Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association.

Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association's pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association's commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.

The Arkansas Minority Barber and Beauty Shop Health Initiative: Meeting People Where They Are.

INTRODUCTION: The Office of Health Equity at the Arkansas Department of Health created the Arkansas Minority Barber & Beauty Shop Health Initiative (ARBBS) to address cardiovascular disease (CVD) among racial/ethnic minority populations. The objective of this study was to describe CVD-related screening results for ARBBS participants and their knowledge of CVD-related risk factors, signs, and symptoms before and immediately after participation in a screening event. METHODS: ARBBS screening events were held from February 2016 through June 2019 at barber and beauty shops in 14 counties in Arkansas. During each event, participants were screened for hypertension, high cholesterol, and diabetes; surveys on CVD-related knowledge were administered before (pretest) and after (posttest) screening. Onsite public health practitioners reviewed surveys and identified abnormal screening results. Participants with abnormal screening results were counseled and given a referral to follow up with a primary care physician, wellness center, or charitable clinic. The nurse coordinator followed up to confirm that a visit or appointment had been made and provide case-management services. RESULTS: During the study period, 1,833 people were screened. The nurse coordinator followed up with 320 (55.7%) of 574 unique referrals. Of the 574 referrals, 418 (72.8%) were for hypertension, 156 (27.2%) for high cholesterol, and 120 (20.9%) for diabetes. The overall knowledge of risk factors and symptoms of heart attack and stroke increased significantly by 15.4 percentage points from pretest to posttest (from 76.9% to 92.3%; P < .001). The follow-up approach provided anecdotal information indicating that several participants discovered they had underlying medical conditions and were given medical or surgical interventions. CONCLUSION: Through referrals and follow-ups, ARBBS participants gained greater knowledge of chronic disease prevention and risk factors. Additionally, this program screened for and identified people at risk for CVD.

Classifying intervention modifications in the community pharmacy context: A demonstration study.

OBJECTIVES: The objectives of this study were to apply the Stirman and colleagues' framework to identify modifications made to a motivational interviewing (MI)-based intervention for medication nonadherence and to determine whether the locally modified intervention affected expected patient medication adherence outcomes in community pharmacies. METHODS: Pharmacists at 4 pharmacies were trained to provide a brief MI intervention to 50 patients per pharmacy who were nonadherent to antihypertensive medications. The training included a 3-hour online course in MI and in-pharmacy training on patient identification and documentation. Semistructured interviews were conducted to determine modifications to the patient identification processes, MI interventions, and documentation of interventions. Directed content analysis was guided by the Stirman and colleagues' framework. Preintervention and 6 months postintervention adherence rates for the patients who received the intervention were calculated. Paired samples t tests were used to assess the impact of the intervention on adherence rates. RESULTS: Modifications were made to the context of the intervention (e.g., via telephone instead of in-pharmacy). Additionally, content modifications included "loosening the structure" (e.g., reordering intervention steps), "drifting or departing" (e.g., too busy to attempt), "adding elements" (e.g., reminder cards), and "repeating elements" (e.g., patient identification). There were statistically significant improvements in adherence from preintervention to 6 months postintervention (74.1% to 84.5%; P < 0.05) at each pharmacy regardless of the modifications applied. CONCLUSION: Modifications made during intervention implementation were classified using Stirman and colleagues' framework. Despite the modifications, adherence rates improved and were consistent with expectations based on prior studies of similar interventions. These findings support previous implementation research on adaptability and suggest that the ability to tailor, modify, or refine an intervention to meet the needs of the provider or setting may allow for intervention success. Future research on the impact of specific modifications will help determine which are detrimental or beneficial to patient outcomes and sustainability of services.

Characteristics of E-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) Patients.

During August-December 2019, 23 persons who received a diagnosis of e-cigarette, or vaping, product use-associated lung injury (EVALI) were reported to the Arkansas Department of Health (ADH); none died. Among Arkansas EVALI patients, most were aged <25 years and white; two-thirds were male. Approximately half of Arkansas EVALI patients were admitted to intensive care units. Among 18 patients who were interviewed, 61% reported using both nicotine and tetrahydrocannabinol in an e-cigarette, or vaping, device during the 90 days preceding illness onset. Clinicians should remain vigilant for EVALI and continue to report cases to ADH.

Association Between System Factors and Acute Myocardial Infarction Mortality.

OBJECTIVES: We conducted a cross-sectional study to assess the association between healthcare system factors and death from acute myocardial infarction (AMI), in terms of access (distance to the hospital, mode of transportation), availability (emergency medical services, hospitals), and capability (emergency medical services' 12-lead electrocardiogram capability, continuous percutaneous coronary intervention [PCI] and cardiothoracic surgical services), after accounting for individual and environmental factors. METHODS: Data on 14,663 deaths (in-hospital and out of hospital) and live hospital discharges as a result of AMI for 2012 and 2013 among Arkansas residents were obtained from the Arkansas Department of Health. A mixed-effects logistic regression model was used to account for nesting, in which an individual was nested within either a county or a hospital to evaluate the association of system factors with death from AMI. RESULTS: Deaths from AMI were significantly associated with two system factors: a 9.2% increase in the odds of deaths from AMI for every 10-mi increase in distance to the nearest hospital (odds ratio 1.092, 95% confidence interval 1.009-1.181) and a 64% increase in the odds of death from AMI among hospitals without continuous PCI capability (odds ratio 1.64, 95% confidence interval 1.15-2.34), after adjusting for individual and environmental factors. CONCLUSIONS: A higher risk of AMI deaths was associated with healthcare system factors, especially distance to nearest hospital, and hospitals' continuous PCI capability, even after adjusting for individual and environmental factors. A coordinated system of care approaches that mitigates gaps in these system factors may prevent death from AMI.

High-normal blood pressure is associated with visit-to-visit blood pressure variability in the US adults.

OBJECTIVES: High-normal blood pressure and visit-to-visit blood pressure variability are common in clinical settings. They are associated with cardiovascular outcomes. No population based studies have assessed the association between these two phenomena. Our objective was to test the relationship of high-normal blood pressure with visit-to-visit blood pressure variability. DESIGN: A cross-sectional study. METHODS: We used data from the cross-sectional Third National Health and Nutrition Examination Survey to test the relationship between high-normal blood pressure and visit-to-visit blood pressure variability; we conducted multivariable regression analyses to evaluate the relationship between these two variables. RESULTS: The analysis included 6,071 participants. The participants' mean age was 37.16 years. The means of visit-to-visit systolic and diastolic blood pressure variability were 5.84 mmHg and 5.26 mmHg. High-normal blood pressure was significantly associated with systolic and diastolic blood pressure variability (p values <0.05). CONCLUSIONS: High-normal blood pressure is associated with visit-to-visit blood pressure variability. Additional research is required to replicate the reported results in prospective studies and evaluate approaches to reduce blood pressure variability observed in clinical settings among patients with high-normal blood pressure to reduce the subsequent complications of blood pressure variability.

Community Team-Based Care for Hypertension Management: A Public-Private Partnership in Rural Arkansas.

Hypertension is a major public health problem in Arkansas. Team-based care (TBC), delivered by health care professionals such as a nurse, dietician, social worker, or community health worker rather than a physician alone, has been shown to improve blood pressure control.

Emergency transport of stroke suspects in a rural state: opportunities for improvement.

INTRODUCTION: Time delay is the key obstacle for receiving successful stroke treatment. Alteplase therapy must start within 4.5 hours from stroke occurrence. Rapid transport to a primary stroke center (PSC) or acute stroke-ready hospital (ASRH) by the emergency medical system (EMS) paramedics is vital. We determined transport time and destination data for EMS-identified and -delivered stroke suspects in Arkansas during 2013. Our objective was to analyze transport time and the hospital qualification for stroke care across the state. METHODS: The state's 75 counties were placed into 8 geographical regions (R1-R8). Transport time and hospital qualification were determined for all EMS-identified strokes. Each hospital's stroke care status was categorized as PSC, ASRH, a nonspecialty or unknown care facility (NSCF), out-of-state, or nonapplicable designation facilities. RESULTS: There were 9588 EMS stroke ground transports with median within-region transport times of 29-40 minutes. Statewide, only 65% of EMS-transported stroke patients were transported to either PSC (12%) or ASRH (53%) facilities. One-third of the patients (30.6%) were delivered to NSCFs, where acute stroke therapy may rarely be performed. Regions with the highest suspected-stroke cases per capita also had the highest percentage of transports to NSCFs. CONCLUSION: With only a few PSCs in Arkansas, EMS agencies should prioritize transporting stroke patients to ASRHs when PSCs are not regionally located.

Falls and comorbid conditions among community dwelling Arkansas older adults from a population-based survey.

The prevalence of self-reported falls and associated comorbid conditions among community dwelling Arkansas older adults (ages 65 years and older) was estimated using data from the 2010 Behavioral Risk Factor Surveillance System survey. 1,653 Arkansas older adults were surveyed. Eighteen percent of them had sustained a fall at least once in the past three months prior to the survey period. After adjusting for age, general health, coronary heart disease, diabetes status and quality rest or sleep in a multinomial logistic regression, we found that older adults with visual impairment (OR = 1.47; 95% CI: 1.02, 2.12), and those who use special equipment (OR = 2.85; 95% CI: 1.94, 4.19) were more likely to have sustained a fall. An integrated multidisciplinary approach in caring for older adults is imperative for preventing falls and fall-related injuries. This can also reduce-fall-related hospitalizations and potentially result in substantial cost savings as well as improve the quality of life of older Arkansans.

Effects of home visiting on adolescent mothers' parenting attitudes.

We examined the impact of a home visiting intervention on 227 adolescent mothers' parenting attitudes. At enrollment, half of mothers were at risk for child maltreatment. Mothers assigned to intervention (n = 161) received home visits and case management. Intervention and comparison mothers (n = 66) participated in monthly peer group meetings. Regression analyses controlling for enrollment differences indicated that intervention group mothers had significant improvements in 3 of 5 subscales and in total Adult-Adolescent Parenting Inventory-2 scores relative to the comparison group.

Bringing home the patient centered medical home: lessons learned from an academic family medical center.

Putting patients at the center of health care is the basic premise of the Patient Centered Medical Home (PCMH). Our clinic, the Family Medical Center (FMC) is located at the University of Arkansas for Medical Sciences campus and has over 23,000 annual patient visits. In 2008, we decided to apply for the National Committee for Quality Assurance' (NCQA) PCMH recognition and had made several process changes at our clinic to meet the requirements. In 2010, FMC was the first clinic in Arkansas to be recognized by NCQA as a Level 3 PCMH. In this article, we share the actions taken and lessons learned in bringing home the PCMH to our practice.

Aldehyde dehydrogenase as an alternative to enumeration of total and viable CD34(+) cells in autologous hematopoietic progenitor cell transplantation.

We validated the correlation of aldehyde dehydrogenase ALDH(br) cells with total and viable CD34(+) cells in fresh and thawed hematopoietic progenitor cell (HPC) products, and looked for a correlation with time to white blood cell (WBC) and platelet engraftment after autologous transplantation, using simple linear regression analyzes. We found a significant correlation between pre-freeze ALDH(br) cell numbers and pre-freeze total CD34(+) (P < 0.001), viable CD34(+) (P < 0.001) and post-thaw viable CD34(+) (P < 0.001) cell numbers. We suggest that ALDH(br) may be substituted for CD34(+) cell numbers when evaluating HPC. As post-thaw viability testing apparently adds no significant information, we suggest that it may not be necessary. Finally, neither marker correlated with time to engraftment in our patients, supporting previous data suggesting the existence of a threshold dose for timely engraftment around 2.5 × 10(6) cells/kg.

Subsequent primary cancers among men and women with in situ and invasive melanoma of the skin.

BACKGROUND: An estimated 750,000 melanoma survivors in the United States are at increased risk of subsequent primary cancers. OBJECTIVE: We sought to assess the risk of developing subsequent primary cancers among people with cutaneous melanoma. METHODS: Using 1992 to 2006 data from the National Cancer Institute Surveillance, Epidemiology, and End Results Program, 40,881 people with in situ melanoma and 76,041 people with invasive melanoma were followed up (mean of 5.6 years) for the development of subsequent primary cancers. The observed number of subsequent cancers was compared with those expected based on age-/race-/year-/site-specific rates in the Surveillance, Epidemiology, and End Results population. Standardized incidence ratios (SIRs) (SIR = observed number/expected number) were considered statistically significant if they differed from 1, with an alpha level of 0.05. RESULTS: After a first primary in situ melanoma, risk was significantly elevated for subsequent invasive melanoma and chronic lymphocytic leukemia among men (SIRs = 8.43 and 1.44, respectively) and women (SIRs = 12.33 and 1.79, respectively). After a first primary invasive melanoma, risk was significantly elevated for subsequent invasive melanoma, thyroid cancer, non-Hodgkin lymphoma, and chronic lymphocytic leukemia among both men (SIRs = 12.50, 2.67, 1.56, and 1.57, respectively) and women (SIRs = 15.67, 1.77, 1.42, and 1.63, respectively). LIMITATIONS: Case ascertainment issues particularly affecting in situ melanoma cases could affect results. The role of detection bias in the diagnoses of some subsequent cancers cannot be completely eliminated. CONCLUSIONS: The findings of the study should guide the development of strategies such as posttreatment surveillance, screening, and ultraviolet exposure education among melanoma survivors to improve cancer survivorship.

Quarantine and isolation facility: A State Health Department's response to the COVID-19 pandemic.

BACKGROUND: State Health Departments are at the helm of addressing the myriad needs during the COVID-19 pandemic, including those of vulnerable populations who do not have a place to self-isolate or quarantine to prevent the spread. An estimated 5,000 Arkansas residents face homelessness and are at increased risk of contracting and spreading COVID-19. Additionally, those living in multigenerational families face similar challenges. OBJECTIVE: We share our experiences and lessons learned in planning, executing, and maintaining a quarantine and isolation facility for vulnerable population during the COVID-19 pandemic. SETTING AND PATIENTS: A 29-bed quarantine and isolation facility was instituted and maintained by the Arkansas Department of Health to meet the quarantine and isolation needs of vulnerable populations. Outcomes and conclusions: As the COVID-19 pandemic persists, need for a facility to meet quarantine and isolation requirements of vulnerable population is not just a critical mitigation strategy but is an ethical imperative.

Prevalence of visual impairment and eye diseases in Arkansas.

Visual impairment and eye diseases are major public health concerns of the 21st century, particularly as our population ages. The prevalence of these conditions has not been described in Arkansas. We analyzed the vision module of the Arkansas behavioral risk factor surveillance system to estimate the burden due to these disabling conditions. The prevalence of glaucoma, age-related macular degeneration, and cataract among Arkansans > 40 years was found to be 5.5% (95% CI, 4.7 - 6.3), 5.3% (95% CI, 4.5 - 6.0), and 13.7% (95% CI, 12.6 - 14.8), respectively. Vision related quality of life was also studied. Public health strategies to reduce the burden due to visual impairment and eye diseases are the need of the hour.

A pilot study of diabetes education via telemedicine in a rural underserved community--opportunities and challenges: a continuous quality improvement process.

PURPOSE: Telemedicine technology may offer an avenue to implement diabetes self-management education (DSME) for people with diabetes in underserved rural communities. The continuous quality improvement process was used to identify the problem, collect and analyze data, and develop and implement a DSME program via telemedicine (DSME-T) in an underserved rural community. METHODS: A pilot study was conducted in 2006, implementing a DSME-T utilizing facilities at the University of Arkansas for Medical Sciences and a rural community hospital in Arkansas (Ozark Health, Inc). A total of 38 people were enrolled to receive DSME-T. Participant knowledge, self-efficacy, and self-care practices were assessed before participants began the education program and after they had completed it. Also, select clinical measures (glycosylated hemoglobin, lipid profile, and urine microalbumin) were collected. RESULTS: A total of 66% of participants (n = 25) completed the DSME-T program. A significantly greater proportion of participants demonstrated improved knowledge (39% vs 83%; P = .012), endorsed greater self-efficacy (54% vs 86%; P = .016), and reported more frequent self-care practices to manage their diabetes at the conclusion of the study period. CONCLUSIONS: The results of this pilot study suggest that DSME-T may offer opportunities for DSME among rural residents with diabetes. Plans are in place to explore the possibility of sustaining and expanding the program to other underserved rural communities.

Incidence of female breast cancer in Arkansas: are we following the national trend?

The incidence of invasive female breast cancer declined 6.7% in the United States from 2002 to 2003 following a nationwide decrease in the use of hormone replacement therapy that began in 2002. We used data from the Arkansas Central Cancer Registry to look for similar changes in the incidence of female breast cancer in Arkansas. There was a 9.3% decline in the incidence of invasive female breast cancer in Arkansas in 2003, and the decline continued through 2005. The decline was significantly higher (p<0.05) among invasive cancers, particularly among women ages 50 and older and for those having an estrogen-receptor positive tumor.

A Pilot Study Validating Video-Based Training on Pre-Hospital Stroke Recognition.

INTRODUCTION: Delays in recognizing stroke during pre-hospital emergency medical system (EMS) care may affect triage and transport time to an appropriate stroke ready hospital and may preclude patients from receiving time dependent treatment. All EMS transports in a large urban area in the stroke belt were evaluated for transport destinations, triage and transport time and stroke recognition following distribution ofan educational training video to local EMS services. HYPOTHESIS: Following video training, local paramedics will improve stroke recognition and shorten triage and transport time to appropriate stroke centers of care. METHODS: A training module (<10 min) containing a stroke triage scenario, instruction on the Cincinnati Prehospital Stroke Score (CPSS) and the Los Angeles Prehospital Stroke Score (LAPSS) and 'where to transport' stroke patients was distributed and viewed by 96 paramedics. Data was collected from February to October 2016. Stroke recognition was determined from one primary stroke center (PSC) hospital's confirmation of EMS delivered patients (Site A). Yearly stroke recognition percentages of 44% from Site A in 2014 were used as baseline. RESULTS: A total of 34,833 emergency 911 response transports were made with a total of 502 (1.4%) suspected strokes identified by paramedics. Median [IQR] triage and transport time for stroke transports was 33 [27-41] min. The PSC hospitals received a 5% increase in stroke transports and non-specific care facilities decreased by 7%. From 8,554 transports to site A (PSC) confirmed strokes totalled 107 transports with 139 suspected strokes by paramedics. Of these transports, 60 were correctly identified by paramedics (positive predictive value of 43%, sensitivity of 56%). By the second month following training, recognition percentages increased from baseline to 64%. At five months, percentages of correct stroke identification had dropped to 36%. CONCLUSION: Video based training improved stroke recognition by an additional 19%, but continual monthly or quarterly training is recommended for maintenance of increased stroke recognition.

Health communications in rural America: lessons learned from an arthritis campaign in rural Arkansas.

CONTEXT: Lack of awareness about diseases and associated risk factors could partially account for some rural health disparities. Health communications campaigns can be an effective means of increasing awareness in these areas. PURPOSE: To review findings and lessons learned from a rural health communications campaign. METHODS: The health communications campaign titled "Physical Activity. The Arthritis Pain Reliever," developed by the Centers for Disease Control and Prevention, was implemented in a rural Arkansas county to promote awareness about arthritis and the beneficial effects of physical activity among residents 45-64 years of age with arthritis. The campaign was implemented through radio spots, print ads in local newspapers, and distribution of brochures and posters. A survey of 193 residents with arthritis assessed the reach of the campaign. FINDINGS: Whereas 86% of respondents reported having seen or heard the messages related to arthritis during the 13-week period of the campaign, only 11% recalled messages from the "Physical Activity. The Arthritis Pain Reliever" campaign. Challenges faced during campaign implementation included limited fiscal resources, distrust, and staff and time constraints. CONCLUSION: Challenges to health communications campaigns in rural areas can decrease campaign reach and effectiveness. If resource constraints exist, leveraging partnerships and building trust among residents of the community are important for achieving campaign success.