Design and Rationale of the Cardiometabolic Health Program Linked with Community Health Workers and Mobile Health Telemonitoring to Reduce Health DisparitieS (LINKED-HEARTS) Program.

BACKGROUND: Hypertension and diabetes are major risk factors for cardiovascular diseases, stroke, and chronic kidney disease (CKD). Disparities in hypertension control persist among Black and Hispanic adults and persons living in poverty in the United States. The "LINKED-HEARTS Program" (a Cardiometabolic Health Program LINKED with Community Health WorkErs and Mobile HeAlth TelemonitoRing To reduce Health DisparitieS"), is a multi-level intervention that includes home blood pressure (BP) monitoring (HBPM), blood glucose telemonitoring, and team-based care. This study aims to examine the effect of the LINKED-HEARTS Program intervention in improving BP control compared to enhanced usual care (EUC) and to evaluate the reach, adoption, sustainability, and cost-effectiveness of the program. METHODS: Using a hybrid type I effectiveness-implementation design, 428 adults with uncontrolled hypertension (systolic BP ≥ 140 mm Hg) and diabetes or CKD will be recruited from 18 primary care practices, including community health centers, in Maryland. Using a cluster-randomized trial design, practices are randomly assigned to the LINKED-HEARTS intervention arm or EUC arm. Participants in the LINKED-HEARTS intervention arm receive training on HBPM, BP and glucose telemonitoring, and community health worker and pharmacist telehealth visits on lifestyle modification and medication management over 12 months. The primary outcome is the proportion of participants with controlled BP (<140/90 mm Hg) at 12 months. CONCLUSIONS: The study tests a multi-level intervention to control multiple chronic diseases. Findings from the study may be leveraged to reduce disparities in the management and control of chronic diseases and make primary care more responsive to the needs of underserved populations.

Association Between Maladaptive Eating Behaviors Among Black Women and Vicarious Racial Discrimination Following a High-Profile Event.

OBJECTIVE: Evidence suggests that racial discrimination causes stress among non-Hispanic Black women, and some Black women may cope with exposure to vicarious racial discrimination by engaging in maladaptive eating behaviors. METHODS: We examined eating behaviors among Black women (N = 254) before and after Freddie Gray's death while in police custody. Maladaptive eating behaviors were assessed using the three-factor eating questionnaire. Our independent variables included the following: (1) time period and (2) geographic proximity to the event. Three two-way analysis of covariance tests were conducted to assess potential effects of geographic proximity (close, distant), time period in relation to unrest (before, after unrest), and their interaction on emotional eating, uncontrolled eating, and cognitive restraint controlling for participant age. RESULTS: There was a statistically significant main effect of proximity to the unrest on emotional eating, F (1, 252) = 5.64, p = .018, and partial η2 = .022 such that women living in close geographic proximity to the unrest reported higher mean levels of emotional eating as compared to those living more distant to the unrest. There was also a borderline statistically significant interaction between geographic proximity and time period on cognitive restraint, F (1, 252) = 3.89, p = .050, and partial η2 = .015. CONCLUSION: Our study found a relationship between vicarious racial discrimination and maladaptive eating behaviors among Black women. Future work should examine stress related to vicarious racial discrimination and maladaptive eating behaviors longitudinally.

African Immigrants' perceptions and attitudes toward cardiovascular health.

AIM: To explore perceptions and attitudes of African immigrants (Ghanaians, Nigerians, Liberians, and Sierra Leoneans) in the Baltimore-Washington, DC, metropolitan area toward cardiovascular health. METHODS: This was a qualitative study among African immigrants recruited from religious and community-based organizations in the Baltimore-Washington metro area. A purposive sample of 66 African immigrants originally from Ghana, Nigeria, Liberia, and Sierra Leone completed a sociodemographic survey and participated in focus group discussions. Focus group data were analysed using qualitative description to develop emergent themes. RESULTS: A total of 66 African immigrants with a mean (±standard deviation) age of 51 (±11.8) years participated in the focus group discussions. Fifty percent were women, 91% had at least a bachelor's degree, 84% were employed, 80% had health insurance, and 75% were married/cohabitating. The majority of the participants (74%) had lived in the US for 10 years or more, 44% of them had hypertension, and 12% had diabetes. Findings from the focus group discussions revealed: gender differences in descriptions of cardiovascular health and healthiness, an emotional response associated with cardiovascular disease (evoking fear and anxiety and associated with family secrecy), positive and negative lifestyle changes after migration, cardiovascular screening behaviours, and facilitators and barriers to cardiovascular disease prevention practices and heart-healthy lifestyle. CONCLUSIONS: Participants understood health to be a holistic state of well-being. Secrecy in disclosing their cardiovascular disease diagnoses informed by historical socio-cultural belief systems, perceived racial discrimination by healthcare providers, communication and health literacy barriers, economic barriers of holding multiple jobs and the exorbitant cost of heart-healthy foods were identified as some barriers to achieving optimal cardiovascular health in this immigrant population. IMPACT: Our study expanded on the body of knowledge on African immigrants' perceptions and attitudes toward cardiovascular health. Addressing this knowledge gap will provide important intervention opportunities targeted at improving cardiovascular health outcomes in this population. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Voices, Images, And Experiences Of Community Health Workers: Advancing Antiracist Policy And Practice.

Community health workers (CHWs) are front-line public health personnel who share common attributes with or have a nuanced understanding of the communities they serve. Their membership in marginalized communities gives them expertise in delivering contextualized interventions that mitigate their clients' social risk factors, but it also places them at greater risk for exposure to various harms. We employed the photovoice method to illuminate how the lived experiences of CHWs working, residing, or both in Baltimore City, Maryland, dovetail with facets of their jobs. In partnership with our sixteen predominantly racial and ethnic minoritized study participants, we surfaced the ways in which CHWs negotiated and subsequently leveraged experiences with social risk factors rooted in structural racism to shape their approach to intervention delivery for structurally vulnerable communities. We also uncovered several occupational hazards that participants faced as a function of their identities. Our findings underscore the need to embed antiracist principles in the fabric of policies and practices that directly affect the CHW workforce.

Neighborhood Factors, Individual Stressors, and Cardiovascular Health Among Black and White Adults in the US: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

Importance: Chronic stress has been posited to contribute to racial disparities in cardiovascular health. Investigation of whether neighborhood- and individual-level stressors mediate this disparity is needed. Objective: To examine whether racial differences in ideal cardiovascular health (ICH) are attenuated by experiences with neighborhood- and individual-level stressors within a racially and geographically diverse population sample. Design, Setting, and Participants: This cross-sectional study examined data from 7720 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study who completed the second in-home visit (2013-2016). The REGARDS study is a population-based, longitudinal study of 30 239 non-Hispanic Black and non-Hispanic White adults aged 45 years or older at baseline (2003-2007). Data for the present study were analyzed from June to July 2021 and in March 2022. Exposures: Neighborhood physical environment (eg, excessive noise, violence; scored from 7-28, with higher scores indicating more problems), neighborhood safety (scored as very safe, safe, or not safe), neighborhood social cohesion (eg, shared values; scored from 5-25, with higher scores indicating higher cohesion), perceived stress (eg, coping; scored from 0-16, with higher scores indicating greater perceived stress), and the experience of discrimination (yes or no). Main Outcomes and Measures: Ideal cardiovascular health (ICH), measured as a composite of 4 health behaviors (cigarette smoking, diet, physical activity, body mass index) and 3 health factors (blood pressure, cholesterol, and glucose levels). Results: The sample included 7720 participants (mean [SD] age, 71.9 [8.3] years; 4390 women [56.9%]; 2074 Black participants [26.9%]; and 5646 White participants [73.1%]). Black participants compared with White participants reported higher perceived stress (mean [SD] score, 3.2 [2.8] vs 2.8 [2.7]) and more often reported discrimination (77.0% vs 24.0%). Black participants also reported poorer neighborhood physical environment (mean [SD] score, 11.2 [3.8] vs 9.8 [2.9]) and social cohesion (mean [SD] score, 15.5 [2.0] vs 15.7 [1.9]) and more often reported their neighborhoods were unsafe (54.7% vs 24.3%). The odds of having a high total ICH score (ie, closer to ideal) were lower for Black adults compared with White adults, both overall (adjusted odds ratio [AOR], 0.53; 95% CI, 0.45-0.61) and by gender (men: AOR, 0.73 [95% CI, 0.57-0.93]; women: AOR, 0.45 [95% CI, 0.37-0.54]). In mediation analyses, the racial disparity in total ICH score was attenuated by neighborhood physical environment (5.14%), neighborhood safety (6.27%), neighborhood social cohesion (1.41%), and discrimination (11.01%). In stratified analyses, the factors that most attenuated the racial disparity in total ICH scores were neighborhood safety among men (12.32%) and discrimination among women (14.37%). Perceived stress did not attenuate the racial disparity in total ICH scores. Conclusions and Relevance: In this cross-sectional study of Black and White US adults aged 45 years and older, neighborhood-level factors, including safety and physical and social environments, and individual-level factors, including discrimination, attenuated racial disparities in cardiovascular health. Interventional approaches to improve ICH that separately target neighborhood context and discrimination by gender and race are warranted.

Dissemination and Implementation of a Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC): a study protocol for a hybrid type 1 randomized controlled trial.

BACKGROUND: There are persistent racial and ethnic health disparities in end-of-life health outcomes in the United States. African American patients are less likely than White patients to access palliative care, enroll in hospice care, have documented goals of care discussions with their healthcare providers, receive adequate symptom control, or die at home. We developed Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC) to address these disparities. DeCIDE PC is an integrated community health worker (CHW) palliative care intervention that uses community health workers (CHWs) as care team members to enhance the receipt of palliative care for African Americans with advanced cancer. The overall objectives of this study are to (1) assess the effectiveness of the DeCIDE PC intervention in improving palliative care outcomes amongst African American patients with advanced solid organ malignancy and their informal caregivers, and (2) develop generalizable knowledge on how contextual factors influence implementation to facilitate dissemination, uptake, and sustainability of the intervention. METHODS: We will conduct a multicenter, randomized, assessor-blind, parallel-group, pragmatic, hybrid type 1 effectiveness-implementation trial at three cancer centers across the United States. The DeCIDE PC intervention will be delivered over 6 months with CHW support tailored to the individual needs of the patient and caregiver. The primary outcome will be advance care planning. The treatment effect will be modeled using logistic regression. The secondary outcomes are quality of life, quality of communication, hospice care utilization, and patient symptoms. DISCUSSION: We expect the DeCIDE PC intervention to improve integration of palliative care, reduce multilevel barriers to care, enhance clinic and patient linkage to resources, and ultimately improve palliative care outcomes for African American patients with advanced cancer. If found to be effective, the DeCIDE PC intervention may be a transformative model with the potential to guide large-scale adoption of promising strategies to improve palliative care use and decrease disparities in end-of-life care for African American patients with advanced cancer in the United States. TRIAL REGISTRATION: Registered on ClinicalTrials.gov (NCT05407844). First posted on June 7, 2022.

Randomized controlled trial of a group peer mentoring model for U.S. academic medicine research faculty.

Introduction: Midcareer is a critical transition point for biomedical research faculty and a common dropout point from an NIH-funded career. We report a study to assess the efficacy of a group peer mentoring program for diverse biomedical researchers in academic medicine, seeking to improve vitality, career advancement, and cross-cultural competence. Methods: We conducted a stratified randomized controlled trial with a waitlist control group involving 40 purposefully diverse early midcareer research faculty from 16 states who had a first-time NIH R01 (or equivalent) award, a K training grant, or a similar major grant. The yearlong intervention (2 to 3 days quarterly) consisted of facilitated, structured, group peer mentoring. Main study aims were to enhance faculty vitality, self-efficacy in achieving research success, career advancement, mentoring others, and cultural awareness and appreciation of diversity in the workplace. Results: Compared to the control group, the intervention group's increased vitality did not reach statistical significance (P = 0.20), but perceived change in vitality was 1.47 standard deviations higher (D = 1.47, P = 0.03). Self-efficacy for career advancement was higher in the intervention group (D = 0.41, P = 0.05) as was self-efficacy for research (D = 0.57, P = 0.02). The intervention group also valued diversity higher (D = 0.46, P = 0.02), had higher cognitive empathy (D = 0.85, P = 0.03), higher anti-sexism/racism skills (D = 0.71, P = 0.01), and higher self-efficacy in mentoring others (D = 1.14, P = 0.007). Conclusions: The mentoring intervention resulted in meaningful change in important dimensions and skills among a national sample of diverse early midcareer biomedical faculty. This mentoring program holds promise for addressing the urgencies of sustaining faculty vitality and cross-cultural competence.

Health Experiences of African American Mothers, Wellness in the Postpartum Period and Beyond (HEAL): A Qualitative Study Applying a Critical Race Feminist Theoretical Framework.

The objective of this study is to explore the cultural, social, and historical factors that affect postpartum primary care utilization among Black women with cardiometabolic risk factors and to identify the needs, barriers, and facilitators that are associated with it. We conducted in-depth interviews of 18 Black women with one or more cardiometabolic complications (pre-pregnancy chronic hypertension, diabetes, obesity, preeclampsia, or gestational diabetes) within one year of delivery. We recruited women from three early home-visiting programs in Baltimore, Maryland, between May 2020 and June 2021. We used Critical Race Feminism theory and a behavioral model for healthcare utilization as an analytical lens to develop a codebook and code interview transcripts. We identified and summarized emergent patterns and themes using textual and thematic analysis. We categorized our findings into six main themes: (1) The enduring influence of structural racism, (2) personally mediated racism in healthcare and beyond, (3) sociocultural beliefs about preventative healthcare, (4) barriers to postpartum care transitions, such as education and multidisciplinary communication, (5) facilitators of postpartum care transitions, such as patient-provider relationships and continuity of care, and (6) postpartum health and healthcare needs, such as mental health and social support. Critical race feminism provides a valuable lens for exploring drivers of postpartum primary care utilization while considering the intersectional experiences of Black women.

Assessing Factors Influencing Commitment to a Disparities Reduction Intervention: Social Justice Attitudes and Organizational Mission.

ABSTRACT: This mixed-methods study aims to understand what the perceptions of leaders and healthcare professionals are regarding causes of disparities, cultural competence, and motivation before launching a disparity reduction project in hypertension care, contrasting perceptions in Federally Qualified Health Centers (FQHCs), and in a non-FQHC system. We interviewed leaders of six participating primary care systems and surveyed providers and staff. FQHC respondents reported more positive cultural competence attitudes and behavior, higher motivation to implement the project, and less concern about barriers to caring for disadvantaged patients than those in the non-FQHC practices; however, egalitarian beliefs were similar among all. Qualitative analysis suggested that the organizational missions of the FQHCs reflect their critical role in serving vulnerable populations. All system leaders were aware of the challenges of provider care to underserved groups, but comprehensive initiatives to address social determinants of health and improve cultural competence were still needed in both system types. The study provides insights into the perceptions and motivations of primary care organizational leaders and providers who are interested in improving chronic care. It also offers an example for care disparity programs to understand commitment and values of the participants for tailoring interventions and setting baseline for progress.

Are researchers in academic medicine flourishing? A survey of midcareer Ph.D. and physician investigators.

Introduction: Midcareer research faculty are a vital part of the advancement of science in U.S. medical schools, but there are troubling trends in recruitment, retention, and burnout rates. Methods: The primary sampling frame for this online survey was recipients of a single R01 or equivalent and/or K-award from 2013 to 2019. Inclusion criteria were 3-14 years at a U.S. medical school and rank of associate professor or two or more years as assistant professor. Forty physician investigators and Ph.D. scientists volunteered for a faculty development program, and 106 were propensity-matched controls. Survey items covered self-efficacy in career, research, work-life; vitality/burnout; relationships, inclusion, trust; diversity; and intention to leave academic medicine. Results: The majority (52%) reported receiving poor mentoring; 40% experienced high burnout and 41% low vitality, which, in turn, predicted leaving intention (P < 0.0005). Women were more likely to report high burnout (P = 0.01) and low self-efficacy managing work and personal life (P = 0.01) and to be seriously considering leaving academic medicine than men (P = 0.003). Mentoring quality (P < 0.0005) and poor relationships, inclusion, and trust (P < 0.0005) predicted leaving intention. Non-underrepresented men were very likely to report low identity self-awareness (65%) and valuing differences (24%) versus underrepresented men (25% and 0%; P < 0.0005). Ph.D.s had lower career advancement self-efficacy than M.D.s (P < .0005). Conclusions: Midcareer Ph.D. and physician investigators faced significant career challenges. Experiences diverged by underrepresentation, gender, and degree. Poor quality mentoring was an issue for most. Effective mentoring could address the concerns of this vital component of the biomedical workforce.

Design and Rationale of the Home Blood Pressure Telemonitoring Linked with Community Health Workers to Improve Blood Pressure (LINKED-BP) Program.

BACKGROUND: Disparities in hypertension outcomes persist among Black and Hispanic adults and persons living in poverty in the United States. The "LINKED-BP Program" is a multi-level intervention linking home blood pressure (BP) monitoring with a mobile health application, support from community health workers (CHWs), and BP measurement training at primary care practices to improve BP. This study is part of the American Heart Association RESTORE (AddREssing Social Determinants TO pRevent hypErtension) Network. This study aims to examine the effect of the LINKED-BP Program on BP reduction and to evaluate the reach, adoption, sustainability, and cost-effectiveness of the intervention. METHODS: Using a hybrid type I effectiveness-implementation design, 600 adults who have elevated BP or untreated stage 1 hypertension without diabetes, chronic kidney disease, history of cardiovascular disease (stroke or coronary heart disease) and age < 65 years will be recruited from 20 primary care practices including community health centers in the Maryland area. The practices are randomly assigned to the intervention or the enhanced usual care arms. Patients in the LINKED-BP Program receive training on home BP monitoring, BP telemonitoring through the Sphygmo app, and CHW telehealth visits for education and counseling on lifestyle modification over 12 months. The primary clinical outcome is change from baseline in systolic BP at 6 and 12 months. DISCUSSIONS: The LINKED-BP Program tests a sustainable, scalable approach to prevent hypertension and advance health equity. The findings will inform implementation strategies that address social determinants of health and barriers to hypertension prevention in underserved populations. CLINICALTRIALS.GOV IDENTIFIER: NCT05180045.

AddREssing Social Determinants TO pRevent hypErtension (The RESTORE Network): Overview of the Health Equity Research Network to Prevent Hypertension.

BACKGROUND: The American Heart Association funded a Health Equity Research Network on the prevention of hypertension, the RESTORE Network, as part of its commitment to achieving health equity in all communities. This article provides an overview of the RESTORE Network. METHODS: The RESTORE Network includes five independent, randomized trials testing approaches to implement non-pharmacological interventions that have been proven to lower blood pressure (BP). The trials are community-based, taking place in churches in rural Alabama, mobile health units in Michigan, barbershops in New York, community health centers in Maryland, and food deserts in Massachusetts. Each trial employs a hybrid effectiveness-implementation research design to test scalable and sustainable strategies that mitigate social determinants of health (SDOH) that contribute to hypertension in Black communities. The primary outcome in each trial is change in systolic BP. The RESTORE Network Coordinating Center has five cores: BP measurement, statistics, intervention, community engagement, and training that support the trials. Standardized protocols, data elements and analysis plans were adopted in each trial to facilitate cross-trial comparisons of the implementation strategies, and application of a standard costing instrument for health economic evaluations, scale up, and policy analysis. Herein, we discuss future RESTORE Network research plans and policy outreach activities designed to advance health equity by preventing hypertension. CONCLUSIONS: The RESTORE Network was designed to promote health equity in the US by testing effective and sustainable implementation strategies focused on addressing SDOH to prevent hypertension among Black adults.

mHealth Intervention for Promoting Hypertension Self-management Among African American Patients Receiving Care at a Community Health Center: Formative Evaluation of the FAITH! Hypertension App.

BACKGROUND: African American individuals are at a higher risk of premature death from cardiovascular diseases than White American individuals, with disproportionate attributable risk from uncontrolled hypertension. Given their high use among African American individuals, mobile technologies, including smartphones, show promise in increasing reliable health information access. Culturally tailored mobile health (mHealth) interventions may promote hypertension self-management among this population. OBJECTIVE: This formative study aimed to assess the feasibility of integrating an innovative mHealth intervention into clinical and community settings to improve blood pressure (BP) control among African American patients. METHODS: A mixed methods study of African American patients with uncontrolled hypertension was conducted over 2 consecutive phases. In phase 1, patients and clinicians from 2 federally qualified health centers (FQHCs) in the Minneapolis-St Paul, Minnesota area, provided input through focus groups to refine an existing culturally tailored mHealth app (Fostering African-American Improvement in Total Health! [FAITH!] App) for promoting hypertension self-management among African American patients with uncontrolled hypertension (renamed as FAITH! Hypertension App). Phase 2 was a single-arm pre-post intervention pilot study assessing feasibility and patient satisfaction. Patients receiving care at an FQHC participated in a 10-week intervention using the FAITH! Hypertension App synchronized with a wireless BP monitor and community health worker (CHW) support to address social determinants of health-related social needs. The multimedia app consisted of a 10-module educational series focused on hypertension and cardiovascular risk factors with interactive self-assessments, medication and BP self-monitoring, and social networking. Primary outcomes were feasibility (app engagement and satisfaction) and preliminary efficacy (change in BP) at an immediate postintervention assessment. RESULTS: In phase 1, thirteen African American patients (n=9, 69% aged ≥50 years and n=10, 77% women) and 16 clinicians (n=11, 69% aged ≥50 years; n=14, 88% women; and n=10, 63% African American) participated in focus groups. Their feedback informed app modifications, including the addition of BP and medication tracking, BP self-care task reminders, and culturally sensitive contexts. In phase 2, sixteen African American patients were enrolled (mean age 52.6, SD 12.3 years; 12/16, 75% women). Overall, 38% (6/16) completed ≥50% of the 10 education modules, and 44% (7/16) completed the postintervention assessment. These patients rated the intervention a 9 (out of 10) on its helpfulness in hypertension self-management. Qualitative data revealed that they viewed the app as user-friendly, engaging, and informative, and CHWs were perceived as providing accountability and support. The mean systolic and diastolic BPs of the 7 patients decreased by 6.5 mm Hg (P=.15) and 2.8 mm Hg (P=.78), respectively, at the immediate postintervention assessment. CONCLUSIONS: A culturally tailored mHealth app reinforced by CHW support may improve hypertension self-management among underresourced African American individuals receiving care at FQHCs. A future randomized efficacy trial of this intervention is warranted. TRIAL REGISTRATION: ClinicalTrials.gov NCT04554147; https://clinicaltrials.gov/ct2/show/NCT04554147.

A framework for setting enrollment goals to ensure participant diversity in sponsored clinical trials in the United States.

BACKGROUND: Diversity in clinical trials (CTs) has the potential to improve health equity and close health disparities. Underrepresentation of historically underserved groups compromises the generalizability of trial findings to the target population, hinders innovation, and contributes to low accrual. The aim of this study was to establish a transparent and reproducible process for setting trial diversity enrollment goals informed by the disease epidemiology. METHOD: An advisory board of epidemiologists with expertise in health disparities, equity, diversity, and social determinants of health was convened to evaluate and strengthen the initial goal-setting framework. Data sources used were the epidemiologic literature, US Census, and real-world data (RWD); limitations were considered and addressed where appropriate. A framework was designed to safeguard against the underrepresentation of historically medically underserved groups. A stepwise approach was created with Y/N decisions based on empirical data. RESULTS: We compared race and ethnicity distributions in the RWD of six diseases from Pfizer's portfolio chosen to represent different therapeutic areas (multiple myeloma, fungal infections, Crohn's disease, Gaucher disease, COVID-19, and Lyme disease) to the distributions in the US Census and established trial enrollment goals. Enrollment goals for potential CTs were based on RWD for multiple myeloma, Gaucher disease, and COVID-19; enrollment goals were based on the Census for fungal infections, Crohn's disease, and Lyme disease. CONCLUSIONS: We developed a transparent and reproducible framework for setting CT diversity enrollment goals. We note how limitations due to data sources can be mitigated and consider several ethical decisions in setting equitable enrollment goals.

A Path Forward: COVID-19 Vaccine Equity Community Education and Outreach Initiative.

COVID-19 vaccines offer hope to end the COVID-19 pandemic. In this article, we document key lessons learned as we continue to confront COVID-19 variants and work to adapt our vaccine outreach strategies to best serve our community. In the fall of 2020, the Office of Diversity, Inclusion and Health Equity at Johns Hopkins Medicine, in collaboration with the Office of Government and Community Affairs for Johns Hopkins University and Medicine, established the COVID-19 Vaccine Equity Community Education and Outreach Initiative in partnership with faith and community leaders, local and state government representatives, and community-based organizations. Working with community and government partnerships established before COVID-19 enabled our team to quickly build infrastructure focused on COVID-19 vaccine education and equity. These partnerships resulted in the development and implementation of web-based educational content, major culturally adapted media campaigns (reaching more than 200,000 individuals), community and faith education outreach, youth-focused initiatives, and equity-focused mobile vaccine clinics. The community mobile vaccine clinics vaccinated over 3,000 people in the first 3 months. Of these, 90% identified as persons of color who have been disproportionately impacted during the COVID-19 pandemic. Academic-government-community partnerships are vital to ensure health equity. Community partnerships, education events, and open dialogues were conducted between the community and medical faculty. Using nontraditional multicultural media venues enabled us to reach many community members and facilitated informed decisionmaking. Additionally, an equitable COVID-19 vaccine policy requires attention to vaccine access as well as access to sound educational information. Our initiative has been thoughtful about using various types of vaccination sites, mobile vaccine units, and flexible hours of operation.

Addressing Hypertension Care in Africa (ADHINCRA): Study protocol for a cluster-randomized controlled pilot trial.

BACKGROUND: Uncontrolled hypertension is a major risk factor for cardiovascular disease. Evidence-based interventions to improve hypertension control in high-income countries have not been translated equally in sub-Saharan Africa (SSA). The objective of the Addressing Hypertension Care in Africa (ADHINCRA) Study was to test the feasibility and signal of efficacy of a multilevel, nurse-led, mobile health enhanced intervention in improving hypertension control in Ghana. METHODS: Using a cluster randomized controlled pilot trial design, four hospitals in Kumasi, Ghana, were randomized to the intervention arm (2 hospitals) and enhanced usual care arm (2 hospitals). A total of 240 patients with uncontrolled hypertension defined as systolic blood pressure (BP) ≥140 mmHg on their most recent visit were included (60 patients per hospital). Patients in the intervention arm received an intervention that consisted of nurse-led task-shifting and a mobile health application (Medtronic® Labs' Empower Health), and home BP monitoring. The enhanced usual care arm received usual care as determined by their providers, plus short text messages on health. The intervention was administered for six months, after which it was withdrawn, and patients were followed for six more months to assess outcomes. Feasibility measures included recruitment and dropout rates of study participants, protocol adherence in both arms. Clinical outcomes included changes in BP control status and systolic BP levels from baseline. Secondary outcomes included change in glycemic control, rates of hypertensive urgencies/emergencies, cardiovascular disease events, and medication adherence. DISCUSSION: Findings from this study will provide critical pilot data to inform the conduct of a larger scale trial and the development of scalable health system and policy interventions to improve hypertension control in low-resource settings. Trial registration NCT04010344. Registered on July 8, 2019 at ClinicalTrials.govhttps://clinicaltrials.gov/ct2/show/NCT04010344.

Adverse Childhood Experiences, Depression, Patient Activation, and Medication Adherence Among Patients With Uncontrolled Hypertension.

BACKGROUND: Identifying potential pathways through which adverse childhood experiences (ACEs) impact health and health behavior remains important, given ACE survivors' increased risk for cardiovascular disease and poor cardiovascular health behaviors. This study examines whether modifiable variables-depression and patient activation-explain the relationship between ACEs and medication adherence. METHODS: Using baseline data from a pragmatic trial designed to decrease disparities in hypertension control, we conducted regression analyses to examine whether depression and patient activation mediated the association between ACEs and medication adherence. Data were collected between August 2017 and October 2019 (n = 1,818). RESULTS: Participants were predominantly female (59.4%) and Black or African American (57%) with uncontrolled blood pressure (mean-152.3/85.5 mm Hg). Most participants reported experiencing at least 1 ACE (71%) and approximately 50% reported being adherent to their blood pressure medication. A significant indirect effect between ACEs and medication adherence was found for depression symptoms (Sobel's test z = -5.46, P < 0.001). Patient activation was not a mediator in these relationships. CONCLUSIONS: Experiencing more depression symptoms significantly accounted for the association between ACEs and medication adherence in a diverse sample of adults with uncontrolled blood pressure. Addressing depression symptoms, which may result from experiences with ACEs and other current stressors, could translate to better medication adherence and, potentially, better blood pressure control among this high-risk group. Given the serious lifetime health implications of ACEs, continued efforts are needed for primary prevention of childhood adversities.

Puerto Rican healthcare workers' perspectives on the impact of COVID-19 pandemic on their role, patient care, and mental health.

PURPOSE: To explore the personal and work-related stressors of healthcare workers in Puerto Rico and the organizational support they received during the pandemic. DESIGN AND METHODS: We used a qualitative descriptive design and from April - November, 2021, conducted semi-structured individual interviews with Puerto Rican frontline healthcare workers (n = 12) and supervisors (n = 5). FINDINGS: Thematic analysis revealed five major themes: (a) Organizations' response to COVID-19; (b) increased complexity of patients; (c) intensified work and psychological demand for nurses; (d) overwhelmed and overworked; and (e) recommendations for healthcare leadership. Participants explained that their organizations' responses to COVID-19 were insufficient for  meeting the demands and acuity of the patients. Closure of outpatient services contributed to people presenting to hospitals with exacerbated chronic conditions - especially the elderly. With COVID-19 precautions prohibiting family visitation, nurses became responsible for total care, including emotional support of patients. In addition, the shortage of staff contributed to nurses assuming greater workloads, feeling overwhelmed and overworked, and healthcare worker resignations. Given their experiences, healthcare workers recommended that healthcare leadership show more appreciation for staff, demonstrate empathy, include frontline workers in decision-making, and provide mental health resources for staff. CONCLUSIONS: This study with Puerto Rican frontline workers and supervisors uncovers the multiple stressors experienced during the COVID-19 pandemic. Our findings underscore the need for prioritizing the well-being of healthcare workers, preparing healthcare leadership on how to support staff, and mandating nurse-to-patient ratios. CLINICAL RELEVANCE: Healthcare workers explained the barriers they experienced for providing quality care to their patients. They also presented recommendations for healthcare leadership to facilitate supporting frontline workers, which ultimately contributes to optimal patient care.

"Living like an empty gas tank with a leak": Mixed methods study on post-acute sequelae of COVID-19.

BACKGROUND: The burden and presentation of post-acute sequela of SARS-CoV-2 infection (PASC) are a developing major public health concern. OBJECTIVES: To characterize the burden of PASC in community-dwelling individuals and understand the experiences of people living with PASC. METHODS: This mixed-methods study of COVID-19 positive community-dwelling persons involved surveys and in-depth interviews. Main outcome was self-report of possible PASC symptoms 3 weeks or longer after positive COVID-19 test. In-depth interviews were guided by a semi-structured interview guide with open-ended questions and probes based on emerging literature on PASC and the impact of COVID-19. RESULTS: With a survey response rate of 70%, 442 participants were included in this analysis, mean (SD) age 45.4 (16.2) years, 71% female, 12% Black/African American. Compared to those with no PASC symptoms, persons who reported PASC symptoms were more likely to be older (mean age: 46.5 vs. 42; p = 0.013), female (74.3% vs. 61.2%; p = 0.010), to have pre-existing conditions (49.6% vs. 34%; p = 0.005), and to have been hospitalized for COVID-19 (14.2% vs. 2.9%; p = 0.002). About 30% of the participants experienced severe fatigue; the proportion of persons reporting severe fatigue was 7-fold greater in those with PASC symptoms (Adjusted Prevalence Ratio [aPR] 6.73, 95%CI: 2.80-16.18). Persons with PASC symptoms were more likely to report poor quality of life (16% vs. 5%, p<0.001) and worse mental health functioning (Mean difference: -1.87 95%CI: -2.38, -1.37, p<0.001). Themes from in-depth interviews revealed PASC was experienced as debilitating. CONCLUSIONS: In this study, the prevalence of PASC among community-dwelling adults was substantial. Participants reported considerable coping difficulties, restrictions in everyday activities, invisibility of symptoms and experiences, and impediments to getting and receiving PASC care.