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Scovia Nalugo Mbalinda,1 Mark Kaddumukasa,2 Josephine Nambi Najjuma,3 Martin Kaddumukasa,1,4 Jane Nakibuuka,1,4 Christopher J Burant,5 Shirley Moore,6 Carol Blixen,7 Elly T Katabira,1 Martha Sajatovic7 1Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda; 2Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda; 3Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda; 4Department of Medicine, Mulago Hospital, Kampala, Uganda; 5Louis Stokes VA Medical Center, Geriatric Research Education, and Clinical Center, Cleveland, OH, 44106, USA; 6Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, 44106, USA; 7Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center & Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USACorrespondence: Scovia Nalugo Mbalinda, Department of Nursing, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda, Tel +256782212151, Email snmbalinda@gmail.comPurpose: Evidence supporting secondary stroke in sub-Saharan Africa is scarce. This study describes the incidence of stroke recurrence and associated risk factors in sub-Saharan Africa.Methods and Materials: Scientific databases were systematically searched from January 2000 to December 2022 for population-based observational studies, case-control or cohort studies of recurrent stroke involving adults aged 18 years and above in sub-Saharan Africa (SSA). We assessed the quality of the eligible studies using the Critical Appraisal Skills Program (CASP) checklist for observational studies.Results: Six studies met the inclusion criteria and were included in this study. Stroke recurrence rates in SSA ranged from 9.4% to 25%. Majority of the studies were conducted from Western Africa and showed that stroke recurrence rates are high within sub-Saharan Africa ranging from 2% to 25%. The known stroke risk factors such as hypertension, chronic alcohol consumption, etc., remained the leading causes of stroke recurrence. The studies reported a higher mortality rate ranging from 20.5 − 23% among those with recurrent strokes compared to primary strokes.Conclusion: This systematic review is an update and summary of the available literature on stroke recurrence within sub-Saharan Africa. Further studies are warranted to assess the outcomes and burden of stroke recurrence in SSA.Keywords: stroke recurrence, sub-Saharan Africa, risk factors, secondary prevention, cardiovascular disease

Martin Kaddumukasa,1 Alyssa M Edwards,2 Josephine Nambi Najjuma,3 Scovia Nalugo Mbalinda,4 Jane Nakibuuka,1 Christopher J Burant,5 Shirley M Moore,6 Carol Blixen,2 Elly T Katabira,1 Martha Sajatovic,2 Mark Kaddumukasa1 1Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda; 2Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA; 3Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda; 4Department of Nursing, College of Health Sciences, Makerere University, Kampala, Uganda; 5Louis Stokes VA Medical Center, Geriatric Research Education, and Clinical Center, Cleveland, OH, USA; 6Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USACorrespondence: Martin Kaddumukasa, Email kaddumart@gmail.comAbstract: The study set out to perform a systematic literature review of evidence-based interventions that target the reduction of secondary stroke risk in Africa. The review analyzed longitudinal intervention studies conducted in Sub-Saharan Africa, focusing on adult participants who had suffered a prior stroke. It encompassed publications and peer-reviewed papers sourced from reputable databases, including PubMed, Ovid, Cochrane, and Web of Science. Three randomized clinical trial (RCT) studies were included with sample sizes ranging from 16 to 400 participants, mean age ranged between 50 and 66 years, with 64.5% male participants. All studies applied multidisciplinary team interventions of enhanced patient follow-up involving care givers, nurse educators, physicians, and social workers. Interventions ranged from comprehensive patient education, tracking of medication adherence and enforcing healthy lifestyle behaviors (regular exercise, regular BP checks, and dietary changes). We found a decrease in Systolic Blood Pressure over time in 2 of 3 treatment groups, an improvement in medical adherence in all treatment groups, and a decrease in cholesterol levels in 1 treatment group. Evidence-based interventions involving multidisciplinary teams and comprehensive patient education were found to demonstrate promising results in reducing secondary stroke risk in Africa, leading to significant improvements in medical adherence and reductions in systolic blood pressure in the majority of treatment groups. However, more research is required to confirm the influence of these interventions on cholesterol levels and to establish their lasting advantages in preventing strokes among African communities.Keywords: secondary stroke risk, risk interventions, Sub-Saharan Africa

Carol Blixen,1,2 Jennifer B Levin,2 Kristin A Cassidy,2 Adam T Perzynski,1 Martha Sajatovic2–4 1Center for Health Care Research and Policy, MetroHealth Medical Center, 2Department of Psychiatry, 3Department of Neurology, Neurological Institute, 4Department of Biostatistics & Epidemiology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA Background: Bipolar disorder (BD) is a chronic mental illness associated with reduced quality of life, high rates of suicide, and high financial costs. Evidence indicates that psychosocial stress might play an important role in the onset and course of BD. Objective: The objective of this study was to address the gap between coping theory and the clinical use of coping strategies used to self-manage BD.Methods: In-depth interviews were conducted with a sample of 21 poorly adherent patients with BD. All interviews were audiotaped, transcribed verbatim, and analyzed using content analysis with an emphasis on dominant themes.Results: Transcript-based analysis generated two major domains of coping strategies used to self-manage BD: 1) problem focused (altering eating habits, managing mood-stabilizing medications, keeping psychiatric appointments, seeking knowledge, self-monitoring, and socializing) and 2) emotion focused (distracting activities, denial, isolation, modifying/avoiding, helping others, and seeking social support). Participants used both types of coping strategies to deal with stressful situations brought about by the internal and external demands associated with self-management of BD.Conclusion: This qualitative study provided a first step in evaluating coping strategies as a possible mediator in the self-management of BD and has implications for health care providers. Being able to characterize an individual’s coping behaviors can help patients modify or replace more maladaptive coping with better coping strategies in the self-management of this chronic mental illness. Keywords: bipolar disorder, coping strategies, self-management

The advent of managed care in the context of rising health care costs has clearly affected the processes and outcomes of care delivery.While nurses can clearly play a role in the new challenges inherent in managing chronic illness, patient information, and continuity of care in a managed care environment, they have had very little formal training in this regard.The authors surveyed schools of nursing and employers of nurses regarding their efforts to provide educational programs about the mechanisms and effects of managed care on nursing practice and care delivery.They also assessed the extent to which managed care had penetrated their state, the extent to which educational programs were provided in conjunction with managed care organizations or physician education initiatives, and the perceptions of faculty in being prepared to teach the topic.Approximately a third of schools of nursing and half of employers reported providing education on the topic of managed care to their students or employees. [ABSTRACT FROM AUTHOR]

Background: Mood-stabilizing medications are a cornerstone of treatment for people with bipolar disorder, though approximately half of these individuals are poorly adherent with their medication, leading to negative and even severe health consequences. While a variety of approaches can lead to some improvement in medication adherence, there is no single approach that has superior adherence enhancement and limited data on how these approaches can be implemented in clinical settings. Existing data have shown an increasing need for virtual delivery of care and interactive telemedicine interventions may be effective in improving adherence to long-term medication., Methods: Customized adherence enhancement (CAE) is a brief, practical bipolar-specific approach that identifies and targets individual patient adherence barriers for intervention using a flexibly administered modular format that can be delivered via telehealth communications. CAE is comprised of up to four standard treatment modules including Psychoeducation, Communication with Providers, Medication Routines, and Modified Motivational Interviewing. Participants will attend assigned module sessions with an interventionist based on their reasons for non-adherence and will be assessed for adherence, functioning, bipolar symptoms, and health resource use across a 12-month period. Qualitative and quantitative data will also be collected to assess barriers and facilitators to CAE implementation and reach and adoption of CAE among clinicians in the community., Discussion: The proposed study addresses the need for practical adherence interventions that are effective, flexible, and designed to adapt to different settings and patients. By focusing on a high-risk, vulnerable group of people with bipolar disorder, and refining an evidence-based approach that will integrate into workflow of public-sector care and community mental health clinics, there is substantial potential for improving bipolar medication adherence and overall health outcomes on a broad level., Trial Registration: The study was registered on ClinicalTrials.gov NCT04622150 on November 9, 2020., (© 2022. The Author(s).)

Background: Epilepsy is associated with stigma and negatively impacts the lives of people living with epilepsy (PLWE) and their immediate families. More understanding of the stigma and discrimination experienced by PLWE in sub-Saharan Africa is needed., Methods: In a cross-sectional, mixed methods study, forty- eight PLWE who met the study inclusion criteria were enrolled. In depth interviews and focus group discussions were conducted and were audiotaped and transcribed verbatim. Analysis was conducted using a thematic, constant comparative approach with an emphasis on dominant themes. Perceived stigma was measured using the Kilifi epilepsy stigma score. Associations between socio-demographic factors and Kilifi epilepsy stigma score were assessed., Results: The median age of the study participants was 25 years, with median age (IQR) of epilepsy onset of 12 (6-18) years. The prevalence of high-perceived stigma was 31.9% (15/48). Seizure frequency was associated with high levels of perceived stigma (p-value of 0.038). Psychological abuse, rejections at home, places of employment and schools, poor relationships and intimacy and unmet engagements in social activities were cited as the perceived stigmatizing aspects among PLWE., Conclusion: In this Ugandan sample perceived stigma remains unacceptably high and interventions to address it are urgently needed in our settings., (© 2022 Kaddumukasa M et al.)

Background: Many people living with epilepsy (PLWE) reside in rural communities, and epilepsy self-management may help address some of the gaps in epilepsy care for these communities. A prior randomized control trial of a remotely delivered, Web-based group format 12-week self-management program (SMART) conducted in Northeast Ohio, a primarily urban and suburban community, demonstrated improved outcomes in negative health events such as depression symptoms and quality of life. However, there is a paucity of research addressing the needs of PLWE in rural settings., Methods: The present study leverages collaboration between investigators from 2 mid-western US states (Ohio and Iowa) to replicate testing of the SMART intervention and prioritize delivery to PLWE in rural and semi-rural communities. In phase 1, investigators will refine the SMART program using input from community stakeholders. A Community Advisory Board will then be convened to help identify barriers to trial implementation and strategies to overcome barriers. In phase 2, the investigators will conduct a 6-month prospective randomized control trial of the SMART program compared to 6-month waitlist controls, with the primary outcome being changes in negative health events defined as seizure, self-harm attempt, emergency department visit, or hospitalization. Additional outcomes of interest include quality of life and physical and mental health functioning. The study will also assess process measures of program adopters and system end-users to inform future outreach, education, and self-management strategies for PLWE., Discussion: The method of this study employs lived experience of PLWE and those who provide care for PLWE in rural and underserved populations to refine a remotely delivered Web-based self-management program, to improve recruitment and retention, and to deliver the intervention. Pragmatic outcomes important to PLWE, payers, and policymakers will be assessed. This study will provide valuable insights on implementing future successful self-management programs., Trial Registration: ClinicalTrials.gov NCT04705441 . Registered on January 12, 2021., (© 2021. The Author(s).)

Background: Epilepsy is a common neurological condition characterized by poor quality of life and associated stigma. Studies in long-term health conditions suggest that self-management interventions improve the quality of life (QoL) and reduce the perceived stigma among people with epilepsy (PWE). Yet, the utilization of these interventions remains low in sub-Saharan Africa., Objectives: We investigated the feasibility, acceptability, and preliminary efficacy of an adopted novel self-management intervention, Self-management for people with epilepsy and a history of negative health events (SMART) among PWE in Uganda., Design: A two-year, uncontrolled, prospective pilot study in Ugandans with epilepsy was conducted., Participants: Adults aged ≥ 18 years with epilepsy attending a neurology outpatient clinic were enrolled., Intervention: Using a nurse led and peer educator interactions; nine self-management approach sessions (1 individual session and 8 group sessions) were conducted., Main Outcome Measures: The primary outcome was QoL, perceived stigma and depression in PWE at 24-month follow-up using the Quality Of Life In Epilepsy 31 (QOLIE-31) scale and perceived stigma using the Kilifi stigma score and Neurological disorders depression index for epilepsy (NDDI-E)., Results: There were 17 individuals and their caregivers who were enrolled into this study with a mean age of 23.47 (SD = 5.3) years. The study intervention was feasible and acceptable within our settings. Overall, quality of life, stigma level, depression, and seizure frequency in the past 30 days were significantly improved from the baseline scores before the intervention with p-values of <0.0001, <0.0001, 0.004, and <0.0001, respectively., Significance: The SMART intervention engages individuals to actively participate in self-management, and can help reduce depressive symptom severity in PWE. Given the high morbidity and mortality associated with epilepsy, additional research is needed to better identify how SMART might be implemented in routine care settings., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Stroke burden is rapidly increasing globally. Modifiable risk factors offer an opportunity to intervene, and targeting hypertension is a key actionable target for stroke risk reduction in sub-Saharan Africa. This 3-site planned randomized controlled trial builds on promising preliminary data., Methods: A total of 246 Ugandan adults will be recruited randomized to experimental intervention vs. enhanced treatment control. Intervention participants will receive six weekly group-format stroke risk reduction self-management training sessions, and the controls will receive information on cardiovascular risk. The primary study outcome is systolic B.P. measured at baseline, 13-week, 24 weeks (6 months). Secondary outcomes include other biological and behavioral stroke risk factors., Discussion: The curriculum-guided self-management TargetEd MAnageMent Intervention (TEAM) program is anticipated to reduce the stroke burden in Uganda., Trial Registration: ClinicalTrials.gov identifier: NCT04685408, registered on 28 December 2020., Competing Interests: The authors have declared that no competing interests exist.

A growing body of research supports self-management approaches that can improve outcomes in people living with epilepsy (PLWE). An evidence-based remotely delivered self-management program (SMART) that was successfully delivered in an urban/suburban setting has the potential to be particularly helpful to PLWE who live in rural communities, where heavy stigma burden and limited access to healthcare is common. In this Phase 1 exploratory study, focus groups of key rural stakeholders (PLWE, family members, care providers) were used to: (1) gather information on factors that may impede or facilitate participation in SMART and (2) elicit overall perceptions of the program, as well as suggestions and feedback for refining it for implementation in Phase 2 of the randomized controlled study (RCT). Qualitative data analysis revealed that focus group participants identified geographic and social isolation, and the more limited access to epilepsy care, as the major barriers to epilepsy self-management for rural populations. However, they felt strongly that SMART could fill an epilepsy care gap in rural communities, and provided suggestions for recruitment and retention strategies of subjects, as well as improvement/modifications to the program curriculum for the Phase 2 RCT., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The burden of chronic psychotic disorders (CPDs) in sub-Saharan Africa (SSA) is significant. Poorly medically adherent patients are more likely to have worse outcomes and require more resources. However, factors impacting effective treatment of CPD in this population are unclear., Aim: Examine the relationship between alcohol use and disease management and compare alcohol risk stratification between the Alcohol Use Disorders Identification Test (AUDIT) and Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in poorly medication adherent Tanzanians with CPD., Setting: Muhimbili National Hospital and ambulatory clinics in Dar es Salaam, Tanzania., Methods: 100 Tanzanians with CPDs and suboptimal medication adherence were dichotomized into low and moderate-to-high risk alcohol use based on AUDIT scores and compared regarding medication attitudes, adherence and psychiatric symptoms. Patients completed the ASSIST for comparison to AUDIT risk stratification., Results: Moderate-to-high risk alcohol users had worse medication attitudes ( p < 0.01), medication adherence (previous week, p = 0.01; previous month, p < 0.001), and psychiatric symptoms ( p = 0.03). They were younger, predominately male and more likely to have a family history of alcohol abuse. A logistic regression analysis found age, gender and family history of abuse as significant predictors of hazardous alcohol use ( p = 0.02, 0.02, < 0.01, respectively). Risk stratification between AUDIT and ASSIST aligned in 85% of participants., Conclusion: Alcohol use is an important consideration in treating poorly adherent Tanzanians with CPD. The ASSIST was comparable to the AUDIT in stratifying risky alcohol use with the additional benefit of screening for other substances., Competing Interests: Dr Martha Sajatovic has received grants from Nuromate, Otsuka, Alkermes, and the International Society for Bipolar Disorders (ISBD); is a consultant for Alkermes, Otsuka, Janssen, Myriad, Health Analytics, and Frontline Medical Communications; has royalties with Springer Press, Johns Hopkins University Press, Oxford Press, and UpToDate; and has been compensated for preparation of the following CME activities: American Physician’s Institute, MCM Education, CMEology, Potomac Center for Medical Education, Global Medical Education, Creative Educational Concepts, and Psychopharmacology Institute. The other authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2021. The Authors.)

Background and Purpose: Epilepsy is often associated with substantial stigma. This study evaluated clinical correlates of stigma in a sample of people living with epilepsy (PLWE) considered high risk due to frequent seizures or other negative health events., Methods: Data were derived from an epilepsy self-management clinical trial. Standardized measures assessed socio-demographics, epilepsy stigma, epilepsy severity, self-efficacy, self-management competency, health literacy, depressive symptoms severity, functional status, social support and quality of life., Results: There were 120 individuals, mean age of 41.73 (SD=17.08), 81 men (66.9%), and 79 (65.3%) African-American. Individual factors correlated with worse stigma w ere indicative of more severe or poorly controlled seizures (frequent seizures, worse seizure severity scores, more antiepileptic drugs), mental health comorbidity (worse depression severity, other comorbidities) and factors related to individual functioning and perceived competency in managing their health (health literacy, health functioning, self-efficacy, quality of life). Multivariable linear regression found that worse quality of life, and having a mental condition were associated with more stigma (β=6.4 and 6.8, respectively), while higher self-efficacy, health literacy and social support were associated with less stigma (β=-0.06, -2.1, and -0.3, respectively). These five variables explained 50% of stigma variation., Conclusions: Stigma burden can be substantial among PLWE and may vary depending on contextual factors such as mental health comorbidity. Care approaches that screen for psychiatric comorbidities, address low health literacy, institute promising self-management programs, and employ effective health communication strategies about epilepsy misconceptions, may reduce epilepsy related burden., Competing Interests: Martha Sajatovic, MD: Research grants within past 3 years: Otsuka, Alkermes, Janssen, International Society for Bipolar Disorders, Reuter Foundation, Woodruff Foundation, Reinberger Foundation, National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC); Consultant: Alkermes, Bracket, Otsuka, Janssen, Neurocrine, Health Analytics, Frontline Medical Communications; Royalties: Springer Press, Johns Hopkins University Press, Oxford Press, UpToDate; CME activities: American Physician's Institute, MCM Education, CMEology, Potomac Center for Medical Education, Global Medical Education, Creative Educational Concepts., (Copyright © 2020 Korean Neurological Association.)

Significance: Health literacy, the ability to understand necessary health information to make proper health decisions, has been linked to greater frequency of hospitalizations. However, there is limited literature on the associations between health literacy and outcomes in patients with epilepsy, and thus, this secondary analysis investigates the associations between health literacy and outcomes in patients with epilepsy enrolled in the self-management intervention "Self-management for people with epilepsy and a history of negative events" (SMART). We examined the associations between higher health literacy and higher education level and outcomes of the SMART trial., Methods: This is a secondary analysis of data from the SMART self-management intervention, where individuals were randomized to the SMART intervention or a 6-month waitlist (WL) control. Health literacy was assessed at baseline before randomization using the Rapid Estimate of Adult Literacy in Medicine (REALM-R). Education level was self-reported by participants at baseline. Pearson correlations between REALM-R scores and continuous demographic and clinical variables were conducted. Point-biserial Pearson correlations were computed for REALM-R and dichotomous variables. The effect of education on change in negative health events (NHEs) counts from baseline to six months was conducted using a linear regression. A logistic regression with health literacy and randomization arm as predictors and improvement in NHE (1 = improvement, 0 = no change or increased NHEs at 6 months) as the outcome was conducted., Results: Lower education and lower income were significantly correlated with lower health literacy (p < 0.001 and p = 0.03). Higher education level was associated with a greater improvement in 6-month seizure counts (r s (105) = 0.29, p = 0.002), and a greater improvement in total 6-month NHEs (r s (95) = 0.20, p = 0.045). Health literacy was not associated with change in NHEs or with study retention., Conclusions: The SMART intervention appears effective for individuals regardless of health literacy competency. Nevertheless, individuals with higher levels of education have fewer epilepsy complications, and thus, those with limited education may still require additional support while participating in epilepsy self-management programs., Competing Interests: Declaration of competing interest The author has no conflict of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Individuals with serious mental illnesses such as bipolar disorder (BD) are at an increased risk for poor medication adherence compared to the general population. Individuals with BD also have high rates of chronic comorbid medical conditions like hypertension (HTN), diabetes, and cardiovascular disease. Cognitive-behavioral therapies often integrate strategies to improve medication adherence by targeting medication attitudes and self-efficacy, but the pathway toward behavior change needs further investigation., Methods: This 3-month prospective, single-arm cohort study tested an automated SMS intervention entitled Individualized Texting for Adherence Building- Cardiovascular (iTAB-CV) in 38 participants with BD and HTN. The Tablets Routine Questionnaire (TRQ) measures the percentage of BD and HTN non-adherence over the past week and the past month. Attitudinal and habit measures including the Brief Illness Perception Questionnaire (Brief IPQ), the Medication Adherence Self-Efficacy Scale-Revised (MASES-R), the Self-Report Habit Index (SRHI), the Beliefs about Medicines Questionnaire (BMQ), and the Attitudes toward Mood Stabilizers Questionnaire (AMSQ) were given for BD and HTN medications. Correlational analyses were run to determine the associations between BD and HTN attitudinal and habit indices. Additionally, longitudinal analyses were conducted to determine if attitudes changed over time as a function of a 2-month mobile-health intervention., Results: Illness attitudes towards BD were worse than towards HTN at the start of the study. Attitudes toward BD and towards mood-stabilizing drugs as well as antihypertensives improved following a mHealth intervention aimed at improving adherence. Furthermore, self-efficacy and habit strength for both BD and HTN drugs were correlated and were responsive to the intervention, with most of the change occurring after the first month of the intervention and not requiring the addition of the explicit reminders., Conclusion: Participants who received iTAB-CV showed improved attitudes towards BD and mood-stabilizing medication, and had an improvement in self-efficacy and habit strength towards taking both BD and HTN medications. Increased attention to mechanisms of change in mHealth interventions for adherence may facilitate impact. It should be noted that the methodology of the study limits drawing causal conclusions and suggests the need for a randomized control trial.

Background: Low- and middle-income countries (LMICs) experience a disproportionate burden from chronic psychotic disorders (CPDs), which are the most disabling conditions among people aged 10-24 in Sub-Saharan Africa. Poor medication adherence is seen in approximately half of individuals with CPDs in Sub-Saharan Africa, and is a major driver of relapse. A CPD treatment approach that combines the use of long-acting injectable (LAI) antipsychotic medications with a brief and practical customised adherence-enhancement behavioural intervention (CAE-L) was recently developed and tested for use in the USA., Aims: To use a qualitative cross-sectional analysis to gather information on potentially modifiable barriers to management of CPDs, and assess attitudes about LAIs from community participants in Tanzania. Findings were intended to refine the CAE-L curriculum for use in Tanzania., Method: In-depth interviews and focus groups were conducted with 44 participants (patients with CPD, caregivers, mental healthcare providers). All interviews and focus groups were audiotaped, translated, transcribed and analysed using content analysis, with an emphasis on dominant themes., Results: Findings indicated that promoting medication adherence and management of CPDs in the Tanzanian setting needs to consider the individual with CPD, the family, the healthcare setting and the broader community context., Conclusions: Qualitative findings enabled the study team to better understand the real-time barriers to medication adherence, LAI use and management of CPDs more broadly. Refinement of the CAE-L is expected to pave the way for an intervention trial for individuals with CPDs that is culturally and linguistically appropriate to the Tanzanian setting.

Objective: The objective of the study was to assess level of knowledge and attitudes of SUDEP among people living with epilepsy (PLWE) and healthcare workers providing epilepsy care in Uganda., Methods: This cross-sectional study of 48 PLWE and 19 epilepsy care providers used a tailored questionnaire to evaluate epilepsy and SUDEP knowledge, frequency of SUDEP discussion, reasons for not discussing SUDEP, timing of SUDEP discussions, and perceived patient reactions to being provided information on SUDEP., Results: Median PLWE sample age was 25 (IQR; 19-34) years, 10 (20.8%) were male, median age of onset of epilepsy 12 (IQR; 6-18) years. Half of the PLWE reported that they had never heard of SUDEP. Most PLWE desired detailed information regarding SUDEP and preferred this information during the subsequent visits. Healthcare provider sample mean age was 35.7 (22.8) years, 12 (63.2%) were male and composed of 4 physicians (21.1%). Only 15% (3/20) of providers discussed SUDEP with their patients while 85% (17/20) have never discussed it. The main reasons for not discussing SUDEP were not knowing enough about SUDEP (89.5%) and no adequate support network available (30%). Providers that discussed SUDEP (100%) reported that negative reactions were the most common patient response., Significance: In this Ugandan sample, most PLWE are not aware of SUDEP and epilepsy care providers rarely discuss SUDEP with their patients or patient caregivers. Negative reactions to SUDEP discussions are common but not universal. There is an urgent need for epilepsy educational programs in clinics and targeted communities addressing SUDEP., Competing Interests: The authors declare that they have no competing interests. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines., (© 2019 The Authors. Epilepsia Open published by Wiley Periodicals Inc. on behalf of International League Against Epilepsy.)

Background: Epilepsy is a common neurological disease with substantial impact on the subject and their caretakers. This exploratory study identified barriers to care for persons living with epilepsy (PLWE) to develop a culturally acceptable nurse led self-management intervention for PLWE previously developed in the United States., Methods: The study involving 48 participants (31 PLWE and 17 caregivers) with in depth interviews and focus groups was conducted. We obtained insights into barriers to care in PLWE and their caregivers. Using a thematic analytic procedure emphasizing the dominant themes the qualitative responses were analyzed. Median age of PLWE was 24 years (IQR 19-30), and10 (52.6%) were male. The median age of epilepsy onset was 12 years (IQR 6-18), range of 1-37 years. The median age of caregivers was 50 years (IQR 45-50.5), with a range of 18-78 years. Seventy five percent of caregivers (6/8) were females., Results: Three major areas of perceived barriers involving individual, family or community and provider and healthcare system barriers to epilepsy care emerged. Individual factors like limited epilepsy knowledge and medication non-adherence were reported to be key barriers to epilepsy care. Caregiver burden and lack of family support as well as poor health care access were identified from the family and health care systems., Conclusions: The main barrier to epilepsy care is limited epilepsy knowledge in PLWE and their caregivers. Improving epilepsy care awareness and knowledge within communities and appropriate health care provider service for epilepsy would help reduce epilepsy barriers and improve care.

Objective: This study evaluated the feasibility, acceptability, and preliminary efficacy of psychoeducation plus an automated text messaging intervention (Individualized Texting for Adherence Building-Cardiovascular [iTAB-CV]) to improve adherence to antihypertensives and bipolar disorder medication., Methods: After a psychoeducation program, iTAB-CV was administered for 2 months. In month 1, participants received one educational-motivational and one mood rating text daily. In month 2, medication reminders were added., Results: The sample (N=38) was 74% African American and 53% women, with a mean±SD age of 51.53±9.06. Antihypertensive nonadherence decreased from a mean of 43%±23% to 21%±18% at 12 weeks (χ 2 =34.6, df=3, p<0.001). Systolic blood pressure decreased from a mean of 144.8±15.5 mmHg to 136.0±17.8 mmHg (χ 2 =17.6, df=3, p<.001). Retention was 100%., Conclusions: In this uncontrolled trial, participants were highly engaged and medication adherence and reduced systolic blood pressure were sustained after psychoeducation plus iTAB-CV. Because iTAB-CV is automated and delivered remotely, it has the potential to reach a large and challenging population.

Rationale: There is a paucity of information about the association of seizure severity and quality of life (QoL) in people living with epilepsy (PLWE) in sub-Saharan Africa. We evaluated the relationship between seizure severity and health-related quality of life (HRQoL) of patients with epilepsy being followed up in an outpatient neurology clinic in urban central Uganda., Methods: Forty-eight PLWE who met the study inclusion criteria were enrolled. The study questionnaire was comprised of the Chalfont Seizure Severity Scale (CSSS) and the Quality of Life Inventory in Epilepsy (QOLIE-31). Spearman's rank correlation coefficient was used to determine the association between seizure severity and QoL score., Results: The median age of the study participants was 25 years, with median age (interquartile range (IQR)) of epilepsy onset of 12 (6-18) years. Over 57.4% of the study participants were unemployed. The mean (standard deviation (SD)) of QOLIE-31 and Seizure Severity Score was 62.5 (14.5) and 62.4 (1.6), respectively. There was no gender difference in the seizure severity scores (p = 0.451). An inverse relationship existed between seizure severity and the total QOLIE-31 score (Spearman's rank correlation coefficient, r = -0.48, p = 0.001), and seizure worry (r = -0.31, p = 0.030)., Conclusions: In this Ugandan sample, seizure severity is unacceptably high and directly impacts the life of PLWE. Interventions that reduce seizure severity are urgently needed in our settings to reduce seizures and improve the QoL in PLWE., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Chronic psychotic disorders (CPDs) occur worldwide and cause significant burden including reduced quality of life and functional impairment. Care for CPD includes psychosocial and pharmacologic interventions (i.e. antipsychotic drugs) and ongoing health monitoring. This is challenging in resource-limited settings where staff are sparse and/or undertrained. Importantly, mental health human resource needs predict continued deficits compounded by increasing disease burden. A U.S. team recently developed and tested a CPD treatment approach that combines the use of long-acting antipsychotic medication (LAI) with a brief and practical customized adherence enhancement behavioral intervention (CAE-L). This report describes the methodological details of an ongoing, first-ever refinement and preliminary testing of CAE-L in poorly adherent patients with CPD in Tanzania. Additional innovative elements include: 1) a manualized curriculum that targets specific barriers and facilitators to medication adherence in Tanzanians with CPD, and 2) targeting known, high-risk individuals with CPD (those who miss ≥20% of prescribed antipsychotic medication). The study procedures are intended to pave the way for implementing a large-scale intervention trial for CPD in the Tanzanian setting. An important component of this project is capacity building to help form the next generation of care providers. Visit exchanges modeled on a successful NIH-funded Medical Education Partnership Initiative (MEPI) template will also use the U.S. and Tanzanian teams to share expertise, problem-solve, and plan iterative refinements of project deliverables. Taken together, this project has potential to advance the care of people with CPD in Tanzania and has high generalizability to Sub-Saharan Africa and other lower-resource settings.

Objective: Nonadherence in bipolar disorder (BD) ranges from 20% to 60%. Customized adherence enhancement (CAE) is a brief, BD-specific approach that targets individual adherence barriers. This prospective, 6-month, randomized controlled trial conducted from October 2012 to July 2017 compared CAE versus a rigorous BD-specific educational program (EDU) on adherence, symptoms, and functional outcomes in poorly adherent individuals., Methods: One hundred eighty-four participants with DSM-IV BD were randomized to CAE (n = 92) or EDU (n = 92). Primary outcome was adherence change measured by the Tablets Routine Questionnaire (TRQ) and BD symptoms measured by the Brief Psychiatric Rating Scale. Other outcomes were scores on the Global Assessment of Functioning, Montgomery-Asberg Depression Rating Scale, Young Mania Rating Scale, and Clinical Global Impressions Scale. Assessments were conducted at screening, baseline, 10 weeks, 14 weeks, and 6 months., Results: The sample mean (SD) age was 47.40 (10.46) years; 68.5% were female, and 63.0% were African American. At screening, individuals missed a mean (SD) of 55.15% (28.22%) of prescribed BD drugs within the past week and 48.01% (28.46%) in the past month. Study attrition was < 20%. At 6 months, individuals in CAE had significantly improved past-week (P = .001) and past-month (P = .048) TRQ scores versus those in EDU. Past-week TRQ score improvement remained significant after adjustment for multiple comparisons. There were no treatment arm differences in BPRS scores or other symptoms, possibly related to low symptom baseline values. Baseline-to-6-month comparison showed significantly higher GAF scores (P = .036) for CAE versus EDU. Although both groups used more mental health services at 6 months compared to baseline, increase for CAE was significantly less than that for EDU (P = .046)., Conclusions: Whereas both CAE and EDU were associated with improved outcomes, CAE had additional positive effects on adherence, functioning, and mental health resource use compared to EDU., Trial Registration: ClinicalTrials.gov identifier: NCT00183495., (© Copyright 2018 Physicians Postgraduate Press, Inc.)

Objectives: Targeted Training in Illness Management (TTIM) focuses on enhancing care engagement for people living with serious mental illness and diabetes. This secondary analysis from a 60-week, randomized controlled trial of TTIM versus treatment as usual evaluated racial subgroup outcomes., Method: Demographics, clinical characteristics, and diabetes status were evaluated for those self-identifying as non-Hispanic White, African American, and Hispanic. Longitudinal response to TTIM was evaluated using a multiple domain risk index. Due to their small sample size; those identifying as Hispanic were excluded from this analysis., Results: Non-Hispanic White participants had greater baseline socioeconomic advantages. Baseline risk scores, glycosylated hemoglobin (HbA1c) values, and HbA1c differences over time were similar for African American and non-Hispanic White participants., Conclusions and Implications for Practice: African American participants living with serious mental illness and diabetes receiving TTIM did as well as non-Hispanic White participants. Inclusive approaches that feature peer support and are situated in safety-net health care settings need to be further investigated with respect to potentially impacting health disparities. (PsycINFO Database Record, ((c) 2018 APA, all rights reserved).)

Objective: This systematic review identified papers that described epilepsy misconceptions or stigma in sub-Saharan Africa (SSA) and research interventions focused on reducing these misconceptions., Materials and Methods: Publications in the English language from January 2000 to October 2017 that described original research conducted in SSA on misconceptions about epilepsy were utilized., Results: Twenty-three publications were identified. Studies were from Nigeria (N = 4), Cameroon (N = 4), Uganda (N = 3), Zambia (N = 2), Ethiopia (N = 2), Tanzania (N = 2), Kenya (N = 2), Ghana, Zimbabwe, Benin, and Mali (N = 1 each). The studies included assessments of misconceptions among healthcare providers and medical students (N = 3), high school students (N = 2), teachers (N = 2), the general public (N = 10), people with epilepsy (N = 7), and traditional healers (N = 1). Only two studies had stigma-focused interventions. Majority of the studies reported limitations to socialization with people with epilepsy and various beliefs associated with epilepsy., Conclusions: Epilepsy misconceptions, stigmatizing cultural beliefs, and perceptions were widely prevalent in SSA, and there are a few studies targeting epilepsy stigma. Existing stigma-reduction educational approaches may be impractical for general population implementation. Scalable approaches to reduce stigma are urgently needed within SSA., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Stroke remains a global concern due to increasing lifespan, patterns of industrialization, adoption of harmful western diets, and an increasing prevalence of risk factors such as hypertension, obesity, and diabetes. We investigated an adopted novel self-management intervention, TargetEd mAnageMent Intervention (TEAM) to reduce modifiable stroke risk factors in Uganda., Methods: A six-month, uncontrolled, prospective pilot study to establish feasibility, acceptability and preliminary efficacy of TEAM in Ugandans at high risk for stroke was conducted. The primary outcome was change in systolic BP from baseline to 24-week follow-up. Secondary outcomes included change in diastolic BP, serum cholesterol, high and low density lipoprotein (HDL, LDL) and triglycerides., Results: Mean (SD) baseline systolic BP was 162.9 (±25.6) mmHg while mean (SD) baseline diastolic BP was 99.1 (±13.8) mmHg. There was a significant reduction in mean baseline blood pressure of 163/98.8mmHg to blood pressure of 147.8/88.0mmHg at 24weeks, P=0.023. There were also significant reductions in the serum total cholesterol levels at 24weeks with P=0.001., Conclusion: Targeted training in self-management (TEAM) adapted to the Ugandan setting is feasible, highly acceptable to participants and appears to be associated with reduced blood pressure, improved lipid profiles and improved glucose control in diabetics., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To develop a deeper understanding of "how" a nurse led self-management intervention in a successful randomized controlled trial (RCT) for individuals with both serious mental illness (SMI) and diabetes (DM) influenced health outcomes and the lives of the participants., Methods: In depth interviews, were conducted with a sample of 10 participants who received the self-management intervention in the RCT. Interviews were audiotaped, transcribed verbatim, and analyzed using content analysis, with an emphasis on dominant themes., Results: The mean age of the respondents was 53.9years (SD=5.6); 6 (60%) were women and the mean level of education was 12.4years (SD=2.4). Transcript based analysis generated 3 major mechanisms of action that led to improved self-management of their SMI and DM: (Colton & Manderscheid, 2006) positive group experience, (Osborn et al., 2008) increased health knowledge, and (Newcomer, 2005) increased self- confidence., Conclusions: Developing complex interventions for testing in RCTs of individuals with SMI and other comorbid conditions is of increasing importance in healthcare planning for this vulnerable population. Using qualitative methods to explore mechanisms of action underlying quantitative outcomes, can enrich our understanding of processes relevant for individuals with SMI and comorbid conditions., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: This study compared a novel self-management (TargetEd MAnageMent Intervention [TEAM]) versus treatment as usual (TAU) to reduce stroke risk in African American (AA) men., Design: Six-month prospective randomized controlled trial with outcomes evaluated at baseline, 3 months, and 6 months., Setting: Academic health center., Participants: Thirty-eight (age < 65) AA men who had a stroke or transient ischemic attack and a Barthel index score of >60 were randomly assigned to TEAM (n = 19) or TAU (n = 19)., Intervention: Self-management training, delivered in 1 individual and 4 group sessions (over 3 months)., Measures: Blood pressure, glycosylated hemoglobin (HbA 1c ), lipids, medication adherence, weight, and standardized measures of health behaviors (diet, exercise, smoking, substances), depression, and quality of life. Qualitative assessments evaluated the perspectives of TEAM participants., Analysis: T tests for paired differences and nonparametric tests. Thematic content qualitative analysis., Results: Mean age was 52.1 (standard deviation [SD] = 7.4) and mean body mass index was 31.4 (SD = 7.4). Compared to TAU, TEAM participants had significantly lower mean systolic blood pressure by 24 weeks, and there was also improvement in HbA 1c and high-density lipoprotein cholesterol ( P = .03). Other biomarker and health behaviors were similar between groups. Qualitative results suggested improved awareness of risk factors as well as positive effects of group support.

Objective: Individuals living with bipolar disorder (BD) have poorer management of chronic medical conditions such as hypertension (HTN), and worse treatment adherence than the general population. The study objective was to obtain information from patients with both BD and HTN that would inform the development of an m-Health intervention to improve medication adherence for poorly adherent individuals living with both these chronic illnesses., Methods: Focus group methodology was used to collect information from 13 participants on perceived barriers and facilitators to BD and HTN medication adherence, as well as feedback on the demonstration and use of a bidirectional text messaging system for medication reminders. Focus groups were audiotaped, transcribed verbatim, and analyzed using content analysis with an emphasis on dominant themes., Results: Forgetfulness was the most frequently mentioned barrier to taking antihypertensive medications, and decisions about taking them were often influenced by BD mood fluctuations and the burden of having to take "too many pills" for both chronic illnesses. Participants' feedback about the use of a text-messaging system to help with medication adherence for BD and HTN was very positive, and their suggestions for modification were incorporated into a more customized system for testing in a Phase 2 trial., Conclusions: Our findings indicate that patient engagement in the development of an m-health intervention has the potential to improve adherence with both BD and HTN medications in individuals with known sub-optimal adherence. Patient engagement in health care is essential if we are to optimize patient outcomes., Competing Interests: CONFLICT OF INTEREST DISCLOSURE Dr. Sajatovic has research grants from Alkermes, Pfizer, Merck, Janssen, Reuter Foundation, Woodruff Foundation, Reinberger Foundation, National Institute of Health (NIH), and the Centers for Disease Control and Prevention (CDC). Dr. Sajatovic is a consultant to Bracket, Otsuka, Supernus, Neurocrine, Health Analytics and Sunovion and has received royalties from Springer Press, Johns Hopkins University Press, Oxford Press, and UpToDate. Dr. Moore has research grants from National Institute of Health (NIH), California HIV/AIDS Research Program, and Gilead Sciences has provided study drug for work unrelated to this project. Dr. Blixen, Dr. Depp, Mr. Cushman, Dr. Cage, Ms. Barboza, Mr. Eskew, Ms. Cassidy, and Dr. Levin declare no conflicts of interest.

Objective: To describe the modifiable lifestyle risk factors for stroke among a high risk population for stroke. Africa suffers from rapid population growth, adoption of harmful western diets, and increased prevalence of hypertension and obesity., Results: A total of 440 study participants were screened and 87 individuals with hypertension plus at least one other known stroke risk factor were enrolled. The prevalence of hypertension and diabetes mellitus in the screened population was 19.7 and 1.8%, respectively. Among those with hypertension only 2.3% (2/87) had ever had serum lipid assessment. Seventy-two percent (68/87) had very high serum LDL-cholesterol, while 33.3% (29/87) had low levels of HDL-cholesterol, and 67.8% had mean blood pressures greater than 160/100 mmHg and 40% (35/87) were obese, with a BMI ≥30. Targeting individuals with modifiable stroke risk factors and implementing self-management programs may be a way to reduce stroke burden in Uganda.

Objective: Stroke risk and stroke burden are increasing in Sub Saharan Africa. Qualitative analysis was used to assess perceived barriers to stroke recovery and prevention in an urban/suburban Ugandan population in order to refine and implement a promising nurse and peer-led self-management intervention previously conducted in the United States., Methods: In depth i nterviews and focus groups were conducted with 48 participants (stroke survivors, caretakers, and those at risk for stroke. All interviews and focus groups were audiotaped, transcribed verbatim, and analyzed using content analysis, with an emphasis on dominant themes., Results: Three major domains of perceived barriers to stroke recovery and prevention emerged from the data: (1) Individual barriers (PTSD, stress, resistance to seeking care, medication non-adherence, unhealthy lifestyles, functional impairment, and a paucity of stroke knowledge); (2) Family/community barriers (lack of family and community support and caretaker burden); and (3) Provider and healthcare system barriers (lack of access and inadequate follow-up). Importantly, participants in this study identified a pressing need for increasing stroke awareness in the community as part of recovery and prevention efforts., Conclusions: Stroke risk reduction efforts implemented at the patient, community, and healthcare system levels are needed. These efforts could, perhaps, be modeled along the lines of a previous very successful public health initiative to reduce HIV burden in Uganda., Competing Interests: CONFLICTS OF INTEREST DISCLOSURE Dr. Sajatovic declares the following potential conflict of interest with respect to research grants within the past 3 years: Merck, Alkermes, Janssen, Reuter Foundation, Woodruff Foundation, Reinberger Foundation, National Institute of Health (NIH), Centers for Disease Control and Prevention (CDC)Consultant: Bracket, Otsuka, Pfizer, Sunovion, Neurocrine, Supernus. In addition, the following royalties from: Springer Press, Johns Hopkins University Press, Oxford Press, UpToDate, Lexicomp, and CME activities from the American Physician’s Institute, MCM Education, CMEology. All other authors declare no potential conflicts of interest.

Background: Stroke is a neurological condition with rapidly increasing burden in many low- and middle income countries. Africa is particularly hard-hit due to rapid population growth, patterns of industrialization, adoption of harmful western diets, and increased prevalence of risk factors such as hypertension and obesity. Reducing stroke risk factors and teaching people to respond to stroke warning signs can prevent stroke and reduce burden. However, being able to address gaps in knowledge and improving both preventative and early-response care requires a clear understanding of practical and potentially modifiable topics. In this cross sectional study, we assessed the knowledge and attitudes among an urban population residing within the greater Kampala, Uganda., Methods: A population cross sectional survey was conducted in urban Mukono, district, central Uganda. Through the systematic sampling method, data were gathered from 440 adult participants who were interviewed about selected aspects of stroke knowledge, attitudes and perception using a pretested structured questionnaire., Results: A total of 440 study participants were enrolled. The leading risk factors for stroke identified by the participants were stress (75.7%) and hypertension (45.2%) respectively. Only two (0.5%) of the study participants identified cigarette smoking as a stroke risk factor. Individuals with hypertension have poor knowledge regarding stroke in spite their high risk for stroke., Conclusion: Stroke knowledge is poor while, stress and hypertension are the leading perceived risk factors in our settings. While stress is contributing factor, hypertension is likely a more amenable and practical intervention target. Targeting individuals with stroke risk factors to increase stroke knowledge and education is crucial for engagement in healthcare. Implementing a self-management program to support and motivate this high-risk group as well as adopting healthy life-styles may be a way to reduce stroke burden in Uganda., Competing Interests: Competing interests The authors declare that they have no competing interest.

Background: Self-management of bipolar disorder (BD) is challenging for many individuals., Material: Interviews were used to assess perceived barriers to disease self-management among 21 high-risk patients with BD. Content analysis, with an emphasis on dominant themes, was used to analyze the data., Results: Three major domains of barriers emerged: individual barriers (psychological, knowledge, behavioral and physical health); family/community-level barriers (lack of support and resources); and provider/healthcare system (inadequate communication and access to care)., Conclusion: Care approaches providing social and peer support, optimizing communication with providers and integrating medical and psychiatric care may improve self-management of BD in this vulnerable population.

Background: Internalized stigma, which occurs when stigmatized individuals accept society's assessment and incorporate this assessment into their sense of self, is prevalent in individuals with bipolar disorder (BD). This study explored the correlates of internalized stigma in a research sample of patients with BD who were poorly adherent to their medications., Methods: Both quantitative and qualitative analyses were performed. Scores of 115 individuals with BD on the Internalized Stigma of Mental Illness (ISMI) scale were correlated with scores on the General Self-Efficacy (GSE) Scale, Brief Psychiatric Rating Scale (BPRS), Montgomery-Asberg Depression Rating Scale (MADRS), and Young Mania Rating Scale (YMRS). Regression was run for GSE (dependent variable) and ISMI (independent variable). In-depth qualitative interviews were conducted on a representative subsample (N=21)., Results: Internalized stigma levels were moderately high. Internalized stigma and self-efficacy correlated, and internalized stigma related to self-efficacy after adjusting for demographic variables (age, gender, years of education), comorbidities, and symptom severity (BPRS and MADRS). Internalized stigma was also associated with the BD symptoms of depression, anxiety, guilt feelings, suspiciousness, and hallucinogenic behaviors. No association was found with mania., Conclusions: Because internalized stigma has strong psychosocial and psychiatric symptom associations, it is recommended that clinicians address both societal stigma and internalized stigma. Strategies such as cognitive-behavioral therapy may help modify BD patients' internalized stigma., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The burden of stroke is severe among African-Americans. Despite overall declines in the rate of stroke since 2000, outcomes are largely unimproved or have worsened for African-American men. Adverse psychosocial challenges may hinder adherence to a regimen of risk factor reduction., Methods and Results: Focus group analysis was combined with a review of current published guidelines and epidemiologic evidence on risk factors to better understand stroke health disparities and potential policy solutions. Transcripts from three focus groups with ten African-American male stroke survivors under age 65 and their care partners (N = 7) were analyzed and compared with existing published data on (a) the burden of stroke (b) trends in clinical risk factors, and (c) trends in behavioral risk factors. Participants described myriad psychosocial barriers that impede reduction of risk indicators, including low trust in providers, poor social support, access difficulties, depression, and distress., Conclusions: In order to be effective, policies and programs must target mechanisms consistent with the challenges faced by African-American men. Infrastructure is needed to better identify and share practices effective for improving cardiovascular outcomes within specific racial and ethnic groups.

Objective: To understand factors related to managing illness in older individuals with serious mental illness (SMI)., Methods: Baseline data from 200 individuals with SMI and diabetes enrolled in a study were used to compare characteristics between older (age >55) vs. younger (age ≤55) individuals., Results: Older individuals had better diabetes control compared to younger individuals, those with major depressive disorder had diabetes for a longer duration, worse diabetic control, and more emergency department encounters., Conclusions: Helping younger individuals with SMI learn to manage their mental and physical health early-on might minimize the negative and cumulative effect of diabetes., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Patients with serious mental illness (SMI) and diabetes often seek care in primary care settings and have worse health outcomes than patients who have either illness alone. Individual, provider, and system-level barriers present challenges to addressing both psychiatric and medical comorbidities. This article describes the feasibility, acceptability, and implementation of Targeted Training and Illness Management (TTIM), a self-management intervention delivered by trained nurse educators and peer educators to groups of individuals with SMI and diabetes to improve self-management of both diseases. TTIM is intended to be delivered in a primary care setting. Findings are intended to support the future development of nurse-led programs within the primary care setting that teach self-management to individuals with concurrent SMI and diabetes. This approach supports both adaptability and flexibility in delivering the intervention. Interventions such as TTIM can provide self-management skills, accommodate people with both SMI and diabetes in primary care settings such as patient-centered medical homes, and address known barriers to access.

Objective: To assess perceived facilitators and recommendations for stroke recovery and prevention among younger African-American (AA) men (age < 65 years) in order to inform the development and pilot testing of an intervention for this high-risk group., Methods: Focus group methodology was used to collect data from 10 community-dwelling AA stroke survivors and seven of their care partners (CPs) (N = 17). Thematic analysis of session transcripts and the constant comparative method were used to generate themes., Results: Participants cited facilitators to post-stroke care and recovery as Family Support, Stress Reduction, and Dietary Changes. Specific person-level recommendations for AA men included following established stroke guidelines, use of complementary and alternative medicine, and never give up recovery efforts. Community-level recommendations included making a list of community resources available, providing support and education to care partners, using videos that feature AA men to deliver information and use AA men stroke survivors to help disseminate the information. Provider and health system recommendations included consolidation of medical bills, improving provider communication skills, and making providers aware of needs specific to AA men and their families., Conclusions: While AA men and their CPs acknowledged and welcomed learning more about the American Health Association Stroke Prevention Guidelines, it is clear that they desired approaches that addressed their specific needs and preferences as young AA men who sometimes felt de-valued by their community and care providers. Specific person, community and care-system level approaches that are of perceived value to AA men offer potential to improve health outcomes and reduce health disparities.

Aim: To describe the training and participant experience of patients with both severe mental illness (SMI) and diabetes (DM) who were enrolled in a Peer Educator Training Program adapted to a primary health care setting., Background: The mortality of patients with both SMI and DM is high. Illness self-management includes medications, psychosocial treatments, and healthy behaviors, yet treatment engagement is often sub-optimal with adherence rates of 52% for diabetic medications and 62% for antipsychotic medications among the SMI. To address this problem, a new behavioral intervention study targeting SMI and DM self-management used trained peer educators (PEs) with the same chronic conditions to enhance program effectiveness. A manual facilitated training on intervention topics such as SMI and DM therapies, stress management, and stigma reduction as well as training in group intervention techniques, telephone skills, and crisis management., Methods: We assessed PE attitudes and input using in-depth face-to-face interviews. Interviews were audio-taped, transcribed, coded, and analyzed using the classic method of content analysis emphasizing dominant themes. A member check-in was conducted where participants commented on analysis results., Findings: Six relevant descriptive themes emerged: (1) positive group experience; (2) success with learning manual content; (3) increased knowledge about SMI and DM; (4) improved self-management skills; (5) increased self-confidence and self-efficacy in becoming a PE; and being (6) united in purpose to help others self-manage their SMI and DM. Qualitative evidence supports structured training for SMI-DM PEs. Key components include written educational materials and the power of the group process to increase knowledge, self-management skills, confidence, and self-efficacy. Recommendations are offered to support further endeavors to mobilize peers with SMI to help other patients with complex comorbidities better manage their own health.

Background: African Americans (AAs) who experience a first time stroke are younger and have double the stroke rate and more poststroke complications than other Americans., Objective: To assess perceived poststroke care barriers among younger AA men and their care partners (CPs) in order to inform the development of acceptable and effective improvements in poststroke care for this high-risk group., Methods: Ten community-dwelling AA stroke survivors and 7 of their CPs participated in focus groups and advisory board meetings. Survivors had stroke or transient ischemic attack within 1 year and a Barthel Index score ≯60. In focus groups, using a semi-structured interview guide, survivors and CPs identified self-perceived barriers and facilitators to poststroke care. Thematic analysis of session transcripts and the constant comparative method were used to generate themes., Results: Survivor age ranged from 34 to 64 years. Mean Barthel score was 95.5. CPs, all AA women, ranged in age from 49 to 61 years. Five CPs were wives, 1 was a fiancée, and 1 was a niece. Participants cited multiple personal, social, and societal stroke recovery challenges. Although hypertension and smoking risks were acknowledged, stress, depression, posttraumatic stress disorder, anger/frustration, personal identity change, and difficulty communicating unique needs as AA men were more frequently noted. Facilitators included family support, stress reduction, and dietary changes., Conclusions: Younger AA men and their CPs perceive multiple poststroke care barriers. Biological risk reduction education may not capture all salient aspects of health management for AA stroke survivors. Leveraging family and community strengths, addressing psychological health, and directly engaging patients with health care teams may improve care management.

The objective of the study was to assess the feasibility of implementing and evaluating a culturally appropriate in-patient asthma education program specifically targeted for African-Americans. A consecutive sample of 28 African-American patients ages 18-50 who were hospitalized for asthma were randomized to an intervention group, which received three one-on-one sessions on chronic asthma management, or a control group, which received the usual care. Data on symptom frequency, self-management behaviors, quality of life, depression, and health care resource use were collected at baseline and at 3 and 6 months. Although the time required to recruit our sample took longer than anticipated, 28 subjects agreed to be in the study (70% acceptance rate) and complete the baseline interview. We observed no statistically significant differences from baseline or changing trends in frequency of asthma symptoms, self-management behaviors, and health care resource use between the intervention and control groups at 3 and 6 months. However patients in the intervention group demonstrated a greater average increase in asthma-related quality of life and a greater average decrease in depression than the control group. Feasibility issues included shortened length of stay, which necessitated conducting all three self-management sessions together; multiple interruptions during the sessions, and retention issues at 3- and 6-month follow-ups. The lessons learned from this pilot study are invaluable in that they will enable us to make changes in our existing protocol to ensure the success of a larger clinical trial.

Purpose: To develop an understanding of the quality of life of older adults with osteoarthritis (OA) with varying levels of depression and social support as a basis for nursing interventions. Osteoarthritis in the United States is the number one chronic disease in late life and the major cause of disability in older adults. In addition to the functional disability and economic effect of OA, older people with this disease experience suffering, depression, and diminished quality of life., Design: For this cross-sectional survey, a convenience sample of 50 older adults with OA was recruited from two U.S. hospital-based arthritis clinics in northern Ohio for 3-months during 1995., Methods: During face-to-face interviews, the Arthritis Impact Scales, Center for Epidemiological Studies Depression Scale, Social Support Questionnaire, and Quality of Life Survey, were used to measure osteoarthritis severity, depression, informal social support, and quality of life., Findings: Although few formal social support services were used, high levels of satisfaction from the subjects' large informal networks of family and friends were reported. In addition, satisfaction with subjects' quality of life was extremely high despite depression, co-morbid conditions, pain, and functional limitation., Conclusions: Social support appeared to play an important role in moderating the effects of pain, functional limitation, and depression on these subjects' quality of life. Nurses who work with older adults are in a unique position to help them adjust to living with osteoarthritis by providing them the support needed to help them manage their disease.

The objective of this study was to determine whether racial differences in patterns of asthma care persist in a healthcare environment when financial barriers to health care are minimized. The study cohort consisted of African-American (AA) and Caucasian (C) patients, 18-50 years old, enrolled in a large HMO and hospitalized for asthma in 1993-1995. Baseline and 1-year follow-up data were collected from the HMO computerized database. Of the 193 patients in the cohort, 124 (65.3%) were AA and 67 (34.7%) were C. AAs were younger (mean = 36.2, SD = 9.9) than Cs (mean = 39.4, SD = 9.1), had a lower median household income, and made more asthma-related emergency department (ED) visits (45.2%) than Cs (22.4%) during the 1 year after the initial hospitalization (all p values <0.001). During the same time period, Cs made more asthma-related primary care (70.2%) and allergy/pulmonary visits (38.8%) than AAs (47.6% and 27%, respectively). Although there were no significant racial differences in the rehospitalization rate, AA Medicaid contract patients (32%) had more rehospitalizations for asthma than AA regular contract patients (15.8%). These differential patterns in the use of asthma-related healthcare in this study indicate that the provision of health insurance alone is not sufficient to promote optimal levels of asthma management by all beneficiaries. Asthma education programs targeted for low-income AA patients may improve inappropriate healthcare use patterns.

Recent evidence indicates persons 60 years and over experience significant alcohol and substance abuse problems. Since a combination of alcoholism and depression is likely to increase the relative rsk of suicide, it is important to examine the prevalence of dual diagnosis in older adults. The purpose of this study is to examine the prevalence and correlates of dual diagnosis in older psychiatric inpatient populations and compare our results with findings from studies of younger hospitalized dually diagnosed patients. A retrospective chart audit was performed on 101 elders who were discharged from three psychiatric hospitals. Clinical variables that were examined included length of hospital stay, psychiatric and medical diagnoses, medications and history of suicidal ideation or intent. The leading psychiatric disorder diagnosis for our sample of hospitalized psychiatric elders was depression. Over one-third (37.6%) had a substance abuse disorder in addition to a psychiatric disorder, and almost three-fourths (71%) of this 'dual diagnosis' group abused alcohol and 29% abused both alcohol and other substances. In addition, significantly more elders in the "dual diagnosis' group (17.7%) than in the group with only a mental disorder diagnosis (3.3%) made a suicide attempt prior to admission to the hospital. Because, affective disorders in conjunction with alcohol abuse are the most frequently found disorders in completed suicides, our findings have important relevance for the advocating of routine use of diagnostic assessment and screening for both substance abuse and mental disorders in this population.

The demands of providing care to impaired older adults frequently results in strain and depressive symptomatology. These outcomes of caregiving may be affected by social support such as home health care. Forty-nine caregivers to impaired older adults receiving home health care and 51 caregivers not receiving home health care were interviewed soon after identification by hospital personnel and 3 months later. Strain and depressive symptomatology were not significantly lower and positive caregiving appraisal was not significantly higher for caregivers receiving home health care even when controlling for their pretest measures. Strain and depressive symptomatology were significantly higher for caregivers of cognitively impaired persons. Home health care nurses need to identify those caregivers at greater risk to individualize services.

Approximately 5% to 18% of kidney transplant recipients do not comply with their posttransplant medical treatment. This study examined the relationship between pretransplant noncompliance and posttransplant outcomes. Using a longitudinal retrospective chart audit, pretransplant and posttransplant data were collected for 126 kidney transplant recipients over a 3-year period. Sixty-one percent of those identified as noncompliant before transplant lost their graft or died after transplant. Significant relationships between pretransplant noncompliance and graft loss and between pre- and posttransplant noncompliance were found. Clinicians must identify those with pretransplant noncompliance, as they are at risk for poor outcomes and might benefit from an intensive posttransplant follow-up regimen.

Visits to hospital outpatient clinics and emergency rooms by patients age 65 and over were studied. Differences were found in the use of mental health services between the oldest old and youngest old. A significant portion of psychiatric and substance abuse disorders was found among the youngest old, while the oldest old made a greater number of visits to emergency rooms.