Hae Ra Han

Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months*

BACKGROUND African American men with hypertension in low socioeconomic urban populations achieve poor rates of hypertension control and suffer early from its complications. METHODS In a randomized clinical trial with 309 hypertensive urban African American men aged 21 to 54 years, we evaluated the effectiveness of a more intensive comprehensive educational-behavioral-pharmacologic intervention by a nurse practitioner-community health worker-physician (NP/CHW/MD) team and a less intensive education and referral intervention in controlling blood pressure (BP) and minimizing progression of left ventricular hypertrophy (LVH) and renal insufficiency. Changes in BP, left ventricular mass (LVM), and serum creatinine from baseline to 36 months were compared between groups. RESULTS At 36 months, the mean systolic BP/diastolic BP change from baseline was -7.5/-10.1 mm Hg for the more intensive group and +3.4/-3.7 mm Hg for the less intensive group (P =.001 and.005 for between-group differences in systolic BP and diastolic BP, respectively). The proportion of men with controlled BP (<140/90 mm Hg) was 44% in the more intensive group and 31% in the less intensive group (P =.045). The LVM was significantly lower in the more intensive group than in the less intensive group (more intensive, 274 g; less intensive, 311 g; P =.004). There was a trend toward slowing of the progression of renal insufficiency (incidence of 50% increase in serum creatinine) in the more intensive group compared to the less intensive group (more intensive, 5.2%; less intensive, 8.0%; P =.08). CONCLUSIONS During 36 months, the more intensive intervention led to a lower BP and decreased progression of LVH in a sample of hypertensive young African American men.

Depression, substance use, adherence behaviors, and blood pressure in urban hypertensive Black men

Relationships between depression, alcohol and illicit drug use, adherence behaviors, and blood pressure (BP) were examined in 190 urban hypertensive Black men enrolled in an ongoing hypertension control clinical trial. More than one fourth (27.4%) of the sample scored greater than 16 on the Center for Epidemiological Studies- Depression Scale (CES-D), indicating a high risk of clinical depression. Depression was significantly associated with an increased likelihood of meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for alcohol abuse or dependence (odds ratio = 5.2; 95% confidence interval = 1.897–14.214). The level of depression was significantly correlated with poor medication (r = .301) and poor dietary compliance (r = .164). Both alcohol intake and illicit drug use were significantly correlated with poor dietary compliance (r = .195 and .185, respectively) and smoking (r = .190 and .269, respectively). Although no direct relationship between depression and the level of BP was substantiated by multivariate analysis, findings of descriptive analyses revealed statistically significant associations among depression, substance use, poor adherence, and poor BP outcomes. Given the harsh environment in which a large number of young urban Black men live, the high prevalence of substance abuse might be an attempt to fight off depression. Further in- depth investigation is needed to identify the role of depression and BP control in urban young Blacks in order to construct effective interventions that address their unique needs.

Tailored lay health worker intervention improves breast cancer screening outcomes in non-adherent Korean-American women.

Despite rapidly increasing incidence rates of breast cancer, recent immigrants such as Korean-American (KA) women report disproportionately lower utilization of screening tests compared with other ethnic groups. Early screening of breast cancer for this population may be greatly facilitated by indigenous lay health workers (LHWs). We conducted an intervention trial with a 6-month follow-up. Trained LHWs recruited 100 KA women 40 years of age or older who had not had a mammogram during the past 2 years. Ninety-three completed follow-up questionnaires. A 120-min, in-class education combined with LHW follow-up counseling and navigation assistance through the health care system was provided. Rates of breast cancer screening behaviors significantly increased at 6 months (P < 0.001); changes between pre- and post-intervention were 31.9% for mammography, 23% for clinical breast examination and 36.2% for breast self-examination. Modesty toward screening significantly decreased over time, but we did not find any significant differences in breast cancer knowledge and beliefs before and after the intervention. Results support the efficacy of this neighborhood-based, culturally sensitive intervention. Further research should seek to replicate these findings and to incorporate more self-care skills such as health literacy when designing an intervention program for linguistically and culturally isolated immigrant women.

A Community-Based, Culturally Tailored Behavioral Intervention for Korean Americans With Type 2 Diabetes

Purpose The purpose of this study is to test the efficacy of a culturally tailored comprehensive type 2 diabetes management intervention for Korean American immigrants (KAIs) with type 2 diabetes. Methods A randomized controlled pilot trial with 2 parallel arms (intervention vs control) with a delayed intervention design was used. A total of 79 KAIs, recruited from the Baltimore-Washington area, completed baseline, 18-week, and 30-week follow-ups (intervention, n = 40; control, n = 39). All participants had uncontrolled type 2 diabetes (hemoglobin A1C ≥7.5%) at baseline. The authors’ comprehensive, self-help intervention program for type 2 diabetes management (SHIP-DM) consisted of a 6-week structured psychobehavioral education, home glucose monitoring with teletransmission, and bilingual nurse telephone counseling for 24 weeks. The primary outcome of the study was A1C level, and secondary outcomes included an array of psychobehavioral variables. Results Using analysis of covariance, the findings support that the proposed intervention was effective in significantly lowering A1C and fasting glucose and also in improving psychosocial outcomes in the sample. Specifically, the amount of reduction in A1C among intervention group participants was 1.19% at 18 weeks and 1.31% at 30 weeks, with 10% and 15.5% of the participants achieving the suggested goal of A1C <7% at 18 and 30 weeks of follow-up, respectively. Conclusions The results highlight the clinical efficacy of the SHIP-DM intervention composed of a 6-week education program, self-monitoring, and follow-up counseling, in terms of maintaining the improved intervention effects obtained and in terms of glucose control.

Does knowledge matter? Intentional medication nonadherence among middle-aged Korean Americans with high blood pressure

Aim: To examine predictors of intentional and unintentional nonadherence to antihypertensive medication regimens and their relationships to blood pressure outcomes. Background: Although poor adherence to medical regimens is a major concern in the care of patients with high blood pressure (HBP), our understanding of the complex behavior related to adherence is limited. Moreover, few studies have been devoted to understanding adherence issues in ethnic minority groups, such as the interplay between cultural beliefs and HBP medication-taking behaviors. Design: A cross-sectional analysis was performed to assess the factors affecting nonadherence to antihypertensive medication regimens. Methods: The data used in this analysis came from an ongoing HBP intervention trial involving middle-aged (40-64 years) Korean Americans with HBP. A total of 445 Korean Americans with HBP was enrolled in the trial at baseline. Of these, 208 participants who were on antihypertensive medication were included in the analysis. Using multivariate logistic regression, we examined theoretically selected variables to assess their relationships to intentional and unintentional nonadherence in this sample. Results: Approximately 53.8% of the subjects endorsed 1 or more types of nonadherent behaviors. After controlling for demographic variables, multivariate analysis revealed that a greater number of side effects from the medication (adjusted odds ratio [OR], 1.19; 95% confidence interval [CI], 1.07 to 1.33) and a lower level of HBP knowledge (adjusted OR, 0.89; 95% CI, 0.79 to 0.99) were significantly associated with intentional nonadherence. Unintentional nonadherence was less strongly associated with the study variables examined in the analysis. Conclusion: Our findings indicate that intentional nonadherence to antihypertensive medication that stems from incomplete knowledge of HBP treatment is prevalent among middle-aged Korean Americans with HBP. The results highlight the strong need for an intervention that focuses on increasing patient knowledge about HBP, including the benefits and side effects of antihypertensive medication. This type of focused intervention may help reduce intentional nonadherence to antihypertensive medications and ultimately result in achieving adequate BP control in this high-risk group.

Effects of Community-Based Health Worker Interventions to Improve Chronic Disease Management and Care Among Vulnerable Populations: A Systematic Review

BACKGROUND Community-based health workers (CBHWs) are frontline public health workers who are trusted members of the community they serve. Recently, considerable attention has been drawn to CBHWs in promoting healthy behaviors and health outcomes among vulnerable populations who often face health inequities. OBJECTIVES We performed a systematic review to synthesize evidence concerning the types of CBHW interventions, the qualification and characteristics of CBHWs, and patient outcomes and cost-effectiveness of such interventions in vulnerable populations with chronic, noncommunicable conditions. SEARCH METHODS We undertook 4 electronic database searches-PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane-and hand searched reference collections to identify randomized controlled trials published in English before August 2014. SELECTION We screened a total of 934 unique citations initially for titles and abstracts. Two reviewers then independently evaluated 166 full-text articles that were passed onto review processes. Sixty-one studies and 6 companion articles (e.g., cost-effectiveness analysis) met eligibility criteria for inclusion. DATA COLLECTION AND ANALYSIS Four trained research assistants extracted data by using a standardized data extraction form developed by the authors. Subsequently, an independent research assistant reviewed extracted data to check accuracy. Discrepancies were resolved through discussions among the study team members. Each study was evaluated for its quality by 2 research assistants who extracted relevant study information. Interrater agreement rates ranged from 61% to 91% (average 86%). Any discrepancies in terms of quality rating were resolved through team discussions. MAIN RESULTS All but 4 studies were conducted in the United States. The 2 most common areas for CBHW interventions were cancer prevention (n = 30) and cardiovascular disease risk reduction (n = 26). The roles assumed by CBHWs included health education (n = 48), counseling (n = 36), navigation assistance (n = 21), case management (n = 4), social services (n = 7), and social support (n = 18). Fifty-three studies provided information regarding CBHW training, yet CBHW competency evaluation (n = 9) and supervision procedures (n = 24) were largely underreported. The length and duration of CBHW training ranged from 4 hours to 240 hours with an average of 41.3 hours (median: 16.5 hours) in 24 studies that reported length of training. Eight studies reported the frequency of supervision, which ranged from weekly to monthly. There was a trend toward improvements in cancer prevention (n = 21) and cardiovascular risk reduction (n = 16). Eight articles documented cost analyses and found that integrating CBHWs into the health care delivery system was associated with cost-effective and sustainable care. CONCLUSIONS Interventions by CBHWs appear to be effective when compared with alternatives and also cost-effective for certain health conditions, particularly when partnering with low-income, underserved, and racial and ethnic minority communities. Future research is warranted to fully incorporate CBHWs into the health care system to promote noncommunicable health outcomes among vulnerable populations.

Do cultural factors predict mammography behaviour among Korean immigrants in the USA

AIM This paper is a report of a study of the correlates of mammogram use among Korean American women. BACKGROUND Despite the increasing incidence of and mortality from breast cancer, Asian women in the United States of America report consistently low rates of mammography screening. A number of health beliefs and sociodemographic characteristics have been associated with mammogram participation among these women. However, studies systematically investigating cultural factors in relation to mammogram experience have been scarce. METHODS We measured screening-related health beliefs, modesty and use of Eastern medicine in 100 Korean American women in 2006. Hierarchical logistic regression was used to examine the unique contribution of the study variables, after accounting for sociodemographic characteristics. FINDINGS Only 51% reported past mammogram use. Korean American women who had previously had mammograms were statistically significantly older and had higher perceived benefit scores than those who had not. Perceived benefits (odds ratio = 6.3, 95% confidence interval = 2.12, 18.76) and breast cancer susceptibility (odds ratio = 3.18, 95% confidence interval = 1.06, 9.59) were statistically significant correlates of mammography experience, whereas cultural factors did not correlate. Post hoc analysis showed that for women with some or good English skills, cultural factors statistically significantly correlated with health beliefs and breast cancer knowledge (P < 0.05). CONCLUSION Nurses should consider the inclusion in culturally tailored interventions of more targeted outreach and healthcare system navigation assistance for promoting mammography screening in Korean American women. Further research is needed to unravel the interplay between acculturation, cultural factors and health beliefs related to cancer screening behaviours of Korean American women.

Barriers to and strategies for recruiting Korean Americans for community-partnered health promotion research

While increasing numbers of researchers are targeting ethnic minorities in order to address their health disparities, the unique health needs of Korean Americans are not well known to the mainstream community, and only relatively few systematic research studies have been conducted in this “hard-to reach” population. The purpose of this paper is to describe the barriers to recruiting participants for health promotion research and to identify facilitators in the community that can contribute to this effort. We have analyzed data pertaining to the 14 studies we have conducted since 1998, which included a total sample of about 2,400 Korean Americans. We describe in detail the unique recruitment challenges that we have faced in regard to the culture, language, sociodemographic characteristics of the participants, such as gender and age, and other community level barriers. Multiple strategies at different levels (individual and community) to address these issues are discussed.

Unmet needs for social support and effects on diabetes self-care activities in Korean Americans with type 2 diabetes

Objective The purpose of this study was (1) to characterize the primary sources of social support and the extent of unmet needs for support (defined as the gap between social support needs and the receipt of social support) in a sample of Korean Americans (KAs) with type 2 diabetes and (2) to examine the effect of unmet needs for support on their self-care activities. Methods Baseline data obtained from a community-based intervention trial were used for this study of 83 middle-aged KAs with type 2 diabetes. Study design and data analysis were guided by social cognitive theory. The key variables were dictated the order of the variables in multivariate regression analysis. Results Our findings indicated that for diabetic KAs, the primary source of social support differed according to gender. Unmet needs for support were significantly associated with self-care activities, but the amount of support needs and of social support received were not. Multivariate analysis also confirmed that unmet needs for social support are a significant strong predictor of inadequate type 2 diabetes self-care activities, after controlling for other covariates. The hierarchical regression model explained about 30% of total variance in self-care activities. Conclusions The findings highlight the importance of considering unmet needs for social support when addressing self-care activities in type 2 diabetes patients. Future interventions should focus on filling gaps in social support and tailoring approaches according to key determinants, such as gender or education level, to improve self-care activities in the context of type 2 diabetes care.

A Meta-Analysis of Interventions to Promote Mammography Among Ethnic Minority Women

Background:Although many studies have been focused on interventions designed to promote mammography screening among ethnic minority women, few summaries of the effectiveness of the interventions are available. Objective:The aim of this study was to determine the effectiveness of the interventions for improving mammography screening among asymptomatic ethnic minority women. Methods:A meta-analysis was performed on intervention studies designed to promote mammography use in samples of ethnic minority women. Random-effects estimates were calculated for interventions by measuring differences in intervention and control group screening rates postintervention. Results:The overall mean weighted effect size for the 23 studies was 0.078 (Z = 4.414, p < .001), indicating that the interventions were effective in improving mammography use among ethnic minority women. For mammography intervention types, access-enhancing strategies had the biggest mean weighted effect size of 0.155 (Z = 4.488, p < .001), followed by 0.099 (Z = 6.552, p < .001) for individually directed approaches such as individual counseling or education. Tailored, theory-based interventions resulted in a bigger effect size compared with nontailored interventions (effect sizes = 0.101 vs. 0.076, respectively; p < .05 for all models). Of cultural strategies, ethnically matched intervention deliveries and offering culturally matched intervention materials had effect sizes of 0.067 (Z = 2.516, p = .012) and 0.051 (Z = 2.365, p = .018), respectively. Discussion:Uniform improvement in mammography screening is a goal to address breast cancer disparities in ethnic minority communities in this country. The results of this meta-analysis suggest a need for increased use of a theory-based, tailored approach with enhancement of access.