Journal of correctional health care : the official journal of the National Commission on Correctional Health Care, 2016
Prior research has not examined the self-identified goals and plans of incarcerated people as the... more Prior research has not examined the self-identified goals and plans of incarcerated people as they approach release from prison. This study analyzed the goals and plans generated during a motivational interviewing counseling session of incarcerated men who participated in a randomized controlled trial of a smoking abstinence intervention in a tobacco-free prison in the northeastern United States. Using thematic analysis, 53 written goals and plans were independently coded by trained research assistants to identify major themes that included (1) staying smoke-free or reducing the number of cigarettes smoked postrelease, (2) engaging in physical activities to improve health and wellness, and (3) spending time with family and/or friends. Implications for working with inmates to identify their plans and goals to remain smoke-free after incarceration are discussed.
International journal of environmental research and public health, Jan 12, 2016
Prior research has found high levels of depression and stress among persons who are incarcerated ... more Prior research has found high levels of depression and stress among persons who are incarcerated in the United States (U.S.). However, little is known about changes in depression and stress levels among inmates post-incarceration. The aim of this study was to examine changes in levels of depression and stress during and after incarceration in a tobacco-free facility. Questionnaires that included valid and reliable measures of depression and stress were completed by 208 male and female inmates approximately eight weeks before and three weeks after release from a northeastern U.S. prison. Although most inmates improved after prison, 30.8% had a worsening in levels of depression between baseline and the three-week follow-up. In addition, 29.8% had a worsening in levels of stress after release than during incarceration. While it is not surprising that the majority of inmates reported lower levels of depression and stress post-incarceration, a sizable minority had an increase in symptoms...
Patient-centered medical home transformation initiatives for enhancing team-based, patient-center... more Patient-centered medical home transformation initiatives for enhancing team-based, patient-centered primary care are widespread in the United States. However, there remain large gaps in our understanding of these efforts. This article reports findings from a contextual, whole system evaluation study of a transformation intervention at eight primary care teaching practice sites in Rhode Island. It provides a picture of system changes from the perspective of providers, staff, and patients in these practices. Quantitative/qualitative evaluation methods include patient, provider, and staff surveys and qualitative interviews; practice observations; and focus groups with the intervention facilitation team. Patient satisfaction in the practices was high. Patients could describe observable elements of patient-centered medical home functioning, but they lacked explicit awareness of the patient-centered medical home model, and their activation decreased over time. Providers' and staff'...
International journal of environmental research and public health, Jan 27, 2018
Exposure to environmental tobacco smoke (ETS) presents substantial health risks for pregnant wome... more Exposure to environmental tobacco smoke (ETS) presents substantial health risks for pregnant women and newborn infants. Measurements of ETS include invasive and expensive biochemical tests, as well as less invasive and lower-cost, self-reported exposure and avoidance measures. Better understanding of self-report measures will help to select ETS assessments for evaluation. This analysis was conducted within the context of a tailored video intervention to reduce tobacco smoking and ETS exposure during pregnancy and after delivery in the control group sample of 147 nonsmoking women. Measurements of salivary cotinine concentration, self-reported ETS exposure, and avoidance behaviors were captured at 32 weeks’ gestation and 6 months postpartum. Salivary cotinine concentration was significantly related to ETS avoidance among pregnant nonsmokers at 32 weeks’ gestation, but not ETS exposure. At 6 months postpartum, both the reported ETS exposure of the infant and maternal avoida...
Problems with self-reported drug use include difficulties with recall and recognition as well as ... more Problems with self-reported drug use include difficulties with recall and recognition as well as the desire to respond to questions in a socially desirable manner. Various methods have been developed to improve and/or validate estimates based on direct questioning of individuals regarding their substance use. For this study, we were interested in validating self-reported use of: 1) tobacco, 2) marijuana, and 3) other substances (i.e., heroin, cocaine, opiates, oxycodone, benzodiazepines, methamphetamine, phencyclidine, and barbiturates) employing urinalysis among inmates who participated in a randomized controlled trial of a smoking abstinence intervention in a tobacco-free prison located in the northeastern United States. Two-hundred and seven men and women with a mean age of 34.9 (standard deviation = 9.0) completed questions regarding their substance use on a 7-day Timeline Follow-Back and provided urine specimens three weeks following prison release. Self-reported tobacco and ma...
Low-cost interventions to decrease environmental tobacco smoke (ETS) exposure of pregnant women a... more Low-cost interventions to decrease environmental tobacco smoke (ETS) exposure of pregnant women and their newborns are needed to lower health risks of exposed fetuses and infants. Baby's Breath is a tailored video intervention developed and tested in a randomized controlled trial. The study aimed to test the efficacy of tailored video versus usual care approaches to reduce the ETS exposure of fetuses of low-income women during and after pregnancy; and to assess this intervention separately among non-smoking and smoking women. Participating women, recruited early in pregnancy, who spoke English, were at least 18 years old, smoke exposed (current smokers, quit smoking on their own, or were exposed to smoke of others), pregnant with only one baby, and had access to a telephone and video player, were randomized to experimental or control conditions. Intervention participants received newsletters containing content aimed at smoking cessation and avoidance (5 during and 3 after pregnancy), in addition to videos (3 during and 2 after pregnancy) individually tailored on behavioral theory-based survey questions. Comparison participants received newsletters and videos on healthy pregnancy topics. Outcomes included salivary cotinine of both mother and baby (32 weeks gestation and 6 months postpartum) as well as self-reported ETS exposure and avoidance behaviors. This study may demonstrate the efficacy of a low-cost intervention to decrease ETS exposure, and will fill an important gap in describing the utility of this innovative intervention technology, as well as demonstration of potential benefits to this type of intervention.
The proliferation of mobile devices and emergence of interoperable ‘mHealth’ apps is accelerating... more The proliferation of mobile devices and emergence of interoperable ‘mHealth’ apps is accelerating development and deployment of patient-facing risk assessments in primary care. The present study describes a user-centered design and an agile development approach to creation of an app for assessing lungfunction as part of a randomized controlled trial for the  dentification of chronic obstructive lung disease in primary care. Seventeen patients recruited from a hospital-based, ambulatory family medicine clinic agreed to be videotaped while using the app, Lung Age, on a first-generation iPad prior to their providerencounter. Subsequently, participants were interviewed using a semi-structured interview guide upon exiting their medical visit. Observational data indicated that participants took advantage of the portability and flexibility of the tablet device in the exam room to engage with the Lung Age app with the optionto share and discuss their results with their providers. Results f...
H eart disease is the leading cause of mortality among women in the United States. 1 The importan... more H eart disease is the leading cause of mortality among women in the United States. 1 The importance of knowing whether a woman's risk of coronary heart disease (CHD) is low, medium, or high is important when considering when and how aggressively to modify her CHD risk factors. If we had an earlier window of detection into a woman's level of CHD risk, we would be better able to institute earlier lifestyle-change counseling and, when appropriate, pharmacotherapy to change risk factors such as hypertension or dyslipidemia. Clinical Perspective on p 2158 Background-Reproductive factors provide an early window into a woman's coronary heart disease (CHD) risk; however, their contribution to CHD risk stratification is uncertain. Methods and Results-In the Women's Health Initiative Observational Study, we constructed Cox proportional hazards models for CHD including age, pregnancy status, number of live births, age at menarche, menstrual irregularity, age at first birth, stillbirths, miscarriages, infertility ≥1 year, infertility cause, and breastfeeding. We next added each candidate reproductive factor to an established CHD risk factor model. A final model was then constructed with significant reproductive factors added to established CHD risk factors. Improvement in C statistic, net reclassification index (or net reclassification index with risk categories of <5%, 5 to <10%, and ≥10% 10-year risk of CHD), and integrated discriminatory index were assessed. Among 72 982 women (CHD events, n=4607; median follow-up,12.0 [interquartile range, 8.3-13.7] years; mean [standard deviation] age, 63.2 [7.2] years), an age-adjusted reproductive risk factor model had a C statistic of 0.675 for CHD. In a model adjusted for established CHD risk factors, younger age at first birth, number of still births, number of miscarriages, and lack of breastfeeding were positively associated with CHD. Reproductive factors modestly improved model discrimination (C statistic increased from 0.726 to 0.730; integrated discriminatory index, 0.0013; P<0.0001). Net reclassification for women with events was not improved (net reclassification index events, 0.007; P=0.18); and, for women without events, net reclassification was marginally improved (net reclassification index nonevents, 0.002; P=0.04) Conclusions-Key reproductive factors are associated with CHD independently of established CHD risk factors, very modestly improve model discrimination, and do not materially improve net reclassification.
Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, Jan 25, 2015
A major health challenge facing persons who are incarcerated is tobacco smoking. Upon reentry to ... more A major health challenge facing persons who are incarcerated is tobacco smoking. Upon reentry to the community, concerns regarding smoking cessation may be less likely to receive needed attention. Many individuals have partners who are pregnant and/or reside in households where children and pregnant women live. We explored incarcerated adults' attitudes of smoking in the presence of children and pregnant women and how post-release smoking behaviors are influenced by their attitudes. 247 incarcerated adults participated in a smoking cessation RCT in a tobacco-free prison. An instrument was developed to examine smoking attitudes and behaviors around children and pregnant women. Moderating effects of smoking factors on post-release abstinence were examined by evaluating interactions between smoking factors and treatment group. 4 factors were defined using factor analysis: smoking around children; impact of smoking on child's health; awareness of ETS risk for pregnant women; and...
Journal of health care for the poor and underserved, 2015
Background. Tobacco use among prisoners is much higher than among the general population. Little ... more Background. Tobacco use among prisoners is much higher than among the general population. Little is known about changes in smoking-related symptoms during periods of incarceration. The objective of this study is to evaluate changes in smoking-related symptoms during incarceration. Methods. We recruited 262 inmates from a tobacco-free prison. At baseline, participants were asked about smoking-related symptoms prior to incarceration and then asked about recent symptoms. Results. All symptom scores on the American Thoracic Society Questionnaire (ATSQ) improved during incarceration. Higher ATSQ scores were associated with asthma, depressive symptoms, stress, higher addiction and more pack years of smoking. Greater improvement in symptoms was not associated with smoking status after release. Conclusion. Forced tobacco abstinence leads to significant improvements in smoking-related symptoms. However, improvements in symptoms are not associated with smoking behavior changes. Addressing cha...
Little is known about smoking behaviors involving shared and previously used cigarettes, which we... more Little is known about smoking behaviors involving shared and previously used cigarettes, which we refer to as "smoking used cigarettes." Examples include: cigarette sharing with strangers, smoking discarded cigarettes ('butts'), or remaking cigarettes from portions of discarded cigarettes. The current study focuses on the prevalence of and factors associated with smoking used cigarettes prior to incarceration among a US prison population. Questionnaires were administered to 244 male and female inmates at baseline. Prevalence of smoking used cigarettes was assessed using three questions; one about sharing cigarettes with strangers, one about smoking a "found" cigarette, and one about smoking previously used cigarettes. Factors associated
Despite the impact of high-visibility evidence-based clinical practice guidelines, physician adhe... more Despite the impact of high-visibility evidence-based clinical practice guidelines, physician adherence to guidelines remains low. This study explored primary care physicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; perceptions of barriers and facilitators in following the National Cholesterol Education Program guidelines. The authors conducted 9 focus groups and performed qualitative content analysis utilizing immersion-crystallization processes, codebooks, and qualitative coding software. Key barriers to implementing guidelines included the complexity and transience of existing cholesterol guidelines as well as perceived threats to multidimensional care of the patient that unifocal single-decision guidelines may create. Key facilitators included growing patient awareness regarding cholesterol, patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; willingness to take cholesterol medication, and technological breakthroughs. These findings have helped identify factors that prevent or enhance the adoption of cholesterol guidelines. While factors considered to be facilitators are significant, barriers may be sufficient to limit adherence. Opportunities may exist for improving adherence to cholesterol guidelines by providing training to providers and developing structural support through patient-physician activation tools.
Background Short stature has been associated with an increased risk of coronary heart disease (CH... more Background Short stature has been associated with an increased risk of coronary heart disease (CHD), although the reason for the association remains unclear. Data on the relation between stature and stroke is more limited. We examined the association between stature and CHD as well as between stature and stroke in men and women from two communities in southeastern New England. Methods Coronary heart disease and stroke events were abstracted from medical records between January 1980 and December 1991. An epidemiological diagnostic algorithm developed to measure CHD was used in the present analysis. Unadjusted relative risks (RR) and RR adjusted for age, smoking status, obesity, high-density lipoprotein (HDL) cholesterol <0.91 mmol/1, total cholesterol >6.21 mmol/1, hypertension, diabetes, education, and being foreign born were computed by gender-specific height categories separately for men (n = 2826) and women (n = 3741). Results A graded inverse association between stature and risk of CHD was observed among men which persisted after adjustment for confounders. Men >69.75 inches had an 83% lower risk of CHD compared with men «65 inches. In addition, the tallest men had a 67% decreased risk of stroke compared with the shortest men. No significant relation between stature and CHD or stroke was observed among women. Conclusions These data support the hypothesis that stature is inversely related to both risk of CHD and stroke at least among men. Factors which might explain this association remain to be determined.
Background: Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating disease a... more Background: Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating disease associated with significant clinical burden and is estimated to affect 15 million individuals in the US. Although a large number of individuals are diagnosed with COPD, many individuals still remain undiagnosed due to the slow progression of the disorder and lack of recognition of early symptoms. Not only is there under-diagnosis but there is also evidence of sub-optimal evidence-based treatment of those who have COPD. Despite the development of international COPD guidelines, many primary care physicians who care for the majority of patients with COPD are not translating this evidence into effective clinical practice. Method/Design: This paper describes the design and rationale for a randomized, cluster design trial (RCT) aimed at translating the COPD evidence-based guidelines into clinical care in primary care practices. During Phase 1, a needs assessment evaluated barriers and facilitat...
Background: Evidence suggests that there is an association between chronic obstructive pulmonary ... more Background: Evidence suggests that there is an association between chronic obstructive pulmonary disease (COPD) and coronary heart disease (CHD). An important etiological link between COPD and CHD may be an underlying systemic inflammatory process. Given that COPD patients are at greater risk of cardiovascular mortality, understanding the burden of CHD on COPD patients could permit future risk attenuation. Methods: Longitudinal cohort analyses of the Third National Health and Nutrition Examination Survey from 1988-1994 were performed. 3,681 individuals ≥40 years of age with good quality spirometry data were included. Participants were divided into 5 groups: 1) no COPD, no CHD; 2) COPD without inflammation, no CHD; 3) COPD with inflammation, no CHD; 4) CHD only, and 5) CHD + COPD. A novel "inflammatory" COPD designation included those with COPD and clinical evidence of inflammation (i.e., CRP ≥95.24 nmol/L). Results: The risk for CHD mortality was significant only for the CHD group (HR 5.56, 95% CI 3.24-9.55) and the COPD + CHD group (HR 5.02, 95% CI 2.83-8.90). Similarly, the risk for cardiovascular disease (CVD) mortality was significant only for the CHD group (HR 4.25, 95% CI 2.70-6.69) and the CHD + COPD group (HR 4.12, 95% CI 2.60-6.54) after adjusting for nonmodifiable CHD risk factors (age, gender, race/ethnicity, family history of CHD). After adjusting for modifiable CHD risk factors (diabetes, BMI, physical activity, systolic blood pressure, cholesterol, and smoking), hazard ratios of the two groups remained similar but attenuated. For total mortality, the risk was significant for the four groups: the non-inflammatory COPD group; the COPD with inflammation group, the CHD group, and the COPD + CHD group. Conclusions: Our study did not confirm that inflammatory COPD may be a CHD risk equivalent. However, due to the small size of the "inflammatory" COPD group, further prospective replication and validation is needed. Moreover, given that COPD results from inflammation, the systemic inflammation associated with COPD may have worsened comorbid conditions and may have lead to the increased total mortality found in the COPD with inflammation and COPD + CHD groups which requires further investigation.
Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, 2007
This study reports on the evaluation of the feasibility, cost, and cost-effectiveness of a proact... more This study reports on the evaluation of the feasibility, cost, and cost-effectiveness of a proactively provided telephone-based motivational smoking cessation intervention to an underserved population of pregnant smokers who may or may not receive ongoing prenatal care. As part of the New England SCRIPT randomized clinical trial comparing the efficacy of three types of smoking cessation interventions for pregnant smokers, one-third of the women (n = 358) received a motivational telephone counseling intervention (MI) delivered by trained counselors using a semistructured protocol. Although this population was very mobile, the MI counselors were able to reach 86% of the women with at least one call and 46% received all three calls. The group receiving three MI calls had a cotinine-confirmed quit rate of 23%. Cost-effectiveness analyses for those women receiving telephone counseling supported the net benefit in favor of the three phone calls compared with the women who did not receive ...
While e-health tools have been designed for patient/consumer empowerment and for decision support... more While e-health tools have been designed for patient/consumer empowerment and for decision support focusing on healthcare providers, they have had only modest success in primary care settings. Creating complementary e-health tools that provide patient activation and decision support for a common clinical problem such as hyperlipidemia using a behaviorally oriented risk communication strategy has not been previously described. This paper presents the details regarding the development of two complementary software programs: HeartAge, an interactive risk communication program focusing on patient activation placed on a laptop computer in the doctor's waiting room, and a PDA-based, clinical decision support program for lipid management utilizing algorithms recommended by the National Cholesterol Education Program. The efficacy of these programs in improving cholesterol management in five primary care practices is described.
Autopsy data suggest that plaque neovascularization may be associated with coronary heart disease... more Autopsy data suggest that plaque neovascularization may be associated with coronary heart disease (CHD) death. Since vascular endothelial growth factor-A (VEGF-A) is upregulated in angiogenesis and therefore neovascularization, we hypothesized that individuals with elevated levels of VEGF-A at baseline would be a greater risk of dying of CHD compared to those with lower levels over time. We measured VEGF-A levels in 46 CHD death cases and a 14% random sample of 2321 community participants who were free of self-reported CHD at baseline. Traditional CHD risk factors such as age, gender, family history of CHD, cigarette smoking, hypertension, total cholesterol/HDL ratio, diabetes mellitus, were also evaluated at baseline. Mortality follow-up was determined through linkage of baseline data with the National Death Index. During a median of 13 years of follow-up, 46 subjects died of coronary heart disease. Mean VEGF-A levels were significantly higher in the CHD death cases than among the random population sample (400 pg/ml vs. 303 pg/ml, p=0.0004). In proportional hazards models adjusting for traditional risk factors, the hazard ratios (95%CI) for CHD death associated with increasing tertiles of VEGF-A were 1.0 (referent), 2.12 (0.74, 6.10), and 3.85 (1.37, 10.78), respectively (P(test for trend)=0.008). In this population-based prospective, case-cohort study, baseline levels of VEGF-A showed a significant independent association with the risk of CHD death.
Journal of correctional health care : the official journal of the National Commission on Correctional Health Care, 2016
Prior research has not examined the self-identified goals and plans of incarcerated people as the... more Prior research has not examined the self-identified goals and plans of incarcerated people as they approach release from prison. This study analyzed the goals and plans generated during a motivational interviewing counseling session of incarcerated men who participated in a randomized controlled trial of a smoking abstinence intervention in a tobacco-free prison in the northeastern United States. Using thematic analysis, 53 written goals and plans were independently coded by trained research assistants to identify major themes that included (1) staying smoke-free or reducing the number of cigarettes smoked postrelease, (2) engaging in physical activities to improve health and wellness, and (3) spending time with family and/or friends. Implications for working with inmates to identify their plans and goals to remain smoke-free after incarceration are discussed.
International journal of environmental research and public health, Jan 12, 2016
Prior research has found high levels of depression and stress among persons who are incarcerated ... more Prior research has found high levels of depression and stress among persons who are incarcerated in the United States (U.S.). However, little is known about changes in depression and stress levels among inmates post-incarceration. The aim of this study was to examine changes in levels of depression and stress during and after incarceration in a tobacco-free facility. Questionnaires that included valid and reliable measures of depression and stress were completed by 208 male and female inmates approximately eight weeks before and three weeks after release from a northeastern U.S. prison. Although most inmates improved after prison, 30.8% had a worsening in levels of depression between baseline and the three-week follow-up. In addition, 29.8% had a worsening in levels of stress after release than during incarceration. While it is not surprising that the majority of inmates reported lower levels of depression and stress post-incarceration, a sizable minority had an increase in symptoms...
Patient-centered medical home transformation initiatives for enhancing team-based, patient-center... more Patient-centered medical home transformation initiatives for enhancing team-based, patient-centered primary care are widespread in the United States. However, there remain large gaps in our understanding of these efforts. This article reports findings from a contextual, whole system evaluation study of a transformation intervention at eight primary care teaching practice sites in Rhode Island. It provides a picture of system changes from the perspective of providers, staff, and patients in these practices. Quantitative/qualitative evaluation methods include patient, provider, and staff surveys and qualitative interviews; practice observations; and focus groups with the intervention facilitation team. Patient satisfaction in the practices was high. Patients could describe observable elements of patient-centered medical home functioning, but they lacked explicit awareness of the patient-centered medical home model, and their activation decreased over time. Providers' and staff'...
International journal of environmental research and public health, Jan 27, 2018
Exposure to environmental tobacco smoke (ETS) presents substantial health risks for pregnant wome... more Exposure to environmental tobacco smoke (ETS) presents substantial health risks for pregnant women and newborn infants. Measurements of ETS include invasive and expensive biochemical tests, as well as less invasive and lower-cost, self-reported exposure and avoidance measures. Better understanding of self-report measures will help to select ETS assessments for evaluation. This analysis was conducted within the context of a tailored video intervention to reduce tobacco smoking and ETS exposure during pregnancy and after delivery in the control group sample of 147 nonsmoking women. Measurements of salivary cotinine concentration, self-reported ETS exposure, and avoidance behaviors were captured at 32 weeks’ gestation and 6 months postpartum. Salivary cotinine concentration was significantly related to ETS avoidance among pregnant nonsmokers at 32 weeks’ gestation, but not ETS exposure. At 6 months postpartum, both the reported ETS exposure of the infant and maternal avoida...
Problems with self-reported drug use include difficulties with recall and recognition as well as ... more Problems with self-reported drug use include difficulties with recall and recognition as well as the desire to respond to questions in a socially desirable manner. Various methods have been developed to improve and/or validate estimates based on direct questioning of individuals regarding their substance use. For this study, we were interested in validating self-reported use of: 1) tobacco, 2) marijuana, and 3) other substances (i.e., heroin, cocaine, opiates, oxycodone, benzodiazepines, methamphetamine, phencyclidine, and barbiturates) employing urinalysis among inmates who participated in a randomized controlled trial of a smoking abstinence intervention in a tobacco-free prison located in the northeastern United States. Two-hundred and seven men and women with a mean age of 34.9 (standard deviation = 9.0) completed questions regarding their substance use on a 7-day Timeline Follow-Back and provided urine specimens three weeks following prison release. Self-reported tobacco and ma...
Low-cost interventions to decrease environmental tobacco smoke (ETS) exposure of pregnant women a... more Low-cost interventions to decrease environmental tobacco smoke (ETS) exposure of pregnant women and their newborns are needed to lower health risks of exposed fetuses and infants. Baby's Breath is a tailored video intervention developed and tested in a randomized controlled trial. The study aimed to test the efficacy of tailored video versus usual care approaches to reduce the ETS exposure of fetuses of low-income women during and after pregnancy; and to assess this intervention separately among non-smoking and smoking women. Participating women, recruited early in pregnancy, who spoke English, were at least 18 years old, smoke exposed (current smokers, quit smoking on their own, or were exposed to smoke of others), pregnant with only one baby, and had access to a telephone and video player, were randomized to experimental or control conditions. Intervention participants received newsletters containing content aimed at smoking cessation and avoidance (5 during and 3 after pregnancy), in addition to videos (3 during and 2 after pregnancy) individually tailored on behavioral theory-based survey questions. Comparison participants received newsletters and videos on healthy pregnancy topics. Outcomes included salivary cotinine of both mother and baby (32 weeks gestation and 6 months postpartum) as well as self-reported ETS exposure and avoidance behaviors. This study may demonstrate the efficacy of a low-cost intervention to decrease ETS exposure, and will fill an important gap in describing the utility of this innovative intervention technology, as well as demonstration of potential benefits to this type of intervention.
The proliferation of mobile devices and emergence of interoperable ‘mHealth’ apps is accelerating... more The proliferation of mobile devices and emergence of interoperable ‘mHealth’ apps is accelerating development and deployment of patient-facing risk assessments in primary care. The present study describes a user-centered design and an agile development approach to creation of an app for assessing lungfunction as part of a randomized controlled trial for the  dentification of chronic obstructive lung disease in primary care. Seventeen patients recruited from a hospital-based, ambulatory family medicine clinic agreed to be videotaped while using the app, Lung Age, on a first-generation iPad prior to their providerencounter. Subsequently, participants were interviewed using a semi-structured interview guide upon exiting their medical visit. Observational data indicated that participants took advantage of the portability and flexibility of the tablet device in the exam room to engage with the Lung Age app with the optionto share and discuss their results with their providers. Results f...
H eart disease is the leading cause of mortality among women in the United States. 1 The importan... more H eart disease is the leading cause of mortality among women in the United States. 1 The importance of knowing whether a woman's risk of coronary heart disease (CHD) is low, medium, or high is important when considering when and how aggressively to modify her CHD risk factors. If we had an earlier window of detection into a woman's level of CHD risk, we would be better able to institute earlier lifestyle-change counseling and, when appropriate, pharmacotherapy to change risk factors such as hypertension or dyslipidemia. Clinical Perspective on p 2158 Background-Reproductive factors provide an early window into a woman's coronary heart disease (CHD) risk; however, their contribution to CHD risk stratification is uncertain. Methods and Results-In the Women's Health Initiative Observational Study, we constructed Cox proportional hazards models for CHD including age, pregnancy status, number of live births, age at menarche, menstrual irregularity, age at first birth, stillbirths, miscarriages, infertility ≥1 year, infertility cause, and breastfeeding. We next added each candidate reproductive factor to an established CHD risk factor model. A final model was then constructed with significant reproductive factors added to established CHD risk factors. Improvement in C statistic, net reclassification index (or net reclassification index with risk categories of <5%, 5 to <10%, and ≥10% 10-year risk of CHD), and integrated discriminatory index were assessed. Among 72 982 women (CHD events, n=4607; median follow-up,12.0 [interquartile range, 8.3-13.7] years; mean [standard deviation] age, 63.2 [7.2] years), an age-adjusted reproductive risk factor model had a C statistic of 0.675 for CHD. In a model adjusted for established CHD risk factors, younger age at first birth, number of still births, number of miscarriages, and lack of breastfeeding were positively associated with CHD. Reproductive factors modestly improved model discrimination (C statistic increased from 0.726 to 0.730; integrated discriminatory index, 0.0013; P<0.0001). Net reclassification for women with events was not improved (net reclassification index events, 0.007; P=0.18); and, for women without events, net reclassification was marginally improved (net reclassification index nonevents, 0.002; P=0.04) Conclusions-Key reproductive factors are associated with CHD independently of established CHD risk factors, very modestly improve model discrimination, and do not materially improve net reclassification.
Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, Jan 25, 2015
A major health challenge facing persons who are incarcerated is tobacco smoking. Upon reentry to ... more A major health challenge facing persons who are incarcerated is tobacco smoking. Upon reentry to the community, concerns regarding smoking cessation may be less likely to receive needed attention. Many individuals have partners who are pregnant and/or reside in households where children and pregnant women live. We explored incarcerated adults' attitudes of smoking in the presence of children and pregnant women and how post-release smoking behaviors are influenced by their attitudes. 247 incarcerated adults participated in a smoking cessation RCT in a tobacco-free prison. An instrument was developed to examine smoking attitudes and behaviors around children and pregnant women. Moderating effects of smoking factors on post-release abstinence were examined by evaluating interactions between smoking factors and treatment group. 4 factors were defined using factor analysis: smoking around children; impact of smoking on child's health; awareness of ETS risk for pregnant women; and...
Journal of health care for the poor and underserved, 2015
Background. Tobacco use among prisoners is much higher than among the general population. Little ... more Background. Tobacco use among prisoners is much higher than among the general population. Little is known about changes in smoking-related symptoms during periods of incarceration. The objective of this study is to evaluate changes in smoking-related symptoms during incarceration. Methods. We recruited 262 inmates from a tobacco-free prison. At baseline, participants were asked about smoking-related symptoms prior to incarceration and then asked about recent symptoms. Results. All symptom scores on the American Thoracic Society Questionnaire (ATSQ) improved during incarceration. Higher ATSQ scores were associated with asthma, depressive symptoms, stress, higher addiction and more pack years of smoking. Greater improvement in symptoms was not associated with smoking status after release. Conclusion. Forced tobacco abstinence leads to significant improvements in smoking-related symptoms. However, improvements in symptoms are not associated with smoking behavior changes. Addressing cha...
Little is known about smoking behaviors involving shared and previously used cigarettes, which we... more Little is known about smoking behaviors involving shared and previously used cigarettes, which we refer to as "smoking used cigarettes." Examples include: cigarette sharing with strangers, smoking discarded cigarettes ('butts'), or remaking cigarettes from portions of discarded cigarettes. The current study focuses on the prevalence of and factors associated with smoking used cigarettes prior to incarceration among a US prison population. Questionnaires were administered to 244 male and female inmates at baseline. Prevalence of smoking used cigarettes was assessed using three questions; one about sharing cigarettes with strangers, one about smoking a "found" cigarette, and one about smoking previously used cigarettes. Factors associated
Despite the impact of high-visibility evidence-based clinical practice guidelines, physician adhe... more Despite the impact of high-visibility evidence-based clinical practice guidelines, physician adherence to guidelines remains low. This study explored primary care physicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; perceptions of barriers and facilitators in following the National Cholesterol Education Program guidelines. The authors conducted 9 focus groups and performed qualitative content analysis utilizing immersion-crystallization processes, codebooks, and qualitative coding software. Key barriers to implementing guidelines included the complexity and transience of existing cholesterol guidelines as well as perceived threats to multidimensional care of the patient that unifocal single-decision guidelines may create. Key facilitators included growing patient awareness regarding cholesterol, patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; willingness to take cholesterol medication, and technological breakthroughs. These findings have helped identify factors that prevent or enhance the adoption of cholesterol guidelines. While factors considered to be facilitators are significant, barriers may be sufficient to limit adherence. Opportunities may exist for improving adherence to cholesterol guidelines by providing training to providers and developing structural support through patient-physician activation tools.
Background Short stature has been associated with an increased risk of coronary heart disease (CH... more Background Short stature has been associated with an increased risk of coronary heart disease (CHD), although the reason for the association remains unclear. Data on the relation between stature and stroke is more limited. We examined the association between stature and CHD as well as between stature and stroke in men and women from two communities in southeastern New England. Methods Coronary heart disease and stroke events were abstracted from medical records between January 1980 and December 1991. An epidemiological diagnostic algorithm developed to measure CHD was used in the present analysis. Unadjusted relative risks (RR) and RR adjusted for age, smoking status, obesity, high-density lipoprotein (HDL) cholesterol <0.91 mmol/1, total cholesterol >6.21 mmol/1, hypertension, diabetes, education, and being foreign born were computed by gender-specific height categories separately for men (n = 2826) and women (n = 3741). Results A graded inverse association between stature and risk of CHD was observed among men which persisted after adjustment for confounders. Men >69.75 inches had an 83% lower risk of CHD compared with men «65 inches. In addition, the tallest men had a 67% decreased risk of stroke compared with the shortest men. No significant relation between stature and CHD or stroke was observed among women. Conclusions These data support the hypothesis that stature is inversely related to both risk of CHD and stroke at least among men. Factors which might explain this association remain to be determined.
Background: Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating disease a... more Background: Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating disease associated with significant clinical burden and is estimated to affect 15 million individuals in the US. Although a large number of individuals are diagnosed with COPD, many individuals still remain undiagnosed due to the slow progression of the disorder and lack of recognition of early symptoms. Not only is there under-diagnosis but there is also evidence of sub-optimal evidence-based treatment of those who have COPD. Despite the development of international COPD guidelines, many primary care physicians who care for the majority of patients with COPD are not translating this evidence into effective clinical practice. Method/Design: This paper describes the design and rationale for a randomized, cluster design trial (RCT) aimed at translating the COPD evidence-based guidelines into clinical care in primary care practices. During Phase 1, a needs assessment evaluated barriers and facilitat...
Background: Evidence suggests that there is an association between chronic obstructive pulmonary ... more Background: Evidence suggests that there is an association between chronic obstructive pulmonary disease (COPD) and coronary heart disease (CHD). An important etiological link between COPD and CHD may be an underlying systemic inflammatory process. Given that COPD patients are at greater risk of cardiovascular mortality, understanding the burden of CHD on COPD patients could permit future risk attenuation. Methods: Longitudinal cohort analyses of the Third National Health and Nutrition Examination Survey from 1988-1994 were performed. 3,681 individuals ≥40 years of age with good quality spirometry data were included. Participants were divided into 5 groups: 1) no COPD, no CHD; 2) COPD without inflammation, no CHD; 3) COPD with inflammation, no CHD; 4) CHD only, and 5) CHD + COPD. A novel "inflammatory" COPD designation included those with COPD and clinical evidence of inflammation (i.e., CRP ≥95.24 nmol/L). Results: The risk for CHD mortality was significant only for the CHD group (HR 5.56, 95% CI 3.24-9.55) and the COPD + CHD group (HR 5.02, 95% CI 2.83-8.90). Similarly, the risk for cardiovascular disease (CVD) mortality was significant only for the CHD group (HR 4.25, 95% CI 2.70-6.69) and the CHD + COPD group (HR 4.12, 95% CI 2.60-6.54) after adjusting for nonmodifiable CHD risk factors (age, gender, race/ethnicity, family history of CHD). After adjusting for modifiable CHD risk factors (diabetes, BMI, physical activity, systolic blood pressure, cholesterol, and smoking), hazard ratios of the two groups remained similar but attenuated. For total mortality, the risk was significant for the four groups: the non-inflammatory COPD group; the COPD with inflammation group, the CHD group, and the COPD + CHD group. Conclusions: Our study did not confirm that inflammatory COPD may be a CHD risk equivalent. However, due to the small size of the "inflammatory" COPD group, further prospective replication and validation is needed. Moreover, given that COPD results from inflammation, the systemic inflammation associated with COPD may have worsened comorbid conditions and may have lead to the increased total mortality found in the COPD with inflammation and COPD + CHD groups which requires further investigation.
Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, 2007
This study reports on the evaluation of the feasibility, cost, and cost-effectiveness of a proact... more This study reports on the evaluation of the feasibility, cost, and cost-effectiveness of a proactively provided telephone-based motivational smoking cessation intervention to an underserved population of pregnant smokers who may or may not receive ongoing prenatal care. As part of the New England SCRIPT randomized clinical trial comparing the efficacy of three types of smoking cessation interventions for pregnant smokers, one-third of the women (n = 358) received a motivational telephone counseling intervention (MI) delivered by trained counselors using a semistructured protocol. Although this population was very mobile, the MI counselors were able to reach 86% of the women with at least one call and 46% received all three calls. The group receiving three MI calls had a cotinine-confirmed quit rate of 23%. Cost-effectiveness analyses for those women receiving telephone counseling supported the net benefit in favor of the three phone calls compared with the women who did not receive ...
While e-health tools have been designed for patient/consumer empowerment and for decision support... more While e-health tools have been designed for patient/consumer empowerment and for decision support focusing on healthcare providers, they have had only modest success in primary care settings. Creating complementary e-health tools that provide patient activation and decision support for a common clinical problem such as hyperlipidemia using a behaviorally oriented risk communication strategy has not been previously described. This paper presents the details regarding the development of two complementary software programs: HeartAge, an interactive risk communication program focusing on patient activation placed on a laptop computer in the doctor's waiting room, and a PDA-based, clinical decision support program for lipid management utilizing algorithms recommended by the National Cholesterol Education Program. The efficacy of these programs in improving cholesterol management in five primary care practices is described.
Autopsy data suggest that plaque neovascularization may be associated with coronary heart disease... more Autopsy data suggest that plaque neovascularization may be associated with coronary heart disease (CHD) death. Since vascular endothelial growth factor-A (VEGF-A) is upregulated in angiogenesis and therefore neovascularization, we hypothesized that individuals with elevated levels of VEGF-A at baseline would be a greater risk of dying of CHD compared to those with lower levels over time. We measured VEGF-A levels in 46 CHD death cases and a 14% random sample of 2321 community participants who were free of self-reported CHD at baseline. Traditional CHD risk factors such as age, gender, family history of CHD, cigarette smoking, hypertension, total cholesterol/HDL ratio, diabetes mellitus, were also evaluated at baseline. Mortality follow-up was determined through linkage of baseline data with the National Death Index. During a median of 13 years of follow-up, 46 subjects died of coronary heart disease. Mean VEGF-A levels were significantly higher in the CHD death cases than among the random population sample (400 pg/ml vs. 303 pg/ml, p=0.0004). In proportional hazards models adjusting for traditional risk factors, the hazard ratios (95%CI) for CHD death associated with increasing tertiles of VEGF-A were 1.0 (referent), 2.12 (0.74, 6.10), and 3.85 (1.37, 10.78), respectively (P(test for trend)=0.008). In this population-based prospective, case-cohort study, baseline levels of VEGF-A showed a significant independent association with the risk of CHD death.
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Papers by Donna Parker