A Systematic Review of the Hill-Bone Compliance to Blood Pressure Therapy Scale

Background

Poor medication adherence hampers hypertension control and increases the risk of adverse health outcomes. Medication adherence can be measured with direct and indirect methods. The Hill-Bone Compliance to High Blood Pressure Therapy (HBCHBPT) Scale, one of the most popular adherence measures, indirectly assesses adherence to hypertension therapy in three behavioral domains: appointment keeping, diet and medication adherence.

Aim

To synthesize evidence on the use of the HBCHBPT Scale, including psychometric properties, utility in diverse patient populations, and directions for future clinical use and research.

Methods

We searched electronic databases, specifically CINAHL, PubMed, PsychInfo, Embase, and Web of Science. We included original studies that used the HBCHBPT Scale or its subscales to measure a health outcome, or methodological studies involving translations and validations of the scale. We extracted and synthesized data following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines.

Results

Fifty studies were included in this review, 44 on hypertension, two on diabetes, and others on other chronic conditions. The scale was successfully translated into numerous languages and used in descriptive and intervention studies. The scale demonstrated sound psychometric properties (Cronbach's α coefficient 0.75) and sensitivity to capture intervention effects when used to evaluate the effectiveness of high blood pressure adherence interventions. The medication-taking subscale of HBCHBPT performs best and is widely used in diverse contexts to assess medication adherence for chronic conditions.

Conclusion

The HBCHBPT Scale has high versatility globally and has been used in various settings by various healthcare worker cadres and researchers. The scale has several strengths, including high adherence phenotyping capabilities, contributing to the paradigm shift toward personalized health care.

Integrating community voices in the research continuum: Perspectives on a consultation service

The Community Research Advisory Council (C-RAC) of the Johns Hopkins Institute for Clinical and Translational Research was established in 2009 to provide community-engaged research consultation services. In 2016-2017, C-RAC members and researchers were surveyed on their consultation experiences. Survey results and a 2019 stakeholder meeting proceeding helped redesign the consultation services. Transitioning to virtual consultations during COVID-19, the redesigning involved increasing visibility, providing consultation materials in advance, expanding member training, and effective communications. An increase in consultations from 28 (2009-2017) to 114 (2020-2022) was observed. Implementing stakeholder-researcher inputs is critical to holistic and sustained community-engaged research.

The benefits and challenges of established peer support programmes for patients, informal caregivers, and healthcare providers

PURPOSE

Peer support programmes that provide services for various health conditions have been in existence for many years; however, there is little study of their benefits and challenges. Our goal was to explore how existing peer support programmes help patients with a variety of health conditions, the challenges that these programmes meet, and how they are addressed.

METHODS

We partnered with 7 peer support programmes operating in healthcare and community settings and conducted 43 semi-structured interviews with key informants. Audiorecordings were transcribed and qualitative analysis was conducted using grounded theory methods.

RESULTS

Peer support programmes offer informational and psychosocial support, reduce social isolation, and connect patients and caregivers to others with similar health issues. These programmes provide a supportive community of persons who have personal experience with the same health condition and who can provide practical information about self-care and guidance in navigating the health system. Peer support is viewed as different from and complementary to professional healthcare services. Existing programmes experience challenges such as matching of peer supporter and peer recipient and maintaining relationship boundaries. They have gained experience in addressing some of these challenges.

CONCLUSIONS

Peer support programmes can help persons and caregivers manage health conditions but also face challenges that need to be addressed through organizational processes. Peer support programmes have relevance for improving healthcare systems, especially given the increased focus on becoming more patient-centred. Further study of peer programmes and their relevance to improving individuals' well-being is warranted.

Exploring community engaged research experiences and preferences: a multi-level qualitative investigation

BACKGROUND

Community engagement may make research more relevant, translatable, and sustainable, hence improving the possibility of reducing health disparities. The purpose of this study was to explore strategies for community engagement adopted by research teams and identify areas for enhancing engagement in future community engaged research.

METHODS

The Community Engagement Program of the Johns Hopkins Institute for Clinical and Translational Research hosted a forum to engage researchers and community partners in group discussion to reflect on their diverse past and current experiences in planning, implementing, and evaluating community engagement in health research. A total of 50 researchers, research staff, and community partners participated in five concurrent semi-structured group interviews and a whole group wrap-up session. Group interviews were audiotaped, transcribed verbatim, and analyzed using content analysis.

RESULTS

Four themes with eight subthemes were identified. Main themes included: Community engagement is an ongoing and iterative process; Community partner roles must be well-defined and clearly communicated; Mutual trust and transparency are central to community engagement; and Measuring community outcomes is an evolving area. Relevant subthemes were: engaging community partners in various stages of research; mission-driven vs. "checking the box"; breadth and depth of engagement; roles of community partner; recruitment and selection of community partners; building trust; clear communication for transparency; and conflict in community engaged research.

CONCLUSION

The findings highlight the benefits and challenges of community engaged research. Enhanced capacity building for community engagement, including training and communication tools for both community and researcher partners, are needed.

Social Determinants of Health as Potential Influencers of a Collaborative Care Intervention for Patients with Hypertension

Objectives

The use of collaborative care teams, comprising nurse care managers and community health workers, has emerged as a promising strategy to tackle hypertension disparities by addressing patients' social determinants of health. We sought to identify which social determinants of health are associated with a patient's likelihood of engaging with collaborative care team members and with the nurse care manager's likelihood of enlisting community health workers (CHW) to provide additional support to patients.

Methods

We conducted a within-group longitudinal analysis of patients assigned to receive a collaborative care intervention in a pragmatic, cluster randomized trial that aims to reduce disparities in hypertension control (N=888). Generalized estimating equations were used to identify which social determinants of health, reported on the study's baseline survey, were associated with the odds of patients engaging with the collaborative care intervention, and of nurses deploying community health workers.

Results

Patients who were unable to work and those with higher health literacy were less likely to engage with the collaborative care team than those who were employed full time or had lower health literacy, respectively. Patients had a greater likelihood of being referred to a community health worker by their care manager if they reported higher health literacy, perceived stress, or food insecurity, while those reporting higher numeracy had lower odds of receiving a CHW referral.

Implications/Conclusions

A patient's social determinants of health influence the extent of engagement in a collaborative care intervention and nurse care manager appraisals of the need for supplementary support provided by community health workers.

Methodology and baseline characteristics of a randomized controlled trial testing a health care professional and peer-support program for patients with chronic obstructive pulmonary disease: The BREATHE2 study

BACKGROUND

Self-management support (SMS) for patients with COPD can improve health-related quality of life (HRQOL). However, it remains unclear what SMS strategies are most effective. Using peer support to advance self-management is promising, as peer supporters possess credibility and can serve as role models.

METHODS

We conducted a single-blinded RCT comparing the effectiveness of two strategies to support patients with COPD. The strategies were 'Health Care Professional (HCP)' and 'HCP Plus Peer' support. Peer support was provided by patients with COPD who have stopped smoking, completed an acute pulmonary rehabilitation program, and met the requirements for becoming a peer supporter. We enrolled patients receiving treatment at inpatient and outpatient settings. Patients were encouraged to invite one family-caregiver to enroll with them. The primary outcome measure was the change in HRQOL at 6 months post enrollment. Secondary outcomes included COPD-related and all-cause hospitalizations and ED visits. Caregiver outcomes included preparedness for caregiving, caregiver stress, and coping.

RESULTS

A total of 292 patients as well as 50 family-caregivers were enrolled. The average patient age was 67.3 yrs. (SD 9.4), 61% were female and 26% were African-Americans. The majority of caregivers were females (68%) and were a spouse/partner (58%).

DISCUSSION

This study tested a dual strategy for providing support to patients with COPD that incorporates peer and health care professional support. The study had minimal exclusion criteria. If shown effective, the study offers a program of peer support that can be readily implemented in health care settings.

Effect of a Hospital-Initiated Program Combining Transitional Care and Long-term Self-management Support on Outcomes of Patients Hospitalized With Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial

IMPORTANCE

Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations have high rehospitalization rates and reduced quality of life.

OBJECTIVE

To evaluate whether a hospital-initiated program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers can improve outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Single-site randomized clinical trial conducted in Baltimore, Maryland, with 240 participants. Participants were patients hospitalized due to COPD, randomized to intervention or usual care, and followed up for 6 months after hospital discharge. Enrollment occurred from March 2015 to May 2016; follow-up ended in December 2016.

INTERVENTIONS

The intervention (n = 120) involved a comprehensive 3-month program to help patients and their family caregivers with long-term self-management of COPD. It was delivered by nurses with special training on supporting patients with COPD using standardized tools. Usual care (n = 120) included transition support for 30 days after discharge to ensure adherence to discharge plan and connection to outpatient care.

MAIN OUTCOMES AND MEASURES

The primary outcome was number of COPD-related acute care events (hospitalizations and emergency department visits) per participant at 6 months. The co-primary outcome was change in participants' health-related quality of life measured by the St George's Respiratory Questionnaire (SGRQ) at 6 months after discharge (score, 0 [best] to 100 [worst]; 4-point difference is clinically meaningful).

RESULTS

Among 240 patients who were randomized (mean [SD] age, 64.9 [9.8] years; 61.7% women), 203 (85%) completed the study. The mean (SD) baseline SGRQ score was 62.3 (18.8) in the intervention group and 63.6 (17.4) in the usual care group. The mean number of COPD-related acute care events per participant at 6 months was 1.40 (95% CI, 1.01-1.79) in the intervention group vs 0.72 (95% CI, 0.45-0.97) in the usual care group (difference, 0.68 [95% CI, 0.22-1.15]; P = .004). The mean change in participants' SGRQ total score at 6 months was 2.81 in the intervention group and -2.69 in the usual care group (adjusted difference, 5.18 [95% CI, -2.15 to 12.51]; P = .11). During the study period, there were 15 deaths (intervention: 8; usual care: 7) and 339 hospitalizations (intervention: 202; usual care: 137).

CONCLUSIONS AND RELEVANCE

In a single-site randomized clinical trial of patients hospitalized due to COPD, a 3-month program that combined transition and long-term self-management support resulted in significantly greater COPD-related hospitalizations and emergency department visits, without improvement in quality of life. Further research is needed to determine reasons for this unanticipated finding.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02036294.

The Baltimore Community-Based Organizations Neighborhood Network: Enhancing Capacity Together (CONNECT) Cluster RCT

INTRODUCTION

This cluster RCT aimed to reduce healthcare utilization and increase the referral of patients between an academic health center and local community-based organizations (CBOs) that address social determinants of health.

STUDY DESIGN

Cluster RCT.

SETTINGS/PARTICIPANTS

Twenty-two CBOs located in Baltimore, Maryland, were randomly assigned to the intervention or control group, and 5,255 patients were allocated to the intervention or control group based on whether they lived closer to an intervention or control CBO. Data were collected in 2014-2016; the analysis was conducted in 2016.

INTERVENTION

A multicomponent intervention included an online tool to help refer clients to community resources, meet-and-greet sessions between CBO staff and healthcare staff, and research assistants.

MAIN OUTCOME MEASURES

The primary outcomes were patient emergency department visits and days spent in the hospital. Additional outcomes for CBO clients included knowledge of other CBOs, number of referrals to CBOs by the healthcare system, and number of referrals to healthcare system by CBOs. Outcomes for CBO staff included the number of referrals made to and received from the healthcare system and the number of referrals made to and received from other CBOs.

RESULTS

There was no significant effect of the intervention on healthcare utilization outcomes, CBO client outcomes, or CBO staff outcomes. Ancillary analyses demonstrated a 2.9% increase in referrals by inpatient staff to intervention CBOs (p=0.051) and a 6.6% increase in referrals by outpatient staff to intervention CBOs between baseline and follow-up (p=0.027). Outpatient staff reported a significant reduction in barriers related to the lack of information about CBO services (-18.3%, p=0.004) and an increase in confidence in community resources (+14.4%, p=0.023) from baseline to follow-up.

CONCLUSIONS

The intervention did not improve healthcare utilization outcomes but was associated with increased healthcare staff knowledge of, and confidence in, local CBOs.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02222909.

How Co-Developed Are Community and Academic Partnerships?

BACKGROUND

The world-renowned resources of Johns Hopkins Hospital (JHH) in Baltimore, Maryland, stand in marked contrast with the surrounding impoverished neighborhoods. Community-based organizations (CBOs) are critical frontline responders to residents' needs. Baltimore CONNECT, an academic-community partnership, co-developed an intervention to strengthen connections between CBOs and between CBOs and the health care system.

OBJECTIVES

To understand how members of an academic- community partnership define the act of "co-development" and share perceptions of barriers, facilitators, and ways to measure it.

METHODS

We conducted semistructured interviews with 15 community partners, academic partners, and external stakeholders.

RESULTS

Partners conceptualized co-development as a fluid and evolving process that is the outcome of shared decision making. This exploration revealed nuances within partnership dynamics, including motivations for participation, underlying incentives, partnership equality, balance of power, and trust and relation building.

CONCLUSIONS

We present insights that can be used by academic researchers and community leaders looking to co-develop interventions to improve health in urban communities domestically and internationally.JHH in Baltimore, Maryland, is one of the most highly regarded hospitals in the United States. However, its institutional resources stand in marked contrast with those available to the impoverished neighborhoods that surround it. Many have called for JHH to play a greater role in the surrounding community, where it serves as a leading source of health care.

Patient-level Predictors of Extent of Exposure to a Community Health Worker Intervention in a Randomized Controlled Trial

Objective

Community health worker (CHW) interventions have been cited as a best practice for reducing health disparities, but patient-level attributes may contribute to differential uptake. We examined patient characteristics associated with the extent of exposure to a CHW coaching intervention among a predominantly low-income, African American population participating in a randomized controlled trial of hypertension interventions.

Design

We conducted a within-group longitudinal analysis of those receiving a CHW intervention from a study conducted between September 2003 and August 2005. We employed mixed effects models to ascertain relationships between patients' characteristics, length of time spent with the CHW, and the number of topics discussed during the intervention.

Setting

Baltimore, MD.

Participants

140 patients with a diagnosis of hypertension in the CHW intervention arm.

Results

Marital status, stress, depression symptomology, and having multiple comorbid conditions were each independently and positively related to the length of time patients spent with CHWs. An indirect relationship between higher perceived physical health and time spent with the CHW was observed. Patients with multiple comorbid conditions discussed more intervention-related topics, while patients who perceived themselves as being healthier discussed fewer topics. Marital status and extreme poverty were the strongest predictors of the length of time spent with the CHW, while having multiple comorbid conditions was the strongest predictor of the number of coaching topics discussed.

Conclusions

Differential exposure to a CHW intervention is influenced by patients' physical, psychosocial, and sociodemographic characteristics.

Community Engagement to Address Cancer Health Disparities: A Process EVALUATION using the Partnership Self-Assessment Tool

BACKGROUND

African Americans suffer disproportionately from cancer health disparities, and population-level prevention is needed.

OBJECTIVES

A community-academic partnership to address cancer health disparities in two predominately African American jurisdictions in Maryland was evaluated.

METHODS

The Partnership Self-Assessment Tool (PSAT) was used in a process evaluation to assess the partnership in eight domains (partnership synergy, leadership, efficiency, management, resources, decision making, participation, and satisfaction).

RESULTS

Mean scores in each domain were high, indicative of a functional and synergistic partnership. However, scores for decision making (Baltimore City's mean score = 9.3; Prince George's County's mean score = 10.8; p = .02) and participation (Baltimore City's mean score = 16.0; Prince George's County's mean score = 18.0; p = .04) were significantly lower in Baltimore City.

CONCLUSIONS

Community-academic partnerships are promising approaches to help address cancer health disparities in African American communities. Factors that influence decision making and participation within partnerships require further research.

Effect of a Program Combining Transitional Care and Long-term Self-management Support on Outcomes of Hospitalized Patients With Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial

IMPORTANCE

Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations have high rehospitalization rates and reduced quality of life.

OBJECTIVE

To evaluate a hospital-initiated program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers.

DESIGN, SETTING, AND PARTICIPANTS

This single-site randomized clinical trial was conducted in Baltimore, Maryland, with 240 participants. Participants were patients hospitalized due to COPD, randomized to intervention or usual care, and followed up for 6 months after hospital discharge. Enrollment occurred from March 2015 to May 2016; follow-up ended in December 2016.

INTERVENTIONS

The intervention (n = 120) was a comprehensive 3-month program to help patients and their family caregivers with long-term self-management of COPD. It was delivered by COPD nurses (nurses with special training on supporting patients with COPD using standardized tools). Usual care (n = 120) included transition support for 30 days after discharge to ensure adherence to discharge plan and connection to outpatient care.

MAIN OUTCOMES AND MEASURES

The primary outcome was number of COPD-related acute care events (hospitalizations and emergency department visits) per participant at 6 months. The co-primary outcome was change in participants' health-related quality of life measured by the St George's Respiratory Questionnaire (SGRQ) at 6 months after discharge (score, 0 [best] to 100 [worst]; 4-point difference is clinically meaningful).

RESULTS

Among 240 patients who were randomized (mean [SD] age, 64.9 [9.8] years; females, 61.7%), 203 (85%) completed the study. The mean (SD) baseline SGRQ score was 63.1 (19.9) in the intervention group and 62.6 (19.3) in the usual care group. The mean number of COPD-related acute care events per participant at 6 months was 0.72 (95% CI, 0.45-0.97) in the intervention group vs 1.40 (95% CI, 1.01-1.79) in the usual care group (difference, 0.68 [95% CI, 0.22 to 1.15]; P = .004). The mean change in participants' SGRQ total score at 6 months was -1.53 in the intervention and +5.44 in the usual care group (adjusted difference, -6.69 [95% CI, -12.97 to -0.40]; P = .04). During the study period, there were 15 deaths (intervention: 7; usual care: 8) and 337 hospitalizations (intervention: 135; usual care: 202).

CONCLUSIONS AND RELEVANCE

In a single-site randomized clinical trial of patients hospitalized due to COPD, a 3-month program that combined transition and long-term self-management support resulted in significantly fewer COPD-related hospitalizations and emergency department visits and better health-related quality of life at 6 months after discharge. Further research is needed to evaluate this intervention in other settings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02036294.

Correlates of Patterns of Health Values of African Americans Living With HIV/AIDS: Implications for Advance Care Planning and HIV Palliative Care

CONTEXT

Advance care planning rates remain low, especially among people who are HIV positive, disadvantaged, and African American. Although advance care planning can be a sensitive topic for clinicians and patients to discuss, health values clarification can be an important initial step.

OBJECTIVES

The purpose of the study was to explore health values of African Americans living with HIV/AIDS and to examine correlates of these values.

METHODS

Data were from the first 325 participants in the AFFIRM Care study, which enrolled adults living with HIV/AIDS in Baltimore, Maryland, who had histories of illicit drug use. Respondents were asked whether (yes/no) they thought any of six health states would be worse than death: severe unremitting pain, total dependency on others, irreversible coma, being on mechanical ventilation, nursing home residence, and severe dementia. Latent class analysis was used to group individuals by their pattern of responses, interpretable as preference for aggressive (life-sustaining) or nonaggressive (palliative) end-of-life care. Latent class regression analysis was used to examine associations between class membership and background, health status, and social variables.

RESULTS

We found statistical support for a three-class latent class analysis model: 1) the nonaggressive treatment class, comprising 43% of cases, in which members perceived that every state was worse than death; 2) the aggressive treatment class, comprising 33% of cases, in which members perceived that none of the states was worse than death; and 3) the mixed class (24% of cases), in which members perceived that only four of the six states were worse than death.

CONCLUSION

Three-quarters of participant response patterns had clear preferences for treatment decisions. Further research is needed to ensure inclusion of end-of-life scenarios relevant to this population.

Better Respiratory Education and Treatment Help Empower (BREATHE) study: Methodology and baseline characteristics of a randomized controlled trial testing a transitional care program to improve patient-centered care delivery among chronic obstructive pulmonary disease patients

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of hospitalizations. Interventional studies focusing on the hospital-to-home transition for COPD patients are few. In the BREATHE (Better Respiratory Education and Treatment Help Empower) study, we developed and tested a patient and family-centered transitional care program that helps prepare hospitalized COPD patients and their family caregivers to manage COPD at home.

METHODS

In the study's initial phase, we co-developed the BREATHE transitional care program with COPD patients, family-caregivers, and stakeholders. The program offers tailored services to address individual patients' needs and priorities at the hospital and for 3months post discharge. We tested the program in a single-blinded RCT with 240 COPD patients who were randomized to receive the program or 'usual care'. Program participants were offered the opportunity to invite a family caregiver, if available, to enroll with them into the study. The primary outcomes were the combined number of COPD-related hospitalizations and Emergency Department (ED) visits per participant at 6months post discharge, and the change in health-related quality of life over the 6months study period. Other measures include 'all cause' hospitalizations and ED visits; patient activation; self-efficacy; and, self-care behaviors.

DISCUSSION

Unlike 1month transitional care programs that focus on patients' post-acute care needs, the BREATHE program helps hospitalized COPD patients manage the post discharge period as well as prepare them for long term self-management of COPD. If proven effective, this program may offer a timely solution for hospitals in their attempts to reduce COPD rehospitalizations.

Abstract A86: Challenges and opportunities for increasing the rates of HPV vaccination

Purpose: The purpose of this study is to determine the association between awareness of human papillomavirus (HPV), cervical cancer, and HPV vaccine and intention to vaccinate preteens and teens against HPV.

Background: Genital human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, and results in 14 million new cases each year. Around 50% of new HPV infections occur among persons aged 15-24 years old. Cervical cancer is primarily attributable to HPV, and the yearly cost of cervical cancer screening as well as treatment of HPV-related diseases is around $8 billion. In 2009, around 35,000 HPV-related cancers were reported in the United States. The level of coverage for 3 HPV vaccine doses for females aged 13-15 years was only 30% in 2011. This is far below the 80% target coverage level set by Healthy People 2020. The 2013 National Immunization Survey-Teen found that only 50% of Maryland females aged 13-17 years and only 34.2% of male adolescents reported beginning the HPV vaccine series.

According to the 2013 Maryland Cancer Data, Maryland had the 25th highest cervical cancer mortality rate from 2006-2010. During these years, more black women were diagnosed with cervical cancer than White women, and their rate of cervical cancer incidence has been increasing at a rate of 4.9% more per year than white women. We investigate the relationship between HPV, cervical cancer, and HPV vaccine awareness and intention to vaccinate preteens and teens against HPV.

Methods: Utilizing the principles of community-based participatory research (CBPR), the Johns Hopkins Center to Reduce Cancer Disparities, in collaboration with its Community Advisory Groups in Baltimore City and Prince George's County, developed and implemented a survey to assess the knowledge, awareness and behavioral intentions on cervical cancer, HPV and HPV vaccine. The study was approved by the Johns Hopkins School of Medicine's Institutional Review Board and implemented between March 2015 and July 2015 in Baltimore City and Prince George's County. Four hundred and three individuals recruited through community events completed the assessment. Upon completion of the assessment, participants were given feedback on their responses to address any knowledge gap and educational materials. Binary and multinomial logistic regression were used to determine the association between awareness of HPV, cervical cancer, and HPV vaccine and intention to vaccinate children between the ages of 11 and 18 years against HPV.

Results: The majority of study participants were female (78%), black or African American (87%), have at least one year of college or technical school (55%) and have an annual household income of less $20,000 (38%).

Awareness of the existing of HPV vaccine is significantly associated (OR=2.54, P<0.0007, CI 1.487-4.355) with the intention to vaccinate children against HPV. We also found that individuals who never heard of the HPV vaccine are significantly less likely (OR=0.394, p<0.0007, CI 0.230-0.673) to vaccinate their children against HPV than those who have heard of the vaccine. Furthermore, those who are aware of HPV are significantly more likely to know that HPV can cause cervical cancer (OR=5.25, P<0.0001, CI 3.272-8.454) and to know that HPV is transmitted through sexual contact (OR=3.66, P<0.0001, CI 2.199-6.100) compared to those who never heard of HPV.

Conclusion: Awareness of HPV, cervical cancer, and HPV vaccine are significantly associated the intention to vaccinate children between the ages of 11 and 18 years against HPV. Increasing knowledge of cervical cancer and the importance of HPV vaccination among parents and caretakers of preteens and teens have the potential to increase the rates of HPV vaccination and prevent future cervical cancers. More research is needed to explore other factors that are related to HPV vaccination.

Citation Format: Ahmed Elmi, Saad Tassaduq, Olive Mbah, Ashleigh DeFries, Lee Bone, Anjani Kapadia, Theron Scott, Nichole Tuite, Adrian Dobs. Challenges and opportunities for increasing the rates of HPV vaccination. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A86.

Characterizing Community Health Workers on Research Teams: Results From the Centers for Population Health and Health Disparities

OBJECTIVES

To quantify the characteristics of community health workers (CHWs) involved in community intervention research and, in particular, to characterize their job titles, roles, and responsibilities; recruitment and compensation; and training and supervision.

METHODS

We developed and administered a structured questionnaire consisting of 25 closed- and open-ended questions to staff on National Institutes of Health-funded Centers for Population Health and Health Disparities projects between March and April 2014. We report frequency distributions for CHW roles, sought-after skills, education requirements, benefits and incentives offered, and supervision and training activities.

RESULTS

A total of 54 individuals worked as CHWs across the 18 research projects and held a diverse range of job titles. The CHWs commonly collaborated on research project implementation, provided education and support to study participants, and collected data. Training was offered across projects to bolster CHW capacity to assist in intervention and research activities.

CONCLUSIONS

Our experience suggests national benefit in supporting greater efforts to recruit, retain, and support the work of CHWs in community-engagement research.

Effect of Patient Navigation on Breast Cancer Screening Among African American Medicare Beneficiaries: A Randomized Controlled Trial

BACKGROUND

There is growing evidence that patient navigation improves breast cancer screening rates; however, there are limited efficacy studies of its effect among African American older adult women.

OBJECTIVE

To evaluate the effect of patient navigation on screening mammography among African American female Medicare beneficiaries in Baltimore, MD.

DESIGN

The Cancer Prevention and Treatment Demonstration (CPTD), a multi-site study, was a randomized controlled trial conducted from April 2006 through December 2010.

SETTING

Community-based and clinical setting.

PARTICIPANTS

The CPTD Screening Trial enrolled 1905 community-dwelling African American female Medicare beneficiaries who were ≥65 years of age and resided in Baltimore, MD. Participants were recruited from health clinics, community centers, health fairs, mailings using Medicare rosters, and phone calls.

INTERVENTIONS

Participants were randomized to either: printed educational materials on cancer screening (control group) or printed educational materials + patient navigation services designed to help participants overcome barriers to cancer screening (intervention group).

MAIN MEASURE

Self-reported receipt of mammography screening within 2 years of the end of the study.

KEY RESULTS

The median follow-up period for participants in this analysis was 17.8 months. In weighted multivariable logistic regression analyses, women in the intervention group had significantly higher odds of being up to date on mammography screening at the end of the follow-up period compared to women in the control group (odds ratio [OR] 2.26, 95 % confidence interval [CI]1.59-3.22). The effect of the intervention was stronger among women who were not up to date with mammography screening at enrollment (OR 3.63, 95 % CI 2.09-6.38).

CONCLUSION

Patient navigation among urban African American Medicare beneficiaries increased self-reported mammography utilization. The results suggest that patient navigation for mammography screening should focus on women who are not up to date on their screening.

Mobilizing social support networks to improve cancer screening: the COACH randomized controlled trial study design

BACKGROUND

Disadvantaged populations face many barriers to cancer care, including limited support in navigating through the complexities of the healthcare system. Family members play an integral role in caring for patients and provide valuable care coordination; however, the effect of family navigators on adherence to cancer screening has not previously been evaluated. Training and evaluating trusted family members and other support persons may improve cancer outcomes for vulnerable patients.

METHODS

Guided by principles of community based participatory research (CBPR), "Evaluating Coaches of Older Adults for Cancer Care and Healthy Behaviors (COACH)" is a community-based randomized controlled trial to assess the effectiveness of a trained participant-designated coach (support person or care giver) in navigating cancer-screening for older African American adults, 50-74 years old. Participants are randomly assigned as dyads (participant+coach pair) to receiving either printed educational materials only (PEM--control group) or educational materials plus coach training (COACH--intervention group). We defined a coach as family member, friend, or other lay support person designated by the older adult. The coach training is designed as a one-time, 35- to 40-minute training consisting of: 1) a didactic session that covers the role of the coach, basic facts about colorectal, breast and cervical cancers (including risk factors, signs and symptoms and screening modalities), engaging the healthcare provider in cancer screening, insurance coverage for screening, and related healthcare issues, 2) three video skits addressing misconceptions about and planning for cancer screening, and 3) an interactive role-play session with the trainer to reinforce and practice strategies for encouraging the participant to get screened. The primary study outcome is the difference in the proportion of participants completing at least one of the recommended screenings (for breast, cervix or colorectal cancer) between the control and intervention groups.

DISCUSSION

Building on trusted patient contacts to encourage cancer screening, COACH is a highly sustainable intervention in a high-risk population. It has the potential to minimize the effect of mistrust of the medical establishment on screening behaviors by mobilizing participants' existing support networks. If effective, the intervention could have a high impact on health care disparities research across multiple diseases.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT01613430 ). Registered June 5, 2012.

The Relationship Between Education and Prostate-Specific Antigen Testing Among Urban African American Medicare Beneficiaries

PURPOSE

We examined the association between socioeconomic status (SES) and prostate-specific antigen (PSA) cancer screening among older African American men.

METHODS

We analyzed baseline data from a sample of 485 community-dwelling African American men who participated in the Cancer Prevention and Treatment Demonstration Trial. The outcome was receipt of PSA screening within the past year. SES was measured using income and educational attainment. Sequential multivariate logistic regression models were performed to study whether health care access, patient-provider relationship, and cancer fatalism mediated the relationship between SES and PSA screening.

RESULTS

Higher educational attainment was significantly associated with higher odds of PSA screening in the past year (odds ratio (OR) 2.08 for college graduate compared to less than high school graduate, 95 % confidence interval (CI) 1.03-4.24); income was not. Health care access and patient-provider communication did not alter the relationship between education and screening; however, beliefs regarding cancer fatalism partially mediated the observed relationship.

CONCLUSION

Rates of prostate cancer screening among African American men vary by level of educational attainment; beliefs concerning cancer fatalism help explain this gradient. Understanding the determinants of cancer fatalism is a critical next step in building interventions that seek to ensure equitable access to prostate cancer screening.

Gender differences in correlates of colorectal cancer screening among Black Medicare beneficiaries in Baltimore

BACKGROUND

Previous research has shown colorectal cancer (CRC) screening disparities by gender. Little research has focused primarily on gender differences among older Black individuals, and reasons for existing gender differences remain poorly understood.

METHODS

We used baseline data from the Cancer Prevention and Treatment Demonstration Screening Trial. Participants were recruited from November 2006 to March 2010. In-person interviews were used to assess self-reported CRC screening behavior. Up-to-date CRC screening was defined as self-reported colonoscopy or sigmoidoscopy in the past 10 years or fecal occult blood testing in the past year. We used multivariable logistic regression to examine the association between gender and self-reported screening, adjusting for covariates. The final model was stratified by gender to examine factors differentially associated with screening outcomes for males and females.

RESULTS

The final sample consisted of 1,552 female and 586 male Black Medicare beneficiaries in Baltimore, Maryland. Males were significantly less likely than females to report being up-to-date with screening (77.5% vs. 81.6%, P = 0.030), and this difference was significant in the fully adjusted model (OR: 0.72; 95% confidence interval, 0.52-0.99). The association between having a usual source of care and receipt of cancer screening was stronger among males compared with females.

CONCLUSIONS

Although observed differences in CRC screening were small, several factors suggest that gender-specific approaches may be used to promote screening adherence among Black Medicare beneficiaries.

IMPACT

Given disproportionate CRC mortality between White and Black Medicare beneficiaries, gender-specific interventions aimed at increasing CRC screening may be warranted among older Black patients.

Mobilizing for policy: using community-based participatory research to impose minimum packaging requirements on small cigars

THE PROBLEM

Cigarette sales have declined in the United States over the past decade; however, small cigar sales have been rapidly increasing. In most urban areas, small cigars are inexpensive and are sold as singles without health warnings.

PURPOSE OF ARTICLE

This paper describes a community- academic-practice partnership's (CAPP) efforts to decrease small cigar use in young adults living in Baltimore, Maryland, through legislative strategies.

KEY POINTS

Survey data among young adults not in school indicated that 20% of individuals reported current small cigar use, often in combination with cigarettes. The community- academic partnership engaged the community in discussion about small cigar use in the fall of 2007. In collaboration with partners, bills were submitted to the legislative bodies for the city and state to impose minimum packaging requirements on small cigars.

CONCLUSION

Collaborative partnerships between community-based organizations, public health agencies, and academic institutions can lead to policy initiatives with the potential to improve public health.

Community Outreach and Cardiovascular Health (COACH) Trial: a randomized, controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers

BACKGROUND

Despite well-publicized guidelines on the appropriate management of cardiovascular disease and type 2 diabetes, the implementation of risk-reducing practices remains poor. This report describes the results of a randomized, controlled clinical trial evaluating the effectiveness of a comprehensive program of cardiovascular disease risk reduction delivered by nurse practitioner /community health worker (NP/CHW) teams versus enhanced usual care (EUC) to improve lipids, blood pressure, glycated hemoglobin (HbA1c), and patient perceptions of the quality of their chronic illness care in patients in urban community health centers.

METHODS AND RESULTS

A total of 525 patients with documented cardiovascular disease, type 2 diabetes, hypercholesterolemia, or hypertension and levels of LDL cholesterol, blood pressure, or HbA1c that exceeded goals established by national guidelines were randomly assigned to NP/CHW (n=261) or EUC (n=264) groups. The NP/CHW intervention included aggressive pharmacological management and tailored educational and behavioral counseling for lifestyle modification and problem solving to address barriers to adherence and control. Compared with EUC, patients in the NP/CHW group had significantly greater 12-month improvement in total cholesterol (difference, 19.7 mg/dL), LDL cholesterol (difference,15.9 mg/dL), triglycerides (difference, 16.3 mg/dL), systolic blood pressure (difference, 6.2 mm Hg), diastolic blood pressure (difference, 3.1 mm Hg), HbA1c (difference, 0.5%), and perceptions of the quality of their chronic illness care (difference, 1.2 points).

CONCLUSIONS

An intervention delivered by an NP/CHW team using individualized treatment regimens based on treat-to-target algorithms can be an effective approach to improve risk factor status and perceptions of chronic illness care in high-risk patients.

Abstract B23: Socioeconomic factors and correlates of prostatespecific antigen testing in urban African-American Medicare beneficiaries

Background: Prostate specific antigen (PSA) testing is frequently used for early detection of prostate cancer, including among older adults. Since both race and socioeconomic status are associated with prostate cancer incidence and outcomes, it is often difficult to separate race from socioeconomic status as a determinant of prostate cancer screening. We sought to describe the relationship between socioeconomic status and PSA testing in a sample of urban, African American Medicare beneficiaries, and to examine factors that may contribute to this relationship.

Methods: We examined baseline questionnaire data collected from the Cancer Prevention and Treatment Demonstration, a community-based randomized, controlled trial in Baltimore, MD. The study population consisted of 511 community-dwelling African-American men, age 65–75, without a history of prostate cancer. Our main outcome was PSA testing within the past year. Sequential multivariate logistic regression models were performed to study factors that may mediate the relationship between socioeconomic status and PSA screening.

Results: Eighty percent of participants reported having had at least one PSA test in their lifetime, and approximately 50% reported having one within the past year. About half of the sample population reported a household income of less than $30,000 a year and one-third reported education past high school, but only 14% reported a bachelor's degree or higher. In bivariate analyses both higher income ($30,000 vs. < $10,000) (Odds Ratio [OR] 3.14, 95% Confidence Interval [CI] 1.79, 5.52) and higher levels of education (Bachelor's degree vs. less than high school) (OR 3.19, CI 1.72, 5.71) were associated with screening in the past year. In a multivariable regression model, which controlled for marital status, family history, and self-reported health status, income was no longer a significantly associated with PSA testing while the association between educational attainment and PSA testing was reduced (OR 2.13, 95% CI 1.07–4.22). The addition of increased healthcare access and patient-provider relationship measures in sequential models did not alter the relationship between educational attainment and screening. However, upon inclusion of cancer knowledge and belief measures the association between education and PSA testing was no longer significant (OR 1.84, 95% CI 0.90–3.75).

Conclusions: In this urban, African American Medicare population, socioeconomic status was associated with PSA testing. This relationship may be explained, in part, by demographic factors and cancer knowledge and beliefs.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B23.

Abstract B11: Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American Medicare beneficiaries

Background: In recent years, colorectal cancer screening rates have increased steadily in the United States, though racial and ethnic disparities persist. We investigated the effect of a patient navigation intervention on adherence to colorectal cancer screening guidelines among African American older adults in Baltimore, MD.

Methods: We examined data collected from the Cancer Prevention and Treatment Demonstration (CPTD), a community-based randomized, controlled trial. Our study population consisted of 661 African American men and women aged 65 to 75 years who were Medicare beneficiaries and residents of Baltimore City. Participants were randomized to receive either printed educational materials only (PEM) or the addition of a patient navigator (NAV). The Johns Hopkins trained and certified patient navigator assisted participants with identifying and overcoming potential barriers to cancer screening. Self-reported colorectal cancer screening data were collected at baseline and at one-year follow-up through inperson interviews. Rates of screening between the two groups were examined using multivariable logistic regression modeling. All participants irrespective of their baseline screening status were included in calculating the adjusted odds of completing colorectal cancer screening during the follow-up period.

Results: At baseline, 68% of the PEM group and 71% of the NAV group (P = 0.45) reported being up-to-date with colorectal cancer screening, defined as having either a fecal occult blood test (FOBT) within one year or colonoscopy/sigmoidoscopy within ten years of randomization. At the one-year follow-up visit, participants in the NAV group were more likely to report having undergone any colorectal cancer screening during the previous year, compared to the PEM group, 54% versus 46%, though this did not reach statistical significance (P = 0.12). After adjusting for age, gender, number of co-morbidities, education, participants’ health perception and level of health literacy, individuals in the NAV group were more likely to report being screened by colonoscopy/sigmoidoscopy (OR, 1.53; 95% CI, 1.07–2.18) compared to those in the PEM group. Individuals who underwent patient navigation did not have a statistically significant change in the likelihood of reporting a FOBT compared to the PEM group.

Conclusions: In a population of urban African American older adults, patient navigation was effective in increasing the likelihood of screening by colonoscopy/sigmoidoscopy but not fecal occult blood testing at one-year follow-up. The lack of effect on screening by FOBT likely represents the relatively low rate of provider utilization of this screening modality in the target population.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B11.

COACH trial: a randomized controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers: rationale and design

BACKGROUND

Despite well-publicized guidelines on the appropriate management of cardiovascular disease (CVD) and type 2 diabetes, implementation of risk-reducing practices remains poor. This paper describes the rationale and design of a randomized controlled clinical trial evaluating the effectiveness of a comprehensive program of CVD risk reduction delivered by nurse practitioner (NP)/community health worker (CHW) teams versus enhanced usual care in improving the proportion of patients in urban community health centers who achieve goal levels recommended by national guidelines for lipids, blood pressure, HbA1c and prescription of appropriate medications.

METHODS

The COACH (Community Outreach and Cardiovascular Health) trial is a randomized controlled trial in which patients at federally-qualified community health centers were randomly assigned to one of two groups: comprehensive intensive management of CVD risk factors for one year by a NP/CHW team or an enhanced usual care control group.

RESULTS

A total of 3899 patients were assessed for eligibility and 525 were randomized. Groups were comparable at baseline on sociodemographic and clinical characteristics with the exception of statistically significant differences in total cholesterol and hemoglobin A1c.

CONCLUSIONS

This study is a novel amalgam of multilevel interdisciplinary strategies to translate highly efficacious therapies to low-income federally-funded health centers that care for patients who carry a disproportionate burden of CVD, type 2 diabetes and uncontrolled CVD risk factors. The impact of such a community clinic-based intervention is potentially enormous.

Influences on tobacco use among urban Hispanic young adults in Baltimore: findings from a qualitative study

BACKGROUND

Among Hispanics, lung cancer is the leading cause of cancer-related death for men and the second leading cause of cancer death for women in the United States. Despite recent growth in Baltimore City's Hispanic population, few data exist on tobacco use behaviors in this group.

OBJECTIVES

The present research sought to explore the social and environmental influences and norms that encourage or discourage tobacco use among Hispanic young adults in Baltimore.

METHODS

In collaboration with several community stakeholders, we conducted focus groups with Hispanic young adults 18 to 24 years old. Participants were recruited from a community-based service organization and invited to take part in one of four focus groups segregated by gender.

RESULTS

A total of 13 young men and 11 young women participated. Data from these focus groups indicate that cultural identity and gender norms leverage substantial influence in young adults' decision about whether, where, and with whom to smoke. The data also suggest multiple social and familial influences on their smoking and nonsmoking behaviors. Participants identified smoking practices and clear brand preferences that they feel distinguish Hispanics from other racial and ethnic groups. Despite acknowledging the high price of cigarettes, cost was not mentioned as a factor influential in their smoking decisions.

CONCLUSION

These results provide essential guidance for the development of appropriate tobacco prevention and cessation intervention strategies and policy recommendations to eliminate tobacco use among Hispanic young adults in Baltimore.

Partnering with education and job and training programs for sustainable tobacco control among Baltimore african american young adults

BACKGROUND

Young adults are generally overlooked in tobacco control initiatives, even though they are critical to sustained success. African American young adults who are not in higher education or working are particularly vulnerable to harmful tobacco use, given high smoking rates and limited access to cessation services.

OBJECTIVES

Guided by community-based participatory research (CBPR) principles, we sought to identify program and community-level strategies to reduce tobacco use among African American young adults in Baltimore. We describe the challenges and opportunities for integrating effective tobacco control into community-based education and job training programs for unemployed young adults.

METHODS

As part of a longstanding community-research partnership in Baltimore, we conducted fourteen semistructured key informant interviews with leaders from city government and education and job training programs for young adults. The research design, data collection, analysis, and dissemination all included dialogue between and active contribution by both research and community partners.

RESULTS

Interview data were structured into opportunities (mindset for change and desire for bonds with a trusted adult), challenges (culture of fatalism, tobacco as a stress reliever, and culture of tobacco use among young adults), and possible tobacco control solutions (tobacco education designed with and for program staff and participants and integration of tobacco issues into holistic program goals and policies).

CONCLUSIONS

The emergent themes enhance our understanding of how tobacco is situated in the lives of unemployed young adults and the potential for building sustainable, community-based public health solutions.

Abstract B15: Effect of patient navigation on mammography screening among African American female Medicare beneficiaries at risk for low health literacy

Context: African American older adult women are diagnosed with more advanced breast cancer and have lower survival rates than White women. While differences in health literacy may contribute to this disparity, there is limited information on intervention strategies to promote cancer screening among low-literate African American older adults.

Objective: To evaluate the effect of a patient navigator on adherence to mammography screening among African American female Medicare beneficiaries with low literacy scores. Design, Setting, and Participants: We analyzed data from the Cancer Prevention and Treatment Demonstration (CPTD) at Johns Hopkins, an ongoing community-based trial designed to determine whether patient navigation is an effective strategy for improving adherence to cancer screening among African American older adults. Participants are randomized to either a high intensity group (patient navigation = educational materials) or a low intensity group (educational materials only). This analysis included 272 women ages of 65 and older with low literacy scores, who were enrolled into the study between November 2006 and March 2010, and had at least one year of follow up data. Baseline and one year follow up interviews were conducted face to face by trained interviewers through standardized questionnaires. The REALM-R instrument was used to identify participants at risk for low health literacy, based on their score.

Main Outcome Measure: The outcome measure for this analysis was the between-group difference in the proportion of women receiving mammography screening during the follow up period. Multiple logistic regression was performed to control for potential confounders such as age, education, Medicaid coverage, and perceived health status.

Results: Compared to the educational materials only group (n=77), the patient navigation group (n=107) had a similar proportion of women who reported a mammogram at one year follow up (64% vs. 71 %, p-value = 0.32). However, after adjusting for baseline health and demographic characteristics, women in the patient navigation group were more likely to report a mammogram at one year follow up, compared to those in the educational materials group (OR 1.90 95% CI 1.01-3.54). Women who rated themselves as having excellent to good health at baseline were less likely to report a mammogram, than those who reported fair to poor health (OR 0.43 95% CI 0.21-0.87).

Conclusions: Use of a patient navigation-based intervention was positively associated with mammography screening adherence among African American older adult women with low literacy scores. In this study population, perception of health status may influence mammography screening adherence. Our findings underscore the need for tailored intervention strategies to reduce cancer screening disparities among low-literate African American older adults.

Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B15.

Training community health workers as diabetes educators for urban African Americans: value added using participatory methods

BACKGROUND

With growing use of Community Health Workers (CHWs) to reach underserved populations, there is a need for more information on training methods to prepare CHWs, particularly in a health educator role.

OBJECTIVES

To describe procedures used to recruit, train, and evaluate CHWs in Project Sugar 2, a randomized controlled trial of a nurse case manager and CHW team intervention designed to improve diabetes care and control in a sample of 542 urban African Americans with type 2 diabetes.

METHODS

CHWs received a Core Training on guidelines and procedures, didactic diabetes self-management education, and research protocol training. However, barriers to CHW implementation of the intervention were encountered, including CHW attrition, job performance and satisfaction issues, low self-confidence in knowledge and skills as educators, difficulties with maintaining a large caseload, and inefficiencies experienced in conducting home visits. To address barriers, the initial training was modified and condensed. A supplemental training utilizing participatory methods was developed collaboratively by CHWs and trainers to facilitate CHWs' designing of intervention materials in their own words and contributing processes for intervention implementation and quality control.

RESULTS

The supplemental training resulted in CHW retention, satisfaction, confidence in skills, and feelings of ownership of the intervention. Participant satisfaction with care received from the CHWs and the Project Sugar 2 intervention was rated as high by 97% and 93% of responders, respectively.

CONCLUSION

Core training in research intervention policies, procedures, and protocols, combined with an extended participatory training, led to effective preparation of laypersons to serve as CHWs.

A vision for progress in community health partnerships

Community-based participatory research (CBPR) is an increasingly used approach for conducting research to improve community health. Using Rogers' diffusion of innovations theory as a framework, it follows that future adoption of CBPR will occur if academic and community partners perceive CBPR to have greater relative advantage, compatibility, trialability, and observability, and less complexity than other research approaches. We propose that articles published in our new peer-reviewed journal--Progress in Community Health Partnerships: Research, Education, and Action (PCHP)--can influence academic and community partners' perceptions of CBPR that promote its adoption. Eight areas of scholarly activity are described that can promote health partnership research, education, and action: (1) original research, (2) work-in-progress and lessons learned, (3) policy and practice, (4) theory and methods, (5) education and training, (6) practical tools, (7) systematic reviews, and (8) community perspectives. These eight areas correspond with the eight main sections of PCHP. A brief description of each area's importance in promoting CBPR is provided along with examples of completed and ongoing work. Specific recommendations are made regarding issues, problems, and topics within each area on which CBPR work should focus. These recommendations, which present a vision for progress in community health partnerships, are based on idea generation and prioritization by a group of CBPR experts--PCHP's editors and editorial board.

Development and pilot evaluation of literacy-adapted diabetes and CVD education in urban, diabetic African Americans

BACKGROUND

Despite prevalent low literacy nationally, empirical research on the development and testing of literacy-adapted patient education remains limited.

OBJECTIVE

To describe procedures for developing and evaluating usability and acceptability of an adapted diabetes and CVD patient education.

DESIGN

Materials adaptation for literacy demand and behavioral activation criteria, and pre-/post-test intervention evaluation design.

PARTICIPANTS

Pilot sample of 30 urban African-American adults with type 2 diabetes with Below Average literacy (n = 15) and Average literacy (n = 15).

MEASUREMENTS

Wide Range Achievement Test (WRAT-3, Reading), assessment of diabetes and CVD knowledge, and patient rating scale.

RESULTS

Reading grade levels were: > 12th, 30%; 10th-12th, 20%; 7th-9th, 10%; 4th-6th grade, 10%; and < or = 3rd grade or unable to complete WRAT-3, 30%. Education materials were modified to a reading level of < or = 4th grade. Knowledge improved for Below Average (2.7 to 4.7, p = 0.005) and Average (3.8 to 5.7, p = 0.002) literacy groups, with up to a ten-fold increase, at post-education, in the number of participants responding correctly to some content items. The print materials and class received maximum usability and acceptability ratings from patients.

CONCLUSIONS

Development of patient education meeting very low literacy criteria was feasible, effective for knowledge acquisition, and highly acceptable irrespective of literacy level.

Barriers to smoking cessation in inner-city African American young adults

The prevalence of tobacco use among urban African American persons aged 18 to 24 years not enrolled in college is alarmingly high and a challenge for smoking cessation initiatives. Recent data from inner-city neighborhoods in Baltimore, Md, indicate that more than 60% of young adults smoke cigarettes. We sought to describe community-level factors contributing to this problem. Data from focus groups and surveys indicate that the sale and acquisition of "loosies" are ubiquitous and normative and may contribute to the high usage and low cessation rates.

Buying and selling "loosies" in Baltimore: the informal exchange of cigarettes in the community context

Since the release of the first Surgeon General's report, the proportion of adult smokers in the U.S. has been reduced by half (U.S. Department of Health and Human Services, 2004). This success has not, however, been equally felt across all social strata. Recent survey data from Baltimore show considerably elevated smoking rates within urban, African-American communities. Of particular concern was that in some communities, over half of the young adults (18-24 years old) smoke cigarettes. As yet, there has been little focus on understanding or preventing cigarette smoking among young adults, particularly for those seeking entry into the workforce rather than being engaged in higher education. In this paper, we explore community factors contributing to high young adult smoking prevalence. Our analysis is based on data from four focus groups conducted in 2004 as part of a community-based participatory research project with two urban education and job training organizations. The focus group data reflect the experiences and opinions of 28 young adult program participants (23 smokers and 5 nonsmokers). The data highlight a normalized practice of buying and selling single cigarettes ("loosies") within the community, with participants describing buying loose cigarettes as a preferred acquisition practice. We apply theories of informal economy and suggest that this alternative purchasing option may influence the smoking behavior of these young adults. We argue that public health efforts need to more closely consider the impact of community structures on program implementation. Overlooking key community characteristics such as the availability of single cigarettes may serve to intensify health disparities.

Effects of stressful life events in young black men with high blood pressure

OBJECTIVES

1) To describe stressful life events as experienced by a sample of young Black men with high blood pressure (HBP) living in inner-city Baltimore, Maryland; and 2) to examine the effect of cumulative stressful life events on substance use, depression, and quality of life.

METHODS

Data were obtained over 48 months by interview from 210 men in an HBP management study.

RESULTS

Stressors repeatedly occurring over time included death of family member or close friend (65.2%), having a new family member (32.9%), change in residence (31.4%), difficulty finding a job (24.3%), and fired or laid off from work (17.6%). Involvement with crime or legal matters was reported at least twice during the 48 months by 33.3% of men. When a cumulative stressful life events score was calculated by summing the number of events experienced at 6-month points over 48 months and tested for its relationship with the health outcomes, the findings of multivariate analyses revealed significant associations between cumulative life stressors and depression and quality of life. No significant relationship was found between stressful life events and substance use.

CONCLUSIONS

The results suggest that cumulative stressful life events have a negative effect on mental health and quality of life in young Black men with HBP. Future study should focus on developing interventions to assist individuals in managing distress related to stressful events with necessary community resources.

Help-seeking behaviors and depression among African American adolescent boys

This study examined the help-seeking behaviors of depressed, African American adolescents. Qualitative interviews were conducted with 18 urban, African American boys, ages 14 to 18, who were recruited from community-based mental health centers and after-school programs for youths. Interviews covered sociodemographic information, questions regarding depressive symptomotology, and open-ended questions derived from the Network-Episode Model--including knowledge, attitudes and behaviors related to problem recognition, help seeking, and perceptions of mental health services. Most often adolescents discussed their problems with their family and often received divergent messages about problem resolution; absent informal network resolution of their problems, professional help would be sought, and those receiving treatment were more likely to get support from friends but were less likely to tell friends that they were actually receiving care. Implications for social work research and practice are discussed.

Patient priorities and needs for diabetes care among urban African American adults

PURPOSE

This study was conducted to determine diabetes care priorities and needs in a group of urban African American adults with type 2 diabetes mellitus.

METHODS

One hundred nineteen African American adults with type 2 diabetes, aged 35 to 75, received behavioral/educational interventions from a nurse case manager, a community health worker, or both. Priorities and needs were assessed during 3 intervention visits.

RESULTS

The most frequently reported priorities for diabetes care were glucose self-monitoring (61%), medication adherence (47%), and healthy eating (36%). The most frequently addressed diabetes needs were glucose self-monitoring and medication adherence. Most of the intervention visits (77%) addressed non-diabetes-related health issues such as cardiovascular disease (36%) and social issues such as family responsibilities (30%).

CONCLUSIONS

Participants' self-reported priorities for diabetes care directly reflected the diabetes needs addressed. Needs beyond the focus of traditional diabetes care (social issues and insurance) are important to address in urban African Americans with type 2 diabetes. Interventions designed to address comprehensive health and social needs should be included in treatment and educational plans for this population.

The human connexin32 gene is transcribed from two tissue-specific promoters

The connexin32 (cx32) gene codes for the gap junction protein found in liver, pancreas and nervous tissue. Recently mutations in the coding region of this gene have been associated with the dominant X-linked form of Charcot-Marie-Tooth (CMTX1) neuropathy. Since some CMTX1 patients show no mutations in their cx32 gene coding region, it was speculated that these patients carry mutations in the promoter region of the gene. This paper describes the organization of the human cx32 gene and its tissue-specific transcription. The gene consists of three exons that are alternatively spliced to produce mRNAs with different 5'-untranslated regions (UTRs). Transcription is initiated from two tissue-specific promoters. In liver and pancreas, promoter P1, located more than 8 kb upstream of the translation start codon, is used, and the transcript is processed to remove a large intron. In contrast, in nerve cells, transcription is initiated from promoter P2, located 497 bp upstream from the translation start codon, and the transcript is processed to remove a small 355-pb intron. The downstream exon, which includes the entire coding sequence, is shared by both mRNAs. CMTX1 patients with a normal cx32 coding region are expected to have mutations in this newly described promoter P2 rather than the known promoter P1.

Management protocol for unreamed interlocking tibial nails for open tibial fractures

Over a 15-month period, 41 open grade I-IIIA tibia fractures were treated with unreamed interlocking nails. A protocol previously established by the authors to enhance fracture union was followed. The purpose of the study was to determine if union rate for the comminuted statically locked fracture could be reduced through early dynamization, bone grafting, or a combination of both. Of the 41 patients, 15 had grade I wounds, 12 had grade II wounds, and 14 had grade IIIA wounds. Fracture classification using the Orthopaedic Trauma Association Classification showed 19 42A fractures, 15 42B fractures, and seven 42C fractures. Fifteen of the 41 fractures required dynamization for rotational and axial stabilization. Of these 15 patients, five subsequently underwent dynamization only, six underwent autogenous bone grafting, and three underwent both dynamization and bone grafting, one of which also underwent exchange rodding. One patient underwent bone grafting and exchange rodding. Comparing the fractures of these 15 patients to similar fractures previously reported, union rate was reduced from 37 to 24 weeks. This was statistically significant to 0.002. It is the authors' recommendation that statically locked unreamed tibial nails be dynamized and/or bone grafted at 6-8 weeks postinjury to enhance union and reduce the time of fracture healing.

External fixation of severely comminuted and open tibial pilon fractures

Twenty patients with severely comminuted fractures about the ankle, either severely comminuted pilon fractures or open pilon fractures (three Grade II, seven Grade III), were managed with the use of a Delta-framed external fixator across the ankle joint. All fractures had open reduction and internal fixation (ORIF) with either screw fixation or small plates to stabilize the articular surface with minimal soft-tissue dissection. Average external fixator time was 2.5 months, and the time to union averaged 4.5 months. All fractures healed. Three delayed unions required bone grafting and two had plate stabilization. No infection occurred in the 12 open fractures. There was no infection of the closed injuries, no skin sloughs, and only two minor pin tract infections. Follow-up analysis averaged 12 months (range, six to 30 months). Range of motion (ROM) at last follow-up observation was excellent in six patients, good in nine, fair in three, and poor in two. Two patients required ankle arthrodesis because of posttraumatic arthritis. The ROM and outcomes of the severely comminuted or open fractures of the distal intraarticular tibia were very good.

The impact of a planned health education approach on the control of hypertension in a high risk population

This paper reports on the effectiveness of a planned health education programme on enhancing the control of hypertension in a community demonstrating the highest rates of high blood pressure, cerebrovascular disease, and diseases of the heart in the State of Maryland. Within the community intervention programme, a specific focus was directed at younger black males (ages 18-49) who demonstrated the lowest rates of awareness, treatment, and control for their hypertension, as compared to all other age/race/sex groups. The programme consisted of targeted screenings, outreach, and follow-up; influencing specific health beliefs regarding diagnosis and treatment; and family and community support strategies. Formally trained community health workers provided educational counselling, monitoring, outreach and follow-up services in coordination with a community-wide health provider task force. Results to date indicate that this planned health education approach has been successful in significantly improving the control of hypertension in a high-risk population.

Electrocardiographic values from clinically normal, anesthetized ferrets (Mustela putorius furo)

Electrocardiograms were recorded from 25 clinically normal male ferrets anesthetized with ketamine and xylazine and from 7 ferrets anesthetized with ketamine alone. Ferrets anesthetized with ketamine alone had excessive salivation, open eyes, muscle tremors, muscle twitching, paddling motions, attempts to stand, and an unstable ECG baseline. Because ketamine/xylazine combination resulted in induction and good muscle relaxation, the ECG had little interference resulting from muscular movement.