[show abstract][hide abstract] ABSTRACT: Innovative approaches are needed to promote physical activity among young adult overweight and obese African American women. We sought to describe key elements that African American women desire in a culturally relevant Internet-based tool to promote physical activity among overweight and obese young adult African American women.
A mixed-method approach combining nominal group technique and traditional focus groups was used to elicit recommendations for the development of an Internet-based physical activity promotion tool. Participants, ages 19 to 30 years, were enrolled in a major university. Nominal group technique sessions were conducted to identify themes viewed as key features for inclusion in a culturally relevant Internet-based tool. Confirmatory focus groups were conducted to verify and elicit more in-depth information on the themes.
Twenty-nine women participated in nominal group (n = 13) and traditional focus group sessions (n = 16). Features that emerged to be included in a culturally relevant Internet-based physical activity promotion tool were personalized website pages, diverse body images on websites and in videos, motivational stories about physical activity and women similar to themselves in size and body shape, tips on hair care maintenance during physical activity, and online social support through social media (eg, Facebook, Twitter).
Incorporating existing social media tools and motivational stories from young adult African American women in Internet-based tools may increase the feasibility, acceptability, and success of Internet-based physical activity programs in this high-risk, understudied population.
[show abstract][hide abstract] ABSTRACT: Current US colorectal cancer screening guidelines that call for shared decision making regarding the choice among several recommended screening options are difficult to implement. Multicriteria decision analysis (MCDA) is an established method well suited for supporting shared decision making. Our study goal was to determine whether a streamlined form of MCDA using rank-order-based judgments can accurately assess patients' colorectal cancer screening priorities.
We converted priorities for 4 decision criteria and 3 subcriteria regarding colorectal cancer screening obtained from 484 average-risk patients using the analytic hierarchy process (AHP) in a prior study into rank-order-based priorities using rank order centroids. We compared the 2 sets of priorities using Spearman rank correlation and nonparametric Bland-Altman limits of agreement analysis. We assessed the differential impact of using the rank-order-based versus the AHP-based priorities on the results of a full MCDA comparing 3 currently recommended colorectal cancer screening strategies. Generalizability of the results was assessed using Monte Carlo simulation.
Correlations between the 2 sets of priorities for the 7 criteria ranged from 0.55 to 0.92. The proportions of differences between rank-order-based and AHP-based priorities that were more than ±0.15 ranged from 1% to 16%. Differences in the full MCDA results were minimal, and the relative rankings of the 3 screening options were identical more than 88% of the time. The Monte Carlo simulation results were similar.
Rank-order-based MCDA could be a simple, practical way to guide individual decisions and assess population decision priorities regarding colorectal cancer screening strategies. Additional research is warranted to further explore the use of these methods for promoting shared decision making.
Medical Decision Making 12/2013; · 2.89 Impact Factor
[show abstract][hide abstract] ABSTRACT: PurposeThis study examined the relationship between coping style and understanding of diabetes self-care among African American and white elders in a southern Medicare-managed care plan.Methods
Participants were identified through a diabetes-related pharmacy claim or ICD-9 code and completed a computer-assisted telephone survey in 2006-2007. Understanding of diabetes self-care was assessed using the Diabetes Care Profile Understanding (DCP-U) scale. Coping styles were classified as active (talk about it/take action) or passive (keep it to yourself). Linear regression was used to estimate the associations between coping style with the DCP-U, adjusting for age, sex, education, and comorbidities. Based on the conceptual model, 4 separate categories were established for African American and white participants who displayed active and passive coping styles.ResultsOf 1420 participants, the mean age was 73 years, 46% were African American, and 63% were female. Most respondents (77%) exhibited active coping in response to unfair treatment. For African American participants in the study, active coping was associated with higher adjusted mean DCP-U scores when compared to participants with a passive coping style. No difference in DCP-U score was noted among white participants on the basis of coping style.Conclusions
Active coping was more strongly associated with understanding of diabetes self-care among older African Americans than whites. Future research on coping styles may give new insights into reducing diabetes disparities among racial/ethnic minorities.
The Diabetes Educator 10/2013; · 1.94 Impact Factor
[show abstract][hide abstract] ABSTRACT: Objectives. We sought to determine if reported racial discrimination was associated with medication nonadherence among African Americans with hypertension and if distrust of physicians was a contributing factor. Methods. Data were obtained from the TRUST project conducted in Birmingham, Alabama, 2006 to 2008. All participants were African Americans diagnosed with hypertension and receiving care at an inner city, safety net setting. Three categories of increasing adherence were defined based on the Morisky Medication Adherence Scale. Trust in physicians was measured with the Hall General Trust Scale, and discrimination was measured with the Experiences of Discrimination Scale. Associations were quantified by ordinal logistic regression, adjusting for gender, age, education, and income. Results. The analytic sample consisted of 227 African American men and 553 African American women, with a mean age of 53.7 ±9.9 years. Mean discrimination scores decreased monotonically across increasing category of medication adherence (4.1, 3.6, 2.9; P = .025), though the opposite was found for trust scores (36.5, 38.5, 40.8; P < .001). Trust mediated 39% (95% confidence interval = 17%, 100%) of the association between discrimination and medication adherence. Conclusions. Within our sample of inner city African Americans with hypertension, racial discrimination was associated with lower medication adherence, and this association was partially mediated by trust in physicians. Patient, physician and system approaches to increase "earned" trust may enhance existing interventions for promoting medication adherence. (Am J Public Health. Published online ahead of print September 12, 2013: e1-e8. doi:10.2105/AJPH.2013.301554).
American Journal of Public Health 09/2013; · 3.93 Impact Factor
[show abstract][hide abstract] ABSTRACT: There are limited data informing the optimal treatment strategy for acute myocardial infarction in the oldest old (aged ≥85 years). The study aim was to examine whether decade-long increases in guideline-based cardiac medication use mediate declines in post-discharge mortality among oldest old patients hospitalized with acute myocardial infarction.
The study sample included 1137 patients aged ≥85 years hospitalized in 6 biennial periods between 1997 and 2007 for acute myocardial infarction at all 11 greater Worcester, Massachusetts, medical centers. We examined trends in 90-day survival after hospital discharge and guideline-based medication use (aspirin, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, lipid-lowering agents) for acute myocardial infarction during hospitalization and at discharge. Sequential multivariable Cox regression models examined the relationship among guideline-based medication use, study year, and 90-day post-discharge survival rates.
Patients hospitalized between 2003 and 2007 experienced higher 90-day survival rates than those hospitalized between 1997 and 2001 (69.1% vs 59.8%, P < .05). Between 1997 and 2007, the average number of guideline-based medications prescribed at discharge increased significantly (1.8 to 2.9, P < .001). The unadjusted hazard ratio for 90-day post-discharge mortality in 2003-2007 compared with 1997-2001 was 0.73 (95% confidence interval, 0.60-0.89); after adjustment for patient characteristics and guideline-based cardiac medication use, this relationship was no longer significant (hazard ratio, 1.26; 95% confidence interval, 1.00-1.58).
Between 1997 and 2007, 90-day survival improved among a population-based sample of patients aged ≥85 years hospitalized for acute myocardial infarction. This encouraging trend was explained by increased use of guideline-based medications.
The American journal of medicine 07/2013; · 4.47 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Relative validity (RV), a ratio of ANOVA F-statistics, is often used to compare the validity of patient-reported outcome (PRO) measures. We used the bootstrap to establish the statistical significance of the RV and to identify key factors affecting its significance. METHODS: Based on responses from 453 chronic kidney disease (CKD) patients to 16 CKD-specific and generic PRO measures, RVs were computed to determine how well each measure discriminated across clinically-defined groups of patients compared to the most discriminating (reference) measure. Statistical significance of RV was quantified by the 95% bootstrap confidence interval. Simulations examined the effects of sample size, denominator F-statistic, correlation between comparator and reference measures, and number of bootstrap replicates. RESULTS: The statistical significance of the RV increased as the magnitude of denominator F-statistic increased or as the correlation between comparator and reference measures increased. A denominator F-statistic of 57 conveyed sufficient power (80%) to detect an RV of 0.6 for two measures correlated at r = 0.7. Larger denominator F-statistics or higher correlations provided greater power. Larger sample size with a fixed denominator F-statistic or more bootstrap replicates (beyond 500) had minimal impact. CONCLUSIONS: The bootstrap is valuable for establishing the statistical significance of RV estimates. A reasonably large denominator F-statistic (F > 57) is required for adequate power when using the RV to compare the validity of measures with small or moderate correlations (r < 0.7). Substantially greater power can be achieved when comparing measures of a very high correlation (r > 0.9).
Health and Quality of Life Outcomes 05/2013; 11(1):89. · 2.27 Impact Factor
[show abstract][hide abstract] ABSTRACT: We conducted a cluster randomized trial testing the effectiveness of an intervention to increase the use of osteoporosis medications in high-risk patients receiving home health care. The trial did not find a significant difference in medication use in the intervention arm. INTRODUCTION: This study aims to test an evidence implementation intervention to improve the quality of care in the home health care setting for patients at high risk for fractures. METHODS: We conducted a cluster randomized trial of a multimodal intervention targeted at home care for high-risk patients (prior fracture or physician-diagnosed osteoporosis) receiving care in a statewide home health agency in Alabama. Offices throughout the state were randomized to receive the intervention or to usual care. The primary outcome was the proportion of high-risk home health patients treated with osteoporosis medications. A t test of difference in proportions was conducted between intervention and control arms and constituted the primary analysis. Secondary analyses included logistic regression estimating the effect of individual patients being treated in an intervention arm office on the likelihood of a patient receiving osteoporosis medications. A follow-on analysis examined the effect of an automated alert built into the electronic medical record that prompted the home health care nurses to deploy the intervention for high-risk patients using a pre-post design. RESULTS: There were 11 offices randomized to each of the treatment and control arms; these offices treated 337 and 330 eligible patients, respectively. Among the offices in the intervention arm, the average proportion of eligible patients receiving osteoporosis medications post-intervention was 19.1 %, compared with 15.7 % in the usual care arm (difference in proportions 3.4 %, 95 % CI, -2.6 to 9.5 %). The overall rates of osteoporosis medication use increased from 14.8 % prior to activation of the automated alert to 17.6 % afterward, a nonsignificant difference. CONCLUSIONS: The home health intervention did not result in a significant improvement in use of osteoporosis medications in high-risk patients.
Osteoporosis International 03/2013; · 4.04 Impact Factor
[show abstract][hide abstract] ABSTRACT: Background: The Veterans Health Administration has im-plemented patient to clinical team electronic asynchronous secure messaging (SM). This disruptive technology has the potential to support continuous, coordinated quality care, but limited evidence supports this connection.
Medical Care 03/2013; 51(3, Supp 1):S21-S28. · 3.23 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Brief clinician delivered advice helps in tobacco cessation efforts. This study assessed the impact of our intervention on instances of advice given to dental patients during visits on tobacco use quit rates 6 months after the intervention. METHODS: The intervention was cluster randomized trial at the dental practice level. Intervention dental practices were provided a longitudinal technology-assisted intervention, oralcancerprevention.org that included a series of interactive educational cases and motivational email cues to remind dental provides to complete guideline-concordant brief behavioral counseling at the point of care. In all dental practices, exit cards were given to the first 100 consecutive patients, in which tobacco users provided contact information for a six month follow-up telephone survey. RESULTS: A total of 564 tobacco using dental patients completed a six month follow-up survey. Among intervention patients, 55% reported receiving advice to quit tobacco, and 39% of control practice patients reported receiving advice to quit tobacco (p < 0.01). Six-month tobacco use quit rates were not significantly between the Intervention (9%) and Control (13%) groups, (p = 0.088). CONCLUSION: Although we increased rates of cessation advice delivered in dental practices, this study shows no evidence that brief advice by dentist's increases long-term abstinence in smokers.Trial registration: ClinicalTrials.gov NCT00627185.
BMC Oral Health 02/2013; 13(1):13. · 1.34 Impact Factor
[show abstract][hide abstract] ABSTRACT: OBJECTIVES/HYPOTHESIS: The purpose of this study was to examine factors associated with prophylactic placement of feeding tubes in head and neck cancer patients receiving radiation therapy as a part of treatment using multilevel models that account for patient-, physician-, and institution-level sources of variation. STUDY DESIGN: A retrospective analysis using binary logistic regression and hierarchical linear models was run to evaluate independent predictors of prophylactic feeding tube placement. METHODS: Surveillance, Epidemiology, and End Results-Medicare data were used. Head and neck cancer patients diagnosed with locoregionally advanced stage disease from 2000 to 2005 were included in this study (N = 8,306). RESULTS: Across all models, prophylactic gastrostomy tube placement was found to be more likely in patients who had cancer of the larynx or oropharynx compared with those with cancer of the nasopharynx or oral cavity; who had regional instead of local cancer; who did not receive surgery as a part of treatment, but did receive chemotherapy; and who were divorced, separated, or widowed. Additionally, although practice variation was observed to occur, its overall contribution in predicting prophylactic gastrostomy tube placement was minimal. CONCLUSIONS: As health care enters an era of patient-centered care, further investigation of the potential role of social support (or lack of social support) in influencing treatment decisions of head and neck cancer patients and providers is warranted. LEVEL OF EVIDENCE: 2b Laryngoscope, 2013.
[show abstract][hide abstract] ABSTRACT: In this article we provide an overview of the different study designs commonly utilized in carrying out clinical and public health research and of the points to consider in reviewing these study designs. The design and conduct of cross-sectional health surveys, case-control, prospective, and case-crossover observational studies, and randomized controlled trials, are discussed in this review article. It is hoped that careful attention to the concerns we have raised will lead to the design and conduct of high-quality research projects and their write-up.
The American journal of medicine 02/2013; 126(2):169.e1-169.e8. · 4.47 Impact Factor
[show abstract][hide abstract] ABSTRACT: Cardiovascular disease (CVD) is one of the leading causes of morbidity and mortality in Vietnam and hypertension (HTN) is an important and prevalent risk factor for CVD in the adult Vietnamese population. Despite an increasing prevalence of HTN in this country, information about the awareness, treatment, and control of HTN is limited. The objectives of this study were to describe the prevalence, awareness, treatment, and control of HTN, and factors associated with these endpoints, in residents of a mountainous province in Vietnam.
Data from 2,368 adults (age≥25 years) participating in a population-based survey conducted in 2011 in Thai Nguyen province were analyzed. All eligible participants completed a structured questionnaire and were examined by community health workers using a standardized protocol.
The overall prevalence of HTN in this population was 23%. Older age, male sex, and being overweight were associated with a higher odds of having HTN, while higher educational level was associated with a lower odds of having HTN. Among those with HTN, only 34% were aware of their condition, 43% of those who were aware they had HTN received treatment and, of these, 39% had their HTN controlled.
Nearly one in four adults in Thai Nguyen is hypertensive, but far fewer are aware of this condition and even fewer have their blood pressure adequately controlled. Public health strategies increasing awareness of HTN in the community, as well as improvements in the treatment and control of HTN, remain needed to reduce the prevalence of HTN and related morbidity and mortality.
PLoS ONE 01/2013; 8(6):e66792. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: Background
Tailored, web-assisted interventions can reach many smokers. Content from other smokers (peers) through crowdsourcing could enhance relevance.
To evaluate whether peers can generate tailored messages encouraging other smokers to use a web-assisted tobacco intervention (Decide2Quit.org).
Phase 1: In 2009, smokers wrote messages in response to scenarios for peer advice. These smoker-to-smoker (S2S) messages were coded to identify themes. Phase 2: resulting S2S messages, and comparison expert messages, were then e-mailed to newly registered smokers. In 2012, subsequent Decide2Quit.org visits following S2S or expert-written e-mails were compared.
Phase 1: a total of 39 smokers produced 2886 messages (message themes: attitudes and expectations, improvements in quality of life, seeking help, and behavioral strategies). For not-ready-to-quit scenarios, S2S messages focused more on expectations around a quit attempt and how quitting would change an individual’s quality of life. In contrast, for ready-to-quit scenarios, S2S messages focused on behavioral strategies for quitting. Phase 2: In multivariable analysis, S2S messages were more likely to generate a return visit (OR=2.03, 95% CI=1.74, 2.35), compared to expert messages. A significant effect modification of this association was found, by time-from-registration and message codes (both interaction terms p<0.01). In stratified analyses, S2S codes that were related more to “social” and “real-life” aspects of smoking were driving the main association of S2S and increased return visits.
S2S peer messages that increased longitudinal engagement in a web-assisted tobacco intervention were successfully collected and delivered. S2S messages expanded beyond the biomedical model to enhance relevance of messages.
This study is registered at www.clinicaltrials.gov NCT00797628 (web-delivered provider intervention for tobacco control [QUIT-PRIMO]) and NCT01108432 (DPBRN Hygienists Internet Quality Improvement in Tobacco Cessation [HiQuit]).
American Journal of Preventive Medicine. 01/2013; 45(5):543–550.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Previous studies examining characteristics of Internet health information seekers do not distinguish between those who only seek for themselves, and surrogate seekers who look for health information for family or friends. Identifying the unique characteristics of surrogate seekers would help in developing Internet interventions that better support these information seekers. OBJECTIVE: To assess differences between self seekers versus those that act also as surrogate seekers. METHODS: We analyzed data from the cross-sectional Pew Internet and American Life Project November/December 2008 health survey. Our dependent variable was self-report of type of health information seeking (surrogate versus self seeking). Independent variables included demographics, health status, and caregiving. After bivariate comparisons, we then developed multivariable models using logistic regression to assess characteristics associated with surrogate seeking. RESULTS: Out of 1250 respondents who reported seeking health information online, 56% (N=705) reported being surrogate seekers. In multivariable models, compared with those who sought information for themselves only, surrogate seekers were more likely both married and a parent (OR=1.57, CI=1.08, 2.28), having good (OR=2.05, CI=1.34, 3.12) or excellent (OR=2.72, CI=1.70, 4.33) health status, being caregiver of an adult relative (OR=1.76, CI=1.34, 2.30), having someone close with a serious medical condition (OR=1.62, CI=1.21, 2.17) and having someone close to them facing a chronic illness (OR=1.55, CI=1.17, 2.04). CONCLUSIONS: Our findings provide evidence that information needs of surrogate seekers are not being met, specifically of caregivers. Additional research is needed to develop new functions that support surrogate seekers.
International Journal of Medical Informatics 11/2012; · 2.06 Impact Factor
[show abstract][hide abstract] ABSTRACT: Background- Cardiovascular disease continues to cause significant morbidity, mortality, and impaired quality of life, with unrealized health gains from the underuse of available evidence. The Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) aims to advance the science of acute coronary syndromes by examining the determinants and outcomes of the quality of transition from hospital to community and by quantifying the impact of potentially modifiable characteristics associated with decreased quality of life, rehospitalization, and mortality. Methods and Results- TRACE-CORE comprises a longitudinal multiracial cohort of patients hospitalized with acute coronary syndromes, 2 research projects, and development of a nucleus of early stage investigators. We are currently enrolling 2500 adults hospitalized for acute coronary syndromes at 6 hospitals in the northeastern and southeastern United States. We will follow these patients for 24 months after hospitalization through medical record abstraction and 5 patient interviews focusing on quality of life, cardiac events, rehospitalizations, mortality, and medical, behavioral, and psychosocial characteristics. The Transitions Project studies determinants of and disparities in outcomes of the quality of patients' transition from hospital to community. Focusing on potentially modifiable factors, the Action Scores Project will develop and validate action scores to predict recurrent cardiac events, death, and quality of life, describe longitudinal variation in these scores, and develop a dashboard for patient and provider action on the basis of these scores. Conclusions- In TRACE-CORE, sound methodologic principles of observational studies converge with outcomes and effectiveness research approaches. We expect that our data, research infrastructure, and research projects will inform the development of novel secondary prevention approaches and underpin the careers of cardiovascular outcomes researchers.
[show abstract][hide abstract] ABSTRACT: Purpose: To explore the relationship between degree of rurality and glucose (hemoglobin A1c), blood pressure (BP), and lipid (LDL) control among patients with diabetes. Methods: Descriptive study; 1,649 patients in 205 rural practices in the United States. Patients' residence ZIP codes defined degree of rurality (Rural-Urban Commuting Areas codes). Outcomes were measures of acceptable control (A1c < = 9%, BP < 140/90 mmHg, LDL < 130 mg/dL) and optimal control (A1c < 7%, BP < 130/80 mmHg, LDL < 100 mg/dL). Statistical significance was set at P < .008 (Bonferroni's correction). Findings: Although the proportion of patients with reasonable A1c control worsened by increasing degree of rurality, the differences were not statistically significant (urban 90%, large rural 88%, small rural 85%, isolated rural 83%; P= .10); mean A1c values also increased by degree of rurality, although not statistically significant (urban 7.2 [SD 1.6], large rural 7.3 [SD 1.7], small rural 7.5 [SD 1.8], isolated rural 7.5 [SD 1.9]; P= .16). We observed no differences between degree of rural and reasonable BP or LDL control (P= .42, P= .23, respectively) or optimal A1c or BP control (P= .52, P= .65, respectively). Optimal and mean LDL values worsened as rurality increased (P= .08, P= .029, respectively). Conclusions: In patients with diabetes who seek care in the rural Southern United States, we observed no relationship between degree of rurality of patients' residence and traditional measures of quality of care. Further examination of the trends and explanatory factors for relative worsening of metabolic control by increasing degree of rurality is warranted.
The Journal of Rural Health 09/2012; 28(4):364-371. · 1.44 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: US colorectal cancer screening guidelines for people at average risk for colorectal cancer endorse multiple screening options and recommend that screening decisions reflect individual patient preferences. METHODS: . The authors used the analytic hierarchy process (AHP) to ascertain decision priorities of people at average risk for colorectal cancer attending primary care practices in Rochester, New York; Birmingham, Alabama; and Indianapolis, Indiana. The analysis included 4 decision criteria, 3 subcriteria, and 10 options. RESULTS: . Four hundred eighty-four people completed the study; 66% were female, 49% were African American, 9% had low literacy skills, and 27% had low numeracy skills. Overall, preventing cancer was given the highest priority (mean priority 55%), followed by avoiding screening test side effects (mean priority 17%), minimizing false-positive test results (mean priority 15%), and the combined priority of screening frequency, test preparation, and the test procedure(s) (mean priority 14%). Hierarchical cluster analysis revealed 6 distinct priority groupings containing multiple instances of decision priorities that differed from the average value by a factor of 4 or more. More than 90% of the study participants fully understood the concepts involved, 79% met AHP analysis quality standards, and 88% were willing to use similar methods to help make important health care decisions. CONCLUSION: . These results highlight the need to facilitate incorporation of patient preferences into colorectal cancer screening decisions. The large number of study participants able and willing to perform the complex AHP analysis used for this study suggests that the AHP is a useful tool for identifying the patient-specific priorities needed to ensure that screening decisions appropriately reflect individual patient preferences.
Medical Decision Making 08/2012; · 2.89 Impact Factor
[show abstract][hide abstract] ABSTRACT: We examined the relationship between trust in the medical system, medication adherence, and hypertension control in Southern African American men. The sample included 235 African American men aged 18 years and older with hypertension. African American men with higher general trust in the medical system were more likely to report better medication adherence (odds ratio [OR] = 1.06), and those with higher self-efficacy were more likely to report better medication adherence and hypertension control (OR = 1.08 and OR = 1.06, respectively). (Am J Public Health. Published online ahead of print June 14, 2012: e1-e3. doi: 10.2105/AJPH.2012.300777).
American Journal of Public Health 06/2012; · 3.93 Impact Factor