Faculty Bibliography

PURPOSE: Millions of homeless Americans have lower cancer screening and higher cancer mortality rates. We explored perspectives and perceptions regarding cancer and cancer screening among homeless. METHODS: Using random and criteria sampling, we conducted in-depth semi-structured interviews with 50 homeless adults from New York City's (NYC) shelters and shelter-based clinics. RESULTS: Mean age was 51.66 years with average 2.03 years of homelessness; 33/50 were older than 50. Only a small number of participants had their recommended cancer screening. Contrary to general assumptions and despite significant barriers, the homeless were concerned about cancer, believed their risk of cancer is higher compared to the general population, and generally considered screening a high priority during homelessness. While they acknowledged several individual- and systems-level barriers, they welcomed targeted measures to address their multi-level barriers. Suggested strategies included active counseling by providers, health education or reminders via mHealth strategies or face-to-face in shelters, addressing potential providers' prejudice and biases regarding their priorities, incentives, and patient navigators or coach to help navigating the complex cancer screening process. CONCLUSIONS: There are gaps in effective cancer screening despite adequate attitude and perceptions among homeless. The health system needs to shift from addressing only basic care to a more equitable approach with accessible and acceptable opportunities for preventive cancer care for the homeless.

INTRODUCTION: In sub-Saharan Africa (SSA), an estimated 74.7 million individuals are hypertensive. Reducing the growing burden of hypertension in sub-Saharan Africa will require a variety of strategies one of which is identifying the extent to which actions originating at the health systems level improves optimal management and control. METHODS AND RESULTS: We conducted a narrative synthesis of available papers examining health systems factors influencing optimal hypertension in SSA. Eligible studies included those that analyzed the impact of health systems on hypertension awareness, treatment, control and medication adherence. Twenty-five articles met the inclusion criteria and the narrative synthesis identified the following themes: 1) how physical resources influence mechanisms supportive of optimal hypertension control; 2) the role of human resources with enabling and/or inhibiting hypertension control goals; 3) the availability and/or use of intellectual resources; 4) how health systems financing facilitate and/or compromise access to products necessary for optimal hypertension control. CONCLUSION: The findings highlight the need for further research on the health systems factors that influence management and control of hypertension in the region.

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.

Metabolic syndrome is associated with higher rates of cardiovascular morbidity and mortality. Although significant disparities in the risks of metabolic syndrome by occupation type and sex are well documented, the factors associated with metabolic syndrome in low- to middle-income countries remain unclear. These gaps in evidence identify the need for patterns of metabolic syndrome among hospital personnel of both sexes in Nigeria. A total of 256 hospital workers comprising 32.8% men were studied. The mean age of the participants was 42.03+/-9.4 years. Using International Diabetic Federation criteria, the prevalence of metabolic syndrome was 24.2%. Women were substantially and significantly more likely to be identified with metabolic syndrome compared with men (34.9% vs 2.4%, respectively; P=.0001). This study identified metabolic syndrome among health workers with over one third of women with metabolic syndrome compared with <10% of men. These results support the implementation of lifestyle modification programs for management of metabolic syndrome in the health care workplace.

OBJECTIVES: African-Americans (AAs) have a high prevalence of hypertension and their blood pressure (BP) control on treatment still lags behind other groups. In 2004, NHLBI funded five projects that aimed to evaluate clinically feasible interventions to effect changes in medical care delivery leading to an increased proportion of AA patients with controlled BP. Three of the groups performed a pooled analysis of trial results to determine: 1) the magnitude of the combined intervention effect; and 2) how the pooled results could inform the methodology for future health-system level BP interventions. METHODS: Using a cluster randomized design; the trials enrolled AAs with uncontrolled hypertension to test interventions targeting a combination of patient and clinician behaviors. The 12-month Systolic BP (SBP) and Diastolic BP (DBP) effects of intervention or control cluster assignment were assessed using mixed effects longitudinal regression modeling. RESULTS: 2,015 patients representing 352 clusters participated across the three trials. Pooled BP slopes followed a quadratic pattern, with an initial decline, followed by a rise toward baseline, and did not differ significantly between intervention and control clusters: SBP linear coefficient = -2.60+/-0.21 mmHg per month, p<0.001; quadratic coefficient = 0.167+/- 0.02 mmHg/month, p<0.001; group by time interaction group by time group x linear time coefficient=0.145 +/- 0.293, p=0.622; group x quadratic time coefficient= -0.017 +/- 0.026, p=0.525). Results were similar for DBP. The individual sites did not have significant intervention effects when analyzed separately. CONCLUSION: Investigators planning behavioral trials to improve BP control in health systems serving AAs should plan for small effect sizes and employ a "run-in" period in which BP can be expected to improve in both experimental and control clusters.

BACKGROUND: The current Ebola Virus Disease (EVD) epidemic has ravaged the social fabric of three West African countries and affected people worldwide. We report key themes from an agenda-setting, multi-disciplinary roundtable convened to examine experiences and implications for health systems in Ghana, a nation without cases but where risk for spread is high and the economic, social and political impact of the impending threat is already felt. DISCUSSION: Participants' personal stories and the broader debates to define fundamental issues and opportunities for preparedness focused on three inter-related themes. First, the dangers of the fear response itself were highlighted as a threat to the integrity and continuity of quality care. Second, healthcare workers' fears were compounded by a demonstrable lack of societal and personal protections for infection prevention and control in communities and healthcare facilities, as evidenced by an ongoing cholera epidemic affecting over 20,000 patients in the capital Accra alone since June 2014. Third, a lack of coherent messaging and direction from leadership seems to have limited coordination and reinforced a level of mistrust in the government's ability and commitment to mobilize an adequate response. Initial recommendations include urgent investment in the needed supplies and infrastructure for basic, routine infection control in communities and healthcare facilities, provision of assurances with securities for frontline healthcare workers, establishment of a multi-sector, "all-hazards" outbreak surveillance system, and engaging directly with key community groups to co-produce contextually relevant educational messages that will help decrease stigma, fear, and the demoralizing perception that the disease defies remedy or control. The EVD epidemic provides an unprecedented opportunity for West African countries not yet affected by EVD cases to make progress on tackling long-standing health systems weaknesses. This roundtable discussion emphasized the urgent need to strengthen capacity for infection control, occupational health and safety, and leadership coordination. Significant commitment is needed to raise standards of hygiene in communities and health facilities, build mechanisms for collaboration across sectors, and engage community stakeholders in creating the needed solutions. It would be both devastating and irresponsible to waste the opportunity.

OBJECTIVES: The objective of the study was to examine explanatory models of diabetes and diabetes complications among urban poor Ghanaians living with diabetes and implications for developing secondary prevention strategies. DESIGN: Twenty adults with type 2 diabetes were recruited from three poor communities in Accra. Qualitative data were obtained using interviews that run between 40 and 90 minutes. The interviews were audio-taped, transcribed and analysed thematically, informed by the 'explanatory model of disease' concept. RESULTS: Respondents associated diabetes and its complications with diet, family history, lifestyle factors (smoking, excessive alcohol consumption and physical inactivity), psychological stress and supernatural factors (witchcraft and sorcery). These associations were informed by biomedical and cultural models of diabetes and disease. Subjective experience, through a process of 'body-listening,' constituted a third model on which respondents drew to theorise diabetes complications. Poverty was an important mediator of poor self-care practices, including treatment non-adherence. CONCLUSIONS: The biomedical model of diabetes was a major source of legitimate information for self-care practices. However, this was understood and applied through a complex framework of cultural theories of chronic disease, the biopsychological impact of everyday illness experience and the disempowering effects of poverty. An integrated biopsychosocial approach is proposed for diabetes intervention in this research community.

BACKGROUND: Angiotensin converting enzyme inhibitors (ACEi) are widely used in the treatment of patients with hypertension. However, their efficacy in hypertensive blacks when compared with other antihypertensive agents is not well established. METHODS: Cohort study of patients using data from a clinical data warehouse of 434,646 patients from New York City's Health and Hospitals Corporation (HHC) from January 2004 - December 2009. Patients were divided into the following comparison groups: ACEi vs. Calcium Channel Blocker (CCB); ACEi vs. thiazide diuretics and ACEi vs. beta-blockers. Primary outcome was a composite of death, myocardial infarction or stroke. Secondary outcomes include the individual components and heart failure. RESULTS: In the propensity score matched ACEi vs. CCB comparison cohort (4,506 blacks in each group), ACEi was associated with higher risk of primary outcome (HR=1.45; 95% CI 1.19, 1.77; P=0.0003), myocardial infarction (HR=3.40; 95% CI 1.25, 9.22; P=0.02), stroke (HR=1.82; 95% CI 1.29, 2.57; P=0.001) and heart failure (HR=1.77; 95% CI 1.30, 2.42; P=0.0003) when compared with CCB. For the ACEi vs. thiazide diuretics comparison (5,337 blacks in each group), ACEi was associated with higher risk of primary outcome (HR=1.65; 95% CI 1.33, 2.05; P<0.0001), death (HR=1.35; 95% CI 1.03, 1.76; P=0.03), myocardial infarction (HR=4.00; 95% CI 1.34, 11.96; P=0.01), stroke (HR=1.97; 95% CI 1.34, 2.92; P=0.001) and heart failure (HR=3.00; 95% CI 1.99, 4.54; P<0.0001). For the ACEi vs. beta-blocker comparison, the outcomes between the groups were not significantly different. CONCLUSIONS: In a real-world cohort of hypertensive blacks, ACEi was associated with higher risk of cardiovascular events when compared with CCB or thiazide diuretics.