Faculty Bibliography

BACKGROUND:: Research in industrialized countries has demonstrated that a key factor limiting the control of hypertension is poor patient adherence and that the most successful interventions for long-term adherence employ multiple strategies. Very little data exist on this question in low-income countries, wherein medication-taking behavior may be less well developed. METHOD:: We conducted a treatment adherence trial of 544 patients [mean age approximately 63 years, mean blood pressure (BP) approximately 168/92 mmHg] with previously untreated hypertension in urban and rural Nigeria. Eligible participants were randomized to one of two arms: clinic management only, or clinic management and home visits. Both interventions included three elements: a community based, nurse-led treatment program with physician backup; facilitation of clinic visits and health education; and the use of diuretics and a beta blocker as needed. After initial diagnosis, the management protocol was implemented by a nurse with physician backup. Participants were evaluated monthly for 6 months. RESULTS:: Medication adherence was assessed with pill count and urine testing. Drop-out rates, by treatment group, ranged from 12 to 28%. Among participants who completed the 6-month trial, overall adherence was high ( approximately 77% of participants took >98% of prescribed pills). Adherence did not differ by treatment arm, but was better at the rural than the urban site and among those with higher baseline BP. Hypertension control (BP <140/90 mmHg) was achieved in approximately 66% of participants at 6 months. CONCLUSION:: This community-based intervention confirms relatively modest default rates compared with industrialized societies, and suggests that medication adherence can be high in developing world settings in clinic attenders.

Background. Evidence shows that blacks exhibit greater daytime sleepiness compared with whites, based on the Epworth Sleepiness Scale. In addition, sleep complaints might differ based on individuals' country of origin. However, it is not clear whether individuals' country of origin has any influence on excessive daytime sleepiness (EDS). Study Objectives. We tested the hypothesis that US-born blacks would show a greater level of EDS compared with foreign-born blacks. The potential effects of sociodemographic and medical risk were also determined. Design. We used the Counseling African-Americans to Control Hypertension (CAATCH) data. CAATCH is a group randomized clinical trial that was conducted among 30 community healthcare centers in New York, yielding baseline data for 1,058 hypertensive black patients. Results. Results of univariate logistic regression analysis indicated that US-born blacks were nearly twice as likely as their foreign-born black counterparts to exhibit EDS (OR = 1.87, 95% CI: 1.30-2.68, P < 0.001). After adjusting for effects of age, sex, education, employment, body mass index, alcohol consumption, and smoking habit, US-born blacks were 69% more likely than their counterparts to exhibit EDS (OR = 1.69, 95% CI: 1.11-2.57, P < 0.01). Conclusion. Findings demonstrate the importance of considering individuals' country of origin, in addition to their race and ethnicity, when analyzing epidemiologic sleep data.

Background. Evidence suggests that insufficient sleep duration is associated with an increased likelihood for hypertension. Both short (<6 hours) and long (>8 hour) sleep durations as well as hypertension are more prevalent among blacks than among whites. This study examined associations between sleep duration and hypertension, considering differential effects of race and ethnicity among black and white Americans. Methods. Data came from a cross-sectional household interview with 25,352 Americans (age range: 18-85 years). Results. Both white and black short sleepers had a greater likelihood of reporting hypertension than those who reported sleeping 6 to 8 hours. Unadjusted logistic regression analysis exploring the race/ethnicity interactions between insufficient sleep and hypertension indicated that black short (<6 hours) and long (>8 hours) sleepers were more likely to report hypertension than their white counterparts (OR = 1.34 and 1.37, resp.; P < 0.01). Significant interactions of insufficient sleep with race/ethnicity were observed even after adjusting to effects of age, sex, income, education, body mass index, alcohol use, smoking, emotional distress, diabetes, coronary heart disease, and stroke. Conclusion. Results suggest that the race/ethnicity interaction is a significant mediator in the relationship between insufficient sleep and likelihood of having a diagnosis of hypertension.

Patient adherence to antihypertensive medication is an important strategy for blood pressure control in hypertensive patients. However, rates of antihypertensive medication adherence among hypertensive African-Americans are unacceptably low. This article examines the current understanding of patient, clinical, provider and healthcare system factors associated with medication adherence in hypertensive African-Americans. Studies demonstrated that patient and clinical factors, such as self-efficacy and depression, are consistently associated with medication adherence in hypertensive African-Americans patients. Provider communication shows promise as a correlate of medication adherence, but more research on provider and healthcare system factors are still needed. The authors recommend that interventions targeted at increasing medication adherence among hypertensive African-Americans focus on self-efficacy. It is also imperative that clinicians screen hypertensive patients for depression and treat, if necessary.

OBJECTIVE: Although blacks are at higher risk for obstructive sleep apnea (OSA), they are not as likely as their white counterparts to receive OSA evaluation and treatment. This study assessed knowledge, beliefs, and attitudes towards OSA evaluation and treatment among blacks residing in Brooklyn, New York. METHODS: Five focus groups involving 39 black men and women (aged > or =18 years) were conducted at State University of New York (SUNY) Downstate Medical Center in Brooklyn to ascertain barriers preventing or delaying OSA evaluation and treatment. RESULTS: Misconceptions about sleep apnea were a common theme that emerged from participants' responses. Obstructive sleep apnea was often viewed as a type of insomnia, an age-related phenomenon, and as being caused by certain bedtime activities. The major theme that emerged about barriers to OSA evaluation was unfamiliarity with the study environment. Barriers were categorized as: problems sleeping in a strange and unfamiliar environment, unfamiliarity with the study protocol, and fear of being watched while sleeping. Barriers to continuous positive airway pressure (CPAP) treatment adoption were related to the confining nature of the device, discomfort of wearing a mask while they slept, and concerns about their partner's perceptions of treatment. CONCLUSION: Results of this study suggest potential avenues for interventions to increase adherence to recommended evaluation and treatment of OSA. Potential strategies include reducing misconceptions about OSA, increasing awareness of OSA in vulnerable communities, familiarizing patients and their partners with laboratory procedures used to diagnose and treat OSA. We propose that these strategies should be used to inform the development of culturally and linguistically tailored sleep apnea interventions to increase awareness of OSA among blacks who are at risk for OSA and associated comorbidities.

BACKGROUND: Several reports have demonstrated a relationship between post-traumatic stress disorder (PTSD) and type 2 diabetes (T2DM) mainly in combat veterans. The relationship between PTSD and T2DM has not been evaluated among vulnerable migrant populations. The main objective of this study was therefore to assess the relationship between PTSD and T2DM among asylum seekers in the Netherlands. METHODS: Analysis of a national electronic database of the Dutch Community Health Services for Asylum seekers aged>/=18 years (N=105,180). RESULTS: Asylum seekers with PTSD had a higher prevalence of T2DM compared with those without PTSD. The age-adjusted prevalence ratios (APR) were 1.40 (95% CI, 1.12-1.76) in men and 1.22 (95% CI, 0.95-1.56) in women compared with individuals without PTSD, respectively. There was an interaction between PTSD and comorbid depression (P<0.05) in men and women, indicating that the effect of PTSD and comorbid depression on T2DM differed. When the analyses were stratified by depression status, among non-depressed group, individuals with PTSD had a higher prevalence of T2DM compared with those without PTSD [APR=1.47 (95% CI, 1.15-1.87) in men and APR=1.27 (95% CI, 0.97-1.66) in women]. Among the depressed individuals, however, there was no association between PTSD and T2DM [APR=0.87 (95% CI, 0.43-1.76) in men, and APR=1.00, (95% CI, 0.54-1.83) in women]. CONCLUSION: The findings suggest that history of PTSD is related to high levels of T2DM among asylum seekers independent of comorbid depression. Clinicians and policy makers need to take PTSD into account when assessing and treating diabetes among vulnerable migrant populations.

This paper examines the challenges and opportunities in establishing and sustaining north-south research partnerships in Africa through a case study of the UK-Africa Academic Partnership on Chronic Disease. Established in 2006 with seed funding from the British Academy, the partnership aimed to bring together multidisciplinary chronic disease researchers based in the UK and Africa to collaborate on research, inform policymaking, train and support postgraduates and create a platform for research dissemination. We review the partnership's achievements and challenges, applying established criteria for developing successful partnerships. During the funded period we achieved major success in creating a platform for research dissemination through international meetings and publications. Other goals, such as engaging in collaborative research and training postgraduates, were not as successfully realised. Enabling factors included trust and respect between core working group members, a shared commitment to achieving partnership goals, and the collective ability to develop creative strategies to overcome funding challenges. Barriers included limited funding, administrative support, and framework for monitoring and evaluating some goals. Chronic disease research partnerships in low-income regions operate within health research, practice, funding and policy environments that prioritise infectious diseases and other pressing public health and developmental challenges. Their long-term sustainability will therefore depend on integrated funding systems that provide a crucial capacity building bridge. Beyond the specific challenges of chronic disease research, we identify social capital, measurable goals, administrative support, creativity and innovation and funding as five key ingredients that are essential for sustaining research partnerships.