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1.  Understanding Narrative Effects: The Impact of Breast Cancer Survivor Stories on Message Processing, Attitudes, and Beliefs among African American Women 
OBJECTIVE
Examine the longitudinal effects of personal narratives about mammography and breast cancer compared with a traditional informational approach.
METHOD
African American women (n=489) ages 40 and older were recruited from low-income neighborhoods in St. Louis, MO and randomized to watch a narrative video comprised of stories from African American breast cancer survivors or a content-equivalent informational video. Effects were measured immediately post-exposure (T2) and at 3- (T3) and 6-month (T4) follow-up. T2 measures of initial reaction included positive and negative affect, trust, identification, and engagement. T3 message-processing variables included arguing against the messages (counterarguing) and talking to family members about the information (cognitive rehearsal). T4 behavioral correlates included perceived breast cancer risk, cancer fear, cancer fatalism, perceived barriers to mammography, and recall of core messages. Structural equation modeling examined inter-relations among constructs.
RESULTS
Women who watched the narrative video (n=244) compared to the informational video (n=245) experienced more positive and negative affect, identified more with the message source, and were more engaged with the video. Narratives, negative affect, identification, and engagement influenced counterarguing, which in turn influenced perceived barriers and cancer fatalism. More engaged women talked with family members more, which increased message recall. Narratives also increased risk perceptions and fear via increased negative affect.
CONCLUSIONS
Narratives produced stronger cognitive and affective responses immediately, which in turn influenced message processing and behavioral correlates. Narratives reduced counterarguing and increased cognitive rehearsal, which may increase acceptance and motivation to act on health information in populations most adversely affected by cancer disparities.
doi:10.1037/a0025395
PMCID: PMC3217077  PMID: 21895370
mammography; breast cancer survivors; health communication; storytelling; narratives; cancer disparities
2.  Rheumatic heart disease: pilot study for a population-based evaluation of prevalence and cardiovascular outcomes among schoolchildren in Nepal 
BMJ Open  2012;2(5):e001616.
Objectives
To evaluate a protocol for a population-based programme targeting the prevention of rheumatic heart disease (RHD) progression by early echocardiographic diagnosis of valvular lesions and timely implementation of secondary prevention.
Design
Observational survey with a subsequent prospective cohort study.
Setting
Private boarding school in the urban area of the Sunsari district situated on the foothills of the Lower Himalayan Range in Eastern Nepal.
Participants
Fifty-four unselected school-going children 5–15 years of age, 24 girls and 30 boys.
Primary outcome measure
Logistic feasibility of a large-scale population-based screening study using the echocardiographic criteria formulated by the World Heart Federation, with longitudinal follow-up of children with definite or borderline RHD in a prospective cohort study.
Results
Standardised interview, physical examination and screening echocardiography were performed in a three-staged process and took approximately 6 min per child. Socio-economic status was assessed using surrogate markers such as the occupation of the primary caregiver, numbers of rooms at home, car, television, cell phone and internet connection. Physical examination was focused on cardiac auscultation and signs of acute rheumatic fever and targeted echocardiography was performed by an independent examiner without knowledge of the clinical findings. Two children with evidence of borderline RHD were re-examined at B.P. Koirala Institute of Health Sciences and the indication for secondary antibiotic prevention was discussed with the parents and the children. At 6 months of follow-up, echocardiographic findings were stable in both children. Implementation of secondary antibiotic prevention was challenged by impaired awareness of subclinical RHD among parents and inadequate cooperation with family physicians.
Conclusions
This pilot study shows that the methods outlined in the protocol can be translated into a large-scale population-based study. We learned that education and collaboration with teachers, parents and family physicians/paediatricians will be of key importance in order to establish a sustainable programme.
doi:10.1136/bmjopen-2012-001616
PMCID: PMC3488717  PMID: 23087010
Cardiology
3.  Protocol for a population-based study of rheumatic heart disease prevalence and cardiovascular outcomes among schoolchildren in Nepal 
BMJ Open  2012;2(3):e001320.
Introduction
Rheumatic heart disease (RHD) remains a major contributor to morbidity and mortality in developing countries. The reported prevalence rates of RHD are highly variable and mainly attributable to differences in the sensitivity of either clinical screening to detect advanced heart disease or echocardiographic evaluation where disease is diagnosed earlier across a continuous spectrum. The clinical significance of diagnosis of subclinical RHD by echocardiographic screening and early implementation of secondary prevention has not been clearly established.
Methods and analysis
The authors designed a cross-sectional survey to determine the prevalence of RHD in children from private and public schools between the age of 5 and 15 years in urban and rural areas of Eastern Nepal using both cardiac auscultation and echocardiographic evaluation. Children with RHD will be treated with secondary prevention and enrolled in a prospective cohort study. The authors will compare the prevalence rates by cardiac auscultation and echocardiography, determine risk factors associated with diagnosis and progression of RHD, investigate social and economic barriers for receiving adequate cardiac care and assess clinical outcomes with regular medical surveillance as a function of stage of disease at the time of diagnosis. Prospective clinical studies investigating the impact of secondary prevention for subclinical RHD on long-term clinical outcome will be of central relevance for future health resource utilisation in developing countries.
Ethics and dissemination
The study was considered ethically uncritical and was given an exempt status by the ethics committee at University of Bern, Switzerland. The study has been submitted to the National Nepal Health Research Council and was registered with http://www.ClinicalTrials.gov (NCT01550068). The study findings will be reported in peer-reviewed publications.
ClinicalTrials.gov Identifier
NCT01550068.
Article summary
Article focus
Study protocol of a population-based evaluation of the prevalence rate of RHD among schoolchildren in Eastern Nepal, with a subsequent prospective longitudinal cohort study assessing long-term clinical outcome of children undergoing secondary prevention for borderline and definite RHD according to the World Heart Federation criteria.
Key messages
RHD remains a major contributor to morbidity and mortality in developing countries.
Echocardiographic screening allows diagnosis of RHD at an earlier stage across a continuous spectrum as compared with cardiac auscultation.
The clinical significance of diagnosis of subclinical RHD by echocardiographic screening and early implementation of secondary prevention has not been clearly established.
Strengths and limitations of this study
The protocol describes a comprehensive approach to implement echocardiographic screening in a high prevalence region as recommended by the WHO and outlines a robust analysis plan to investigate clinical outcome with secondary prevention for subclinical RHD.
Since access to education is a marker of socioeconomic status, restriction of screening to school going children is subjected to selection bias likely to underestimate the real disease burden related to RHD in Eastern Nepal.
Cultural sensitivity with education programmes and focus group discussions will anticipate the potential social stigma of a diagnosis with a heart condition during childhood and increase public awareness.
doi:10.1136/bmjopen-2012-001320
PMCID: PMC3371575  PMID: 22685225
4.  Comparing the Use of Evidence and Culture in Targeted Colorectal Cancer Communication for African Americans 
Patient education and counseling  2010;81S1:S22-S33.
Objective
This study examined the effects (affective reactions, cognitive reactions and processing, perceived benefits and barriers and intent to screen) of targeted Peripheral + Evidential (PE) and Peripheral+Evidential+Socio-cultural (PE+SC) colorectal cancer communications.
Methods
This study was a two-arm randomized control study of cancer communication effects on affective, cognitive processing, and behavioral outcomes over a 22-week intervention. There were 771 African American participants, 45 to 75 years, participating in the baseline survey related to CRC screening. Three follow-up interviews that assessed intervention effects on affective response to the publications, cognitive processing, and intent to obtain CRC screening were completed.
Results
There were no statistically significant differences between PE and PE+SC intervention groups for affect, cognitive processing or intent to screen. However, there were significant interactions effects on outcome variables.
Conclusions
The advantages and disadvantages of PE+SC targeted cancer communications and implications of sex differences are considered.
Practice Implications
While there do not appear to be significant differences in behavioral outcomes when using PE and PE+SC strategies, there appear to be subtle differences in affective and cognitive processing outcomes related to medical suspicion and ethnic identity, particularly as it relates to gender.
doi:10.1016/j.pec.2010.07.019
PMCID: PMC2988986  PMID: 20702056
5.  Comparing narrative and informational videos to increase mammography in low-income African American women 
Patient education and counseling  2010;81(Suppl):S6-14.
OBJECTIVE
Compare effects of narrative and informational videos on use of mammography, cancer-related beliefs, recall of core content and a range of reactions to the videos.
METHOD
African American women (n=489) ages 40 and older were recruited from low-income neighborhoods in St. Louis, MO and randomly assigned to watch a narrative video comprised of stories from African American breast cancer survivors (Living Proof) or a content-equivalent informational video using a more expository and didactic approach (Facts for Life). Effects were measured immediately post-exposure and at 3- and 6-month follow-up.
RESULTS
The narrative video was better liked, enhanced recall, reduced counterarguing, increased breast cancer discussions with family members and was perceived as more novel. Women who watched the narrative video also reported fewer barriers to mammography, more confidence that mammograms work, and were more likely to perceive cancer as an important problem affecting African Americans. Use of mammography at 6-month follow-up did not differ for the narrative vs. informational groups overall (49% vs. 40%, p=.20), but did among women with less than a high school education (65% vs. 32%, p<.01), and trended in the same direction for those who had no close friends or family with breast cancer (49% vs. 31%, p=.06) and those who were less trusting of traditional cancer information sources (48% vs. 30%, p=.06).
CONCLUSIONS
Narrative forms of communication may increase the effectiveness of interventions to reduce cancer health disparities.
PRACTICE IMPLICATIONS
Narratives appear to have particular value in certain population sub-groups; identifying these groups and matching them to specific communication approaches may increase effectiveness.
doi:10.1016/j.pec.2010.09.008
PMCID: PMC3146295  PMID: 21071167
6.  Genetic Polymorphisms of Peroxisome Proliferator-Activated Receptors and the Risk of Cardiovascular Morbidity and Mortality in a Community-Based Cohort in Washington County, Maryland 
PPAR Research  2007;2008:276581.
The primary aim of this study was to examine prospectively the associations between 5 peroxisome proliferator-activated receptor (PPAR) single nucleotide polymorphisms (SNPs) and cardiovascular morbidity and mortality in a community-based cohort study in Washington County, Maryland. Data were analyzed from 9,364 Caucasian men and women participating in CLUE-II. Genotyping on 5 PPAR polymorphisms was conducted using peripheral DNA samples collected in 1989. The followup period was from 1989 to 2003. The results showed that there were no statistically significant associations between the PPAR SNPs and cardiovascular deaths or events. In contrast, statistically significant age-adjusted associations were observed for PPARG rs4684847 with both baseline body mass and blood pressure, and for PPARG rs709158, PPARG rs1175543, and PPARD rs2016520 with baseline cholesterol levels. Future studies should be conducted to confirm these findings and to explore the associations in populations with greater racial and ethnic diversity.
doi:10.1155/2008/276581
PMCID: PMC2233806  PMID: 18288282

Results 1-6 (6)