Faculty Bibliography

INTRODUCTION/BACKGROUND:In Africa, 75% of households are exposed to household air pollution (HAP), a key contributor to cardiovascular disease (CVD). In Nigeria, 90 million households rely on solid fuels for cooking, and 40% of adults have hypertension. Though clean fuel and clean stove (CF-CS) technologies can reduce HAP and CVD risk, their adoption in Africa remains limited. METHODS AND ANALYSIS/METHODS:Using the Exploration, Preparation, Implementation and Sustainment framework, this cluster-randomised controlled trial evaluates the implementation and effectiveness of a community mobilisation (CM) strategy versus a self-directed condition (i.e., receipt of information on CF-CS use without CM) on adoption of CF-CS technologies and systolic blood pressure (SBP) reduction among 1248 adults from 624 households across 32 peri-urban communities in Lagos, Nigeria. The primary outcome is CF-CS adoption at 12 months; secondary outcomes are SBP reduction at 12 months and sustainability of CF-CS use at 24 months. Adoption is assessed via objective monitoring of stove usage with temperature-triggered iButton sensors. SBP is assessed in 2 adults per household using validated automated blood pressure monitor. Generalised linear mixed-effects regression models will be used to assess study outcomes, accounting for clustering at the level of the peri-urban communities (unit of randomisation) and households. To date, randomisation is completed, and a total of 1248 households have enrolled in the study. The final completion of the study is expected in June 2026. ETHICS AND DISSEMINATION/BACKGROUND:The study was approved by the Institutional Review Boards (IRB) of NYU Grossman School of Medicine (primary IRB of record; protocol ID: i21-00586; Version 6.0 approved on 4 June 2024), and Lagos State University Teaching Hospital (protocol ID: LREC 06/10/1621). Written consent was obtained from all participants. Findings will inform scalable and culturally appropriate strategies for reducing HAP and CVD risk in low-resource settings. Results will be disseminated through peer-reviewed publications, conference presentations and stakeholder engagements. TRIAL REGISTRATION NUMBER/BACKGROUND:NCT05048147.

Social determinants of health (SDoH), health care use, and cardiovascular disease (CVD) risk perception are understudied among men who identify as Black and Hispanic. In this study we sought to describe these factors among a cohort of urban-residing Black men, participants in a community-engaged trial on hypertension prevention. We focused on presenting intermediary SDoH, including material circumstances, health behaviors, and psychosocial factors, which allow for a more robust understanding of health inequities but are underexplored. We analyzed baseline trial data (N=430) and compared subgroups (44% of participants self-identified as having Hispanic ethnicity and a Black racial identity). Average age was 38 years, with mean blood pressure of 129/83 mmHg. Hispanic Black (HB) men reported higher unemployment (21.4% versus 11.1%, P=.02) and more housing instability (28.7% versus 18.6%, P=.01) than did non-Hispanic Black (NHB) men. Overall, HB men reported worse household conditions compared with NHB men. Approximately half of both groups reported high stress, 45% (HB) and 51% (NHB), respectively. Both groups had low perception of personal CVD risk and underutilized health care. Hispanic Black men were less likely to have a primary care provider than were NHB men (17.6% versus 29.3%, P<.001). Non-Hispanic Black men reported lower physical activity than did HB men (median, 2655 vs 2547 metabolic equivalent minutes/week, P=.03). Recognizing heterogeneity among Black populations, including in social drivers of CVD disparities, will allow for more precision in designing CVD health promotion interventions. Findings also suggest that perception of personal CVD risk and health care utilization may be important targets for CVD prevention in Black men.

IMPORTANCE/UNASSIGNED:Inequities in rapid access to emergency medical services (EMS) represent a critical gap in prehospital care and the first system-level milestone for critically injured patients. As delays in EMS response are associated with increased mortality and known disparities within historically redlined areas are prevalent, this study sought to examine disparities in rapid access to EMS across the United States. OBJECTIVE/UNASSIGNED:To assess the association between historically redlined areas and rapid EMS access (defined as ≤5-minute response time) across the United States. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This retrospective, cross-sectional study analyzed the geographic distribution of EMS centers in relation to 2020 US Census block groups and Home Owners' Loan Corporation (HOLC) residential security maps, classified by grades (A-D). Populations of 236 US cities with publicly available redlining data were included. Travel distance radius (5-minute drive times) was centered on population-weighted block group centroids. Redlining grades include A ("most desirable," green), B ("still desirable," blue), C ("declining," yellow), and D ("hazardous," red). EXPOSURE/UNASSIGNED:HOLC grade classification (A-D). MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was the proportion of the population with rapid EMS access. Secondary outcomes included the socioeconomic and demographic profiles of populations without rapid access. RESULTS/UNASSIGNED:Of the total US population (N = 333 036 755), 41 367 025 (12.42%) lived in cities with redlining data. Among these, 2 208 269 (5.34%) lacked rapid access to 42 472 EMS stations. Grade D areas had a higher proportion of residents without rapid EMS access compared with grade A areas (7.06% vs 4.36%; P < .001). The odds of having no rapid access to EMS in grade D areas were 1.67 (95% CI, 1.66-1.68) times higher than in grade A areas. Compared with grade A, grade D areas had a lower percentage of non-Hispanic White residents (65.21% [95% CI, 59.43%-70.99%] vs 39.36% [95% CI, 36.99%-41.73%]; P < .001), a higher percentage of non-Hispanic Black residents (10.38% [95% CI, 7.14%-13.62%] vs 27.85% [95% CI, 25.4%-30.3%]; P < .001), and greater population density (7500.72 [95% CI, 4341.26-10 660.18] persons/km2 vs 15 277.87 [95% CI, 13 281.7-17 274.04] persons/km2; P < .001). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cross-sectional study, structural disparities in rapid EMS access were associated with historically redlined areas. Strategic resource allocation and system redesign are warranted to address these inequities in prehospital emergency care.

This article reviews the development and evolution of Fogarty International Center-funded research ethics training programs in West Africa over the past decade. In response to local and global challenges in bioethics and biomedical research, these programs are fostering ethical awareness, shaping local and national ethics review systems, and enhancing bioethics capacity in the region. These efforts have expanded alongside increased democratic governance, technological advances, and significant increases in global research funding and international research collaborations, particularly related to HIV/AIDS and malaria. We believe that the West Africa Bioethics (WAB) Training Program in Nigeria played a central role in this growth, serving as a model for subsequent programs in Ghana, Mali, and The Gambia. This paper describes the nature, successes, and challenges of these programs. It also outlines an agenda and strategies for future work to enhance research ethics and bioethics capacities in the region, both in terms of education and governance.

BACKGROUND:Black men are underrepresented in hypertension trials, even though this population has higher prevalence and more adverse sequelae from hypertension, compared to other groups. In this article we present recruitment and community engagement strategies for the Community-to-Clinic Linkage Implementation Program (CLIP), a cluster-randomized trial on hypertension prevention among Black men. METHODS:Using a 2-stage recruitment process: 1) we enrolled Black-owned barbershops from zip-codes with high hypertension prevalence; and 2) recruited Black male participants who fulfilled the eligibility criteria and were customers of the barbershops. Barbershop and participant recruitment was conducted by a partner community-based organization. RESULTS:The study met the recruitment goals for barbershop enrollment (N=22) and individual participants. Of eligible individuals (N=461), 430 enrolled in the study (93% consent rate, exceeding the original enrollment goal of N=420 participants). Throughout recruitment, the study team conducted 101 unique engagements (41 prior to recruitment, 60 during recruitment), totaling engagement with180 partners across all events, including individual and group meetings, attendance at community events, and educational presentations. In addition to a primary partner community organization, the study team collaborated with a Community Advisory Council, comprised of residents, and civic and community leaders, and with the local health department and varied other organizations. CONCLUSIONS:In CLIP, a high number of academic-community engagement encounters and close collaboration with community partners contributed to successful recruitment of Black men at risk for hypertension and with adverse social determinants. Our experience may serve as to inform investigators focused on recruiting underserved populations in hypertension research trials.

BACKGROUND:While a growing body of scientific literature suggests that evidence-based interventions may improve health outcomes in diverse settings, little is known about the best strategies for large-scale implementation. In Africa, music-an important positive social determinant of health-leverages existing cultural values, which may effectively enhance the reach, uptake, and long-term sustainability of evidence-based interventions in the region. To understand how music interventions work, why they are effective, and with whom they resonate, this systematic review aims to evaluate the quality and empirical application of music as an implementation strategy for adopting evidence-based interventions in Africa using the RE-AIM framework as a guide. METHODS:A comprehensive librarian-assisted search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five major electronic databases, EBSCOhost, PubMed, Web of Science, Embase, and MEDLINE, were searched for empirical studies focused on using music as an implementation strategy to improve health outcomes in Africa. Two independent investigators extracted components of retrieved papers using the RE-AIM framework as a guide. RESULTS:From 981 citations, eight studies met the inclusion criteria, each reporting a unique music intervention. The interventions were conducted in West Africa (n = 3), South African regions (n = 4), and East Africa (n = 1) and included seven observational studies and one randomized controlled trial (RCT). Using the RE-AIM scoring criteria, we summarize the RE-AIM dimensions reported from selected studies - Adoption (72.5%) being the highest, followed by Reach (62.5%), Implementation (41.7%), and Efficacy/Effectiveness (20.0%). All eight studies (100%) described the intervention location, the expertise of delivery agents, the target population, and the participant characteristics. Moreover, our analysis highlighted the effectiveness of music interventions in enhancing health outcomes, particularly in improving knowledge and awareness (62.5%), facilitating behavioral change (50%), and promoting mental health (25%). CONCLUSION/CONCLUSIONS:Music interventions adapted to the sociocultural context in Africa have the potential to help prevent diseases, improve well-being, and enhance health outcomes. Our review emphasizes the importance of customizing music-based interventions to fit the cultural context, which can enhance the programs' effectiveness, acceptance, and sustainability. Clinical trials are necessary to confirm the efficacy of music interventions in specific medical conditions and from a public health promotion perspective.

INTRODUCTION/BACKGROUND:Delayed Emergency Medical Services (EMS) response and transport (time from injury occurrence to hospital arrival) are associated with increased injury mortality. Inequities in accessing EMS care for injured patients are not well characterized. We sought to evaluate the association between the area deprivation index (ADI), a measure of geographic socioeconomic disadvantage, and timely access to EMS care within the United States. METHODS:The Homeland Infrastructure Foundation Level Data open-source database from the National Geospatial Intelligence Agency was used to evaluate the location of EMS stations across the United States using longitude and latitude coordinates. The ADI was obtained from Neighborhood Atlas at the census block group level. An ambulance desert (AD) was defined as populated census block groups with a geographic center outside of a 25-minute ambulance service area. The total population (urban and rural) located within an AD and outside an AD (non-ambulance desert [NAD]) and the ADI index distribution within those areas were calculated with their statistical significance derived from χ2 testing. Spearman correlations between the number of EMS stations available within 25-minutes service areas and ADI were calculated, and statistical significance was derived after accounting for spatial autocorrelation. RESULTS:A total of 42,472 ground EMS stations were identified. Of the 333,036,755 people (current US population), 2.6% are located within an AD. When stratified by type of population, 0.3% of people within urban populations and 8.9% of people within rural populations were located within an AD (p < 0.01). When compared with NADs, ADs were more likely to have a higher ADI (ADIAD, 53.13; ADINAD, 50.41; p < 0.01). The number of EMS stations available per capita was negatively correlated with ADI (rs = -0.25, p < 0.01), indicating that people living in more disadvantaged neighborhoods are likely to have fewer EMS stations available. CONCLUSION/CONCLUSIONS:Ambulance deserts are more likely to affect rural versus urban populations and are associated with higher ADIs. The impact of inequities in access to EMS care on outcomes deserves further study. LEVEL OF EVIDENCE/METHODS:Prognostic and Epidemiological; Level III.

UNLABELLED:Adolescents and young adults (AYAs) participatory approaches for HIV control have increased across LMICs, but there are few trials to evaluate effectiveness. We assessed a crowdsourced HIV self-testing (HIVST) intervention among a cohort of AYA in Nigeria. METHODS:We conducted a pragmatic stepped-wedge cluster randomized control trial recruiting participants (aged 14-24 years) from 32 local government areas across four geo-political zones in Nigeria. Eligible AYA were HIV negative or unknown HIV status, residing in study sites, spoke English, and consented. Areas were randomly assigned to one of four steps and AYA were followed for 24 months. AYA research facilitators implemented a 4YBY crowdsourced HIV prevention bundle. The primary outcome was self-reported HIVST uptake. We compared the probability of HIVST between the control and intervention periods using a generalized linear mixed model. We examined the fixed cost and per capita cost of the intervention. The protocol was registered with Clinical Trials.gov on January 15, 2021, under registration NCT04710784. RESULTS:2652 AYA were screened, and 1500 were enrolled in the study (March 10, 2021- August 31, 2023). 1333/1500 (89 %) were followed up at 24 months. The mean age of AYA was 20 ± 2.65 years old, most were students (1155/1500, 77 %), and unemployed (915/1500, 61 %). The intervention led to a 9.96-fold increase in HIV self-testing uptake compared to the control period (95 % CI: 8.36-11.85, p < 0.0001). The annual fixed cost of the intervention was estimated at US$42,237, with a per capita testing cost of US$14.8. No significant adverse events were reported. CONCLUSION/CONCLUSIONS:A crowdsourced HIV prevention intervention increased HIVST uptake among Nigerian AYA. Greater participation of AYA in the design and implementation of clinical trials is needed to achieve UNAIDS targets.