Faculty Bibliography

BACKGROUND: Among US medical schools, demand for Global Health (GH) programs continues to grow. At the same time, cultural competency training has become a priority for medical students who will care for an increasingly diverse US patient population. We describe a pilot period for a new GH Selective designed to introduce medical students to global medicine and enhance culturally-sensitive communication skills. METHODS: As a 4-week clinical clerkship, the GH Selective was offered annually over a three-year period to a total of 33 students. Activities included clinical assignments, cultural competency and clinical skills simulations, patient case discussions in tropical medicine, journal clubs, and lectures. Faculty assessments of student performance and student evaluations of course content were focused on 6 course objectives, adapted from standardized GH objectives. RESULTS: For each offering of the GH Selective, at least 40 faculty members and fellows volunteered over 200 teaching hours from 11 medical school departments. Student feedback was consistently positive through competency-based curricular evaluations. As a result of its successes, the course is now offered on a biannual basis. DISCUSSION: Experiential, student-centered teaching employed in this course proved successful as an introduction to delivery of evidence-based and culturally sensitive GH. Special emphasis on working with standardized patients in interdisciplinary and cross-cultural simulations provided students with clinical skills applicable for care provided both locally and on international rotations. CONCLUSION: With a special emphasis on cross-cultural sensitivity, this pilot elective trained future practitioners in fund of knowledge, clinical skills, and service delivery methods in GH.

BACKGROUND: Stroke is a leading cause of adult disability and mortality. Intravenous thrombolysis can minimize disability when patients present to the emergency department for treatment within the 3 - 4(1/2) h of symptom onset. Blacks and Hispanics are more likely to die and suffer disability from stroke than whites, due in part to delayed hospital arrival and ineligibility for intravenous thrombolysis for acute stroke. Low stroke literacy (poor knowledge of stroke symptoms and when to call 911) among Blacks and Hispanics compared to whites may contribute to disparities in acute stroke treatment and outcomes. Improving stroke literacy may be a critical step along the pathway to reducing stroke disparities. The aim of the current study is to test a novel intervention to increase stroke literacy in minority populations in New York City. DESIGN AND METHODS: In a two-arm cluster randomized trial, we will evaluate the effectiveness of two culturally tailored stroke education films - one in English and one in Spanish - on changing behavioral intent to call 911 for suspected stroke, compared to usual care. These films will target knowledge of stroke symptoms, the range of severity of symptoms and the therapeutic benefit of calling 911, as well as address barriers to timely presentation to the hospital. Given the success of previous church-based programs targeting behavior change in minority populations, this trial will be conducted with 250 congregants across 14 churches (125 intervention; 125 control). Our proposed outcomes are (1) recognition of stroke symptoms and (2) behavioral intent to call 911 for suspected stroke, measured using the Stroke Action Test at the 6-month and 1-year follow-up. DISCUSSION: This is the first randomized trial of a church-placed narrative intervention to improve stroke outcomes in urban Black and Hispanic populations. A film intervention has the potential to make a significant public health impact, as film is a highly scalable and disseminable medium. Since there is at least one church in almost every neighborhood in the USA, churches have the ability and reach to play an important role in the dissemination and translation of stroke prevention programs in minority communities. TRIAL REGISTRATION: NCT01909271 ; July 22, 2013.

AIMS: To determine whether chronic life stress is differentially associated with quality of life (QoL) for Blacks vs. Hispanics with type 2 diabetes. METHODS: We assessed self-reported chronic stress and QoL in 125 patients with type 2 diabetes who self-identified as either non-Hispanic Black or Hispanic. Separate cross-sectional two-way interaction models (stressxrace/ethnicity) with physical and mental health as outcomes were examined. RESULTS: The two-way interaction predicted mental (b=3.12, P=.04) but not physical health. Simple slopes analyses indicated that under conditions of high stress, Blacks (b=-4.4, P<.001), but not Hispanics, experienced significantly lower levels of mental health. In exploratory analyses, we examined a three-way interaction (stressxrace/ethnicityxsocial support) with physical and mental health as outcomes. Results indicated the three-way interaction predicted mental (b=.62, P=.01) but not physical health. Simple slopes analyses indicated that under conditions of high stress, high levels of social support improved mental health for Hispanics (b=1.2, P<.001), but not for Blacks. CONCLUSIONS: Black patients with type 2 diabetes may be particularly vulnerable to the deleterious effects of high chronic stress. Social support buffers effects of stress on mental health in Hispanics but not Blacks, which suggests differences in the use and/or quality of social support between Hispanics and Blacks. Longitudinal investigations that examine race/ethnicity, stress, social support, and QoL should help clarify the processes that underlie these observed relations.

The 2014 Evidence-based Guideline for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) raised the systolic blood pressure (SBP) threshold for treatment initiation and goal attainment to 150 mm Hg in adults 60 years and older without a history of diabetes or chronic kidney disease (CKD). Using data from the nationwide Reasons for Geographic and Racial Difference in Stroke (REGARDS) study linked with Medicare claims, we examined the association between SBP levels and coronary heart disease (CHD), stroke, cardiovascular disease (CVD), heart failure, and serious injurious fall events among adults > 65 years of age taking antihypertensive medication. We excluded participants with a history of diabetes, CKD, and diastolic blood pressure > 90 mm Hg. Baseline REGARDS data were collected during telephone interviews and in-home study visits in 2003 through 2007 and included two blood pressure measurements following a standardized protocol. SBP was categorized as < 140 mm Hg, 140-149 mm Hg, and > 150 mm Hg. Outcomes were identified through December 31, 2011 using primary data collection and Medicare claims. Of the 2,279 REGARDS participants taking antihypertensive medications with Medicare linked data (mean age 72.2 years, 54.8% female), 309 (13.6%) had SBP of 140 to 149 mm Hg and 200 (8.8%) had SBP > 150 mm Hg. After multivariable adjustment, SBP of 140 to 149 mm Hg versus SBP < 140 mm Hg was not associated with any of the outcomes (Table 1) whereas SBP > 150 mm Hg was associated with an increased risk for CVD. In summary, SBP levels between 140 and 149 mm Hg were not associated with CVD-related outcomes or falls in comparison to SBP < 140 mm Hg among adults > 65 years taking antihypertensive medication. These data suggest the higher SBP threshold for treatment initiation and goal attainment among individuals > 65 years of age without a history of diabetes or CKD, with

The poor rate of adherence to anti-hypertensive medication is most pervasive and predominant among adult blacks. Unfortunately, patient factors contributing to poor adherence are poorly understood. The present study examined whether patients' expectation of care influenced the relationships of hypertension (HTN) knowledge and perception of social support to medication adherence among hypertensive blacks. Data were analyzed from the Counseling African Americans to Control Hypertension (CAATCH) trial. In this randomized clinical trial, participants (N=1,038; females 70.4%; mean age of 56.57+/-12.18) were hypertensive adult patients from 30 Community Health Centers across the New York City Metropolitan area. Of the trial participants, 56.6% had a high school education or less; 63% were unemployed; 91% had health insurance; and 71% had an income of <$20,000. Of the entire sample, 62.9% were non-adherent. Mixed-effects regression models were used to assess the mediating role of expectation of care on the relationships between HTN knowledge and medication adherence and between perception of social support and medication adherence. Covariates included age, sex, education, income, employment, and insurance. The results showed that greater expectation of care was associated with higher levels of medication adherence (F=6.49; p=0.011; Est. =0.042; S.E. =0.016). Increased perception of social support was associated with medication adherence (F=5.31; p=.021; Est. =0.129; S.E. =0.056). Also, expectation of care mediated the relationship between HTN knowledge and medication adherence (Estimated Indirect Effect= 0.130), (p<0.001). Our study indicated that patients' expectation of care and perceived social support may be important facilitators for developing knowledge-based interventions to increase medication adherence in blacks