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Cardiovascular disease (CVD) is the leading cause of death among all non-communicable diseases (NCDs) in Vietnam. The objectives of the present study were to analyse contemporary gaps in CVD control studies, which were published in Vietnam between 2013 and 2017. A systematic literature review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Research articles written in English or Vietnamese, published between 2013 and 2017, and focused on the four main WHO themes of CVD control were identified. Among 11,385 Vietnamese-based CVD studies published during this period, only 119 studies (1.0%) were relevant to public health CVD control outcomes, and only 17 of 20 CVD indicators were addressed in these studies. Most studies were published in Vietnamese journals (73.9%), focused on disease and intermediate risk factors (73.9%), were cross-sectional (84.8%) and hospital-based (54.6%). We observed a lack of studies, many of which suffered design and analysis limitations, focused on several WHO themes for effective CVD control. Future Vietnamese-based CVD control studies should focus on the WHO-recommended themes and health indicators in broader community settings to provide better data to inform effective public health policies to control CVD. [ABSTRACT FROM AUTHOR]

Interventions to teach protective behaviors may be differentially effective within an adolescent population. Identifying the characteristics of youth who are less likely to respond to an intervention can guide program modifications to improve its effectiveness. Using comprehensive longitudinal data on adolescent risk behaviors, perceptions, sensation-seeking, peer and family influence, and neighborhood risk factors from 2564 grade 10–12 students in The Bahamas, this study employs machine learning approaches (support vector machines, logistic regression, decision tree, and random forest) to identify important predictors of non-responsiveness for precision prevention. We used 80% of the data to train the models and the rest for model testing. Among different machine learning algorithms, the random forest model using longitudinal data and the Boruta feature selection approach predicted intervention non-responsiveness best, achieving sensitivity of 85.4%, specificity of 78.4% and AUROC of 0.93 on the training data, and sensitivity of 84.3%, specificity of 67.1%, and AUROC of 0.85 on the test data. Key predictors include self-efficacy, perceived response cost, parent monitoring, vulnerability, response efficacy, HIV/AIDS knowledge, communication about condom use, and severity of HIV/STI. Machine learning can yield powerful predictive models to identify adolescents who are unlikely to respond to an intervention. Such models can guide the development of alternative strategies that may be more effective with intervention non-responders. [ABSTRACT FROM AUTHOR]

Background: There is a lack of nationally representative estimates for the consequences of early childhood undernutrition on preadolescent outcomes in India. Understanding this relationship is helpful to develop interventions that not only prevent child undernutrition but also mitigate its consequences.Methods and Findings: In this cohort study, we analyzed prospectively gathered data from 2 waves of the India Human Development Survey (IHDS) to investigate the association of undernutrition during early childhood (0 to 5 years) in 2004 to 2005 with physical and cognitive outcomes during preadolescent (8 to 11 years) years in 2011 to 2012. These surveys interviewed 41,554 households across all 33 states and union territories in India in 2004 to 2005 and reinterviewed 83% of the households in 2011 to 2012. Primary exposure was assessed using the Composite Index of Anthropometric Failure (CIAF) based on 2004 to 2005 survey. Primary outcomes were short stature (height-for-age z-score [HAZ] <-2), thinness (body mass index [BMI] <18.5 kg/m2), reading, and arithmetic skills during preadolescence based on the 2011 to 2012 survey. Survey-weighted generalized linear models were used, and effect modification based on child sex and sociodemographic variables were evaluated using 3-way interaction terms. Of the 7,868 children included in this analysis, 4,334 (57.3%) were undernourished. Being undernourished was associated with increased odds of short stature (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.45 to 2.06) and thinness (OR 1.52, 95% CI 1.33 to 1.73) during the preadolescent period, while it was associated with decreased odds of achieving a higher reading (cumulative odds ratio [cumOR]: 0.76, 0.66 to 0.87) and arithmetic (cumOR: 0.72, 0.63 to 0.82) outcomes. The disparity in outcomes based on CIAF increased with age, especially for female children. Increased level of female education within the household reduced the disadvantages of undernutrition among female children. Study limitations include observational and missing data, which limit our ability to draw strong causal inferences.Conclusions: In this study, we found that early child undernutrition was associated with several adverse preadolescent physical and cognitive outcomes, especially among female children. Improved female education mitigates this association. Female education promotion should assume a central role in Indian public health policy making. [ABSTRACT FROM AUTHOR]

Cervical cancer is caused by human papillomavirus (HPV) infection, which can be prevented by vaccination. Mothers play an important role in promoting vaccination and health education. However, Cambodian American mothers reported to have challenges to play a role as primary health educators due to lack of health knowledge and language and cultural gaps. Therefore, this study aims to understand the Cambodian American daughters' and mothers' awareness, knowledge and social norms of HPV vaccination and their health communication and vaccination decision-making. We conducted a pilot randomized clinical trial to promote HPV vaccination. In this study, we have only reported findings from baseline data examining individual, interpersonal and social determinants of HPV vaccination behavior among 19 dyads of Cambodian American mothers and daughters. Both mothers and daughters demonstrated low levels of awareness and knowledge. A significant relationship was found between the daughters' HPV vaccine decisions and their perception of their mothers' intention on HPV vaccination for them. Culturally and linguistically appropriate communication strategies such as storytelling or visual presentation approaches may be more effective than the current practice of using information-based written materials to promote HPV vaccination and health education among Cambodian Americans. [ABSTRACT FROM AUTHOR]

Background: Home remedies (HRs) are described as foods, herbs, and other household products used to manage chronic conditions. The objective of this study was to examine home remedy (HR) use among Blacks with hypertension and to determine if home remedy use is correlated with blood pressure and medication adherence.Methods: Data for this cross-sectional study were obtained from the TRUST study conducted between 2006-2008. Medication adherence was measured using the Morisky Medication Adherence Scale, and HR use was self-reported. Multivariable associations were quantified using ordinal logistic regression.Results: The study sample consisted of 788 Blacks with hypertension living in the southern region of the United States. HR use was associated with higher systolic (HR users 152.79, nonusers 149.53; P=.004) and diastolic blood pressure (HR users 84.10, nonusers 82.14 P=.005). Use of two or more HRs was associated with low adherence (OR: .55, CI: .36-.83, P= .004).Conclusion: The use of HR and the number of HRs used may be associated with medication nonadherence, and higher systolic and diastolic blood pressure among Blacks with hypertension. Medication nonadherence is of critical importance for individuals with hypertension, and it is essential that health care providers be aware of health behaviors that may serve as barriers to medication adherence, such as use of home remedies. [ABSTRACT FROM AUTHOR]

Although Korean American women have a higher risk of developing cervical cancer, currently there are limited culturally relevant intervention strategies for improving primary prevention of cervical cancer by promoting HPV vaccination in this population. This study reports the development of a cross-cultural, cross-generational storytelling HPV intervention using a peer-paired method, in which two storytellers interactively share their stories, as a particular innovation that might resonate with Korean American young women. The acceptability of the intervention was assessed by self-reported satisfaction and endorsement with the intervention in a pilot randomized control trial (RCT). We compared participants' responses to the intervention by their generation and cultural identity. One hundred and four Korean college women between the ages of 18–26 were recruited from the Northeastern US Participants randomized to the intervention group received a storytelling video (n = 54); the comparison group received written information (n = 50). The acceptability of the intervention was measured immediately post-intervention. The intervention group had significantly greater satisfaction than the comparison group (P < 0.05). Participants reported greater endorsement for videos that reflected their cultural and generational experiences. Future study is needed to examine the impact of such interventions on objective follow-up on HPV vaccination in a large-scale RCT. [ABSTRACT FROM AUTHOR]

Marginalized two-part random-effects generalized Gamma models have been proposed for analyzing medical expenditure panel data with excessive zeros. While these models provide marginal inference on expected healthcare expenditures, the usual unilateral specification of heteroscedastic variance on one of the two shape parameters for the generalized Gamma distribution in these models fails to encompass important special cases within the generalized gamma modeling framework. In this article, we construct marginalized two-part random-effects models that employ the log-normal, log-skew-normal, generalized Gamma, Weibull, Gamma, and inverse Gamma distributions to delineate the spectrum of nonzero healthcare expenditures in the second part of the models. These marginalized models supply additional choices for analyzing healthcare expenditure panel data with excessive zeros. We review the concepts of marginal effect and incremental effect, and summarize how these effects are estimated. For studies whose primary goal is to make inference on marginal effect or incremental effect of an independent variable with respect to healthcare expenditures, we advocate empirical mean square error criterion and information criteria to choose among candidate models. Then, we use the proposed models in an empirical analysis to examine the impact of the New Cooperative Medical Scheme on healthcare expenditures among older adults in rural China. [ABSTRACT FROM AUTHOR]

African Americans remain underrepresented in health- related research. We examined the association between spirituality using the Self-Rating Spirituality Scale (range 6-24) and self-reported willingness to participate in health-related research studies among African Americans. Covariates included gender, education level, employment status, and previous research experience. Adjusted associations were calculated with logistic regression models, with multiple imputation to account for missing data. Results from the logistic regression model show that each one-point increase in the Self- Rating Spirituality Scale was associated with a 24% increase in the odds of being very likely to participate in research (OR: 1.24, 95% CI: 1.07-1.44). Those with less than a college degree (OR: 3.59, 95% CI: 1.51-8.54), who were unemployed (OR: 2.34, 95% CI: 1.03-5.33), and had previous research experience (OR: 2.92, 95% CI: 1.22-6.99) reported increased willingness to participate. This work offers new insight for developing recruitment initiatives within African American spiritual communities. [ABSTRACT FROM AUTHOR]

Background: Cognitive function is often impaired during hospitalization, but whether this impairment resolves or persists after discharge is unknown.Methods and Results: We enrolled (April 2011-May 2013) and interviewed during hospitalization and 1-month post-discharge 1521 nondemented acute coronary syndrome survivors enrolled in TRACE (Transitions, Risks and Actions in Coronary Events). Cognitive function was assessed using the Telephone Interview of Cognitive Status (range: 0-41) at both time points. Patients reported demographic and psychosocial characteristics and medical records were abstracted. Using the Telephone Interview of Cognitive Status cut point of ≤28, we defined 4 groups of cognitive change based on cognitive status during hospitalization and 1 month later: consistently impaired, transiently impaired, newly impaired, and consistently nonimpaired. Characteristics associated with cognitive change categories were examined using multinomial logistic regression. Participants were 67% male, 84% non-Hispanic white, with mean age±SD 62±11 years; 16% (n=237) were cognitively impaired during hospitalization, and 11% (n=174) were impaired 1 month after discharge. Overall, 80% were consistently nonimpaired, 9% transiently impaired, 7% consistently impaired, and 4% newly impaired. Lower education level, minority status, low health literacy and numeracy, and higher severity of disease were independently associated with cognitive impairment during and after hospitalization. Male sex was associated with increased risk of cognitive impairment after hospital discharge.Conclusions: Cognitive function changes during the transition from hospital to home after acute coronary syndrome are less favorable for men and those with psychosocial vulnerability. Assessing cognitive status both in hospital and post-discharge is important for detecting patients who could benefit from tailored transitional care including early follow-up and booster discharge instructions. [ABSTRACT FROM AUTHOR]

Background: Obesity has been associated with lower function and more pain before and after total hip or knee replacement (THR or TKR). We examined the changes between preoperative and postoperative function and pain in a large representative U.S. cohort to determine if there was a relationship to obesity status.Methods: Preoperative and 6-month postoperative data on function (Short Form-36 Physical Component Summary [PCS] score), joint pain (Hip disability and Osteoarthritis Outcome Score and Knee injury and Osteoarthritis Outcome Score), and body mass index (BMI) were collected from a national sample of 2,040 patients who had undergone THR and 2,964 who had undergone TKR from May 2011 to March 2013. Preoperative and postoperative function and pain were evaluated according to BMI status, defined as under or of normal weight, overweight, obese, severely obese, or morbidly obese.Results: Patients undergoing THR were an average of 65 years of age; 59% were women, 94% were white, and 14% were severely or morbidly obese. A greater obesity level was associated with a lower (worse) PCS score at baseline and 6 months postoperatively. Severely and morbidly obese patients had less postoperative functional gain than the other BMI groups. A greater obesity level was associated with more pain at baseline but greater postoperative pain relief, so the average postoperative pain scores did not differ significantly according to BMI status. Patients undergoing TKR had an average age of 69 years; 61% were women, 93% were white, and 25% were severely or morbidly obese. A greater obesity level was associated with a lower PCS score at baseline and 6 months. The postoperative gain in PCS score did not differ by BMI level. A greater obesity level was associated with worse pain at baseline but greater pain relief at 6 months, so the average pain scores at 6 month were similar across the BMI levels.Conclusions: Six months after total joint replacement (TJR), severely or morbidly obese patients reported excellent pain relief and substantial functional gain that was similar to the findings in other patients. While obesity is associated with a greater risk of early complications, obesity in itself should not be a deterrent to undergoing TJR to relieve symptoms.Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The purpose of this study was to develop a participant-informed technology-based physical activity (PA) promotion tool for young overweight and obese African American (AA) women. A mixed-method 3-phase study protocol design was used to develop text messages to promote PA in AA women attending the University of Alabama at Birmingham during the Spring of 2013. Nominal focus groups and a 2-week pilot were used to generate and test participant-developed messages. Participants (n = 14) had a mean age of 19.79 years (SD = 1.4) and mean body mass index of 35.9 (SD = 5.926). Focus group data identified key themes associated with the use of text messages to promote PA including message frequency, length, tone, and time of day. Participants preferred text messages that were brief, specific, and time sensitive. Results showed that text messaging was a feasible and acceptable strategy to promote PA in overweight and obese AA women in a university setting. [ABSTRACT FROM AUTHOR]

Introduction: Although technology-assisted tobacco interventions (TATIs) are effective, they are underused due to recruitment challenges. We tested whether we could successfully recruit smokers to a TATI using peer marketing through a social network (Facebook).Methods: We recruited smokers on Facebook using online advertisements. These recruited smokers (seeds) and subsequent waves of smokers (peer recruits) were provided the Share2Quit peer recruitment Facebook app and other tools. Smokers were incentivized for up to seven successful peer recruitments and had 30 days to recruit from date of registration. Successful peer recruitment was defined as a peer recruited smoker completing the registration on the TATI following a referral. Our primary questions were (1) whether smokers would recruit other smokers and (2) whether peer recruitment would extend the reach of the intervention to harder-to-reach groups, including those not ready to quit and minority smokers.Results: Overall, 759 smokers were recruited (seeds: 190; peer recruits: 569). Fifteen percent (n = 117) of smokers successfully recruited their peers (seeds: 24.7%; peer recruits: 7.7%) leading to four recruitment waves. Compared to seeds, peer recruits were less likely to be ready to quit (peer recruits 74.2% vs. seeds 95.1%), more likely to be male (67.1% vs. 32.9%), and more likely to be African American (23.8% vs. 10.8%) (p < .01 for all comparisons).Conclusions: Peer marketing quadrupled our engaged smokers and enriched the sample with not-ready-to-quit and African American smokers. Peer recruitment is promising, and our study uncovered several important challenges for future research.Implications: This study demonstrates the successful recruitment of smokers to a TATI using a Facebook-based peer marketing strategy. Smokers on Facebook were willing and able to recruit other smokers to a TATI, yielding a large and diverse population of smokers. [ABSTRACT FROM AUTHOR]

Introduction Latina mothers play a central role in raising and socializing their children; however, few studies have examined the cultural, socio-cognitive and neighborhood-related variables influencing the level of communication between Puerto Rican mothers and their children about sexuality and sexual health. This cross-sectional study sought to examine these influences. Methods Puerto Rican mothers with children aged 10-19 years (n = 193) were selected randomly for an ethnographic interview as part of a community participatory action research project in a U.S. urban northeastern community. Results Bivariate analyses found statistically significant associations between the child's age ( p = 0.002), the mother's past communication about traditional gender role norms of women ( marianismo) ( p < 0.001), her positive outcome expectations for communications with her child ( p < 0.025), and her perceptions of the physical condition ( p < 0.001) and sexual health problems ( p = 0.047) in the neighborhood. In a multivariate model, all of these variables remained significant except sexual health problems, and mother's attitudes toward the obligations of children to parents ( familismo) emerged as a factor associated with a decrease in the number of sexual health topics that mothers raised with their children. No significant effects were found for mother's spiritual and religious experience ( religiosidad). Discussion Our study highlights the importance of marianismo as a framework within which Puerto Rican mothers communicate sexual health information as well as the need to improve mothers' confidence discussing sexual health issues with their children. Future public health interventions to promote communication about sexuality and sexual health among Puerto Rican mothers should consider addressing this issue as a part of comprehensive neighborhood improvement projects. [ABSTRACT FROM AUTHOR]

Aim: This study determined the effect of physician champions on the two main components of Kangaroo Mother Care (KMC): skin-to-skin care and breastfeeding.Methods: KMC practices among a retrospective cohort of 648 infants admitted to a rural Indian neonatal intensive care unit (NICU) between January 5, 2011 and October 7, 2014 were studied. KMC champions were identified based on their performance evaluation. We examined the effect of withdrawing physician champions on overall use, time to initiation and intensity of skin-to-skin care and breastfeeding, using separate models.Results: In comparison with when KMC champions were present, their absence was associated with a 45% decrease in the odds of receiving skin-to-skin care, with a 95% confidence interval (CI) of 64% to 17%, a 38% decrease in the rate of initiation skin-to-skin care (95% CI 53-82%) and an average of 1.47 less hours of skin-to-skin care (95% CI -2.07 to -0.86). Breastfeeding practices were similar across the different champion environments.Conclusion: Withdrawing physician champions from the NICU setting was associated with a decline in skin-to-skin care, but not breastfeeding. Training health care workers and community stakeholders to become champions could help to scale up and maintain KMC practices. [ABSTRACT FROM AUTHOR]

Purpose: This study evaluated a culturally relevant, social cognitive theory–based, Internet-enhanced physical activity (PA) pilot intervention developed for overweight/obese African American (AA) female college students. Design: Using a 3-month, single group, pretest–posttest design, participants accessed a culturally relevant PA promotion website and engaged in four moderate-intensity PA sessions each week. Results: Study completers (n = 25, mean age = 21.9 years) reported a decrease in sedentary screen time (p < .0001); however, no changes in moderate-to-vigorous PA were reported (p = .150). A significant increase in self-regulation for PA (p < .0001) and marginally significant increases in social support (p = .052) and outcome expectations (p = .057) for PA were observed. No changes in body mass index (p = .162), PA enjoyment (p = .151), or exercise self-efficacy (p = .086) were reported. Conclusions: Findings of this exploratory study show some preliminary support for Internet-enhanced approaches to promote PA among overweight/obese AA women. Implications for Practice: Future studies with larger samples are needed to further explore culturally relevant Internet-enhanced PA programs in this underserved population. [ABSTRACT FROM AUTHOR]

Background: Vietnam is experiencing an epidemiologic transition with an increased prevalence of non-communicable diseases. At present, the major risk factors for cardiovascular disease (CVD) are either on the rise or at alarming levels in Vietnam; inasmuch, the burden of CVD will continue to increase in this country unless effective prevention and control measures are put in place. A national survey in 2008 found that the prevalence of hypertension (HTN) was approximately 25 % among Vietnamese adults and it increased with advancing age. Therefore, novel, large-scale, and sustainable interventions for public health education to promote engagement in the process of detecting and treating HTN in Vietnam are urgently needed.Methods: A feasibility randomized trial will be conducted in Hung Yen province, Vietnam to evaluate the feasibility and acceptability of a novel community-based intervention using the "storytelling" method to enhance the control of HTN in adults residing in four rural communities. The intervention will center on stories about living with HTN, with patients speaking in their own words. The stories will be obtained from particularly eloquent patients, or "video stars," identified during Story Development Groups. The study will involve two phases: (i) developing a HTN intervention using the storytelling method, which is designed to empower patients to facilitate changes in their lifestyle practices, and (ii) conducting a feasibility cluster-randomized trial to investigate the feasibility, acceptability, and potential efficacy of the intervention compared with usual care in HTN control among rural residents. The trial will be conducted at four communes, and within each commune, 25 individuals 50 years or older with HTN will be enrolled in the trial resulting in a total sample size of 100 patients.Discussion: This feasibility trial will provide the necessary groundwork for a subsequent large-scale, fully powered, cluster-randomized controlled trial to test the efficacy of our novel community-based intervention. Results from the full-scale trial will provide health policy makers with practical evidence on how to combat a key risk factor for CVD using a feasible, sustainable, and cost-effective intervention that could be used as a national program for controlling HTN in Vietnam and other developing countries.Trial Registration: ClinicalTrials.gov.Registration Number: https://clinicaltrials.gov/ct2/show/NCT02483780 (registration date June 22, 2015). [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Frequent use and serious adverse effects related to non-steroidal anti-inflammatory drugs ( NSAIDs) underscore the need to raise patient awareness about potential risks. Partial success of patient- or provider-based interventions has recently led to interest in combined approaches focusing on both patient and physician. This research tested a shared decision-making intervention for increasing patient-reported awareness of NSAID risk. Methods A group randomized trial was performed in Alabama from 2005 to 2007. Intervention group doctor practices received continuing medical education ( CME) about NSAIDs and patient activation tools promoting risk assessment and communication during visits. Comparison group doctor practices received only CME. Cross-sectional data were collected before and after the intervention. Generalized linear latent and mixed models with logistic link tested relationships among the intervention, study phase, intervention by study phase interaction and patient-reported awareness of risks with either prescription or over-the-counter ( OTC) NSAIDs. Results Three hundred and forty-seven patients at baseline and 355 patients at follow-up participated in this study. The intervention [adjusted odds ratio ( AOR) = 0.74, P = 0.248], follow-up study phase ( AOR = 1.31, P = 0.300) and intervention by study phase interaction ( AOR = 0.98, P = 0.942) were not significantly associated with patient-reported awareness of any prescription NSAID risk. Follow-up study phase was associated with increased odds of reporting any OTC NSAID risk awareness ( AOR = 2.99, P < 0.001), but the patient activation intervention and intervention by study phase interaction were not significantly associated with patient-reported awareness of any OTC NSAID risk ( AOR = 0.98, P = 0.929; AOR = 0.87, P = 0.693, respectively). Conclusions Our point-of-care intervention encouraging shared decision making did not increase NSAID risk awareness. [ABSTRACT FROM AUTHOR]

Objectives. We sought to determine if reported racial discrimination was associated with medication nonadherence among African Americans with hypertension and if distrust of physicians was a contributing factor. Methods. Data were obtained from the TRUST project conducted in Birmingham, Alabama, 2006 to 2008. All participants were African Americans diagnosed with hypertension and receiving care at an inner city, safety net setting. Three categories of increasing adherence were defined based on the Morisky Medication Adherence Scale. Trust in physicians was measured with the Hall General Trust Scale, and discrimination was measured with the Experiences of Discrimination Scale. Associations were quantified by ordinal logistic regression, adjusting for gender, age, education, and income. Results. The analytic sample consisted of 227 African American men and 553 African American women, with a mean age of 53.7 69.9 years. Mean discrimination scores decreased monotonically across increasing category of medication adherence (4.1, 3.6, 2.9; P = .025), though the opposite was found for trust scores (36.5, 38.5, 40.8; P < .001). Trust mediated 39% (95% confidence interval = 17%, 100%) of the association between discrimination and medication adherence. Conclusions. Within our sample of inner city African Americans with hypertension, racial discrimination was associated with lower medication adherence, and this association was partially mediated by trust in physicians. Patient, physician and system approaches to increase "earned" trust may enhance existing interventions for promoting medication adherence. [ABSTRACT FROM AUTHOR]

We examined the relationship between trust in the medical system, medication adherence, and hypertension control in Southern African American men. The sample included 235 African American men aged 18 years and older with hypertension. African American men with higher general trust in the medical system were more likely to report better medication adherence (odds ratio [OR] = 1.06), and those with higher self-efficacy were more likely to report better medication adherence and hypertension control (OR = 1.08 and OR = 1.06, respectively). (Am J Public Health. 2012;102:2242-2245.) [ABSTRACT FROM AUTHOR]

Purpose: To explore the relationship between degree of rurality and glucose (hemoglobin A1c), blood pressure (BP), and lipid (LDL) control among patients with diabetes. Methods: Descriptive study; 1,649 patients in 205 rural practices in the United States. Patients' residence ZIP codes defined degree of rurality (Rural-Urban Commuting Areas codes). Outcomes were measures of acceptable control (A1c < = 9%, BP < 140/90 mmHg, LDL < 130 mg/dL) and optimal control (A1c < 7%, BP < 130/80 mmHg, LDL < 100 mg/dL). Statistical significance was set at P < .008 (Bonferroni's correction). Findings: Although the proportion of patients with reasonable A1c control worsened by increasing degree of rurality, the differences were not statistically significant (urban 90%, large rural 88%, small rural 85%, isolated rural 83%; P= .10); mean A1c values also increased by degree of rurality, although not statistically significant (urban 7.2 [SD 1.6], large rural 7.3 [SD 1.7], small rural 7.5 [SD 1.8], isolated rural 7.5 [SD 1.9]; P= .16). We observed no differences between degree of rural and reasonable BP or LDL control ( P= .42, P= .23 , respectively) or optimal A1c or BP control ( P= .52, P= .65 , respectively). Optimal and mean LDL values worsened as rurality increased ( P= .08, P= .029 , respectively). Conclusions: In patients with diabetes who seek care in the rural Southern United States, we observed no relationship between degree of rurality of patients' residence and traditional measures of quality of care. Further examination of the trends and explanatory factors for relative worsening of metabolic control by increasing degree of rurality is warranted. [ABSTRACT FROM AUTHOR]

Introduction: CME providers may be interested in identifying effective marketing strategies to direct users to specific content. Online advertisements for recruiting participants into activities such as clinical trials, public health programs, and continuing medical education (CME) have been effective in some but not all studies. The purpose of this study was to compare the impact of 2 marketing strategies in the context of an online CME cultural competence curriculum (www.c-comp.org). Methods: In an interrupted time-series quasi-experimental design, 2 marketing strategies were tested: (1) wide dissemination to relevant organizations over a period of approximately 4 months, and (2) Internet paid search using Google Ads (5 consecutive 8-week periods—control 1, cultural/CME advertisement, control 2, hypertension/ content advertisement, control 3). Outcome measures were CME credit requests, Web traffic (visits per day, page views, pages viewed per visit), and cost. Results: Overall, the site was visited 19,156 times and 78,160 pages were viewed. During the wide dissemination phase, the proportion of visits requesting CME credit decreased between the first (5.3%) and second (3.3%) halves of this phase (p = .04). During the Internet paid search phase, the proportion of visits requesting CME credit was highest during the cultural/CME advertisement period (control 1, 1.4%; cultural/CME ad, 4.3%; control 2, 1.5%; hypertension/content ad, 0.6%; control 3, 0.8%; p < .001). All measures of Web traffic changed during the Internet paid search phase (p < .01); however, changes were independent of the advertisement periods. The incremental cost for the cultural advertisement per CME credit requested was US $0.64. Discussion: Internet advertisement focusing on cultural competence and CME was associated with about a threefold increase in requests for CME credit at an incremental cost of under US $1; however, Web traffic changes were independent of the advertisement strategy. [ABSTRACT FROM AUTHOR]

Most women with perinatal depression do not receive depression treatment. The authors describe the development and beta testing of a new program, PRogram In Support of Moms (PRISM), to improve treatment of perinatal depression in obstetric practices. A multidisciplinary work group of seven perinatal and behavioral health professionals was convened to design, refine, and beta-test PRISM in an obstetric practice. Iterative feedback and problem solving facilitated development of PRISM components, which include provider training and a toolkit, screening procedures, implementation assistance, and access to immediate psychiatric consultation. Beta testing with 50 patients over two months demonstrated feasibility and suggested that PRISM may improve provider screening rates and self-efficacy to address depression. On the basis of lessons learned, PRISM will be enhanced to integrate proactive patient engagement and monitoring into obstetric practices. PRISM may help overcome patient-, provider-, and system-level barriers to managing perinatal depression in obstetric settings. [ABSTRACT FROM AUTHOR]

Background: The conceptualization of patient complexity is just beginning in clinical medicine.Objectives: This study aims (1) to propose a conceptual approach to complex patients; (2) to demonstrate how this approach promotes achieving congruence between patient and provider, a critical step in the development of maximally effective treatment plans; and (3) to examine availability of evidence to guide trade-off decisions and assess healthcare quality for complex patients.Methods/results: The Vector Model of Complexity portrays interactions between biological, socioeconomic, cultural, environmental and behavioral forces as health determinants. These forces are not easily discerned but exert profound influences on processes and outcomes of care for chronic medical conditions. Achieving congruence between patient, physician, and healthcare system is essential for effective, patient-centered care; requires assessment of all axes of the Vector Model; and, frequently, requires trade-off decisions to develop a tailored treatment plan. Most evidence-based guidelines rarely provide guidance for trade-off decisions. Quality measures often exclude complex patients and are not designed explicitly to assess their overall healthcare.Conclusions/recommendations: We urgently need to expand the evidence base to inform the care of complex patients of all kinds, especially for the clinical trade-off decisions that are central to tailoring care. We offer long- and short-term strategies to begin to incorporate complexity into quality measurement and performance profiling, guided by the Vector Model. Interdisciplinary research should lay the foundation for a deeper understanding of the multiple sources of patient complexity and their interactions, and how provision of healthcare should be harmonized with complexity to optimize health. [ABSTRACT FROM AUTHOR]

Background: "Clinical inertia" has been defined as inaction by physicians caring for patients with uncontrolled risk factors such as blood pressure. Some have proposed that it accounts for up to 80% of cardiovascular events, potentially an important quality problem. However, reasons for so-called clinical inertia are poorly understood.Objective: To derive an empiric conceptual model of clinical inertia as a subset of all clinical inactions from the physician perspective.Methods: We used Nominal Group panels of practicing physicians to identify reasons why they do not intensify medications when seeing an established patient with uncontrolled blood pressure.Measurements and Main Results: We stopped at 2 groups (N = 6 and 7, respectively) because of the high degree of agreement on reasons for not intensifying, indicating saturation. A third group of clinicians (N = 9) independently sorted the reasons generated by the Nominal Groups. Using multidimensional scaling and hierarchical cluster analysis, we translated the sorting results into a cognitive map that represents an empirically derived model of clinical inaction from the physician's perspective. The model shows that much inaction may in fact be clinically appropriate care.Conclusions/recommendations: Many reasons offered by physicians for not intensifying medications suggest that low rates of intensification do not necessarily reflect poor quality of care. The empirically derived model of clinical inaction can be used as a guide to construct performance measures for monitoring clinical inertia that better focus on true quality problems. [ABSTRACT FROM AUTHOR]

Objective: To compare the use of medications in African-American and Caucasian elderly Medicare patients hospitalized with acute myocardial infarction (AMI) in Alabama.Design: Retrospective medical record review.Setting: All acute care hospitals in Alabama.Patients: All Medicare patients with a principal discharge diagnosis of AMI from June 1992 through February 1993. We excluded those patients less than 65 years of age and those of ethnicity other than African-American or Caucasian (N = 4,052).Measurements: We first performed a crude analysis using all cases to compare by race the use of thrombolysis, beta-adrenergic blockade, and aspirin in the setting of AMI. In addition, we developed a multivariable model with receipt of therapy as the outcome and demographics, severity of illness, comorbidity, and algorithm-determined candidacy for therapy as covariates. The algorithms, developed as part of the Cooperative Cardiovascular Project, were designed to identify an "ideal" pool of candidates for each therapy.Main Results: For all cases, 9.2% (95% confidence interval [CI] 6.8, 12.1) of African Americans received thrombolysis compared with 17.3% (95% CI 16.0, 18.6) of Caucasians. Approximately 16.4% of patients received beta-adrenergic blockade, and 45.1% received aspirin, both with no racial difference. By multivariate analysis, the adjusted odds ratio for African Americans receiving thrombolysis was 0.55 (95% CI 0.41, 0.76). The corresponding odds ratio was 1.25 (95% CI 0.99, 1.59) for beta-adrenergic blockade and 1.13 (95% CI 0.96, 1.37) for aspirin. African Americans presented later after the onset of chest pain, but the refusal rate of thrombolytic therapy did not differ.Conclusions: According to this analysis, Alabama physicians used beta-adrenergic blockade and aspirin equivalently in African Americans and Caucasians. African Americans received thrombolysis less often according to the crude analysis. The multivariable analysis suggests less use of thrombolytics, even after adjusting for several covariates including indication by clinical algorithm. However, the small number of African-American patients deemed ideal candidates for thrombolysis attenuates the precision of this finding. [ABSTRACT FROM AUTHOR]

Objectives: This study examined how physicians perceive pharmaceutical companies' medication assistance programs (MAPs).Methods: The study was conducted using a survey of 373 primary care physicians from four southern states; they were surveyed within the formative evaluation phase of a larger study (MI-Plus). Respondents were queried about use and usefulness of MAPs for patients who cannot afford drugs, and barriers to using them. Bivariate associations between physician-level variables (patients without drug coverage) and usefulness and barriers to using MAPs were assessed using Chi square tests. Independence of associations was assessed using multiple logistic regressions.Results: Of the 364 (97.6%) respondents who used MAPs, 70% used them regularly, the rest occasionally; 63% found MAPs very useful in caring for patients who could not afford drugs. About 89% reported one or more barriers to using MAPs; 47% saw "inability of patients to apply directly;" and 57% saw "enrollment process being time-consuming for staff" as barriers. Compared to physicians with fewer elderly patients without drug coverage, those with more of these patients were less likely to find MAPs very useful; less likely to report no barriers to using MAPs; and more likely to see "low income thresholds" and "inability of patients to apply directly" as barriers.Conclusion: While MAPs are considered useful in caring for patients in need of assistance, there are many barriers to their use. Pharmaceutical companies should address these barriers. Limitations include a low response rate (about 10%). [ABSTRACT FROM AUTHOR]

Objectives: This study examined patterns, characteristics, and predictors of cross-racial friendships as the context for understanding contemporary race relations.Method: A national survey included 1,055 respondents, of whom 55% were white, 32% were black, and 74% were female; ages ranged from 18 to ≥65 years. Focus groups were conducted to assess societal and personal benefits. Participants (n = 31) were racially diverse and aged 20 to 66 years.Results: After accounting for multiple covariates, regression analysis revealed that Asians, Hispanics, and multiracial individuals are more likely than their white and black counterparts to have cross-racial friends. Females were less likely than males to have 8 or more cross-racial friends. Regression analysis revealed that the depth of cross-racial friendships was greater for women than men and for those who shared more life experiences. Increasing age was associated with lower cross-racial friendship depth. Qualitative analysis of open-ended questions and focus group data established the social context as directly relevant to the number and depth of friendships. Despite the level of depth in cross-racial friendships, respondents described a general reluctance to discuss any racially charged societal events, such as police shootings of unarmed black men.Conclusion: This study identified salient characteristics of individuals associated with cross-racial friendships and highlighted the influence of the social, historical, and political context in shaping such friendships. Our findings suggest that contemporary race relations reflect progress as well as polarization. (PsycINFO Database Record [ABSTRACT FROM AUTHOR]

Objective: To examine a wide range of study designs and outcomes to estimate the extent to which interventions in outpatient perinatal care settings are associated with an increase in the uptake of depression care.Data Sources: PubMed, CINAHL, PsycINFO, ClinicalTrials.gov, and Scopus (EMBASE) were searched for studies published between 1999 and 2014 that evaluated mental health care use after screening for depression in perinatal care settings.Methods Of Study Selection: Inclusion criteria were: 1) English language; 2) pregnant and postpartum women who screened positive for depression; 3) exposure (validated depression screening in outpatient perinatal care setting); and, 4) outcome (mental health care use). Searches yielded 392 articles, 42 met criteria for full-text review, and 17 met inclusion criteria. Study quality was assessed using a modified Downs and Black scale.Tabulation, Integration, and Results: Articles were independently reviewed by two abstractors and consensus reached. Study design, intervention components, and mental health care use were defined and categorized. Seventeen articles representing a range of study designs, including one randomized controlled trial and one cluster randomized controlled trial, were included. The average quality rating was 61% (31.0-90.0%). When no intervention was in place, an average of 22% (13.8-33.0%) of women who screened positive for depression had at least one mental health visit. The average rate of mental health care use was associated with a doubling of this rate with patient engagement strategies (44%, 29.0-90.0%), on-site assessments (49%, 25.2-90.0%), and perinatal care provider training (54%, 1.0-90.0%). High rates of mental health care use (81%, 72.0-90.0%) were associated with implementation of additional interventions, including resource provision to women, perinatal care provider training, on-site assessment, and access to mental health consultation for perinatal care providers.Conclusion: Screening alone was associated with 22% mental health care use among women who screened positive for depression; however, implementation of additional interventions was associated with a two to fourfold increased use of mental health care. Although definitive studies are still needed, screening done in conjunction with interventions that target patient, health care provider, and practice-level barriers is associated with increased improved rates of depression detection, assessment, referral, and treatment in perinatal care settings. [ABSTRACT FROM AUTHOR]

Background: Limited contemporary data compare the clinical and psychosocial characteristics and acute management of patients hospitalized with an initial vs a recurrent episode of acute coronary disease. We describe these factors in a cohort of patients recruited from 6 hospitals in Massachusetts and Georgia after an acute coronary syndrome.Materials and Methods: We performed structured baseline in-person interviews and medical record abstractions for 2174 eligible and consenting patients surviving hospitalization for an acute coronary syndrome between April 2011 and May 2013.Results: The average patient age was 61 years, 64% were men, and 47% had a high school education or less; 29% had a low general quality of life, and 1 in 5 were cognitively impaired. Patients with a recurrent coronary episode had a greater burden of previously diagnosed comorbidities. Overall, psychosocial burden was high, and more so in those with a recurrent vs those with an initial episode. Patients with an initial coronary episode were as likely to have been treated with all 4 effective cardiac medications (51.6%) as patients with a recurrent episode (52.3%), but were significantly more likely to have undergone cardiac catheterization (97.9% vs 92.9%) and a percutaneous coronary intervention (73.7% vs 60.9%) (P < .001) during their index hospitalization.Conclusions: Patients with a first episode of acute coronary artery disease have a more favorable psychosocial profile, less comorbidity, and receive more invasive procedures but similar medical management, than patients with previously diagnosed coronary disease. Implications of the high psychosocial burden on various patient-related outcomes require investigation. [ABSTRACT FROM AUTHOR]

Background: Interventions to improve the fracture prevention in nursing homes are needed.Methods: Cluster-randomized, single-blind, controlled trial of a multi-modal quality improvement intervention. Nursing homes (n=67) with > or =10 residents with a diagnosis of osteoporosis or recent hip fracture (n=606) were randomized to receive an early or delayed intervention consisting of audit and feedback, educational modules, teleconferences, and academic detailing. Medical record abstraction and the Minimum Data Set were used to measure the prescription of osteoporosis therapies before and after the intervention period. Analysis was at the facility-level and Generalized Estimating Equation modeling was used to account for clustering.Results: No significant improvements were observed in any of the quality indicators. The use of osteoporosis pharmacotherapy or hip protectors improved by 8.0% in the intervention group and 0.6% in the control group, but the difference was not statistically significant (P=.72). Participation in the intervention activities was low, but completion of the educational module (odds ratio [OR] 4.8, 95% confidence interval [CI], 1.9-12.0) and direct physician contact by an academic detailer (OR 4.5, 95% CI, 1.1-18.2) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors in multivariable models.Conclusions: Audit-feedback and education interventions were ineffective in improving fracture prevention in the nursing home setting, although results may have been tempered by low participation in the intervention activities. [ABSTRACT FROM AUTHOR]