Faculty Bibliography

BACKGROUND:Improved access to antiretroviral therapy (ART) has increased survival among people living with HIV (PLWH) but also the burden of cardiovascular risk factors like hypertension. While the task-strengthening strategy for hypertension control (TASSH) is a viable integrated care model, evidence of its clinical impact in Africa is limited. This report presents baseline findings from a trial evaluating two implementation strategies for integrating TASSH into HIV care across primary health centers (PHCs) in Lagos, Nigeria. METHODS:A total of 3504 PLWH on ART in 30 PHCs were screened, and 830 were enrolled. Baseline data on patient sociodemographic, clinical, laboratory results, and lifestyle characteristics were gathered. RESULTS:Among the 3504 screened, 1046 (29.9%) had hypertension. Of the 830 enrolled, mean [SD] age was 49.4 [9.5] years, 63.5% were women, 69.5% had at least secondary school education, 92.3% were employed, and 84.6% earned less than 100,000 Naira (64.74 USD) monthly. The median BP was 150.0/95.3 mmHg, and 63.9% were overweight or obese. 25.8% continued previously prescribed antihypertensive medications, while 66.3% received new prescriptions. Additionally, 25.1% and 1.8% were alcohol users and current smokers, while 30.9% were physically inactive. CONCLUSIONS:The prevalence of hypertension among PLWH was higher than previously reported. Although most participants adopted healthy lifestyle behaviors, the majority were overweight or obese, and many were not on antihypertensive medications. These findings highlight the importance of integrating hypertension control into HIV care across PHCs in Nigeria.

IMPORTANCE/UNASSIGNED:At a time when diversity in higher education is increasingly perceived as beneficial only to minority students and disadvantaging to majority-group students, it is crucial to investigate its benefits broadly. OBJECTIVE/UNASSIGNED:To assess whether meaningful interactional diversity (ie, cross-cultural engagement that influences knowledge or opinions) is associated with key educational outcomes among White medical students. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cross-sectional study included self-identified White-only medical students who matriculated to a US allopathic medical school between 2013 and 2022, graduated between 2015 and 2024, and responded to the Association of American Medical Colleges Graduation Questionnaire (GQ). GQ responses were anonymous. Data were analyzed from September 2024 to April 2025. EXPOSURE/UNASSIGNED:Meaningful interactional diversity, defined by agreement on a 5-point Likert scale with the GQ item, "My knowledge or opinion was influenced or changed by becoming more aware of the perspectives of individuals from different backgrounds." MAIN OUTCOMES AND MEASURES/UNASSIGNED:Six self-reported binary outcomes derived from the GQ were assessed: personal and professional development fostered by medical schools, ability to care for and work with people from different backgrounds, and intention to work in an underserved area and with an underserved population regardless of practice location. RESULTS/UNASSIGNED:Among 80 542 students (38 589 [47.91%] female) from 155 medical schools, 495 (0.61%) strongly disagreed, 1416 (1.76%) disagreed, 7387 (9.17%) were neutral, 35 155 (43.65%) agreed, and 36 089 (44.81%) strongly agreed with meaningful interactional diversity. Across increasing agreement with meaningful interactional diversity, higher likelihoods of personal and professional development and care and teamwork competence were observed, whereas associations with service intentions were confined to strong agreement. Compared with strong disagreement, strong agreement was associated with greater personal (adjusted relative risk [aRR], 2.37; 95% CI, 2.05-2.74) and professional (aRR, 1.59; 95% CI, 1.42-1.69) development, competence to care for (aRR, 1.23; 95% CI, 1.17-1.29) and work with (aRR, 10.69; 95% CI, 7.84-14.57) people from different backgrounds, and plans to work in underserved areas (aRR, 1.31; 95% CI, 1.08-1.58) or with underserved populations regardless of practice location (aRR, 1.59; 95% CI, 1.30-1.93). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cross-sectional study of White medical students, meaningful interactional diversity was associated with graded improvements in core developmental outcomes and threshold-level associations with service intentions.

BACKGROUND:Obstructive sleep apnea (OSA) is associated with Alzheimer's disease (AD) risk. Racial-, ethnic-, and sex-specific mechanisms of OSA and AD risk were examined. METHODS:We analyzed data from 3978 polysomnography patients without cognitive decline aged ≥ 60 including 663 OSA+ patients (284 non-Hispanic White, 207 Black, 172 Hispanic) matched to OSA- cohorts (1:1, n = 663; 1:4, n = 2652) and followed for AD through 2013. RESULTS:During the 8.5 (standard deviation 1.4) year period, 358 patients developed AD. AD risk was higher for Black (adjusted hazard ratio [aHR] 2.24 [1.24-2.71]), Hispanic (aHR 1.73, [1.38-3.51]), White (aHR 1.83, [1.21-3.37]), male (aHR 2.38, [1.31-3.47]), and female (aHR 1.37, [1.14-2.41]) patients. Hypoxia, sleep fragmentation, and sleep duration (p < 0.01) were associated with increased risk. Black and Hispanic, and female patients showed stronger effects for hypoxia and duration, and fragmentation, respectively. DISCUSSION/CONCLUSIONS:Hypoxia, fragmentation, and duration may underlie racial-, ethnic-, and sex-specific effects of AD risk.

OBJECTIVES/OBJECTIVE:To identify stakeholder perceived challenges and facilitators for implementing a clean fuel and clean stove intervention to reduce household air pollution and hypertension in Lagos, Nigeria. DESIGN/METHODS:Qualitative study guided by the Exploration and Preparation phases of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework, using focus group discussions and in-depth semi-structured interviews with inductive and deductive thematic analysis. SETTING/METHODS:Peri-urban communities across the five administrative divisions of Lagos State, Nigeria. PARTICIPANTS/METHODS:128 stakeholders from 32 communities, including community, religious, market and youth leaders, primary healthcare staff, and household decision makers. Approximately half were female. INTERVENTIONS/METHODS:This was a pre-implementation needs assessment that included demonstrations of the clean stove and fuel. PRIMARY AND SECONDARY OUTCOME MEASURES/METHODS:Thematic domains describing barriers and enablers to adoption and implementation, mapped to EPIS inner, outer, and bridging factors. RESULTS:Stakeholders reported barriers that included stove stacking, upfront stove cost, concerns about long-term fuel price and availability, equipment durability and maintenance, safety, mistrust of new technology, and uncertainty about stove performance for dishes requiring high heat and long cooking times. Reported facilitators included payment flexibility and subsidies, opportunities to test the stove, perceived benefits of cleaner and faster cooking with less soot, endorsement by community leaders, and interest in local retail and distribution to improve access. CONCLUSIONS:Implementation planning for clean fuel and clean stove programmes should address affordability, reliable fuel supply chains, durability and service, culturally relevant cooking needs, and trust building through community leadership. These findings inform adaptation strategies for scale-up in similar low-resource settings. TRIAL REGISTRATION NUMBER/BACKGROUND:NCT05048147.

OBJECTIVE:In Nigeria, adolescents and young adults (AYA) who engage in multiple sexual partnerships, transactional sex, and needle-sharing are eligible for preexposure prophylaxis (PrEP) and are prioritized for HIV testing. AYA with PrEP-eligible behaviors should be using facility-based HIV testing services. We examined associations between these behaviors and facility-based HIV testing among AYA aged 14-24 years. DESIGN/METHODS:A longitudinal analysis of a stepped-wedge trial. METHODS:Using Innovative Tools to Expand Youth-friendly HIV Self-Testing (I-TEST) data, we fit generalized linear models using generalized estimating equations. We used a two-stage weighted approach to generalize I-TEST estimates to all AYA in Nigeria. RESULTS:Of 1429 trial participants, the median age was 20 years (IQR: 18-22), 50.3% were female, and 69.4% reported secondary education as highest level of education completed. Recent facility-based HIV testing uptake was higher among AYA with one [unadjusted risk difference: 11.7%, 95% confidence interval (95% CI): 8.1-15.2], two [11% (5.3, 16.8)], and three or more sexual partners in the past 3 months [17.3% (10.5, 24)], compared to AYA with no recent sexual partners. AYA who engaged in transactional sex had higher facility-based testing uptake [14.7% (9.8, 19.5)] than AYA who never engaged in transactional sex. AYA who shared needles had lower facility-based testing uptake [-3.3% (-6.7, 0.2)] than AYA with no needle-sharing history. The trial and generalized estimates were in the same direction. CONCLUSION/CONCLUSIONS:While facility-based testing may reach AYA who engaged in multiple sexual partnerships or transactional sex, AYA who shared needles may require more tailored HIV testing approaches.

BACKGROUND/UNASSIGNED:Evidence-based interventions (EBI) for cardiovascular disease (CVD) in low- and middle-income countries (LMIC) may face feasibility challenges due to the inadequacy of existing instruments. To address this, researchers developed the Contextual Index of Feasibility on Early-Stage Implementation in LMIC (CATALYTIC) tool, which integrates contextual factors into the assessment of feasibility. METHODS/UNASSIGNED:The tool's items were developed through a systematic review and key informant interviews, and were later assessed for relevance and importance by 13 LMIC researchers and implementers employing a Delphi technique. The survey was then tested for usability by five individuals with CVD experience in LMIC. The CATALYTIC tool consists of 17 items that measure contextual factors that directly influence early-stage LMIC implementation. Descriptive analysis, logistic regression, item reliability using Cronbach's alpha, and exploratory factor analysis (EFA) were performed on survey data. RESULTS/UNASSIGNED:In a survey of 216 respondents from 46 countries, 63.4 to 81.5% of respondents noted a significant impact of contextual factors on implementation feasibility, with high reliability (Cronbach's alpha 0.88) for 12 items. The majority of interventions focused on patient-level care in rural settings. The survey items align primarily with constructs related to implementation climate and readiness for implementation, as well as inductive themes addressing existing needs and barriers to inform intervention design. The survey found diversity in geographic and experiential backgrounds, with significant representation from South Africa, Mexico, and India. Over a third identified as researchers, and 15% held multiple roles. The survey identified three distinct factors influencing how researchers and implementers assess CVD intervention feasibility in LMIC. A 6% increase in odds for moderately feasible interventions was linked to each point increase in the composite score of perceived contextual influence. CONCLUSION/UNASSIGNED:Overall, the CATALYTIC tool with 12 reliable survey items can help researchers and implementers elucidate perceptions of contextual factors influencing the feasibility of CVD-related EBI in LMIC. The survey items reflect respondents' practical focus in resource-limited settings and can inform intervention design by addressing existing needs and barriers. The tool's integration of contextual factors into the assessment of feasibility can help overcome the inadequacy of existing instruments by providing more tailored and conceptually clear assessments of feasibility.

BACKGROUND/UNASSIGNED:Hypertension is a major risk factor for cardiovascular diseasemorbidity and mortality, affecting 25% of adults in Ghana. Access to adequate care is critical for effective hypertension management. OBJECTIVE/UNASSIGNED:Evaluate healthcare utilisation among patients with hypertension and identify determinants. METHODS/UNASSIGNED:Guided by the Andersen and Newman model, we examined predisposing, enabling, and need factors affecting HCU. Data were collected from 600 patients with hypertension, 19 in-depth interviews with health workers, and six focus group discussions with patients. Logistic regression was used for quantitative analysis, while qualitative data were analyzed thematically. RESULTS/UNASSIGNED:In all, 73% of patients with hypertension used health care. Key predisposing factors included age 70+ years (adjusted odds ratio [aOR]: 1.97, 95% CI: 1.06-3.69) and being female (aOR: 2.32, 95% CI: 1.53-3.54). Enabling factors included health insurance (aOR: 4.07, 95% CI: 2.04-8.20), closer proximity to referral facilities (aOR: 2.28, 95% CI: 1.44-3.65), and care at district hospitals (aOR: 3.37, 95% CI: 1.94-6.03). Need factors were not associated with HCU. Barriers included financial difficulties, reliance on alternative medicines, poor health-seeking behavior, delays, erratic medication supplies, and health insurance limitations. CONCLUSIONS/UNASSIGNED:This study finds high healthcare use (73%) among rural Ghanaian hypertension patients, mainly driven by demographic and structural factors. It highlights ongoing inequalities, especially among men. Interventions should focus on addressing gender issues, enhancing access to insurance, and strengthening district hospital services. Future research should evaluate the quality and consistency of hypertension care to improve health outcomes.

BACKGROUND:In Nigeria, cardiovascular diseases, especially hypertension, are on the rise. This increase in hypertension correlates with more strokes, significantly impacting mortality. Since hypertension often persists into adulthood, early interventions are crucial to prevent its complications. Non-invasive methods, such as music and creative activities, can effectively improve blood pressure and reduce stroke risk. This study aims to improve intergenerational awareness of hypertension and promote sustainable preventive practices by involving youth and caregivers within families and communities. METHODS:We employed a participatory, observational design, incorporating a five-month crowdsourcing open call followed by a designathon event. Participatory social and health innovations were combined and implemented as part of a larger study titled "Innovative Tool to Expand Music-Inspired Strategies for Blood Pressure and Stroke Prevention" (I-TEST BP/Stroke). Our study targeted youths aged 14 to 24, a critical period for shaping health behaviors and attitudes toward diseases. The 20 finalist textual entries were categorized into themes using the PEN-3 cultural model. The PLAN framework analyzed the effectiveness of participants' entries in conveying public health messages. RESULTS:The crowdsourced open call for musical ideas received 85 submissions between October 2023 and March 2024. More males (74.3%) than females, mainly aged 22-24, and mostly undergraduates (44.3%), participated in the open call, with 88.65% having heard of hypertension. Qualitative analysis with PEN-3 highlighted themes regarding Perceptions and Enablers, such as monitoring blood pressure, engaging in physical activity, and avoiding alcohol and smoking. The use of Pidgin English and Nigerian languages in songs represents Positive Cultural Empowerment. The Negative Cultural Empowerment domain addresses misconceptions about hypertension, including the belief that hypertension is a curse. Utilizing the PLAN framework, the submissions demonstrated an effective blend of catchy, memorable tunes with health education messages. CONCLUSION/CONCLUSIONS:The designathon produced various music genres, including afrobeats, rap, and R&B, with lyrics deemed feasible and socio-culturally appropriate. This suggests that music interventions tailored to Nigeria could enhance public awareness of hypertension and stroke prevention if scaled up.

BACKGROUND:Fall injury is a sentinel event for mortality among older adults, and activity intensity may play a role in mitigating this outcome. This study assessed the relationship between activity intensity and all-cause mortality following fall injury among community-dwelling U.S. older adults. METHODS:For this retrospective cohort study, we pooled 12 years of data from the National Health Interview Survey and identified older adults (aged 65 years and older) who sustained fall injuries (N = 2454). The outcome variable was time to death following a fall injury. We defined activity intensity as a binary variable, none-to-low and normal-to-high, using the American Heart Association's weekly 500 Metabolic Equivalent of Task (MET) as a cutoff. We controlled for sociodemographic, healthcare access, and health characteristics; performed survey-weighted Cox proportional hazard regression analysis; and reported the adjusted mortality risks (plus 95% confidence interval (CI)). RESULTS:The survey comprised 2454 older adults with fall injuries, representing 863,845 US older adults. The population was predominantly female (68%), non-Hispanic White (85%), and divorced/separated (54%). During the follow-up period, 45% of the study population died. Approximately 81% of the study population had low activity levels. However, between 2006 and 2017, the proportion of the study population with low physical activity decreased from 90% to 67%. After adjusting for sociodemographic, healthcare access, and health characteristics, none-to-low activity intensity was associated with 50% increased mortality risk (aHR: 1.50; 95% CI: 1.20-1.87). CONCLUSIONS:Promoting higher physical activity levels may significantly reduce the all-cause mortality risk following fall injury among older adults.