Advancing Health Equity: The Role of a Community-Academic-Public Health-Practice (CAPP) Partnership in Addressing COVID-19 Disparities in Louisiana

We assessed the impact of an innovative Louisiana community-academic-public health-practice (CAPP) partnership in addressing COVID-19-associated Black-White vaccination disparities over 19 months. Initially (April 2021), the cumulative vaccinations for Black versus White Louisianans were 54 542 per 100 000 versus 62 435 per 100 000, respectively. By October 2022, cumulative vaccinations for Black versus White Louisianans were 142 437 per 100 000 versus 132 488 per 100 000, respectively. The vaccination equity score increased from 908 out of 1000 in April 2021 to 942 out of 1000 in October 2022. CAPP partnership efforts contributed to addressing initial Black-White COVID-19 vaccination disparities. (Am J Public Health. 2024;114(S1):S55-S58. https://doi.org/10.2105/AJPH.2023.307509).

COVID-19 vaccination likelihood among federally qualified health center patients: Lessons learned for future health crises

BACKGROUND

To prepare for rollout of a COVID-19 vaccine in fall 2020, there was an urgent need to understand barriers to ensuring equitable access and addressing vaccine skepticism and resistance. This study aimed to understand the association between trusted sources of COVID-19 information and likelihood of vaccination during that time, focusing on lessons learned to prepare for future public health crises.

METHODS

From December 2020-March 2021, we surveyed a probability-based, cross-sectional sample of 955 patients across seven federally qualified health centers (FQHCs) serving predominantly low-income, Black and White populations in southeastern Louisiana. Vaccination likelihood was measured on a 7-point scale; "very likely to vaccinate" was defined as score=7. Trust in healthcare provider was measured with a single survey item. High trust in personal contacts, government, and media, respectively, were defined as the highest tertiles of summative scores of trust items. Weighted multivariable logistic regression estimated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for being very likely to vaccinate.

RESULTS

Participants were 56% Black, 64% women, mean age 44.6 years; 33% were very likely to vaccinate. High trust in healthcare provider (aOR=4.14, 95% CI 2.26-7.57) and government sources (aOR=3.23, 95% CI 1.98-5.28) were associated with being very likely to vaccinate.

CONCLUSIONS

During initial COVID-19 vaccination rollout, trust in healthcare providers and government sources of COVID-19 information was associated with likelihood to vaccinate in FQHC patients. To inform public health planning for future crises, we highlight lessons learned for translating community-relevant insights into direct action to reach those most impacted.

Abstract TMP25: Major Adverse Brain Events: Incidence Rates Of A Novel Composite Vascular Neurologic Outcome

Background: The classical 3-point composite outcome MACE (major adverse cardiovascular events) includes incident stroke, myocardial infarction, and cardiovascular death. Conventional use of MACE may fail to account for important neurological consequences of vascular risk factors. We sought to report incidence rates of a novel composite neurologic outcome called major adverse brain events (MABE), comprised of incident stroke, dementia, and impaired balance in individuals with the vascular risk factor of hypertension.

Methods: We analyzed TriNetX, the Health and Retirement Study (HRS), and Atherosclerosis Risk in Communities (ARIC), three longitudinal, publicly available datasets. We ascertained MABE as well as MACE and MACABE (MABE & MACE) as comparators by applying distinct adjudication methodologies in each dataset. We also evaluated the effect of good vascular health (maintenance of systolic blood pressure <140mm Hg and moderate or high physical activity, GVH) on rates of MABE and MACE in HRS through odds ratios (OR) adjusted for age, sex, and race/ethnicity.

Results: We included 10,496,366 hypertensive individuals aged ≥40 years in the TriNetX sample with up to 4 years of follow-up, 2,251 hypertensive individuals aged ≥60 years in HRS with 4 years of follow-up, and 1,409 hypertensive individuals in ARIC with a mean of 4.9 years of follow-up. The incidence of MABE was 10.5% in TriNetX (Figure 1), 35.9% in HRS, and 33.3% in ARIC, of MACE was 17.5%, 40.8% and 12.9%, and of MACABE was 21.2%, 56.3%, and 39.9%, respectively. MABE incidence was highest in older, female, and Black individuals. In HRS, the adjusted OR in those with GVH was 0.50 (95% CI 0.34-0.73) for MABE, 0.71 (95% CI 0.51-0.99) for MACE, and 0.59 (95% CI 0.43-0.82) for MACABE.

Conclusions: These data suggest that MABE is common among patients with hypertension, even in administrative datasets which are expected to have lower event rates. MABE may be useful for interventions that target brain health.

Health Disparities: Statin Prescribing Patterns Among Patients with Diabetes in a Family Medicine Clinic

Purpose:

To analyze the impact of gender and race on statin prescribing patterns in patients with diabetes in a family medicine clinic.

Methods:

This study (n=192) was a single-center, cross-sectional study that examined statin prescribing patterns at a family medicine clinic. Patients were obtained from January 2015 to November 2018, who were considered eligible for statin therapy based on a documented diagnosis of diabetes. The patients were divided into four subgroups for analysis (white males, non-white males, white females, and non-white females).

Results:

Females were found to have higher rates of prescribed statin therapy and appropriate statin intensity therapy when compared to males (p>0.05). When evaluating gender and race, white females were more likely to be prescribed an appropriate statin when compared to non-white females (p<0.05).

Conclusion:

The study shows that although males had a significantly higher mean 10-year atherosclerotic cardiovascular disease risk score, they were less likely than females to receive the appropriate intensity statin. Previous studies have shown race and gender disparities exist in the prevention of cardiovascular disease. A more collective, unified approach to improve prescribing patterns for statin therapy can eliminate these disparities.

Allostatic Load, Single, and Dual Chronic Conditions: Evidence from the National Health and Nutrition Examination Survey

Background:

Allostatic load (AL) is defined as a cumulative burden of chronic stress and life events, which involves the interaction of different physiological systems at varying degrees of activity. AL is suspected of contributing to health disparities among different populations. Suppressed or overactive physiological systems can interrupt AL affecting proper tissue and organ function leading to disease. The objective of our study was to determine the association of AL with dual chronic conditions.

Methods:

We used data from the National Health and Nutrition Examination Survey (NHANES). For the current analysis, we used the data cycles of 2007–2010, which is the most recent data that collected comprehensive measures of the composite AL outcome variable. Descriptive, bivariate, and multivariable logistic regression, with stepwise forward variable selection method (P < 0.05), were conducted using STATA/IC 15.0.

Results:

AL levels were high among 20% of the respondents (n = 2179). Having a lower income to poverty ratio, being married, physical inactivity, experiencing sleep problems, and a history of smoking were significantly associated with high AL (P < 0.05). Non-Hispanic blacks [odds ratio (OR): 1.8; 95% confidence interval (CI): 1.6–2.4] and Mexicans and other Hispanics (OR: 1.4; 95% CI: 1.1–1.7) had higher AL compared to Caucasians. Having cardiovascular disease (CVD) (OR: 1.7; 95% CI: 1.4–2.2) and diabetes (OR: 4.7; 95% CI: 3.8–5.7) independently, as well as both CVD and diabetes (OR: 3.1; 95% CI 2.7–3.6), were associated with higher odds of AL. We conducted an age-adjusted regression model that indicated higher odds of elevated AL among females with diabetes independently (OR: 1.4; 95% CI: 1.2–1.9) and with both CVD and diabetes (OR: 1.6; 95% CI: 1.2–2.1) compared to men.

Conclusions:

Despite the significant impact and association of AL with overall health, there is minimal evidence of its risk factors and linkage to disease burden. Modifiable lifestyle factors were associated with a higher AL. There is a critical need to support ethnic and gender contextual interventions to reduce the burden of AL on chronic conditions.

Community Engagement Practices at Research Centers in U.S. Minority Institutions: Priority Populations and Innovative Approaches to Advancing Health Disparities Research

This paper details U.S. Research Centers in Minority Institutions (RCMI) Community Engagement Cores (CECs): (1) unique and cross-cutting components, focus areas, specific aims, and target populations; and (2) approaches utilized to build or sustain trust towards community participation in research. A mixed-method data collection approach was employed for this cross-sectional study of current or previously funded RCMIs. A total of 18 of the 25 institutions spanning 13 U.S. states and territories participated. CEC specific aims were to support community engaged research (94%); to translate and disseminate research findings (88%); to develop partnerships (82%); and to build capacity around community research (71%). Four open-ended questions, qualitative analysis, and comparison of the categories led to the emergence of two supporting themes: (1) establishing trust between the community-academic collaborators and within the community and (2) building collaborative relationships. An overarching theme, building community together through trust and meaningful collaborations, emerged from the supporting themes and subthemes. The RCMI institutions and their CECs serve as models to circumvent the historical and current challenges to research in communities disproportionately affected by health disparities. Lessons learned from these cores may help other institutions who want to build community trust in and capacities for research that addresses community-related health concerns.

The Effects of Social, Personal, and Behavioral Risk Factors and PM2.5 on Cardio-Metabolic Disparities in a Cohort of Community Health Center Patients

(1) Background: Cardio-metabolic diseases (CMD), including cardiovascular disease, stroke, and diabetes, have numerous common individual and environmental risk factors. Yet, few studies to date have considered how these multiple risk factors together affect CMD disparities between Blacks and Whites. (2) Methods: We linked daily fine particulate matter (PM2.5) measures with survey responses of participants in the Southern Community Cohort Study (SCCS). Generalized linear mixed modeling (GLMM) was used to estimate the relationship between CMD risk and social-demographic characteristics, behavioral and personal risk factors, and exposure levels of PM2.5. (3) Results: The study resulted in four key findings: (1) PM2.5 concentration level was significantly associated with reported CMD, with risk rising by 2.6% for each µg/m3 increase in PM2.5; (2) race did not predict CMD risk when clinical, lifestyle, and environmental risk factors were accounted for; (3) a significant variation of CMD risk was found among participants across states; and (4) multiple personal, clinical, and social-demographic and environmental risk factors played a role in predicting CMD occurrence. (4) Conclusions: Disparities in CMD risk among low social status populations reflect the complex interactions of exposures and cumulative risks for CMD contributed by different personal and environmental factors from natural, built, and social environments.

Cardiotoxicity in Hematopoietic Stem Cell Transplant: Keeping the Beat

INTRODUCTION

The number of hematopoietic stem cell transplants (HSCTs) performed in the United States and worldwide is increasing. Cardiac events have been well described in HSCT, and the incidence and type of cardiac events have not changed over recent decades.

PATIENTS AND METHODS

This study adds to the body of evidence in describing the incidence and type of cardiac events experienced by an allogeneic and autologous HSCT population at a single institution from 2012 to 2017.

RESULTS

Sixty-five (9.8%) patients experienced cardiac events, including atrial arrhythmia (N = 39), acute heart failure (N = 9), acute coronary syndrome (N = 7), and new onset hypertension (N = 9), with a few instances of bradycardia, ventricular arrhythmia, pericardial effusion, and pericarditis. Our multivariable regression analysis identified age (older), creatinine (higher), and history of coronary artery disease to significantly correlate with risk of cardiac event (P = .005, P = .039, and P = .038, respectively). A subgroup analysis of those patients experiencing a cardiac event found pre-transplant atrial dilation by trans-thoracic echocardiogram to correlate with increased risk of atrial arrhythmia (33.8% vs. 9.7%; P = .03). Patients developing a CE had an increased risk of death within 1 year (11% vs. 32%; P < .001).

CONCLUSION

We review our results in context of other important HSCT cardiac studies to illuminate the most relevant factors of medical history, laboratory data, and cardiac measurements that will identify patients at higher risk, allowing for intervention to improve HSCT outcomes.

Groundnut spread likability, sensory properties, and intent to pay for quality certification

Quality-certified, nutritious novel groundnut spread has great commercialization possibilities due to evolving urban lifestyles in Africa, but lack of information about likability, sensory attributes, and consumer safety awareness is a severe barrier for small enterprises.

This paper examines a novel groundnut spread, made of sorted kernels deemed free of aflatoxin, intended for use on bread in a fashion similar to groundnut paste or groundnut butter, but with modified sensory characteristics. In particular, it seeks to measure the effects of sensory attributes of the novel spread on the intent to pay for safety certification and the role of consumer awareness of aflatoxin.

A novel spread was prepared with groundnut paste from sorted kernels (to eliminate the risk of aflatoxin contamination) and cocoa. Adults intercepted at Ghana’s International Fair in 2012 volunteered to sample the spread and complete a questionnaire. Results from a tasting panel of untrained participants established that sensory attributes and panellist characteristics are relevant to the intent to pay for quality certification. Spread likability, aroma, education, knowledge about aflatoxin, packaging and being married were identified as major factors increasing the probability of intent to pay for quality certification whereas young age and the presence of children in a household lowered the probability. Results also identified income, education level, and having young children at home as increasing the chances of knowing about aflatoxin.

Groundnut paste available in Ghana is often contaminated by aflatoxin as it is in other countries in the region and consumers cannot visually assess paste quality. Under the circumstances, quality certification is necessary.

The Cost of Recommended Diets: Development and Application a Food Price Index Based on Food-Based Dietary Guidelines (P10-033-19)

Objectives

Food price data is routinely collected by governments but has not been utilized to its full potential for tracking the cost of nutritious diets. Food prices typically are used to monitor the cost of a basket of goods purchased by consumers, which may bear little relation to recommended diets. National food-based dietary guidelines (FBDG) attempt to provide specific, actionable recommendations for diets that meet nutritional needs and protect long-term health, based on expert evidence review and in-country dialogue. The objective of this research is to show how governments can use their food price data to track the cost of meeting FBDG.

Methods

The Cost of Recommended Diets (CoRD) is an estimate of the minimum cost of meeting FBDG. It requires data on food prices and quantitative FBDG. Food price data can be sourced from national statistical organizations that track inflation using a Consumer Price Index (CPI); from ministries of food/agriculture/trade; and from national household budget surveys. CoRD is calculated by identifying the least-cost 2–3 foods (by edible portion) in each food category contained in FBDG (e.g., starchy staples, protein foods, dairy, fruits, vegetables, oils), and summing the mean cost of obtaining the average gram amounts of each group. We demonstrate the results of CoRD using data from Ghana. A stakeholder dialogue was conducted with official food price data collectors in Ghana in 2016–2018 on the applicability of CoRD within existing monitoring systems.

Results

Using data from the Ghana Statistical Service and the Ghana Ministry of Food and Agriculture (MoFA), we find that meeting FBDG for vegetables and fruits is relatively expensive compared to starchy staples and the cheapest forms of protein foods, and that consumers typically underspend on fruits and vegetables compared to the expenditure shares required to obtain recommended amounts. MoFA has made changes in their food price monitoring system to enable tracking of CoRD.

Conclusions

The CoRD indicator is a policy-coherent metric of food prices that measures the cost of meeting FBDG. It rests on existing data and can be incorporated into national food price monitoring systems.

Funding Sources

Funding for this work is provided by the Bill and Melinda Gates Foundation and DFID, partially through an IMMANA (Innovative Metrics and Methods for Agriculture and Nutrition Actions) grant.

The Association of Black Cardiologists (ABC) Cardiovascular Implementation Study (CVIS): A Research Registry Integrating Social Determinants to Support Care for Underserved Patients

African Americans, other minorities and underserved populations are consistently under- represented in clinical trials. Such underrepresentation results in a gap in the evidence base, and health disparities. The ABC Cardiovascular Implementation Study (CVIS) is a comprehensive prospective cohort registry that integrates social determinants of health. ABC CVIS uses real world clinical practice data to address critical gaps in care by facilitating robust participation of African Americans and other minorities in clinical trials. ABC CVIS will include diverse patients from collaborating ABC member private practices, as well as patients from academic health centers and Federally Qualified Health Centers (FQHCs). This paper describes the rationale and design of the ABC CVIS Registry. The registry will: (1) prospectively collect socio-demographic, clinical and biospecimen data from enrolled adults, adolescents and children with prioritized cardiovascular diseases; (2) Evaluate the safety and clinical outcomes of new therapeutic agents, including post marketing surveillance and pharmacovigilance; (3) Support National Institutes of Health (NIH) and industry sponsored research; (4) Support Quality Measures standards from the Center for Medicare and Medicaid Services (CMS) and Commercial Health Plans. The registry will utilize novel data and technology tools to facilitate mobile health technology application programming interface (API) to health system or practice electronic health records (EHR). Long term, CVIS will become the most comprehensive patient registry for underserved diverse patients with cardiovascular disease (CVD) and co morbid conditions, providing real world data to address health disparities. At least 10,000 patients will be enrolled from 50 sites across the United States.

Knowledge Management for Fostering Biostatistical Collaboration within a Research Network: The RTRN Case Study

Purpose: While the intellectual and scientific rationale for research collaboration has been articulated, a paucity of information is available on a strategic approach to facilitate the collaboration within a research network designed to reduce health disparities. This study aimed to (1) develop a conceptual model to facilitate collaboration among biostatisticians in a research network; (2) describe collaborative engagement performed by the Network’s Data Coordinating Center (DCC); and (3) discuss potential challenges and opportunities in engaging the collaboration. Methods: Key components of the strategic approach will be developed through a systematic literature review. The Network’s initiatives for the biostatistical collaboration will be described in the areas of infrastructure, expertise and knowledge management and experiential lessons will be discussed. Results: Components of the strategic approach model included three Ps (people, processes and programs) which were integrated into expert management, infrastructure management and knowledge management, respectively. Ongoing initiatives for collaboration with non-DCC biostatisticians included both web-based and face-to-face interaction approaches: Network’s biostatistical capacities and needs assessment, webinar statistical seminars, mobile statistical workshop and clinics, adjunct appointment program, one-on-one consulting, and on-site workshop. The outreach program, as a face-to-face interaction approach, especially resulted in a useful tool for expertise management and needs assessment as well as knowledge exchange. Conclusions: Although fostering a partnered research culture, sustaining senior management commitment and ongoing monitoring are a challenge for this collaborative engagement, the proposed strategies centrally performed by the DCC may be useful in accelerating the pace and enhancing the quality of the scientific outcomes within a multidisciplinary clinical and translational research network.

Risk Factors for Low Pharmacy Refill Adherence Among Older Hypertensive Men and Women by Race

BACKGROUND

Sex-race stratification may lead to identification of risk factors for low antihypertensive medication adherence that are not apparent when assessing risk factors in women and men without race stratification. We examined risk factors associated with low pharmacy refill adherence across sex-race subgroups (white women, black women, white men, black men) within the Cohort Study of Medication Adherence among Older Adults (n = 2,122).

METHODS

Pharmacy refill adherence was calculated as proportion of days covered using all antihypertensive prescriptions filled in the year prior to a baseline risk factor survey. Sex- and sex-race-stratified multivariable Poisson regression models with robust standard errors were used to estimate adjusted prevalence ratios and 95% confidence intervals for associations between participant characteristics and low adherence.

RESULTS

Prevalence of low adherence was 22.9% vs. 40.7% in white vs. black women (P < 0.001) and 26.3% vs. 37.2% in white vs. black men (P = 0.003). In multivariable models, reducing antihypertensive medication due to cost was associated with low adherence within each sex-race subgroup. Additional factors associated with low adherence included shorter hypertension duration and comorbidities in white women; not being married and depressive symptoms in white men; and ≥6 primary care visits/year and complementary and alternative medicine use in black men. Among men, not being married and reporting depressive symptoms were associated with low adherence for whites, but not blacks.

CONCLUSIONS

Identification of sex-race-specific risk factors for low antihypertensive medication adherence may guide development and implementation of tailored interventions to increase antihypertensive medication adherence and blood pressure control among older patients.

Patients' perception of community pharmacists as healthcare providers and willingness to participate in pharmacist services: a pilot study

OBJECTIVES

To explore the extent to which patients identify community pharmacists as healthcare providers and the relationship of this perception to a willingness to engage in pharmacist-provided services.

METHODS

A cross-sectional survey was conducted at a retail pharmacy and a patient centered medical home (PCMH) in the New Orleans, Louisiana metropolitan area. The survey assessed patients' perception of community pharmacists and their roles in the provision of healthcare, as well as willingness to participate in commonly offered pharmacist-provided services.

RESULTS

This study included 49 participants who interacted with pharmacy personnel to receive prescriptions regularly. Of the 49 patients surveyed, 91.8% perceived community pharmacists to be healthcare providers and this perception significantly impacted patient willingness to participate in medication therapy management, medication optimization, and travel vaccination services. Other services were not significantly impacted by perception.

CONCLUSION

A greater percentage of patients perceived community pharmacists as healthcare providers. This affirmative perception positively impacted patient willingness to participate in several pharmacist-provided services. Since no comparative studies are available, further study is needed to assess consistency of observations and assess innovative ways to highlight pharmacists' cognitive attributes and increase participation in pharmacist-provided services.

An mHealth Framework to Improve Birth Outcomes in Benue State, Nigeria: A Study Protocol

BACKGROUND

The unprecedented coverage of mobile technology across the globe has led to an increase in the use of mobile health apps and related strategies to make health information available at the point of care. These strategies have the potential to improve birth outcomes, but are limited by the availability of Internet services, especially in resource-limited settings such as Nigeria.

OBJECTIVE

Our primary objective is to determine the feasibility of developing an integrated mobile health platform that is able to collect data from community-based programs, embed collected data into a smart card, and read the smart card using a mobile phone-based app without the need for Internet access. Our secondary objectives are to determine (1) the acceptability of the smart card among pregnant women and (2) the usability of the smart card by pregnant women and health facilities in rural Nigeria.

METHODS

We will leverage existing technology to develop a platform that integrates a database, smart card technology, and a mobile phone-based app to read the smart cards. We will recruit 300 pregnant women with one of the three conditions-HIV, hepatitis B virus infection, and sickle cell trait or disease-and four health facilities in their community. We will use Glasgow's Reach, Effectiveness, Adoption, Implementation, and Maintenance framework as a guide to assess the implementation, acceptability, and usability of the mHealth platform.

RESULTS

We have recruited four health facilities and 300 pregnant women with at least one of the eligible conditions. Over the course of 3 months, we will complete the development of the mobile health platform and each participant will be offered a smart card; staff in each health facility will receive training on the use of the mobile health platform.

CONCLUSIONS

Findings from this study could offer a new approach to making health data from pregnant women available at the point of delivery without the need for an Internet connection. This would allow clinicians to implement evidence-based interventions in real time to improve health outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03027258; https://clinicaltrials.gov/ct2/show/NCT03027258 (Archived by WebCite at http://www.webcitation.org/6owR2D0kE).

Assessing Program Coverage of Two Approaches to Distributing a Complementary Feeding Supplement to Infants and Young Children in Ghana

The work reported here assesses the coverage achieved by two sales-based approaches to distributing a complementary food supplement (KOKO Plus^™) to infants and young children in Ghana. Delivery Model 1 was conducted in the Northern Region of Ghana and used a mixture of health extension workers (delivering behavior change communications and demand creation activities at primary healthcare centers and in the community) and petty traders recruited from among beneficiaries of a local microfinance initiative (responsible for the sale of the complementary food supplement at market stalls and house to house). Delivery Model 2 was conducted in the Eastern Region of Ghana and used a market-based approach, with the product being sold through micro-retail routes (i.e., small shops and roadside stalls) in three districts supported by behavior change communications and demand creation activities led by a local social marketing company. Both delivery models were implemented sub-nationally as 1-year pilot programs, with the aim of informing the design of a scaled-up program. A series of cross-sectional coverage surveys was implemented in each program area. Results from these surveys show that Delivery Model 1 was successful in achieving and sustaining high (i.e., 86%) effective coverage (i.e., the child had been given the product at least once in the previous 7 days) during implementation. Effective coverage fell to 62% within 3 months of the behavior change communications and demand creation activities stopping. Delivery Model 2 was successful in raising awareness of the product (i.e., 90% message coverage), but effective coverage was low (i.e., 9.4%). Future programming efforts should use the health extension / microfinance / petty trader approach in rural settings and consider adapting this approach for use in urban and peri-urban settings. Ongoing behavior change communications and demand creation activities is likely to be essential to the continued success of such programming.

Prescribing Patterns of Metformin in High-risk Patients with Prediabetes

AIMS

The primary objective of this study is to examine the rates of metformin prescribing in patients with prediabetes who are either less than 60 years of age, have a BMI greater than 35 kg/m2, or women with a history of gestational diabetes mellitus (GDM). Secondary objectives include: 1) examination of the time from diagnosis of prediabetes to the initiation of metformin and 2) if metformin initiation status and length of time correlates to the patient having any other additional diabetes mellitus (DM) risk factors.

METHODS

This was a single center, retrospective cohort study. This study included all patients with prediabetes, defined as having hemoglobin A1c (HbA1c) of 39 through 46 mmol/mol (5.7-6.4 percent), who were patients at the Interim LSU Hospital and Clinics from January 2012-September 2013.

RESULTS

There were a total of 13 patients out of 160 patients in the study population who were prescribed metformin for an overall metformin initiation rate of 8.1 percent. The metformin initiation rate for the three individual groups; history of GDM, aged less than 60 years, and BMI greater than 35 kg/m2 were 0 percent, 9.0 percent, and 17.5 percent respectively.

CONCLUSION

Metformin initiation rates in patients with prediabetes are not in accordance with current recommendations, and provider education is necessary to increase rates to delay or prevent the progression of prediabetes to type 2 Diabetes Mellitus.

Unequal burden of sleep-related obesity among black and white Americans

BACKGROUND

This study ascertained whether individuals of the black race/ethnicity are unequally burdened by sleep-related overweight/obesity.

METHODS

Analysis was based on data obtained from Americans (ages, 18-85 years) in the National Health Interview Survey (1977-2009). Sleep duration was coded as either very short sleep (VSS) (≤5 hours), short sleep (SS) (5-6 hours), or long sleep (>8 hours), referenced to 7-8-hour sleepers. Overweight was defined as body mass index (BMI) ≥25.0 and ≤29.9 kg/m² and obesity, BMI ≥30 kg/m², referenced to normal weight (BMI = 18.5-24.9 kg/m²).

RESULTS

Multivariate-adjusted regression analyses indicated that, among whites, VSS was associated with a 10% increased likelihood of being overweight and 51% increased likelihood of being obese, relative to 7-8-hour sleepers. Short sleep was associated with a 13% increased likelihood of being overweight and 45% increased likelihood of being obese. Long sleep was associated with 21% increased likelihood of being obese. Among blacks, VSS was associated with a 76% increased likelihood of being overweight and 81% increased likelihood of being obese. Short sleep was associated with a 16% increased likelihood of being overweight and 32% increased likelihood of being obese. As for the white stratum, long sleep was associated with a 25% increased likelihood of being obese.

CONCLUSION

Our investigation demonstrates strong linkages between inadequate sleep and overweight/ obesity among black and white Americans. Although it cannot be said that insufficient sleep causes overweight/obesity, individuals of the black race/ethnicity sleeping ≤5 hours may be unequally burdened by sleep-related overweight/obesity.

Improving complementary feeding in Ghana: reaching the vulnerable through innovative business--the case of KOKO Plus

Reaching vulnerable populations in low-resource settings with effective business solutions is critical, given the global nature of food and nutrition security. Over a third of deaths of children under 5 years of age are directly or indirectly caused by undernutrition. The Lancet series on malnutrition (2013) estimates that over 220,000 lives of children under 5 years of age can be saved through the implementation of an infant and young child feeding and care package. A unique project being undertaken in Ghana aims to bring in two elements of innovation in infant and young child feeding. The first involves a public-private partnership (PPP) to develop and test the efficacy and effectiveness of the delivery of a low-cost complementary food supplement in Ghana called KOKO Plus™. The second involves the testing of the concepts of social entrepreneurship and social business models in the distribution and delivery of the product. This paper shares information on the ongoing activities in the testing of concepts of PPPs, social business, social marketing, and demand creation using different delivery platforms to achieve optimal nutrition in Ghanaian infants and young children in the first 2 years of life. It also focuses on outlining the concept of using PPP and base-of-the-pyramid approaches toward achieving nutrition objectives.

Associations between inadequate sleep and obesity in the US adult population: analysis of the national health interview survey (1977-2009)

BACKGROUND

Epidemiologic studies show a curvilinear relationship between inadequate sleep (< 7 or > 8 hours) and obesity (Body Mass Index > 30 kg/m2), which have enormous public health impact.

METHODS

Using data from the National Health Interview Survey, an ongoing nationally representative cross-sectional study of non-institutionalized US adults (≥18 years) (1977 through 2009), we examined the hypothesis that inadequate sleep is independently related to overweight/obesity, with adjustment for socio-demographic, health risk, and medical factors. Self- reported data on health risks, physician-diagnosed medical conditions, sleep duration, and body weight and height were used.

RESULTS

Prevalence of overweight and obesity increased from 31.2% to 36.9% and 10.2% to 27.7%, respectively. Whereas prevalence of very short sleep (<5 hours) and short sleep (5-6 hours) has increased from 1.7% to 2.4% and from 19.7% to 26.7%, it decreased from 11.6% to 7.8% for long sleep. According to multivariate-adjusted multinomial regression analyses, odds of overweight and obesity associated with very short sleep and short sleep increased significantly from 1977 to 2009. Odds of overweight and obesity conferred by long sleep did not show consistent and significant increases over the years. Analyses based on aggregated data showed very short sleepers had 30% greater odds of being overweight or were twice as likely to be obese, relative to 7-8 hour sleepers. Likewise, short sleepers had 20% greater odds of being overweight or 57% greater odds of being obese. Long sleepers had 20% greater odds of being obese, but no greater odds of being overweight.

CONCLUSIONS

Our findings support the hypothesis that prevalence of very short and short sleep has gradually increased over the last 32 years. Inadequate sleep was associated with overweight and obesity for each available year.

Socioeconomic status, John Henryism and blood pressure among African-Americans in the Jackson Heart Study

John Henryism connotes a strong behavioral predisposition to engage in effortful, active coping with difficult social and economic stressors. This behavioral predisposition is measured by the 12 item John Henryism Scale for Active Coping (JHAC). The John Henry hypothesis predicts that the well-known inverse socioeconomic status (SES)-blood pressure association will be stronger among persons who score high rather than low on the JHAC. We tested this hypothesis in a large African American cohort using baseline data from the Jackson Heart Study. Unlike previous studies, we used multiple indicators of SES: income, education, occupation, childhood SES and cumulative SES. Because the hypothesis is most relevant for adults still in the labor force, we excluded retired participants, yielding a sample size of 3978. Gender-specific Poisson regression models for hypertension adjusting for age, John Henryism, SES, and a John Henryism-SES interaction term, were fit to examine associations. Separate models were fit for each SES indicator. We found some evidence that John Henryism modified the association between income and hypertension in men: low income was associated with higher prevalence of hypertension in men who scored high on John Henryism (prevalence ratio (PR) for low vs. high income tertile 1.12), but with lower hypertension prevalence among men who scored low on John Henryism (PR 0.85, one sided P value for multiplicative interaction <0.05). For women, the association of low income with higher hypertension prevalence was stronger at lower than higher levels of John Henryism (PR 1.27 and 1.06 at low and high levels of John Henryism respectively, P value<0.05). There was no evidence that John Henryism modified the associations of hypertension with other SES indicators in men or women. The modest support of the John Henryism Hypothesis in men only, adds to the literature on this subject, but underscores questions regarding the gender, spatial, socioeconomic and historical contexts in which the hypothesis is valid.

Transferability and fine-mapping of glucose and insulin quantitative trait loci across populations: CARe, the Candidate Gene Association Resource

AIMS/HYPOTHESIS

Hyperglycaemia disproportionately affects African-Americans (AfAs). We tested the transferability of 18 single-nucleotide polymorphisms (SNPs) associated with glycaemic traits identified in European ancestry (EuA) populations in 5,984 non-diabetic AfAs.

METHODS

We meta-analysed SNP associations with fasting glucose (FG) or insulin (FI) in AfAs from five cohorts in the Candidate Gene Association Resource. We: (1) calculated allele frequency differences, variations in linkage disequilibrium (LD), fixation indices (F(st)s) and integrated haplotype scores (iHSs); (2) tested EuA SNPs in AfAs; and (3) interrogated within ± 250 kb around each EuA SNP in AfAs.

RESULTS

Allele frequency differences ranged from 0.6% to 54%. F(st) exceeded 0.15 at 6/16 loci, indicating modest population differentiation. All iHSs were <2, suggesting no recent positive selection. For 18 SNPs, all directions of effect were the same and 95% CIs of association overlapped when comparing EuA with AfA. For 17 of 18 loci, at least one SNP was nominally associated with FG in AfAs. Four loci were significantly associated with FG (GCK, p = 5.8 × 10(-8); MTNR1B, p = 8.5 × 10(-9); and FADS1, p = 2.2 × 10(-4)) or FI (GCKR, p = 5.9 × 10(-4)). At GCK and MTNR1B the EuA and AfA SNPs represented the same signal, while at FADS1, and GCKR, the EuA and best AfA SNPs were weakly correlated (r(2) <0.2), suggesting allelic heterogeneity for association with FG at these loci.

CONCLUSIONS/INTERPRETATION

Few glycaemic SNPs showed strict evidence of transferability from EuA to AfAs. Four loci were significantly associated in both AfAs and those with EuA after accounting for varying LD across ancestral groups, with new signals emerging to aid fine-mapping.

Correlates of willingness to participate in microbicide research among African Americans

The objective of the present article is to identify predictors of willingness to participate (WTP) in microbicide trials among African Americans. A total of 595 participants completed a survey on WTP in microbicide trials and predictors of WTP. Significant associations were observed for relationships of greater WTP with female gender, greater HIV risk, lower mistrust of research, and knowing someone with HIV/AIDS. An interaction revealed HIV risk was positively associated with WTP for women only. Accurate knowledge of the Tuskegee Syphilis Study was associated with greater WTP. These predictors may be employed in microbicide trials to enhance African American participation.

The effects of priming on a public health campaign targeting cardiovascular risks

Public health interventions are cost-effective methods to reduce heart disease. The present study investigated the impact of a low-cost priming technique on a public health campaign targeting cardiovascular risk. Participants were 415 individuals (66% female) ages 18 and older recruited through clinics and churches. The study consisted of three phases. In Phase I, participants completed a brief survey to assess knowledge of the cardiovascular health indicators. The survey served as the prime (intervention) for the study. At Phase II, participants were provided with access to a public health campaign consisting of an education brochure on cardiovascular health. Following the educational campaign, all participants completed a post-campaign survey in Phase III of the study. Participants who completed the surveys in both Phase I and III were placed in the intervention condition (26%) and those who only completed the Phase III survey were placed in the control condition (74%). Participants who were primed reported greater awareness of the public health campaign. Additionally, more intervention participants reported they had knowledge of their own and the normal ranges for cholesterol, glucose, and body mass index. For participants who were aware of the health promotion campaign, more participants in the primed group indicated they had knowledge of their own cholesterol and glucose levels and had made positive lifestyle changes as a result of the campaign. Results suggest the presence of a priming effect. Public health campaigns may benefit from the inclusion of a low-cost prime prior to intervention.

The socioeconomic gradient of diabetes prevalence, awareness, treatment, and control among African Americans in the Jackson Heart Study

PURPOSE

Little research has focused on the social patterning of diabetes among African Americans. We examined the relationship between socioeconomic status (SES) and the prevalence, awareness, treatment, and control of diabetes among African Americans.

METHODS

Education, income and occupation were examined among 4,303 participants (2,726 women and 1,577 men). Poisson regression estimated relative probabilities (RP) of diabetes outcomes by SES.

RESULTS

The prevalence of diabetes was 19.6% in women and 15.9% in men. Diabetes awareness, treatment, and control were 90.0%, 86.8%, and 39.2% in women, respectively, and 88.2%, 84.4%, and 35.9% in men, respectively. In adjusted models, low-income men and women had greater probabilities of diabetes than high-income men and women (RP, 1.94; 95% confidence interval [CI], 1.28-2.92; and RP, 1.35; 95% CI, 1.04-1.74, respectively). Lack of awareness was associated with low education and low occupation in women (RP, 2.28; 95%CI 1.01-5.18; and RP, 2.62; 95% CI, 1.08-6.33, respectively) but not in men. Lack of treatment was associated with low education in women. Diabetes control was not patterned by SES.

CONCLUSIONS

Diabetes prevalence is patterned by SES, and awareness and treatment are patterned by SES in women but not men. Efforts to prevent diabetes in African Americans need to address the factors that place those of low SES at higher risk.

Relationship between medication use and cardiovascular disease health outcomes in the Jackson Heart Study

Even though some medications have the potential to slow the progress of atherosclerosis and development of CVD, there are many at-risk individuals who continue to resist the benefits that are available by not following the advice of medical professionals. Non-adherence to prescribed drug regimens is a pervasive medical problem that negatively affects treatment outcomes. Information from standardized interviews of 5301 African Americans participating in the Jackson Heart Study was examined to determine the association between demographic parameters, behavior including adherence to prescribed medical regimens, and health outcomes. Data were also collected at Annual Follow-Up and Surveillance visits. During the two weeks prior to the examination visit, almost 52% of the participants reported taking blood pressure medication, 14% took cholesterol medication, 16% took medication for diabetes, and 19% took blood thinning medication. Of those who did not take the prescribed medications, the reasons given were the following: 47% were in a hurry, too busy, or forgot to take medications; 23% were trying to do without medications; 18% had no money to purchase medications; 19% indicated that the medications made them feel bad; 17% felt that they could not carry out daily functions when taking medications. The African American population can benefit from heightened awareness of the risk factors that are associated with CVD and the benefits of following a prescribed treatment regimen. Unacceptable secondary effects of prescribed medication comprised an important cause of non-compliance. Encouragement of this population to communicate with their healthcare providers to ensure that medication regimens are better tolerated could increase compliance and improve health outcomes.

Association of the joint effect of menopause and hormone replacement therapy and cancer in African American women: the Jackson Heart Study

Cancer is the second leading cause of death in the US and in Mississippi. Breast cancer (BC) is the most common cancer among women, and the underlying pathophysiology remains unknown, especially among African American (AA) women. The study purpose was to examine the joint effect of menopause status (MS) and hormone replacement therapy (HRT) on the association with cancers, particularly BC using data from the Jackson Heart Study. The analytic sample consisted of 3202 women between 35 and 84 years of which 73.7% and 22.6% were postmenopausal and on HRT, respectively. There were a total of 190 prevalent cancer cases (5.9%) in the sample with 22.6% breast cancer cases. Menopause (p<0.0001), but not HRT (p=0.6402), was independently associated with cancer. Similar results were obtained for BC. BC, cancer, hypertension, type 2 diabetes, prevalent cardiovascular disease, physical activity and certain dietary practices were all significantly associated with the joint effect of menopause and HRT in the unadjusted analyses. The family history of cancer was the only covariate that was significantly associated with cancer in the age-adjusted models. In examining the association of cancer and the joint effect of menopause and HRT, AA women who were menopausal and were not on HRT had a 1.97 (95% CI: 1.15, 3.38) times odds of having cancer compared to pre-menopausal women after adjusting for age; which was attenuated after further adjusting for family history of cancer. Given that the cancer and BC cases were small and key significant associations were attenuated after adjusting for the above mentioned covariates, these findings warrant further investigation in studies with larger sample sizes of cancer (and BC) cases.

Pericardial adipose tissue, atherosclerosis, and cardiovascular disease risk factors: the Jackson heart study

OBJECTIVE

Pericardial adipose tissue (PAT), a regional fat depot that surrounds the heart, is associated with an unfavorable cardiometabolic risk factor profile. The associations among PAT, cardiometabolic risk factors, and coronary artery calcification (CAC) and abdominal aortic artery calcification (AAC) in African American populations have not been explored.

RESEARCH DESIGN AND METHODS

A total of 1,414 African Americans (35% men; mean +/- SD age 58 +/- 11 years) drawn from the Jackson Heart Study (JHS) underwent multidetector computed tomography assessment of abdominal visceral adipose tissue (VAT) and PAT between 2007 and 2009. Cardiometabolic risk factors, CAC, and AAC were examined in relation to increments of PAT and VAT.

RESULTS

PAT was significantly correlated with BMI, waist circumference, and VAT (r = 0.35, 0.46, and 0.69; all P < 0.0001). PAT (per 1-SD increase) was associated with elevated levels of systolic blood pressure (P < 0.04), fasting glucose, triglycerides, and C-reactive protein and lower levels of HDL (all P values<0.0001). PAT was also associated with metabolic syndrome (odds ratio [OR] 1.89; P < 0.0001), hypertension (1.48; P < 0.0006), and diabetes (1.40; P < 0.04); all associations were diminished after further adjustment for VAT (most P > 0.05). However, the association of PAT with CAC but not with AAC remained significant (OR 1.34 [95% CI 1.10-1.64]; P < 0.004) after multivariable and VAT adjustment.

CONCLUSIONS

PAT is significantly correlated with most cardiometabolic risk factors and CAC in the JHS cohort. The results suggest that PAT is an important VAT depot that may exert a local effect on the coronary vasculature.

Importance of capacity assessment for an early staged-research network designed to eliminate health disparity: lessons from RTRN

BACKGROUND

RCMI Translational Research Network (RTRN) is the first academic-based national network to address the problem of health disparities by integrating minority medical schools in a collaborative effort. While there was a great interest in forming the research network, limited systematic effort has been made in understanding members' existing capacity and future demand.

OBJECTIVE

The aim of this study was to report the results of the RTRN Statistical Capacity Assessment and discuss the importance of an initial capacity assessment in building the biostatistical capacity of a research network in its early stage.

METHODS

The assessment was based on survey responses submitted by program directors/managers from 12 of the 18 RTRN institutions. In this assessment the capacity is defined as the statistical tools and human resources which are required for effective and efficient performance.

RESULTS

A total of 52 biostatisticians (mean of 4.5 per site) were working for 12 RTRN institutions; 84% were fulltime employees, and 53% held a doctoral degree. On average, they had about 13 years of job experience. SAS, SPSS and STATA were the most frequently used and were selected as their major statistical software. A wide inter-institutional variability was found in number of biostatisticians (ranged from 1 to 8), mean years of experience in their position (4.5-20 years) and in major software (5-20), and the number of statistical software in use (1-11).

CONCLUSION

The initial capacity assessment provided valuable information on members' background and the network's research capacity which will be used as the basic data in developing programs to build research capacity. Therefore, it is important to include the initial capacity survey and on-going evaluation of network activities when making business plans of research networks intended to reduce health disparities.

Development of the Jackson Heart Study Coordinating Center

The public health burden caused by cardiovascular disease (CVD) continues to adversely affect individuals in terms of cost, life expectancy, medical, pharmaceutical and hospital care. This burden has been excessive in the case of African Americans. The objective of this paper is to chronicle the procedures and processes that were implemented in the development of the Jackson Heart Study Coordinating Center. The Jackson Heart Study (JHS) is a population-based investigation of traditional and emerging risk factors that predict progression to CVD among African Americans. In response to the struggle against CVD, the Jackson Heart Study has convened a professional, technical, and administrative staff with specific competence in the operation of a coordinating center to handle the wide variety of areas related to CVD studies. The Jackson Heart Study Coordinating Center (JHSCC) was created to assure validity of the JHS findings and provide the resources necessary to meet comprehensive statistical needs (planning, implementing and monitoring data analysis); data management (designing, implementing and managing data collection and quality control), and administrative support. The JHSCC began with a commitment to support study functions in order to increase participant recruitment, retention and safety, meet regulatory requirements, prepare progress reports, and facilitate effective communication with the community and between all JHS centers. The JHSCC facilitates the efforts of the JHS scientists through the development and implementation of the study protocol. The efforts of the JHSCC have resulted in the successful preparation of scientific reports and manuscripts for publication and presentation of study findings and results. In summary, the JHSCC has emerged as an effective research mechanism that serves as the driving force behind the Jackson Heart Study activities.

Dyslipidemia and the treatment of lipid disorders in African Americans

BACKGROUND

Despite the high prevalence of cardiovascular disease documented among the African-American population, there has been little emphasis on the role of dyslipidemia as a prominent risk factor in this large subpopulation. Questions of medication efficacy also have been raised. Together, these factors may have affected awareness, diagnosis, and treatment rates.

METHODS AND RESULTS

Dyslipidemia was defined as the presence of either hypercholesterolemia or hypertriglyceridemia using National Cholesterol Education Program III criteria and the fasting lipid measurements, self-reported treatment history, and medication survey available from 5302 Jackson Heart Study participants. Dyslipidemia was more common in men (compared with women) aged less than 50 years and increased with age in both genders. Hypercholesterolemia prevalence rates approached 50% in women aged more than 65 years. The lifestyle-related attributes found to be related to prevalence were being overweight and less physically active, and all disease status variables exhibited significant (P<.05) associations. Awareness of hypercholesterolemia is approximately 55% or more in both men and women aged more than 35 years. Treatment rates lag far behind awareness, particularly in younger adult men, and less than 50% of women and men aged less than 65 years were treated for hypercholesterolemia.

CONCLUSION

Higher rates of identification and effective treatment of dyslipidemia are clearly needed in this, and probably other African-American communities. Despite the less than optimal treatment, the identification and importance of the known cardiovascular disease states and risk factors in these analyses suggest the adoption of National Cholesterol Education Program III "high-risk strategy" algorithms in treatment recommendations and decisions by providers is occurring.

Genetic differences between the determinants of lipid profile phenotypes in African and European Americans: the Jackson Heart Study

Genome-wide association analysis in populations of European descent has recently found more than a hundred genetic variants affecting risk for common disease. An open question, however, is how relevant the variants discovered in Europeans are to other populations. To address this problem for cardiovascular phenotypes, we studied a cohort of 4,464 African Americans from the Jackson Heart Study (JHS), in whom we genotyped both a panel of 12 recently discovered genetic variants known to predict lipid profile levels in Europeans and a panel of up to 1,447 ancestry informative markers allowing us to determine the African ancestry proportion of each individual at each position in the genome. Focusing on lipid profiles -- HDL-cholesterol (HDL-C), LDL-cholesterol (LDL-C), and triglycerides (TG) -- we identified the lipoprotein lipase (LPL) locus as harboring variants that account for interethnic variation in HDL-C and TG. In particular, we identified a novel common variant within LPL that is strongly associated with TG (p = 2.7 x 10(-6)) and explains nearly 1% of the variability in this phenotype, the most of any variant in African Americans to date. Strikingly, the extensively studied "gain-of-function" S447X mutation at LPL, which has been hypothesized to be the major determinant of the LPL-TG genetic association and is in trials for human gene therapy, has a significantly diminished strength of biological effect when it is found on a background of African rather than European ancestry. These results suggest that there are other, yet undiscovered variants at the locus that are truly causal (and are in linkage disequilibrium with S447X) or that work synergistically with S447X to modulate TG levels. Finally, we find systematically lower effect sizes for the 12 risk variants discovered in European populations on the African local ancestry background in JHS, highlighting the need for caution in the use of genetic variants for risk assessment across different populations.

Cardiovascular disease event classification in the Jackson Heart Study: methods and procedures

OBJECTIVE

The process of identifying, abstracting, and classifying cardiovascular disease (CVD) endpoints in the Jackson Heart Study (JHS) is described.

METHOD

Trained interviewers conduct telephone annual followup interviews on or near the JHS exam 1 anniversary to ascertain any significant health events since the last JHS contact, including diagnostic tests, hospitalizations, or death. Information on cohort hospitalizations and deaths is transmitted to the medical record abstraction (MRA) unit who review death certificates and hospital records to identify CVD events in the cohort. Interviews with the next of kin and completed questionnaires by physicians and medical examiners or coroners are used to obtain information on deaths in the cohort. A computer-generated diagnosis with follow-up review and adjudication by trained medical personnel completes final, disease-specific event classification of hospitalized and fatal coronary heart disease (CHD), stroke, and congestive heart failure (CHF) events.

DISCUSSION

Surveillance of this well-characterized group of African Americans for CVD events as well as sub- and preclinical manifestations of disease is a central aspect of the JHS. Particular focus is placed on the leading causes of CVD illness and death, including fatal and nonfatal CHD, stroke, and CHF.

Laboratory, reading center, and coordinating center data management methods in the Jackson Heart Study

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in the United States. In comparison to whites, African-Americans have a higher risk of dying from CVD and have a worse risk factor profile. The Jackson Heart Study (JHS) is designed to investigate the origin and natural history of CVD in African-Americans.

METHODS

Reading centers for electrocardiograms, echocardiograms, carotid ultrasonograms, pulmonary function tests, and ambulatory blood pressure monitoring provide training for data accrual, quality assurance assessments, and specialized measurements for research objectives. Laboratories adhering to well-established quality assurance programs provide blood and urine analyses, as well as storage of specimens for future assays. A new Coordinating Center was created to perform functions analogous to those of coordinating centers for multisite studies, including protocol development, data management, statistical analyses, and operational support for the study. An established coordinating center serves as a resource to the JHS Coordinating Center, providing assistance in preparing procedure manuals and data collection forms. This group also designed and developed the JHS data management system.

RESULTS

This network of specialized research organizations is implementing state- of-the-science methodologies to assess prevalence, progression, and incidence of CVD and subclinical atherosclerosis, and to evaluate a myriad of risk factors. From November 2000 through March 2004, JHS collected 4000 data fields on each of more than 5300 African-American participants.

CONCLUSIONS

This article describes the roles of specialized research agencies contributing to JHS, and the methodologies being utilized to accumulate study data. A diverse collection of scientific disciplines is required to collect the information needed to meet the objectives of the JHS.