The Prevention Research Center at UMass Chan Medical School (PRC) is committed to working toward optimal health of communities, families and individuals. Founded in 2009 as part of the CDC's Prevention Research Center Network, our mission is to prevent disease, promote health and advance health equity through the integration of community engaged research, practice, policy and education. With a focus on integrating our work into the Greater Worcester’s collaborative public health system, we also seek to be a research partner that addresses real-world challenges across Massachusetts, and a national model for research that connects academia, public health, community and health care systems.

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  • Monitoring Diversity in Faculty Using Applicant Flow Data: Lessons Learned

    Rosal, Milagros C; Duncan, Marlina; Hirabayashi, Natasja; Person, Sharina (2023-04-12)
    We applaud Dr Adaugo Amobi’s commentary in this issue of Medical Care regarding physician workforce diversity, the importance of systems to track physician hiring practices in aggregate and over time, and the use of these data to inform efforts to improve workforce diversity.
  • Barriers and Facilitators to the Implementation of Adolescent Cancer Prevention Interventions in Rural Primary Care Settings: A Scoping Review

    Ryan, Grace W; Whitmire, Paula; Batten, Annabelle J.; Goulding, Melissa; Baltich Nelson, Becky; Lemon, Stephenie C.; Pbert, Lori (2023-03-13)
    Purpose: We conducted a scoping review of studies to examine the implementation of interventions to promote adolescent cancer prevention in rural, primary care settings and identify barriers and facilitators. Methods: We followed the JBI scoping review protocol and used a systematic extraction and coding process. Our search of MEDLINE, PsycInfo, Cochrane, CINAHL, and Scopus identified articles related to implementation of interventions in the following areas: obesity, human papillomavirus (HPV) vaccination, tobacco use, and sun exposure. We used the Consolidated Framework for Implementation Research (CFIR), an implementation framework consisting of 5 domains (outer setting, inner setting, intervention characteristics, individual characteristics, process), each with a sub-set of constructs, to classify barriers and facilitators reported. Results: We identified 3046 references, excluded 2969 during initial screening, assessed 74 for full-text eligibility, and abstracted 24. Of these, 17 addressed obesity, 6 addressed HPV vaccination, 1 addressed skin cancer, and 1 addressed multiple behaviors. 10 studies were either non-randomized experimental designs (n=8) or randomized controlled trials (n=2). The remaining were observational or descriptive research. Barriers in the outer setting (e.g., lack of external funding sources, patients' beliefs) and inner setting (e.g., time available for implementation efforts and clinic infrastructure) were most common, compared to the other CFIR domains. Similarly, facilitators in the outer setting (e.g., partnerships with other organizations and parents' trust in health care providers) and inner setting (e.g., efficiency in practice protocols) were commonly reported. Conclusions: Adolescence is a critical growth window to establish healthy behaviors to prevent future cancers. Rural areas have higher rates of cancer morbidity and mortality than urban ones, putting rural adolescents at heightened risk for cancers. Yet, we found a dearth of studies addressing the implementation of adolescent cancer prevention in rural primary care settings. Further research is needed to understand the implementation challenges and potential strategies to improve implementation efforts to promote cancer prevention among rural adolescents.
  • Putting Evidence Into Practice: An Update on the US Preventive Services Task Force Methods for Developing Recommendations for Preventive Services

    Barry, Michael J; Wolff, Tracy A; Pbert, Lori; Davidson, Karina W; Fan, Tina M; Krist, Alex H; Lin, Jennifer S; Mabry-Hernandez, Iris R; Mangione, Carol M; Mills, Justin; et al. (2023-03-01)
    Purpose: The US Preventive Services Task Force (USPSTF) is an independent body that makes evidence-based recommendations regarding preventive services to improve health for people nationwide. Here, we summarize current USPSTF methods, describe how methods are evolving to address preventive health equity, and define evidence gaps for future research. Methods: We summarize current USPSTF methods as well as ongoing methods development. Results: The USPSTF prioritizes topics on the basis of disease burden, extent of new evidence, and whether the service can be provided in primary care and going forward will increasingly consider health equity. Analytic frameworks specify the key questions and linkages connecting the preventive service to health outcomes. Contextual questions provide information on natural history, current practice, health outcomes in high-risk groups, and health equity. The USPSTF assigns a level of certainty to the estimate of net benefit of a preventive service (high, moderate, or low). The magnitude of net benefit is also judged (substantial, moderate, small, or zero/negative). The USPSTF uses these assessments to assign a letter grade from A (recommend) to D (recommend against). I statements are issued when evidence is insufficient. Conclusions: The USPSTF will continue to evolve its methods for simulation modeling and to use evidence to address conditions for which there are limited data for population groups who bear a disproportionate burden of disease. Additional pilot work is underway to better understand the relations of the social constructs of race, ethnicity, and gender with health outcomes to inform the development of a USPSTF health equity framework.
  • Social Determinants, Blood Pressure Control, and Racial Inequities in Childbearing Age Women With Hypertension, 2001 to 2018

    Meyerovitz, Claire V; Juraschek, Stephen P; Ayturk, Didem; Moore Simas, Tiffany A; Person, Sharina D; Lemon, Stephenie C; McManus, David D; Kovell, Lara C (2023-02-27)
    Background Hypertension is an important modifiable risk factor of serious maternal morbidity and mortality. Social determinants of health (SDoH) influence hypertension outcomes and may contribute to racial and ethnic differences in hypertension control. Our objective was to assess SDoH and blood pressure (BP) control by race and ethnicity in US women of childbearing age with hypertension. Methods and Results We studied women (aged 20-50 years) with hypertension (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg or use of antihypertensive medication) in the National Health and Nutrition Examination Surveys 2001 to 2018. SDoH and BP control (systolic BP <140 mm Hg and diastolic BP <90 mm Hg) were examined by race and ethnicity (White race, Black race, Hispanic ethnicity, and Asian race). Using multivariable logistic regression, odds of uncontrolled BP by race and ethnicity were modeled, adjusting for SDoH, health factors, and modifiable health behaviors. Responses on hunger and affording food determined food insecurity status. Across women of childbearing age with hypertension (N=1293), 59.2% were White race, 23.4% were Black race, 15.8% were Hispanic ethnicity, and 1.7% were Asian race. More Hispanic and Black women experienced food insecurity than White women (32% and 25% versus 13%; both P<0.001). After SDoH, health factor, and modifiable health behavior adjustment, Black women maintained higher odds of uncontrolled BP than White women (odds ratio, 2.31 [95% CI, 1.08-4.92]), whereas Asian and Hispanic women showed no difference. Conclusions We identified racial inequities in uncontrolled BP and food insecurity among women of childbearing age with hypertension. Further exploration beyond the SDoH measured is needed to understand the inequity in hypertension control in Black women.
  • Performance of Rapid Antigen Tests Based on Symptom Onset and Close Contact Exposure: A secondary analysis from the Test Us At Home prospective cohort study [preprint]

    Herbert, Carly; Wang, Biqi; Lin, Honghuang; Hafer, Nathaniel; Pretz, Caitlin; Stamegna, Pamela; Tarrant, Seanan; Hartin, Paul; Ferranto, Julia; Behar, Stephanie; et al. (2023-02-24)
    Background: The performance of rapid antigen tests for SARS-CoV-2 (Ag-RDT) in temporal relation to symptom onset or exposure is unknown, as is the impact of vaccination on this relationship. Objective: To evaluate the performance of Ag-RDT compared with RT-PCR based on day after symptom onset or exposure in order to decide on 'when to test'. Design setting and participants: The Test Us at Home study was a longitudinal cohort study that enrolled participants over 2 years old across the United States between October 18, 2021 and February 4, 2022. All participants were asked to conduct Ag-RDT and RT-PCR testing every 48 hours over a 15-day period. Participants with one or more symptoms during the study period were included in the Day Post Symptom Onset (DPSO) analyses, while those who reported a COVID-19 exposure were included in the Day Post Exposure (DPE) analysis. Exposure: Participants were asked to self-report any symptoms or known exposures to SARS-CoV-2 every 48-hours, immediately prior to conducting Ag-RDT and RT-PCR testing. The first day a participant reported one or more symptoms was termed DPSO 0, and the day of exposure was DPE 0. Vaccination status was self-reported. Main outcome and measures: Results of Ag-RDT were self-reported (positive, negative, or invalid) and RT-PCR results were analyzed by a central laboratory. Percent positivity of SARS-CoV-2 and sensitivity of Ag-RDT and RT-PCR by DPSO and DPE were stratified by vaccination status and calculated with 95% confidence intervals. Results: A total of 7,361 participants enrolled in the study. Among them, 2,086 (28.3%) and 546 (7.4%) participants were eligible for the DPSO and DPE analyses, respectively. Unvaccinated participants were nearly twice as likely to test positive for SARS-CoV-2 than vaccinated participants in event of symptoms (PCR+: 27.6% vs 10.1%) or exposure (PCR+: 43.8% vs. 22.2%). The highest proportion of vaccinated and unvaccinated individuals tested positive on DPSO 2 and DPE 5-8. Performance of RT-PCR and Ag-RDT did not differ by vaccination status. Ag-RDT detected 78.0% (95% Confidence Interval: 72.56-82.61) of PCR-confirmed infections by DPSO 4. For exposed participants, Ag-RDT detected 84.9% (95% CI: 75.0-91.4) of PCR-confirmed infections by day five post-exposure (DPE 5). Conclusions and relevance: Performance of Ag-RDT and RT-PCR was highest on DPSO 0-2 and DPE 5 and did not differ by vaccination status. These data suggests that serial testing remains integral to enhancing the performance of Ag-RDT.
  • Serologic Screening for Genital Herpes Infection: US Preventive Services Task Force Reaffirmation Recommendation Statement

    Mangione, Carol M; Barry, Michael J; Nicholson, Wanda K; Cabana, Michael; Chelmow, David; Coker, Tumaini Rucker; Davis, Esa M; Donahue, Katrina E; Jaén, Carlos Roberto; Kubik, Martha; et al. (2023-02-14)
    Importance: Genital herpes is a common sexually transmitted infection caused by 2 related viruses, herpes simplex type 1 (HSV-1) and herpes simplex type 2 (HSV-2). Infection is lifelong; currently, there is no cure for HSV infection. Antiviral medications may provide clinical benefits to symptomatic persons. Transmission of HSV from a pregnant person to their infant can occur, most commonly during delivery; when genital lesions or prodromal symptoms are present, cesarean delivery can reduce the risk of transmission. Neonatal herpes infection is uncommon yet can result in substantial morbidity and mortality. Objective: To reaffirm its 2016 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a reaffirmation evidence update on targeted key questions to systematically evaluate the evidence on accuracy, benefits, and harms of routine serologic screening for HSV-2 infection in asymptomatic adolescents, adults, and pregnant persons. Population: Adolescents and adults, including pregnant persons, without known history, signs, or symptoms of genital HSV infection. Evidence assessment: The USPSTF concludes with moderate certainty that the harms outweigh the benefits for population-based screening for genital HSV infection in asymptomatic adolescents and adults, including pregnant persons. Recommendation: The USPSTF recommends against routine serologic screening for genital HSV infection in asymptomatic adolescents and adults, including pregnant persons. (D recommendation).
  • Understanding Implementation of Evidence-Based Interventions to Address Human Papillomavirus Vaccination: Qualitative Perspectives of Middle Managers

    Ryan, Grace W; Charlton, Mary E; Scherer, Aaron M; Ashida, Sato; Gilbert, Paul A; Daly, Eliza; Askelson, Natoshia M (2023-02-10)
    Engaging individuals in middle management positions (eg, nurse or clinic managers) could facilitate implementation of evidence-based interventions (EBIs) to improve uptake of human papillomavirus (HPV) vaccination. Our goal was to understand middle managers' role in and perspectives on implementation of EBIs for HPV vaccination. We conducted qualitative interviews with middle managers in pediatric and family practice clinics. We used constructs from the Consolidated Framework for Implementation Research (CFIR) to design the interview guide and as a coding framework. Participants (n = 19) reported overseeing implementation related to HPV vaccination. Across interviews, CFIR inner setting constructs (eg, structural characteristics and implementation climate) were identified as being both barriers and facilitators. As evidenced in this study, middle managers have a deep understanding of organizational factors, and they have the ability to facilitate implementation efforts related to HPV vaccination. Future efforts could focus on engaging middle managers and leveraging their expertise and understanding of barriers and facilitators.
  • Identifying strategies to advance equitable implementation of co-occurring mental health and substance use disorder treatment in drug treatment courts: A study protocol

    Gaba, Ayorkor; LoVette, Ashleigh; Pridgen, Bailey; Taylor, Marquita; Woodward, Eva; Rosal, Milagros C; Anderson, Melissa; Smelson, David (2023-02-07)
    Introduction: Behavioral health treatment disparities by race and ethnicity are well documented across the criminal legal system. Despite criminal legal settings such as drug treatment courts (DTCs) increasingly adopting evidence-based programs (EBPs) to improve care, there is a dearth of research identifying strategies to advance equitable implementation of EBPs and reduce racial/ethnic treatment disparities. This paper describes an innovative approach to identify community- and provider-generated strategies to support equitable implementation of an evidence-based co-occurring mental health and substance use disorder intervention, called Maintaining Independence and Sobriety through Systems Integration, Outreach and Networking-Criminal Justice (MISSION-CJ), in DTCs. Methods/design: Guided by the Health Equity Implementation Framework, qualitative interviews and surveys will assess factors facilitating and hindering equitable implementation of MISSION-CJ in DTCs among 30 Black/African American and/or Hispanic/Latino persons served and providers. Concept mapping with sixty Black/African American and/or Hispanic/Latino persons served and providers will gather community- and provider-generated strategies to address identified barriers. Finally, an advisory board will offer iterative feedback on the data to guide toolkit development and inform equitable implementation of MISSION-CJ within DTCs. Conclusions: The paper illustrates a protocol of a study based in community-engaged research and implementation science to understand multilevel drivers of racial/ethnic disparities in co-occurring disorder treatment and identify opportunities for intervention and improvements within criminal legal settings.
  • Facilitators and barriers to collaboration between drug courts and community-based medication for opioid use disorder providers

    Pivovarova, Ekaterina; Taxman, Faye S; Boland, Alexandra K; Smelson, David A; Lemon, Stephenie C; Friedmann, Peter D (2023-01-13)
    Introduction: Access to medications for opioid use disorder (MOUD) is limited for individuals in drug courts - programs that leverage sanctions for mandatory substance use treatment. Drug courts rely on community agencies to provide MOUD. However, relationships with MOUD agencies, which impact access to treatment, are understudied. We examined barriers and facilitators from drug court staffs' perspectives to understand how to enhance collaborations with MOUD providers. Methods: Drug court staff (n = 21) from seven courts participated in semi-structured interviews about their experience in collaborating with MOUD providers. Interviews were informed by the Consolidated Framework for Implementation Research. Inductive (theory-based) and deductive (ground-up) approaches were used for analyses. Results: Facilitator and barrier themes centered around the needs and resources of drug court participants, external policies such MOUD access in jails, networking with external agencies, and beliefs about MOUD providers. Drug court staff preferred working with agencies that offered MOUD alongside comprehensive services. Drug courts benefited when jails offered MOUD in-house and facilitated community referrals. Existing relationships with providers and responsive communication eased referrals and served to educate the courts about MOUD. Barriers included logistical limitations (limited hours, few methadone providers) and inadequate communication patterns between providers and drug court staff. A lack of confidence in providers' prescribing practices and concerns around perceived overmedication of participants impacted referrals, interagency collaboration, and further burdened the participants. Conclusions: Collaboration between drug courts and MOUD providers was driven by patient needs, external policies, communication patterns, and perceptions. Interventions to increase access MOUD for drug court participants will need to incorporate collaboration strategies while considering the unique features of drug courts.
  • Video-based communication assessment for weight management counseling training in medical residents: a mixed methods study

    Faro, Jamie M; D'Addario, Angelo; King, Ann M; Mazor, Kathleen M; Pbert, Lori; Sadasivam, Rajani S; Geller, Alan C; Murphy, Elizabeth A; Ockene, Judith K. (2022-12-28)
    Background: Physician delivered weight management counseling (WMC) occurs infrequently and physicians report lack of training and poor self-efficacy. The purpose of this study was to develop and test the Video-based Communication Assessment (VCA) for weight management counseling (WMC) training in medical residents. Methods: This study was a mixed methods pilot conducted in 3 phases. First, we created five vignettes based on our prior data and expert feedback, then administered the vignettes via the VCA to Internal Medicine categorical residents (n = 16) from a University Medical School. Analog patients rated responses and also provided comments. We created individualized feedback reports which residents were able to view on the VCA. Lastly, we conducted debriefing interviews with the residents (n = 11) to obtain their feedback on the vignettes and personalized feedback. Interviews were transcribed, and we used thematic analysis to generate and apply codes, followed by identifying themes. Results: Descriptive statistics were calculated and learning points were created for the individualized feedback reports. In VCA debriefing interviews with residents, five themes emerged: 1) Overall the VCA was easy to use, helpful and more engaging than traditional learning and assessment modes, 2) Patient scenarios were similar to those encountered in the clinic, including diversity, health literacy and different stages of change, 3) The knowledge, skills, and reminders from the VCA can be transferred to practice, 4) Feedback reports were helpful, to the point and informative, including the exemplar response of how to best respond to the scenario, and 5) The VCA provide alternatives and practice scenarios to real-life patient situations when they aren't always accessible. Conclusions: We demonstrated the feasibility and acceptability of the VCA, a technology delivered platform, for delivering WMC to residents. The VCA exposed residents to diverse patient experiences and provided potential opportunities to tailor providers responses to sociological and cultural factors in WMC scenarios. Future work will examine the effect of the VCA on WMC in actual clinical practice.
  • Discrimination and Sleep: Differential Effects by Type and Coping Strategy

    Majeno, Angelina; Molina, Kristine M; Frisard, Christine F.; Lemon, Stephenie C; Rosal, Milagros C (2022-12-19)
    Background: Discrimination has been posited as a contributor of sleep disparities for Latinxs. The strategy used to cope with discrimination may reduce or exacerbate its effects on sleep. This study examined whether different types of discrimination (everyday and major lifetime discrimination) were associated with sleep indices (quality, disturbances, efficiency) and whether coping strategy used moderated associations. Method: Data of Latinx adults (N = 602; 51% women, 65% Dominican, Mage = 46.72 years) come from the Latino Health and Well-being Project, a community-based, cross-sectional study of Latinxs in Lawrence, MA. Multiple linear regressions were estimated separately for each sleep outcome. Results: Everyday discrimination was significantly associated with poorer sleep quality and greater disturbances; major lifetime discrimination was significantly associated with worse sleep across the three sleep indices. Coping strategy moderated associations between discrimination and sleep. Compared with Latinxs who used passive coping, those who used passive-active coping strategies had poorer sleep quality the more they experienced everyday discrimination. Latinxs who used any active coping strategy, compared with passive coping, had greater sleep disturbances the more frequently they experienced major lifetime discrimination. Conclusions: Findings show that everyday discrimination and major lifetime discrimination are associated with different dimensions of sleep and suggest that coping with discrimination may require the use of different strategies depending on the type of discrimination experienced.
  • Extent and Equity of the Implementation of Clinical Practice Guidelines for Pediatric Blood Pressure Screening in a Massachusetts Safety-net Health Care System

    Goulding, Melissa; Frisard, Christine F.; Person, Sharina D.; Goldberg, Robert J.; Garg, Arvin; Lemon, Stephenie C. (2022-12-13)
    Background: The American Academy of Pediatrics 2017 clinical practice guidelines (CPG) call for regular blood pressure (BP) screening in children ≥3 years. However, it is unknown to what extent the BP screening CPG has been implemented or if such implementation has been equitable. Methods: Cross-sectional data from January 1-December 31, 2018 were extracted from electronic health records from the largest health care system in Central Massachusetts. Outpatient visits for children aged 3-to-17-years without a prior hypertension diagnosis were included. Adherence was defined by the BP screening CPG recommending ≥1 BP screening per year for children of a healthy body mass index ((BMI) <85%) and at every encounter for children who are overweight (BMI ≥85%). Independent variables included social determinant of health indicators at the child-level (insurance, language, child opportunity index) and clinic-level (urban/rural, Medicaid population). Covariates included child’s age, gender, race/ethnicity, and BMI, as well as clinic’s specialty (pediatrics/family medicine), patient panel size, and number of providers. We used direct estimation to calculate prevalence estimates and multivariable mixed effects logistic regression to determine the odds of undergoing CPG adherent BP screening. Findings: We identified 44,947 visits for 19,787 children (median age 11 years) across 7 pediatric and 20 family medicine clinics in 2018. The prevalence of CPG adherent BP screening was 83%. In the multivariable adjusted model, children with private insurance (adjusted odds ratio (aOR) 1.22, 95% CI 1.09-1.35) and those seen in clinics with a lower Medicaid population (aOR 1.02, 95% CI 1.0-1.05 per 1% decrease) were more likely to undergo CPG adherent screening. CPG adherent screening was also more likely among older children, those with BMI <85%, those in family medicine clinics, and those in clinics with more providers. Implications for D&I Research: Despite overall high adherence to pediatric BP CPG indicating relatively successful implementation, our findings suggest that this implementation is not equitable. Adherence was lower for children who are more likely to be impoverished, have higher social needs, and benefit from preventive screenings (BMI ≥85%, publicly insured, and treated in Medicaid predominant clinics). Future implementation efforts should address structural factors, especially those related to insurance and pediatric practice to achieve more equitable implementation.
  • Electronic Health Record-Assisted Community Health Worker Coaching for Medication Adherence: Adaptation of an Evidence-Based Intervention

    Rosal, Milagros C.; Borg, Amy; Bertrand, Sarah; Plasencia, Nelly; Le, Thuha; Negron Cruz, Leopoldo; Frisard, Christine F.; Azaroff, Lenore; Ortiz, Evelyn; Blumhofer, Rebecca; et al. (2022-12-12)
    Background: Community health workers (CHWs) are often employed in healthcare settings to link patients with services and providers to improve the quality and cultural competence of healthcare service delivery, particularly among populations experiencing health inequities. However, limited data exist on strategies to best integrate CHWs into the patient’s clinical team to deliver evidence-based care. Electronic health records (EHRs) may facilitate this integration and support care delivery. The BP Control project uses the EHR to facilitate the delivery of an evidence-based antihypertensive medication adherence coaching intervention by CHWs while integrating CHWs into the clinical team. The methods and process used to adapt the coaching intervention for EHR-assisted delivery by CHWs are described. Methods: A team from two community health centers, each represented by a medical champion, operations champion, CHW, CHW supervisor and information technology staff, and a university-based practice facilitator, used a co-production methodology to adapt the EHR-assisted CHW-delivered coaching intervention. The practice facilitator led bi-monthly 90-minute meetings to discuss and identify strategies to leverage the EHR. The team identified key skills for the CHW to deliver the intervention and contributed to developing the CHW training curriculum. A smaller team of the CHWs, CHW supervisors and practice facilitator conducted Beta testing and made recommendations for improving functionality. EHR technical adaptations were implemented by an Information Technology consultant. Findings: Strategies for EHR-assisted CHW-delivered coaching and CHW clinical team integration included: 1) EHR prompts to deliver each step of the evidence-based coaching algorithm, 2) EHR fields to document session information and generate fidelity reports, 3) EHR algorithms to track patient progress/follow up, and 4) EHR prompts to facilitate referrals to CHWs and CHW-initiated messaging to referring providers. The CHW training curriculum included basic medical knowledge (hypertension, medications, adherence) and behavioral counseling (5As, motivational interviewing) skills and addressed comfort utilizing technology and logistical matters of implementing the intervention in a larger care system. This curriculum was implemented via didactic sessions, videos, and role-plays to build skills. Implications for D&I Research: Our co-production adaptation methodology leveraged EHR potential to improve the delivery of evidence-based interventions by CHWs to improve quality of patient care and address disparities in hypertension control.
  • Association between dietary inflammatory potential and mortality after cancer diagnosis in the Women's Health Initiative

    Zheng, Jiali; Tabung, Fred K; Zhang, Jiajia; Caan, Bette; Hebert, James R; Kroenke, Candyce H; Ockene, Judith K.; Shivappa, Nitin; Steck, Susan E (2022-12-08)
    Background: Chronic inflammation is implicated in cancer prognosis and can be modulated by diet. We examined associations between post-diagnosis dietary inflammatory potential and mortality outcomes among post-menopausal women diagnosed with cancer in the Women's Health Initiative (WHI). Methods: Energy-adjusted dietary inflammatory index scores (E-DII) were calculated from dietary and supplemental intake data collected on the first food frequency questionnaire following the diagnosis of primary invasive cancer for 3434 women in the WHI. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CIs) for risk of death from any cause, cancer, cardiovascular disease (CVD) and other causes by post-diagnosis quartiles of E-DII. Subgroup analyses by cancer stage and grade were performed. Results: There were 1156 deaths after a median 13 years of follow-up from the date of a cancer diagnosis. In the multivariable-adjusted analyses, a more anti-inflammatory diet plus supplements after cancer diagnosis was associated with lower all-cause mortality, cancer mortality, CVD mortality and mortality from other causes with HRsQ1vs.Q4 ranging from 0.47 to 0.68 (all P-trends < 0.05). Associations were stronger for cancers diagnosed at more distant stages or moderately differentiated grades. Conclusion: A more anti-inflammatory diet plus supplements after a cancer diagnosis may improve survival for post-menopausal cancer survivors.
  • The Healthy Kids & Families study: Outcomes of a 24-month childhood obesity prevention intervention

    Rosal, Milagros C; Lemon, Stephenie C; Borg, Amy; Lopez-Cepero, Andrea; Sreedhara, Meera; Silfee, Valerie; Pbert, Lori; Kane, Kevin; Li, Wenjun (2022-12-07)
    Socioeconomically disadvantaged children experience a high burden of obesity but few interventions address obesity prevention in this population subgroup. The Healthy Kids & Families study tested the effect of a parent-focused community health worker (CHW)-delivered lifestyle intervention to prevent childhood obesity. Participants were child-parent/guardian (Kindergarten to 6th grade at baseline) dyads (n = 247) recruited through schools located in socioeconomically disadvantaged neighborhoods in Worcester, MA, USA. Using a quasi-experimental design, the study tested the impact of Healthy Kids & Families, a theory-based, low-intensity, parent-focused, CHW-delivered intervention to improve children's weight, healthy eating and physical activity. The attention-control comparison condition was a positive parenting intervention. The primary outcome was change in child body mass index (BMI) z-score at 24 months. Secondary outcomes included number of positive child and parent changes in selected diet and physical activity behaviors targeted by the intervention and change in parent BMI. Outcomes were assessed following the intent-to-treat principle and using multivariable generalized linear mixed models. Compared to the attention-control comparison condition, the Healthy Kids & Families intervention led to a greater reduction in children's BMI z-score (β = -0.17, 95 %CI: -1.92 to -0.36; p = 0.057) and a greater number of positive behavior changes among children (β = 0.57, 95 %CI: 0.08-1.06; p = 0.02) at 24 months. There was no significant change in parent outcomes. The Healthy Kids & Families intervention shows promise for obesity prevention among children in socioeconomically disadvantaged communities.
  • Development and Beta-Testing of the CONFIDENCE Intervention to Increase Pediatric COVID-19 Vaccination

    Ryan, Grace W; Goulding, Melissa; Borg, Amy; Minkah, Princilla; Beeler, Angela; Rosal, Milagros C; Lemon, Stephenie C (2022-11-17)
    Introduction: Innovative strategies are needed to improve pediatric COVID-19 vaccination rates. We describe the process for developing a clinic-based intervention, CONFIDENCE, to improve pediatric COVID-19 vaccine uptake and present results of our beta-test for feasibility and acceptability. Method: CONFIDENCE included communication training with providers, a poster campaign, and parent-facing educational materials. We assessed feasibility and acceptability through interviews and measured preliminary vaccine intention outcomes with a pre-post parent survey. Interviews were analyzed using rapid qualitative methods. We generated descriptive statistics for variables on the parent survey and used Fisher's exact test to assess pre-post differences. Results: Participating providers (n = 4) reported high levels of feasibility and acceptability. We observed positive trends in parents' (n = 69) reports of discussing vaccination with their provider and the parental decision to accept COVID-19 vaccination. Discussion: Our next steps will be to use more rigorous methods to establish the efficacy and effectiveness of the CONFIDENCE intervention.
  • Screening for Obstructive Sleep Apnea in Adults: US Preventive Services Task Force Recommendation Statement

    Mangione, Carol M; Barry, Michael J; Nicholson, Wanda K; Cabana, Michael; Chelmow, David; Rucker Coker, Tumaini; Davidson, Karina W; Davis, Esa M; Donahue, Katrina E; Jaén, Carlos Roberto; et al. (2022-11-15)
    Importance: Current prevalence of obstructive sleep apnea (OSA) in the US is not well established; however, based on cohort and survey data, in 2007-2010 the estimated prevalence of at least mild OSA (defined as an apnea-hypoxia index [AHI] ≥5) plus symptoms of daytime sleepiness among adults aged 30 to 70 years was 14% for men and 5% for women, and the estimated prevalence of moderate to severe OSA (defined as AHI ≥15) was 13% for men and 6% for women. Severe OSA is associated with increased all-cause mortality. Other adverse health outcomes associated with untreated OSA include cardiovascular disease and cerebrovascular events, type 2 diabetes, cognitive impairment, decreased quality of life, and motor vehicle crashes. Objective: To update its 2017 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for OSA in adults. Population: Asymptomatic adults (18 years or older) and adults with unrecognized symptoms of OSA. Evidence assessment: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in the general adult population. Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in the general adult population. (I statement).
  • The Impact of COVID-19 on the Behavioral Health of Massachusetts Tribal Communities

    Aronowitz, Teri; Woods, Cedric; Kim, BoRam; Frisard, Christine F.; Beatriz, Elizabeth; Cardoso, Lauren; Lin, Ta-Wei; Stack, Caroline; Lemon, Stephenie C. (2022-11-07)
    Background: American Indian/Alaskan Native (AI/AN) individuals were 3.5 times more likely to be hospitalized from the virus compared to other race/ethic groups (CDC, 2021). Despite being disproportionately impacted by COVID-19, the experiences of the AI/AN population during the pandemic have not been documented. There are approximately 93,123 individuals in Massachusetts (MA) that identify as AI/AN (U.S. Census, 2020). This study examined the impact of COVID-19 on the behavioral health of the MA AI/AN population. Methods: A web-based survey was completed by 452 AI/ANs. A focus group with members of the AN/AI/AN (n=10) community was conducted to provide insights into the survey results. Individuals were recruited through the Institute of New England Native American Studies research team’s Community Advisory Board. Results: Forty-two percent of sample were between 45-64 years of age, female (77.2%), and identified as AN/AN in combination with another race (85%). Almost half of AI/AN participants had 15 or more days of poor mental health in the past month with rates highest among younger individuals. Forty-four percent reported that their substance use was a lot or somewhat more than pre-pandemic. Focus group findings indicated that the pandemic exacerbated (1) behavioral health challenges; (2) isolation from others and from AI/AN organizations; (3) telehealth was helpful to some; but (4) 30% had limited broadband access. Conclusion & Implications: The AI/AN community in MA has experienced devastating behavioral health outcomes during the pandemic. Urgent action is needed to address with crisis. Funding for risk-reducing programs and culturally specific treatment interventions are needed.
  • Youth Empowerment Modeling in building COVID-19 Vaccine Confidence in Local Communities

    Minkah, Princilla; Borg, Amy; Ryan, Grace W.; Goulding, Melissa; Perrone, Domenica; Castiel, Matilde; Rosal, Milagros C.; Lemon, Stephenie C. (2022-11-07)
    Background: Rates of COVID-19 vaccinations among youth remain sub-optimal, particularly among racial and ethnic minority populations. The Centers for Disease Control and Prevention-funded UMass Worcester Prevention Research Center partnered with the vaccination equity initiative of Worcester, Massachusetts and youth-serving organizations to develop, implement, and evaluate a youth led public health campaign to promote COVID-19 vaccine confidence and uptake. Methods: Guided by the youth empowerment model to promote behavior change by helping youth reflect, identify, and take action on what is meaningful to them, we created a youth vaccine ambassador public health campaign to promote COVID-19 vaccination. Ambassadors were guided through self-reflection of questions, answers and motivations for COVID-19 vaccination. Youth motivations and narratives became the campaign messaging. Youth collaborated to create and disseminate social media, video, and print content to display in local neighborhoods, using social norming approaches to foster youth and family vaccine confidence and vaccination. Results: We trained nine youth (aged 18- 22 years) as vaccine ambassadors. English/Spanish vaccine messages developed by youth ambassadors were disseminated through social media platforms (n=3), radio (n=2), local TV (n=2), flyers (n=2,086), posters (n=362), billboards (n=7), and local bus ads (n=18). Qualitative youth feedback indicated participation in the campaign was a positive and empowering experience which reinforces the importance of engaging youth in public health messaging. Discussion: Amplifying youth voices by engaging them to develop and share their personal vaccine stories and motivations facilitated youths’ role as public health messengers. Youth empowerment through storytelling and personal narratives holds promise for future public health campaigns.
  • Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons: US Preventive Services Task Force Recommendation Statement

    Mangione, Carol M; Barry, Michael J; Nicholson, Wanda K; Cabana, Michael; Caughey, Aaron B; Chelmow, David; Coker, Tumaini Rucker; Davis, Esa M; Donahue, Katrina E; Jaén, Carlos Roberto; et al. (2022-11-01)
    Importance: Menopause is defined as the cessation of a person's menstrual cycle. It is defined retrospectively, 12 months after the final menstrual period. Perimenopause, or the menopausal transition, is the few-year time period preceding a person's final menstrual period and is characterized by increasing menstrual cycle length variability and periods of amenorrhea, and often symptoms such as vasomotor dysfunction. The prevalence and incidence of most chronic diseases (eg, cardiovascular disease, cancer, osteoporosis, and fracture) increase with age, and US persons who reach menopause are expected on average to live more than another 30 years. Objective: To update its 2017 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of systemic (ie, oral or transdermal) hormone therapy for the prevention of chronic conditions in postmenopausal persons and whether outcomes vary by age or by timing of intervention after menopause. Population: Asymptomatic postmenopausal persons who are considering hormone therapy for the primary prevention of chronic medical conditions. Evidence assessment: The USPSTF concludes with moderate certainty that the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal persons with an intact uterus has no net benefit. The USPSTF concludes with moderate certainty that the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy has no net benefit. Recommendation: The USPSTF recommends against the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal persons. (D recommendation) The USPSTF recommends against the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy. (D recommendation).

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