Faculty Bibliography

BACKGROUND:Stroke is a major public health problem, with the disabilities of the patients increasing their risk of poor oral health. Currently, in Ghana and Nigeria, no guideline exists for oral health care in stroke patients, while most of our acute stroke care settings have no documented protocol. AIM/OBJECTIVE:This study sought to understand the perspectives of healthcare professionals in Ghana and Nigeria about oral healthcare in acute stroke patients. METHODS:A qualitative inductive approach was employed to explore healthcare professionals' perspectives. After obtaining informed consent, in-depth interviews were conducted among doctors, nurses, and physiotherapists using semi-structured question guides. Participants' responses were audiotaped for transcription and analysis. Interviews were conducted until data saturation was reached. Data were analyzed thematically to generate themes and sub-themes using an inductive approach. THE RESULTS/RESULTS:Twenty-five (25) health care professionals (HCP) aged 25-60 years with a mean age of 36.2 ± 4.2 years were interviewed. There were 15 (60.0%) males and 10 (40.0%) females. HCP included nurse practitioners 14 (56.0%), medical doctors 7 (28.0%), and physiotherapists 4 (16.0%). The HCP demonstrated adequate knowledge of stroke and considered oral health important for esthetic and clinical reasons. They, however, reported being unable to give it the required attention due to inadequate collaboration between the various professional cadres, insufficient equipment, and a skewed focus on other clinical needs of the acute stroke patients. CONCLUSIONS:The findings indicate that HCPs perceived oral health care as very important among patients with acute stroke. However, they reported a lack of collaboration and integration of oral health care in routine stroke care as a major impediment.

IMPORTANCE/UNASSIGNED:Black and Hispanic patients have high rates of recurrent stroke and uncontrolled hypertension in the US. The effectiveness of home blood pressure telemonitoring (HBPTM) and telephonic nurse case management (NCM) among low-income Black and Hispanic patients with stroke is unknown. OBJECTIVE/UNASSIGNED:To determine whether NCM plus HBPTM results in greater systolic blood pressure (SBP) reduction at 12 months and lower rate of stroke recurrence at 24 months than HBPTM alone among Black and Hispanic stroke survivors with uncontrolled hypertension. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Practice-based, multicenter, randomized clinical trial in 8 stroke centers and ambulatory practices in New York City. Black and Hispanic study participants were enrolled between April 18, 2014, and December 19, 2017, with a final follow-up visit on December 31, 2019. INTERVENTIONS/UNASSIGNED:Participants were randomly assigned to receive either HBPTM alone (12 home BP measurements/week for 12 months, with results transmitted to a clinician; n = 226) or NCM plus HBPTM (20 counseling calls over 12 months; n = 224). MAIN OUTCOMES AND MEASURES/UNASSIGNED:Primary outcomes were change in SBP at 12 months and rate of recurrent stroke at 24 months. Final statistical analyses were completed March 14, 2024. RESULTS/UNASSIGNED:Among 450 participants who were enrolled and randomized (mean [SD] age, 61.7 [11.0] years; 51% were Black [n = 231]; 44% were women [n = 200]; 31% had ≥3 comorbid conditions [n = 137]; 72% had household income <$25 000/y [n = 234/324]), 358 (80%) completed the trial. Those in the NCM plus HBPTM group had a significantly greater SBP reduction than those in the HBPTM alone group at 12 months (-15.1 mm Hg [95% CI, -17.2 to -13.0] vs -5.8 mm Hg [95% CI, -7.9 to -3.7], respectively; P < .001). The between-group difference in SBP reduction at 12 months, adjusted for primary care physician clustering, was -8.1 mm Hg (95% CI, -11.2 to -5.0; P < .001) at 12 months. The rate of recurrent stroke was similar between both groups at 24 months (4.0% in the NCM plus HBPTM group vs 4.0% in the HBPTM alone group, P > .99). CONCLUSIONS AND RELEVANCE/UNASSIGNED:Among predominantly low-income Black and Hispanic stroke survivors with uncontrolled hypertension, addition of NCM to HBPTM led to greater SBP reduction than HBPTM alone. Additional studies are needed to understand the long-term clinical outcomes, cost-effectiveness, and generalizability of NCM-enhanced telehealth programs among low-income Black and Hispanic stroke survivors with significant comorbidity. TRIAL REGISTRATION/UNASSIGNED:Clinical Trials.gov Identifier: NCT02011685.

BACKGROUND/UNASSIGNED:This study aimed to quantify the association between childhood family environment and longitudinal cardiovascular health (CVH) in adult CARDIA (Coronary Artery Risk Development in Young Adults) Study participants. We further investigated whether the association differs by adult income. METHODS/UNASSIGNED:We applied the CVH framework from the American Heart Association including metrics for smoking, cholesterol, blood pressure, glucose, body mass index, physical activity, and diet. CVH scores (range, 0-14) were calculated at years 0, 7, and 20 of the study. Risky Family environment (range, 7-28) was assessed at year 15 retrospectively, for childhood experiences of abuse, caregiver warmth, and family or household challenges. Complete case ordinal logistic regression and mixed models associated risky family (exposure) with CVH (outcome), adjusting for age, sex, race, and alcohol use. RESULTS/UNASSIGNED:The sample (n=2074) had a mean age of 25.3 (±3.5) years and 56% females at baseline. The median risky family was 10 with ideal CVH (≥12) met by 288 individuals at baseline (28.4%) and 165 (16.3%) at year 20. Longitudinally, for every 1-unit greater risky family, the odds of attaining high CVH (≥10) decreased by 3.6% (OR, 0.9645 [95% CI, 0.94-0.98]). Each unit greater child abuse and caregiver warmth score corresponded to 12.8% lower and 11.7% higher odds of ideal CVH (≥10), respectively (OR, 0.872 [95% CI, 0.77-0.99]; OR, 1.1165 [95% CI, 1.01-1.24]), across all 20 years of follow-up. Stratified analyses by income in adulthood demonstrated associations between risky family environment and CVH remained significant for those of the highest adult income (>$74k), but not the lowest (<$35k). CONCLUSIONS/UNASSIGNED:Although risky family environmental factors in childhood increase the odds of poor longitudinal adult CVH, caregiver warmth may increase the odds of CVH, and socioeconomic attainment in adulthood may contextualize the level of risk. Toward a paradigm of primordial prevention of cardiovascular disease, childhood exposures and economic opportunity may play a crucial role in CVH across the life course.

BACKGROUND:Access to antiretroviral therapy has increased life expectancy and survival among people living with HIV (PLWH) in African countries like Nigeria. Unfortunately, non-communicable diseases such as cardiovascular diseases are on the rise as important drivers of morbidity and mortality rates among this group. The aim of this study was to explore the perspectives of key stakeholders in Nigeria on the integration of evidence-based task-sharing strategies for hypertension care (TASSH) within existing HIV clinics in Nigeria. METHODS:Stakeholders representing PLWH, patient advocates, health care professionals (i.e. community health nurses, physicians and chief medical officers), as well as policymakers, completed in-depth qualitative interviews. Stakeholders were asked to discuss facilitators and barriers likely to influence the integration of TASSH within HIV clinics in Akwa Ibom, Nigeria. The interviews were transcribed, keywords and phrases were coded using the PEN-3 cultural model as a guide. Framework thematic analysis guided by the PEN-3 cultural model was used to identify emergent themes. RESULTS:Twenty-four stakeholders participated in the interviews. Analysis of the transcribed data using the PEN-3 cultural model as a guide yielded three emergent themes as assets for the integration of TASSH in existing HIV clinics. The themes identified are: 1) extending continuity of care among PLWH; 2) empowering health care professionals and 3) enhancing existing workflow, staff motivation, and stakeholder advocacy to strengthen the capacity of HIV clinics to integrate TASSH. CONCLUSION/CONCLUSIONS:These findings advance the field by providing key stakeholders with knowledge of assets within HIV clinics that can be harnessed to enhance the integration of TASSH for PLWH in Nigeria. Future studies should evaluate the effect of these assets on the implementation of TASSH within HIV clinics as well as their effect on patient-level outcomes over time.

BACKGROUND/UNASSIGNED:Individuals living with hypertension are at an increased risk of cardiovascular- and cerebrovascular-related outcomes. Interventions implemented at the community level to improve hypertension control are considered useful to prevent cardiovascular and cerebrovascular events; however, systematic evaluation of such community level interventions among patients living in low- and middle-income countries (LMICs) is scarce. METHODS/UNASSIGNED:Nine databases were searched for randomized controlled trials (RCTs) and cluster randomized control trials (cRCTs) implementing community level interventions in adults with hypertension in LMICs. Studies were included based on explicit focus on blood pressure control. Quality assessment was done using the Revised Cochrane Risk of Bias tool for randomized trials (ROBS 2). Results were presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Fixed-effect meta-analyses were conducted for studies that reported continuous outcome measures. RESULTS/UNASSIGNED:We identified and screened 7125 articles. Eighteen studies, 7 RCTs and 11 cRCTs were included in the analysis. The overall summary effect of blood pressure control was significant, risk ratio = 1.48 (95%CI = 1.40-1.57, n = 12). Risk ratio for RCTs was 1.68 (95%CI = 1.40-2.01, n = 5), for cRCTs risk ratio = 1.46 (95%CI = 1.32-1.61, n = 7). For studies that reported individual data for the multicomponent interventions, the risk ratio was 1.27 (95% CI = 1.04-1.54, n = 3). DISCUSSION/UNASSIGNED:Community-based strategies are relevant in addressing the burden of hypertension in LMICs. Community-based interventions can help decentralize hypertension care in LMIC and address the access to care gap without diminishing the quality of hypertension control.

BACKGROUND:, a diverse workforce alone is not sufficient; rather holistic health equity should be established as the anchoring principal mission of all academic medical centres, residing at the intersection of clinical care, education, research and community. METHODS:, which serves as the organising framework through which we conduct embedded pragmatic research in our healthcare delivery system to target and eliminate health inequities across our tripartite mission of patient care, medical education and research. RESULTS:. These elements include: (1) developing processes for collecting accurate disaggregate data on race, ethnicity and language, sexual orientation and gender identity and disability; (2) using a data-driven approach to identify health equity gaps; (3) creating performance and metric-based quality improvement goals to measure progress toward elimination of health equity gaps; (4) investigating the root cause of the identified health equity gap; (5) developing and evaluating evidence-based solutions to address and resolve the inequities; and (6) continuous monitoring and feedback for system improvements. CONCLUSION/CONCLUSIONS:can provide a model for how academic medical centres can use pragmatic research to embed a culture of health equity into their health system.

INTRODUCTION:Uncontrolled hypertension (HTN) is prevalent in persons experiencing homelessness (PEH) and contributes to significant suffering and financial cost. Mobile health approaches such as short messaging service (SMS) texting have led to better control of HTN in the general population. Despite the high utilisation of mobile phones by PEH, SMS texting to support HTN control has not been evaluated among this population. We hypothesise that an SMS testing programme will enhance health communication, information management, outreach and care coordination, and provide behavioural support to address some barriers to HTN management in PEH. METHODS AND ANALYSIS:This study will use a mixed-methods study design to address two objectives: First, it will evaluate, in a randomised controlled trial, the efficacy of a 6-month SMS texting strategy vs an attention control on blood pressure reduction and adherence to medications and clinical appointments in 120 adults PEH with uncontrolled HTN. Outcomes will be measured at 0, 2, 4 and 6 months. Second, it will assess patients' and providers' acceptability and experience of SMS texting using semistructured interviews with PEH (n=30) and providers (n=10). The study will be conducted in shelter clinics in New York City in collaboration with community organisations. The primary statistical analysis will be on an intention-to-treat basis. The trial results will be reported as comparative summary statistics (difference in response rate or means) with 95% CIs and in accordance with the Consolidated Standards of Reporting Trials (CONSORT). Interviews will be transcribed, coded and analysed using an inductive grounded theory analysis. ETHICS AND DISSEMINATION:This study has been approved by the Institutional Review Board (IRB) at George Washington University. Written consent will be obtained from participants. The findings will be disseminated in peer-reviewed journals. TRIAL REGISTRATION NUMBER:NCT05187013.

BACKGROUND:With improved access to anti-retroviral drugs, persons living with HIV/AIDS (PLWHA) are living longer but with attendant increased risks of non-communicable diseases (NCDs). The increasing burden of NCDs, especially hypertension, could reverse gains attributed to HIV care. Nurses and Community Health Officers (CHO) in Nigeria are cardinal in delivering primary health care. A task-strengthening strategy could enable them to manage hypertension in HIV care settings. This study aimed to assess their knowledge and practice of hypertension management among Healthcare workers (HCWs) and to explore the challenges involved in conducting onsite training during pandemics. METHODS:Nurses and CHOs in the employment of the Lagos State Primary Health Care Board (LSPHCB), Lagos State, Nigeria, were recruited. They were trained through hybrid (virtual and onsite) modules before study implementation and a series of refresher trainings. A pre-and post-training test survey was administered, followed by qualitative interviews to assess skills and knowledge uptake, the potential barriers and facilitators of task-sharing in hypertension management in HIV clinics, and the lessons learned. RESULTS:Sixty HCWs participated in the two-day training at baseline. There was a significant improvement in the trainees' knowledge of hypertension management and control. The average score during the pre-test and post-test was 59% and 67.6%, respectively. While about 75% of the participants had a good knowledge of hypertension, its cause, symptoms, and management, 20% had moderate knowledge, and 5% had poor knowledge at baseline. There was also an increase in the mean score between the pre-test and post-test of the refresher training using paired t-tests (P < 0.05). Role-playing and multimedia video use improved the participants' uptake of the training. The primary barrier and facilitator of task sharing strategy in hypertension management reported were poor delineation of duties among HCWs and the existing task shifting at the Primary Healthcare Centres (PHC) level, respectively. CONCLUSIONS:The task strengthening strategy is relevant in managing hypertension in HIV clinics in Nigeria. The capacity development training for the nurses and CHOs involved in the Integration of Hypertension Management into HIV Care in Nigeria: A Task Strengthening Strategy (TASSH-Nigeria) study yielded the requisite improvement in knowledge uptake, which is a reassurance of the delivery of the project outcomes at the PHCs.