Measuring Access to Mental Health Services Among Primary Care Patients.

BACKGROUND: The lifetime risk of mental health disorders is almost 50% and, in any year, about 25% of the population have a psychiatric disorder. Many of those people are cared for in primary care settings. RESEARCH OBJECTIVE: Measure access to mental health services, such as getting counselling or prescription mental health medications, using new patient survey questions that can be added to Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. STUDY DESIGN: Surveys were conducted with a stratified probability sample of patients receiving primary care services in a single state in 2018-2019. Medicaid and privately insured patients were surveyed by mail or telephone, respectively. RESULTS: Approximately 14% of sampled patients responded to a survey. More than 10% of privately insured respondents and about 20% of Medicaid respondents got or tried to get appointments for mental health care. About 15% of privately insured respondents and 11% of Medicaid respondents reported problems getting appointments with counselors. Only 8%-9% of respondents seeking mental health medicines reported problems getting appointments for prescriptions. A composite measure combining access to counselors and prescribers of mental health medicines evidenced adequate internal consistency reliability. Group level reliability estimates were low. CONCLUSIONS: Many respondents got or tried to get mental health services and a substantial number reported problems getting appointments or getting mental health prescriptions. The tested questions can be combined into an Access to Mental Health Care measure, which can be included in patient experience surveys for ambulatory care to monitor access to behavioral health care.

Changes in Antidementia Medications upon Admission to the Nursing Home: Who Decides and Why? Results From a National Survey of Nursing Home Administrators.

OBJECTIVE: Little is known about who is involved and what factors influence changes in antidementia medications for older adults living in nursing homes. The study sought to describe factors associated with initiation and discontinuation of antidementia medications in nursing home residents with dementia. DESIGN: National survey of nursing homes with ≥30 beds; homes with dementia units were oversampled. SETTINGS AND PARTICIPANTS: Nursing home administrators [eg, Directors of Nursing (DoNs)]. METHODS: In 2022, 1293 homes were surveyed (response rate: 26.6%, n = 340). Weighted analyses provided nationally representative results corrected for nonresponse (n = 14,455). RESULTS: DoNs reported that people always/almost always involved in antidementia medication decisions included nursing home prescriber (84.4%), nursing staff (33.2%), family (23.4%), resident (13.8%), community primary care provider (12.1%), and dementia specialist (5.8%). DoNs reported that antidementia medications were much more likely to be initiated if residents (55.8%) and family members (53.2%) wanted antidementia medications, a dementia specialist was involved (51.9%), resident had aggressive behaviors (44.8%), resisted care (31.6%), or had severe physical/cognitive impairment (22.3%). DoNs reported that antidementia medications were much more likely to be discontinued with dementia specialist involvement (46.5%), progression to severe impairment (39.2%), hospice involvement (31.5%), <6 months' prognosis (28.5%), emergence of aggressive behaviors (25.2%), or resisting care (19.0%) and much less likely to be discontinued if residents (30.2%) and family (27.3%) were reluctant to discontinue. One in 6 homes reported that residents had no immediate family/caregivers usually or almost always/always. CONCLUSIONS AND IMPLICATIONS: DoNs report that family/caregivers and dementia specialists have significant influence on antidementia medication decisions in nursing homes, but many residents lack their involvement. Real-world evidence on the risks and benefits of antidementia medications in nursing homes is needed to inform clinical guidance about appropriate use of antidementia medications in nursing homes.

Rising to the Occasion: A National Nursing Home Study Documenting Attempts to Address Social Isolation During the COVID-19 Pandemic.

OBJECTIVES: COVID-19-related policies introduced extraordinary social disruption in nursing homes. In response, nursing facilities implemented strategies to alleviate their residents' loneliness. This study sought to describe interventions nursing homes used, document the perceived effectiveness of efforts, and determine barriers to implementing strategies to mitigate social isolation and loneliness. DESIGN: National survey of nursing homes sampled in strata defined by facility size (beds: 30-99, 100+) and quality ratings (1, 2-4, 5). SETTINGS AND PARTICIPANTS: US Nursing Home Directors of Nursing/Administrators (n = 1676). METHODS: The survey was conducted between February and May 2022 (response rate: 30%; n = 504, weighted n = 14,506). Weighted analyses provided nationally representative results. RESULTS: One-third were extremely concerned about their home's ability to meet residents' medical and social needs during COVID-19 before vaccines were available and 13% after vaccines. Nearly all reported trying to mitigate residents' social isolation during the pandemic. Efforts tried, and perceived as most useful, included using technology (tablets, phones, emails), assigning staff as a family contact, and more staff time with residents. Most frequently cited barriers to implementation were related to staffing issues. CONCLUSIONS AND IMPLICATIONS: Despite multiple challenges, nearly all nursing homes tried to implement many different approaches to address residents' social needs, with some (eg, having an assigned family contact, use of tablets and phones) perceived as more useful than others. Staffing issues presented barriers for addressing the social needs of nursing home residents. Many strategies for addressing social isolation placed more demands on a workforce already stretched to the limit. While concerns about resident social isolation reduced after vaccine availability, administrators remained extremely concerned about staff burnout and mental health.

Developing a Storytelling Study for African Americans with Hypertension:: A Study Protocol.

Objective: Storytelling is an engaging approach for promoting health and wellness among individuals with health conditions including type 2 diabetes (TTDM), breast cancer, and hypertension. Storytelling interventions are an evidence-based approach that has been effective in promoting behavioral change such as increasing physical activity, medication adherence, and making dietary changes. The use of storytelling to convey health information and promote behavior change is associated with increased engagement in self-management particularly in communities of color. The primary objective of this paper was to describe our process for developing the storytelling study; specifically, recruitment, screening, selecting storytellers, and developing a study-specific interactive website. The secondary objective was to describe the approach for conducting the feasibility study and conduct a 6-week web-based storytelling study. Methods: Between 2017 to 2020, we developed a storytelling study for African Americans with hypertension. During that period we recruited participants from a Federally Qualified Health Center, a local church, and at community events. We selected storytellers to share their experiences managing hypertension and filmed 10 storytellers. Presently, a feasibility and pilot study are underway, the goal of the feasibility study is to ascertain feedback about the stories and the study website from African American adults with hypertension. We will also conduct a 6-week pilot study with 30 African American adults to see if conducting a storytelling study online would be an effective approach for promoting behavioral change. Conclusions: We successfully recruited and filmed 10 storytellers and produced 9 stories about living with and managing hypertension. The feedback we received from participants in the feasibility and pilot study will be useful as we refine the design of the study to determine the potential for a future randomized controlled trial (RCT).

A Systematic Review of Strategies to Enhance Response Rates and Representativeness of Patient Experience Surveys.

BACKGROUND: Data from surveys of patient care experiences are a cornerstone of public reporting and pay-for-performance initiatives. Recently, increasing concerns have been raised about survey response rates and how to promote equity by ensuring that responses represent the perspectives of all patients. OBJECTIVE: Review evidence on survey administration strategies to improve response rates and representativeness of patient surveys. RESEARCH DESIGN: Systematic review adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. STUDY SELECTION: Forty peer-reviewed randomized experiments of administration protocols for patient experience surveys. RESULTS: Mail administration with telephone follow-up provides a median response rate benefit of 13% compared with mail-only or telephone-only. While surveys administered only by web typically result in lower response rates than those administered by mail or telephone (median difference in response rate: -21%, range: -44%, 0%), the limited evidence for a sequential web-mail-telephone mode suggests a potential response rate benefit over sequential mail-telephone (median: 4%, range: 2%, 5%). Telephone-only and sequential mixed modes including telephone may yield better representation across patient subgroups by age, insurance type, and race/ethnicity. Monetary incentives are associated with large increases in response rates (median increase: 12%, range: 7%, 20%). CONCLUSIONS: Sequential mixed-mode administration yields higher patient survey response rates than a single mode. Including telephone in sequential mixed-mode administration improves response among those with historically lower response rates; including web in mixed-mode administration may increase response at lower cost. Other promising strategies to improve response rates include in-person survey administration during hospital discharge, incentives, minimizing survey language complexity, and prenotification before survey administration.

Vaccination intentions generate racial disparities in the societal persistence of COVID-19.

We combined survey, mobility, and infections data in greater Boston, MA to simulate the effects of racial disparities in the inclination to become vaccinated on continued infection rates and the attainment of herd immunity. The simulation projected marked inequities, with communities of color experiencing infection rates 3 times higher than predominantly White communities and reaching herd immunity 45 days later on average. Persuasion of individuals uncertain about vaccination was crucial to preventing the worst inequities but could only narrow them so far because 1/5th of Black and Latinx individuals said that they would never vaccinate. The results point to a need for well-crafted, compassionate messaging that reaches out to those most resistant to the vaccine.

Comparing Web and Mail Protocols for Administering Hospital Consumer Assessment of Healthcare Providers and Systems Surveys.

OBJECTIVE: The objective of this study was to compare results of using web-based and mail (postal) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data collection protocols. RESEARCH DESIGN: Patients who had been hospitalized in a New England Hospital were surveyed about their hospital experience. Patients who provided email addresses were randomized to 1 of 3 data collection protocols: web-alone, web with postal mail follow-up, and postal mail only. Those who did not provide email addresses were surveyed using postal mail only. Analyses compared response rates, respondent characteristics, and patient-reported experiences. SUBJECTS: For an 8-week period, patients were discharged from the study hospital to home. MEASURES: Measures included response rates, characteristics of respondents, 6 composite measures of their patient experiences, and 2 ratings of the hospital. RESULTS: Response rates were significantly lower for the web-only protocol than the mail or combined protocols, and those who had not provided email addresses had lower response rates. Those over 65 were more likely than others to respond to all protocols, especially for the mail-only protocols. Respondents without email addresses were older, less educated, and reported worse health than those who provided email addresses. After adjusting for respondent differences, those in the combined protocol differed significantly from the mail (postal) only respondents on 2 measures of patient experience; those in the web-only protocol differed on one. Those not providing an email address differed from those who did on one measure. CONCLUSION: If web-based protocols are used for HCAHPS surveys, adjustments for a mode of data collection are needed to make results comparable.

Oral health curriculum evaluation tool (OHCET) for primary care training programs.

BACKGROUND: Primary care training schools and programs lack a validated tool to assess their oral health curriculum, and researchers lack a tool to compare oral health curricula across programs/schools and different disciplines. OBJECTIVE: This study describes the process and results of creating a 15-item oral health curriculum evaluation tool (OHCET). METHODS: Three-phased development of the OHCET from 2018 to 2020 including (a) Delphi group/tool development; (b) tool pilot test; and (c) tool validation/cognitive interviews. RESULTS: A total of 23 program deans/directors participated in the tool validation/cognitive interviews. Summarizing accuracy scores of all 15 items, the mean accuracy score was 87.1. There was a high correlation (0.917) between the program's total score and the program director's self-assessed competence of their learners at the time of graduation. CONCLUSIONS: The OHCET was validated and can be used in primary care training programs and schools across the country for institutional evaluation and for research purposes. Program directors and deans can also have some confidence that their ability to subjectively assess their learner's oral health knowledge and skills at graduation is accurate.

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.

The effect of different sampling and recall periods in the CAHPS Clinician & Group (CG-CAHPS) survey.

OBJECTIVE: To examine the effect of changing the sampling and reference periods for the CAHPS® Clinician & Group Survey from 12 to 6 months. DATA SOURCES/STUDY SETTING: Adult patients with a visit in the last 12 months to New England community health centers. STUDY DESIGN: We randomly assigned patients to receive a survey with either a 12- or 6-month recall period. DATA COLLECTION/EXTRACTION METHODS: Questionnaires were mailed to patients, with a second questionnaire mailed to nonrespondents, followed by six attempts to complete a telephone interview. PRINCIPAL FINDINGS: If the sampling criterion was a visit in the last 6 months, 9 percent of those with a visit in the last 12 months would not have been surveyed. A total of 1837 patients completed 6-month surveys (44.9 percent response rate); 588 completed 12-month surveys (46.0 percent response rate). Shortening the reference from 12 to 6 months reduced the proportion of respondents reporting a blood test, X-ray, or other tests. Adjusting for respondent characteristics, the most positive response was selected more often on the 6-month survey for 12 out of 13 questions, and three of these differences were statistically significant (P < 0.05). CONCLUSIONS: Surveys using a 6-month recall period may yield slightly higher scores than surveys with a 12-month recall period.

A randomized controlled trial of community health workers using patient stories to support hypertension management: Study protocol.

BACKGROUND: Uncontrolled hypertension is a significant public health problem in the U.S. with about one half of people able to keep blood pressure (BP) under control. Uncontrolled hypertension leads to increased risk of stroke, heart attack, and death. Furthermore, the social and economic costs of poor hypertension control are staggering. People living with hypertension can benefit from additional educational outreach and support. METHODS: This randomized trial conducted at two Community Health Centers (CHCs) in Massachusetts assessed the effect of community health workers (CHWs) assisting patients with hypertension. In addition to the support provided by CHWs, the study uses video narratives from patients who have worked to control their BP through diet, exercise, and better medication adherence. Participants enrolled in the study were randomly assigned to immediate intervention (I) by CHWs or a delayed intervention (DI) (4 to 6 months later). Each participant was asked to meet with the CHW 5 times (twice in person and three times telephonically). Study outcomes include systolic and diastolic BP, diet, exercise, and body mass index. CONCLUSION: CHWs working directly with patients, using multiple approaches to support patient self-management, can be effective agents to support change in chronic illness management. Moreover, having culturally appropriate tools, such as narratives available through videos, can be an important, cost effective aid to CHWs. Recruitment and intervention delivery within a busy CHC environment required adaptation of the study design and protocols for staff supervision, data collection and intervention delivery and lessons learned are presented. RETROSPECTIVE TRIAL REGISTRATION: Clinical Trials.gov registration submitted 8/17/16: Protocol ID# 5P60MD006912-02 and Clinical trials.gov ID# NCT02874547 Community Health Workers Using Patient Stories to Support Hypertension Management.

Preparation for Transition to Adult Care Among Medicaid-Insured Adolescents.

BACKGROUND: Parents of children with chronic illness consistently report suboptimal preparation for transition from pediatric- to adult-focused health care. Little data are available on transition preparation for low-income youth in particular. METHODS: We conducted a mailed survey of youth with chronic illness enrolled in 2 large Medicaid health plans to determine the quality of transition preparation using the Adolescent Assessment of Preparation for Transition (ADAPT). ADAPT is a new 26-item survey designed for 16- to 17-year-old youth to report on the quality of health care transition preparation they received from medical providers. ADAPT generates composite scores (possible range: 0%-100%) in 3 domains: counseling on transition self-management, counseling on prescription medication, and transfer planning. We examined differences in ADAPT scores based on clinical and demographic characteristics. RESULTS: Among 780 and 575 respondents enrolled in the 2 health plans, respectively, scores in all domains reflected deficiencies in transition preparation. The highest scores were observed in counseling on prescription medication (57% and 58% in the 2 plans, respectively), and lower scores were seen for counseling on transition self-management (36% and 30%, respectively) and transfer planning (5% and 4%, respectively). There were no significant differences in composite scores by health plan, sex, or type of chronic health condition. CONCLUSIONS: The ADAPT survey, a novel youth-reported patient experience measure, documented substantial gaps in the quality of transition preparation for adolescents with chronic health conditions in 2 diverse Medicaid populations.

Development and Validation of the Adolescent Assessment of Preparation for Transition: A Novel Patient Experience Measure.

PURPOSE: Significant gaps exist in health care transition (HCT) preparation that can impact care and outcomes in young adults with chronic illness. No quality measure exists to directly assess adolescent experiences of HCT preparation. Our objective was to develop an adolescent-reported measure of the quality of HCT preparation received from pediatric health care providers. METHODS: The Adolescent Assessment of Preparation for Transition (ADAPT) is a 26-item mailed survey designed for completion by 16- and 17-year-old adolescents with a chronic health condition. Adolescents from three samples (two large Medicaid insurance plans [n = 3,000 each] and one large tertiary care pediatric hospital [n = 623]) were mailed the survey. An iterative developmental process included focus groups and cognitive interviews, and validity was assessed using confirmatory factor analysis and ordinal reliability coefficients. RESULTS: Reliability and validity was evaluated for the following three prespecified composite measures: (1) counseling on transition self-management; (2) counseling on prescription medication; and (3) transfer planning. Across the three samples, all but one measure had good internal consistency (ordinal reliability coefficient ≥ .7). Confirmatory factor analysis using tetrachoric correlation coefficients was stable across samples and supported the construct validity of the first two composite measures. CONCLUSIONS: ADAPT is a reliable, validated instrument measuring the quality of HCT preparation experiences reported by adolescents with chronic disease. ADAPT will enable clinical programs and health care delivery systems to assess the quality of HCT preparation and provide targets for improvement in adolescent counseling related to transition.

Translating comparative effectiveness research into Medicaid payment policy: views from medical and pharmacy directors.

BACKGROUND: As the USA seeks to expand the conduct and dissemination of comparative effectiveness research (CER), views of key stakeholders will help guide the way. METHODS: We surveyed 60 medical and pharmacy directors from 46 state Medicaid programs. RESULTS: Over 90% felt that CER would lead to better clinical decision-making and overall value within 5 years and were willing to consider cost-effectiveness in setting medical policy. However, perceived poor quality, inconclusive research, restrictive legislative mandates, lack of budget impact and coverage recommendations, and lack of an independent body to interpret study results were major barriers cited to using CER evidence. CONCLUSION: Given the significant resources being invested in CER, it is critical that these barriers are overcome to maximize its usefulness for stakeholders.

A longitudinal study of electronic cigarette use among a population-based sample of adult smokers: association with smoking cessation and motivation to quit.

AIMS: Increasingly popular electronic cigarettes (e-cigarettes) may be the most promising development yet to end cigarette smoking. However, there is sparse evidence that their use promotes cessation. We investigated whether e-cigarette use increases smoking cessation and/or has a deleterious effect on quitting smoking and motivation to quit. METHODS: Representative samples of adults in 2 US metropolitan areas were surveyed in 2011/2012 about their use of novel tobacco products. In 2014, follow-up interviews were conducted with 695 of the 1,374 baseline cigarette smokers who had agreed to be re-contacted (retention rate: 51%). The follow-up interview assessed their smoking status and history of electronic cigarette usage. Respondents were categorized as intensive users (used e-cigarettes daily for at least 1 month), intermittent users (used regularly, but not daily for more than 1 month), and non-users/triers (used e-cigarettes at most once or twice). RESULTS: At follow-up, 23% were intensive users, 29% intermittent users, 18% had used once or twice, and 30% had not tried e-cigarettes. Logistic regression controlling for demographics and tobacco dependence indicated that intensive users of e-cigarettes were 6 times more likely than non-users/triers to report that they quit smoking (OR: 6.07, 95% CI = 1.11, 33.2). No such relationship was seen for intermittent users. There was a negative association between intermittent e-cigarette use and 1 of 2 indicators of motivation to quit at follow-up. CONCLUSIONS: Daily use of electronic cigarettes for at least 1 month is strongly associated with quitting smoking at follow-up. Further investigation of the underlying reasons for intensive versus intermittent use will help shed light on the mechanisms underlying the associations between e-cigarette use, motivation to quit, and smoking cessation.

Inaccurate risk perceptions and individualized risk estimates by patients with type 2 diabetes.

BACKGROUND: We evaluated how diabetic patients understand and respond to the presentation of personalized risk information. METHODS: This was a mixed methods study involving 56 patients with type 2 diabetes and at least 1 additional cardiovascular risk factor. We assessed participants' perceptions of diabetes-related risks; asked them to rank order 6 events (death, heart attack, stroke, blindness, amputation, and kidney failure) by likelihood of occurrence in a specified time frame; presented them with personalized risk estimates; and asked them to re-rank the risks. The final 18 participants were tested to verify understanding before re-ranking risks. Qualitative analysis of interview transcripts identified themes and concepts underlying participants' ways of perceiving and reacting to risk. RESULTS: While mortality was the most likely outcome for almost all participants, nearly all estimated it to be least likely; only 28% adjusted their mortality rankings to match model predictions. Some did not understand the risk information: only two thirds of those asked could rank risks according to the information presented. Risk perceptions were influenced by factors including "knowing myself," powerful anecdotes, and belief that a "warning shot" would occur before death. CONCLUSIONS: Personalized risk estimates, particularly about mortality, had limited salience. Some participants could not understand the information, despite presentation in ways suggested by previous research.

The effect of response scale, administration mode, and format on responses to the CAHPS Clinician and Group survey.

OBJECTIVE: To examine how different response scales, methods of survey administration, and survey format affect responses to the CAHPS (Consumer Assessment of Healthcare Providers and Systems) Clinician and Group (CG-CAHPS) survey. STUDY DESIGN: A total of 6,500 patients from a university health center were randomly assigned to receive the following: standard 12-page mail surveys using 4-category or 6-category response scales (on CG-CAHPS composite items), telephone surveys using 4-category or 6-category response scales, or four-page mail surveys. PRINCIPAL FINDINGS: A total of 3,538 patients completed surveys. Composite score means and provider-level reliabilities did not differ between respondents receiving 4-category or 6-category response scale surveys or between 12-page and four-page mail surveys. Telephone respondents gave more positive responses than mail respondents. CONCLUSIONS: We recommend using 4-category response scales and the four-page mail CG-CAHPS survey.

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.

Exploring the association between reported discrimination and hypertension among African Americans: a systematic review.

BACKGROUND: The experience of racial discrimination among African Americans may contribute to an increased risk of developing hypertension and having poor hypertension control once diagnosed. Although it is a commonly held belief that experiences of discrimination may exert lasting effects on health behavior and physiology, the existing evidence is mixed. OBJECTIVE: The objective of this review was to identify evidence linking the experience of discrimination with hypertension among African Americans and to provide an updated synthesis of the literature. DESIGN: Articles for the review were identified through an electronic search of PubMed, OVID, and other pertinent journals. The review was augmented with a manual search of references. We assessed the quality of included articles using modified Downs and Black criteria. RESULTS: In total, 15 articles were selected for the review, 12 cross-sectional studies and 3 cohort studies. The preponderance of evidence (9 of 15 articles) indicated that discrimination was associated with an increased risk of developing hypertension, difficulty obtaining control of existing hypertension, and/or elevated blood pressure among those without a diagnosis of hypertension. CONCLUSIONS: This systematic review supports the association of racial discrimination with an increased risk of developing hypertension; however, the picture is not uniform. Methodological challenges, such as floor or ceiling effects of reported discrimination and low sample size, may have prevented researchers from detecting important associations. A better understanding of the emerging but complex relationship between discrimination and hypertension among African Americans is needed, as we seek to resolve existing cardiovascular health disparities.

Community health worker encounter forms: a tool to guide and document patient visits and worker performance.

OBJECTIVES: We explored the benefits of using community health worker (CHW) encounter forms to collect data on patient interactions and assessed the effectiveness of these forms in guiding and directing interactions. METHODS: A 1-page standardized encounter form was developed to document topics discussed during visits with diabetes patients. A portion of the form was designed to be used as a script to guide the interaction and assist patients in setting appropriate self-management goals. Data were also collected via CHW work logs and interviews with CHWs and their supervisors to validate findings. RESULTS: Data were collected for 1198 interactions with 540 patients at 6 community health centers. Self-management goals were set during 62% of encounters. With respect to the most recent self-management goal set, patients who had set a challenging goal were more likely to be in the action stage of change than in other stages. Work logs revealed that CHWs engaged in a number of activities not involving direct patient interactions and thus not captured on encounter forms. CONCLUSIONS: Evaluating and monitoring CHWs' daily activities has been challenging. Encounter forms have great potential for documenting the work of CHWs with patients.