Publications

Abstract

The overarching goal for providing behavioral and mental health services in pediatric primary care settings is to provide immediate and effective services to children, adolescents, and their families to change the course from potential adverse behavioral health outcomes to supportive positive directions in growth and developmental behavioral health. This textbook provides an analysis of evidence-based behavioral health practices to foster growth and developmental behavioral health through early behavioral health screenings and assessments with the goal of intercepting behavioral development and characteristics that are not within the “norm” of pediatric and adolescent development. The conceptual model for Intercepting Behavioral Health problems focuses on identifying the very earliest presentation of even one symptom that may lead to a behavioral health problem and immediately beginning the process for intercepting the potential problem with evidence-based treatments. Pediatric primary care providers play a unique role in caring for children with behavioral health problems.

Abstract

Since the completion of the Human Genome Project, there have been pitched debates about its implications and the research it enables. One prominent thread of concern focuses on the role of post-genomic science on technically enabling and generating interest in genetic ancestry testing (GAT). Critical analyses of GAT have pointed to multiple issues, raising the alarm on consumers’ experiences with such technologies. This paper describes the results of a pilot study in which we tracked women’s experiences receiving their genetic ancestry results, and their understandings of, reactions to, and valuing of this information over time. Overwhelmingly, our participants reported a curious combination of anticipation and satisfaction yet no discernable impact on their sense of self or racial identity. We elaborate on the effects and non-effects of GAT for the women in our study, and how we make sense of their simultaneous experiences of ‘knowing something’ but not ‘feeling different.’.

Abstract

Objective: To examine the mouth and body knowledge, beliefs and behaviours of Dominican, Puerto Rican and African American older adults, and their relationships to oral and general health and health care. Background: In his seminal framework, Handwerker posited that the norms, attitudes and behaviours related to the experience of disease and treatment reflect where patients live and have lived and are seeking and have sought care, along with their webs of social and health relations. This framework guides the analysis for the present study, wherein qualitative data are used to understand mouth and body knowledge, beliefs and behaviours among racial/ethnic minority older adults, ie, why individuals do what they do and what it means to them. Materials and methods: Focus groups were conducted in Spanish or English with 194 racial/ethnic minority older adults living in northern Manhattan who participated in one of 24 focus group sessions about improving oral health. All groups were digitally audio-recorded, transcribed and translated into English from Spanish, where apt. Analysis involved the classification of evidence from all datasets, organised to identify patterns and relationships. Results: Four themes were manifest in the data regarding cultural understandings of the mouth, the body and health: (a) the ageing mouth and its components; (b) the mouth in relation to the body, health and disease; (c) social meanings of the mouth; and (d) care of the ageing mouth. Conclusion: Underserved older adults from diverse cultural backgrounds understand the importance of their mouths to both their overall health and social lives.

Abstract

Background: In the digital era when mHealth has emerged as an important venue for health care, the application of computer science, such as machine learning, has proven to be a powerful tool for health care in detecting or predicting various medical conditions by providing improved accuracy over conventional statistical or expert-based systems. Symptoms are often indicators for abnormal changes in body functioning due to illness or side effects from medical treatment. Real-time symptom report refers to the report of symptoms that patients are experiencing at the time of reporting. The use of machine learning integrating real-time patient-centered symptom report and real-time clinical analytics to develop real-time precision prediction may improve early detection of lymphedema and long term clinical decision support for breast cancer survivors who face lifelong risk of lymphedema. Lymphedema, which is associated with more than 20 distressing symptoms, is one of the most distressing and dreaded late adverse effects from breast cancer treatment. Currently there is no cure for lymphedema, but early detection can help patients to receive timely intervention to effectively manage lymphedema. Because lymphedema can occur immediately after cancer surgery or as late as 20 years after surgery, real-time detection of lymphedema using machine learning is paramount to achieve timely detection that can reduce the risk of lymphedema progression to chronic or severe stages. This study appraised the accuracy, sensitivity, and specificity to detect lymphedema status using machine learning algorithms based on real-time symptom report.Methods: A web-based study was conducted to collect patients' real-time report of symptoms using a mHealth system. Data regarding demographic and clinical information, lymphedema status, and symptom features were collected. A total of 355 patients from 45 states in the US completed the study. Statistical and machine learning procedures were performed for data analysis. The performance of five renowned classification algorithms of machine learning were compared: Decision Tree of C4.5, Decision Tree of C5.0, gradient boosting model (GBM), artificial neural network (ANN), and support vector machine (SVM). Each classification algorithm has certain user-definable hyper parameters. Five-fold cross validation was used to optimize these hyper parameters and to choose the parameters that led to the highest average cross validation accuracy.Results: Using machine leaning procedures comparing different algorithms is feasible. The ANN achieved the best performance for detecting lymphedema with accuracy of 93.75%, sensitivity of 95.65%, and specificity of 91.03%.Conclusions: A well-trained ANN classifier using real-time symptom report can provide highly accurate detection of lymphedema. Such detection accuracy is significantly higher than that achievable by current and often used clinical methods such as bio-impedance analysis. Use of a well-trained classification algorithm to detect lymphedema based on symptom features is a highly promising tool that may improve lymphedema outcomes.

Abstract

Background: The effects of tobacco smoking on epigenome-wide methylation signatures in white blood cells (WBCs) collected from persons living with HIV may have important implications for their immune-related outcomes, including frailty and mortality. The application of a machine learning approach to the analysis of CpG methylation in the epigenome enables the selection of phenotypically relevant features from high-dimensional data. Using this approach, we now report that a set of smoking-associated DNA-methylated CpGs predicts HIV prognosis and mortality in an HIV-positive veteran population. Results: We first identified 137 epigenome-wide significant CpGs for smoking in WBCs from 1137 HIV-positive individuals (p < 1.70E-07). To examine whether smoking-associated CpGs were predictive of HIV frailty and mortality, we applied ensemble-based machine learning to build a model in a training sample employing 408,583 CpGs. A set of 698 CpGs was selected and predictive of high HIV frailty in a testing sample [(area under curve (AUC) = 0.73, 95%CI 0.63~0.83)] and was replicated in an independent sample [(AUC = 0.78, 95%CI 0.73~0.83)]. We further found an association of a DNA methylation index constructed from the 698 CpGs that were associated with a 5-year survival rate [HR = 1.46; 95%CI 1.06~2.02, p = 0.02]. Interestingly, the 698 CpGs located on 445 genes were enriched on the integrin signaling pathway (p = 9.55E-05, false discovery rate = 0.036), which is responsible for the regulation of the cell cycle, differentiation, and adhesion. Conclusion: We demonstrated that smoking-associated DNA methylation features in white blood cells predict HIV infection-related clinical outcomes in a population living with HIV.

Abstract

Objectives: The objectives of this research were to describe the interactions (formal and informal), in which macrocognitive functions occur and their location on a pediatric intensive care unit, to describe challenges and facilitators of macrocognition using space syntax constructs (openness, connectivity, and visibility), and to analyze the healthcare built environment (HCBE) using those constructs to explicate influences on macrocognition. Background: In high reliability, complex industries, macrocognition is an approach to develop new knowledge among interprofessional team members. Although macrocognitive functions have been analyzed in multiple healthcare settings, the effect of the HCBE on those functions has not been directly studied. The theoretical framework, “macrocognition in the healthcare built environment” (mHCBE) addresses this relationship. Method: A focused ethnographic study was conducted including observation and focus groups. Architectural drawing files used to create distance matrices and isovist field view analyses were compared to panoramic photographs and ethnographic data. Results: Neighborhoods comprised of corner configurations with maximized visibility enhanced team interactions as well as observation of patients, offering the greatest opportunity for informal situated macrocognitive interactions (SMIs). Conclusions: Results from this study support the intricate link between macrocognitive interactions and space syntax constructs within the HCBE. These findings help increase understanding of how use of the framework of Macrocognition in the HCBE can improve design and support adaptation of interprofessional team practices, maximizing macrocognitive interaction opportunities for patient, family, and team safety and quality.

Abstract

Maternal lipid profiles during pregnancy are associated with risk for preterm birth. This study investigates the association between maternal dyslipidemia and subsequent preterm birth among pregnant women in the state of California. Births were identified from California birth certificate and hospital discharge records from 2007–2012 (N = 2,865,987). Preterm birth was defined as <37 weeks completed gestation and dyslipidemia was defined by diagnostic codes. Subtypes of preterm birth were classified as preterm premature rupture of membranes (PPROM), spontaneous labor, and medically indicated, according to birth certificate data and diagnostic codes. The association between dyslipidemia and preterm birth was tested with logistic regression. Models were adjusted for maternal age at delivery, race/ethnicity, hypertension, pre-pregnancy body mass index, insurance type, and education. Maternal dyslipidemia was significantly associated with increased odds of preterm birth (adjusted OR: 1.49, 95%CI: 1.39, 1.59). This finding was consistent across all subtypes of preterm birth, including PPROM (adjusted OR: 1.54, 95%CI: 1.34, 1.76), spontaneous (adjusted OR: 1.51, 95%CI: 1.39, 1.65), and medically indicated (adjusted OR: 1.454, 95% CI: 1.282, 1.649). This study suggests that maternal dyslipidemia is associated with increased risk for all types of preterm birth.

Abstract

Medication literacy is the ability of individuals to access and understand medication information and then use that information to act and take their medication in a safe and appropriate way. The purpose of this study was to explore medication literacy in a group of Somali older adults and their families using qualitative secondary analysis. We conducted an analytic expansion of an existing qualitative study that explored the home healthcare perceptions of Somali older adults and their families. Qualitative data collected from 14 Somali families about home healthcare were reviewed and analyzed for material related to medication literacy. Data analysis revealed a number of important findings related to medication literacy and resulted in the discovery of four themes: Medication literacy is needed among Somali older adults and their families, Using home healthcare (HHC) to improve medication literacy, Better communication is essential to improving medication literacy, and Medication literacy is an intersecting family and social issue. The results of this study indicate that HHC has a role to play in improving the health and medication literacy of these families. They also highlight the need to further explore what techniques, tools, and/or supports HHC professionals need to care for non-English speaking populations. Future research needs to address how to meet the needs of diverse and vulnerable patients like Somali older adults, and how best to prepare HHC providers to do this.

Abstract

Background: Migraine is one of the top 10 most disabling conditions among adults worldwide. Most migraine research is quantitative and indicates concerns about medication adherence, stigma, and more. Qualitative studies might reveal an improved understanding of migraine patients’ perspectives regarding migraine treatment. Objective: The aim of this study was to synthesize the qualitative research on migraine patients’ perspectives regarding migraine treatment to (a) identify common patterns across various types of migraine treatment studies and (b) inform future research. Methods: A systematic search for qualitative studies in the HA (HA) literature was conducted in Medline (PubMed), PsycINFO, EMBASE, CINAHL, Web of Science, Joanna Briggs Institute EBP Database, and The Cochrane Library. Search terms (subject headings and keywords) were HA, HA disorders, migraine, qualitative studies, and qualitative research. Qualitative studies were systematically identified by using published qualitative search filters recommended by The InterTASC Information Specialists’ Sub-Group (ISSG). The search was limited to English only, peer reviewed publications, and studies published between 1996 and 2016. For screening, additional inclusion criteria were (1) adult migraine patients; (2) must mention treatment in the title or study design of the abstract. Ten studies met the inclusion criteria. The Critical Appraisal Skills Program tool was applied to appraise study quality. Thematic analysis produced the codes and themes. Two authors read articles separately and individually created codes. Code lists were synthesized and themes emerged iteratively from the process. Results: Study sample sizes ranged from 10 to 33 participants, with our findings representing 161 participants. Data were collected either using interviews or focus groups. The more common methodologies were grounded theory and phenomenology. Few (3) studies described the number of headache (HA) days for inclusion in the study. Eight out of 10 used International Classification of Headache Disorders (ICHD) criteria. Our synthesis produced five major themes. The first theme was “Migraine patients’ difficulties with health care utilization,” and it included issues surrounding the cost of migraine treatment (seeing providers and prescription medications). The second theme was “Migraine patients’ perceived relationships with their providers,” which included the role and relationship with the provider, as well as trust in the provider and the providers’ knowledge in managing HAs. The third theme was “Thoughts about the various migraine treatments.” It was based on patients’ comments indicating an aversion to prescription medications, the use of non-pharmacological interventions for treatment, behavioral modification as a form of treatment, and the need for additional treatment options. The fourth and fifth themes were “Understanding diagnosis/triggers” and “Societal implications,” respectively. The latter theme included feelings of not being taken seriously and issues surrounding quality of life. Discussion: The metasynthesis revealed several key commonalities regarding patients’ perspectives on migraine treatment and identified new areas for research using a qualitative approach. Researchers conducting qualitative research with patients experiencing migraines might consider using and reporting more of the inclusion and exclusion criteria commonly used in migraine research, for example, reporting whether the ICHD criteria were used and the number of HA days for patients to be in a study. Future studies might be done to determine how the role of allied health care providers, for example, pharmacists, physical therapists, and psychologists, might be expanded to help with migraine treatment and ultimately to improve patient outcomes.

Abstract

Background: Migration is a fundamental demographic process that has been observed globally. It is suggested that migration is an issue of global health importance that can have an immediate and lasting impact on an individual’s health and well-being. There is now an increasing body of evidence linking migration with cognitive function in older adults. In this paper, we synthesized the current evidence to develop a general conceptual framework to understand the factors contributing to the association between migration and cognitive function. Methods: A comprehensive review of the literature was conducted on the associations between migration and cognition among middle-aged and older adults. Results: Five potential mechanisms were identified from the literature: 1) socioeconomic status—including education, occupation, and income; 2) psychosocial factors—including social networks, social support, social stressors, and discrimination; 3) behavioral factors—including smoking, drinking, and health service utilization; 4) physical and psychological health status—including chronic conditions, physical function, and depression; and 5) environmental factors—including both physical and social environment. Several underlying factors were also identified—including early-life conditions, gender, and genetic factors. Conclusions: The factors linking migration and cognitive function are multidimensional and complex. This conceptual framework highlights potential implications for global health policies and planning on healthy aging and migrant health. Additional studies are needed to further examine these mechanisms to extend and refine our general conceptual framework.

Abstract

Sexual minority (i.e., non-heterosexual) individuals experience poorer mental and physical health, accounted for in part by the additional burden of sexual minority stress occurring from being situated in a culture favoring heteronormativity. Informed by previous research, the purpose of this study was to identify the relationship between sexual minority stress and leukocyte gene expression related to inflammation, cancer, immune function, and cardiovascular function. Sexual minority men living with HIV who were on anti-retroviral medication, had viral load < 200 copies/mL, and had biologically confirmed, recent methamphetamine use completed minority stress measures and submitted blood samples for RNA sequencing on leukocytes. Differential gene expression and pathway analyses were conducted comparing those with clinically elevated minority stress (n = 18) and those who did not meet the clinical cutoff (n = 20), covarying reactive urine toxicology results for very recent stimulant use. In total, 90 differentially expressed genes and 138 gene set pathways evidencing 2-directional perturbation were observed at false discovery rate (FDR) < 0.10. Of these, 41 of the differentially expressed genes and 35 of the 2-directionally perturbed pathways were identified as functionally related to hypothesized mechanisms of inflammation, cancer, immune function, and cardiovascular function. The neuroactive-ligand receptor pathway (implicated in cancer development) was identified using signaling pathway impact analysis. Our results suggest several potential biological pathways for future work investigating the relationship between sexual minority stress and health.

Abstract

African American youth continue to be disproportionately affected by HIV. Early sexual debut has been identified as a major determinant of HIV risk. However, emerging research suggests that the overarching context in which first sex occurs may have greater implications for sexual health than simply age alone. The purpose of this exploratory, qualitative study was to better understand the broader context of African Americans’ sexual debut. In-depth, semi-structured interviews were conducted with 10 African American men and women aged 18–24 years. Thematic analysis was used to analyze the data. The mean age at sexual debut for the sample was 15.4 (SD = 3.3), and youth framed their sexual debut as positive (50%), negative (30%), and both positive and negative (20%). The majority of youth initiated pre-sex conversations with their partners to gauge potential interest in engaging in sexual activity, and all youth utilized at least one HIV/sexually transmitted infection and pregnancy prevention method. However, most youth failed to talk to their partners prior to sex about their past sexual histories and what the experience meant for their relationship. Key differences emerged between youth who framed the experience as positive and those who framed the experience as negative or both positive and negative in terms of their motivations for initiating sex (i.e., readiness to initiate sex, pressure, and emotionally safety) and post-sex emotions (i.e., remorse and contentment). Findings provide further support for examining the broader sexual context of African American’s sexual debut. A more comprehensive understanding of sexual debut will aid in the development and tailoring of sexual risk reduction programs targeting African American youth.

Abstract

In an attempt to address the issue of undertreated pain, the Pain as the Fifth Vital Sign (P5VS) Initiative was established to improve the quality of pain care across clinical settings. This initiative included policy efforts such as mandatory pain screening and the implementation of pain-related questions on patient satisfaction surveys. These policies have failed to enhance the treatment of pain and may have unintentionally contributed, in part, to the opioid epidemic. To assess pain more effectively, an inter-professional team approach using multi-dimensional pain assessment tools is needed. The inter-professional team can use these multi-dimensional tools to conduct comprehensive assessments to measure aspects of the pain experience (e.g., psychological, spiritual and socio-emotional pain; impact on daily functioning) beyond its sensory component and establish realistic goals that align with patients' needs. To implement multi-dimensional pain assessments in busy clinical practices, nurses will need to play a central role. Nurses can work to ensure that patients complete the questionnaires prior to the visit. Nurses can also take the lead in the use of new technologies in the form of tablets, smart phones, and mobile apps to facilitate collecting patient-level data in the home or in a waiting room before their visits.

Abstract

Reports have indicated that nursing programs in the United States are not generally effective in teaching nursing science, natural science, the social sciences, and the humanities. The value of the lifelong study of humanities for nurses is the invitation for contemplation on the human experience so we can make informed moral, spiritual, and intellectual sense of the world. In essence, when we understand, we become more empathetic. This article adds to the call for teaching for a sense of salience in nursing through the meaningful synthesis of humanities in baccalaureate education.

Abstract

Knowledge of nutrition among breast cancer patients is insufficient, despite their motivation to seek valid information about healthy food choices. This study examines the feasibility of nutrition education workshops for cancer survivors, to inform the design of a multi-center intervention. Fifty-nine female English-speaking breast cancer patients, who had completed treatment, were enrolled. Participants were randomized to the intervention or control group. The intervention group attended six nutrition education sessions, and the control group received brochures. Measurements were done at baseline and 3-month follow-up and included the Assessment Instrument for Breast Cancer (NLit-BCa), fruit/vegetable and general health literacy screeners. Height and weight were measured. Changes in nutrition literacy, health literacy, and food intake from baseline to follow-up (within-group change) were calculated for both groups (effect sizes were reported as Cohen’s d). Participants were mostly white, with a mean age of 58 years, BMI of 31.6 kg/m2, and had college degrees. Follow-up rates were high (89% = control and 77% = intervention group). At baseline, participants scored high for most NLit-BCa assessment components except food portions in both groups. At the 3-month follow-up, effect sizes (d) on the NLit-BCa ranged from −0.5 to 0.16. The study met its recruitment goals within 6 months. Focus groups indicated that (a) attending six sessions was acceptable, (b) patients found social/emotional support, (c) improvements should include information for special diets and booster sessions. This pilot study suggests that the intervention was acceptable and that scaling up of this intervention is feasible and could provide benefit to breast cancer survivors.

Abstract

Context: Although recommendations are for goals of care (GoC) conversations to happen early and often, their timing and content over the disease course remain unclear. Objectives: To describe perceptions of the timing and content of GoC conversations among oncologists and patients with advanced cancer. Methods: Semi-structured interviews with oncologists and patients at four hospitals in New York and Connecticut. We analyzed data using interpretive description. Results: Oncologists (n = 21) were 67% male, averaged 46 years old (range 34–68 years), and had a mean 20 years (range 8–42 years) in practice. Advanced cancer patients (n = 39) were 59% female with a mean age of 58 years (range 26–88 years). Oncologists and patients viewed GoC conversations along an initial, intermediate, and final continuum. Oncologists reported having initial GoC conversations to build rapport, provide disease information, and clarify and consider treatment intent and options. Intermediate conversations focused on changes in treatment and side effects. Final conversations occurred when patients were hospice-eligible and covered the shift to comfort care, a treatment summary, and advance directives. Timing and content were influenced by cancer type, disease status, and emotional state. Patients supported beginning GoC conversations early, but had different preferences for content of initial conversations. Some wanted complete information; others found this overwhelming. Patients felt intermediate GoC conversations should occur at decision points with time for processing. Content of intermediate and final conversations was dependent on patients’ prognosis, questions, and treatment decisions. Conclusion: Although GoC conversations should follow individual patient preferences, our findings offer structure for their timing and content.

Abstract

A 10-year research program systematically examined organizational features of nurses' workplaces in relation to nurse and patient outcomes. Its major results have been published in peer-reviewed international journals and presented here with replicated analyses and largely new datasets. First, a set of measures of nurse practice environment features and nurse work characteristics such as workload, decision latitude, and social capital along with burnout and work engagement as well as nurses' self-assessed job outcomes and quality of care was developed. These were examined in various populations of nurses such as those working in acute care hospitals and in long-term facilities. Secondly, models to explain associations between these selected variables were developed and tested in samples of acute hospital nurses. Thirdly, multilevel analyses of the associations between these variables confirmed that the phenomenon of organizational influences on work experiences occurred not only at the individual level but also at the team level in various study populations and across healthcare domains. Next, a longitudinal study design was set up to investigate the impact of planned transformations in the hospital organization as well as the implementation of the Productive Ward-Releasing Time to Care program aimed at strengthening practice environments and outcomes in a university hospital. Finally, a phenomenological study was undertaken to examine staff nurse and nurse manager perceptions and experiences of structural empowerment and the extent to which structural empowerment supports high-quality patient care. In addition, an explanatory sequential mixed methods design blended qualitative study results regarding staff nurses' experiences and perceptions of workload with prior quantitative results regarding structural empowerment to explain and interpret the findings of both models.

Abstract

Purpose: Strategies to decrease societal and cultural barriers for ethnic minorities to participate in health research are well established. However, limited data are available regarding participation of ethnic minorities in mobile and Internet technology–based interventions to self-manage type 2 diabetes where health disparities are predominant. Thus, the purpose was to understand the participation of ethnic minorities in technology-based intervention programs to manage type 2 diabetes. Design/Method: A scoping review was used to review a total of 21 intervention studies containing participant information about ethnic minorities and one qualitative study discussing participation of ethnic minorities. Findings: There was limited enrollment and participation of ethnic minorities. Technological barriers in addition to existing societal and cultural barriers were identified. Strategies to decrease the barriers were recommended. Conclusions: Technological barriers were identified on top of the societal and cultural barriers in traditional interventions. Further research to reduce the barriers is warranted.