Faculty Bibliography

The disproportionately high prevalence of hypertension and its associated mortality and morbidity in minority older adults is a major public health concern in the United States. Despite compelling evidence supporting the beneficial effects of therapeutic lifestyle changes on blood pressure reduction, these approaches remain largely untested among minority elders in community-based settings. The Counseling Older Adults to Control Hypertension trial is a two-arm randomized controlled trial of 250 African-American and Latino seniors, 60years and older with uncontrolled hypertension, who attend senior centers. The goal of the trial is to evaluate the effect of a therapeutic lifestyle intervention delivered via group classes and individual motivational interviewing sessions versus health education, on blood pressure reduction. The primary outcome is change in systolic and diastolic blood pressure from baseline to 12months. The secondary outcomes are blood pressure control at 12months; changes in levels of physical activity; body mass index; and number of daily servings of fruits and vegetables from baseline to 12months. The intervention group will receive 12 weekly group classes followed by individual motivational interviewing sessions. The health education group will receive an individual counseling session on healthy lifestyle changes and standard hypertension education materials. Findings from this study will provide needed information on the effectiveness of lifestyle interventions delivered in senior centers. Such information is crucial in order to develop implementation strategies for translation of evidence-based lifestyle interventions to senior centers, where many minority elders spend their time, making the centers a salient point of dissemination.

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.

OBJECTIVE: The prehypertension classification was introduced to facilitate prevention efforts among patients at increased risk for hypertension. Although patients who have been told that they have hypertension report worse outcomes than unaware hypertensives, little is known about whether or not prehypertension labeling has negative effects. We evaluated the effects of labeling individuals with prehypertension on blood pressure and health-related quality of life three months later. METHODS: One hundred adults (aged 19 to 82 [mean=40.0] years; 54% women; 64% racial/ethnic minorities) with screening blood pressure in the prehypertensive range (120-139/80-89mmHg) and no history of diagnosis or treatment of elevated blood pressure were randomly assigned to either a "Labeled" group in which they were informed of their prehypertension, or an "Unlabeled" group in which they were not informed. Subjects underwent office blood pressure measurement, 24-hour ambulatory blood pressure monitoring and completed self-report questionnaires at baseline and at three months. RESULTS: Multilevel mixed effects regression analyses indicated that changes in the white coat effect, office blood pressure, mean daytime ambulatory blood pressure, and physical and mental health did not differ significantly between the two groups. Adjusting for age, sex, race/ethnicity and body mass index did not affect the results. CONCLUSION: These findings suggest that labeling patients with prehypertension does not have negative effects on blood pressure or quality of life. Additional research is needed to develop approaches to communicating with patients about their blood pressure that will maximize the clinical and public health impact of the prehypertension classification.

This paper describes the application of a translational research model in developing The Trial Using Motivational Interviewing and Positive Affect and Self-Affirmation in African-Americans with Hypertension (TRIUMPH), a theoretically-based, randomized controlled trial. TRIUMPH targets blood pressure control among African-Americans with hypertension in a community health center and public hospital setting. TRIUMPH applies positive affect, self-affirmation, and motivational interviewing as strategies to increase medication adherence and blood pressure control. A total of 220 participants were recruited in TRIUMPH and are currently being followed. This paper provides a detailed description of the theoretical framework and study design of TRIUMPH and concludes with a critical reflection of the lessons learned in the process of implementing a health behavior intervention in a community-based setting. TRIUMPH provides a model for incorporating the translational science research paradigm to conducting pragmatic behavioral trials in a real-world setting in a vulnerable population. Lessons learned through interactions with our community partners reinforce the value of community engagement in research.

Obstructive sleep apnea (OSA) has emerged as a new and important risk factor for cardiovascular disease (CVD). Over the last decade, epidemiologic and clinical research has consistently supported the association of OSA with increased cardiovascular (CV) morbidity and mortality. Such evidence prompted the American Heart Association to issue a scientific statement describing the need to recognize OSA as an important target for therapy in reducing CV risk. Emerging facts suggest that marked racial differences exist in the association of OSA with CVD. Although both conditions are more prevalent in blacks, almost all National Institutes of Health-funded research projects evaluating the relationship between OSA and CV risk have been conducted in predominantly white populations. There is an urgent need for research studies investigating the CV impact of OSA among high-risk minorities, especially blacks. This article first examines the evidence supporting the association between OSA and CVD and reviews the influence of ethnic/racial differences on this association. Public health implications of OSA and future directions, especially regarding minority populations, are discussed.

[Correction Notice: An Erratum for this article was reported in Vol 81(2) of Journal of Consulting and Clinical Psychology (see record 2012-29655-001). In the article a citation and reference were mistakenly omitted. Under the heading "Case Study: TBSRC," subheading "Positive affect," the first sentence should have read: "Positive affect (PA) is a mild feeling state induced by small events, such as receiving a small, unexpected gift, seeing a few minutes of comedy, or receiving a report of success on a small task (Ashby, Valentin, & Turken, 2002)." The corresponding reference is: Ashby, F., Valentin, V., & Turken, U. (2002). The effects of positive affect and arousal on working memory and executive attention: Neurobiology and computational models. In S. Moore & M. Oaksford (Eds.), Emotional Cognition: From Brain to Behaviour (pp. 245-287). Amsterdam: John Benjamins. All versions of this article have been corrected.] Objective: To describe a mixed-methods approach to develop and test a basic behavioral science-informed intervention to motivate behavior change in 3 high-risk clinical populations. Our theoretically derived intervention comprised a combination of positive affect and self-affirmation (PA/SA), which we applied to 3 clinical chronic disease populations. Method: We employed a sequential mixed methods model (EVOLVE) to design and test the PA/SA intervention in order to increase physical activity in people with coronary artery disease (post-percutaneous coronary intervention [PCI]) or asthma (ASM) and to improve medication adherence in African Americans with hypertension (HTN). In an initial qualitative phase, we explored participant values and beliefs. We next pilot tested and refined the intervention and then conducted 3 randomized controlled trials with parallel study design. Participants were randomized to combined PA/SA versus an informational control and were followed bimonthly for 12 months, assessing for health behaviors and interval medical events. Results: Over 4.5 years, we enrolled 1,056 participants. Changes were sequentially made to the intervention during the qualitative and pilot phases. The 3 randomized controlled trials enrolled 242 participants who had undergone PCI, 258 with ASM, and 256 with HTN (n = 756). Overall, 45.1% of PA/SA participants versus 33.6% of informational control participants achieved successful behavior change (p = .001). In multivariate analysis, PA/SA intervention remained a significant predictor of achieving behavior change (p < .002, odds ratio = 1.66), 95% CI [1.22, 2.27], controlling for baseline negative affect, comorbidity, gender, race/ethnicity, medical events, smoking, and age. Conclusions: The EVOLVE method is a means by which basic behavioral science research can be translated into efficacious interventions for chronic disease populations. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

OBJECTIVE: We sought to characterize temporal trends in hospitalizations with heart failure as a primary or secondary diagnosis. BACKGROUND: Heart failure patients are frequently admitted for both heart failure and other causes. METHODS: Using the Nationwide Inpatient Sample (NIS), we evaluated trends in heart failure hospitalizations between 2001 and 2009. Hospitalizations were categorized as either primary or secondary heart failure hospitalizations based the location of heart failure in the discharge diagnosis. National estimates were calculated using the sampling weights of the NIS. Age- and gender-standardized hospitalization rates were determined by dividing the number of hospitalizations by the United States population in a given year and using direct standardization. RESULTS: The number of primary heart failure hospitalizations in the United States decreased from 1,137,944 in 2001 to 1,086,685 in 2009, while secondary heart failure hospitalizations increased from 2,753,793 to 3,158,179 over the same period. Age- and gender-adjusted rates of primary heart failure hospitalizations decreased steadily over 2001-2009, from 566 to 468 per 100,000 people. Rates of secondary heart failure hospitalizations initially increased, from 1370 to 1476 per 100,000 from 2001-2006, then decreased to 1359 per 100,000 in 2009. Common primary diagnoses for secondary heart failure hospitalizations included pulmonary disease, renal failure, and infections. CONCLUSIONS: Although primary heart failure hospitalizations declined, rates of hospitalizations with a secondary diagnosis of heart failure were stable in the past decade. Strategies to reduce the high burden of hospitalizations of heart failure patients should include consideration of both cardiac disease and non-cardiac conditions.

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:Poor adherence explains poor blood pressure (BP) control; however African Americans suffer worse hypertension-related outcomes. METHODS:This randomized controlled trial evaluated whether a patient education intervention enhanced with positive-affect induction and self-affirmation (PA) was more effective than patient education (PE) alone in improving medication adherence and BP reduction among 256 hypertensive African Americans followed up in 2 primary care practices. Patients in both groups received a culturally tailored hypertension self-management workbook, a behavioral contract, and bimonthly telephone calls designed to help them overcome barriers to medication adherence. Also, patients in the PA group received small gifts and bimonthly telephone calls to help them incorporate positive thoughts into their daily routine and foster self-affirmation. The main outcome measures were medication adherence (assessed with electronic pill monitors) and within-patient change in BP from baseline to 12 months. RESULTS:The baseline characteristics were similar in both groups: the mean BP was 137/82 mm Hg; 36% of the patients had diabetes; 11% had stroke; and 3% had chronic kidney disease. Based on the intention-to-treat principle, medication adherence at 12 months was higher in the PA group than in the PE group (42% vs 36%, respectively; P =.049). The within-group reduction in systolic BP (2.14 mm Hg vs 2.18 mm Hg; P = .98) and diastolic BP (-1.59 mm Hg vs -0.78 mm Hg; P = .45) for the PA group and PE group, respectively, was not significant. CONCLUSIONS:A PE intervention enhanced with PA led to significantly higher medication adherence compared with PE alone in hypertensive African Americans. Future studies should assess the cost-effectiveness of integrating such interventions into primary care. Trial Registration clinicaltrials.gov Identifier: NCT00227175.

BACKGROUND:Hypertension is becoming a common health problem worldwide with increasing life expectancy and increasing prevalence of risk factors. Epidemiological data on hypertension in Ghana is necessary to guide policy and develop effective interventions. METHODS:A review of population-based studies on hypertension in Ghana was conducted by a search of the PUBMED database, supplemented by a manual search of bibliographies of the identified articles and through the Ghana Medical Journal. A single reviewer extracted data using standard data collection forms. RESULTS:Eleven studies published on hypertension with surveys conducted between 1973 and 2009 were identified. The prevalence of hypertension was higher in urban than rural areas in studies that covered both types of area and increased with increasing age (prevalence ranging from 19.3% in rural to 54.6% in urban areas). Factors associated with high blood pressure included increasing body mass index, increased salt consumption, family history of hypertension and excessive alcohol intake. The levels of hypertension detection, treatment and control were generally low (control rates ranged from 1.7% to 12.7%). CONCLUSION/CONCLUSIONS:An increased burden of hypertension should be expected in Ghana as life expectancy increases and with rapid urbanisation. Without adequate detection and control, this will translate into a higher incidence of stroke and other adverse health outcomes for which hypertension is an established risk factor. Prevention and control of hypertension in Ghana is thus imperative and any delays in instituting preventive measures would most likely pose a greater challenge on the already overburdened health system.