Faculty Bibliography

BACKGROUND:The majority of global cardiovascular disease (CVD) burden falls on people living in low- and middle-income countries (LMICs). In order to reduce preventable CVD mortality and morbidity, LMIC health systems and health care providers need to improve the delivery and quality of CVD care. OBJECTIVES/OBJECTIVE:As part of the Disease Control Priorities Three (DCP3) Study efforts addressing quality improvement, we reviewed and summarized currently available evidence on interventions to improve quality of clinic-based CVD prevention and management in LMICs. METHODS:We conducted a narrative review of published comparative clinical trials that evaluated efficacy or effectiveness of clinic-based CVD prevention and management quality improvement interventions in LMICs. Conditions selected a priori included hypertension, diabetes, hyperlipidemia, coronary artery disease, stroke, rheumatic heart disease, and congestive heart failure. MEDLINE and EMBASE electronic databases were systematically searched. Studies were categorized as occurring at the system or patient/provider level and as treating the acute or chronic phase of CVD. RESULTS:From 847 articles identified in the electronic search, 49 met full inclusion criteria and were selected for review. Selected studies were performed in 19 different LMICs. There were 10 studies of system level quality improvement interventions, 38 studies of patient/provider interventions, and one study that fit both criteria. At the patient/provider level, regardless of the specific intervention, intensified, team-based care generally led to improved medication adherence and hypertension control. At the system level, studies provided evidence that introduction of universal health insurance coverage improved hypertension and diabetes control. Studies of system and patient/provider level acute coronary syndrome quality improvement interventions yielded inconclusive results. The duration of most studies was less than 12 months. CONCLUSIONS:The results of this review suggest that CVD care quality improvement can be successfully implemented in LMICs. Most studies focused on chronic CVD conditions; more acute CVD care quality improvement studies are needed. Longer term interventions and follow-up will be needed in order to assess the sustainability of quality improvement efforts in LMICs.

BACKGROUND: Metabolic syndrome poses an increased global burden of disease and causes immense financial burden, warranting heightened public health attention. The present study assessed the prevalence and severity of cardiometabolic risk among foreign-born versus US-born blacks, while exploring potential gender-based effects. METHODS: A total of 1035 patients from the Metabolic Syndrome Outcome Study (Trial registration: NCT01946659) provided sociodemographic, medical history, and clinical data. General Linear Model (GLM) was used to assess the effects of birthplace and gender on cardiometabolic parameters, adjusting for age differences in the sample. RESULTS: Of the sample, 61.6 % were foreign-born blacks (FBB) and 38.4 % were US-born blacks (USB). FBB had significantly lower BMI compared with USB (32.76 +/- 0.35 vs. 35.41 +/- 0.44, F = 22.57), but had significantly higher systolic blood pressure (136.70 +/- 0.77 vs. 132.83 +/- 0.98; F = 9.60) and fasting glucose levels than did USB (146.46 +/- 3.37 vs. 135.02 +/- 4.27; F = 4.40). Men had higher diastolic BP (76.67 +/- 0.65 vs. 75.05 +/- 0.45; F = 4.20), glucose (146.53 +/- 4.48 vs. 134.95 +/- 3.07; F = 4.55) and triglyceride levels (148.10 +/- 4.51 vs. 130.60 +/- 3.09; F = 10.25) compared with women, but women had higher LDL-cholesterol (109.24 +/- 1.49 vs. 98.49 +/- 2.18; F = 16.60) and HDL-cholesterol levels (50.71 +/- 0.66 vs. 42.77 +/- 0.97; F = 46.01) than did men. CONCLUSIONS: Results showed that birthplace has a significant influence on cardiometabolic profiles of blacks with metabolic syndrome. Patients' gender also had an independent influence on cardiometabolic profile.

Introduction: There is growing evidence suggesting relationships between depression and insomnia symptoms, yet scant evidence indicating directionality of those relationships or potential mediators. Evidence also suggests that social connectedness is a vital, protective factor for depression. Social connectedness may hold promise for helping sleep scientists better understand relationships between disrupted sleep and depression symptomology. Methods: The current study drew on social network analysis, an underexplored approach in sleep medicine, and survey methods to examine social connections, insomnia severity, and depression symptoms. Participants (n = 38) were 44.7% female, with an average age of 56.7 years; 86.8% of the participants self-identified as black. Bivariate correlations and logistic regression were performed to examine relationships between social connectedness, insomnia severity, and depression symptoms. Results: Of the sample, 71.1% reported insomnia and 23.7% reported depression. Participants provided responses to social network items across kin (m = 2.8 people), non-kin (m = 2.4 people), and formal networks (m = 1.6 people). Case by case agreement was strong between kin network size and depression symptomology (chi square < .05), but not between kin network and insomnia (chi square = .658). The logistic regression in the current study showed individuals with depressive symptoms were 6.75 (95% CI 1.45-31.47, p < 0.) times more likely to have severe insomnia versus individuals without clinically significant depression symptoms. There was no significant relationship in the regression between network variables and insomnia or depression symptoms. Conclusion: Our findings are consistent with previous findings and evidence on a strong, positive relationship between depression symptomology and insomnia severity. However, they are not in line with literature suggesting a positive relationship between kin networks and depression symptomology. It is of interest to explore the causal relationship between social connectedness and sleep, and how social networks might serve as a protective (or risk) factor for insomnia, and maybe depression

Introduction: Poor adherence to evaluation and treatment of obstructive sleep apnea (OSA) is a public health challenge. Despite higher prevalence of OSA, blacks are less likely to adhere to physician-recommended OSA care than are whites. Methods: Among black patients with metabolic syndrome, we compared, in an RCT, effectiveness of a telephone-delivered culturally and linguistically tailored OSA health messages over 6 months (Intervention) versus standard patient education (Control) in improving adherence to recommended OSA care. We hypothesized that patients randomized to the intervention arm would exhibit greater adherence to OSA consultation, evaluation, and treatment than those in the control arm. We also evaluated the predictive role of baseline sociodemographics, health risks, comorbidity, and psychosocial factors on adherence status using multivariate-adjusted regression analyses. Results: 380 patients (mean age = 59yrs; 71%, women) were enrolled with 80% retention rate (intervention = 160 and control = 143). Of the sample, 69.4% of patients exposed to the intervention attended initial consultations, compared with 36.7% of patients in the control arm (p < .001); 74.7% versus 66.7% of patients in the intervention and control arms, respectively, completed diagnostic evaluations (p = 0.46), while 86.4% versus 88.9% in the intervention and control arm, respectively, adhered to OSA treatment. Based on adjusted logistic regression, patients in the intervention arm were 3.17 times (95% CI = 1.68-5.99, p < 0.001) more likely to have initial consultations, relative to controls. Treatment self-efficacy was the strongest predictor of OSA adherence (OR = 1.11, 95% CI = 1.03-1.20, p < 0.01). Adjusted models revealed no significant differences between the two arms regarding adherence to OSA evaluation and treatment. Conclusion: The culturally and linguistically tailored OSA health messages were successful in improving initial consultation for OSA diagnosis. However, once patients were in treatment, there was no difference in OSA adherence rates between the two groups

Introduction: Health intervention is successful when messages are culturally and linguistically tailored to a specific population. The current study utilized a comprehensive approach involving multiple stakeholders to develop tailored health messages to promote awareness of sleep apnea among Blacks. Methods: We engaged several stakeholders (community-based organizations, patients, and healthcare providers) to develop and implementan online sleep educational inter vention. First round of focus groups were conducted with patients (N = 35; 71% Female, 100% Black, average age 45.2 years). Next, community leaders from churches, barbershops, and other organizations (N = 8, 75% Female, 87% Black, average age 48.1 years). Finally, interviews were conducted with healthcare providers (N = 6, 16% Female, 83% White, average age 51.2 years). All data collection was focused on barriers to awareness, diagnosis and treatment of sleep apnea. This paper presents results of the qualitative analysis conducted to inform the design of this community-engaged, linguistically and culturally tailored online sleep education program. Results: Analysis illuminated key barriers preventing sleep apnea awareness, including 1) low knowledge about the connection between daytime somnolence and associated sleep difficulties, 2) embarrassment about snoring and sleep apnea, and 3) inadequate healthcare access for effective treatments. The educational tool was designed using evidence-based approaches to diagnosis and treatment of sleep apnea, while acknowledging the primary themes identified in the focus groups. The tool was then refined with feedback from stakeholders (community members, sleep medicine doctors, and health communication experts. The TASHE resource included four key components, 1) tailored, population-appropriate reading level, 2) evidence-based tips and suggestions for sleep health and sleep apnea, 3) partnership with community-based organizations, and 4) cultural context. Conclusion: A conceptual model for tailored interventions in sleep medicine has been developed and implemented based on the principles of community-engaged research to ensure acceptability of tailored health messages and sustainability of the online sleep apnea educational program. The model developed can be used to structure the design and implementation of community-based, tailored sleep education programs that aim to promote sleep health at the population level

Introduction: rist actigraphy has been used extensively to measure objective sleep duration in sleep-related research. It has been validated against polysomngraphic and self-reported sleep measures. We sought to compare the accuracy of sleep measurements produced by three algorithms developed for wrist actigraphic scoring. Methods: A random sample of 263 participants were selected from among those participating in the Research on Obesity and Type 2 Diabetes among African Migrants (RODAM) study in Kumasi, Ghana. Each participant completed a sleep diary and wore a wrist actigraph for a period of seven days. Actigraphic data were scored using Actilife software, and th ree sepa rate validated algorithms developed separately by Sadeh, Cole-Kripke, and Jean-Louis were applied. SPSS was used to compare actigraphic sleep durations, derived from each algorithm, with self-reported sleep durations. Results: Valid actigraphic data, defined as having data for at least 5 of the 7-day period, were collected from 255 participants. Total sleep time in minutes varied substantially by sleep algorithm. Average sleep time derived from the Sadeh, Cole-Kripke, and Jean-Louis' algorithms were 346.8 (SD 49.3), 320.1 (SD 53.8), and 453.4 (SD 68.1), respectively. Participants self-reported an average of 468.3 (SD 85.7) minutes of sleep per night. The Sadeh and Cole-Kripke algorithms classified only 2.7% and 6.8% of the sample as sleeping the recommended 7 to 8 hours, respectively, whereas Jean-Louis' classified 28.2% in the 7 to 8 hour range. Conclusion: When employing actigraphy for sleep duration measurement, care should be exercised in choosing the most appropriate algorithm for scoring actigraphic data based on specific study populations in order to increase the accuracy of study results. The Jean-Louis' algorithm seems to fare better than other actigraphic scoring algorithms

Introduction: Although the association between sleep disturbance and cancer is well documented, there is little evidence regarding how sleep duration among cancer survivors may be associated with other chronic diseases. Growing evidence suggests that cancer and diabetes may share common risk factors such as age, gender, race, being over weight, physical inactivity, smoking and alcohol. However, it is yet unclear how unhealthy sleep duration (a known cardiometabolic risk factor) may affect the relationship between cancer and diabetes. The aim of this study was to investigate whether sleep duration moderated the relationship between physician-diagnosed cancer and diabetes. Methods: Data was extracted from the NHIS dataset (2004-2013), providing demographics, chronic diseases and sleep duration. For the present analysis, we used a subset of individuals providing complete data for the following variables: physician-diagnosed cancer and diabetes and self-reported habitual hours of sleep. Data were analyzed to assess the moderating effect of sleep duration on cancer and diabetes risk. Results: Of the total sample of 283,086 participants, 15.8% were black and 77.2% were white; 55.7% were female and the mean age was 47.7 (18.0) years. In the first adjusted regression model, short sleep duration [< 7 hours] (Beta = 0.15, p < .001) and cancer (Beta = 0.91, p8 hours] (Beta = 0.28, p < .001) and cancer (Beta = 0.14, p < .001) were independently associated with diabetes. However, moderation analysis indicated that only long sleep significantly moderated relationships between cancer and diabetes (Beta = -0.218, S.E. = 0.055, p < .0001, 95% CI = -0.326-0.110). Short sleep did not significantly moderate those relationships. Conclusion: Our findings demonstrate significant associations of short and long sleep with cancer and diabetes. We should note that among people with long sleep, having a cancer diagnosis did not increase diabetes r isk. However, among people with a cancer diag nosis, short sleep seemed to have increased diabetes risk

Introduction: Previous research has shown that Blacks/African-Americans (vs Non-Hispanic Whites) are more likely to be obese, suffer from stroke, and experience short sleep(SS8hrs/day) durations. Also, sleep duration itself is related to obesity and stroke risk, and the relationship between sleep duration and obesity is stronger in Blacks/African-Americans. This study explored the mediating role of obesity on relationships of SS and LS with stroke, while also contrasting traditional and newer multivariate machine modeling approaches. Methods: Data from the National Health Interview Survey from 20042013 (N = 288,888) was used. Structural equation modeling (SEM) and Bayesian Belief Network (BBN) analysis assessed the mediating effects of BMI on the relationship between SS, LS, and stroke, and whether race/ethnicity differences in obesity moderated relationships. Covariates included age, gender, marital status, and income. Results: Based on SEM results, BMI positively mediated relationships between SS and stroke (Path Coefficient Estimates < 0.027;p < 0.001), and between LS and stroke (Path Coefficient Estimates = 0.024; p < .001), adjusting for covariates. In SEM, race/ethnicity did not significantly moderate relationships between SS or LS and obesity. In contrast, BBN analysis showed that these relationships differed between blacks and whites. Blacks who were SS and obese had a 5.14% stroke probability, while white counterparts had a 3.73% stroke probability, with a significant difference of 37.8% (p < 0.001). Blacks who were LS and obese had an 11.71% stroke probability compared to whites with an 8.66% stroke probability and a significant difference of 35.21% (p < 0.001). Conclusion: No racial/ethnic influences on the mediating effect of BMI on the sleep-CVD relationship were detected using SEM. However, BBN analysis (but not SEM) showed racial/ethnic influences on the mediating effect of BMI on the sleep-stroke relationship, suggesting that obese blacks who reported short or long sleep were at greater risk for stroke. Findings also highlight the power of BBN analysis to elucidate disparities in complex chronic diseases

Introduction: Past research indicates that insomnia symptoms, defined as an inability to initiate or maintain sleep, may be associated with cardiovascular disease (CVD). In many low- and middle-income countries, urbanization and changing lifestyles have contributed to a rapidly growing burden of non-communicable disease, such as CVD. The present study assessed whether insomnia symptoms were associated with CVD in a sample of community-dwelling Ghanaian adults. Methods: Data were collected by structured questionnaires from a community-based sample of 263 participants (> 25 years) in Ghana, randomly selected from among participants in the Research on Obesity and Type 2 Diabetes among African Migrants (RODAM) study. Insomnia symptoms were assessed with three items: 1) having difficulty falling asleep, 2) having difficulty staying asleep, and 3) having problems waking up too early. Insomnia was coded as experiencing one or more of these symptoms. Incident CVD was measured using the Rose questionnaire. We used multiple logistic regression to test the association between insomnia and CVD, adjusting for age and sex. Results: The mean age of the sample was 47.3 years +/- 11.5, 41.1% were men, 44.9% had never been to school or attended only elementary school. Over 59% of the sample reported having one or more insomnia symptoms and 24% had CVD. After adjusting for age and sex, having insomnia symptoms was positively associated with having CVD, and this association approached significance (adjusted OR = 1.78, p = 0.063). This relationship was reduced after adjusting for comorbid conditions (adjusted OR = 1.66, p = 0.110). Conclusion: Our results indicate that insomnia may be related to having incident CVD, and that this relationship may be accounted for by comorbid conditions, which might confound the relationship between sleep and CVD. Nevertheless, assessing and treating insomnia may have important implications for managing CVD. This may be particularly important given the growing burden of chronic diseases in subSaharan Africa

Introduction: Sleep apnea is an impor tant medical condition, which is associated with adverse health outcomes and socioeconomic costs. As novel approaches to promoting awareness about sleep apnea symptoms and treatment emerge, there is a compelling need to develop a valid tool to assess sleep apnea health literacy in at-risk populations. The goal of this study was to develop a scale to assess sleep apnea literacy at the population level. Methods: Using a multi-phase design, we developed a scale for measuring sleep apnea health literacy. This included 1) devising a list of relevant sleep apnea-related questions in consultation with several established sleep investigators, 2) collecting preliminary data, 3) exploring natural component str uct ure, 4) selecting items compr ising the final scale using standardized procedures, 5) collecting additional data, and 6) generating construct validity of the scale. The final scale was approved by an independent expert in sleep medicine and an expert in scale design. Results: Data were collected using Amazon Mechanical Turk (MTurk) to gather data from 91 participants (mean age = 38yrs; 48% were White and 27%, African American). Analyses were conducted using exploratory and confirmatory factor analyses (SPSS version 20). The scale includes 26 items across three sub-domains, including sleep apnea health literacy (component alpha = 0.74), sleep apnea self-efficacy (component alpha = 0.76), and sleep apnea clinical management (component alpha = 0.65). Analysis showed that the concurrent scale validity was = 0.85. Conclusion: This is the first scale to feature characteristics that assess sleep apnea health literacy at the population level. This scale can be useful in designing and evaluating sleep apnea health education programs. It will also enable adequate tailoring of future interventions to ascertain specific areas of knowledge about sleep apnea