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In 2020, medical schools across the U.S. were called to task by students who demanded a response to structural racism in medicine. Many medical schools made anti-racism declarations and pledged to promote more inclusive learning environments. Much of the focus was on changing the pre-clinical curriculum and less on the everyday interactions that occur in clinical settings. As medical educators, we have an obligation to reinforce statements of solidarity by role modeling behaviors that demonstrate anti-racism in clinical practice.This article proposes a framework that provides practical steps for role modeling anti-racism in the clinical learning environment. These steps are drawn from a review of the literature on role modeling, constructs from Social Cognitive Learning Theory, and anti-racism praxis.The resulting framework uses the acronym R.E.A.C.T to describe practical steps that include Reflecting on implicit biases, Educating ourselves on historical and current forms of structural racism, Assessing the use of race in clinical practice and asking how racism is impacting a clinical interaction, Calling out behaviors that perpetuate racism, and Treating everyone with dignity and respect.The R.E.A.C.T framework is of value to medical educators because it provides practical steps on role modeling anti-racism in the clinical learning environment. The framework calls medical educators not to merely passively 'react,' but to be introspective, proactive, and intentional in their response to racism. Examples are provided on how each step can be actualized and adapted for different learning environments.

Community-engaged research is a well-established approach to tackling health disparities in communities of color. However, the devastation caused by coronavirus disease 2019 (COVID-19) calls for a reexamination of the practice of community-engaged research. Syndemic framework characterizes the clustering and synergistic interactions between two or more diseases amid an underlay of social and environmental threats. This framework has been used to explain the disproportionately higher rates of COVID-19 in communities of color and may have utility in guiding future community-engaged research.This article describes the process by which a syndemic framework was used to generate discussions on lessons learned from COVID-19 and describes the ensuing collaborative writing process that emerged from this discourse.This article was developed by the Community Engagement Working Group (CEWG) of the Jackson Heart Study, a community-based epidemiologic study focused on cardiovascular disease among African Americans in the Jackson, Mississippi Metropolitan Area. By drawing upon a syndemic framework and lessons from COVID-19, the CEWG identified gaps and opportunities to enhance community-engaged research.Using syndemic framework as a starting point, the CEWG identified the following as aspects of community-engaged research that may warrant further consideration: 1) the need to examine multiple dimensions and assets of a community, 2) the need to view communities through an intersectionality lens, 3) the need to acknowledge the impact of historical and current trauma on the community, and 4) the need to provide support to community-engaged researchers who may be members of minoritized groups themselves and therefore, experience similar trauma.

Background: African Americans in New York City (NYC) are more likely to have sedentary lifestyles and lack access to physical activity (PA) opportunities. In 2015, the New York City Department of Health and Mental Hygiene (NYCDOHMH) initiated a church-placed PA program to provide PA opportunities in underserved communities in NYC. Objective: To explore whether characteristics of a church-placed PA program such as location, type of exercise equipment used, and timing of classes were associated with PA uptake in church-going African Americans. Design and setting: This cross-sectional study used the Posttest Only Design. A sufficiently powered sample size (327) was obtained from NYCDOHMH survey data from church-placed PA program in African American churches. We hypothesized that the location of the church, time of day exercise classes were held and the type of exercise equipment used impacted PA participation. Participants: Program participants were drawn from the participating churches. Intervention: Weekly exercise classes were led by paid fitness instructors. Churches also received free exercise equipment. Measures: Bivariate analyses tested for association between PA uptake and the convenience of the church location, the type of exercise equipment used and time of the day exercise classes were offered. Results: We found that there were associations between the convenience of the church location and PA participation (p=0.001) and the time of the day exercises classes were held and PA participation (p = 0.018) but not for the type of exercise equipment used and PA participation (p = 0.209). Conclusion: Overall, the church location, and the timing of exercise classes significantly impact PA uptake among church-going African Americans in NYC.

Mounting evidence shows a disproportionate COVID-19 burden among Blacks. Early findings indicate pre-existing metabolic burden (eg, obesity, hypertension and diabetes) as key drivers of COVID-19 severity. Since Blacks exhibit higher prevalence of metabolic burden, we examined the influence of metabolic syndrome on disparate COVID-19 burden. We analyzed data from a NIH-funded study to characterize metabolic burden among Blacks in New York (Metabolic Syndrome Outcome Study). Patients (n=1035) were recruited from outpatient clinics, where clinical and self-report data were obtained. The vast majority of the sample was overweight/obese (90%); diagnosed with hypertension (93%); dyslipidemia (72%); diabetes (61%); and nearly half of them were at risk for sleep apnea (48%). Older Blacks (age≥65 years) were characterized by higher levels of metabolic burden and co-morbidities (eg, heart disease, cancer). In multivariate-adjusted regression analyses, age was a significant (p≤.001) independent predictor of hypertension (OR=1.06; 95% CI: 1.04-1.09), diabetes (OR=1.03; 95% CI: 1.02-1.04), and dyslipidemia (OR=0.98; 95% CI: 0.97-0.99), but not obesity. Our study demonstrates an overwhelmingly high prevalence of the metabolic risk factors related to COVID-19 among Blacks in New York, highlighting disparate metabolic burden among Blacks as a possible mechanism conferring the greater burden of COVID-19 infection and mortality represented in published data.

Objectives This qualitative study explored factors that may influence decisions regarding kidney transplantation among African-American and Latino adults on dialysis. Methods Qualitative interviews were audio-recorded and transcribed. Open-coding techniques were used to identify concepts, categories, and themes. The Social Ecological Model (SEM) was used to organize themes and identify potential solutions across multiple levels (individual, interpersonal, community, and policy/health system). Results Thirty-six patients were interviewed. Their mean age was 53 SD 12 years; 50% were female; and their duration on dialysis was 4.9 SD 6 years. Five themes emerged and were organized according to the levels of the SEM: 1) Fear about the outcomes of transplantation and 2) faith in God (individual level); 3) Family dynamics and reluctance to involve family in the decision making process (interpersonal level); 4) The experiences of friends and social networks (community level); and 5) Concerns about the social and economic impact of transplantation (policy and health system). Discussion The application of a Social Ecological model in this study helped to illuminate the complex and multilevel factors that may influence the decisions for kidney transplantation. Future studies are needed to further explore how family members, social networks, faith communities, and policies/health systems influence the decision making process.

PURPOSE The majority of women managed for breast cancer in Nigeria are relatively young, many in their forties. Mastectomy, the most common surgical treatment, raises psychosocial concerns. Understanding these concerns may help address the fears of women who refuse treatment and aid in the care of those who have had mastectomy. METHODS Using qualitative methods, we purposively sampled women 45 years of age and younger who underwent mastectomy for breast cancer at a Nigerian teaching hospital. One-on-one in-depth interviews were conducted using an unstructured interview guide. Data were transcribed verbatim and analyzed to identify themes and subthemes. RESULTS The study identified six major themes on the impact of mastectomy on psychosocial lives of women, namely decision for mastectomy, postmastectomy transition, body image changes, relationship with husband and sexual life, coping with life postmastectomy, and social support. CONCLUSION Our findings highlight the importance of addressing individual patient’s psychosocial needs and preferences when discussing breast cancer treatment with young women. The experiences of women described in this study reveal several useful themes for planning treatment protocols and postmastectomy care.

OBJECTIVE: Disparities exist between population subgroups in the use of gynecologic oncologists and high-volume hospitals. The objectives of this study were to explore the experiences of black women obtaining ovarian cancer (OC) care at a high-volume center (HVC) and to identify patient-, provider-, and systems-related factors affecting their access to and use of this level of care. MATERIALS AND METHODS: Twenty-one semistructured interviews were conducted as part of an institutional review board–approved protocol with women who self-identified as black or African American, treated for OC at a single HVC from January 2013 to May 2017. Recurring themes were identified in transcribed interviews through the process of independent and collaborative thematic content analysis. RESULTS: Five themes were identified: (1) internal attributes contributing to black women’s ability/desire to be treated at an HVC, (2) pathways to high- and low-volume centers, (3) obstacles to obtaining care, (4) potential barriers for black women interested in treatment at an HVC, and (5) suggestions for improving HVC use by black women. Study participants who successfully accessed care were comfortable navigating the health care system, understood the importance of self-advocacy, and valued the expertise of an HVC. Barriers to obtaining care at an HVC included lack of knowledge about the HVC, lack of referral, transportation difficulties, and lack of insurance coverage. CONCLUSION: In this qualitative study, black women treated at an HVC shared attributes and experiences that helped them access care. There is a need to collaborate with black communities and establish interventions to reduce barriers, facilitate access, and disseminate information about the value of receiving care for OC at an HVC.

The widely used Modification of Diet in Renal Disease (MDRD) formula adapts a 1.212 multiplier for individuals who are identified as African Americans (AAs) or Blacks, which leads to a higher GFR estimation. As it stands, AAs have a lower prevalence of chronic kidney disease (CKD) but higher incidence of end-stage renal disease (ESRD) compared with Whites. Many hypotheses have been postulated to explain this paradox, but the imprecision of the GFR estimation with race-adaptation could be contributory. We performed a single-center, longitudinal, retrospective study on a cohort of outpatient AA patients using the MDRD and MDRDrace removed and CKD-EPI and CKD-EPIrace removed and their progression to CKD G5 (eGFR p < 0.0001 . Comparing the CKD-EPI formula against the MDRD in our cohort, we found that 8.2%, 18.8%, and 11.4% of patients were reclassified from CKD G1/2 to CKD G3a, CKD G3a to G3b, and CKD G3b to CKD G4 respectively. Overall median time to progression to CKD G5 was 137.4 (131.9–142.8) months in patients who were not reclassified and 133.6 (127.6–139.6) months for patients who were reclassified by MDRDrace removed p < 0.288 . Concerns of inequitable access to healthcare have elicited calls to review race-corrected eGFR equations. A substantial number of individuals would have their CKD stage reclassified should have the MDRDrace removed equation be adopted en masse on an AA-only population. The discrepancy is highest at the 45–59 and >60 ml/min/1.72 min2 ranges. This will have tremendous impact on our center’s approach to pharmacological dosing, referral system, best practices, and outcome surveillance. Comprehensive review of the current “race-corrected” eGFR will require a multifaceted approach and adjunctive use of noncreatinine-based approach.

Mounting evidence shows a disproportionate COVID-19 burden among Blacks. Early findings indicate pre-existing metabolic burden (eg, obesity, hypertension and diabetes) as key drivers of COVID-19 severity. Since Blacks exhibit higher prevalence of metabolic burden, we examined the influence of metabolic syndrome on disparate COVID-19 burden. We analyzed data from a NIH-funded study to characterize metabolic burden among Blacks in New York (Metabolic Syndrome Outcome Study). Patients (n=1035) were recruited from outpatient clinics, where clinical and self-report data were obtained. The vast majority of the sample was overweight/obese (90%); diagnosed with hypertension (93%); dyslipidemia (72%); diabetes (61%); and nearly half of them were at risk for sleep apnea (48%). Older Blacks (age≥65 years) were characterized by higher levels of metabolic burden and co-morbidities (eg, heart disease, cancer). In multivariate-adjusted regression analyses, age was a significant (p≤.001) independent predictor of hypertension (OR=1.06; 95% CI: 1.04–1.09), diabetes (OR=1.03; 95% CI: 1.02–1.04), and dyslipidemia (OR=0.98; 95% CI: 0.97–0.99), but not obesity. Our study demonstrates an overwhelmingly high prevalence of the metabolic risk factors related to COVID-19 among Blacks in New York, highlighting disparate metabolic burden among Blacks as a possible mechanism conferring the greater burden of COVID-19 infection and mortality represented in published data.

BACKGROUND Early postmastectomy discharge with a drain in place is standard practice in most developed countries. Its feasibility has not been evaluated in low resource settings like Nigeria. METHODS Consenting patients undergoing mastectomy were discharged on the third postoperative day and assessed as outpatients for wound complications as well as their experience at home. Wound outcomes were compared with patients who had traditional long stay. RESULTS Forty-five of the 58 patients who had a mastectomy during the study period participated in the early discharge program (77.6%). Of these, four patients (8.9%) had drain malfunction, seroma occurred in eight patients (17.8%), eight patients (17.8%) had wound infection, and six patients (13.3%) had flap necrosis. There was no readmission. Compared with long stay patients, postoperative stay was significantly shorter (3 vs 11 days; P

Background: African Americans develop hypertension earlier and have worse cardiovascular outcomes than Caucasians. Accumulating evidence suggests that psychological distress may play a role in the observed racial differences in hypertension. Several studies have investigated the relationship between depression and hypertension while little is still known about the role of demoralization. Methods: Using data from the Trial Using Motivational Interviewing, Positive Affect, and Self-affirmation in African Americans with Hypertension (TRIUMPH), logistic regression models were used to estimate differences in blood pressure control at 12 months among participants with demoralization, depression, and both conditions. Results: Our logistic models showed that reported psychosocial symptoms significantly differed in predicting success in blood pressure control at 12 months. Contrast analyses showed that, after adjusting for sociodemographic, clinical, and psychosocial variables, demoralized patients were less likely to achieve blood pressure control than participants without affective conditions (p = 0.020). Similar results emerged for patients with depression (p = 0.042) and both conditions (p = 0.022). Conclusions: Depression can be extremely debilitating and has serious health consequence. Our findings confirm this result and show that, even though depression and demoralization share common features, they are two distinct clinical phenomena with similar negative impact on blood pressure control in African Americans.

Objectives. To test the effectiveness of a preclinical, telephone-based patient navigation intervention to encourage colorectal cancer (CRC) screening among older Black men. Methods. We conducted a 3-parallel-arm, randomized trial among 731 self-identified Black men recruited at barbershops between 2010 and 2013 in New York City. Participants had to be aged 50 years or older, not be up-to-date on CRC screening, have uncontrolled high blood pressure, and have a working telephone. We randomized participants to 1 of 3 groups: (1) patient navigation by a community health worker for CRC screening (PN), (2) motivational interviewing for blood pressure control by a trained counselor (MINT), or (3) both interventions (PLUS). We assessed CRC screening completion at 6-month follow-up. Results. Intent-to-treat analysis revealed that participants in the navigation interventions were significantly more likely than those in the MINT-only group to be screened for CRC during the 6-month study period (17.5% of participants in PN, 17.8% in PLUS, 8.4% in MINT; P Conclusions. Telephone-based preclinical patient navigation has the potential to be effective for older Black men. Our results indicate the importance of community-based health interventions for improving health among minority men.

Background Valuable insights on the health and behavior of transit workers can be obtained from qualitative research that considers the social environment, which affects job performance and determines levels of perceived stress. Methods Using a grounded theory approach, semi-structured interviews were conducted with American transit workers (n = 32). Recorded interviews were transcribed and analyzed using a constant comparative method. Results Participants described categories related to entrenched organizational practices, particularly managements’ leadership style, which created an atmosphere of distrust. High demanding work schedules, as a result of technological advances, were discussed in relation to diminished breaks, fatigue, and unhealthy diets. Transit workers also attributed increased work demands and irregular working hours to compromised time with family and friends. Conclusions The described barriers to positive health behaviors and social support underscore the need for interventions that ensure adequate breaks and recovery between shifts and increase safety for transit passengers. Am. J. Ind. Med. 60:350–367, 2017. © 2017 Wiley Periodicals, Inc.

SUMMARYBackground Approximately 500,000 people in the United States are affected by end-stage kidney disease (ESKD), 53% of whom are Black or Latino. ESKD significantly impacts psychosocial health and quality of life. However, few studies address the psychosocial aspects of ESKD, especially among black and Latino adults. This study sought to understand the psychosocial context of living with ESKD among black and Latino adults who reside in a medically underserved community. Study Design A qualitative study. Setting and Participants Participants were recruited from a dialysis centre in East New York, Brooklyn, a medically underserved community. Methodology Descriptive phenomenology was used as a qualitative approach for capturing the experiences of patients who received dialysis in this community. Analytical Approach Open-ended interviews were audio-taped, transcribed, coded and analysed using standard qualitative techniques. Results Data saturation was achieved at 36 participants. The following five themes emerged: the transition to dialysis is abrupt and unexpected; denial is often an initial response; dialysis is the new normal and in order to survive one must forget the past and press forward; dialysis changes everything and impacts the entire family; strength was often found in faith and family. Limitations This study was conducted in one setting and may need to be expanded to other sites to capture the experiences of patients cared for in other settings. Conclusion These findings have practical implications for informing patient-centered models of care that are more responsive to the psychosocial needs of patients with ESKD living in medically underserved communities.

New York City (NYC) Latinos are disproportionately affected by obesity. However, little information is available on demographic and behavioral factors linked to body mass index (BMI) in this population. A community-based survey was conducted in the inner-city Bronx community of NYC to evaluate these factors among Latino New Yorkers. 738 Latinos completed the survey. 241 (32.7 %) participants were obese (BMI 30 kg/m(2)) and 302 (41 %) individuals were overweight (BMI 25-30 kg/m(2)). Adjusted regression analyses show that Latinos who are overweight or obese were found at greater odds of being men, residing in the US for10 years, in early stages 1-3 of change of physical activity behavior, and at lower odds of being young adults aged35 years or with college education. Analysis of factors associated stages of change (SOC) revealed that subjects in these preliminary SOC related to physical activity were at greater odds of speaking Spanish alone, in the same SOC with respect to diet, and at lower odds of living10 years in the US. With respect to diet, subjects in preliminary stages were at greater odds of being young adults35 years of age or in early SOC of physical activity and at lower odds of low income20 dollars per year. The survey shows that Latino New-Yorkers in the Bronx with high prevalence of overweight status and obesity have unique demographic, socio-economic, behavioral and cultural factors that can be linked to excessive body weight.

Background The taxicab industry is a burgeoning occupation that predominantly employs immigrant males from low socioeconomic backgrounds. Factors such as sedentary nature, environmental factors, high stress coupled with socioeconomic factors may increase cardiovascular disease risk among taxicab drivers. Latinos, a growing immigrant population make up approximately 20% of this industry. However, few studies focus on their experiences as cab drivers or on the factors that may increase their cardiovascular risks. Methods This was an ethnographic qualitative study. Data was collected via individual interviews combined with Go-Alongs. The Go-Along is an observational qualitative method whereby researchers accompany participants during routine activities and make observations. Interviews and observations were transcribed and coded to identify emerging themes. Results Thirty-two Latino male cab drivers participated; their mean age was 45 + 12 years; 47% did not finish high school; and 63% earned $30 000 or less. Time and stress emerged as dominant themes. Time constraints posed a barrier to healthy eating and physical activity. Drivers reported stress from constantly worrying about their finances and personal safety. Drivers also described stress from the physical toll of driving on the body. Go-Alongs supported these themes and identified social interactions and environmental factors that could be leveraged for health promotion. Conclusions This study provided an opportunity for cab drivers to describe their perspectives on reasons why their occupation was associated with a high risk for cardiovascular disease. The Go-Alongs contributed to the understanding of the social and environmental context that characterized cardiovascular risks in this occupation.

BACKGROUND: Early post-mastectomy discharge with a drain in place is standard practice in most developed countries. Its feasibility has not been evaluated in low resource settings like Nigeria. METHODS: Consenting patients undergoing mastectomy, were discharged on the third post-operative day and assessed as outpatients for wound complications as well as their experience at home. Wound outcomes were compared with patients who had traditional long stay. RESULTS: Forty-five of the 58 patients who had a mastectomy during the study period participated in the early discharge programme (77.6%). Of these, 4 patients (8.9%) had drain malfunction, seroma occurred in 8 patients (17.8%), 8 patients had wound infection (17.8%), and 6 patients had flap necrosis (13.3%). There was no re-admission. Compared to long stay patients, post-operative stay was significantly shorter (3 versus 11 days, p

African-Americans are disproportionately impacted by cardiovascular disease (CVD). Faith-based institutions provide a non-traditional route for health education targeted at African-Americans. This paper describes HeartSmarts, a faith-based CVD education program. Evidence-based literature was used to develop a curriculum, which was tailored by integrating biblical scripture representing aspects of health behaviors. Eighteen church peer-educators were recruited to participate in a 12-week training. They then disseminated the faith-based curriculum to members of their congregations. There were 199 participants of which 137 provided feedback via open-ended surveys indicating that HeartSmarts was well accepted and effective for disseminating CVD health messages while engaging spirituality.

OBJECTIVES Among all South Asians, Bangladeshis have the highest prevalence of cardiovascular disease (CVD). The purpose of our study was to compare the understanding of CVD risk factors among Bangladeshi immigrants to the general Caucasian population in the U.S. DESIGN We surveyed Bangladeshi immigrants in Queens, New York using a CVD risk factor knowledge instrument used in the Coronary Artery Risk Development in Young Adults (CARDIA) study to assess awareness of risk factors. Using multivariate regression modeling, we compared scores on the knowledge instrument between Bangladeshis we surveyed and Caucasians from the CARDIA study, controlling for potential confounders. We subsequently examined the frequency of mentioning each risk factor to understand what was driving the difference in the overall score. RESULTS The proportion of Bangladeshis scoring low on the knowledge assessment was 0.53, where as the proportion of whites scoring low in the CARDIA study was 0.32 (p value

The objective of this study was to identify the types of interactions between asthma patients and their social networks such as close family and friends that influence the management of asthma.Participants were Latino adults presenting for a repeat visit to the emergency department for asthma treatment. Qualitative interviews were conducted with 76 participants. They were asked to describe the experiences of their social networks that have asthma and how interactions with these individuals influenced their own asthma management. Responses were transcribed and analyzed using Grounded Theory as a qualitative analytic approach. Responses were assigned codes; similar codes were grouped into concepts and then categorized to form overarching themes.Four themes emerged: (1) Perceptions of severity of asthma may be based on the experiences of social networks; (2) Economic factors may contribute to the sharing and borrowing of asthma medications between patients and their social networks; (3) Economic factors may contribute to using home remedies instead of prescribed medications; (4) Social network members may be unaware of the factors that trigger asthma and therefore, contribute to asthma exacerbations.This study identified important social network interactions that may impact asthma management in Latino adults. These results can be used to broaden the current focus of asthma self-management programs to incorporate discussions on the role of social networks. A focus on social network interactions addresses the social epidemiology of asthma and advances our understanding of root causes that may underlie the high prevalence of asthma in many Latino communities.

Objective: The objective of this study was to document the frequency and clinical characteristics associated with repeat emergency department (ED) visits for asthma in an inner city population with a high burden of asthma.During an ED visit for asthma in an inner city hospital ('index visit'), patients completed a valid survey addressing disease and behavioral factors. Hospital records were reviewed for information about ED visits and hospitalizations for asthma during the 12 months before and the 90 days after the index visit.One hundred and ninety-two patients were enrolled; the mean age was 42 years, 69% were women, 36% were black, 54% were Latino, 69% had Medicaid, and 17% were uninsured. 100 patients (52%) were treated and released from the ED, 88 patients (46%) were hospitalized, and 4 patients (2%) left against medical advice. During the subsequent 90 days, 64 patients (33%) had at least one repeat ED visit for asthma and 27 (14%) were hospitalized for asthma. In a multivariate model, more past ED visits (OR 1.7, 95% CI 1.4, 2.1; p 0.0001) and male gender (OR 2.5, 95% CI 1.2, 5.4; p = 0.02) remained associated with having a repeat ED visit. Most patients had the first repeat ED visit within 30 days and 18 returned within only 7 days. Among all patients with a repeat visit, those who were not hospitalized for the index visit were more likely to have a repeat visit within 7 days (37%) compared to those who were hospitalized (17%) (p = 0.05 in multivariate analysis).Repeat ED visits were prevalent among inner city asthma patients and most occurred shortly after the index visit. The strongest predictors of repeat visits were male gender and more ED visits in the 12 months before the index visit.

To support patients in making decisions that align with their unique cultural beliefs, an understanding of factors underlying patient preferences is needed. We sought to identify psychosocial factors that influenced decision making among African-American and Hispanic patients referred for knee or hip arthroplasty. Thirty-six participants deciding on surgery were interviewed. Responses were audio-taped, transcribed, and read. Codes were assigned to the raw data and then clustered into categories that were analyzed to yield overarching themes. This process was repeated independently by two corroborators. Six categories described the mental calculations made in patients' decision-making processes: 1) self-assessment of fit for surgery based on age and comorbidity, 2) research and development of mental report cards of their surgeons, 3) reliving of social network experiences, 4) reliance on faith and spirituality for guidance, 5) acknowledgment of fear and anxiety, and 6) setting expectations for recovery. This study advanced the understanding of how decisions about joint replacement are constructed and identified cultural levers that can be targeted for intervention. Developing culturally tailored health information that addresses some of our findings and disseminating messages through social networks may reduce the underutilization of joint replacement among racial and ethnic minority populations.

To measure knowledge of the health consequences of obesity among overweight/obese Black and Hispanic adults and examine the relationship to prior weight loss.Knowledge of the health consequences of obesity was assessed among 410 Black and Hispanic adults with BMI ≥ 25 kg/m2 enrolled in a behavior change weight loss study. The relationship between obesity risk knowledge and previous weight loss was also examined.The majority of participants were knowledgeable of the risk of hypertension (94%), diabetes (96%), high cholesterol (91%), joint pains/arthritis (89%) and sleep apnea (89%) associated with obesity. Among post-menopausal age women, 53% were aware of the increased risk of breast cancer. There was no significant relationship between obesity risk knowledge and previous weight loss of 10 pounds or more (OR = 1.075, 95% CI: [0.808, 1.430]).We found that knowledge of the health consequences of obesity was high, except for knowledge of the risk of breast cancer. Obesity risk knowledge was not associated with past weight loss.Further health education is needed regarding the increased risk of breast cancer associated with obesity. Our data suggest that knowledge of the health consequences of obesity is not associated with weight loss success.

Introduction: Physicians in training must be able to counsel their patients on smoking cessation, however, little is known about the barriers that they face to counselling their patients.Aims: The study sought to identify barriers to smoking cessation counselling specific to physicians in training.Methods: Qualitative interviews in the form of focus groups were conducted with 30 medical residents. Focus groups were audio taped, transcribed verbatim and coded by two independent reviewers. Similar codes were grouped to form categories and then aggregated to form themes.Results: Seven themes emerged describing resident barriers to provision of smoking cessation counselling : (1) Lack of self-efficacy for providing counselling; (2) their perception that patients are not willing to change; (3) a lack of available resources/information for providers and patients; (4) differences in supervising physician's recommendations; (5) perceived lack of time; (6) a perception of lack of continuous care; and (7) a lack of practical skills in counselling.Conclusions: This study highlighted residents’ perceived barriers to providing smoking cessation counselling. These barriers are similar to those encountered by other providers. Additional barriers specific to residency exist and more training is necessary.Practice Implications: The barriers that physicians encounter to smoking cessation counselling must be addressed early on in residency training.

Among patients with chronic cardiopulmonary disease, increasing healthy behaviors improves outcomes, but such behavior changes are difficult for patients to make and sustain over time. This study aims to demonstrate how positive affect and self-affirmation improve health behaviors compared with a patient education control group. The patient education (PE control) patients completed a behavioral contract, promising to increase their physical activity or their medication adherence and received an educational guide. In addition to the contract and guide, the positive affect/self-affirmation intervention (PA intervention) patients also learned to use positive affect and self-affirmation to facilitate behavior change. Follow-up was identical. In 756 patients, enrolled in three randomized trials, the PA intervention resulted in increased positive affect and more success in behavior change than the PE control (p

The US has increasingly growing Bangladeshi population, a South Asian sub-ethnic group with a high prevalence of cardiovascular disease (CVD). We conducted a qualitative study using individual in-depth interviews to explore attitudes towards and difficulties with modifying CVD related behaviors among a Bangladeshi cohort. We interviewed 55 patients before reaching data saturation. Bangladeshis discussed the meaning of health and heart disease in the context of how disease can potentially impact their ability to care for their family. Behavioral and psychological factors were discussed as the causes of CVD. Internal forces and external forces were brought up to explain difficulties addressing the causes of CVD. Bangladeshi individuals in our study were aware of CVD, but felt unable to address behavioral risk factors. They cite a combination of internal and external factors as barriers to lifestyle modification. Interventions to address these barriers must simultaneously addressing self-efficacy and work-life balance.

This paper describes the application of a translational research model in developing The Trial Using Motivational Interviewing and Positive Affect and Self-Affirmation in African-Americans with Hypertension (TRIUMPH), a theoretically-based, randomized controlled trial. TRIUMPH targets blood pressure control among African-Americans with hypertension in a community health center and public hospital setting. TRIUMPH applies positive affect, self-affirmation, and motivational interviewing as strategies to increase medication adherence and blood pressure control. A total of 220 participants were recruited in TRIUMPH and are currently being followed. This paper provides a detailed description of the theoretical framework and study design of TRIUMPH and concludes with a critical reflection of the lessons learned in the process of implementing a health behavior intervention in a community-based setting. TRIUMPH provides a model for incorporating the translational science research paradigm to conducting pragmatic behavioral trials in a real-world setting in a vulnerable population. Lessons learned through interactions with our community partners reinforce the value of community engagement in research.

Bullying is an important public health issue in the United States. Up to 30% of children report exposure to such victimization. Not only does it hurt bully victim, but it also negatively impacts the bully, other children, parents, school staff, and health care providers. Because bullying often presents with accompanying serious emotional and behavioral symptoms, there has been an increase in psychiatric referrals to emergency departments. Emergency physicians may be the first responders in the health care system for bullying episodes. Victims of bullying may present with nonspecific symptoms and be reluctant to disclose being victimized, contributing to the underdiagnosis and underreporting of bully victimization. Emergency physicians therefore need to have heightened awareness of physical and psychosocial symptoms related to bullying. They should rapidly screen for bullying, assess for injuries and acute psychiatric issues that require immediate attention, and provide appropriate referrals such as psychiatry and social services. This review defines bullying, examines its presentations and epidemiology, and provides recommendations for the assessment and evaluation of victims of bullying in the emergency department.

Valuable insights on the health and behavior of transit workers can be obtained from qualitative research that considers the social environment, which affects job performance and determines levels of perceived stress.Using a grounded theory approach, semi-structured interviews were conducted with American transit workers (n = 32). Recorded interviews were transcribed and analyzed using a constant comparative method.Participants described categories related to entrenched organizational practices, particularly managements' leadership style, which created an atmosphere of distrust. High demanding work schedules, as a result of technological advances, were discussed in relation to diminished breaks, fatigue, and unhealthy diets. Transit workers also attributed increased work demands and irregular working hours to compromised time with family and friends.The described barriers to positive health behaviors and social support underscore the need for interventions that ensure adequate breaks and recovery between shifts and increase safety for transit passengers. Am. J. Ind. Med. 60:350-367, 2017. © 2017 Wiley Periodicals, Inc.

Approximately 500,000 people in the United States are affected by end-stage kidney disease (ESKD), 53% of whom are Black or Latino. ESKD significantly impacts psychosocial health and quality of life. However, few studies address the psychosocial aspects of ESKD, especially among black and Latino adults. This study sought to understand the psychosocial context of living with ESKD among black and Latino adults who reside in a medically underserved community.A qualitative study.Participants were recruited from a dialysis centre in East New York, Brooklyn, a medically underserved community.Descriptive phenomenology was used as a qualitative approach for capturing the experiences of patients who received dialysis in this community.Open-ended interviews were audio-taped, transcribed, coded and analysed using standard qualitative techniques.Data saturation was achieved at 36 participants. The following five themes emerged: the transition to dialysis is abrupt and unexpected; denial is often an initial response; dialysis is the new normal and in order to survive one must forget the past and press forward; dialysis changes everything and impacts the entire family; strength was often found in faith and family.This study was conducted in one setting and may need to be expanded to other sites to capture the experiences of patients cared for in other settings.These findings have practical implications for informing patient-centered models of care that are more responsive to the psychosocial needs of patients with ESKD living in medically underserved communities.

In order to effectively address cardiovascular disease among African Americans, evidence-based health information must be disseminated within a context aligned with the values and beliefs of the population. Faith-based organizations play a critical role in meeting the religious and spiritual needs of many African Americans. Additionally, faith-based organizations can be effective in health promotion. A manual was created by incorporating biblical scriptures relating to health messages drawn from existing health manuals oriented toward African Americans. Lay health educators active in their churches participated in a 12-week training to learn the basics of cardiovascular disease and methods for delivering the program to their congregations’ members. After the completion of the training, these lay health educators recruited participants from their respective churches and administered their own 12-week HeartSmarts program. Measurements of participants’ systolic and diastolic blood pressure (mmHg), height (in.), weight (lbs.), and waist circumference (in.) were taken, and cardiovascular disease knowledge assessments (based on 20 open-ended questions) were administered at the start and end of the 12-week programs. Fourteen predominantly African American churches in NYC participated. Of the 221 participants, 199 completed the program. There were significant reductions in pretest and posttest total participant averages for systolic BP (4.48 mmHg, p

Leadership positions in global health are greatly skewed toward men; the imbalance is more pronounced in low- and middle-income countries (LMICs). The under-representation of women in leadership is a threat to gender equality, and also impacts the improvement of women's health outcomes globally. In this perspectives piece, we assert that the promotion and retention of women in global health leadership has a ripple effect that can achieve improvement in global health outcomes. We present pragmatic, actionable solutions to promote and retain female global health leaders in this field.Les positions de dirigeant dans la santé du monde sont largement orientées vers les hommes et ce déséquilibre est encore plus prononcé dans les pays à revenu faible et moyen. La sous-représentation des femmes en termes de dirigeant menace l'égalité des genres et a également un impact sur l'amélioration de l'état de santé des femmes dans le monde. Dans cette perspective, nous affirmons que la promotion et la rétention des femmes au sein du leadership de la santé dans le monde a un effet d'entraînement qui peut aboutir à une amélioration de l'état de santé dans le monde. Nous présentons des solutions pragmatiques et réalisables pour promouvoir et retenir des leaders féminins en matière de santé dans le monde.Los puestos directivos en materia de salud mundial se asignan de manera desproporcionada a los hombres; este desequilibrio es aun más notorio en los países de ingresos bajos y medianos. La subrepresentación de las mujeres en los cargos de responsabilidad pone en peligro la equidad entre los hombres y las mujeres y tiene además repercusiones en los resultados de salud de las mujeres en el mundo. En el presente artículo de opinión, se sostiene que promover a las mujeres a las funciones directivas relacionadas con la salud mundial y facilitar su permanencia en ellas genera una reacción en cadena que puede dar lugar a mejores resultados de salud a escala mundial. Se proponen soluciones viables y prácticas encaminadas a estimular la presencia de las mujeres en los cargos de responsabilidad en materia de salud mundial y a respaldar su permanencia en esta actividad.

Background: Previous studies of racial disparities in total joint replacement, particularly total knee arthroplasty, in the U.S. have predominantly focused on disparities between blacks and whites and were limited to Medicare patients or veterans, populations that are not representative of the entire U.S. population. We sought to study racial disparities in the utilization of total knee arthroplasty, the use of high-volume hospitals, and total knee arthroplasty outcomes, including mortality and complications, using all-payer databases. Methods: We analyzed data from 8 years and 8 racially diverse states in the State Inpatient Databases (SID). Patient race was categorized according to the SID as white, black, Hispanic, Asian, Native American, and mixed race. Both crude and adjusted racial and/or ethnic disparities were evaluated. Results: In comparison with whites (4.65 per 1000 population per year), black (3.90), Hispanic (3.71), Asian (3.89), Native American (4.40), and mixed-race (3.69) populations had lower rates of total knee arthroplasty utilization (p < 0.0001). After risk adjustment, the rate of total knee arthroplasty utilization was significantly lower for blacks (odds ratio [OR] = 0.87 [95% confidence interval (CI), 0.85 to 0.89]; p < 0.0001), Hispanics (OR = 0.76 [95% CI, 0.68 to 0.83]; p < 0.0001), Asians (OR = 0.83 [95% CI, 0.78 to 0.89]; p < 0.0001), Native Americans (OR = 0.87 [95% CI, 0.81 to 0.93]; p < 0.0001), and mixed race (OR = 0.84 [95% CI, 0.79 to 0.90]; p < 0.0001) compared with the rate for whites. Lower rates of total knee arthroplasty utilization for blacks, Hispanics, and mixed-race groups became worse over the years. Patients from minority groups were less likely to undergo total knee arthroplasty in high-volume hospitals than were whites. Moreover, the rates of mortality were significantly higher for blacks (OR = 1.52 [95% CI, 1.17 to 1.97]; p = 0.0017), Native Americans (OR = 6.52 [95% CI, 4.63 to 9.17]; p < 0.0001), and mixed-race patients (OR = 4.35 [95% CI, 3.24 to 5.84]; p < 0.0001). Blacks (OR = 1.08 [95% CI, 1.01 to 1.15]; p = 0.01) and mixed-race patients (OR = 1.17 [95% CI, 1.001 to 1.36]; p = 0.04) had higher rates of complications than whites. Conclusions: Minorities had lower rates of total knee arthroplasty utilization but higher rates of adverse health outcomes associated with the procedure, even after adjusting for patient-related and health-care system-related characteristics. Utilization rates were based on overall population as the proportion of the population with osteoarthritis requiring arthroplasty is unknown. Future studies that consider specific patient-level information with psychosocial and behavioral factors are needed. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Although readmission occurs following 25% of heart failure hospitalizations, identifying patients at greatest risk has been challenging. To date, prediction models have offered only modest discriminatory power (C-Statistic: 0.58-0.65). Their limitations underscore the need for novel approaches to risk prediction. Hypothesis: Multi-level analysis and the inclusion of population-level factors will improve the predictive ability of our 30-day HF readmission model. Methods: We studied patients with a principal diagnosis of HF who were discharged home from an academic hospital in 2013-2014. Index hospitalizations and 30-day readmissions were identified by query of the electronic medical record. Variables of analysis included demographics, HF characteristics, comorbidities, echocardiographic (echo) parameters and clinical indices. Heart failure with preserved ejection fraction (HFpEF) was defined as LVEF ≥ 50 on echo. Conventional logistic regression models were first used to examine the association between patient characteristics and 30-day readmissions. Next, multi-level modeling was used wherein hierarchical clustering techniques identified key drivers of readmission. The final predictive model incorporated these findings. Results: Of the 821 patients admitted with HF, 242 (29.5%) were readmitted within 30 days. HFpEF (p = .008), LVEF (p= .03) and NYHA classification (p=.002) were associated with early readmission, as were end stage renal disease (p=.04) and gastrointestinal bleeding (p =.02). In addition, serum sodium (p =.02), creatinine (p =.03) and hemoglobin (p =.002) were also associated with readmission. The initial multivariable logistic regression model based on patient characteristics was significant (p=.01) with 66% convergence. This model found ventricular tachycardia (VT) (OR = 3.47 CI 1.49-8.08) and HFpEF (OR =1.49 CI 1.01-2.22) to be associated with readmission. As expected, NYHA Class II (OR = 0.28 CI 0.09-0.834) and Hemoglobin (OR = 0.89 CI 0.80-0.98) were inversely associated with readmission. Multi-level analysis revealed that beyond the characteristics of the individuals alone, patients with HFpEF represented a significant sub-population that was driving readmissions. The final model incorporated this nested sub-group and was found to have an improved convergence of 73% (p =.02). In this model, the association of HFpEF and readmission increased in magnitude (OR = 3.43 CI 1.39-8.45), whereas factors including VT, NYHA Class II, and hemoglobin were no longer significant. Conclusion: Multi-level analysis increased the predictive ability of our 30-day HF readmission model (c stat 0.66 to 0.73) by accounting for both individual and population-level characteristics. HFpEF emerged as a key driver of readmission and its inclusion in the model led to a more accurate and clinically meaningful tool for our clinicians and medical center.

Purpose Breast cancer outcomes are poor in most low- and middle-income countries. This is a result, in part, of delayed presentation. Critical to improving this gloomy picture is the promotion of breast cancer screening programs; however, designing a formidable screening program requires obtaining necessary background data. This survey evaluates breast cancer screening practices and barriers in two Nigerian communities with different geographic access to screening facilities. Methods We administered a 35-item questionnaire to women age 40 years and older—1,169 participants (52.6%) in the Ife Central Local Government, where mammography services are offered, and 1,053 (47.4%) in the Iwo Local Government, where there are no mammography units. Information on breast cancer screening practices and barriers to mammography screening were compared between the two communities. Results Most women had heard of breast cancer (Ife, 94%; Iwo, 97%), but few have had any form of breast cancer screening recommended to them—37.7% of Ife respondents and 36.6% of Iwo respondents. Few women were aware of mammography (Ife, 11.8%; Iwo, 11.4%), whereas mammography uptake was 2.8% Ife respondents and 1.8% in Iwo respondents, despite the latter offering mammography services. Awareness and practice of mammography were not statistically different between the two communities ( P = .74 and P = .1 for Ife and Iwo, respectively). Lack of awareness was the most common reason cited for not undergoing mammography in both communities. Cost was also identified as a barrier, as only 20% of respondents could afford mammography. Despite being offered at little or no cost, uptake of clinical breast examination (CBE) was poor in both communities—27.4% in Iwo and 19.7% in Ife; however, the majority were willing to participate in a routine CBE-based breast cancer screening program. Conclusion Access without awareness and community mobilization does not guarantee use of breast cancer screening services. Given the above findings, a comprehensive breast health program that incorporates awareness creation, routine CBE-based screening, and selective mammography is currently underway in a selected Nigerian community. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST No COIs from the author

Using popular culture to engage students in discussions of HIV prevention is a nontraditional approach that may complement current prevention efforts and enhance the ability to reach youth who are at high risk of contracting HIV and other sexually transmitted infections. Hip-hop or rap music is the dominant genre of music among adolescents, especially Black and Latino youth who are disproportionately impacted by HIV and AIDS. This paper describes the rationale and development of the Reducing HIV and AIDS through Prevention (RHAP) program, a school-based program that uses hip-hop/rap music as a vehicle for raising awareness among adolescents about HIV/AIDS. Constructs from the Social Cognitive Theory and the Sexual Script Theory were used in developing the program. It was piloted and evaluated among 26 middle school students in East Harlem, New York. The lessons learned from a formative evaluation of the program and the implications for developing other programs targeting public health problems are discussed. The RHAP program challenges the traditional pedagogue–student paradigm and provides an alternative approach to teaching about HIV prevention and awareness.

Evidence from well-defined cohort studies has shown that short sleep, through sleep fragmentation caused by obstructive sleep apnea (OSA) or behavioral sleep curtailment because of lifestyle choices, is associated with increased incidence of diabetes. In this report, we review epidemiologic and clinical data suggesting that OSA is involved in the pathogenesis of altered glucose metabolism. Evidence suggesting increased risk of developing diabetes resulting from curtailed sleep duration is also considered. Proposed mechanisms explaining associations between short sleep and diabetes are examined and clinical management of OSA among patients with diabetes is discussed.

Introduction The Center for Epidemiologic Studies Depression Scale (CES-D) is a measure of depressive symptoms that is commonly used in clinical studies. Studies employing this measure often describe variations in aggregate scores. However, few studies have examined variations in response to specific items by race and ethnicity. Method This was a cross-sectional analysis among adults who were ages 50 and older and who were hospitalized for the management of coronary artery disease. Differential item functioning analysis was used to determine whether there were racial and ethnic variations in response to the items on the CES-D. Results Of the 571 participants, 76% were Caucasian, 12% were African-American, and 8% were Latino-American. After adjusting for age, gender, and education, four items exhibited differential item functioning. The odds of Latinos endorsing the item ‘I was bothered by things that usually don't bother me’ was 2.5 (95% CL 1.2–5.9); 2.7 (95% CL 1.4–5.1) for the item ‘My sleep was restless’; 2.0 (95% CL 1.0–5.0) for the item ‘I felt that I was just as good as other people’; and 2.3 (95% CL 1.3–4.5) for the item ‘I enjoyed life’. The last two items were scored in reverse therefore; higher scores reflect more depressive symptoms. African-Americans were 3.0 times more likely to endorse the item ‘people were unfriendly’ (95% CL 1.4–6.5). Conclusions In this study, differences in somatic, positive affective and interpersonal symptoms were associated with the higher prevalence of depressive symptoms observed among racial and ethnic minorities when compared to Caucasians. Copyright © 2008 John Wiley & Sons, Ltd.

Objectives: The objectives of this pilot study were to determine the incidence of Posttraumatic Stress Disorder (PTSD) one to two months after Myocardial Infarction (MI), and to evaluate potential predictors of PTSD symptoms post-MI. Methods: A convenience sample of 31 patients hospitalized for treatment of acute MI was interviewed during hospitalization and one to two months later. The assessments included socio-demographic questions, questions related to clinical history and hospitalization, assessment of depressive symptoms using the Center for Epidemiologic Studies— Depression (CES-D) scale, medical comorbidity using the Charlson Comorbidity Index (CCI), and perceived social support using the Medical Outcomes Study (MOS) scale. Medical records were reviewed for collection of clinical data. Symptoms of PTSD were evaluated using the Structured Clinical Interview for DSM-IV (SCID) and the Impact of Events Scale-Revised (IES-R). Results: While one patient (4.0%) met DSM IV criteria for PTSD; additional 16% of the patients had significant symptoms of PTSD as measured by the IES-R (scoring above 24). Higher scores of PTSD symptoms were significantly associated ( p < 0.05) with younger age, black race, depressive symptoms in baseline, and self-reported anxiety during the MI. Conclusions: The incidence of PTSD following MI was low, but 16% of MI patients developed subsyndromal PTSD. The emotional status of the patients at the time of the MI and their subjective reaction to the event were important factors in the development of PTSD symptoms. Black and younger patients were in increased risk of developing PTSD symptoms post-MI.

This study evaluated the psychosocial correlates of being overweight or obese among US born and immigrant Latino adults. Depressive symptoms were measured with the Center for Epidemiological Studies Depression Scale (CES-D10). Of the 177 participants, 64% were either overweight or obese, of which, 51% also had comorbid depressive symptoms. On bivariate analyses, these participants were younger (OR = 2.4, 95% CI = 1.5-5.2), female (OR = 2.5, 95% CI = 1.3-4.6), US born (OR = 6, 95% CI = 1.3-9.0), more likely to have lived in the US 15 or more years (OR = 2.6, 95% CI 1.3-5.1), reported fair or poor health, (OR = 3.8, 95% CI = 1.8-8.0), and were more likely to perceive greater stress (OR = 7.8, 95% CI = 3.4-18.0). On multivariate analysis, only perceived stress remained significant (OR = 6.5, 95% CI = 2.7-15.6). This suggests that interventions designed to reduce the epidemic of overweight and obesity in Latino adults may also need to address their psychosocial health.

The high prevalence of depressive symptoms in patients with coronary artery disease has been well documented. However, little is known about the prevalence and correlates of depressive symptoms in Latino patients with coronary artery disease.Among Latino and white patients who had percutaneous transluminal coronary angioplasty (PTCA), this study examined whether differences in the prevalence of depressive symptoms exist and the degree to which psychosocial factors (years of education, employment status, stressful life events, emotional social support) explained any differences.Using a cross-sectional design, closed-format questionnaires were used to obtain clinical and psychosocial history. The definition of high depressive symptoms was based on a score ofor =16 on the Center for Epidemiologic Studies Depression Scale (CES-D).Compared to whites (n=492), Latinos (n=59) were younger, and a greater proportion were female, but fewer completed high school and fewer were employed (P0.05). More Latinos reported experiencingor =2 recent stressful life events, but fewer reported having emotional social support (P0.05). There was a significant association between race/ethnicity and depressive symptoms (OR=2.3, 95% CI: 1.3-4.5). In multivariate analyses, the significance of this association diminished when psychosocial variables were added to the model.In this study, education, employment, stressful life events and emotional social support partially explained the observed racial/ethnic differences in depressive symptoms.