Early childhood undernutrition, preadolescent physical growth, and cognitive achievement in India: A population-based cohort study.

BACKGROUND: There is a lack of nationally representative estimates for the consequences of early childhood undernutrition on preadolescent outcomes in India. Understanding this relationship is helpful to develop interventions that not only prevent child undernutrition but also mitigate its consequences. METHODS AND FINDINGS: In this cohort study, we analyzed prospectively gathered data from 2 waves of the India Human Development Survey (IHDS) to investigate the association of undernutrition during early childhood (0 to 5 years) in 2004 to 2005 with physical and cognitive outcomes during preadolescent (8 to 11 years) years in 2011 to 2012. These surveys interviewed 41,554 households across all 33 states and union territories in India in 2004 to 2005 and reinterviewed 83% of the households in 2011 to 2012. Primary exposure was assessed using the Composite Index of Anthropometric Failure (CIAF) based on 2004 to 2005 survey. Primary outcomes were short stature (height-for-age z-score [HAZ] <-2), thinness (body mass index [BMI] <18.5 kg/m2), reading, and arithmetic skills during preadolescence based on the 2011 to 2012 survey. Survey-weighted generalized linear models were used, and effect modification based on child sex and sociodemographic variables were evaluated using 3-way interaction terms. Of the 7,868 children included in this analysis, 4,334 (57.3%) were undernourished. Being undernourished was associated with increased odds of short stature (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.45 to 2.06) and thinness (OR 1.52, 95% CI 1.33 to 1.73) during the preadolescent period, while it was associated with decreased odds of achieving a higher reading (cumulative odds ratio [cumOR]: 0.76, 0.66 to 0.87) and arithmetic (cumOR: 0.72, 0.63 to 0.82) outcomes. The disparity in outcomes based on CIAF increased with age, especially for female children. Increased level of female education within the household reduced the disadvantages of undernutrition among female children. Study limitations include observational and missing data, which limit our ability to draw strong causal inferences. CONCLUSIONS: In this study, we found that early child undernutrition was associated with several adverse preadolescent physical and cognitive outcomes, especially among female children. Improved female education mitigates this association. Female education promotion should assume a central role in Indian public health policy making.

Complex Patients Have More Emergency Visits: Don't Punish the Systems That Serve Them.

IMPORTANCE: Better patient management can reduce emergency department (ED) use. Performance measures should reward plans for reducing utilization by predictably high-use patients, rather than rewarding plans that shun them. OBJECTIVE: The objective of this study was to develop a quality measure for ED use for people diagnosed with serious mental illness or substance use disorder, accounting for both medical and social determinants of health (SDH) risks. DESIGN: Regression modeling to predict ED use rates using diagnosis-based and SDH-augmented models, to compare accuracy overall and for vulnerable populations. SETTING: MassHealth, Massachusetts' Medicaid and Children's Health Insurance Program. PARTICIPANTS: MassHealth members ages 18-64, continuously enrolled for the calendar year 2016, with a diagnosis of serious mental illness or substance use disorder. EXPOSURES: Diagnosis-based model predictors are diagnoses from medical encounters, age, and sex. Additional SDH predictors describe housing problems, behavioral health issues, disability, and neighborhood-level stress. MAIN OUTCOME AND MEASURES: We predicted ED use rates: (1) using age/sex and distinguishing between single or dual diagnoses; (2) adding summarized medical risk (DxCG); and (3) further adding social risk (SDH). RESULTS: Among 144,981 study subjects, 57% were women, 25% dually diagnosed, 67% White/non-Hispanic, 18% unstably housed, and 37% disabled. Utilization was higher by 77% for those dually diagnosed, 50% for members with housing problems, and 18% for members living in the highest-stress neighborhoods. SDH modeling predicted best for these high-use populations and was most accurate for plans with complex patients. CONCLUSION: To set appropriate benchmarks for comparing health plans, quality measures for ED visits should be adjusted for both medical and social risks.

Evaluating the use of a recommender system for selecting optimal messages for smoking cessation: patterns and effects of user-system engagement.

BACKGROUND: Motivational messaging is a frequently used digital intervention to promote positive health behavior changes, including smoking cessation. Typically, motivational messaging systems have not actively sought feedback on each message, preventing a closer examination of the user-system engagement. This study assessed the granular user-system engagement around a recommender system (a new system that actively sought user feedback on each message to improve message selection) for promoting smoking cessation and the impact of engagement on cessation outcome. METHODS: We prospectively followed a cohort of current smokers enrolled to use the recommender system for 6 months. The system sent participants motivational messages to support smoking cessation every 3 days and used machine learning to incorporate user feedback (i.e., user's rating on the perceived influence of each message, collected on a 5-point Likert scale with 1 indicating strong disagreement and 5 indicating strong agreement on perceiving the influence on quitting smoking) to improve the selection of the following message. We assessed user-system engagement by various metrics, including user response rate (i.e., the percent of times a user rated the messages) and the perceived influence of messages. We compared retention rates across different levels of user-system engagement and assessed the association between engagement and the 7-day point prevalence abstinence (missing outcome = smoking) by using multiple logistic regression. RESULTS: We analyzed data from 731 participants (13% Black; 73% women). The user response rate was 0.24 (SD = 0.34) and user-perceived influence was 3.76 (SD = 0.84). The retention rate positively increased with the user response rate (trend test P < 0.001). Compared with non-response, six-month cessation increased with the levels of response rates: low response rate (odds ratio [OR] = 1.86, 95% confidence interval [CI]: 1.07-3.23), moderate response rate (OR = 2.30, 95% CI: 1.36-3.88), high response rate (OR = 2.69, 95% CI: 1.58-4.58). The association between perceived message influence and the outcome showed a similar pattern. CONCLUSIONS: High user-system engagement was positively associated with both high retention rate and smoking cessation, suggesting that investigation of methods to increase engagement may be crucial to increase the impact of the recommender system for smoking cessation. TRIAL REGISTRATION: Registration Identifier: NCT03224520 . Registration date: July 21, 2017.

Supports for Maternal Communication About Peer Pressure to Have Sex Among Puerto Rican Families.

This research tests the independent contribution of social capital and the use of the internet to obtain health information to support maternal-child communication about peer pressure to have sex among Puerto Rican families. A sample of 413 Puerto Rican households in Springfield, MA provides the data to independently test these hypotheses. The results of a logistic regression model suggest that Puerto Rican mothers with increased social capital and who accessed the internet for health information are more likely to communicate with their adolescent children about peer pressure to have sex. The combination of these two mechanisms provide opportunities to convey culturally generated resources to Puerto Rican mothers to assist them in helping their children develop healthy sexual behaviors.

Association of religiosity and spirituality with quality of life in patients with cardiovascular disease: a systematic review.

PURPOSE: This review systematically identified and critically appraised the available literature that has examined the association between religiosity and/or spirituality (R/S) and quality of life (QOL) in patients with cardiovascular disease (CVD). METHODS: We searched several electronic online databases (PubMed, SCOPUS, PsycINFO, and CINAHL) from database inception until October 2017. Included articles were peer-reviewed, published in English, and quantitatively examined the association between R/S and QOL. We assessed the methodological quality of each included study. RESULTS: The 15 articles included were published between 2002 and 2017. Most studies were conducted in the US and enrolled patients with heart failure. Sixteen dimensions of R/S were assessed with a variety of instruments. QOL domains examined were global, health-related, and disease-specific QOL. Ten studies reported a significant positive association between R/S and QOL, with higher spiritual well-being, intrinsic religiousness, and frequency of church attendance positively related with mental and emotional well-being. Approximately half of the included studies reported negative or null associations. CONCLUSIONS: Our findings suggest that higher levels of R/S may be related to better QOL among patients with CVD, with varying associations depending on the R/S dimension and QOL domain assessed. Future longitudinal studies in large patient samples with different CVDs and designs are needed to better understand how R/S may influence QOL. More uniformity in assessing R/S would enhance the comparability of results across studies. Understanding the influence of R/S on QOL would promote a holistic approach in managing patients with CVD.

Caste matters: perceived discrimination among women in rural India.

The aim of this study is to examine the relationship of caste and class with perceived discrimination among pregnant women from rural western India. A cross-sectional survey was administered to 170 pregnant women in rural Gujarat, India, who were enrolled in a longitudinal cohort study. The Everyday Discrimination Scale and the Experiences of Discrimination questionnaires were used to assess perceived discrimination and response to discrimination. Based on self-report caste, women were classified into three categories with increasing historical disadvantage: General, Other Backward Castes (OBC), and Scheduled Caste or Tribes (SC/ST). Socioeconomic class was determined using the standardized Kuppuswamy scale. Regression models for count and binomial data were used to examine association of caste and class with experience of discrimination and response to discrimination. Sixty-eight percent of women experienced discrimination. After adjusting for confounders, there was a consistent trend and association of discrimination with caste but not class. In comparison to General Caste, lower caste (OBC, SC/ST) women were more likely to (1) experience discrimination (OBC OR: 2.2, SC/ST: 4.1; p trend: 0.01); (2) have a greater perceived discrimination score (OBC IRR: 1.3, SC/ST: 1.5; p trend: 0.07); (3) accept discrimination (OBC OR: 6.4, SC/ST: 7.6; p trend: < 0.01); and (4) keep to herself about discrimination (OBC OR: 2.7, SC/ST: 3.6; p trend: 0.04). The differential experience of discrimination by lower caste pregnant women in comparison to upper caste pregnant women and their response to such experiences highlight the importance of studying discrimination to understand the root causes of existing caste-based disparities.

Neighborhood Socioeconomic Status Predicts Health After Hospitalization for Acute Coronary Syndromes: Findings From TRACE-CORE (Transitions, Risks, and Actions in Coronary Events-Center for Outcomes Research and Education).

OBJECTIVE: To explore the influence of contextual factors on health-related quality of life (HRQoL), which is sometimes used as an indicator of quality of care, we examined the association of neighborhood socioeconomic status (NSES) and trajectories of HRQoL after hospitalization for acute coronary syndromes (ACS). METHODS: We studied 1481 patients hospitalized with acute coronary syndromes in Massachusetts and Georgia querying HRQoL via the mental and physical components of the 36-item short-form health survey (SF-36) (MCS and PCS) and the physical limitations and angina-related HRQoL subscales of the Seattle Angina Questionnaire (SAQ) during hospitalization and at 1-, 3-, and 6-month postdischarge. We categorized participants by tertiles of the neighborhood deprivation index (a residence-census tract-based measure) to examine the association of NSES with trajectories of HRQoL after adjusting for individual socioeconomic status (SES) and clinical characteristics. RESULTS: Participants had mean age 61.3 (SD, 11.4) years; 33% were female; 76%, non-Hispanic white; 11.2% had household income below the federal poverty level. During 6 months postdischarge, living in lower NSES neighborhoods was associated with lower mean PCS scores (1.5 points for intermediate NSES; 1.8 for low) and SAQ scores (2.4 and 4.2 points) versus living in high NSES neighborhoods. NSES was more consequential for patients with lower individual SES. Individuals living below the federal poverty level had lower average MCS and SAQ physical scores (3.7 and 7.7 points, respectively) than those above. CONCLUSIONS: Neighborhood deprivation was associated with worse health status. Using HRQoL to assess quality of care without accounting for individual SES and NSES may unfairly penalize safety-net hospitals.

African American Veterans Storytelling: A Multisite Randomized Trial to Improve Hypertension.

BACKGROUND: Disparities in hypertension control persist for African American Veterans. OBJECTIVE: To enhance cultural relevance of hypertension control self-management education, in a multisite, stratified randomized trial, we tested an interactive Veteran-to-Veteran storytelling digital video disk (DVD) intervention created with Veteran partners, versus an education-only DVD comparison. METHODS: At 3 VA facilities, African American Veterans with uncontrolled hypertension were randomized to storytelling DVD intervention or didactic comparison DVD and followed for 6 months. We hypothesized that follow-up blood pressure (BP) would be lower among Veterans in the intervention group. RESULTS: African American Veterans (N=619) were 92% male, 39% over age 65, most had a high-school education, over 50% of both the intervention and comparison group reported a household income of <$20,000, and 40% had less than adequate health literacy. At baseline, mean intervention and comparison group BPs were 138/80 and 139/81 mm Hg, respectively; at 6 months, mean systolic BP (SBP) increased by 0.1 in the intervention group and by 1.9 for the comparison group; diastolic BP fell by 0.1 in the intervention group and rose by 0.2 in the comparison group. No differences between the intervention and control groups were statistically significant (all P>0.3). Site differences were large; at one, the intervention group improved while the comparison groups deteriorated, resulting in 6.3 and 3.9 mm Hg more improvement for the intervention group in SBP and diastolic BP (P=0.06 and 0.04), respectively; at the other 2 sites, there were positive and negative changes, all small, in the 2 measures, with minimal differences-one site favored the comparison group and the other, the intervention (these comparisons did not approach statistical significance (all P>0.20). In a secondary analysis stratified by baseline BP, there was no intervention effect among those with uncontrolled BP, but intervention patients who were in control at baseline were more likely to stay in control, compared with comparison [SBP increase by 6.3 mm Hg (SD=14.4) among intervention, and by 10.9 mm Hg (SD=16.9) in comparison, P=0.02]. CONCLUSIONS: In this multisite trial, we did not find a significant overall storytelling intervention effect (Clinicaltrials.gov Reg. #NCT01276197).

Index of cardiometabolic health: a new method of measuring allostatic load using electronic health records.

OBJECTIVE: We developed a measure of allostatic load from electronic medical records (EMRs), which we named "Index of Cardiometabolic Health" (ICMH). METHODS: Data were collected from participants' EMRs and a written survey in 2005. We computed allostatic load scores using the ICMH score and two previously described approaches. RESULTS: We included 1865 employed adults who were 25-59 years old. Although the magnitude of the association was small, all methods of were predictive of SF-12 physical component subscales (all p < 0.001). CONCLUSION: We found that the ICMH had similar relationships with health-related quality of life as previously reported in the literature.

Share2Quit: Online Social Network Peer Marketing of Tobacco Cessation Systems.

INTRODUCTION: Although technology-assisted tobacco interventions (TATIs) are effective, they are underused due to recruitment challenges. We tested whether we could successfully recruit smokers to a TATI using peer marketing through a social network (Facebook). METHODS: We recruited smokers on Facebook using online advertisements. These recruited smokers (seeds) and subsequent waves of smokers (peer recruits) were provided the Share2Quit peer recruitment Facebook app and other tools. Smokers were incentivized for up to seven successful peer recruitments and had 30 days to recruit from date of registration. Successful peer recruitment was defined as a peer recruited smoker completing the registration on the TATI following a referral. Our primary questions were (1) whether smokers would recruit other smokers and (2) whether peer recruitment would extend the reach of the intervention to harder-to-reach groups, including those not ready to quit and minority smokers. RESULTS: Overall, 759 smokers were recruited (seeds: 190; peer recruits: 569). Fifteen percent (n = 117) of smokers successfully recruited their peers (seeds: 24.7%; peer recruits: 7.7%) leading to four recruitment waves. Compared to seeds, peer recruits were less likely to be ready to quit (peer recruits 74.2% vs. seeds 95.1%), more likely to be male (67.1% vs. 32.9%), and more likely to be African American (23.8% vs. 10.8%) (p < .01 for all comparisons). CONCLUSIONS: Peer marketing quadrupled our engaged smokers and enriched the sample with not-ready-to-quit and African American smokers. Peer recruitment is promising, and our study uncovered several important challenges for future research. IMPLICATIONS: This study demonstrates the successful recruitment of smokers to a TATI using a Facebook-based peer marketing strategy. Smokers on Facebook were willing and able to recruit other smokers to a TATI, yielding a large and diverse population of smokers.

Medical Debt and Related Financial Consequences Among Older African American and White Adults.

OBJECTIVES: To evaluate African American-White differences in medical debt among older adults and the extent to which economic and health factors explained these. METHODS: We used nationally representative data from the 2007 and 2010 US Health Tracking Household Survey (n = 5838) and computed population-based estimates of medical debt attributable to economic and health factors with adjustment for age, gender, marital status, and education. RESULTS: African Americans had 2.6 times higher odds of medical debt (odds ratio = 2.62; 95% confidence interval = 1.85, 3.72) than did Whites. Health status explained 22.8% of the observed disparity, and income and insurance explained 19.4%. These factors combined explained 42.4% of the observed disparity. In addition, African Americans were more likely to be contacted by a collection agency and to borrow money because of medical debt, whereas Whites were more likely to use savings. CONCLUSIONS: African Americans incur substantial medical debt compared with Whites, and more than 40% of this is mediated by health status, income, and insurance disparities. Public health implications. In Medicare, low-income beneficiaries, especially low-income African Americans with poor health status, should be protected from the unintended financial consequences of cost-reduction strategies.

Sustained Use of Patient Portal Features and Improvements in Diabetes Physiological Measures.

BACKGROUND: Personal health records (PHRs) have the potential to improve patient self-management for chronic conditions such as diabetes. However, evidence is mixed as to whether there is an association between PHR use and improved health outcomes. OBJECTIVE: The aim of this study was to evaluate the association between sustained use of specific patient portal features (Web-based prescription refill and secure messaging-SM) and physiological measures important for the management of type 2 diabetes. METHODS: Using a retrospective cohort design, including Veterans with diabetes registered for the My Health e Vet patient portal who had not yet used the Web-based refill or SM features and who had at least one physiological measure (HbA1c, low-density lipoprotein (LDL) cholesterol, blood pressure) in 2009-2010 (baseline) that was above guideline recommendations (N=111,686), we assessed portal use between 2010 and 2014. We calculated the odds of achieving control of each measure by 2013 to 2014 (follow-up) by years of using each portal feature, adjusting for demographic and clinical characteristics associated with portal use. RESULTS: By 2013 to 2014, 34.13% (38,113/111,686) of the cohort was using Web-based refills, and 15.75% (17,592/111,686) of the cohort was using SM. Users were slightly younger (P<.001), less likely to be eligible for free care based on economic means (P<.001), and more likely to be women (P<.001). In models adjusting for both features, patients with uncontrolled HbA1c at baseline who used SM were significantly more likely than nonusers to achieve glycemic control by follow-up if they used SM for 2 years (odds ratio-OR=1.24, CI: 1.14-1.34) or 3 or more years (OR=1.28, CI: 1.12-1.45). However, there was no significant association between Web-based refill use and glycemic control. Those with uncontrolled blood pressure at baseline who used Web-based refills were significantly more likely than nonusers to achieve control at follow-up with 2 (OR=1.07, CI: 1.01-1.13) or 3 (OR=1.08, CI: 1.02-1.14) more years of Web-based refill use. Both features were significantly associated with improvements in LDL cholesterol levels at follow-up. CONCLUSIONS: Although rates of use of the refill function were higher within the population, sustained SM use had a greater impact on HbA1c. Evaluations of patient portals should consider that individual components may have differential effects on health improvements.

Effect of self-referral on bone mineral density testing and osteoporosis treatment.

BACKGROUND: Despite national guidelines recommending bone mineral density screening with dual-energy x-ray absorptiometry (DXA) in women aged 65 years and older, many women do not receive initial screening. OBJECTIVE: To determine the effectiveness of health system and patient-level interventions designed to increase appropriate DXA testing and osteoporosis treatment through (1) an invitation to self-refer for DXA (self-referral); (2) self-referral plus patient educational materials; and (3) usual care (UC, physician referral). RESEARCH DESIGN: Parallel, group-randomized, controlled trials performed at Kaiser Permanente Northwest (KPNW) and Kaiser Permanente Georgia (KPG). SUBJECTS: Women aged 65 years and older without a DXA in past 5 years. MEASURES: DXA completion rates 90 days after intervention mailing and osteoporosis medication receipt 180 days after initial intervention mailing. RESULTS: From >12,000 eligible women, those randomized to self-referral were significantly more likely to receive a DXA than UC (13.0%-24.1% self-referral vs. 4.9%-5.9% UC, P<0.05). DXA rates did not significantly increase with patient educational materials. Osteoporosis was detected in a greater proportion of self-referral women compared with UC (P<0.001). The number needed to receive an invitation to result in a DXA in KPNW and KPG regions was approximately 5 and 12, respectively. New osteoporosis prescription rates were low (0.8%-3.4%) but significantly greater among self-referral versus UC in KPNW. CONCLUSIONS: DXA rates significantly improved with a mailed invitation to schedule a scan without physician referral. Providing women the opportunity to self-refer may be an effective, low-cost strategy to increase access for recommended osteoporosis screening.

Weight-based discrimination and medication adherence among low-income African Americans with hypertension: how much of the association is mediated by self-efficacy?

OBJECTIVES: Much of the excessive morbidity and mortality from cardiovascular disease among African Americans results from low adherence to anti-hypertensive medications. Therefore, we examined the association between weight-based discrimination and medication adherence. METHODS: We used cross-sectional data from low-income African Americans with hypertension. Ordinal logistic regression estimated the odds of medication non-adherence in relation to weight-based discrimination adjusted for age, sex, education, income, and weight. RESULTS: Of all participants (n = 780), the mean (SD) age was 53.7 (9.9) years and the mean (SD) weight was 210.1 (52.8) lbs. Reports of weight-based discrimination were frequent (28.2%). Weight-based discrimination (but not weight itself) was associated with medication non-adherence (OR: 1.94; 95% CI: 1.41-2.67). A substantial portion 38.9% (95% CI: 19.0%-79.0%) of the association between weight-based discrimination and medication non-adherence was mediated by medication self-efficacy. CONCLUSION: Self-efficacy is a potential explanatory factor for the association between reported weight-based discrimination and medication non-adherence. Future research should develop and test interventions to prevent weight-based discrimination at the societal, provider, and institutional levels.

Recommendations for a culturally relevant Internet-based tool to promote physical activity among overweight young African American women, Alabama, 2010-2011.

INTRODUCTION: Innovative approaches are needed to promote physical activity among young adult overweight and obese African American women. We sought to describe key elements that African American women desire in a culturally relevant Internet-based tool to promote physical activity among overweight and obese young adult African American women. METHODS: A mixed-method approach combining nominal group technique and traditional focus groups was used to elicit recommendations for the development of an Internet-based physical activity promotion tool. Participants, ages 19 to 30 years, were enrolled in a major university. Nominal group technique sessions were conducted to identify themes viewed as key features for inclusion in a culturally relevant Internet-based tool. Confirmatory focus groups were conducted to verify and elicit more in-depth information on the themes. RESULTS: Twenty-nine women participated in nominal group (n = 13) and traditional focus group sessions (n = 16). Features that emerged to be included in a culturally relevant Internet-based physical activity promotion tool were personalized website pages, diverse body images on websites and in videos, motivational stories about physical activity and women similar to themselves in size and body shape, tips on hair care maintenance during physical activity, and online social support through social media (eg, Facebook, Twitter). CONCLUSION: Incorporating existing social media tools and motivational stories from young adult African American women in Internet-based tools may increase the feasibility, acceptability, and success of Internet-based physical activity programs in this high-risk, understudied population.

Lessons Learned from the Development and Implementation of Two Internet-enhanced Culturally Relevant Physical Activity Interventions for Young Overweight African-American Women.

This research team has designed and implemented 2 culturally relevant, Internet-enhanced physical activity (PA) interventions for overweight/obese African-American female college students. Presumably, these are the only prospectively designed, culturally relevant interventions using the Internet to promote PA among African-American women. Due to the limited research on this topic, the experiences associated the design and implementation of these studies were syntesized and 5 key lessons learned from this research were formulated. Findings provide insight for researchers to consider when developing Internet-based PA promotion interventions for African-American women. Lessons learned included: 1) Elicit and incorporate feedback from the target population throughout development of an Internet-based PA promotion tool; 2) Incorporate new and emerging technologies into Internet-enhanced PA programs; 3) Maintain frequent participant contact and provide frequent incentives to promote participant engagement; 4) Supplement Internet-based efforts with face-to-face interactions; 5) Include diverse images of African-American women and culturally relevant PA-related information in Internet-based PA promotion materials.

Examining Race-Based and Gender-Based Discrimination, Trust in Providers, and Mental Well-Being Among Black Women.

OBJECTIVES: To examine experiences of discrimination among Black women, and to determine if experiencing race- and gender-based discrimination is associated with mental well-being and trust. METHODS: Data from the TRUST study were used to examine experiences of discrimination among 559 Black women with hypertension receiving healthcare at a safety-net hospital in Birmingham, Alabama. A three-level variable was constructed to combine the race-based and gender-based measures of the Experiences of Discrimination scale. Linear regression was used to examine the association between experiences of discrimination with mental well-being and trust. RESULTS: Women who reported no experiences of race- or gender-based discrimination were older and reported higher mental well-being scores and greater trust. Fifty-three percent of study participants reported experiencing discrimination. Compared to participants who did not experience race- or gender-based discrimination, participants reporting experiences of race- or gender-based discrimination and those reporting experiencing both race- and gender-based discrimination were more likely to report poorer mental health. CONCLUSION: Reported experiences of gender- and/or race-based discrimination in this study were associated with lower mental health scores and less trust in health care providers. Our findings highlight the importance of examining experiences of discrimination among Black women, and the role of discrimination as a stressor and in reducing trust for providers. Incorporating an understanding and acknowledgement of experiences of discrimination into interventions, programs, and during clinical encounters may foster more trusting relationships between providers and patients.

Examining racial/ethnic inequities in treatment participation among perinatal individuals with depression.

OBJECTIVE: A cluster randomized controlled trial (RCT) of two interventions for addressing perinatal depression treatment in obstetric settings was conducted. This secondary analysis compared treatment referral and participation among Minoritized perinatal individuals compared to their non-Hispanic white counterparts. METHODS: Among perinatal individuals with depression symptoms, we examined rates of treatment 1) referral (i.e., offered medications or referred to mental health clinician), 2) initiation (i.e., attended ≥1 mental health visit or reported prescribed antidepressant medication), and 3) sustainment (i.e., attended >1 mental health visit per study month or prescribed antidepressant medication at time of study interviews). We compared non-Hispanic white (NHW) (n = 149) vs. Minoritized perinatal individuals (Black, Asian, Hispanic/Latina, Pacific Islander, Native American, Multiracial, and white Hispanic/Latina n = 157). We calculated adjusted odds ratios (aOR) for each outcome. RESULTS: Minoritized perinatal individuals across both interventions had significantly lower odds of treatment referral (aOR = 0.48;95% CI = 0.27-0.88) than their NHW counterparts. There were no statistically significant differences in the odds of treatment initiation (aOR = 0.64 95% CI:0.36-1.2) or sustainment (aOR = 0.54;95% CI = 0.28-1.1) by race/ethnicity. CONCLUSIONS: Perinatal mental healthcare inequities are associated with disparities in treatment referrals. Interventions focusing on referral disparities across race and ethnicity are needed.

Cost-utility analysis of community-based interventions for hypertension control in Vietnam.

Between 2010 and 2011, stakeholders implemented a multi-faceted community-based intervention in response to the escalating issue of uncontrolled hypertension in Hung Yen province, Vietnam. This initiative integrated expanded community health worker services, home blood pressure self-monitoring, and a unique "storytelling intervention" into routine clinical care. From the limited societal perspective, our study evaluates the cost-effectiveness of this intervention using a Markov model with a one-year cycle over a lifetime horizon. The analysis, based on a cohort of 671 patients, reveals a lifetime incremental cost of approximately VND 90.37 million (USD 3,930) per quality-adjusted life year (QALY) gained. With a willingness to pay at three times GDP (VND 259.2 million per QALY), the intervention proves cost-effective 80% of the time. This research underscores the potential of the community-based approach to effectively control hypertension, offering valuable insights into its broader implications for public health.

Lifestyle practices and associated factors among adults with hypertension: Conquering Hypertension in Vietnam-solutions at the grassroots level study.

BACKGROUND: Vietnam is experiencing an increasing prevalence of hypertension in its adult population. In addition to medical therapy, modifying adverse lifestyle practices is important for effective blood pressure control. There are limited data on unhealthy lifestyle practices in patients with chronic diseases, however, particularly among hypertensive patients living in rural Vietnam. Our study objectives were to examine the prevalence of unhealthy lifestyle practices and associated factors among rural Vietnamese adults with uncontrolled hypertension. METHODS: Data from the baseline survey of a cluster randomized trial among hypertensive Vietnamese adults (2017-2022) were utilized. Information on unhealthy lifestyle practices including smoking, excessive alcohol consumption, physical inactivity, and inadequate fruit and vegetable intake was collected from study participants. The primary study outcome was having ≥2 unhealthy lifestyle practices. A multivariable logistic regression model was used to examine factors associated with the primary study outcome. RESULTS: The mean age of the 671 patients was 67 years and 45.0% were men. Nearly three out of every four participants had one or fewer unhealthy practices, 24.0% had two, and 3.3% had three or all four unhealthy lifestyle practices. Men, individuals who did unpaid work or were unemployed, and individuals with hypertension level III were more likely to have ≥2 unhealthy lifestyle practices, whereas individuals with higher education were less likely to have ≥2 unhealthy lifestyle practices compared with respective comparison groups. CONCLUSIONS: We observed a high prevalence of unhealthy lifestyle practices among rural Vietnamese patients with uncontrolled hypertension. Several demographic factors were associated with a greater number of unhealthy lifestyle practices. Newer interventions and educational programs encouraging lifestyle modification practices are needed to control hypertension among adults living in rural settings of Vietnam.