Mobile Health Intervention to Close the Guidelines-To-Practice Gap in Hypertension Treatment: Protocol for the mGlide Randomized Controlled Trial.

BACKGROUND: Suboptimal treatment of hypertension remains a widespread problem, particularly among minorities and socioeconomically disadvantaged groups. We present a health system-based intervention with diverse patient populations using readily available smartphone technology. This intervention is designed to empower patients and create partnerships between patients and their provider team to promote hypertension control. OBJECTIVE: The mGlide randomized controlled trial is a National Institutes of Health-funded study, evaluating whether a mobile health (mHealth)-based intervention that is an active partnership between interprofessional health care teams and patients results in better hypertension control rates than a state-of-clinical care comparison. METHODS: We are recruiting 450 participants including stroke survivors and primary care patients with elevated cardiovascular disease risk from diverse health systems. These systems include an acute stroke service (n=100), an academic medical center (n=150), and community medical centers including Federally Qualified Health Centers serving low-income and minority (Latino, Hmong, African American, Somali) patients (n=200). The primary aim tests the clinical effectiveness of the 6-month mHealth intervention versus standard of care. Secondary aims evaluate sustained hypertension control rates at 12 months; describe provider experiences of system usability and satisfaction; examine patient experiences, including medication adherence and medication use self-efficacy, self-rated health and quality of life, and adverse event rates; and complete a cost-effectiveness analysis. RESULTS: To date, we have randomized 107 participants (54 intervention, 53 control). CONCLUSIONS: This study will provide evidence for whether a readily available mHealth care model is better than state-of-clinical care for bridging the guideline-to-practice gap in hypertension treatment in health systems serving diverse patient populations. TRIAL REGISTRATION: Clinicaltrials.gov NCT03612271; https://clinicaltrials.gov/ct2/show/NCT03612271. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/25424.

Rural-Urban Differences in Access to Preventive Health Care Among Publicly Insured Minnesotans.

PURPOSE: Reduced access to care and barriers have been shown in rural populations and in publicly insured populations. Barriers limiting health care access in publicly insured populations living in rural areas are not understood. This study investigates rural-urban differences in system-, provider-, and individual-level barriers and access to preventive care among adults and children enrolled in a public insurance program in Minnesota. METHODS: This was a secondary analysis of a 2008 statewide, cross-sectional survey of publicly insured adults and children (n = 4,388) investigating barriers associated with low utilization of preventive care. Sampling was stratified with oversampling of racial/ethnic minorities. RESULTS: Rural enrollees were more likely to report no past year preventive care compared to urban enrollees. However, this difference was no longer statistically significant after controlling for demographic and socioeconomic factors (OR: 1.37, 95% CI: 1.00-1.88). Provider- and system-level barriers associated with low use of preventive care among rural enrollees included discrimination based on public insurance status (OR: 2.26, 95% CI: 1.34-2.38), cost of care concerns (OR: 1.72, 95% CI: 1.03-2.89) and uncertainty about care being covered by insurance (OR: 1.70, 95% CI: 1.01-2.85). These and additional provider-level barriers were also identified among urban enrollees. CONCLUSIONS: Discrimination, cost of care, and uncertainty about insurance coverage inhibit access in both the rural and urban samples. These barriers are worthy targets of interventions for publicly insured populations regardless of residence. Future studies should investigate additional factors associated with access disparities based on rural-urban residence.

Do Local Social Hierarchies Matter for Mental Health? A Study of Neighborhood Social Status and Depressive Symptoms in Older Adults.

OBJECTIVES: Despite a well-established association between relative social position and health, stratification at smaller levels of social organization has received scant attention. Neighborhood is a localized context that has increasing relevance for adults as they age, thus one's relative position within this type of mesolevel group may have an effect on mental health, independent of absolute level of social and economic resources. We examine the relationship between an older adult's relative rank within their neighborhoods on two criteria and depressive symptoms. METHOD: Using data from the Chicago Health and Aging Project, neighborhood relative social position was ascertained for two social domains: income and social reputation (number of neighbors one knows well enough to visit). Using multilevel models, we estimated the effect of relative position within the neighborhood on depressive symptoms, net of absolute level for each domain and average neighborhood level. RESULTS: Higher neighborhood relative rankings on both income and visiting neighbors were associated with fewer depressive symptoms. Although both were modest in effect, the gradient in depressive symptoms was three times steeper for the relative rank of visiting neighbors than for income. Men had steeper gradients than women in both domains, but no race differences were observed. DISCUSSION: These findings suggest that an older adult's relative position in a local social hierarchy is associated with his/her mental health, net of absolute position.

Prevalence of cardiovascular risk factors across six African Immigrant Groups in Minnesota.

BACKGROUND: Although African immigrants represent a large and growing segment of the U.S. population, there are little or no data available on the prevalence of cardiovascular disease (CVD) risk factors among this diverse population. This study compared the prevalence of self-reported CVD risk factors and health behaviors and examined the associations between immigration related characteristics and CVD risk factors and health behaviors across six African immigrants groups. METHODS: Data were from 996 African immigrants in the U.S., (37.9% Somalis; 26.8% Ethiopians; 14% Liberians; 8.5% Sudanese; 5.1% Kenyans and 7.8% others group) from a cross-sectional survey conducted in the Twin cities of Minnesota. Logistic regression models estimated the associations of demographic characteristics, and immigration-related factors (length of stay in the United states, English proficiency, income and health insurance) with prevalence of CVD risk factors (overweight/obese; hypertension and diabetes mellitus) and self-reported health behaviors (cigarette smoking, physical inactivity, conscious effort to exercise and eating a healthy diet). RESULTS: We found a relatively low self-reported prevalence of diabetes, hypertension, and smoking. However, significant differences were noted by country of origin. Using Somalis as our referent country of origin group, we found that Liberians and Kenyans were more likely to report having diabetes or hypertension. On all measures of health behaviors, Liberians were more likely to engage in more health protective behaviors than other individuals. CONCLUSIONS: Although African immigrants have different prevalence rates for CVD risk factors and health behaviors, there is a need to further explore the differences observed by country of emigration.

Socioeconomic status and the incidence of atrial fibrillation in whites and blacks: the Atherosclerosis Risk in Communities (ARIC) study.

BACKGROUND: No previous studies have examined the interplay among socioeconomic status, sex, and race with the risk of atrial fibrillation (AF). METHODS AND RESULTS: We prospectively followed 14 352 persons (25% black, 75% white, 55% women, mean age 54 years) who were free of AF and participating in the Atherosclerosis Risk in Communities (ARIC) study. Socioeconomic status was assessed at baseline (1987-1989) through educational level and total family income. Incident AF through 2009 was ascertained from electrocardiograms, hospitalizations, and death certificates. Cox regression was used to estimate hazard ratios and 95% CIs of AF for education and family income. Interactions were tested between socioeconomic status and age, race, or sex. Over a median follow-up of 20.6 years, 1794 AF cases occurred. Lower family income was associated with higher AF risk (hazard ratio 1.45, 95% CI 1.27 to 1.67 in those with income less than $25 000 per year compared with those with $50 000 or more per year). The association between education and AF risk varied by sex (P=0.01), with the lowest education group associated with higher AF risk in women (hazard ratio 1.88, 95% CI 1.55 to 2.28) but not in men (hazard ratio 1.15, 95% CI 0.97 to 1.36) compared with the highest education group. Adjustment for cardiovascular risk factors attenuated the associations. There were no interactions with race or age. Blacks had lower AF risk than whites in all income and education groups. CONCLUSIONS: Lower family income was associated with a higher AF risk overall, whereas the impact of education on AF risk was present only in women. Differences in socioeconomic status do not explain the lower risk of AF in blacks compared with whites.

Association of cognitive functioning, incident stroke, and mortality in older adults.

BACKGROUND AND PURPOSE: Stroke increases the risk of dementia; however, bidirectional association of incident stroke and cognitive decline below dementia threshold is not well established. Also, both cognitive decline and stroke increase mortality risk. METHODS: A longitudinal population-based cohort of 7217 older adults without a history of stroke from a biracial community was interviewed at 3-year intervals. Cognitive function was assessed using a standardized global cognitive score. Stroke was determined by linkage with Medicare claims, and mortality was ascertained via the National Death Index. We used a Cox model to assess the risk of incident stroke, a joint model with a piecewise linear mixed model with incident stroke as a change point for cognitive decline process, and a time-dependent relative risk regression model for mortality risk. RESULTS: During follow-up, 1187 (16%) subjects had incident stroke. After adjusting for known confounders, lower baseline cognitive function was associated with a higher risk of incident stroke (hazard ratio, 1.61; 95% confidence interval, 1.46-1.77). Cognitive function declined by 0.064 U per year before incident stroke occurrence and 0.122 U per year after stroke, a nearly 1.9-fold increase in cognitive decline (95% confidence interval, 1.78-2.03). Both stroke (hazard ratio, 1.17; 95% confidence interval, 1.08-1.26) and cognitive decline (hazard ratio, 1.90; 95% confidence interval, 1.81-1.98) increased mortality risk. CONCLUSIONS: Baseline cognitive function was associated with incident stroke. Cognitive decline increased significantly after stroke relative to before stroke. Cognitive decline increased mortality risk independent of the risk attributable to stroke and should be followed as a marker for both stroke and mortality.

Neighborhood socioeconomic conditions are associated with psychosocial functioning in older black and white adults.

We examined neighborhood socioeconomic status (NSES) in relation to depressive symptoms, perceived stress, and hostility in 5770 community-dwelling older black and white adults (mean age=73 years; 62% female) from 3 contiguous neighborhoods covering 82 census block groups in Chicago, IL. NSES was an average of z-scores of four Census 2000 block-group variables: % public assistance, % households earning <$25,000 annually, % with >college degree, and % owner-occupied dwellings valued >$200,000. NSES was inversely related to hostility (beta=-0.305), stress (beta=-0.333), and depressive symptoms (beta=-0.223) (p<0.001) in multi-level mixed-effects regression models adjusted for age, sex, race, and the number of years in the neighborhood. With further adjustment for education, income, marital status, and health conditions, NSES remained associated with depressive symptoms (beta=-0.078) and hostility (beta=-0.133) (p<0.05); the association with hostility was strongest in non-black neighborhoods. Neighborhood social conditions contribute to the psychosocial well-being of older residents; research is needed to investigate pathways through which neighborhoods influence health outcomes in an aging population.

Association between exposure to political violence and intimate-partner violence in the occupied Palestinian territory: a cross-sectional study.

BACKGROUND: Intimate-partner violence might increase during and after exposure to collective violence. We assessed whether political violence was associated with male-to-female intimate-partner violence in the occupied Palestinian territory. METHODS: A nationally representative, cross-sectional survey was done between Dec 18, 2005, and Jan 18, 2006, by the Palestinian Central Bureau of Statistics. 4156 households were randomly selected with a multistage random cluster design, from which 3815 ever-married women aged 15-64 years were identified. We restricted our analysis to presently married women (n=3510, 92% participation rate), who completed a short version of the revised conflict tactics scales and exposure to political violence inventory. Exposure to political violence was characterised as the husband's direct exposure, his indirect exposure via his family's experiences, and economic effects of exposure on the household. We used adjusted multinomial logistic regression models to estimate odds ratios (ORs) for association between political violence and intimate-partner violence. FINDINGS: Political violence was significantly related to higher odds of intimate-partner violence. ORs were 1.89 (95% CI 1.29-2.76) for physical and 2.23 (1.49-3.35) for sexual intimate-partner violence in respondents whose husbands were directly exposed to political violence compared with those whose husbands were not directly exposed. For women whose husbands were indirectly exposed, ORs were 1.61 (1.25-2.07) for physical and 1.97 (1.49-2-60) for sexual violence, compared with those whose husbands were not indirectly exposed. Economic effects of exposure were associated with increased odds of intimate-partner violence in the Gaza Strip only. INTERPRETATION: Because exposure to political violence is associated with increased odds of intimate-partner violence, and exposure to many traumas is associated with poor health, a range of violent exposures should be assessed when establishing the need for psychosocial interventions in conflict settings.

Cognitive functioning is related to physical functioning in a longitudinal study of women at midlife.

BACKGROUND: Studies have reported declines with age in cognitive or physical functioning, but rarely identify whether these are parallel or linked events in the same study. Furthermore, most research in this area has focused on persons in late life rather than midlife. OBJECTIVE: The objective of the study was to determine (1) if cognitive functioning was related to physical functioning and whether this relationship persisted after adjustment for age, menopause status, metabolic status, depression and socioeconomic resources, and (2) if changes in physical functioning were associated with changes in cognitive functioning over a 4-year follow-up period. METHODS: Data were from the Study of Women's Health Across the Nation (SWAN), a multi-site, longitudinal study of women aged 46-56 years at follow-up examination 4. Three follow-up examinations (study years 04, 06 and 08) included measures of physical functioning perception (MOS SF-36) and cognitive functioning [Symbol Digit Modality Test (SDMT), Digit Span Backward Test (DSBT), and East Boston Memory Test (EBMT)] (n = 2,405). RESULTS: Women with lower cognitive functioning scores also had lower perceived physical functioning scores. While adjustment for covariates attenuated the association between perceived physical functioning and both the SDMT and EBMT cognitive measures, these associations remained statistically significant. Additionally, the 4-year change in perceived physical functioning was significantly associated with the 4-year change in the EBMT. CONCLUSIONS: At midlife, there were associated declines in cognitive and perceived physical functioning scores, commencing at midlife in women.

Hostility is associated with visceral, but not subcutaneous, fat in middle-aged African American and white women.

OBJECTIVE: To examine the cross-sectional association between hostility and measures of abdominal fat (visceral, subcutaneous) in middle-aged African American and white women. Because fat-patterning characteristics are known to differ by race, we were particularly interested in examining whether these associations were similar for women of both racial/ethnic groups. METHODS: Participants were 418 (45% African American, 55% white) middle-aged women from the Chicago site of the Study of Women's Health Across the Nation. Visceral and subcutaneous fat were measured by computed tomographic scans and hostility was assessed via questionnaire. Multivariate linear regression models were conducted to test associations among race/ethnicity, hostility, and measures of abdominal fat. RESULTS: In models adjusted for race/ethnicity and total percent fat, higher levels of hostility were associated with a greater amount of visceral fat (B = 1.8, standard error = 0.69, p = .01). This association remained significant after further adjustments for education, and multiple coronary heart disease (CHD) risk factors. Hostility was not associated with subcutaneous fat (p = .8). Although there were significant racial/ethnic differences in hostility (p < .001) and the amount of total body (p < .001), subcutaneous (p < .001) and visceral fat (p < .001), the associations between hostility and measures of abdominal fat did not differ for African American compared with white women (race/ethnicity x hostility interaction, p = .67 for visceral, p = .85 for subcutaneous). CONCLUSIONS: Hostility may affect CHD risk in women via the accumulation of visceral fat. Despite significant black-white differences in fat patterning and overall CHD risk, the association between hostility and visceral fat seems to be similar for both African American and white women.

Socioeconomic position in childhood and adulthood and weight gain over 34 years: the Alameda County Study.

PURPOSE: Socioeconomic position (SEP) has been shown to be related to obesity and weight gain, especially among women. It is unclear how different measures of socioeconomic position may impact weight gain over long periods of time, and whether the effect of different measures vary by gender and age group. We examined the effect of childhood socioeconomic position, education, occupation, and log household income on a measure of weight gain using individual growth mixed regression models and Alameda County Study data collected over thirty four years(1965-1999). METHODS: Analyses were performed in four groups stratified by gender and age at baseline: women, 17-30 years (n = 945) and 31-40 years (n = 712); men, 17-30 years (n = 766) and 31-40 years (n = 608). RESULTS: Low childhood SEP was associated with increased weight gain among women 17-30 (0.13 kg/year, p < 0.001). Low educational status was associated with increased weight gain among women 17-30 (0.14 kg/year, p = 0.030), 31-40 (0.14 kg/year, p = 0.014), and men 17-30 (0.20 kg/year, p = 0.001). CONCLUSION: Log household income was inversely associated with weight gain among men 31-40 (-0.10 kg/yr, p = 0.16). Long-term weight gain in adulthood is associated with childhood SEP and education in women and education and income in men.

Psychosocial factors and cardiovascular diseases.

Rapidly accruing evidence from a diversity of disciplines supports the hypothesis that psychosocial factors are related to morbidity and mortality due to cardiovascular diseases. We review relevant literature on (a) negative emotional states, including depression, anger and hostility, and anxiety; (b) chronic and acute psychosocial stressors; and (c) social ties, social support, and social conflict. All three of these psychosocial domains have been significantly associated with increased risk of cardiovascular morbidity and mortality. We also discuss critical pathophysiological mechanisms and pathways that likely operate in a synergistic and integrative way to promote atherogenesis and related clinical manifestations. We conclude by discussing some of the important challenges and opportunities for future investigations.

Early life conditions and cognitive functioning in later life.

Early life conditions are related to cognitive development and abilities in childhood and cognitive function in adulthood. However, the association between early life conditions and cognitive change in old age is unknown. The authors examined the relation between socioeconomic position (SEP) and cognitive milieu in childhood and change in cognitive function in a population-based sample of 4,398 community-dwelling adults (62.1% female; 61.7% Black) aged 65 years or older from Chicago, Illinois. Baseline data were collected in 1993-1997. Change in cognitive function was assessed by means of a global cognitive index derived from measures of memory, perceptual speed, and overall cognitive function administered at three in-home assessments between 1993 and 2003, with an average of 5.3 years of follow-up. After results were controlled for age, sex, race, and education, interactions of time with childhood SEP (beta = -0.003, t = -1.0, p = 0.32) and childhood cognitive milieu (beta = -0.0008, t = -0.5, p = 0.62) were nonsignificant, indicating that early life conditions were not related to cognitive change. SEP (beta = 0.034, t = 2.4, p = 0.01) and cognitive milieu (beta = 0.017, t = 2.2, p = 0.03) were associated with absolute level of cognitive function, with better performance being related to higher SEP and a better cognitive milieu. A better SEP and a more stimulating cognitive milieu in childhood have small but significant effects on absolute level of cognitive function; however, they do not seem to protect against cognitive decline in old age.