Addressing the unexpected: lessons learned from a randomized controlled trial conducted in partnership with a low-income, rural community.

Healthy People 2020 objectives include increasing the proportion of individuals who are adherent to their hypertensive medications. In this paper we highlight lessons learned through the implementation of a clinical trial to evaluate a behavioral intervention to increase medication adherence in a rural, low-income, primarily African American community.

Geographic variation of epilepsy for older Americans: how close to the geographic variation of stroke?

PURPOSE: Given the strong association of stroke and epilepsy in older persons, and the existence of a Stroke Belt in the United States, we hypothesized that geographic variation in epilepsy prevalence would follow geographic patterns similar to stroke. METHODS: We used a 2005 5% random sample of Medicare beneficiaries 65 and older in 48 U.S. contiguous states. Epilepsy was identified from claims for physician visits, hospitalizations, and outpatient procedures. Prevalence was obtained by state and county. Logistic regressions determined the independent association of the likelihood of epilepsy (prevalent or new case) and residence in Stroke Belt states, controlling for residence in highest epilepsy prevalence states, demographics (race, age, gender), comorbid conditions, cerebrovascular disease, dementia, and county characteristics. KEY FINDINGS: Of 1,212,015 beneficiaries, 11.9 per 1,000 had prevalent and 2.9 new cases of epilepsy. Nine of 11 Stroke Belt states were among the 20 states with the highest epilepsy prevalence. Counties in the 10 highest epilepsy prevalence states were more likely to be large urban counties with a higher number of neurologists or neurosurgeons per capita. The higher likelihood of prevalent epilepsy cases associated with Stroke Belt residence was explained by beneficiaries' race; that associated with residence in high epilepsy prevalence states was not. The likelihood of new epilepsy cases was negatively associated with Stroke Belt residence when controlling for covariates. SIGNIFICANCE: The geographic variation in epilepsy prevalence is not explained by variations in known risk factors. Further research should investigate why eastern U.S. states have higher frequency of epilepsy.

Diagnostic tests and neurology care for Medicare beneficiaries with seizures: differences across racial groups.

BACKGROUND: Seizures and epilepsy are common in older adults especially in some minorities. Despite the importance of medical care to maximize seizure control, little is known about its quality across racial groups. One indicator of quality care is the receipt of electroencephalograms (EEG), and magnetic resonance imaging (MRIs) or computer tomography scans (CTs) after a first seizure. Neurologists' care is also important, given associated diagnosis and treatment challenges in older patients. OBJECTIVE: To examine seizure-related care in the year after a first seizure for Medicare beneficiaries by race. RESEARCH DESIGN: Retrospective administrative claims analysis for 186,547 beneficiaries with claims for seizure or epilepsy in 2003-2005. Logistic regressions determined the association between care and race (White, Asian, African and Native Americans) adjusting for beneficiary, seizure, and community factors. MEASURES: EEGs, CTs or MRIs, and neurology visits. RESULTS: About 60% received EEGs, 80% had MRIs or CT scans, and only 55.9% had an EEG and CT scan or an MRI. CT use (74%) was higher than MRI use (41%). About 79% had neurology visits. Compared with Whites, Native Americans were less likely to have neurology visits (66.9% vs. 78.8%; adjusted odds ratio: 0.72; 95% CI, 0.55-0.92). No clinically significant differences (>5%) were found for care received by other minorities compared with Whites. CONCLUSIONS: Medicare beneficiaries with new-onset seizures commonly visit a neurologist, with some groups lagging behind. Use of some diagnostic tests is less common. Studies should continue investigating the quality of medical care for older adults with seizures.

Relationship of health behavior theories with self-efficacy among insufficiently active hypertensive African-American women.

OBJECTIVE: While self-efficacy plays an important role in physical activity, relatively little research has examined this construct in minorities. This study identified theoretical correlates associated with self-efficacy among insufficiently active, hypertensive Black women. METHODS: Correlates of self-efficacy to: (1) overcoming barriers to physical activity; (2) making time for activity; and (3) "sticking with" physical activity were studied. RESULTS: Sixty-one women (M=50.48+/-4.2 years) participated. We accounted for 32% of the variance in confidence in overcoming barriers. Women confident in overcoming barriers reported less worry about physical activity. The TTM processes of change were also in the model: consciousness raising, environmental reevaluation, counter conditioning, and self-liberation. We accounted for 16% of the variance in "making time" self-efficacy. An aversiveness barrier (e.g., physical activity is boring, physical activity is hard work) was the dominant variable in the model. Confidence to 'stick with' physical activity was associated with self-reevaluation (i.e., reflection on how personal values correspond to behavior). Social support and competing demands were not associated with self-efficacy. CONCLUSIONS: Consistent with Social Cognitive Theory, results suggest that self-efficacy is behavior specific and each measure likely provides unique information. PRACTICE IMPLICATIONS: Interventions should be tailored to address specific self-efficacy types.

Stepped-care, community clinic interventions to promote mammography use among low-income rural African American women.

Few studies have investigated community clinic-based interventions to promote mammography screening among rural African American women. This study randomized older low-income rural African American women who had not participated in screening in the previous 2 years to a theory-based, personalized letter or usual care; no group differences in mammography rate were evident at 6-month follow-up. Women who had not obtained a mammogram were then randomized to a tailored call delivered by community health care workers or a tailored letter. There were no group differences in mammography rates after the second 6-month follow-up. However, among women who had never had a mammogram, the tailored call was more effective in promoting mammography use. Tailored counseling may be an effective screening promotion strategy for hard-to-reach rural African American women with no history of screening. Further research into this strategy may facilitate efforts to reduce health disparities in underserved low-income rural African American populations.