Ben S. Gerber

Mobile phone text messaging to promote healthy behaviors and weight loss maintenance: a feasibility study

There is a need to investigate newer strategies pertaining to the maintenance of healthy behaviors and weight. We investigated the feasibility of mobile phone text messaging to enable ongoing communication with African-American women participating in a weight management program. Ninety-five African-American women participated in this pilot study and received regularly scheduled text messages. Forty-two of these women chose to create 165 personal text messages that included tips on healthy eating and physical activity, as well as reminders to drink water and expressions of encouragement. A commercially available client-based application transmitted these personal messages and general health messages at least three times per week. The software transmitted over 4500 text messages during the first 4 months with 114 returned as undeliverable. Participants expressed generally positive attitudes toward incoming text messages, with only one participant declining to continue after enrollment. This study demonstrated early feasibility and acceptability of text messaging as a method for promoting healthy behaviors for weight maintenance.

Traveling Towards Disease: Transportation Barriers to Health Care Access

Transportation barriers are often cited as barriers to healthcare access. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. However, the significance of these barriers is uncertain based on existing literature due to wide variability in both study populations and transportation barrier measures. The authors sought to synthesize the literature on the prevalence of transportation barriers to health care access. A systematic literature search of peer-reviewed studies on transportation barriers to healthcare access was performed. Inclusion criteria were as follows: (1) study addressed access barriers for ongoing primary care or chronic disease care; (2) study included assessment of transportation barriers; and (3) study was completed in the United States. In total, 61 studies were reviewed. Overall, the evidence supports that transportation barriers are an important barrier to healthcare access, particularly for those with lower incomes or the under/uninsured. Additional research needs to (1) clarify which aspects of transportation limit health care access (2) measure the impact of transportation barriers on clinically meaningful outcomes and (3) measure the impact of transportation barrier interventions and transportation policy changes.

Association of A1C levels with vitamin D status in U.S. Adults: data from the national health and nutrition examination survey.

OBJECTIVE Data relating vitamin D status with indices of glucose homeostasis as manifested by A1C in the U.S. adult population are few. RESEARCH DESIGN AND METHODS We examined the association between serum 25 hydroxyvitamin D [25(OH)D] and A1C levels in 9,773 adults (age ≥18 years old) participating in the 2003–2006 National Health and Nutrition Examination Survey. Multivariate linear regression analyzed the association after accounting for potential confounders. RESULTS Serum 25(OH)D levels were inversely associated with A1C levels in subjects age 35–74 years (P = 0.0045) and those who did not report a history of diabetes (P = 0.0282). CONCLUSIONS These findings support a mechanistic link between serum vitamin D concentrations, glucose homeostasis, and the evolution of diabetes in a large segment of the U.S. adult population. Screening people with elevated A1C levels for vitamin D insufficiency should be considered.

Racial differences in medication adherence: A cross-sectional study of Medicare enrollees.

BACKGROUND Racial differences in adherence to prescribed medication regimens have been reported among the elderly. It remains unclear, however, whether these differences persist after controlling for confounding variables. OBJECTIVE The objective of this study was to determine whether racial differences in medication adherence between African American and white seniors persist after adjusting for demographic characteristics, health literacy, depression, and social support. We hypothesized that differences in adherence between the 2 races would be eliminated after adjusting for confounding variables. METHODS A survey on medication adherence was conducted using face-to-face interviews with Medicare recipients >or=65 years of age living in Chicago. Participants had to have good hearing and vision and be able to speak English to enable them to respond to questions in the survey and sign the informed-consent form. Medication adherence measures included questions about: (1) running out of medications before refilling the prescriptions; (2) following physician instructions on how to take medications; and (3) forgetting to take medications. Individual crude odds ratios (CORs) were calculated for the association between race and medication adherence. Adjusted odds ratios (AORs) were calculated using the following covariates in multivariate logistic regression analyses: race; age; sex; living with a spouse, partner, or significant other; income; Medicaid benefits; prescription drug coverage; having a primary care physician; history of hypertension or diabetes; health status; health literacy; depression; and social support. RESULTS Six hundred thirty-three eligible cases were identified. Of the 489 patients who responded to the survey, 450 (266 African American [59%; mean age, 78.2 years] and 184 white [41%; mean age, 76.8 years]; predominantly women) were included in the sample. The overall response rate for the survey was 77.3%. African Americans were more likely than whites to report running out of medications before refilling them (COR = 3.01; 95% CI, 1.72-5.28) and not always following physician instructions on how to take medications (COR = 2.64; 95% CI, 1.50-4.64). However, no significant difference between the races was observed in forgetting to take medications (COR = 0.90; 95% CI, 0.61-1.31). In adjusted analyses, race was no longer associated with low adherence due to refilling (AOR = 1.60; 95% CI, 0.74-3.42). However, race remained associated with not following physician instructions on how to take medications after adjusting for confounding variables (AOR = 2.49; 95% CI, 1.07-5.80). CONCLUSION Elderly African Americans reported that they followed physician instructions on how to take medications less frequently than did elderly whites, even after adjusting for differences in demographic characteristics, health literacy, depression, and social support.

eHealth Technology and Internet Resources Barriers for Vulnerable Populations

Disparities in accessing health information exist for various vulnerable populations. Reviewing access issues for those seeking and/or needing health information suggests that there are many factors that may inhibit access. These include a wide diversity in the education, background, and needs of those seeking information, and the distribution of information among many disciplines and information sources. The most needy among this group may require extensive, multispecialty healthcare and may have particular problems with access, treatment adherence, and working within the healthcare system.

Predictors of urinary tract infection based on artificial neural networks and genetic algorithms

BACKGROUND Among women who present with urinary complaints, only 50% are found to have urinary tract infection. Individual urinary symptoms and urinalysis are not sufficiently accurate to discriminate those with and without the diagnosis. METHODS We used artificial neural networks (ANN) coupled with genetic algorithms to evolve combinations of clinical variables optimized for predicting urinary tract infection. The ANN were applied to 212 women ages 19-84 who presented to an ambulatory clinic with urinary complaints. Urinary tract infection was defined in separate models as uropathogen counts of > or =10(5) colony-forming units (CFU) per milliliter, and counts of > or =10(2) CFU per milliliter. RESULTS Five-variable sets were evolved that classified cases of urinary tract infection and non-infection with receiver-operating characteristic (ROC) curve areas that ranged from 0.853 (for uropathogen counts of > or =10(5) CFU per milliliter) to 0.792 (for uropathogen counts of > or =10(2) CFU per milliliter). Predictor variables (which included urinary frequency, dysuria, foul urine odor, symptom duration, history of diabetes, leukocyte esterase on urine dipstick, and red blood cells, epithelial cells, and bacteria on urinalysis) differed depending on the pathogen count that defined urinary tract infection. Network influence analyses showed that some variables predicted urine infection in unexpected ways, and interacted with other variables in making predictions. CONCLUSIONS ANN and genetic algorithms can reveal parsimonious variable sets accurate for predicting urinary tract infection, and novel relationships between symptoms, urinalysis findings, and infection.

Telehealth Weight Management Intervention for Adults with Physical Disabilities A Randomized Controlled Trial

ObjectiveWeight reduction programs are not generally designed or adapted for people with physical disabilities. This study examined the effect of a 9-months remote, telephone-based weight management program for people with physical disabilities using a Web-based system (Personalized Online Weight and Exercise Response System [POWERS]). DesignA total of 102 participants (mean ± SD age, 46.5 ± 12.7 yrs; body mass index, 32.0 ± 5.8 kg/m2) with a physical disability (spinal cord injury, multiple sclerosis, spina bifida, cerebral palsy, stroke, or lupus) were randomized to one of three conditions: physical activity only (POWERS), physical activity plus nutrition (POWERSplus), and control. The POWERS group received a physical activity tool kit and regular coaching telephone calls. The POWERSplus group received an intervention identical to that of the POWERS group plus nutritional information. The control group received the physical activity tool kit and self-guided health promotion resources at the completion of the trial but no coaching. ResultsPostintervention differences in body weight were found between the groups. There was a significant group × time interaction (P < 0.01) in postintervention body weight, with both the POWERS and POWERSplus groups demonstrating greater reduction in body weight compared with the control group (POWERS: −2.1 ± 5.5 kg, −2.4 ± −5.9%; POWERSplus: −0.5 ± 5.0 kg, −0.6 ± 4.3%; control: +2.6 ± 5.3 kg, 3.1 ± 7.4%). ConclusionsA low-cost telephone intervention supported with a Web-based remote coaching tool (POWERS) can be an effective strategy for assisting overweight adults with physical disabilities in maintaining or reducing their body weight.

The Art and Science of Patient Storytelling—Harnessing Narrative Communication for Behavioral Interventions: The ACCE Project

Narrative communication is an emerging form of persuasive communication used in health education to solicit actual patient stories. Eliciting a narrative is an open-ended process and may or may not map to desired intervention objectives or underlying behavioral constructs. In addition, incorporating actual, unscripted narratives into multimedia interventions is challenging. The authors evaluated a protocol of editing narratives for a multimedia intervention to promote smoking cessation in the African American community that maintains fidelity to the original message and was related to behavioral constructs from social cognitive theory. The authors used four steps: (a) narrative collection (videotaping), (b) narrative review (rating of content), (c) narrative editing (documentary style), and (d) pilot testing (usability and assessment of transportation). The authors videotaped 50 personal smoking cessation narratives. After coding for presence of theoretical constructs, perceived risks of smoking (present in 53% of narratives) was the most common related behavioral construct. Four narratives were chosen for inclusion in the DVD. Pilot testing showed viewers reported high level of transportation into the narrative. The authors found that some behavioral constructs were rare and difficult to solicit in this population but that the final product was engaging to the viewers. Lessons learned may be useful for other video-based behavioral interventions that incorporate personal narratives.

A diabetes education multimedia program in the waiting room setting

IntroductionThis study evaluated the impact of a waiting room-administered, low-literacy, computer multimedia diabetes education program on patient self-management and provider intensification of therapy.MethodsIn this randomized, controlled trial, 129 participants either viewed a computer multimedia education program (intervention group) or read an educational brochure (control group) while in the waiting room. Participants were uninsured, primarily ethnic minority adults with type 2 diabetes receiving care from a county clinic in Chicago, Illinois. Wilcoxon test, t-test, and linear mixed model analyses evaluated changes in diabetes knowledge, self-efficacy, behaviors, medications prescribed, hemoglobin A1c (HbA1c), and blood pressure levels over 3 months.ResultsDuring the study period, there was an increase in the number of oral diabetes medications prescribed over three months to multimedia users compared with those in the control group (P=0.017). HbA1c declined by 1.5 in the multimedia group versus 0.8 in the control group (P=0.06). There were no differences between groups in changes in blood pressure levels, self-efficacy, and most diabetes-related behaviors. Self-reported exercise increased in the control group compared with the multimedia group (0.9 days/week vs. 0.1 days/week, P=0.016).ConclusionMultimedia users received a greater intensification of diabetes therapy, but demonstrated no difference in self-management in comparison with those receiving educational brochures. The availability of a computer multimedia program in the waiting room appears to be a novel and acceptable approach in providing diabetes education for underserved populations.

Probable Interaction Between Lycium barbarum (Goji) and Warfarin

Lycium barbarum (also called goji berry), a Chinese herb used as a supplement for health benefits, is traditionally consumed by the Chinese in the form of a tea. Goji juice, a widely available beverage in the United States, also contains this herb. We describe a 71‐year‐old Ecuadorean‐American woman who was taking warfarin and was hospitalized for a markedly elevated, indeterminate international normalized ratio (INR) (prothrombin time > 120 sec) after consumption of goji juice. She had undergone knee surgery approximately 3 months earlier at which time warfarin therapy was started. She reported no changes in dietary habits or lifestyle other than drinking goji juice for 4 days before hospitalization. On presentation to the emergency department, she described symptoms of epistaxis, bruising, and rectal bleeding. After discontinuation of the goji juice and warfarin, the patient was treated with phytonadione, and her INR decreased to 2.6 over 2 days. Application of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 6) between the patients elevated INR with associated bleeding and her concomitant use of L. barbarum and warfarin. Two other published reports have described similar interactions between warfarin and a tea containing L. barbarum. Patients should be educated about avoiding popular herbal drinks, such as goji juice, that contain L. barbarum while they are taking warfarin. In addition, clinicians should question patients about their use of herbal therapies and document such use in their medical records before prescribing drugs such as warfarin.