Are Racial and Ethnic Minorities Less Willing to Participate in Health Research?

BACKGROUND: It is widely claimed that racial and ethnic minorities, especially in the US, are less willing than non-minority individuals to participate in health research. Yet, there is a paucity of empirical data to substantiate this claim. METHODS AND FINDINGS: We performed a comprehensive literature search to identify all published health research studies that report consent rates by race or ethnicity. We found 20 health research studies that reported consent rates by race or ethnicity. These 20 studies reported the enrollment decisions of over 70,000 individuals for a broad range of research, from interviews to drug treatment to surgical trials. Eighteen of the twenty studies were single-site studies conducted exclusively in the US or multi-site studies where the majority of sites (i.e., at least 2/3) were in the US. Of the remaining two studies, the Concorde study was conducted at 74 sites in the United Kingdom, Ireland, and France, while the Delta study was conducted at 152 sites in Europe and 23 sites in Australia and New Zealand. For the three interview or non-intervention studies, African-Americans had a nonsignificantly lower overall consent rate than non-Hispanic whites (82.2% versus 83.5%; odds ratio [OR] = 0.92; 95% confidence interval [CI] 0.84–1.02). For these same three studies, Hispanics had a nonsignificantly higher overall consent rate than non-Hispanic whites (86.1% versus 83.5%; OR = 1.37; 95% CI 0.94–1.98). For the ten clinical intervention studies, African-Americans' overall consent rate was nonsignificantly higher than that of non-Hispanic whites (45.3% versus 41.8%; OR = 1.06; 95% CI 0.78–1.45). For these same ten studies, Hispanics had a statistically significant higher overall consent rate than non-Hispanic whites (55.9% versus 41.8%; OR = 1.33; 95% CI 1.08–1.65). For the seven surgery trials, which report all minority groups together, minorities as a group had a nonsignificantly higher overall consent rate than non-Hispanic whites (65.8% versus 47.8%; OR = 1.26; 95% CI 0.89–1.77). Given the preponderance of US sites, the vast majority of these individuals from minority groups were African-Americans or Hispanics from the US. CONCLUSIONS: We found very small differences in the willingness of minorities, most of whom were African-Americans and Hispanics in the US, to participate in health research compared to non-Hispanic whites. These findings, based on the research enrollment decisions of over 70,000 individuals, the vast majority from the US, suggest that racial and ethnic minorities in the US are as willing as non-Hispanic whites to participate in health research. Hence, efforts to increase minority participation in health research should focus on ensuring access to health research for all groups, rather than changing minority attitudes

Supporting people with aphasia to ‘settle into a new way to be’: speech and language therapists’ views on providing psychosocial support

Background: People with aphasia are at risk of becoming depressed and isolated. On-line surveys have found that the majority of Speech and Language Therapists (SLTs) lack confidence in addressing the psychological needs of people with aphasia. Aims: To explore how SLTs conceptualise the scope of their role; barriers and facilitators to SLTs addressing psychosocial needs; and SLTs’ experiences of specialist training and support, and working with mental health professionals (MHPs). Methods and procedures: Focus groups conducted in stroke healthcare settings. Purposive sampling was used in selecting sites so as to capture a range of experiences. Results were analysed using Framework Analysis. Outcomes and Results: Twenty-three SLTs took part in six focus groups. Participants’ psychosocial work included counselling-type interactions, psychoeducation, working with families, facilitating peer support, and training other healthcare professionals. There was a lack of consensus on the scope of the SLT role. Many expressed a sense of conflict, both perceiving it as valuable to spend time addressing psychological well-being, while simultaneously feeling uneasy if they deviated from ‘direct SLT’ work. Barriers to addressing psychosocial wellbeing were: emotionally challenging nature of this work, particularly for those who felt unsupported; caseload and time pressures; attitude of senior managers and commissioners; difficulties measuring and documenting more ‘fluid’ psychosocial work; and the complexity of needs and backgrounds of some patients. Enabling factors were: specialist on-going support; peer support from colleagues; experience; support of management; and personal belief. Specialist training was valued. It changed how participants viewed the therapist-client relationship (more client-led); the assessment and goal setting process; and gave them more confidence to acknowledge client emotions. However, many felt that there was a need for on-going specialist advice, and to be able to see approaches modelled for this client group. In terms of mental health professionals (MHPs), a subset of stroke specialist clinical psychologists worked directly with people with marked aphasia and families, as well as supporting the multidisciplinary team to provide holistic care. However, a main theme was that participants perceived many MHPs did not consider people with aphasia as ‘appropriate candidates’ for psychological input. Conclusions and Implications: All participants cared about the emotional well-being of their clients; however, they identified a number of barriers to people with aphasia receiving appropriate psychological support. A cultural shift, whereby psychological care for people with aphasia is seen as valuable, feasible and necessary, delivered collaboratively by SLTs, MHPs and the wider team, may improve services

Interventions for treating anxiety after stroke

Background Approximately 20% of stroke patients experience clinically significant levels of anxiety at some point after stroke. Physicians can treat these patients with antidepressants or other anxiety-reducing drugs, or both, or they can provide psychological therapy. This review looks at available evidence for these interventions. This is an update of the review first published in October 2011. Objectives The primary objective was to assess the effectiveness of pharmaceutical, psychological, complementary, or alternative therapeutic interventions in treating stroke patients with anxiety disorders or symptoms. The secondary objective was to identify whether any of these interventions for anxiety had an effect on quality of life, disability, depression, social participation, caregiver burden, or risk of death. Search methods We searched the trials register of the Cochrane Stroke Group (January 2017). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library; 2017, Issue 1: searched January 2017); MEDLINE (1966 to January 2017) in Ovid; Embase (1980 to January 2017) in Ovid; the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1937 to January 2017) in EBSCO; and PsycINFO (1800 to January 2017) in Ovid. We conducted backward citation searches of reviews identified through database searches and forward citation searches of included studies. We contacted researchers known to be involved in related trials, and we searched clinical trials registers for ongoing studies. Selection criteria We included randomised trials including participants with a diagnosis of both stroke and anxiety for which treatment was intended to reduce anxiety. Two review authors independently screened and selected titles and abstracts for inclusion. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. We performed a narrative review. We planned to do a meta-analysis but were unable to do so as included studies were not sufficiently comparable. Main results We included three trials (four interventions) involving 196 participants with stroke and co-morbid anxiety. One trial (described as a ’pilot study’) randomised 21 community-dwelling stroke survivors to four-week use of a relaxation CD or to wait list control. This trial assessed anxiety using the Hospital Anxiety and Depression Scale and reported a reduction in anxiety at three months among participants who had used the relaxation CD (mean (standard deviation (SD) 6.9 (± 4.9) and 11.0 (± 3.9)), Cohen’s d = 0.926, P value = 0.001; 19 participants analysed). The second trial randomised 81 participants with co-morbid anxiety and depression to paroxetine, paroxetine plus psychotherapy, or standard care. Mean levels of anxiety severity scores based on the Hamilton Anxiety Scale (HAM-A) at follow-up were 5.4 (SD ± 1.7), 3.8 (SD ± 1.8), and 12.8 (SD ± 1.9), respectively (P value < 0.01). The third trial randomised 94 stroke patients, also with co-morbid anxiety and depression, to receive buspirone hydrochloride or standard care. At follow-up, the mean levels of anxiety based on the HAM-A were 6.5 (SD± 3.1) and 12.6 (SD± 3.4) in the two groups, respectively, which represents a significant difference (P value < 0.01). Half of the participants receiving paroxetine experienced adverse events that included nausea, vomiting, or dizziness; however, only 14% of those receiving buspirone experienced nausea or palpitations. Trial authors provided no information about the duration of symptoms associated with adverse events. The trial of relaxation therapy reported no adverse events. The quality of the evidence was very low. Each study included a small number of participants, particularly the study of relaxation therapy. Studies of pharmacological agents presented details too limited to allow judgement of selection, performance, and detection bias and lack of placebo treatment in control groups. Although the study of relaxation therapy had allocated participants to treatment using an adequate method of randomisation, study recruitment methods might have introduced bias, and drop-outs in the intervention group may have influenced results. Authors’ conclusions Evidence is insufficient to guide the treatment of anxiety after stroke. Further well-conducted randomised controlled trials (using placebo or attention controls) are required to assess pharmacological agents and psychological therapies

Diabetes and ischaemic stroke outcome

AimTo compare all‐cause mortality, stroke recurrence and functional outcomes in people who have experienced stroke, with and without diabetes.MethodsWe captured data on population‐based ischaemic strokes (2006–2012) in Nueces County, Texas. Data were collected from participant interviews and medical records. Differences in cumulative mortality and stroke recurrence risk by diabetes status were estimated at 30 days and 1 year using Cox models. Differences in 90‐day functional outcomes (activities of daily living/instrumental activities of daily living score: range 1–4; higher scores worse) by diabetes status were assessed using Tobit regression. Effect modification by ethnicity was examined.ResultsThere were 1301 ischaemic strokes, 46% with history of known diabetes. The median (interquartile range) age was 70 (58–81) years and 61% were Mexican American. People with diabetes were younger and more likely to be Mexican American compared with those without diabetes. After adjustment, diabetes predicted mortality (30‐day hazard ratio 1.44, 95% CI 0.97–2.12; 1‐year hazard ratio 1.47, 95% CI 1.09–1.97) but not stroke recurrence (1‐year hazard ratio 1.27, 95% CI 0.78–2.07). People with diabetes had a worse functional outcome score that was explained by cardiovascular risk factors and pre‐stroke factors. Diabetes was not associated with functional outcome in the fully adjusted model (final adjusted activities of daily living/instrumental activities of daily living score difference 0.11, 95% CI –0.07 to 0.30). Effect modification by ethnicity was not significant (P>0.3 for all models).ConclusionsDiabetes was associated with higher mortality and worse functional outcome but not stroke recurrence. Interventions are needed to decrease the adverse outcomes associated with diabetes, particularly in Mexican‐American people.What’s new?Although diabetes is an established risk factor for incident ischaemic stroke, its role in stroke outcomes remains uncertain, with inconsistent findings across studies and limited data from diverse, population‐based studies.In our ethnically diverse population‐based study, we found that diabetes was associated with higher stroke mortality and worse functional outcome but not with stroke recurrence.Results suggest that interventions are needed to decrease the adverse stroke outcomes associated with diabetes, particularly in Mexican‐American people who experience a high prevalence of diabetes.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/145551/1/dme13665_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/145551/2/dme13665.pd

Niacin or Ezetimibe for Patients with, or at Risk of Coronary Heart Disease

Coronary heart disease treatment with HMG-CoA reductase inhibitors has been very successful. There is increasing interest in adding other lipid lowering therapy, primarily as additional therapy onto HMG-CoA reductase therapy. This paper will examine two of the more popular secondary agents, ezetimibe and niacin, and describe their research data and potential for usefulness in further reducing cardiovascular events

Medication Persistence Rates and Factors Associated with Persistence in Patients Following Stroke: A Cohort Study

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Contaminant Metals as Cardiovascular Risk Factors: A Scientific Statement From the American Heart Association

Exposure to environmental pollutants is linked to increased risk of cardiovascular disease. Beyond the extensive evidence for particulate air pollution, accumulating evidence supports that exposure to nonessential metals such as lead, cadmium, and arsenic is a significant contributor to cardiovascular disease worldwide. Humans are exposed to metals through air, water, soil, and food and extensive industrial and public use. Contaminant metals interfere with critical intracellular reactions and functions leading to oxidative stress and chronic inflammation that result in endothelial dysfunction, hypertension, epigenetic dysregulation, dyslipidemia, and changes in myocardial excitation and contractile function. Lead, cadmium, and arsenic have been linked to subclinical atherosclerosis, coronary artery stenosis, and calcification as well as to increased risk of ischemic heart disease and stroke, left ventricular hypertrophy and heart failure, and peripheral artery disease. Epidemiological studies show that exposure to lead, cadmium, or arsenic is associated with cardiovascular death mostly attributable to ischemic heart disease. Public health measures reducing metal exposure are associated with reductions in cardiovascular disease death. Populations of color and low socioeconomic means are more commonly exposed to metals and therefore at greater risk of metal-induced cardiovascular disease. Together with strengthening public health measures to prevent metal exposures, development of more sensitive and selective measurement modalities, clinical monitoring of metal exposures, and the development of metal chelation therapies could further diminish the burden of cardiovascular disease attributable to metal exposure.S

Development of the Occupational Therapy Stroke Arm and Hand Record: An Upper Limb Treatment Schedule

Introduction: This study aimed to develop a comprehensive occupational therapy treatment schedule of upper limb interventions for stroke survivors with reduced upper limb function. Method: In a three-phased qualitative consensus study, 12 occupational therapists from acute and community settings in North West England contributed to interviews and subsequently group discussions to design and pilot a treatment schedule. Interview data were analysed using thematic analysis; the themes were used to develop a framework for the schedule that was supported by and reflected the International Classification of Functioning, Disability and Health framework. A draft schedule was the subject of a focus group and the resultant schedule was piloted in clinical practice by eight local occupational therapists working in neurological rehabilitation. Findings: Consensus was reached on three themes summarizing aspects of function: interventions that address preparation for activity, functional skills (that is, an aspect of function), and function. Three additional themes summarized other aspects of therapy: advice and education, practice outside therapy sessions, and psychosocial interventions. These themes became the main headings of the treatment schedule. The Occupational Therapy Stroke Arm and Hand Record treatment schedule was piloted and found to be comprehensive and potentially beneficial to clinical practice. Conclusion: The Occupational Therapy Stroke Arm and Hand Record treatment schedule provides a tool for use in stroke research and clinical practice