A multifaceted intervention to improve blood pressure control: The Guideline Adherence for Heart Health (GLAD) study

BACKGROUND

Although high blood pressure is associated with significant morbidity and mortality, the proportion reaching the goal blood pressures as outlined in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, Treatment of High Blood Pressure (JNC 7) is low. We conducted a randomized trial in primary care practices of a multifactorial intervention targeted to improve providers' adherence to hypertension guidelines.

METHOD

A total of 61 primary care practices in North Carolina were randomized to receive either a multifactorial intervention (guideline dissemination via a continuing medical education session, academic detailing sessions, audit and feedback on preintervention rates of adherence, and automated blood pressure machines) or an attention control of similar magnitude but targeted at a different guideline. Outcomes were determined through review of patient charts conducted by an independent masked quality assurance organization.

RESULTS

We found no difference between the 2 groups in any of the adherence measures including no difference in the percentage of patients at goal (intervention 49.2%, control 50.6%), with undiagnosed hypertension (18.1% vs 13.6%), average systolic (126 vs 125.1 mm Hg), or diastolic blood pressure (73.1 vs 73.4 mm Hg). Similarly, there was no difference in provider adherence to treatment recommendations (use of thiazide-type diuretic as first-line therapy: 32% vs 29.5%; use of 2-drug therapy in stage 2 hypertension: 11.3% vs 10.4%).

CONCLUSION

An intensive, multifactorial intervention did not improve adherence to national hypertension guidelines among community-based primary care. Efforts should be focused on other types of interventions to improve rates of control of hypertension.

Child healthcare in two farmworker populations

Children in farmworker families are medically underserved. Little research has documented the healthcare of these children. This analysis uses data collected from two populations of Latino farmworker families, one located in western North Carolina and western Virginia, and the other located in eastern North Carolina, to describe and compare child healthcare utilization and mothers' satisfaction with their children's healthcare. Child, mother, household and health services characteristics are examined as causes of variation in child healthcare utilization and mothers' satisfaction for each farmworker population. Results highlight strengths in the provision of healthcare to farmworker children, including most receiving care at a consistent healthcare facility, age appropriate time since last visit, and satisfaction with the care received. Shortcomings in farmworker child healthcare include few having a consistent healthcare provider, and many not receiving visits with recommended frequency. Differences observed in child health services between the two populations include dissatisfaction with care received, perceptions that healthcare staff members are disrespectful, and difficulties with transportation. Further research is needed to determine the best means of providing care to this underserved population.

Oral Health and Quality of Life of Migrant and Seasonal Farmworkers in North Carolina

Oral health deficits can have a significant effect on workers' general health and their ability to carry out normal activities. Although farmworkers have been found to lack access to dental care, few studies have documented their oral health status or its impact on quality of life (QOL). This research (1) describes the oral health problems experienced and oral health care received by Latino farmworkers in North Carolina, and (2) explores the association between oral health and QOL. Data were collected using face-to-face interviews from a representative sample of 151 farmworkers; data included oral health-related QOL (OHIP-14) and general health-related QOL (SF-12 Health Survey). Workers reported a high number of unmet needs: 52% reported caries, and 33% reported missing teeth. Only 21% had received dental services in the past year, almost all in Mexico rather than the U.S. The dimensions of oral health-related QOL most impaired were psychological discomfort and physical pain caused by dental problems. Number of functional oral health problems was the strongest predictor of oral health-related QOL (p < 0.001) and physical health-related QOL (p < 0.05), but was unrelated to mental health-related QOL. These findings indicate that the high rate of unmet oral health needs is associated with poorer farmworker QOL. The consequences of suffering on-going dental pain for work performance, sleep, and nutritional status are unknown. Because national data indicate that fewer farmworkers are returning to their countries of origin, communities with large farmworker populations need to address their unmet needs for dental care.

Review of pesticide education materials for health care providers providing care to agricultural workers

CONTEXT

Pesticide exposure is an important environmental and occupational health risk for agricultural workers and their families, but health care providers receive little training in it.

OBJECTIVE

To evaluate the medical resources available to providers caring for patients, particularly farmworkers, exposed to pesticides and to recommend a selective bibliography for use in educating clinicians about pesticides and health care. These resources are divided into 3 domains: (1) the working knowledge, (2) the skill set, and (3) the references needed to care for these patients.

METHODS

We searched library databases dating back to 1995, as well as conference materials and Internet resources. Materials were included only if they were readily available through customary sources. Materials were randomly divided into 2 groups. Two authors wrote detailed reviews for each group. The remaining authors read each document and review, making changes that were agreed upon by the team. Review procedures were standardized to examine the contemporary relevance, quality, and overall strengths and weaknesses of the material relative to guidelines developed for each domain. These guidelines were developed from the authors' experience, national focus groups, and literature review.

RESULTS

While no 1 resource adequately addresses all needs, a number of resources were identified addressing the categories of working knowledge, skill set, and reference materials. Few of the reviewed materials address the cultural competence of providers treating farmworkers. Additional education resources are needed.