Race-Specific Patterns of Treatment Intensification Among Hypertensive Patients Using Home Blood Pressure Monitoring: Analysis Using Defined Daily Doses in the Heart Healthy Lenoir Study.

BACKGROUND: Racial disparities in blood pressure (BP) control persist, but whether differences by race in antihypertensive medication intensification (AMI) contribute is unknown. OBJECTIVE: To compare AMI by race for patients with elevated home BP readings. METHODS: This prospective cohort study followed adult patients from 6 rural primary care practices who used home BP monitoring (HBPM) and recorded/reported values. For providers, AMI was encouraged when mean HBPM systolic blood pressure (SBP) values were ⩾135 mm Hg; patients received phone-based coaching on HBPM technique and sharing HBPM findings. AMI was assessed between baseline and 12 months using defined daily dose (DDD) and summed to create a total antihypertensive DDD value. RESULTS: A total of 217 patients (mean age = 61.4 ± 10.2 years; 66% female; 57% black) provided usable HBPM data. Among 90 (41%) intensification-eligible hypertensive patients (ie, mean HBPM SBP values for 6-months ⩾135 mm Hg), mean total antihypertensive DDD was increased in 61% at 12 months. Blacks had significantly higher mean DDD at baseline and 12 months, but intensification (+0.72 vs +0.65; P = 0.83) was similar by race. However, intensification was greater in males than females (+1.1 vs +0.39; P = 0.031). Reduction in mean SBP following intensification was greater in white versus black patients (-8.2 vs -3.9 mm Hg; P = 0.14). Conclusion/Relevance: Treatment intensification in HBPM users was similar by race, differed significantly by gender, and may produce a greater response in white patients. Differential AMI in HBPM users does not appear to contribute to persistent racial disparities in BP control.

Characterizing Community Health Workers on Research Teams: Results From the Centers for Population Health and Health Disparities.

OBJECTIVES: To quantify the characteristics of community health workers (CHWs) involved in community intervention research and, in particular, to characterize their job titles, roles, and responsibilities; recruitment and compensation; and training and supervision. METHODS: We developed and administered a structured questionnaire consisting of 25 closed- and open-ended questions to staff on National Institutes of Health-funded Centers for Population Health and Health Disparities projects between March and April 2014. We report frequency distributions for CHW roles, sought-after skills, education requirements, benefits and incentives offered, and supervision and training activities. RESULTS: A total of 54 individuals worked as CHWs across the 18 research projects and held a diverse range of job titles. The CHWs commonly collaborated on research project implementation, provided education and support to study participants, and collected data. Training was offered across projects to bolster CHW capacity to assist in intervention and research activities. CONCLUSIONS: Our experience suggests national benefit in supporting greater efforts to recruit, retain, and support the work of CHWs in community-engagement research.

A community-based lifestyle and weight loss intervention promoting a Mediterranean-style diet pattern evaluated in the stroke belt of North Carolina: the Heart Healthy Lenoir Project.

BACKGROUND: Because residents of the southeastern United States experience disproportionally high rates of cardiovascular disease (CVD), it is important to develop effective lifestyle interventions for this population. METHODS: The primary objective was to develop and evaluate a dietary, physical activity (PA) and weight loss intervention for residents of the southeastern US. The intervention, given in eastern North Carolina, was evaluated in a 2 year prospective cohort study with an embedded randomized controlled trial (RCT) of a weight loss maintenance intervention. The intervention included: Phase I (months 1-6), individually-tailored intervention promoting a Mediterranean-style dietary pattern and increased walking; Phase II (months 7-12), option of a 16-week weight loss intervention for those with BMI ≥ 25 kg/m(2) offered in 2 formats (16 weekly group sessions or 5 group sessions and 10 phone calls) or a lifestyle maintenance intervention; and Phase III (months 13-24), weight loss maintenance RCT for those losing ≥ 8 lb with all other participants receiving a lifestyle maintenance intervention. Change in diet and PA behaviors, CVD risk factors, and weight were assessed at 6, 12, and 24 month follow-up. RESULTS: Baseline characteristics (N = 339) were: 260 (77 %) females, 219 (65 %) African Americans, mean age 56 years, and mean body mass index 36 kg/m(2). In Phase I, among 251 (74 %) that returned for 6 month follow-up, there were substantial improvements in diet score (4.3 units [95 % CI 3.7 to 5.0]), walking (64 min/week [19 to 109]), and systolic blood pressure (-6.4 mmHg [-8.7 to -4.1]) that were generally maintained through 24 month follow-up. In Phase II, 138 (57 group only, 81 group/phone) chose the weight loss intervention and at 12 months, weight change was: -3.1 kg (-4.9 to -1.3) for group (N = 50) and -2.1 kg (-3.2 to -1.0) for group/phone combination (N = 75). In Phase III, 27 participants took part in the RCT. At 24 months, weight loss was -2.1 kg (-4.3 to 0.0) for group (N = 51) and -1.1 kg (-2.7 to 0.4) for combination (N = 72). Outcomes for African American and whites were similar. CONCLUSIONS: The intervention yielded substantial improvement in diet, PA, and blood pressure, but weight loss was modest. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01433484.

Associations between neighborhood-level factors related to a healthful lifestyle and dietary intake, physical activity, and support for obesity prevention polices among rural adults.

We examined cross-sectional associations among neighborhood- and individual-level factors related to a healthful lifestyle and dietary intake, physical activity (PA), and support for obesity prevention polices in rural eastern North Carolina adults. We examined perceived neighborhood barriers to a healthful lifestyle, and associations between neighborhood barriers to healthy eating and PA, participants' support for seven obesity prevention policies, and dependent variables of self-reported dietary and PA behaviors, and measured body mass index (BMI) (n = 366 study participants). We then used participants' residential addresses and Geographic Information Systems (GIS) software to assess neighborhood-level factors related to access to healthy food and PA opportunities. Correlational analyses and adjusted linear regression models were used to examine associations between neighborhood-level factors related to a healthful lifestyle and dietary and PA behaviors, BMI, and obesity prevention policy support. The most commonly reported neighborhood barriers (from a list of 18 potential barriers) perceived by participants included: not enough bicycle lanes and sidewalks, not enough affordable exercise places, too much crime, and no place to buy a quick, healthy meal to go. Higher diet quality was inversely related to perceived and GIS-assessed neighborhood nutrition barriers. There were no significant associations between neighborhood barriers and PA. More perceived neighborhood barriers were positively associated with BMI. Support for obesity prevention policy change was positively associated with perceptions of more neighborhood barriers. Neighborhood factors that promote a healthful lifestyle were associated with higher diet quality and lower BMI. Individuals who perceived more neighborhood-level barriers to healthy eating and PA usually supported policies to address those barriers. Future studies should examine mechanisms to garner such support for health-promoting neighborhood changes.

Patient and practice perspectives on strategies for controlling blood pressure, North Carolina, 2010-2012.

INTRODUCTION: Patient and practice perspectives can inform development of team-based approaches to improving blood pressure control in primary care. We used a community-based participatory research approach to assess patient and practice perceptions regarding the value of team-based strategies for controlling blood pressure in a rural North Carolina population from 2010 through 2012. METHODS: In-depth interviews were conducted with 41 adults with hypertension, purposely sampled to include diversity of sex, race, literacy, and blood pressure control, and with key office staff at 5 rural primary care practices in the southeastern US "stroke belt." Interviews explored barriers to controlling blood pressure, the practice's role in controlling blood pressure, and opinions on the use of team care delivery. RESULTS: Patients reported that provider strategies to optimize blood pressure control should include regular visits, medication adjustment, side-effect discussion, and behavioral counseling. When discussing team-based approaches to hypertension care, patients valued verbal encouragement, calls from the doctor's office, and the opportunity to ask questions. However, they voiced concerns about the effect of having too many people involved in their care. Practice staff focused on multiple, broad methods to control blood pressure including counseling, regular office visits, media to improve awareness, and support groups. An explicit focus of delivering care as teams was a newer concept. CONCLUSION: When developing a team approach to hypertension treatment, patients value high-quality communication and not losing their primary relationship with their provider. Practice staff members were open to a team-based approach but had limited knowledge of what such an approach would entail.

A pilot study comparing two weight loss maintenance interventions among low-income, mid-life women.

BACKGROUND: Despite high obesity prevalence rates, few low-income midlife women participate in weight loss maintenance trials. This pilot study aims to assess the effectiveness of two weight loss maintenance interventions in this under-represented population. METHODS: Low-income midlife women who completed a 16-week weight loss intervention and lost ≥ 8 lbs (3.6 kg) were eligible to enroll in one of two 12-month maintenance programs. The programs were similar in content and had the same number of total contacts, but were different in the contact modality (Phone + Face-to-Face vs. Face-to-Face Only). Two criteria were used to assess successful weight loss maintenance at 12 months: (1) retaining a loss of ≥ 5% of body weight from the start of the weight loss phase and (2) a change in body weight of < 3%, from the start to the end of the maintenance program. Outcome measures of changes in physiologic and psychosocial factors, and evaluations of process measures and program acceptability (measured at 12 months) are also reported. For categorical variables, likelihood ratio or Fisher's Exact (for small samples) tests were used to evaluate statistically significant relationships; for continuous variables, t-tests or their equivalents were used to assess differences between means and also to identify correlates of weight loss maintenance. RESULTS: Overall, during the 12-month maintenance period, 41% (24/58) of participants maintained a loss of ≥ 5% of initial weight and 43% (25/58) had a <3% change in weight. None of the comparisons between the two maintenance programs were statistically significant. However, improvements in blood pressure and dietary behaviors remained significant at the end of the 12-month maintenance period for participants in both programs. Participant attendance and acceptability were high for both programs. CONCLUSIONS: The effectiveness of two pilot 12-month maintenance interventions provides support for further research in weight loss maintenance among high-risk, low-income women. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00288301.

The Heart Healthy Lenoir project--an intervention to reduce disparities in hypertension control: study protocol.

BACKGROUND: Racial disparities in blood pressure control are well established; however the impact of low health literacy (LHL) on blood pressure has garnered less attention. Office based interventions that are created with iterative patient, practice and community stakeholder input and are rolled out incrementally, may help address these disparities in hypertension control. This paper describes our study protocol. METHODS/DESIGN: Using a community based participatory research (CBPR) approach, we designed and implemented a cohort study that includes both a practice level and patient level intervention to enhance the care and support of patients with hypertension in primary care practices in a rural region of eastern North Carolina. The study is divided into a formative phase and an ongoing 2.5 year implementation phase. Our main care enhancement activities include the integration of a community health coach, using home blood pressure monitoring in clinical decision making, standardizing care delivery processes, and working to improve medication adherence. Main outcomes include overall blood pressure change, the differential change in blood pressure by race (African American vs. White) and health literacy level (low vs. higher health literacy). DISCUSSION: Using a community based participatory approach in primary care practice settings has helped to engage patients and practice staff and providers in the research effort and in making practice changes to support hypertension care. Practices have engaged at varying levels, but progress has been made in implementing and iteratively improving upon the interventions to date. TRIAL REGISTRATION: ClinicalTrials.gov NCT01425515.

A community assessment to inform a multilevel intervention to reduce cardiovascular disease risk and risk disparities in a rural community.

To complete a formative evaluation to identify community-level assets and barriers to healthy lifestyle choices, we conducted qualitative interviews, community audits, and secondary data analyses. We solicited local leaders' perspectives regarding winnability of obesity prevention policy options. Participants noted that many resources were available, yet a barrier was high cost. There were more parks per capita in low-income areas, but they were of lower quality. The most winnable obesity prevention policy was incentives for use of food from local farms. Results are being used to inform an intervention to reduce cardiovascular disease risk in rural eastern North Carolina.

Optimized probability sampling of study sites to improve generalizability in a multisite intervention trial.

INTRODUCTION: Studies of type 2 translation, the adaption of evidence-based interventions to real-world settings, should include representative study sites and staff to improve external validity. Sites for such studies are, however, often selected by convenience sampling, which limits generalizability. We used an optimized probability sampling protocol to select an unbiased, representative sample of study sites to prepare for a randomized trial of a weight loss intervention. METHODS: We invited North Carolina health departments within 200 miles of the research center to participate (N = 81). Of the 43 health departments that were eligible, 30 were interested in participating. To select a representative and feasible sample of 6 health departments that met inclusion criteria, we generated all combinations of 6 from the 30 health departments that were eligible and interested. From the subset of combinations that met inclusion criteria, we selected 1 at random. RESULTS: Of 593,775 possible combinations of 6 counties, 15,177 (3%) met inclusion criteria. Sites in the selected subset were similar to all eligible sites in terms of health department characteristics and county demographics. CONCLUSION: Optimized probability sampling improved generalizability by ensuring an unbiased and representative sample of study sites.

Cost-effectiveness of a behavioral weight loss intervention for low-income women: the Weight-Wise Program.

OBJECTIVE: Assess the cost-effectiveness of a 16-week weight loss intervention (Weight-Wise) for low-income midlife women. METHOD: A randomized controlled trial conducted in North Carolina in 2007 tested a weight loss intervention among 143 women (40-64 years old, mean BMI=35.1 kg/m(2)). Women were randomized to one of two arms-special intervention (n=72) and a wait-listed control group (n=71). Effectiveness measures included changes in weight, systolic and diastolic blood pressure, total cholesterol, and HDL cholesterol. Cost-effectiveness measures calculated life years gained (LYG) from changes in weight, based on excess years life lost (YLL) algorithm. RESULTS: Intervention participants had statistically significant decreases in weight (kg) (-4.4 95% CI=-5.6, -3.2) and in systolic blood pressure (-6.2 mm Hg, 95% CI=-10.6, -1.7) compared to controls. Total cost of conducting Weight-Wise was $17,403, and the cost per participant in intervention group was $242. The incremental cost per life year gained (discounted) from a decrease in obesity was $1862. CONCLUSION: Our results suggest the Weight-Wise intervention may be a cost-effective approach to improving the health of low-income women.

Applicability of Precision Medicine Approaches to Managing Hypertension in Rural Populations.

As part of the Heart Healthy Lenoir Project, we developed a practice level intervention to improve blood pressure control. The goal of this study was: (i) to determine if single nucleotide polymorphisms (SNPs) that associate with blood pressure variation, identified in large studies, are applicable to blood pressure control in subjects from a rural population; (ii) to measure the association of these SNPs with subjects' responsiveness to the hypertension intervention; and (iii) to identify other SNPs that may help understand patient-specific responses to an intervention. We used a combination of candidate SNPs and genome-wide analyses to test associations with either baseline systolic blood pressure (SBP) or change in systolic blood pressure one year after the intervention in two genetically defined ancestral groups: African Americans (AA) and Caucasian Americans (CAU). Of the 48 candidate SNPs, 13 SNPs associated with baseline SBP in our study; however, one candidate SNP, rs592582, also associated with a change in SBP after one year. Using our study data, we identified 4 and 15 additional loci that associated with a change in SBP in the AA and CAU groups, respectively. Our analysis of gene-age interactions identified genotypes associated with SBP improvement within different age groups of our populations. Moreover, our integrative analysis identified AQP4-AS1 and PADI2 as genes whose expression levels may contribute to the pleiotropy of complex traits involved in cardiovascular health and blood pressure regulation in response to an intervention targeting hypertension. In conclusion, the identification of SNPs associated with the success of a hypertension treatment intervention suggests that genetic factors in combination with age may contribute to an individual's success in lowering SBP. If these findings prove to be applicable to other populations, the use of this genetic variation in making patient-specific interventions may help providers with making decisions to improve patient outcomes. Further investigation is required to determine the role of this genetic variance with respect to the management of hypertension such that more precise treatment recommendations may be made in the future as part of personalized medicine.

Eating Well While Dining Out: Collaborating with Local Restaurants to Promote Heart Healthy Menu Items.

BACKGROUND: As Americans commonly consume restaurant foods with poor dietary quality, effective interventions are needed to improve food choices at restaurants. PURPOSE: To design and evaluate a restaurant-based intervention to help customers select and restaurants promote heart healthy menu items with healthful fats and high quality carbohydrates. METHODS: The intervention included table tents outlining 10 heart healthy eating tips, coupons promoting healthy menu items, an information brochure, and link to study website. Pre and post intervention surveys were completed by restaurant managers and customers completed a brief "intercept" survey. RESULTS: Managers (n = 10) reported the table tents and coupons were well received, and several noted improved personal nutrition knowledge. Overall, 4214 coupons were distributed with 1244 (30%) redeemed. Of 300 customers surveyed, 126 (42%) noticed the table tents and of these, 115 (91%) considered the nutrition information helpful, 42 (33%) indicated the information influenced menu items purchased, and 91 (72%) reported the information will influence what they order in the future. DISCUSSION: The intervention was well-received by restaurant managers and positively influenced menu item selection by many customers. TRANSLATION TO HEALTH EDUCATION PRACTICE: Further research is needed to assess effective strategies for scaling up and sustaining this intervention approach.

Successful long-term weight loss among participants with diabetes receiving an intervention promoting an adapted Mediterranean-style dietary pattern: the Heart Healthy Lenoir Project.

OBJECTIVE: To examine weight change by diabetes status among participants receiving a Mediterranean-style diet, physical activity, and weight loss intervention adapted for delivery in the southeastern USA, where rates of cardiovascular disease (CVD) are disproportionately high. RESEARCH DESIGN AND METHODS: The intervention included: Phase I (months 1-6), an individually tailored intervention promoting a Mediterranean-style dietary pattern and increased walking; Phase II (months 7-12), option of a 16-week weight loss intervention for those with BMI≥25 kg/m2 offered as 16 weekly group sessions or 5 group sessions and 10 phone calls, or a lifestyle maintenance intervention; and Phase III (months 13-24), weight loss maintenance intervention for those losing ≥8 pounds with all others receiving a lifestyle maintenance intervention. Weight change was assessed at 6, 12, and 24-month follow-up. RESULTS: Baseline characteristics (n=339): mean age 56, 77% female, 65% African-American, 124 (37%) with diabetes; mean weight 103 kg for those with diabetes and 95 kg for those without. Among participants with diabetes, average weight change was -1.2 kg (95% CI -2.1 to -0.4) at 6 months (n=92), -1.5 kg (95% CI -2.9 to -0.2) at 12 months (n=96), and -3.7 kg (95% CI -5.2 to -2.1) at 24 months (n=93). Among those without diabetes, weight change was -0.4 kg (95% CI -1.4 to 0.6) at 24 months (n=154). CONCLUSIONS: Participants with diabetes experienced sustained weight loss at 24-month follow-up. High-risk US populations with diabetes may experience clinically important weight loss from this type of lifestyle intervention. TRIAL REGISTRATION NUMBER: NCT01433484.

The association of health literacy and blood pressure reduction in a cohort of patients with hypertension: The heart healthy lenoir trial.

OBJECTIVE: Lower health literacy is associated with poorer health outcomes. Few interventions poised to mitigate the impact of health literacy in hypertensive patients have been published. We tested if a multi-level quality improvement intervention could differentially improve Systolic Blood Pressure (SBP) more so in patients with low vs. higher health literacy. METHODS: We conducted a non-randomized prospective cohort trial of 525 patients referred with uncontrolled hypertension. Stakeholder informed and health literacy sensitive strategies were implemented at the practice and patient level. Outcomes were assessed at 0, 6, 12, 18 and 24 months. RESULTS: At 12 months, the low and higher health literacy groups had statistically significant decreases in mean SBP (6.6 and 5.3mmHg, respectively), but the between group difference was not significant (Δ 1.3mmHg, P=0.067). At 24 months, the low and higher health literacy groups reductions were 8.1 and 4.6mmHg, respectively, again the between group difference was not significant (Δ 3.5mmHg, p=0.25). CONCLUSIONS/PRACTICE IMPLICATIONS: A health literacy sensitive multi-level intervention may equally lower SBP in patients with low and higher health literacy. Practical health literacy appropriate tools and methods can be implemented in primary care settings using a quality improvement approach.

A multicomponent quality improvement intervention to improve blood pressure and reduce racial disparities in rural primary care practices.

The Southeastern United States has the highest prevalence of hypertension and African Americans have disproportionately worse blood pressure control. The authors sought to evaluate the effect of a multicomponent practice-based quality improvement intervention on lowering mean systolic blood pressure (SBP) at 12 and 24 months compared with baseline among 525 patients, and to assess for a differential effect of the intervention by race (African Americans vs white). At 12 months, both African Americans (-5.0 mm Hg) and whites (-7.8 mm Hg) had a significant decrease in mean SBP compared with baseline, with no significant between-group difference. Similarly, at 24 months, mean SBP decreased in both African Americans (-6.0 mm Hg) and whites (-7.2 mm Hg), with no significant difference between groups. Notably, no significant racial disparity in mean SBP at baseline was shown. The intervention was effective in lowering mean SBP in both African Americans and whites but there was no differential effect of the intervention by race.

Linking clinical care to community resources for cardiovascular disease prevention: the North Carolina Enhanced WISEWOMAN project.

BACKGROUND: The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) project addresses the need for effective cardiovascular disease (CVD) prevention among underserved, midlife women. We describe an Enhanced Intervention that addressed environmental and individual factors within the context of a clinic-based intervention. We also present the study design and baseline results of the randomized trial to evaluate the enhanced intervention. METHODS: The multicomponent behavior change intervention addressed many elements of the Chronic Care Model (CCM), including the community resources and policy element, wherein Enhanced Intervention participants were encouraged to overcome environmental barriers to a healthy lifestyle by using community resources. Study participants were enrolled at one community health center; all were low-income, underinsured, midlife (40-64 years) women. RESULTS: A total of 236 participants were randomized to receive the Enhanced Intervention or the Minimum Intervention. At baseline, over three fourths of the participants were overweight or obese. Participants reported a variety of problematic neighborhood characteristics, including a paucity of restaurants with healthy food choices (41% reported as a problem); not enough farmer's markets or produce stands (50%), not enough affordable exercise places (52%), not enough physical activity programs that met women's needs (42%), heavy traffic (47%), and speeding drivers (53%). Overall, women knew little about affordable exercise venues and nutrition classes. CONCLUSIONS: In this clinic-based intervention, we addressed environmental factors related to a healthy lifestyle. Results indicate the need for effective and feasible intervention strategies to address the environments in which individuals are making behavior changes. The effectiveness of the WISEWOMAN Enhanced Intervention will be assessed in a randomized trial.

Perceived Social Standing, Medication Nonadherence, and Systolic Blood Pressure in the Rural South.

PURPOSE: Little is known about how perceived social standing versus traditional socioeconomic characteristics influence medication adherence and blood pressure (BP) among African American and white patients with hypertension in the rural southeastern United States. METHODS: Perceived social standing, socioeconomic characteristics, self-reported antihypertensive medication adherence, and BP were measured at baseline in a cohort of rural African American and white patients (n = 495) with uncontrolled hypertension attending primary care practices. Multivariate models examined the relationship of perceived social standing and socioeconomic indicators with medication adherence and systolic BP. FINDINGS: Medication nonadherence was reported by 40% of patients. Younger age [ß = 0.20; P = .001], African American race [ß = -0.30; P = .03], and lower perceived social standing [ß = 0.08; P = .002] but not sex or traditional socioeconomic characteristics including education and household income, were significantly associated with lower medication adherence. Race-specific analyses revealed that this pattern was limited to African Americans and not observed in whites. In stepwise modeling, older age [ß = 0.57, P = .001], African American race [ß = 4.4; P = .03], and lower medication adherence [ß = -1.7, P = .01] but not gender, education, or household income, were significantly associated with higher systolic BP. CONCLUSIONS: Lower perceived social standing and age, but not traditional socioeconomic characteristics, were significantly associated with lower medication adherence in African Americans. Lower medication adherence was associated with higher systolic BP. These findings suggest the need for tailored, culturally relevant medication adherence interventions in rural communities.

Lessons Learned From Implementing Health Coaching in The Heart Healthy Lenoir Hypertension Study.

BACKGROUND: Health coaching is increasingly important in patient-centered medical homes. OBJECTIVES: Describe formative evaluation results and lessons learned from implementing health coaching to improve hypertension self-management in rural primary care. METHODS: A hypertension collaborative was formed consisting of six primary care sites. Twelve monthly health coaching phone calls were attempted for 487 participants with hypertension. LESSONS LEARNED: Participant engagement was challenging; 58% remained engaged, missing fewer than three consecutive calls. Multivariate analyses revealed that older age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.05), African American race (O,R 1.73; 95% CI, 1.15-2.60), greater number of comorbidities (OR, 1.17; 95% CI, 1.05-1.30) and receiving coaching closer to enrollment (OR, 5.03; 95% CI, 2.53-9.99) were correlated independently with engagement. Participants reported the coaching valuable; 96% would recommend health coaching to others. CONCLUSIONS: Health coaching in hypertension care can be successful strategy for engaging more vulnerable groups. A more tailored approach may improve engagement with counseling.

Development, adaptation, and implementation of a cardiovascular health program for Alaska native women.

Southcentral Foundation's Traditions of the Heart program is an innovative cardiovascular disease prevention program for women designed to build on the strengths of the Alaska Native culture as a way to support and encourage positive lifestyle behaviors that focus on healthy eating, active living, stress management, and tobacco cessation. After conducting assessments of existing intervention programs and formative data collection, we adapted two existing programs, Native Nutrition Circles and A New Leaf... Choices for Healthy Living, to develop the Traditions of the Heart program. We implemented and evaluated a pilot intervention study to determine the program's acceptance among Alaska Native women. We used the evaluation results to further refine our study protocol. This article describes the adaptation of these programs to the cultural needs and strengths of Alaska Native women and the results of the formative evaluation used to improve the program design. The complete pilot study outcomes will be published separately.

Using community-based participatory research principles to develop more understandable recruitment and informed consent documents in genomic research.

BACKGROUND: Heart Healthy Lenoir is a transdisciplinary project aimed at creating long-term, sustainable approaches to reduce cardiovascular disease risk disparities in Lenoir County, North Carolina using a design spanning genomic analysis and clinical intervention. We hypothesized that residents of Lenoir County would be unfamiliar and mistrustful of genomic research, and therefore reluctant to participate; additionally, these feelings would be higher in African-Americans. METHODOLOGY: To test our hypothesis, we conducted qualitative research using community-based participatory research principles to ensure our genomic research strategies addressed the needs, priorities, and concerns of the community. African-American (n = 19) and White (n = 16) adults in Lenoir County participated in four focus groups exploring perceptions about genomics and cardiovascular disease. Demographic surveys were administered and a semi-structured interview guide was used to facilitate discussions. The discussions were digitally recorded, transcribed verbatim, and analyzed in ATLAS.ti. RESULTS AND SIGNIFICANCE: From our analysis, key themes emerged: transparent communication, privacy, participation incentives and barriers, knowledge, and the impact of knowing. African-Americans were more concerned about privacy and community impact compared to Whites, however, African-Americans were still eager to participate in our genomic research project. The results from our formative study were used to improve the informed consent and recruitment processes by: 1) reducing misconceptions of genomic studies; and 2) helping to foster participant understanding and trust with the researchers. Our study demonstrates how community-based participatory research principles can be used to gain deeper insight into the community and increase participation in genomic research studies. Due in part to these efforts 80.3% of eligible African-American participants and 86.9% of eligible White participants enrolled in the Heart Healthy Lenoir Genomics study making our overall enrollment 57.8% African-American. Future research will investigate return of genomic results in the Lenoir community.