A Community Health Advisor Program to reduce cardiovascular risk among rural African-American women.

The Uniontown, Alabama Community Health Project trained and facilitated Community Health Advisors (CHAs) in conducting a theory-based intervention designed to reduce the risk for cardiovascular disease (CVD) among rural African-American women. The multiphased project included formative evaluation and community organization, CHA recruitment and training, community intervention and maintenance. Formative data collected to develop the training, intervention and evaluation methods and materials indicated the need for programs to increase knowledge, skills and resources for changing behaviors that increase the risk of CVD. CHAs worked in partnership with staff to develop, implement, evaluate and maintain strategies to reduce risk for CVD in women and to influence city officials, business owners and community coalitions to facilitate project activities. Process data documented sustained increases in social capital and community capacity to address health-related issues, as well as improvements in the community's physical infrastructure. This project is unique in that it documents that a comprehensive CHA-based intervention for CVD can facilitate wide-reaching changes in capacity to address health issues in a rural community that include improvements in community infrastructure and are sustained beyond the scope of the originally funded intervention.

Cancer prevention in rural primary care. An academic-practice partnership.

BACKGROUND: Cancer screening rates are particularly low among poor, minority, and rural women, those segments of the population with the highest cancer mortality risk. Therefore, targeted strategies to increase screening in these population groups are needed. METHODS: This paper describes a partnership between the University of Alabama at Birmingham (UAB) and Family HealthCare of Alabama, a nonprofit health care agency, initiated to promote cancer control and prevention in a predominantly low-income, African-American population in rural western Alabama. The partnership has collaborated in the development of two research proposals designed specifically to evaluate cancer control strategies within the context of routine health care delivery. RESULTS: The UAB/Family HealthCare partnership is conducting two randomized treatment outcome studies funded by the National Cancer Institute to evaluate theory-based patient management strategies to promote patient adherence to screening recommendations for cervical cancer and breast cancer. CONCLUSIONS: The success of this academic-practice partnership can be seen in the funded research projects, the enhancement of preventive services in rural primary care, and in the potential to disseminate theory-based cancer control strategies throughout an extended primary care network.

Effects of multiple attempts to quit smoking and relapses to smoking on pulmonary function. Lung Health Study Research Group.

The effect of intermittent smoking on pulmonary function was assessed among participants in the Lung Health Study, 5887 adult smokers with evidence of early chronic obstructive pulmonary disease (COPD), followed up for 5 years. The mean annual rate of loss in FEV1% of predicted after year 1 was smallest for those who quit at some point during the first year of the study and stayed quit (-0.33%/year, +/-0.05%), intermediate for those who smoked intermittently during the study (-0.58%/year, +/-0.05%) and greatest for those who continued to smoke throughout the study (-1.18%/year, +/-0.03%). Surprisingly, those who made several attempts to quit smoking had less loss of lung function at comparable cumulative doses of cigarettes than those who continued to smoke. Quitting smoking for an interval followed by relapse to smoking appeared to provide a measurable and lasting benefit in comparison to continuous smoking. In this early COPD population, not only quitting smoking but attempts to quit smoking can prevent some loss of lung function. These results provide some encouragement to exsmokers who relapse on their way to complete cessation.

Assessing medication adherence by pill count and electronic monitoring in the African American Study of Kidney Disease and Hypertension (AASK) Pilot Study.

The Medication Event Monitoring System (MEMS), an electronic monitor which records the date and time of bottle cap openings, and pill counts were used to assess patterns of adherence for the primary antihypertensive drug in the African American Study of Kidney Disease and Hypertension Pilot Study (AASK). Blacks with hypertension and moderately reduced renal function were randomized to one of two levels of blood pressure control and to one of three antihypertensive drug regimens: primary therapy with a calcium channel blocker, an angiotension converting enzyme inhibitor, or a beta-blocker. Of the 94 participants in AASK, 91 had MEMS recordings and pill counts for 313 regularly scheduled monthly follow-up visits. The average length of follow-up was 4.6 months. An acceptable level of adherence by pill count was achieved if 80% to 100% of the prescribed pills were not returned to the clinic. Adherence by MEMS to a once-a-day drug dosing schedule was acceptable if 80% of the time intervals between MEMS openings were within 24 +/- 6 h. Acceptable adherence by pill count was observed at 68% of the follow-up visits; MEMS indicated nonadherence at 47% of those visits. Blood pressure was within goal in 50% of the participants who were adherent by both pill count and MEMS throughout their follow-up visits, and only 14% of the participants who were identified nonadherent by one or both methods. These findings suggest that electronic monitoring is a useful adjunct to pill counts in assessing adherence to antihypertensive drugs. Feedback of electronically collected information on dosing intervals to participants and staff may enhance adherence.

Recruitment experience in the African American Study of Kidney Disease and Hypertension (AASK) Pilot Study.

Several approaches for recruitment of African American adults with renal insufficiency due to hypertension (glomerular filtration rate between 25 and 70 ml/min/1.73 m2) were explored in the Pilot Study for the African American Study of Kidney Disease and Hypertension (AASK). Over a period of 42 weeks, prescreening information was obtained on 2880 individuals, of whom 498 (17%) were evaluated at a screening visit. Two hundred and twenty-five (8%) had an 125I-iothalamate assessment of glomerular filtration rate. Ninety-four of 97 participants who met all the study eligibility criteria were enrolled in the trial. The most common reasons for ineligibility during screening were absence of renal insufficiency or hypertension, presence of diabetes mellitus, and a body mass index above the acceptable level. Overall, an average of 31 prescreen contacts and 8 screening visits were conducted for every randomization (3.3% yield from prescreening to randomization). Screening in clinical practice was the most efficient method for recruitment (12.6% yield from prescreen contact to randomization compared to 1.1% from mass mailing campaigns, 1.3% from mass media campaigns, and 1.7% from referrals by patients with end-stage renal disease). Randomization yields increased with progressively higher age ranges (2.4%, 3.3%, and 6.0% prescreen to randomization yields for those aged < or = 50, 51-60, and 61-70, respectively). A slight majority (51%) of the prescreen contacts were women, but 75% of the randomized participants were men. Our results suggest that clinic-based screening is an effective approach for recruitment of African Americans with hypertension and renal insufficiency into clinical trials. They also suggest that enrollment of African American women in such studies is a special challenge.

Appointment attendance, pill counts, and achievement of goal blood pressure in the African American Study of Kidney Disease and Hypertension Pilot Study.

The African American Study of Kidney Disease and Hypertension (AASK) Pilot Study evaluated the feasibility of conducting a 7-year clinical trial to assess the effect of two levels of blood pressure control based on mean arterial pressure (MAP) (low goal < or = 92 mm Hg or usual goal of 102-107 mm Hg) and three antihypertensive drug regimens (atenolol, amlodipine, or enalapril) as initial therapy in slowing the decline of renal function in African Americans with clinically diagnosed hypertensive nephrosclerosis. Ninety-four African American men and women between 18 and 70 years of age were randomized and followed for an average of 4.6 months. On average participants attended 87.5% of the scheduled monthly follow-up visits and achieved an acceptable level of medication adherence (80%-100% of prescribed doses by pill count) at 65.4% of those visits Blood pressure levels within goal were observed in 17.5% and 25.6% of the participants in the low- and usual MAP goal groups, respectively. Neither attendance nor medication adherence by pill count was associated with attainment of goal blood pressure. Although AASK Pilot Study participants maintained excellent attendance, their pill counts were lower than previously reported among clinical trial participants and goal blood pressure levels were difficult to achieve during the short period of follow-up.

Effect of blood pressure control and antihypertensive drug regimen on quality of life: the African American Study of Kidney Disease and Hypertension (AASK) Pilot Study.

The African American Study of Kidney Disease and Hypertension (AASK) Pilot Study evaluated the feasibility of carrying out a randomized, multicenter, 7-year clinical trial to determine the effects of two goal levels of blood pressure control and three antihypertensive drug regimens on decline in glomerular filtration rate in African Americans with clinically diagnosed hypertensive nephrosclerosis. Participants were randomized to either a usual mean arterial blood pressure (MAP) goal group (102-107 mm Hg) or a low-MAP goal group (< or = 92 mm Hg) and to a drug regimen (initial therapy with either atenolol, amlodipine, or enalapril). Quality of life was assessed by the Medical Outcomes Short-Form 36 (MOS SF-36) at baseline and the last follow-up visit for 84 of the 94 participants of the AASK Pilot Study. Symptoms were assessed at baseline and throughout the course of therapy by participant self-report. Mean SF-36 scores increased significantly on physical functioning (9.2), role limitations (physical) (19.0), social functioning (9.0), and vitality dimensions (5.6) from baseline to the last follow-up visit in the usual MAP goal group. Scores for the eight health dimensions assessed by the MOS SF-36 did not change significantly during the same time period either in the low-MAP goal group or in any of the drug regimens. The mean score for general health perception was significantly lower at the last follow-up visit in the enalapril drug regimen (49.9) compared to drug regimens with atenolol (65.4) or amlodipine (63.9). Physical functioning, role limitations (emotional), social functioning, mental health, vitality, and general health perception scores were negatively correlated with self-reported symptoms during treatment. We conclude that selected dimensions of quality of life improved during the AASK Pilot Study only in participants randomized to the usual MAP goal group. Significant differences between MAP goal groups and drug regimens at the end of follow-up were observed for only a few health dimensions.

Distraction and relaxation training in the treatment of anticipatory vomiting: a single subject intervention.

A within-series phase change design (ABABC) was used to evaluate the effect of video distraction and relaxation in the treatment of a 29-year-old male with anticipatory vomiting associated with cancer chemotherapy. Heart rate, blood pressure, nausea ratings, and the occurrence of emesis were recorded during 18 chemotherapy treatments over a 9 month period. Video distraction initially inhibited vomiting but the treatment effects were not maintained. Subsequent relaxation training inhibited vomiting after two sessions. These effects were maintained for the remainder of the patient's chemotherapy protocol.

Improving dietary habits of children: effects of nutrition education and correspondence training.

Evidence that a significant number of children are exposed to risk factors associated with coronary heart disease has prompted health care professionals to develop programs designed to encourage the early development of a healthy life style. The present study used a multiple baseline approach to examine the effects of two procedures on the snack selection behavior of 25 third grade children. In children who selected non-nutritious rather than nutritious snacks for more than 40% of the baseline observations, nutrition education alone had little or no impact on their selection of snacks. However, with the implementation of correspondence training, in which a reward was made contingent upon carrying out a stated intent to choose a nutritious snack, the children consistently chose nutritious snacks. These results indicate that correspondence training may be an efficient and cost-effective way to improve dietary habits of young people.

Preparation for cesarean delivery: a multicomponent analysis of treatment outcome.

We evaluated the effects of sensory information about cesarean delivery on prenatal maternal anxiety and on recovery subsequent to delivery by cesarean section. The 42 participants were recruited from a population of obstetric patients. Patients were assigned to either treatment or control groups and identified as sensitizers or repressors. Treatment groups viewed a slide/tape program presenting procedures involved in cesarean delivery. Control groups viewed a program presenting neutral information. Prepared patients classified as sensitizers showed less physiologic arousal during surgery and enhanced postsurgical recovery. Physiologic and self-report measures of anxiety indicated that the intervention itself was not a stressful event. The relations among arousal, subjective anxiety, coping styles, and treatment outcome are discussed and recommendations are made for further investigation.

Stimulus control of anticipatory nausea in cancer chemotherapy.

A single subject ABA design was used to evaluate the effect of a stimulus manipulation on anticipatory nausea. A lemon solution was orally administered to a 61-year-old female oncology patient in order to mask taste sensations thought to function as a conditioned stimulus eliciting anticipatory symptoms during chemotherapy. A decrease in anticipatory symptoms was observed with the introduction of the taste masking agent and was maintained following withdrawal of the agent.