Faculty Bibliography

Despite strong evidence of effective interventions targeted at blood pressure (BP) control, there is little evidence on the translation of these approaches to routine clinical practice in care of hypertensive blacks. The goal of this study is to evaluate the effectiveness of a multilevel, multicomponent, evidence-based intervention compared with usual care in improving BP control among hypertensive blacks who receive care in community health centers. The primary outcomes are BP control rate at 12 months and maintenance of intervention 1 year after the trial. The secondary outcomes are within-patient change in BP from baseline to 12 months and cost-effectiveness of the intervention. Counseling African Americans to Control Hypertension (CAATCH) is a group randomized clinical trial with 2 conditions: intervention condition and usual care. Thirty community health centers were randomly assigned equally to the intervention condition group (n=15) or the usual care group (n=15). The intervention comprises 3 components targeted at patients (interactive computerized hypertension education, home BP monitoring, and monthly behavioral counseling on lifestyle modification) and 2 components targeted at physicians (monthly case rounds based on Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines, chart audit and provision of feedback on clinical performance and patients' home BP readings). All outcomes are assessed at quarterly study visits for 1 year. Chart review is conducted at 24 months to evaluate maintenance of intervention effects and sustainability of the intervention. Poor BP control is one of the major reasons for the mortality gap between blacks and whites. Findings from this study, if successful, will provide salient information needed for translation and dissemination of evidence-based interventions targeted at BP control into clinical practice for this high-risk population

BACKGROUND: Barbershops constitute potential sites for community health promotion programs targeting hypertension (HTN) in African American men but such programs previously have not been formally evaluated. METHODS: A randomized trial (ClinicalTrials.gov no. NCT00325533) will test whether a continuous HTN detection and medical referral program conducted by influential peers (barbers) in a receptive community setting (barbershops) can promote treatment-seeking behavior and thus lower blood pressure (BP) among the regular customers with HTN. Barbers will offer a BP check with each haircut and encourage appropriate medical referral using real stories of other customers modeling the desired behaviors. A cohort of 16 barbershops will go through a pretest/posttest group-randomization protocol. Serial cross-sectional data collection periods (10 weeks each) will be conducted by interviewers to obtain accurate snapshots of HTN control in each barbershop before and after 10 months of either barber-based intervention or no active intervention. The primary outcome is BP control: BP <135/85 mm Hg (nondiabetic subjects) and <130/80 mm Hg (diabetic subjects) measured in the barbershop during the 2 data collection periods. The multilevel analysis plan uses hierarchical models to assess the effect of covariates on HTN control and secondary outcomes while accounting for clustering of observations within barbershops. CONCLUSIONS: By linking community health promotion to the health care system, this program could serve as a new model for HTN control and cardiovascular risk reduction in African American men on a nationwide scale

BACKGROUND: The objective of the study was to evaluate the association between race/ethnic (r/e) discrimination and subclinical cardiovascular disease (CVD). Although r/e discrimination is a chronic stressor that might have negative health effects, cardiovascular data related to experiences with discrimination among different r/e groups in the United States remain sparse. METHODS: Using data from the Dallas Heart Study, we assessed the association between perceived r/e discrimination and traditional CVD risk factors, C-reactive protein (CRP), aortic plaque area and wall thickness, and coronary calcium (CAC) score among black, white, and Hispanic participants. Prevalent CAC was defined as a CAC score > or =10 Agatston units; CRP elevation was defined as > or =3 mg/L. Participants were asked, 'Have you ever been discriminated against due to your race/ethnicity? (responses: yes, no, or don't know)'. RESULTS: Blacks reported r/e discrimination more frequently than whites or Hispanics (P < .0001). Blacks who reported r/e discrimination were more likely to be college graduates, to have a family history of myocardial infarction, and to be more physically active than blacks who did not report r/e discrimination (each P < .05). Hispanics who reported r/e discrimination had a higher prevalence of smoking (P < .01) and were more likely to be born in the United States. In models that adjusted for traditional CVD risk factors and medication use, we generally found no association between reports of r/e discrimination and aortic wall thickness, aortic plaque area, prevalent CAC, or elevated CRP in any of the r/e groups. Among blacks, stratification by gender and education did not change the observed relationship between perceived r/e discrimination and CAC or CRP. CONCLUSIONS: Although perceived r/e discrimination is associated with certain health characteristics that may result in negative health outcomes, in general, we found no association of r/e discrimination with either subclinical atherosclerosis as determined by CAC score, aortic wall thickness and aortic plaque area, or inflammation as assessed by elevated CRP levels

OBJECTIVES: We sought to elicit barriers to health and primary healthcare use among African-American men residing in a low-income, urban area. METHODS: We conducted a qualitative study of African-American men using focused group interviews. A purposive sampling technique was used to recruit 8 select subgroups: adolescents (age 16-18), trauma survivors, HIV-positive men, homeless men, men who have sex with men (MSM), substance abusers, church affiliated men and a mixed sample (N=71). Focus groups were moderated by trained, African-American male focus group leaders. RESULTS: Qualitative analysis of focused group transcripts yielded 2 major categories-intrinsic barriers and extrinsic barriers. Within the intrinsic barriers category, 5 subcategories emerged: lack of health awareness, fear, healthcare as needed, medical mistrust and fatalism. Extrinsic barriers included cost/benefit, clinic experience, and cultural and linguistic differences. Participants also offered solutions to address key barriers. CONCLUSIONS: African-American men identified key intrinsic and extrinsic barriers to health and primary healthcare, including lack of health awareness and providers' cultural and linguistic differences. These barriers constitute important areas of future research and intervention to address African-American men's health and willingness to seek healthcare

BACKGROUND: Hypertension (HTN) control rates in the United States remain lower in black than white persons, particularly before 65 years of age. Potential sociocultural factors have not been sufficiently addressed. METHODS: We analyzed data from structured interviews and blood pressure measurements in a population-based sample of 1514 hypertensive (1194 non-Hispanic black and 320 non-Hispanic white) subjects aged 18 to 64 years in Dallas County, Texas, from 2000 to 2002 to identify sociocultural factors associated with low rates of HTN control. We calculated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) using multivariate logistic regression. RESULTS: Awareness, treatment, and control of HTN were negatively associated with a common perception of good health, with aORs (95% CIs) of 0.37 (0.27-0.50) for awareness, 0.47 (0.36-0.62) for treatment, and 0.66 (0.51-0.86) for control. They were positively associated with having a regular physician, with aORs (95% CIs) of 3.81 (2.86-5.07) for awareness, 8.36 (5.95-11.74) for treatment, and 5.23 (3.30-8.29) for control. Among untreated hypertensive subjects, lack of perceived need for a regular physician was associated with perceived good health (aOR [95% CI], 2.2 [1.2-4.0]), male gender (aOR [95% CI], 2.4 [1.4-4.1]), and black race/ethnicity (aOR [95% CI], 2.1 [1.0-4.4]). The HTN outcomes were unrelated to perceived racism or lay beliefs about the causes, consequences, and treatment of HTN. CONCLUSIONS: Among young to middle-aged hypertensive subjects, a perception of good health and the lack of perceived need for a regular physician remain major factors associated with untreated and uncontrolled HTN at the community level-particularly among black men. These factors merit greater emphasis in professional education and public health programs on HTN

Barbershops constitute potential sites for community health promotion programs targeting hypertension (HTN) in black men, but such programs have not been evaluated previously. Here we conducted 2 nonrandomized feasibility studies to determine whether an enhanced intervention program of continuous blood pressure (BP) monitoring and peer-based health messaging in a barbershop lowers BP more than standard screening and health education (study 1) and can be implemented by barbers rather than research personnel (study 2). In study 1, we measured changes in HTN treatment and BP in regular barbershop customers with poorly controlled HTN assigned for 8 months to either an enhanced intervention group (n=36) or a contemporaneous comparison group (n=27). Groups were similar at baseline. BP fell by 16+/-3/9+/-2 mm Hg in the enhanced intervention group but was unchanged in the comparison group (P<0.0001, adjusted for age and body mass index). HTN treatment and control increased from 47% to 92% (P<0.001) and 19% to 58% (P<0.001), respectively, in the enhanced intervention group, whereas both remained unchanged in the comparison group. In study 2, barbers were trained to administer the enhanced intervention continuously for 14 months to the entire adult black male clientele (n=321) in 1 shop. Six barbers recorded 8953 BP checks during 11 066 haircuts, thus demonstrating a high degree of intervention fidelity. Furthermore, among 107 regular customers with HTN, treatment and control increased progressively with increasing intervention exposure (P<0.01). Taken together, these data suggest that black-owned barbershops can be transformed into effective HTN detection, referral, and follow-up centers. Further research is warranted

OBJECTIVE: The objective was to elicit patients' perceptions regarding the meaning of hypertension and to identify the personal, social, and environmental factors that might influence their perceptions. DESIGN: Qualitative study. SETTING: Adult ambulatory care practice PARTICIPANTS: African American patients with uncontrolled hypertension. INTERVENTION/METHODS: In-depth structured interviews were conducted with a purposive sample of 60 patients. Interviews were audiotaped, transcribed verbatim, and analyzed by using grounded theory. RESULTS: Patient descriptions of hypertension were grouped into three categories: 1) their thoughts on hypertension; 2) the consequences of hypertension; and 3) the impact that having hypertension had on their lifestyle. Factors that might have shaped how patients described hypertension were grouped into three categories: 1) the experiences of their social networks such as family and friends; 2) their personal experiences; and 3) information about hypertension that they might have gathered from the medical literature or during an encounter with a healthcare provider. Patients with family members who had experienced hypertension-related complications such as stroke were more likely to view hypertension as a serious condition. Patients who themselves experienced hypertension-related symptoms and who also had family members with a history of hypertensive disease were more likely to describe a willingness to make lifestyle changes. CONCLUSIONS: In this study, personal experiences, experiences of family and friends, and encounters with the healthcare environment influenced patients' perceptions of hypertension and their willingness to make lifestyle changes. These findings can be used as a framework for helping to tailor effective and culture-specific interventions

African-American men are disproportionately affected by preventable medical conditions, yet they underutilize primary care health services. Because healthcare utilization is strongly dependent on health beliefs, the purpose of this qualitative study was to identify and explore African-American men's perceptions of health and health influences. We conducted eight focus group interviews with select subgroups of African-American men, including adolescents, trauma survivors, HIV-positive men, homeless men, men who have sex with men, substance abusers, church-affiliated men and a mixed sample (N=71). Definitions of health, beliefs about health maintenance and influences on health were elicited. Participants' definitions of health went beyond the traditional 'absence of disease' definition and included physical, mental, emotional, economic and spiritual well-being. Being healthy also included fulfilling social roles, such as having a job and providing for one's family. Health maintenance strategies included spirituality and self-empowerment. Stress was cited as a dominant negative influence on health, attributed to lack of income, racism, 'unhealthy' neighborhoods and conflict in relationships. Positive influences included a supportive social network and feeling valued by loved ones. This study provides insight into African-American men's general health perceptions and may have implications for future efforts to improve healthcare utilization in this population