Meeting the information needs of lower income cancer survivors: results of a randomized control trial evaluating the american cancer society's "I can cope".

The American Cancer Society is a leader in the development of cancer survivorship resources. One resource of the American Cancer Society is the I Can Cope program, an educational program for cancer survivors and their families. Evaluations of this program indicate that cancer patients highly rate its objectives. Yet, there are gaps in the understanding of the full impact of the program on diverse cancer survivors. In this study, the authors used a randomized trial to evaluate the program. Participants included 140 low-income survivors (79% Black; 38% breast cancer) from community hospitals who were randomized to 4 sessions of I Can Cope (learning about cancer; understanding cancer treatments; relieving cancer pain; and keeping well in mind and body) or 4 sessions of a wellness intervention (humor, meditation, relaxation, and music therapy). The authors' primary outcome was "met information needs." After controlling for covariates, their analysis indicated that I Can Cope was no more effective than the wellness intervention in addressing survivor information needs relative to the learning objectives. Participants provided high overall ratings for both interventions. Self-efficacy for obtaining advice about cancer, age, education, and income were associated with information needs. Educational programs tailored to levels of self-efficacy and patient demographics may be needed.

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.

Reported racial discrimination, trust in physicians, and medication adherence among inner-city African Americans with hypertension.

OBJECTIVES: We sought to determine if reported racial discrimination was associated with medication nonadherence among African Americans with hypertension and if distrust of physicians was a contributing factor. METHODS: Data were obtained from the TRUST project conducted in Birmingham, Alabama, 2006 to 2008. All participants were African Americans diagnosed with hypertension and receiving care at an inner city, safety net setting. Three categories of increasing adherence were defined based on the Morisky Medication Adherence Scale. Trust in physicians was measured with the Hall General Trust Scale, and discrimination was measured with the Experiences of Discrimination Scale. Associations were quantified by ordinal logistic regression, adjusting for gender, age, education, and income. RESULTS: The analytic sample consisted of 227 African American men and 553 African American women, with a mean age of 53.7 ± 9.9 years. Mean discrimination scores decreased monotonically across increasing category of medication adherence (4.1, 3.6, 2.9; P = .025), though the opposite was found for trust scores (36.5, 38.5, 40.8; P < .001). Trust mediated 39% (95% confidence interval = 17%, 100%) of the association between discrimination and medication adherence. CONCLUSIONS: Within our sample of inner city African Americans with hypertension, racial discrimination was associated with lower medication adherence, and this association was partially mediated by trust in physicians. Patient, physician and system approaches to increase "earned" trust may enhance existing interventions for promoting medication adherence.

Trust, medication adherence, and hypertension control in Southern African American men.

We examined the relationship between trust in the medical system, medication adherence, and hypertension control in Southern African American men. The sample included 235 African American men aged 18 years and older with hypertension. African American men with higher general trust in the medical system were more likely to report better medication adherence (odds ratio [OR] = 1.06), and those with higher self-efficacy were more likely to report better medication adherence and hypertension control (OR = 1.08 and OR = 1.06, respectively).

Culturally appropriate storytelling to improve blood pressure: a randomized trial.

BACKGROUND: Storytelling is emerging as a powerful tool for health promotion in vulnerable populations. However, these interventions remain largely untested in rigorous studies. OBJECTIVE: To test an interactive storytelling intervention involving DVDs. DESIGN: Randomized, controlled trial in which comparison patients received an attention control DVD. Separate random assignments were performed for patients with controlled or uncontrolled hypertension. (ClinicalTrials.gov registration number: NCT00875225) SETTING: An inner-city safety-net clinic in the southern United States. PATIENTS: 230 African Americans with hypertension. INTERVENTION: 3 DVDs that contained patient stories. Storytellers were drawn from the patient population. MEASUREMENTS: The outcomes were differential change in blood pressure for patients in the intervention versus the comparison group at baseline, 3 months, and 6 to 9 months. RESULTS: 299 African American patients were randomly assigned between December 2007 and May 2008 and 76.9% were retained throughout the study. Most patients (71.4%) were women, and the mean age was 53.7 years. Baseline mean systolic and diastolic pressures were similar in both groups. Among patients with baseline uncontrolled hypertension, reduction favored the intervention group at 3 months for both systolic (11.21 mm Hg [95% CI, 2.51 to 19.9 mm Hg]; P = 0.012) and diastolic (6.43 mm Hg [CI, 1.49 to 11.45 mm Hg]; P = 0.012) blood pressures. Patients with baseline controlled hypertension did not significantly differ over time between study groups. Blood pressure subsequently increased for both groups, but between-group differences remained relatively constant. LIMITATION: This was a single-site study with 23% loss to follow-up and only 6 months of follow-up. CONCLUSION: The storytelling intervention produced substantial and significant improvements in blood pressure for patients with baseline uncontrolled hypertension. PRIMARY FUNDING SOURCE: Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation.

"I'LL DIE WITH THE HAMMER IN MY HAND": JOHN HENRYISM AS A PREDICTOR OF HAPPINESS.

This paper examines the association between John Henryism - a behavioral predisposition to cope actively with psychosocial environmental stressors - and happiness. On the basis of previous research on aspiration and goal regulation, we predicted that John Henryism would be negatively associated with happiness when controlling for demographic factors and attainment in various domains of life. We tested the prediction in a sample of hypertensive participants (n=758) drawn from an inner-city, mainly African-American, safety-net hospital in Jefferson County, Alabama. Bivariate analysis revealed no association between John Henryism and attainment in six domains of life: marriage, children, education, employment, income, and health. However, a significant negative association between John Henryism and happiness was found both in bivariate analysis (Spearman's ρ= -0.335; p<.001) and when controlling for demographic factors and attainment using ordinal logistic regression analysis. There was a significant interaction effect between John Henryism and gender: being male was positively associated with happiness among participants with low John Henryism, but negatively associated with happiness among participants with high John Henryism. While further study would be required in order to establish the extent to which these findings can be generalized as well as their causal underpinnings, the results indicate that John Henryism is negatively associated with happiness, especially among men, and underscore the limitations of using self-reported measures of happiness as proxies for well-being for purposes of public policy.

An Examination of John Henryism, Trust, and Medication Adherence Among African Americans With Hypertension.

Background. John Henryism is defined as a measure of active coping in response to stressful experiences. John Henryism has been linked with health conditions such as diabetes, prostate cancer, and hypertension, but rarely with health behaviors. Aims. We hypothesized that reporting higher scores on the John Henryism Scale may be associated with poorer medication adherence, and trust in providers may mediate this relationship. Method. We tested this hypothesis using data from the TRUST study. The TRUST study included 787 African Americans with hypertension receiving care at a safety-net hospital. Ordinal logistic regression was used to examine the relationship between John Henryism and medication adherence. Results. Within our sample of African Americans with hypertension, lower John Henryism scores was associated with poorer self-reported adherence (low, 20.62; moderate, 19.19; high, 18.12; p < .001). Higher John Henryism scores were associated with lower trust scores (low John Henryism: 40.1; high John Henryism: 37.9; p < .001). In the adjusted model, each 1-point increase in the John Henryism score decreased the odds of being in a better cumulative medication adherence category by a factor of 4% (odds ratio = 0.96, p = .014, 95% confidence interval = 0.93-0.99). Twenty percent of the association between medication adherence and John Henryism was mediated by trust (standard deviation = 0.205, 95% confidence interval = 0.074-0.335). Discussion. This study provides important insights into the complex relationship between psychological responses and health behaviors. It also contributes to the body of literature examining the construct of John Henryism among African Americans with hypertension. Conclusion. The findings of this study support the need for interventions that promote healthful coping strategies and patient-provider trust.

Does Home Remedy Use Contribute to Medication Nonadherence Among Blacks with Hypertension?

Background: Home remedies (HRs) are described as foods, herbs, and other household products used to manage chronic conditions. The objective of this study was to examine home remedy (HR) use among Blacks with hypertension and to determine if home remedy use is correlated with blood pressure and medication adherence. Methods: Data for this cross-sectional study were obtained from the TRUST study conducted between 2006-2008. Medication adherence was measured using the Morisky Medication Adherence Scale, and HR use was self-reported. Multivariable associations were quantified using ordinal logistic regression. Results: The study sample consisted of 788 Blacks with hypertension living in the southern region of the United States. HR use was associated with higher systolic (HR users 152.79, nonusers 149.53; P=.004) and diastolic blood pressure (HR users 84.10, nonusers 82.14 P=.005). Use of two or more HRs was associated with low adherence (OR: .55, CI: .36-.83, P= .004). Conclusion: The use of HR and the number of HRs used may be associated with medication nonadherence, and higher systolic and diastolic blood pressure among Blacks with hypertension. Medication nonadherence is of critical importance for individuals with hypertension, and it is essential that health care providers be aware of health behaviors that may serve as barriers to medication adherence, such as use of home remedies.

Refractive error and ethnicity in children.

OBJECTIVE: To report the baseline prevalence of refractive error in the study population. DESIGN: A multicenter, longitudinal, observational study of refractive error and ocular development in children from 4 ethnic groups. PATIENTS AND METHODS: The study population included 2523 children (534 African American, 491 Asian, 463 Hispanic, and 1035 white) in grades 1 to 8 (age, 5-17 years). Myopia was defined as -0.75 diopters (D) or more and hyperopia as +1.25 D or more in each principal meridian, and astigmatism was defined as at least a 1.00-D difference between the 2 principal meridians (cycloplegic autorefraction). RESULTS: Overall, 9.2% of the children were myopic, 12.8% were hyperopic, and 28.4% were astigmatic. There were significant differences in the refractive error prevalences as a function of ethnicity (chi2, P<.001), even after controlling for age and sex (polychotomous logistic regression, P<.001). For myopia, Asians had the highest prevalence (18.5%), followed by Hispanics (13.2%). Whites had the lowest prevalence of myopia (4.4%), which was not significantly different from African Americans (6.6%). For hyperopia, whites had the highest prevalence (19.3%), followed by Hispanics (12.7%). Asians had the lowest prevalence of hyperopia (6.3%) and were not significantly different from African Americans (6.4%). For astigmatism, Asians and Hispanics had the highest prevalences (33.6% and 36.9%, respectively) and did not differ from each other (P =.17). African Americans had the lowest prevalence of astigmatism (20.0%), followed by whites (26.4%). CONCLUSION: There were significant differences in the prevalence of refractive errors among ethnic groups, even after controlling for age and sex (P<.001).

Eye care use among a high-risk diabetic population seen in a public hospital's clinics.

IMPORTANCE: Little is known regarding eye care use among low-income persons with diabetes mellitus, especially African Americans. OBJECTIVE: To investigate eye care use among patients with diabetes who were seen in a county hospital clinic that primarily serves high-risk, low-income, non-Hispanic African American patients. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study with 2 years of follow-up examined eye care use among adult patients with diabetes seen in 2007 in an outpatient medical clinic of a large, urban county hospital that primarily serves low-income, non-Hispanic African American patients. Patients with a history of retinopathy and macular edema or a current diagnosis indicating ophthalmic complications were excluded. Eye care use was defined dichotomously as whether or not patients had a visit to the eye clinic for any eye care examination or procedure. We estimated crude and adjusted rate ratios (aRRs) and 95% CIs for the association between eye care use and selected clinical and demographic characteristics. RESULTS: There were 867 patients with diabetes identified: 61.9% were women, 76.2% were non-Hispanic African American, and 61.4% were indigent, with a mean age of 51.8 years. Eye care utilization rates were 33.2% within 1 and 45.0% within 2 years. For patients aged 19 to 39 years compared with those aged 65 years or older, significantly decreased eye care utilization rates were observed within 1 year (aRR, 0.48; 95% CI, 0.27-0.84) and within 2 years (aRR, 0.61; 95% CI, 0.38-0.99). CONCLUSIONS AND RELEVANCE: Overall eye care utilization rates were low. Additional education efforts to increase the perception of need among urban minority populations may be enhanced if focused on younger persons with diabetes.

Recruitment of low income, predominantly minority cancer survivors to a randomized trial of the I Can Cope cancer education program.

This report describes recruitment of minority cancer survivors for a randomized trial of I Can Cope, a support program of the American Cancer Society. Survivor Education and Evaluation (SURE), was designed to recruit patients, age 19 and older, with a primary cancer diagnosis. Recruitment was primarily carried out in a public hospital in Birmingham, Alabama. Of 373 patients approached, 226 were eligible for the study, 175 consented, and 140 were randomized during the 20-month recruitment period. Only 43 declined participation. This resulted in a 61.9% recruitment yield. The mean age of participants was 54.2 years (SD=10.9), 92 (65.7%) were female, and 111 (79.3%) were African American. Twenty-three different cancers were represented including breast (37.1%), colorectal (12.1%), hematologic (12.9%), and lung (7.1%). Over half (63%) had been diagnosed within 12 months. The experience of the SURE project provides evidence for optimism in recruiting racial minorities to cancer research studies.

Tailoring cancer education and support programs for low-income, primarily African American cancer survivors.

PURPOSE/OBJECTIVES: to identify the information and stress-management topics of most interest to low-income, predominantly African American cancer survivors. RESEARCH APPROACH: descriptive, cross sectional. SETTING: outpatient oncology clinic in a public hospital in Birmingham, Alabama. PARTICIPANTS: 25 patients with cancer; 12 were men, 22 were African Americans, and 16 had a 12th-grade education or less. METHODOLOGIC APPROACH: patients ranked potential topics to be included in an educational curriculum. MAIN RESEARCH VARIABLES: quantitative rankings of information and stress-management priorities. FINDINGS: learning about cancer, understanding cancer treatments, relieving cancer pain, and keeping well in mind and body were the most highly ranked topics among those offered within the American Cancer Society's I Can Cope curriculum, which also included supportive topics such as mobilizing social support. The preferred stress-management topics were humor therapy, music therapy, meditation, and relaxation; lower-ranked topics included pet therapy and art as therapy. CONCLUSIONS: cancer survivors appear most interested in topics specific to their illness and treatment versus supportive topics. Stress management also received high rankings. INTERPRETATION: nurses have a key role in providing patient education and support. Tailoring education programs may better target specific needs and improve the quality of cancer care of underserved patients.