The role of implementing instructional design principles on learner experience with training in current good manufacturing practices (cGMP).

INTRODUCTION: The objective of the study was to assess if improvement of the learner experience could be achieved through the use of instructional design strategies in current Good Manufacturing Practices (cGMP) training. This is a novel application in a topic that is known to be boring but is critical to ensuring patient safety. METHODS: An experimental randomized controlled repeated measures cross-over design was utilized in a sample of pharmacy students to determine the effect of an intervention training strategy (which utilized a mix of strategies including weeding, signaling, use of multimedia, and optimized space and type) on the learner experience (Evaluation, Overall Satisfaction, Perceived Knowledge, and Future Recommendation) compared with a control. RESULTS: The sample of 52 pharmacy students that participated evaluated the intervention training strategy with higher scores than the control, with better overall satisfaction, perceived knowledge, and future recommendation scores than the control training strategy. Thus, an apparent effect which resulted from the use of instructional design strategies was seen for all learner experience variables (p < .01). CONCLUSION: Improvement in the learner experience can be achieved by using instructional design strategies in cGMP training. This indicates that similar results could be obtained in other topics where such techniques have not yet been applied.

Intersection of Perceived COVID-19 Risk, Preparedness, and Preventive Health Behaviors: Latent Class Segmentation Analysis.

Background: COVID-19 risk perception is a factor that influences the pandemic spread. Understanding the potential behavioral responses to COVID-19, including preparedness and adoption of preventive measures, can inform interventions to curtail its spread. Objective: We assessed self-perceived and latent class analysis (LCA)-based risks of COVID-19 and their associations with preparedness, misconception, information gap, and preventive practices among residents of a densely populated city in Nigeria. Methods: We used data from a cross-sectional survey conducted among residents (N=140) of Onitsha, Nigeria, in March 2020, before the government-mandated lockdown. Using an iterative expectation-maximization algorithm, we applied LCA to systematically segment participants into the most likely distinct risk clusters. Furthermore, we used bivariate and multivariable logistic regression models to determine the associations among knowledge, attitude, preventive practice, perceived preparedness, misconception, COVID-19 information gap, and self-perceived and LCA-based COVID-19 risks. Results: Most participants (85/140, 60.7%) had good knowledge and did not perceive themselves as at risk of contracting COVID-19. Three-quarters of the participants (102/137, 74.6%; P<.001) experienced COVID-19-related information gaps, while 62.9% (88/140; P=.04) of the participants had some misconceptions about the disease. Conversely, most participants (93/140, 66.4%; P<.001) indicated that they were prepared for the COVID-19 pandemic. The majority of the participants (94/138, 68.1%; P<.001) self-perceived that they were not at risk of contracting COVID-19 compared to 31.9% (44/138) who professed to be at risk of contracting COVID-19. Using the LCA, we identified 3 distinct risk clusters (P<.001), namely, prudent or low-risk takers, skeptics or high-risk takers, and carefree or very high-risk takers with prevalence rates (probabilities of cluster membership that represent the prevalence rate [γc]) of 47.5% (95% CI 40%-55%), 16.2% (95% CI 11.4%-20.9%), and 36.4% (95% CI 28.8%-43.9%), respectively. We recorded a significantly negative agreement between self-perceived risk and LCA-based segmentation of COVID-19 risk (κ=-0.218, SD 0.067; P=.01). Knowledge, attitude, and perceived need for COVID-19 information were significant predictors of COVID-19 preventive practices among the Onitsha city residents. Conclusions: The clustering patterns highlight the impact of modifiable risk behaviors on COVID-19 preventive practices, which can provide strong empirical support for health prevention policies. Consequently, clusters with individuals at high risk of contracting COVID-19 would benefit from multicomponent interventions delivered in diverse settings to improve the population-based response to the pandemic.

Population-based assessment of the burden of COVID-19 infection in African countries: a first-year report card and public health implications.

Background: The COVID-19 pandemic constitutes a global health threat and poses a major burden on the African continent. We assessed the real-world burden of COVID-19 infection in African Union (AU) member states to determine the distributional patterns of epidemiological measures during the first 1 year of the pandemic. Methods: This retrospective cross-sectional study utilized COVID-19 data from publicly available data repositories of the African Center for Disease Control and Prevention and Our World in Data for the period February 2020 to January 2021. AU member states were classified into low, medium, and high burdens based on COVID-19 morbidity. We conducted descriptive and inferential analyses of COVID-19-reported cases, deaths, recoveries, active cases, COVID-19 tests, and epidemiological measures that included morbidity and mortality rates, case fatality rate (CFR), and case ratios. Results: A total of 3.21 million cases were reported during the 1-year period, with 2.6 million recoveries, 536,784 cases remaining active, and 77,486 deaths. Most countries (49.1%, n = 26) in AU experienced a low burden of COVID-19 infection compared to 28.3% (n = 15) with medium burden and 22.6% (n = 12) with high burden. AU nations with a high burden of the disease were mainly in the northern and southern regions. South Africa recorded the highest number of cases (1.31 million), followed by Morocco with 457,625 and Tunisia with 175,065 cases. Correspondently, death tolls for these countries were 36,467, 7888, and 5528 deaths, respectively. Of the total COVID-19 tests performed (83.8 million) during the first 1 year, 62.43% were from high-burden countries. The least testing occurred in the medium-burden (18.42%) countries. The overall CFR of AU was 2.21%. A morbidity rate of 327.52/105 population and mortality rate of 5.96/105 population were recorded during the first 1-year period with significant variations (p < 0.0001) across burden levels. Continental morbidity and mortality rates of 17,359/105 and 315.933/105 populations were recorded with significant correlation (r = 0.863, p < 0.0001) between them and variations across selected epidemiological measures by COVID-19 burden levels. Conclusion: Understanding the true burden of the disease in AU countries is important for establishing the impact of the pandemic in the African continent and for intervention planning, preparedness, and deployment of resources during COVID-19 surges and future pandemics.

Management of metastatic melanoma in Texas: disparities in the utilization of immunotherapy following the regulatory approval of immune checkpoint inhibitors.

BACKGROUND: The utilization of modern-immunotherapies, notably immune checkpoint inhibitors (ICIs), has increased markedly in patients with metastatic melanoma over the past decade and are recommended as standard treatment. Given their increasing adoption in routine care for melanoma, understanding patient access to immunotherapy and patterns of its use in Texas is crucial as it remains one of the few states without Medicaid expansion and with high rates of the uninsured population. The objectives of this study were to examine the trend in the utilization of immunotherapy and to determine factors associated with immunotherapy utilization among patients with metastatic melanoma in the era of ICIs in Texas. METHODS: A retrospective cohort study was conducted using the Texas Cancer Registry (TCR) database. The cohort comprised of adult (≥ 18 years) patients with metastatic melanoma diagnosed between June 2011 and December 2018. The trend in immunotherapy utilization was assessed by determining the proportion of patients receiving immunotherapy each year. The Average Annual Percent Change (AAPC) in immunotherapy utilization was assessed using joinpoint regression, while multivariable logistic regression was used to determine the association between patient characteristics and immunotherapy receipt. RESULTS: A total of 1,795 adult patients with metastatic melanoma were identified from the TCR. Immunotherapy utilization was higher among younger patients, those with no comorbidities, and patients with private insurance. Multivariable analysis showed that the likelihood of receipt of immunotherapy decreased with older age [(adjusted Odds Ratio (aOR), 0.92; 95% CI, 0.89- 0.93, p = 0.001], living in high poverty neighborhood (aOR, 0.52; 95% CI, 0.44 - 0.66, p < 0.0001), having Medicaid (aOR, 0.58; 95% CI, 0.44 - 0.73, p = 0.02), being uninsured (aOR, 0.49; 95% CI, 0.31 - 0.64, p = 0.01), and having comorbidities (CCI score 1: aOR, 0.48; 95% CI, 0.34 - 0.71, p = 0.003; CCI score ≥ 2: aOR, 0.32; 95% CI, 0.16 - 0.56, p < 0.0001). CONCLUSIONS AND RELEVANCE: This cohort study identified sociodemographic and socioeconomic disparities in access to immunotherapy in Texas, highlighting the need for policies such as Medicaid expansion that would increase equitable access to this innovative therapy.

Predictors of opioid prescription among outpatients with osteoarthritis in the United States.

BACKGROUND: Osteoarthritis (OA) management targets pain reduction through multimodal strategies to improve functional status. Among pharmaceutical options, opioids have been selected as a treatment option for pain management, without endorsement by evidence-based guidelines. OBJECTIVE: To examine the predictors of opioid prescriptions for OA during outpatient visits in the United States (US). DESIGN: This study was based on the National Ambulatory Medical Care Survey (NAMCS) database (2012-2016), with a retrospective, cross-sectional study design of US adult outpatient visits with OA. The primary outcome was opioid prescription, and socio-demographic and clinical characteristics were independent variables. Weighted descriptive, bivariate, and multivariable logistic regression analyses were utilized to study patient characteristics and to assess the predictors of opioid prescription. RESULTS: Approximately, 51.68 million (95 percent CI = 44.41-58.95 million) OA-related outpatient visits were made between 2012 and 2016. Most patients were established patients (82.32 percent), and 20.58 percent of the visits resulted in opioid prescriptions. Key prescriptions within the opioid analgesic and combination categories were tramadol-based (5.16 percent) and hydrocodone-based (9.10 percent). Patients who paid through Medicaid were three times more likely (aOR = 3.25, 95 percent CI = 1.60-6.61, p = 0.0012) than those who paid through private insurance to receive an opioid prescrip-tion, new patients were 59 percent less likely (aOR = 0.41, 95 percent CI = 0.24-0.68, p = 0.0007) to receive an opioid prescription as compared to established patients, and obese patients were twice as likely (aOR = 1.88, 95 percent CI = 1.11-3.20, p = 0.0199) than nonobese patients to receive an opioid prescription. CONCLUSIONS: Payment source, obesity, and patient visit status were associated with the receipt of an opioid prescription among OA outpatients. Further research is needed to establish intrinsic factors that drive opioid prescription in this population.

Public opinion regarding government response to COVID-19: case study of a large commercial city in Nigeria.

INTRODUCTION: government measures to contain the COVID-19 pandemic cannot be effective without widespread compliance by the public. A greater understanding of citizens' perceptions of these measures can help government agencies adapt their strategies to boost compliance. We examined citizens' perceptions of government's measures to contain the COVID-19 pandemic and its implications on compliance using data from Onitsha city, Anambra State Nigeria. METHODS: data was obtained through in-person interviews of 140 consenting adults in March 2020. Descriptive and inferential statistics were used to summarize the data. RESULTS: most participants (84.7%) doubted government's ability to manage the COVID-19 outbreak, raising concerns about ineffective governance (25.7%) and inadequate health facilities (20.7%). However, participants expressed a favorable perception of school closures (92.3%) and a ban on large gatherings (83.9%), driven mostly by the need to contain the COVID-19 and avoid its spread. But, they were generally indifferent about the closure of the markets and workplaces due to concerns for food insecurity and lack of government's relief programs. Participants who had a positive perception of the ban on large gatherings were more likely to have high knowledge and to adopt good COVID-19 preventive practices. CONCLUSION: the study showed a lack of public's confidence in the government's ability to manage the pandemic. This provides an opportunity for the city government and the public to reflect on the existing relationships, build mutual trust, and devise collaborative engagement that will boost compliance and help contain the devastating impact of COVID-19 pandemic.

Commercial Sex Work During Novel Coronavirus (SARS-CoV-2) Era in the Niger Delta Region: Relationships Between Knowledge, Preventive Practice, and Transmission Potential.

BACKGROUND: Sex workers, like others, are facing economic hardships and anxiety about their health and safety due to coronavirus disease-2019 (COVID-19), an infectious disease caused by a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Universally, most sex work has largely reduced, moved online, or undertaken covertly because of lockdown measures and need for social distancing to break the transmission of SARS-CoV-2. However, the ability of sex workers to protect themselves against COVID-19 depends on their individual and interpersonal behaviors and work environment. In this study, we sought to determine the relationships between COVID-19 knowledge, awareness and prevention practice (KAP) among female commercial sex workers (FCSW) in the Niger Delta region of Nigeria to inform the development of prevention interventions for this vulnerable population. METHODS: Data used in this study were obtained from a cross-sectional survey of 604 FCSW operating in the Niger Delta region of Nigeria. We used descriptive and inferential statistics to assess their socio-demographic characteristics and COVID-19 KAP adopted against the novel coronavirus. Latent class analysis was used to systematically classify participants' attributes and behaviors into the most likely distinct clusters or risk groups. RESULTS: The majority of the FCSW were singles (86.8%) of childbearing ages, 21-35 years (86.2%), with almost three quarters (73.2%) of them having sex with 3-4 clients per day during the COVID-19 pandemic. Overall, almost three quarters of the participants had both good knowledge and awareness about COVID-19 but less than half of them (41.1%) implemented good practice to prevent the spread of the disease. However, a highly significant and positive relationship was recorded between COVID-19 knowledge (r=0.90, p<0.0001) and awareness (r=0.65, p<0.0001), and preventive practice of FCSW, respectively. About 89.1% of the participants were not very familiar with the symptoms of COVID-19 (p<0.0001). Only 10.9% of the FCSW indicated that they wear facemask at all times, while 45.2% of them do not wear facemask during sexual intercourse with their clients (p<0.0001). Based on the FCSW attributes and behaviors, we identified three distinct clusters or risk groups (p<0.0001), namely, low-risk takers (Cluster 1), high-risk takers (Cluster 2) and very high-risk takers (Cluster 3) with latent class prevalence rates (γc) of 41.13% (95% CI: 37.26-45.10), 33.17% (95% CI: 29.53-37.02) and 25.71% (95% CI: 22.38-29.34), respectively. CONCLUSION: Sex work has high transmission potentials for SARS-CoV-2 because of its operational nature, which does not permit social distancing, and thus, renders certain preventive measures practically ineffective. This is a major challenge in the fight against COVID-19 in this high-risk group and calls for the development of operational guidelines and targeted intervention strategies to help reduce the spread of COVID-19 in the Niger Delta region.

Evaluation of the Sociodemographic, Behavioral and Clinical Influences on Complete Antiretroviral Therapy Adherence Among HIV-Infected Adults Receiving Medical Care in Houston, Texas.

INTRODUCTION: Few studies have estimated complete antiretroviral therapy (ART) adherence following HIV infection since the advent of the new ART guidelines in 2012. This study determined the prevalence and influence of sociodemographic, behavioral, and clinical factors on complete ART adherence among people living with HIV (PLWH) receiving medical care in Houston/Harris County, Texas. METHODS: Data from the Houston Medical Monitoring Project survey collected from 2009 to 2014 among 1073 participants were used in this study. The primary outcome evaluated was combined adherence, defined as complete, partial, and incomplete combined adherence based on three ART adherence types-dose, schedule, and instruction adherence. The duration living since initial HIV diagnosis was classified as <5, 5-10 and >10 years. Rao-Scott Chi-square test and multivariable proportional-odds cumulative logit regression models were employed to identify the sociodemographic, behavioral, and clinical characteristics of complete combined adherence among the three groups of PLWH living with HIV infection. RESULTS: More than one-half (54.4%) of PLWH had complete, 37.4% had partial, and 8.3% had incomplete combined adherence. Among these PLWH, 52.2% had been infected with HIV for >10 years, and 26.5% and 21.4% were infected for <5 years and 5-10 years, respectively. PLWH who were diagnosed <5 and 5-10 years were two times (aOR=1.71, 95% CI=1.13-2.57; aOR=1.69, 95% CI=1.10-2.59; respectively) more likely to experience complete combined adherence than those with >10 years of infection. Multiple sociodemographic, behavioral, and clinical characteristics were significantly associated with complete adherence and varied by the duration of HIV infection. CONCLUSION: Measures of adherence should include all adherence types (dose, schedule, instruction), as utilizing a single adherence type will overestimate adherence level in PLWH receiving medical care. Intervention efforts to maintain adherence should target recently infected PLWH, while those aimed at improving adherence should focus on longer infected PLWH.

COVID-19 Infection among People with HIV/AIDS in Africa: Knowledge Gaps, Public Health Preparedness and Research Priorities.

The emergence of novel virus SARS-CoV-2 that causes COVID-19 has complicated Africa's public health challenges, especially with the pre-existing epidemics such as HIV/AIDS. We highlight the known evidence related to COVID-19 infections among people with HIV (PWH) with specific reference to Africa. The knowledge gaps, level of public health preparedness and the potential research priorities are also outlined. Although the epidemiology and clinical course of COVID-19 in HIV patients are evolving, existing evidence indicate that the disease outcomes are comparable to that of the general population. However, PWH with low CD4 cell counts may have worse outcomes than individuals with restored immunity, whereas old age and co-morbidities such as obesity, hypertension and diabetes can further increase their overall risk. While there may be slight disruption of HIV service delivery in selected African countries, the resilience and resourcefulness of others have helped to sustain HIV service delivery and enhanced the level of public health preparedness and fight against the pandemic. The paucity of data and research studies on HIV-COVID-19 coinfection in Africa, call for concerted efforts to address these limitations.

Predictors of chronic kidney disease among HIV-infected patients on highly active antiretroviral therapy at the University of Calabar Teaching Hospital, Calabar, South-South Nigeria.

Background: The burden of the people living with human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS) is largely borne by communities in Sub-Saharan Africa. The rate of kidney disease is increasing amongst HIV patients and occurs more often in patients with advanced stage of the disease with lower CD4 counts and associated with a high rate of morbidity and mortality. The objective of this study is to determine the prevalence and predictors of chronic kidney disease (CKD) amongst HIV patients on highly active antiretroviral therapy (HAART) at the University of Calabar Teaching Hospital, Calabar. Materials and methods: This was a cross-sectional study that was carried out over a 4-month period from May to August 2018. In all, a total of 118 patients with HIV on HAART were recruited into the study in a consecutive manner and their serum creatinine measured with the calculation of estimated glomerular filtration rate (eGFR). Other data collected were sex, age, weight, height, body mass index (BMI), waist hip ratio (WHR), packed cell volume, CD4 count etcetera. Data collected were inputted and analyzed with SPSS version 18, and statistical significance was taken to be p<0.05. Results: There were more females (69.5%) amongst the HIV participants and the prevalence of CKD was 15.3%. The risk factors seen to be associated with CKD were lower levels of CD4 count below 200 cells/µl, lower PCV, weight, BMI, and eGFR. Also, higher levels of WHR and creatinine were associated with CKD. Factors directly correlated with CKD were weight, BMI and CD4 count levels, while creatinine level was inversely correlated with CKD. However, a logistic regression model showed only creatinine to be a predictor of CKD. Conclusion: HIV patients on antiretroviral therapy, mainly the highly active antiretroviral therapy (HAART) have a relatively high prevalence of CKD of 15.3% and high level of serum creatinine was predictive of CKD in the logistic regression model in our study.

Assessment of sexually transmitted disease/HIV risk among young African Americans: comparison of self-perceived and epidemiological risks utilizing ecodevelopmental theory.

Background: Recent advances in understanding the developmental processes associated with adolescents warrant new thinking and systematic application of key concepts of risk and protective processes. This study examined the association between epidemiological and self-perceived risks of contracting sexually transmitted diseases (STDs)/HIV among young African Americans (AAs) and the multilevel factors identified using ecodevelopmental theory. Methods: A retrospective cross-sectional study was conducted on wave 1 data from the National Longitudinal Study of Adolescent Health comprising 1,619 AA youth aged 14-18 years. Epidemiological and self-perceived HIV-risk indices were developed and their associations with ecodevelopmental system parameters evaluated. Results: Significant discordance (P<0.0001) in the youths' self-perceived risk and epidemiological risk (the "gold standard") was recorded with Cohen's k-coefficient of 0.144 (95% CI 0.104-0.193). Adolescents who felt like talking to their mother had no trouble getting along with schoolteachers, perceived that teachers treated student fairly, experienced mother's disapproval of their sexual debut, and had close friends who knew how to use condoms correctly, were positively related to low epidemiological risk of contracting STDs/HIV. Being older, male, and a mother's positive attitude toward their adolescent's use of birth control (in exosystem) were associated with high epidemiological risk of contracting STDs/HIV. Furthermore, poor connection with the mother (did not feel like talking to mother) and growing older were related to low accuracy of self-risk perception among AA youths. Conclusion: The findings demonstrate the strong need to align self-perceived risk with epidemiological risk of acquiring STDs/HIV using the key multilevel ecodevelopmental system factors identified. This will require changes in relevant social attitudes and norms associated with risk measurement, and allow for a rational basis for safe health practices and behaviors among AA youths.

Smoking habits and attitude toward smoking cessation interventions among healthcare professionals in Pakistan.

BACKGROUND: Tobacco smoking is considered as the second main cause of increased mortality rate and one of the major preventable causes of cardiovascular and pulmonary diseases worldwide. Although the damages caused by smoking are known, the prevalence of smoking is increasing among healthcare professionals (HCPs). Increased smoking rates among HCPs may compromise the ability to effectively counsel patients who are addicted to smoking. The purpose of this study was to assess the smoking habits and attitude toward smoking cessation interventions among HCPs in Pakistan. METHODS: A descriptive cross-sectional study design was used. A prevalidated semi-structured question developed by the University of Arizona was used. The sample size was calculated to be 382 with 95% confidence interval and 5% level of error. Data were cleaned, coded, and analyzed statistically using SPSS 21. Chi-square test (P ≥ 0.05) was used to find association among different variables. RESULTS: The results of the study showed that a majority of the HCPs were smokers (57.6%, n = 220). Use of nicotine patches and other cessation medications, educational programs, and discussion with other healthcare providers were most effective methods for quitting smoking. Significant association (P < 0.05) was found among smokers and nonsmokers regarding self-respect and feeling of loneliness. CONCLUSION: The study concluded that a majority of the HCPs in twin cities were smokers and smoke more than five cigarettes a day. Training programs should be designed and implemented for HCPs to reduce the rate of tobacco smoking.

Sources of clinical information used in HIV care and treatment: Are providers' choices related to their demographic and practice characteristics?

HIV medical care providers need a wide range of evidence-based clinical information resources to manage their patients' health. We determined whether providers' choice of information sources for HIV care and treatment are associated with their demographic and medical practice characteristics. Data used for this study were obtained from a probability sample of HIV medical care providers in 13 outpatient HIV facilities in Houston/Harris County, Texas, surveyed between June and September 2009. The mean number of information sources used by HIV medical care providers for HIV care and treatment was 5.83 (95% confidence interval: 4.90-6.75). Antiretroviral therapy guidelines (95.6%), medical journals and textbooks (82.6%), and Internet sources (69.5%) were ranked first, second, and third as sources of clinical information. At least one of the providers' demographic or medical practice characteristics was significantly (p ⩽ 0.05) associated with six of the clinical information sources. Integration of these information resources into clinicians' workflow may enhance efficiency of HIV care and treatment and facilitate improved patients' care and health outcomes.

Systemic Delays in the Initiation of Antiretroviral Therapy for Clinically Eligible HIV-Infected Patients in Houston, Texas: The Providers' Report Card.

BACKGROUND: The current US HIV treatment guidelines support initiation of antiretroviral therapy (ART) for persons with HIV for personal health benefits and prevention of HIV transmission. However, high levels of adherence to ART are critical to maximize individual and public health benefits. We examined the nonclinical barriers to ART initiation for clinically eligible individuals and the provider- and patient-related factors associated with these barriers among HIV-infected patients in Houston/Harris County, Texas. METHODS: We analyzed data obtained from a probability sample of HIV medical care providers (HMCPs) in 13 outpatient facilities in Houston/Harris County, Texas surveyed between June and September 2009. We used an inductive thematic approach to code HMCP responses to an open-ended question that asked the main reasons why providers may delay initiating ART for clinically eligible patients. RESULTS: The reasons cited by providers for delaying ART for clinically eligible patients were adherence (42.5%; 95% confidence interval [CI]: 28.5-57.8), acceptance (30%; 95% CI: 18.1-45.4), and structural concerns (27.5%; 95% CI: 16.1-42.8), with significant variations ( P < .0001) noted across patients' race/ethnicity and transmission category. HIV medical care providers with 6 to 10 years' experience in HIV care and those providing medical care for more than 100 patients monthly were about 4 times (adjusted odds ratio [aOR]: 3.80; 95% CI: 1.20-5.92; P = .039) and 10 times (aOR: 10.36; 95% CI: 1.42-22.70; P = .019) more likely to state adherence and acceptance concerns, respectively, as reasons for delaying ART for clinically eligible patients. CONCLUSION: Our findings highlight the fact that clinical guidelines are only a starting point for medical decision-making process and that patients themselves play an important role. HMCP access to referrals for other medical issues, support services, and treatment education may help improve adherence and patient readiness for ART, thereby avoiding systemic delays.

Modeling ecodevelopmental context of sexually transmitted disease/HIV risk and protective behaviors among African-American adolescents.

Risk and protective processes are integrated developmental processes that directly or indirectly affect behavioral outcomes. A better understanding of these processes is needed, in order to gauge their contribution to sexual risk behaviors. This retrospective cross-sectional study modeled the ecodevelopmental chain of relationships to examine the social contexts of African-American (AA) adolescents associated with sexually transmitted disease (STD)- and HIV-risk behaviors. We used data from 1,619 AA adolescents with an average age of 16±1.8 years obtained from the first wave of the National Longitudinal Study of Adolescent Health for this study. Confirmatory factor analysis followed by structural equation modeling was conducted to identify the latent constructs that reflect the social-interactional components of the ecodevelopmental theory. Among contextual factors, findings indicated that a feeling of love from father, school, religion, and parent attitudes toward adolescent sexual behavior were all factors that played significant roles in the sexual behavior of AA adolescents. AA adolescents who reported feeling love from their father, feeling a strong negative attitude from their parents toward having sex at a very young age, and having a strong bond with school personnel were associated with better health statuses. The level of parents' involvement in their children's lives was reflected in the adolescents' feeling of love from parents and moderated by their socioeconomic status. Being male, attaining increased age, and being a sexual minority were associated with higher likelihood of exhibiting risky sexual behavior. In contrast, higher socioeconomic status and fathers' level of involvement were indirectly associated with reduced STD/HIV-related sexual risk behavior. In conclusion, our findings suggest that interventions aimed at maximal protection against STD/HIV-related risk behavior among AA adolescents should adopt both self- and context-based strategies that promote positive functioning in the family, school, and peer microsystems.

A Motivational Interviewing Intervention by Pharmacy Students to Improve Medication Adherence.

BACKGROUND: Diabetes mellitus (DM) patients with comorbid hypertension (HTN) are at a higher risk of developing microvascular and macrovascular DM complications. Through guideline-driven recommendations, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are highly recommended for these patients. Unfortunately, medication adherence to these products, though crucial to achieving therapeutic benefit, is frequently suboptimal. Motivational interviewing (MI) is a patient-centered collaborative communication style that is used to strengthen internal motivation for change that may prove effective in enhancing adherence. OBJECTIVE: To examine the effect of an MI telephone intervention conducted by pharmacy students in improving adherence to ACEIs/ARBs among Medicare Advantage Plan (MAP) patients with both DM and HTN. METHODS: A prospective study was conducted among patients enrolled in a Texas MAP. Medical claims data were used to identify patients with DM and HTN, and pharmacy claims were observed to recognize those who filled either an ACEI or an ARB during June 2014. Patients with a 6-month proportion of days covered (PDC) < 0.80 in the previous 6 months were determined nonadherent, and 75% of those were randomly selected to serve as potential subjects for the intervention, while 25% were randomly selected to serve as potential subjects for the control group. The intervention was a telephone call by a pharmacy student on rotation at the health plan, and 5 monthly follow-up calls. Before implementing calls, participating students attended a 3-day MI training course, where their proficiency for MI skills was evaluated. Refill data during the 6-month postintervention were evaluated to examine the intervention effect measured on 3 outcomes: PDC; PDC ≥ 0.80 versus < 0.80; and discontinuation versus continuation. Multivariate linear and logistic regression models were constructed to adjust for any imbalances in baseline characteristics, including age, gender, number of other medications, regimen complexity, health low-income subsidy status, prescriber specialty, comorbidities, 6-month previous hospitalization, baseline 6-month PDC, and Centers for Medicare & Medicaid Services risk score. RESULTS: A total of 11 students participated in the intervention implementation. Patients receiving calls were randomly selected from those potential subjects for the intervention arm until a target of 250 was reached; 500 controls were randomly selected from the potential subjects for the control arm. The final cohort included in multivariate models consisted of 743 patients. Patients completing the initial call and at least 2 follow-ups were less likely to discontinue (OR = 0.29; 95% CI = 0.15-0.54; P < 0.001) and more likely to be adherent in the linear regression model (ß = 0.0604, P < 0.001) and the logistic regression model (OR = 1.53; 95% CI = 1.02-2.28; P = 0.009). Other factors significantly associated with better adherence included higher baseline PDC and number of medications. Depression status was significantly associated with lower adherence. CONCLUSIONS: Patients receiving 2 or more calls had significantly better adherence and less discontinuation during the 6 months following initial calls compared with those who did not receive calls. This finding indicates that an MI-based telephone intervention by pharmacy students may be a promising intervention to improve adherence. Future research should examine the sustainability of the intervention effect for longer time periods and its influence on associated clinical outcomes. DISCLOSURES: This project was supported by the Pharmaceutical Research and Manufacturers of America Foundation (PhRMA). The content is solely the responsibility of the authors and does not necessarily represent the official views of PhRMA. The funding agency was not involved in research design, analysis, or reporting results. Funding was obtained by Abughosh. Holstad provided a consultation regarding the MI guide and provided the MI training. Study concept and design were contributed by Abughosh and Fleming, along with Serna, Esse, and Holstad. Serna, Esse, Mann, Holstad, and Masilamani collected the data, and data interpretation was performed by Abughosh, Wong, and Esse. The manuscript was written by Abughosh, Wong, and Esse and revised by Masilamani and Holstad, along with the other authors.

Predictors of hypertension in an urban HIV-infected population at the University of Calabar Teaching Hospital, Calabar, Nigeria.

BACKGROUND: The introduction of highly active antiretroviral therapy (HAART) has remarkably improved the prognosis of human immunodeficiency virus (HIV)-infected patients, at the expense of the development of long-term complications such as cardiovascular and renal diseases. Hypertension (HTN) is a major risk factor for cardiovascular diseases and its associated mortality. In this study, we aimed to determine the prevalence of HTN and to identify possible predictors among HIV-infected patients attending the HIV Special Treatment Clinic at the University of Calabar Teaching Hospital, Calabar. MATERIALS AND METHODS: A cross-sectional study was carried out over a 5-month period from February to July 2016. A total of 112 HIV-infected persons were consecutively recruited and their blood pressures were measured in two consecutive clinic visits. They were compared with the HIV-negative control group (n=309). Data collected were analyzed with SPSS 18, and statistical significance was set at P<0.05. RESULTS: There was a female preponderance in both the HIV-infected individuals and HIV-negative control group (57.5% vs. 57.4%). The mean ages were 39.3 and 33.9 years in HIV-infected and HIV-negative subjects, respectively. The risk factors that were associated with HTN in both groups were older age (>40 years), increased weight and body mass index (BMI), and presence of obesity. Male sex and duration of exposure to HAART and CD4 count levels >200 cells/mm3 were associated with HTN in HIV-infected patients, whereas the absence of family history of HTN was significantly associated with HTN in both groups. However, in a multivariate logistic regression, the predictors of HTN in both groups are absence of family history of HTN and older age in HIV-infected patients and HIV-negative subjects, respectively. CONCLUSION: Traditional risk factors such as older age, increased BMI, and obesity were linked to HTN in both HIV-infected and HIV-negative subjects, but higher CD4 count level and cumulative HAART exposure were associated with HTN in HIV-positive individuals. In a multivariate logistic regression, the predictors of HTN in both groups are absence of family history of HTN and older age in HIV-infected patients and HIV-negative subjects, respectively.

Comparison of Suicide Attempts/Behaviors Following Smoking Cessation Treatments Among Schizophrenic Smokers.

BACKGROUND: Smoking cessation may lead to depression in some smokers and result in increased risk of suicide. OBJECTIVE: To compare the risk of suicide attempts/behaviors associated with different smoking cessation medications among schizophrenic patients. METHODS: A retrospective cohort study was conducted using General Electric (GE) medical record database (1995-2011). The first day of being prescribed a smoking cessation medication defined as index date. Patients were followed up to one year from index date. Patients' suicide behaviors or attempts were identified through ICD-9 codes and E-codes. Cox proportional hazards model was applied to examine the association between smoking cessation medication and suicidal/self-injurious behaviors. RESULTS: Our cohort consisted of 3925 patients with diagnosis of schizophrenia or schizoaffective disorder who initiated cessation medication. Among them, 104 (2.65%) had suicide attempts or behavior within one-year follow up. However, statistically significant difference in the risk of suicide attempts/behaviors was not detected across cessation regimens in the Cox proportional hazard analysis. Only comorbidity index was found to be associated with suicide, which showed that higher Charlson comorbidity index was associated with higher risks of suicide behaviors within one year (HR=1.15, 95% CI=1.04-1.27). CONCLUSION: There were no significant differences in suicide attempts/behaviors with different cessation medications.

Managing the Personal Side of Health Care among Patients with HIV/AIDS.

The study describes the HIV care providers' sociodemographic and medical practice characteristics and the health care services offered to patients during medical care encounters in Houston/Harris County, Texas. We used data from the pilot cycle of the Centers for Disease Control and Prevention Medical Monitoring Project Provider Survey conducted in June to September 2009. The average age and HIV care experience of the providers were 46.7 and 11.7 years, respectively, and they provided care to an average of 113 patients monthly. The average proportion of HIV-infected patients seen per month by race/ethnicity was 43.3% for blacks, 28.5% for whites, 26.6% for Hispanics, 1.3% for Asians, and 0.6% for other races. A total of 67% of providers offered HIV testing to all patients 13 to 64 years of age. Most HIV care providers (73.9%) reported that patients in their practices sought HIV care only after experiencing symptoms. Understanding the HIV care delivery system from providers' perspectives may help enhance support services, patients' ongoing care and retention, leading to improved health outcomes.

A Pharmacist Telephone Intervention to Identify Adherence Barriers and Improve Adherence Among Nonadherent Patients with Comorbid Hypertension and Diabetes in a Medicare Advantage Plan.

BACKGROUND: Patients with comorbid hypertension (HTN) and diabetes mellitus (DM) are at a high risk of developing macrovascular and microvascular complications of DM. Controlling high blood pressure can greatly reduce these complications. Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are recommended for patients with both DM and HTN by the American Diabetes Association guidelines, and their benefit and efficacy in reducing macrovascular and microvascular complications of DM have been well documented. Poor adherence, however, remains a significant barrier to achieving full effectiveness and optimal outcomes. OBJECTIVE: To examine the effect of a brief pharmacist telephone intervention in identifying adherence barriers and improving adherence to ACEI/ARB medications among nonadherent patients with comorbid HTN and DM who are enrolled in a Medicare Advantage plan. METHODS: Cigna-HealthSpring's medical claims data was used to identify patients with HTN and DM diagnoses by using ICD-9-CM codes 401 and 250, and at least 2 fills for ACEIs or ARBs between January 2013 and October 2013. Patients who failed to refill their medication for more than 1 day and had a proportion of days covered (PDC) < 0.8 were considered nonadherent and were contacted by a pharmacist by phone to identify adherence barriers. Two outcome variables were evaluated: The first was adherence to ACEIs/ARBs, defined as PDC during the 6 months following the phone call intervention. The second outcome variable was a categorical outcome of discontinuation versus continuation. Discontinuation was defined as not using ACEIs/ARBs during the 6-month post-intervention period. Patients who disenrolled from the plan in 2014 or were switched to another medication commonly used for treating DM and HTN were excluded from further analysis. Descriptive statistics were conducted to assess the frequency distribution of sample demographic characteristics at baseline. Multiple linear regression was conducted to assess the intervention effect on adherence during the 6 months post-intervention using the first outcome of post-intervention PDC, adjusting for baseline PDC and other covariates. Logistic regression was performed to assess the association between medication discontinuation and other baseline characteristics using the second outcome of discontinuation. Other control variables in the models included demographics (age, sex, language), physician specialty (primary care vs. specialist), health plan (low-income subsidy vs. other), Centers for Medicare & Medicaid risk score, Charlson Comorbidity Index, and number of distinct medications. RESULTS: In total, 186 hypertensive diabetic patients, nonadherent to ACEIs/ARBs (PDC < 0.8), were included in the study. Of the 186 patients, 87 received the pharmacist phone call intervention. Among these patients, forgetfulness (25.29%) and doctor issues, such as having difficulty scheduling appointments (16.79%), were the most commonly reported barriers. After excluding those who switched from ACEIs/ARBs to another medication, 157 patients were included in the logistic regression model. Of those, 131 had continued using ACEIs/ARBs and were included in the linear regression model. The mean (±SD) post-intervention PDC for the intervention group was 0.58 (±0.26) and for the control group 0.29 (±0.17). Intervention was a significant predictor of better adherence in the linear regression model after adjusting all the other baseline covariates (ß = 0.3182, 95% CI = 0.19-0.38, P < 0.001). Other covariates were not significantly associated with better adherence. In the logistic regression model (discontinuation: 26 [yes]/131 [no]) for predicting medication discontinuation, patients who received intervention were more likely to continue using ACEIs/ARBs (OR = 3.56, 95% CI = 1.06-11.86), and those with a higher comorbidity index were less likely to continue using them (OR = 0.72, 95% CI = 0.53-0.99). CONCLUSIONS: The brief pharmacist telephone intervention resulted in significantly better PDCs during the 6 months following the intervention as well as lower discontinuation rates among a group of nonadherent patients with comorbid HTN and DM. The overall PDC rates in both the intervention and control groups were still lower than the recommended 80%. Improving adherence to clinically meaningful values may require more than a brief pharmacist phone call. Incorporating motivational interviewing techniques with follow-up calls to address adherence barriers may be more influential in forming sustainable behavioral change and enhancing medication adherence.