Real-World Evaluation of an Automated Algorithm to Detect Patients With Potentially Undiagnosed Hypertension Among Patients With Routine Care in Hawai'i.

BACKGROUND: This real-world evaluation considers an algorithm designed to detect patients with potentially undiagnosed hypertension, receiving routine care, in a large health system in Hawai'i. It quantifies patients identified as potentially undiagnosed with hypertension; summarizes the individual, clinical, and health system factors associated with undiagnosed hypertension; and examines if the COVID-19 pandemic affected detection. METHODS AND RESULTS: We analyzed the electronic health records of patients treated across 6 clinics from 2018 to 2021. We calculated total patients with potentially undiagnosed hypertension and compared patients flagged for undiagnosed hypertension to those with diagnosed hypertension and to the full patient panel across individual characteristics, clinical and health system factors (eg, clinic of care), and timing. Modified Poisson regression was used to calculate crude and adjusted risk ratios. Among the eligible patients (N=13 364), 52.6% had been diagnosed with hypertension, 2.7% were flagged as potentially undiagnosed, and 44.6% had no evidence of hypertension. Factors associated with a higher risk of potentially undiagnosed hypertension included individual characteristics (ages 40-84 compared with 18-39 years), clinical (lack of diabetes diagnosis) and health system factors (clinic site and being a Medicaid versus a Medicare beneficiary), and timing (readings obtained after the COVID-19 Stay-At-Home Order in Hawai'i). CONCLUSIONS: This evaluation provided evidence that a clinical algorithm implemented within a large health system's electronic health records could detect patients in need of follow-up to determine hypertension status, and it identified key individual characteristics, clinical and health system factors, and timing considerations that may contribute to undiagnosed hypertension among patients receiving routine care.

Health literacy in former Soviet Union immigrants in the US: A mixed methods study.

BACKGROUND: People with limited health literacy may have trouble finding, understanding, and using health-related information and services and navigating the healthcare system. PURPOSE: The purpose of this study was to assess the health literacy of immigrants from the former Soviet Union (FSU) using the Health Literacy Survey (HLS19-Q12 in Russian) and explore associated socio-demographic factors. METHOD: This mixed methods study recruited adult immigrants through social networks and social media and included data from online survey and follow-up interviews. Variance in health literacy was explained using multiple linear regression. Qualitative data were analyzed through modified Grounded Theory approach. FINDINGS: Survey respondents (n = 318) were primarily female college-educated FSU immigrants aged 20-74 from 14 of the 15 FSU countries and distributed across 33 US states. Forty percent scored at or below predefined cut-offs for inadequate or problematic health literacy levels. Social status, social support, and English proficiency were significant variables in explaining variance in health literacy scores while controlling for age, gender, and education. Interviews (n = 24) identified eight themes: English proficiency, social support, health insurance, experience with health care, complexity of the US healthcare system, relevant health information, health beliefs/practices, and trust. DISCUSSION: There is a need to distribute health-related information in the native language (e.g., Russian), potentially through social media and immigrants' social networks. Health providers should be aware of the prevalence of inadequate and problematic health literacy among FSU immigrants and consider associated social factors.

Social networks in patients hospitalized with preventable conditions for heart disease and diabetes in Hawai'i by health literacy.

OBJECTIVES: Reducing potentially preventable hospitalizations (PPH) for chronic disease is a research and practice priority. Native Hawaiians and other Pacific Islanders (NHOPI) have disparities in PPH, and are understudied in both health literacy and social network research. Greater inclusion of social and familial networks can help address health disparities among people with chronic illness and enhance culturally relevant healthcare. METHODS: Adults hospitalized with a heart disease or diabetes-related PHH in Hawai'i (N = 22) were assessed for health literacy and social network membership ("alters"). RESULTS: Sixty-nine percent of respondents were NHOPI. Three respondents (14%) had no alters ("isolates"). Among non-isolates, 79% desired the participation of at least one alter in chronic disease management-related interventions. Fifty-nine percent of respondents had low health literacy. While the mean number of alters did not vary significantly by health literacy, those with lower health literacy had a trend (p = .055) towards less interest in social network engagement. DISCUSSION: In a sample primarily comprised of NHOPI with chronic disease, many patients wished to include social network members in interventions. Engagement varied by health literacy with implications for health disparities. Not all patients were interested in social network engagement, which must be considered in intervention planning.

A Multilingual Integrative Review of Health Literacy in Former Soviet Union, Russian-Speaking Immigrants.

Large diasporas of former Soviet Union (FSU) immigrants are found in the USA, Germany, and Israel. To synthesize evidence, identify limitations, and propose future directions we conducted an integrative review on the health literacy of FSU immigrants, migrants, or refugees in four languages. Following integrative review and PRISMA guidelines, we searched four databases in English and performed supplementary searches in Russian, German, and Hebrew to identify qualitative and quantitative studies on FSU immigrants and health literacy. Six articles met inclusion criteria in English and one in German; the majority were published in the last five years. Only two articles measured health literacy of FSU immigrants, which was lower than the general population. Four articles were about immigrants with a mean age ≥50 years. All articles stressed the value of translated, culturally relevant health information. The health literacy of FSU immigrants is understudied, despite clear needs. Future research should include assessments of FSU immigrants' health literacy and include diverse (e.g., age, gender) yet well-defined populations to determine both barriers and facilitators to their health literacy. This review, an example of a multilingual search, provided a comprehensive understanding of existing literature and is a useful approach for global health literacy research.

Promoting a Culture of Prevention in Albania: the "Si Je?" Program.

Albania is a small country on the Balkan Peninsula that recently implemented an innovative primary healthcare program called "Si Je?" (How are you?) which allowed all Albanians aged 40-65 years to receive a free, yearly basic health examination at their local health center. Access to basic primary care is a critical component of a nationwide culture of prevention particularly for the non-communicable diseases that comprise 89% of total deaths in the country. Yet, as in many middle-income countries, a culture of prevention in Albania is often secondary to ensuring basic health infrastructure and healthcare access for those critically in need. Using the social-ecological model as our conceptual framework, this paper provides new insights into the culture of prevention in Albania by analyzing the need for, and implementation of, the Si Je? program using (1) findings from a critical literature review, (2) quantitative data from the database created from this program, and (3) qualitative data from key informant interviews from 15 health center directors. Positive developments towards a culture of prevention include the fact that the Si Je? program has been expanded to those 35-70 years, strengthened links between community and primary care, and participation among rural communities who traditionally have limited primary care access. Challenges include continued urgent health infrastructure needs, politicization of the Si Je? effort, limited participation by some groups (particularly urban men), and regional variations. Despite challenges, Albania appears to be building new infrastructure for a sustainable culture of prevention, particularly around chronic disease.

Racial and ethnic disparities in obesity prevalence among children, adolescents, and young adults receiving inpatient care in Hawai'i, 2015-2016.

The number of hospitalizations with an obesity diagnosis have increased among youth in the past two decades, yet remain understudied, particularly among racial/ethnic minority groups. The purpose of this study was to characterize obesity prevalence among children, adolescents, and young adults receiving inpatient care in Hawai'i acute care hospitals during 2015-2016. This study analyzed statewide administrative data from a racially and ethnically diverse population. Participants (N = 7,751) included Hawai'i residents aged 5-29 years receiving inpatient care, excluding those hospitalized due to pregnancy. Recorded height and weight were used to calculate body mass index (BMI) and classify obesity. Primary or secondary diagnoses for obesity were assessed. A multivariable logistic regression model was used to determine characteristics associated with obesity, including race/ethnicity-sex interaction, age group, insurance payer, and county of residence. Based on BMI, 28.4% (2,202/7,751) of patients had obesity. However, an obesity diagnosis was present only in 40.4% (889/2,202) of patients with obesity based on BMI (11.9% of all patients). In the multivariable model, compared to whites, the odds of having obesity were highest among Pacific Islanders [adjusted odds ratio (aOR) = 4.07, 95% CI(3.16-5.23)] and Native Hawaiians [aOR = 2.16, 95% CI(1.75-2.67)] for females, and among Pacific Islanders [aOR = 5.39, 95% CI(4.27-6.81)], Native Hawaiians [aOR = 2.36, 95% CI(1.91-2.91)], and Filipinos [aOR = 2.08, 95% CI(1.64-2.64)] for males. Obesity was also associated with age group, but not insurance payer type or county of residence. These findings support the need for greater attention to obesity in the inpatient setting and equity-focused interventions to reduce obesity among younger hospitalized patients.

Self-Measured Blood Pressure Monitoring: Program Planning, Implementation, and Lessons Learned From 5 Federally Qualified Health Centers in Hawai'i.

Self-measured blood pressure monitoring programs (BPMPs) are effective at controlling hypertension. We examined implementation of self-measured BPMPs at 5 Hawai'i-based Federally Qualified Health Centers (FQHCs). In a process evaluation of these programs, we found that FQHCs developed protocols for self-measured BPMP recruitment and enrollment and provided additional supports to account for their patients' psychosocial needs to achieve blood pressure control, such as lifestyle change education and opportunities through referrals either to on-site or other programs (eg, on-site gym, tobacco cessation program). Common barriers across sites included insufficient material support for blood pressure monitors and data collection; funding, which affects program sustainability; and the lack of an "off-the-shelf" self-measured BPMP intervention. Policy makers and funding organizations should address these issues related to self-measured BPMPs to ensure implementation success.

International Perspective on Health Literacy and Health Equity: Factors That Influence the Former Soviet Union Immigrants.

Among the world's 272 million international migrants, more than 25 million are from the former Soviet Union (FSU), yet there is a paucity of literature available about FSU immigrants' health literacy. Besides linguistic and cultural differences, FSU immigrants often come from a distinct healthcare system affecting their ability to find, evaluate, process, and use health information in the host countries. In this scoping review and commentary, we describe the health literacy issues of FSU immigrants and provide an overview of FSU immigrants' health literacy based on the integrated health literacy model. We purposefully consider the three most common locations where FSU immigrants have settled: the USA, Germany, and Israel. For context, we describe the healthcare systems of the three host countries and the two post-Soviet countries to illustrate the contribution of system-level factors on FSU immigrants' health literacy. We identify research gaps and set a future research agenda to help understand FSU immigrants' health literacy across countries. Amidst the ongoing global population changes related to international migration, this article contributes to a broad-scope understanding of health literacy among FSU immigrants related to the system-level factors that may also apply to other immigrants, migrants, and refugees.

Insights in Public Health: Outpatient Care Gaps for Patients Hospitalized with Ambulatory Care Sensitive Conditions in Hawai'i: Beyond Access and Continuity of Care.

Ambulatory care sensitive conditions (ACSCs) are conditions that can generally be managed in community-based healthcare settings, and, if managed well, should not require hospital admission. A 5-year, mixed methods study was recently concluded that (1) documented disparities in hospitalizations for ACSCs in Hawai'i through quantitative analysis of state-wide hospital discharge data; and (2) identified contributing factors for these hospitalizations through patient interviews. This Public Health Insights article provides deeper context for, and consideration of, a striking study finding: the differences between typical measures of access to care and the quality of patient/provider interactions as reported by study participants. The themes that emerged from the patients' stories of their own potentially preventable hospital admissions shed light on the importance of being heard, trust, communication, and health knowledge in their relationships with their providers. We conclude that improving the quality of the relationship and level of engagement between the patient and community/outpatient providers may help reduce hospitalizations for ACSCs in Hawai'i and beyond. These interpersonal-level goals should be supported by systems-level efforts to improve health care delivery and address health disparities.

Meeting Physical Activity Guidelines by Walking in Older Adults From Three Middle-Income Countries: A Cross-Sectional Analysis From the International Mobility in Aging Study.

Physical activity (PA) among older adults is understudied in middle-income countries. The authors examined the associations of factors across levels of the social ecological model (individual, interpersonal, organizational, and community) with older adults meeting guidelines of 150 min of moderate- to vigorous-intensity PA per week through walking in three middle-income countries: Albania (n = 387), Colombia (n = 404), and Brazil (n = 402). Using 2012 International Mobility in Aging Study data, multivariate logistic regression models identified the following significant associations with meeting PA guidelines through walking (a) individual level: depression (odds ratio [OR] = 0.62, 95% confidence interval, CI [0.45, 0.86]), being female (OR = 0.74, 95% CI [0.56, 0.998]), and high relative education (OR = 1.79, 95% CI [1.33, 2.41]) and (b) interpersonal level: high life partner (OR = 1.38, 95% CI [1.04, 1.83]) and friend social ties (OR = 1.39, 95% CI [1.05, 1.83]). While individual and interpersonal variables were associated with meeting PA guidelines, community-level social and environmental variables were not.

Community Health Workers in Hawai'i: A Scoping Review and Framework Analysis of Existing Evidence.

Introduction: Community health workers (CHWs) play a vital role in health across Hawai'i, but the scope of this work is not comprehensively collated. This scoping review describes the existing evidence of the roles and responsibilities of CHWs in Hawai'i. Methods: Between May and October 2018, researchers gathered documents (eg, reports, journal articles) relevant to Hawai'i CHWs from health organizations, government entities, colleges/universities, and CHWs. Documents were reviewed for overall focus and content, then analyzed using the Centers for Disease Control and Prevention's 10 Essential Public Health Services as well as the Community Health Worker Core Consensus Project roles to identify workplace roles and gaps. Results: Of 92 documents received, 68 were included for review. The oldest document dated to 1995. Document types included curricula outlines, unpublished reports, and peer-reviewed articles. Documents discussed trainings, certification programs, CHWs' roles in interventions, and community-, clinical-, and/or patient-level outcomes. Cultural concordance parity between CHWs and patients, cost savings, and barriers to CHW work were noted. Most roles named by the Community Health Worker Core Consensus Project were mentioned in documents, but few were related to the roles of "community/policy advocacy" and "participation in research and evaluation." Workplace roles, as determined using the 10 Essential Public Health Services, focused more on "assuring workforce competency" and "evaluation," and less on "policy development," and "enforcing laws." Discussion: CHWs are an important part of Hawaii's health system and engage in many public health functions. Although CHW roles in Hawai'i mirrored those identified by the CHW Core Consensus Project and 10 Essential Public Health Services frameworks, there is a noticeable gap in Hawai'i CHW professional participation in research, evaluation, and community advocacy.

Legislative Definitions of Community Health Workers: Examples from Other States to Inform Hawai'i.

Community health workers (CHWs) have been important contributors to the health and wellness of disenfranchised and minority communities for more than 50 years in the United States. Recently the Centers for Disease Control and Prevention (CDC) recommended several policy initiatives to support and advance the CHW workforce, including formalizing a state-level definition for CHWs. Such state-wide standards can lay the groundwork for health insurance reimbursement for CHW services, help establish a professional identity, and generate cohesion among CHWs. Some states have already adopted a formal definition of CHWs. Hawai'i has had grassroots and political movement in this direction, although no widespread, formal consensus has been reached. This paper reviews decisions in other states in formally defining CHWs in order to inform efforts in Hawai'i. As of February 2019, data has been collected on states which have formally defined CHWs. Two independent reviewers compared the definitions used in 15 states with formalized definitions using the American Public Health Association (APHA) CHW Section definition. We found that most states built upon the APHA definition to create working definitions that were codified into law, sometimes with minor modifications for relevance to their communities. Given the widespread use of the APHA definition, Hawai'i may also find benefit from using the APHA definition as a backbone for a state-level definition. Critically, following best practices, it will be important to take steps to ensure CHW self-determination in all aspects of the processes towards a state-level definition of and scope of care for CHWs.

Community Health Workers in Action: Community-Clinical Linkages for Diabetes Prevention and Hypertension Management at 3 Community Health Centers.

In 2014, the Hawai'i State Department of Health (HDOH) received funding from the Centers for Disease Control and Prevention (CDC), via the 1422 Cooperative Agreement, to conduct diabetes prevention and hypertension management. To implement one grant-required strategy-the engagement of community health workers (CHWs) to promote community-clinical linkages-the HDOH partnered with the Hawai'i Primary Care Association and 9 federally qualified health centers (FQHCs). This qualitative evaluation case study sought to understand how 3 of the funded FQHCs engaged CHWs, the types of community-clinical linkages the CHWs promoted, and the facilitators of and barriers to those linkages. Evaluators conducted 2 semi-structured group interviews with 6 administrators/clinicians and 7 CHWs in April 2018. The transcribed interviews were deductively and inductively analyzed to identify major themes. First, CHWs made multiple internal and external linkages using resources provided by the grant as well as other resources. Second, CHWs faced barriers in making community-clinical linkages due to individual patient, geographic, and economic constraints. Third, CHWs have unmet professional needs related to building community-clinical linkages including professional development, networking, and burnout. Reimbursement and payment mechanisms are an all-encompassing challenge to the sustainability of CHW positions, as disease-specific funding and a complete lack of reimbursement structures make CHW positions unstable. Thus, CHWs fulfill a number of grant-specific roles at FQHCs due to this patchwork of funding sources, and this relates to CHWs' experiences of burnout. Policy implications of this study include funding and reimbursement stabilization so FQHCs may consistently engage and support the CHW workforce to meet their patients' complex, diverse needs. More professional development opportunities for CHWs are necessary to build sustainable networks of resources.

Insights in Public Health: Formative Factors for a Statewide Tobacco Control Advocacy Infrastructure: Insights from Hawai'i.

Hawai'i has comprehensive statewide tobacco control policies and was the first US state to raise the minimum age of sale, purchase, and possession of tobacco products to age 21 ("Tobacco 21") in a policy including not just cigarettes, but also electronic smoking devices and other tobacco products. This insights article provides strategic thinking about tobacco control advocacy planning. Specifically, we identify formative factors critical to building and sustaining our cross-sector, statewide advocacy infrastructure that has been able to address many ongoing challenges of tobacco-use prevention and control over time. This can provide new insights for other large-scale tobacco-control advocacy efforts.

Gender Differences in the Rate of 30-Day Readmissions after Percutaneous Coronary Intervention for Acute Coronary Syndrome.

BACKGROUND: It has been reported that women have higher 30-day readmission rates than men after acute coronary syndrome (ACS). However, readmission after percutaneous coronary intervention (PCI) for ACS is a distinct subset of patients in whom gender differences have not been adequately studied. METHODS: Hawaii statewide hospitalization data from 2010 to 2015 were assessed to compare gender differences in 30-day readmission rates among patients hospitalized with ACS who underwent PCI during the index hospitalization. Readmission diagnoses were categorized using an aggregated version of the Centers for Medicare and Medicaid Services Condition Categories. Multivariable logistic regression was applied to evaluate the effect of gender on the 30-day readmission rate. RESULTS: A total of 5,354 patients (29.4% women) who were hospitalized with a diagnosis of ACS and underwent PCI were studied. Overall, women were older, with more identified as Native Hawaiian, and had a higher prevalence of cardiovascular risk factors compared with men. The 30-day readmission rate was 13.9% in women and 9.6% in men (p < .0001). In the multivariable model, female gender (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.09-1.60), Medicaid (OR, 1.48; 95% CI, 1.07-2.06), Medicare (1.72; 95% CI, 1.35-2.19), heart failure (1.88; 95% CI, 1.53-2.33), atrial fibrillation (OR, 1.54; 95% CI-1.21-1.95), substance use (OR, 1.88; 95% CI, 1.27-2.77), history of gastrointestinal bleeding (OR, 2.43; 95% CI, 1.29-4.58), and chronic kidney disease (OR, 1.78; 95% CI, 1.42-2.22) were independent predictors of 30-day readmissions. Readmission rates were highest during days 1 through 6 (peak, day 3) after discharge. The top three cardiac causes of readmissions were heart failure, recurrent angina, and recurrent ACS. CONCLUSIONS: Female gender is an independent predictor of 30-day readmission after ACS that requires PCI. Our finding suggests women are at a higher risk of post-ACS cardiac events such as heart failure and recurrent ACS, and further gender-specific intervention is needed to reduce 30-day readmission rate in women after ACS.

Social and community factors associated with hypertension awareness and control among older adults in Tirana, Albania.

Background: Determinants of hypertension diagnosis and/or awareness and control among older adults are understudied in Albania, a former communist country in South Eastern Europe, which is experiencing rapid demographic, socioeconomic and epidemiological transition. This paper examines the association of individual, interpersonal, organizational and community factors with hypertension awareness and control among older adults in Tirana, the Albanian capital. Methods: Using 2012 International Mobility in Aging Study data on older adults from Albania's capital city (n = 393) and the socioecological model as a conceptual framework, multinomial regression models identified factors associated with controlled, uncontrolled and undiagnosed hypertension. Results: For hypertension, 17.3% participants had none, 23.4% were controlled, 48.4% were uncontrolled and 10.9% were undiagnosed/unaware. Compared to those with controlled hypertension, in multivariable models, a high level of friend support was negatively associated with uncontrolled (OR: 0.4; 95% CI: 0.2-0.9) and undiagnosed (OR: 0.2; 95% CI: 0.1-0.6) hypertension. A high level of perceived neighbourhood safety was negatively associated with uncontrolled (OR: 0.6; 95% CI: 0.3-1.0) and undiagnosed (OR: 0.4; 95% CI: 0.2-1.0) hypertension. Compared to those with no hypertension, children's social support was positively associated with uncontrolled (OR: 2.2; 95% CI: 1.1-4.3) and undiagnosed (OR: 3.6; 95% CI: 1.3-9.6) hypertension. Conclusion: This study provides new insights about distinct risk factors for inadequate hypertension management in Albania. It highlights the importance of community-level factors (safety) and interpersonal factors (family and friend ties) to hypertension diagnosis/awareness and control, which may provide novel intervention opportunities for hypertension programs.