Healthcare professionals' perspectives on oral health care in acute stroke patients: a qualitative study.

BACKGROUND: Stroke is a major public health problem, with the disabilities of the patients increasing their risk of poor oral health. Currently, in Ghana and Nigeria, no guideline exists for oral health care in stroke patients, while most of our acute stroke care settings have no documented protocol. AIM: This study sought to understand the perspectives of healthcare professionals in Ghana and Nigeria about oral healthcare in acute stroke patients. METHODS: A qualitative inductive approach was employed to explore healthcare professionals' perspectives. After obtaining informed consent, in-depth interviews were conducted among doctors, nurses, and physiotherapists using semi-structured question guides. Participants' responses were audiotaped for transcription and analysis. Interviews were conducted until data saturation was reached. Data were analyzed thematically to generate themes and sub-themes using an inductive approach. THE RESULTS: Twenty-five (25) health care professionals (HCP) aged 25-60 years with a mean age of 36.2 ± 4.2 years were interviewed. There were 15 (60.0%) males and 10 (40.0%) females. HCP included nurse practitioners 14 (56.0%), medical doctors 7 (28.0%), and physiotherapists 4 (16.0%). The HCP demonstrated adequate knowledge of stroke and considered oral health important for esthetic and clinical reasons. They, however, reported being unable to give it the required attention due to inadequate collaboration between the various professional cadres, insufficient equipment, and a skewed focus on other clinical needs of the acute stroke patients. CONCLUSIONS: The findings indicate that HCPs perceived oral health care as very important among patients with acute stroke. However, they reported a lack of collaboration and integration of oral health care in routine stroke care as a major impediment.

A Framework for Integrating Telehealth Equitably across the cancer care continuum.

The COVID-19 pandemic placed a spotlight on the potential to dramatically increase the use of telehealth across the cancer care continuum, but whether and how telehealth can be implemented in practice in ways that reduce, rather than exacerbate, inequities are largely unknown. To help fill this critical gap in research and practice, we developed the Framework for Integrating Telehealth Equitably (FITE), a process and evaluation model designed to help guide equitable integration of telehealth into practice. In this manuscript, we present FITE and showcase how investigators across the National Cancer Institute's Telehealth Research Centers of Excellence are applying the framework in different ways to advance digital and health equity. By highlighting multilevel determinants of digital equity that span further than access alone, FITE highlights the complex and differential ways structural determinants restrict or enable digital equity at the individual and community level. As such, achieving digital equity will require strategies designed to not only support individual behavior but also change the broader context to ensure all patients and communities have the choice, opportunity, and resources to use telehealth across the cancer care continuum.

Training primary healthcare workers on a task-strengthening strategy for integrating hypertension management into HIV care in Nigeria: implementation strategies, knowledge uptake, and lessons learned.

BACKGROUND: With improved access to anti-retroviral drugs, persons living with HIV/AIDS (PLWHA) are living longer but with attendant increased risks of non-communicable diseases (NCDs). The increasing burden of NCDs, especially hypertension, could reverse gains attributed to HIV care. Nurses and Community Health Officers (CHO) in Nigeria are cardinal in delivering primary health care. A task-strengthening strategy could enable them to manage hypertension in HIV care settings. This study aimed to assess their knowledge and practice of hypertension management among Healthcare workers (HCWs) and to explore the challenges involved in conducting onsite training during pandemics. METHODS: Nurses and CHOs in the employment of the Lagos State Primary Health Care Board (LSPHCB), Lagos State, Nigeria, were recruited. They were trained through hybrid (virtual and onsite) modules before study implementation and a series of refresher trainings. A pre-and post-training test survey was administered, followed by qualitative interviews to assess skills and knowledge uptake, the potential barriers and facilitators of task-sharing in hypertension management in HIV clinics, and the lessons learned. RESULTS: Sixty HCWs participated in the two-day training at baseline. There was a significant improvement in the trainees' knowledge of hypertension management and control. The average score during the pre-test and post-test was 59% and 67.6%, respectively. While about 75% of the participants had a good knowledge of hypertension, its cause, symptoms, and management, 20% had moderate knowledge, and 5% had poor knowledge at baseline. There was also an increase in the mean score between the pre-test and post-test of the refresher training using paired t-tests (P < 0.05). Role-playing and multimedia video use improved the participants' uptake of the training. The primary barrier and facilitator of task sharing strategy in hypertension management reported were poor delineation of duties among HCWs and the existing task shifting at the Primary Healthcare Centres (PHC) level, respectively. CONCLUSIONS: The task strengthening strategy is relevant in managing hypertension in HIV clinics in Nigeria. The capacity development training for the nurses and CHOs involved in the Integration of Hypertension Management into HIV Care in Nigeria: A Task Strengthening Strategy (TASSH-Nigeria) study yielded the requisite improvement in knowledge uptake, which is a reassurance of the delivery of the project outcomes at the PHCs.

Barbershop-Facilitated Community-to-Clinic Linkage Implementation Program: Rationale and Protocol for a Novel Program to Prevent Hypertension Among Black Men.

BACKGROUND: Black men in the United States have higher hypertension (HTN) prevalence than other groups, largely due to adverse social determinants of health, including poor healthcare access. The Community-to-Clinic Linkage Implementation Program (CLIP) is effective for HTN screening in Black-owned barbershops. However, its effect on HTN prevention among Black men is untested. Here, we describe the rationale and study protocol for the development and testing of a barbershop facilitation (BF) strategy, with trained Community Health Workers, to implement and scale CLIP for HTN prevention in Black men. METHODS: The study is part of the American Heart Association (AHA)-funded RESTORE (Addressing Social Determinants to Prevent Hypertension) Health Equity Research Network. The study is tri-phasic: (i) pre-implementation-qualitative examination of factors affecting adoption of CLIP and development of BF strategy, (ii) implementation-cluster randomized control trial to test the effectiveness of CLIP with and without BF. We will partner with 20 barbershops and enroll 420 Black men with elevated blood pressure (BP)/Stage 1 HTN (2017 ACC/AHA HTN guidelines). Outcomes include reduction in BP, rate of CLIP adoption and linkage to care, and incidence of Stage 2 HTN. The study time frame is 12 months, (iii) post-implementation-we will evaluate program sustainability (6 months post-trial conclusion) and cost-effectiveness (up to 10 years). CONCLUSIONS: This study harnesses community-based resources to address HTN prevention in Black men, who are more adversely impacted by HTN than other groups. It has major policy relevance for health departments and other stakeholders to address HTN prevention in Black communities. CLINICALTRIALS.GOV IDENTIFIER: NCT05447962.

Peer Review in a General Medical Research Journal Before and During the COVID-19 Pandemic.

Importance: Although peer review is an important component of publication for new research, the viability of this process has been questioned, particularly with the added stressors of the COVID-19 pandemic. Objective: To characterize rates of peer reviewer acceptance of invitations to review manuscripts, reviewer turnaround times, and editor-assessed quality of reviews before and after the start of the COVID-19 pandemic at a large, open-access general medical journal. Design, Setting, and Participants: This retrospective, pre-post cohort study examined all research manuscripts submitted to JAMA Network Open between January 1, 2019, and June 29, 2021, either directly or via transfer from other JAMA Network journals, for which at least 1 peer review of manuscript content was solicited. Measures were compared between the period before the World Health Organization declaration of a COVID-19 pandemic on March 11, 2020 (14.3 months), and the period during the pandemic (15.6 months) among all reviewed manuscripts and between pandemic-period manuscripts that did or did not address COVID-19. Main Outcomes and Measures: For each reviewed manuscript, the number of invitations sent to reviewers, proportions of reviewers accepting invitations, time in days to return reviews, and editor-assessed quality ratings of reviews were determined. Results: In total, the journal sought review for 5013 manuscripts, including 4295 Original Investigations (85.7%) and 718 Research Letters (14.3%); 1860 manuscripts were submitted during the prepandemic period and 3153 during the pandemic period. Comparing the prepandemic with the pandemic period, the mean (SD) number of reviews rated as high quality (very good or excellent) per manuscript increased slightly from 1.3 (0.7) to 1.5 (0.7) (P < .001), and the mean (SD) time for reviewers to return reviews was modestly shorter (from 15.8 [7.6] days to 14.4 [7.0] days; P < .001), a difference that persisted in linear regression models accounting for manuscript type, study design, and whether the manuscript addressed COVID-19. Conclusions and Relevance: In this cohort study, the speed and editor-reported quality of peer reviews in an open-access general medical journal improved modestly during the initial year of the pandemic. Additional study will be necessary to understand how the pandemic has affected reviewer burden and fatigue.

An Evaluation of Alternative Technology-Supported Counseling Approaches to Promote Multiple Lifestyle Behavior Changes in Patients With Type 2 Diabetes and Chronic Kidney Disease.

OBJECTIVES: Although technology-supported interventions are effective for reducing chronic disease risk, little is known about the relative and combined efficacy of mobile health strategies aimed at multiple lifestyle factors. The purpose of this clinical trial is to evaluate the efficacy of technology-supported behavioral intervention strategies for managing multiple lifestyle-related health outcomes in overweight adults with type 2 diabetes (T2D) and chronic kidney disease (CKD). DESIGN AND METHODS: Using a 2 × 2 factorial design, adults with excess body weight (body mass index ≥27 kg/m2, age ≥40 years), T2D, and CKD stages 2-4 were randomized to an advice control group, or remotely delivered programs consisting of synchronous group-based education (all groups), plus (1) Social Cognitive Theory-based behavioral counseling and/or (2) mobile self-monitoring of diet and physical activity. All programs targeted weight loss, greater physical activity, and lower intakes of sodium and phosphorus-containing food additives. RESULTS: Of 256 randomized participants, 186 (73%) completed 6-month assessments. Compared to the ADVICE group, mHealth interventions did not result in significant changes in weight loss, or urinary sodium and phosphorus excretion. In aggregate analyses, groups receiving mobile self-monitoring had greater weight loss at 3 months (P = .02), but between 3 and 6 months, weight losses plateaued, and by 6 months, the differences were no longer statistically significant. CONCLUSIONS: When engaging patients with T2D and CKD in multiple behavior changes, self-monitoring diet and physical activity demonstrated significantly larger short-term weight losses. Theory-based behavioral counseling alone was no better than baseline advice and demonstrated no interaction effect with self-monitoring.

Development of the ASSESS tool: a comprehenSive tool to Support rEporting and critical appraiSal of qualitative, quantitative, and mixed methods implementation reSearch outcomes.

BACKGROUND: Several tools to improve reporting of implementation studies for evidence-based decision making have been created; however, no tool for critical appraisal of implementation outcomes exists. Researchers, practitioners, and policy makers lack tools to support the concurrent synthesis and critical assessment of outcomes for implementation research. Our objectives were to develop a comprehensive tool to (1) describe studies focused on implementation that use qualitative, quantitative, and/or mixed methodologies and (2) assess risk of bias of implementation outcomes. METHODS: A hybrid consensus-building approach combining Delphi Group and Nominal Group techniques (NGT) was modeled after comparative methodologies for developing health research reporting guidelines and critical appraisal tools. First, an online modified NGT occurred among a small expert panel (n = 5), consisting of literature review, item generation, round robin with clarification, application of the tool to various study types, voting, and discussion. This was followed by a larger e-consensus meeting and modified Delphi process with implementers and implementation scientists (n = 32). New elements and elements of various existing tools, frameworks, and taxonomies were combined to produce the ASSESS tool. RESULTS: The 24-item tool is applicable to a broad range of study designs employed in implementation science, including qualitative studies, randomized-control trials, non-randomized quantitative studies, and mixed methods studies. Two key features are a section for assessing bias of the implementation outcomes and sections for describing the implementation strategy and intervention implemented. An accompanying explanation and elaboration document that identifies and describes each of the items, explains the rationale, and provides examples of reporting and appraising practice, as well as templates to allow synthesis of extracted data across studies and an instructional video, has been prepared. CONCLUSIONS: The comprehensive, adaptable tool to support both reporting and critical appraisal of implementation science studies including quantitative, qualitative, and mixed methods assessment of intervention and implementation outcomes has been developed. This tool can be applied to a methodologically diverse and growing body of implementation science literature to support reviews or meta-analyses that inform evidence-based decision-making regarding processes and strategies for implementation.

Analysis of Therapeutic Inertia and Race and Ethnicity in the Systolic Blood Pressure Intervention Trial: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Therapeutic inertia may contribute to racial and ethnic differences in blood pressure (BP) control. Objective: To determine the association between race and ethnicity and therapeutic inertia in the Systolic Blood Pressure Intervention Trial (SPRINT). Design, Setting, and Participants: This cross-sectional study was a secondary analysis of data from SPRINT, a randomized clinical trial comparing intensive (<120 mm Hg) vs standard (<140 mm Hg) systolic BP treatment goals. Participants were enrolled between November 8, 2010, and March 15, 2013, with a median follow-up 3.26 years. Participants included adults aged 50 years or older at high risk for cardiovascular disease but without diabetes, previous stroke, or heart failure. The present analysis was restricted to participant visits with measured BP above the target goal. Analyses for the present study were performed in from October 2020 through March 2021. Exposures: Self-reported race and ethnicity, mutually exclusively categorized into groups of Hispanic, non-Hispanic Black, or non-Hispanic White participants. Main Outcomes and Measures: Therapeutic inertia, defined as no antihypertensive medication intensification at each study visit where the BP was above target goal. The association between self-reported race and ethnicity and therapeutic inertia was estimated using generalized estimating equations and stratified by treatment group. Antihypertensive medication use was assessed with pill bottle inventories at each visit. Blood pressure was measured using an automated device. Results: A total of 8556 participants, including 4141 in the standard group (22 844 participant-visits; median age, 67.0 years [IQR, 61.0-76.0 years]; 1467 women [35.4%]) and 4415 in the intensive group (35 453 participant-visits; median age, 67.0 years [IQR, 61.0-76.0 years]; 1584 women [35.9%]) with at least 1 eligible study visit were included in the present analysis. Among non-Hispanic White, non-Hispanic Black, and Hispanic participants, the overall prevalence of therapeutic inertia in the standard vs intensive groups was 59.8% (95% CI, 58.9%-60.7%) vs 56.0% (95% CI, 55.2%-56.7%), 56.8% (95% CI, 54.4%-59.2%) vs 54.5% (95% CI, 52.4%-56.6%), and 59.7% (95% CI, 56.5%-63.0%) vs 51.0% (95% CI, 47.4%-54.5%), respectively. The adjusted odds ratios in the standard and intensive groups for therapeutic inertia associated with non-Hispanic Black vs non-Hispanic White participants were 0.85 (95% CI, 0.79-0.92) and 0.94 (95% CI, 0.88-1.01), respectively. The adjusted odds ratios for therapeutic inertia comparing Hispanic vs non-Hispanic White participants were 1.00 (95% CI, 0.90-1.13) and 0.89 (95% CI, 0.79-1.00) in the standard and intensive groups, respectively. Conclusions and Relevance: Among SPRINT participants above BP target goal, this cross-sectional study found that therapeutic inertia prevalence was similar or lower for non-Hispanic Black and Hispanic participants compared with non-Hispanic White participants. These findings suggest that a standardized approach to BP management, as used in SPRINT, may help ensure equitable care and could reduce the contribution of therapeutic inertia to disparities in hypertension. Trial Registration: ClinicalTrials.gov identifier: NCT01206062.

Motivation to move fast, motivation to wait and see: The association of prevention and promotion focus with clinicians' implementation of the JNC-7 hypertension treatment guidelines.

Roughly half of the adults in the United States are diagnosed with hypertension (HTN). Unfortunately, less than one-third have their condition under control. Clinicians generally have positive regard for the use of HTN guidelines to achieve HTN treatment goals; however, actual uptake remains low. Factors underpinning clinician variation in practice are poorly understood. To understand the relationship between clinicians' personal motivation to complete goals and their uptake of the Joint National Commission's HTN guidelines. The authors used Regulatory Focus Theory (RFT, ie, prevention and promotion focus), an empirically supported motivational theory, as a guiding framework to examine the relationship. The authors hypothesized that clinicians with high prevention focus would report following guidelines more often and have shorter follow-up visit intervals for patients with uncontrolled blood pressure. Clinicians (n  = 27) caring for adult patients diagnosed with HTN (n = 8605) in Federally Qualified Health Centers (n = 8). Clinicians' prevention and promotion focus scores and the number of days between visits for their patients with uncontrolled systolic blood pressure (SBP) (≥ 140 mm Hg). Consistent with RFT, 60% of prevention focused clinicians reported they always followed the monthly visit guideline for the patients with uncontrolled blood pressure, compared with 38% of promotion focused clinicians (p = .254). The unadjusted probability of returning for a follow-up visit within 30 days was greater among patients whose clinician was higher in prevention focus (p = .009), but there was no evidence at the 0.05 significance level in our adjusted model. These findings provide some limited evidence that RFT is a useful framework to understand clinician adherence to HTN treatment guidelines.

Stress interventions and hypertension in Black women.

Hypertension is a risk factor for cardiovascular disease. Black women have high rates of hypertension compared to women of other racial or ethnic groups and are disproportionately affected by psychosocial stressors such as racial discrimination, gender discrimination, and caregiving stress. Evidence suggests that stress is associated with incident hypertension and hypertension risk. Stress management is associated with improvements improved blood pressure outcomes. The purpose of this review is to synthesize evidence on effects of stress management interventions on blood pressure in Black women. A comprehensive search of scientific databases was conducted. Inclusion criteria included studies that were: (1) primary research that tested an intervention; (2) in the English language; (3) included African-American women; (4) incorporated stress in the intervention; (5) included blood pressure as an outcome; and (6) were US based. Eighteen studies met inclusion criteria. Ten (56%) studies tested meditation-based interventions, two (11%) tested coping and affirmation interventions, and six (33%) tested lifestyle modification interventions that included stress management content. Thirteen of the studies were randomized controlled trials. Reductions in blood pressure were observed in all of the meditation-based interventions, although the magnitude and statistical significance varied. Comprehensive lifestyle interventions were also efficacious for reducing blood pressure, although the relative contribution of stress management versus behavior modification could not be evaluated. Coping and affirmation interventions did not affect blood pressure. Most of the reviewed studies included small numbers of Black women and did not stratify results by race and gender, so effects remain unclear. This review highlights the urgent need for studies specifically focusing on Black women. Given the extensive disparities in cardiovascular disease morbidity and mortality, whether stress management can lower blood pressure and improve primary and secondary cardiovascular disease prevention among Black women is an important question for future research.

Association Between Ambulatory Blood Pressure and Coronary Artery Calcification: The JHS.

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Proactive prevention: Act now to disrupt the impending non-communicable disease crisis in low-burden populations.

Non-communicable disease (NCD) prevention efforts have traditionally targeted high-risk and high-burden populations. We propose an alteration in prevention efforts to also include emphasis and focus on low-risk populations, predominantly younger individuals and low-prevalence populations. We refer to this approach as "proactive prevention." This emphasis is based on the priority to put in place policies, programs, and infrastructure that can disrupt the epidemiological transition to develop NCDs among these groups, thereby averting future NCD crises. Proactive prevention strategies can be classified, and their implementation prioritized, based on a 2-dimensional assessment: impact and feasibility. Thus, potential interventions can be categorized into a 2-by-2 matrix: high impact/high feasibility, high impact/low feasibility, low impact/high feasibility, and low impact/low feasibility. We propose that high impact/high feasibility interventions are ready to be implemented (act), while high impact/low feasibility interventions require efforts to foster buy-in first. Low impact/high feasibility interventions need to be changed to improve their impact while low impact/low feasibility might be best re-designed in the context of limited resources. Using this framework, policy makers, public health experts, and other stakeholders can more effectively prioritize and leverage limited resources in an effort to slow or prevent the evolving global NCD crisis.

Addressing Stroke Literacy in Nigeria Through Music: A Qualitative Study of Community Perspectives.

BACKGROUND: The incidence of stroke in Nigeria is unknown, but stroke literacy, defined here as awareness of stroke warning symptoms and risk factors may be poor in high-risk communities. Although there is growing recognition of the use of music as a conduit to promote health literacy, African music is often overlooked as a source of health information. We sought to understand community-level perspectives on using African music to promote acute stroke literacy. METHODS: A purposive sample of education, health and music professionals, high school and university students were recruited to participate in the qualitative study. Study participants completed a brainstorming exercise that elicited their perceptions of potential barriers and facilitators to the use of music to promote acute stroke literacy in Nigeria. Content analysis was used to identify key themes emerging from the brainstorming exercise. RESULTS: A total of 44 individuals, comprising of 25 students with a mean age of 15.9 ± 1.6 years (52% females) and 19 professionals with a mean age of 39 ± 7.7 years (57.9% males) participated in the brainstorming exercise. Facilitators to the use of music to promote acute stroke literacy in Nigeria include the cultural relevance of music, the ubiquity of music, and government involvement. Key barriers include religious beliefs that discourage the use of "secular" music, cost-related barriers, and limited government support. CONCLUSIONS: Findings from this study provide guidance aimed at improving acute stroke literacy in Nigeria, particularly the importance of government involvement in the development and implementation of stroke literacy interventions guided by African music. Future work should consider implementing interventions that leverage the cultural elements of African music and further assess the extent to which these identified facilitators and/or barriers may influence stroke literacy.

Interventions Targeting Racial/Ethnic Disparities in Stroke Prevention and Treatment.

Systemic racism is a public health crisis. Systemic racism and racial/ethnic injustice produce racial/ethnic disparities in health care and health. Substantial racial/ethnic disparities in stroke care and health exist and result predominantly from unequal treatment. This special report aims to summarize selected interventions to reduce racial/ethnic disparities in stroke prevention and treatment. It reviews the social determinants of health and the determinants of racial/ethnic disparities in care. It provides a focused summary of selected interventions aimed at reducing stroke risk factors, increasing awareness of stroke symptoms, and improving access to care for stroke because these interventions hold the promise of reducing racial/ethnic disparities in stroke death rates. It also discusses knowledge gaps and future directions.