including safety and physical and social environments, and individual-level factors, including discrimination, attenuated racial disparities in cardiovascular health. Interventional approaches to improve ICH that separately target neighborhood context and discrimination by gender and race are warranted.
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Affiliation(s)
- Anika L. Hines
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Michelle A. Albert
- Department of Medicine, University of California, San Francisco, San Francisco
| | - Jessica P. Blair
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham
| | - Deidra C. Crews
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lisa A. Cooper
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - D. Leann Long
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham
| | - April P. Carson
- Department of Medicine, University of Mississippi Medical Center, Jackson
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Alvarez C, Perrin N, Carson KA, Marsteller JA, Cooper LA. Adverse Childhood Experiences, Depression, Patient Activation, and Medication Adherence Among Patients With Uncontrolled Hypertension. Am J Hypertens 2023; 36:209-216. [PMID: 36322608 PMCID: PMC10016037 DOI: 10.1093/ajh/hpac123] [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: 05/03/2022] [Revised: 09/12/2022] [Accepted: 10/31/2022] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Identifying potential pathways through which adverse childhood experiences (ACEs) impact health and health behavior remains important, given ACE survivors' increased risk for cardiovascular disease and poor cardiovascular health behaviors. This study examines whether modifiable variables-depression and patient activation-explain the relationship between ACEs and medication adherence. METHODS Using baseline data from a pragmatic trial designed to decrease disparities in hypertension control, we conducted regression analyses to examine whether depression and patient activation mediated the association between ACEs and medication adherence. Data were collected between August 2017 and October 2019 (n = 1,818). RESULTS Participants were predominantly female (59.4%) and Black or African American (57%) with uncontrolled blood pressure (mean-152.3/85.5 mm Hg). Most participants reported experiencing at least 1 ACE (71%) and approximately 50% reported being adherent to their blood pressure medication. A significant indirect effect between ACEs and medication adherence was found for depression symptoms (Sobel's test z = -5.46, P < 0.001). Patient activation was not a mediator in these relationships. CONCLUSIONS Experiencing more depression symptoms significantly accounted for the association between ACEs and medication adherence in a diverse sample of adults with uncontrolled blood pressure. Addressing depression symptoms, which may result from experiences with ACEs and other current stressors, could translate to better medication adherence and, potentially, better blood pressure control among this high-risk group. Given the serious lifetime health implications of ACEs, continued efforts are needed for primary prevention of childhood adversities.
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Affiliation(s)
- Carmen Alvarez
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Johns Hopkins Center for Health Equity, Baltimore, Maryland, USA
| | - Nancy Perrin
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Kathryn A Carson
- Johns Hopkins Center for Health Equity, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, USA
- Johns Hopkins University School of Medicine, Department of Medicine, Division of General Internal Medicine, Baltimore, Maryland, USA
| | - Jill A Marsteller
- Johns Hopkins Center for Health Equity, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland, USA
| | - Lisa A Cooper
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Johns Hopkins Center for Health Equity, Baltimore, Maryland, USA
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
- Johns Hopkins University School of Medicine, Department of Medicine, Division of General Internal Medicine, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, Baltimore, Maryland, USA
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Abel WM, Greer DB, Sue-Ling C, Kirkland TW. Antihypertensive medication adherence and persistence among Black women: A qualitative study. Nurse Pract 2022; 47:40-47. [PMID: 35171867 DOI: 10.1097/01.npr.0000819620.71567.0e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT The prevalence of hypertension in Black women (57.6%) is among the highest in the world. Many of those who identify as Black do not readily adhere to prescribed antihypertensive medications nor persist with long-term therapy. This qualitative study describes self-reported approaches used by Black women with consistent adherence and persistence to medication-taking for BP control.
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Gusty R, Effendi N, Lim KA, Syafrita Y. Correlation of Hypertension Self-Care Activity Level Effects Factors with Perceived Stress in Uncontrolled Hypertensive Patients. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.7218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND: Stress is associated with hypertension self-care behavior activity. Low self-care can cause hypertension and make hypertension uncontrolled. Patients with uncontrolled hypertension are very susceptible to experiencing stress through self-care activities that they must do.
AIM: This study aims to identify the role of perceived stress on the self-care behavior of patients with uncontrolled hypertension. This study aims to assess the correlation of hypertension self-care activity level effect factors with perceived stress in patients with uncontrolled hypertension.
METHODS: This quantitative study with a cross-sectional design recruited 383 patients with uncontrolled hypertension at a community health center. The sampling technique is consecutive sampling. Perceived stress was assessed using Perceived Stress Sclae (PSS) and hypertension self-care activities were assessed using Hypertension Self-Care Activity Level Effect (H-SCALE). Data were analyzed using chi-square and multivariate test.
RESULTS: All respondents experienced stress, where 55.6% severed perceived stress and 44.4% moderate perceived stress. Severe stress occurs 60% in middle age, 54.2% in the elderly, 56.6% of male respondents, and 55.1% of female respondents. About 71.9% of respondents do not go to school, 69.2% are highly educated, and 56.6% of respondents do not work. Medication non-adherence (p = 0.000; OR = 0.941; 95% CI = 0.911–0.973) and weight management non-adherence (p = 0.006; OR = 0.956; 95% CI = 0.927–0.987) were positively correlated with the level of perceived stress in patients uncontrolled hypertension.
CONCLUSION: Improving coping strategies for stress by designing educational provisions about medication and weight management (diet and physical activity) are easily understood by people who do not experience education. Continuity and comprehensive education are needed.
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Hussain M, Howell JL, Peek MK, Stowe RP, Zawadzki MJ. Psychosocial stressors predict lower cardiovascular disease risk among Mexican-American adults living in a high-risk community: Findings from the Texas City Stress and Health Study. PLoS One 2021; 16:e0257940. [PMID: 34618834 PMCID: PMC8496861 DOI: 10.1371/journal.pone.0257940] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/14/2021] [Indexed: 12/02/2022] Open
Abstract
The objective of this study was to examine the link between systemic and general psychosocial stress and cardiovascular disease (CVD) risk in a group of U.S. Latinos as a function of acculturation and education within the blended guiding conceptual framework of the biopsychosocial model of the stress process plus the reserve capacity model. We analyzed data from self-identifying Mexican-origin adults (n = 396, 56.9% female, Mage = 58.2 years, 55.5% < 12 years of education, 79% U.S.-born) from the Texas City Stress and Health Study. We used established measures of perceived stress (general stress), neighborhood stress and discrimination (systemic stress) to capture psychosocial stress, our primary predictor. We used the atherosclerotic CVD calculator to assess 10-year CVD risk, our primary outcome. This calculator uses demographics, cholesterol, blood pressure, and history of hypertension, smoking, and diabetes to compute CVD risk in the next 10 years. We also created an acculturation index using English-language use, childhood interaction, and preservation of cultural values. Participants reported years of education. Contrary to expectations, findings showed that higher levels of all three forms of psychosocial stress, perceived stress, neighborhood stress, and perceived discrimination, predicted lower 10-year CVD risk. Acculturation and education did not moderate the effects of psychosocial stress on 10-year CVD risk. Contextualized within the biopsychosocial and reserve capacity framework, we interpret our findings such that participants who accurately reported their stressors may have turned to their social networks to handle the stress, thereby reducing their risk for CVD. We highlight the importance of examining strengths within the sociocultural environment when considering cardiovascular inequities among Latinos.
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Affiliation(s)
- Maryam Hussain
- Department of Psychological Sciences, University of California-Merced, Merced, California, United States of America
| | - Jennifer L. Howell
- Department of Psychological Sciences, University of California-Merced, Merced, California, United States of America
| | - M. Kristen Peek
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch-Galveston, Galveston, Texas, United States of America
| | - Raymond P. Stowe
- Microgen Laboratories, La Marque, Texas, United States of America
| | - Matthew J. Zawadzki
- Department of Psychological Sciences, University of California-Merced, Merced, California, United States of America
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