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. This site is a repository of publications produced by PRC faculty, staff, students and community partners.


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Recently Published

  • Exploring the relationship between school-supervised asthma therapy and social determinants of health in pediatric asthma care

    Al-Halbouni, Layana; Ryan, Grace W; Radu, Sonia; Spano, Michelle; Sabnani, Reshma; Phipatanakul, Wanda; Gerald, Lynn B; Garg, Arvin; Pbert, Lori; Trivedi, Michelle (2024-05-16)
    Background: Social determinants of health (SDoH), including access to care, economic stability, neighborhood factors, and social context, strongly influence pediatric asthma outcomes. School-supervised asthma therapy (SST) is an evidence-based strategy that improves asthma outcomes, particularly for historically marginalized children, by providing support for daily medication adherence in school. However, little is known about the relationship between these programs and the adverse SDoH commonly affecting underrepresented minority and marginalized children with asthma. Methods: We examined qualitative data from interviews (n = 52) conducted between 2017 and 2020 with diverse multi-level partners involved in Asthma Link, a SST intervention. Participants included end-users (children and their parents), deliverers (school nurses and pediatric providers), and systems-level partners (e.g., insurers, legislators, and state officials). We used inductive coding to determine themes and subthemes and deductive coding using the Healthy People 2030 SDoH framework. Results: Three themes emerged: (1) SST mitigates adverse SDoH (improves access to preventive healthcare and asthma health literacy), (2) SST benefits children experiencing specific adverse SDoH (provides a consistent medication routine to children with unstable family/housing situations) and (3) specific adverse SDoH impede SST implementation (economic instability, culture and language barriers). Conclusion: This study suggests an important relationship between SDoH and SST that warrants further evaluation in our future work on this community-based asthma intervention. Moreover, our findings underscore the importance of measuring SDoH in the implementation and evaluation of pediatric asthma interventions, particularly given the strong influence of these social factors on child health outcomes.
  • Systolic Blood Pressure and Survival to Very Old Age: Results From the Women's Health Initiative

    Haring, Bernhard; Andrews, Chris A; Hovey, Kathleen; Shadyab, Aladdin H; LaCroix, Andrea; Martin, Lisa Warsinger; Rosal, Milagros C; Kuller, Lewis H; Salmoirago-Blotcher, Elena; Saquib, Nazmus; et al. (2024-04-16)
    Background: The relationship between systolic blood pressure (SBP) and longevity is not fully understood. We aimed to determine which SBP levels in women ≥65 years of age with or without blood pressure medication were associated with the highest probability of surviving to 90 years of age. Methods: The study population consisted of 16 570 participants enrolled in the Women's Health Initiative who were eligible to survive to 90 years of age by February 28, 2020, without a history of cardiovascular disease, diabetes, or cancer. Blood pressure was measured at baseline (1993 through 1998) and then annually through 2005. The outcome was defined as survival to 90 years of age with follow-up. Absolute probabilities of surviving to 90 years of age were estimated for all combinations of SBP and age using generalized additive logistic regression modeling. The SBP that maximized survival was estimated for each age, and a 95% CI was generated. Results: During a median follow-up of 19.8 years, 9723 of 16 570 women (59%) survived to 90 years of age. Women with an SBP between 110 and 130 mm Hg at attained ages of 65, 70, 75, and 80 years had a 38% (95% CI, 34%-48%), 54% (52%-56%), 66% (64%-67%), or 75% (73%-78%) absolute probability to survive to 90 years of age, respectively. The probability of surviving to 90 years of age was lower for greater SBP levels. Women at the attained age of 80 years with 0%, 20%, 40%, 60%, 80%, or 100% time in therapeutic range (defined as an SBP between 110 and 130 mm Hg) had a 66% (64%-69%), 68% (67%-70%), 71% (69%-72%), 73% (71%-74%), 75% (72%-77%), or 77% (74%-79%) absolute survival probability to 90 years of age. Conclusions: For women >65 years of age with low cardiovascular disease and other chronic disease risk, an SBP level <130 mm Hg was found to be associated with longevity. These findings reinforce current guidelines targeting an SBP target <130 mm Hg in older women.
  • Vaping Cessation Support Recommendations from Adolescents Who Vape: A Qualitative Study [preprint]

    Pbert, Lori; Dube, Catherine E; Nagawa, Catherine S; Simone, Dante P; Wijesundara, Jessica G; Sadasivam, Rajani S (2024-03-20)
    Background: Youth vaping is an epidemic, being more prevalent than any other tobacco use. To inform cessation interventions, we explored what adolescents perceive to be their reasons for quitting and strategies to help in their quit efforts. Method: Semi-structured interviews were conducted with a convenience sample of 11 adolescents reporting vaping in the past 90 days and recruited from a high school in Massachusetts. Interviews were transcribed, and dual coded. Inductive thematic analysis was employed and thematic summaries were prepared. Results: Reasons adolescents reported for quitting included: cost; experiencing "nic-sick" from nicotine withdrawal or excess intake; negative impacts on mood, concentration, or health; and experiencing symptoms of nicotine dependence. Nearly all tried to quit multiple times. Barriers to quitting included: exposure to vaping; access to vape products; stress; and "cool" new products or flavors. Quit strategies included: avoiding others vaping; seeking social support to quit; addressing peer pressure to continue vaping; learning successful quit strategies from peers; and using distraction strategies or alternatives to vaping. Conclusion: Many adolescents who vape want to quit and most have tried multiple times. Interventions need to engage adolescents with varying reasons to quit, barriers, and quit strategy preferences. Clinical trial registration: This study is registered through ClinicalTrials.gov. The trial registration number is NCT05140915. The trial registration date is 11/18/2021.
  • Participant Perspectives on the Implementation of a School-Linked Text-Message Intervention to Improve Pediatric Asthma Medication Adherence

    Radu, Sonia; Zarinafsar, Sheerin; Ryan, Grace W; Chainani, Sanjay; Becker, Sarah; Arenas, Juliana; Spano, Michelle A; Shillan, Holly N; Hoque, Shushmita; Sadasivam, Rajani S; et al. (2024-02-07)
    Background: Poor adherence to inhaled corticosteroids (ICS) is a significant challenge in pediatric asthma, contributing to health inequities. Text-message reminders for ICS therapy are an evidence-based approach that improves pediatric asthma medication adherence, yet has not been widely adopted into practice, partly due to lack of (1) participant input on design and implementation and (2) use of sustainable community linkages. Remote Asthma Link™ (RAL) seeks to fill this gap as a school-linked text-message intervention wherein parents of children with poorly controlled asthma received daily, 2-way text-message reminders for preventive inhaler use. Responses were shared with school nurses who conducted remote check-ins with families. Enrolled children, largely from underserved backgrounds, experienced improvements in medication adherence and asthma health outcomes. While initial results were promising, we have yet to elicit participant input to refine the protocol for more widespread implementation. Objective: Examine participant perspectives on barriers and facilitators of RAL implementation. Methods: Semistructured interviews were conducted May-June 2022 with intervention participants: 10 parents, 7 school nurses, and 4 pediatric providers (n = 21) until thematic saturation was reached. Interview transcripts were coded using thematic analysis. Results: Several facilitators for RAL implementation were identified, including ease of use and accessibility, personal connection to the school nurse, and receipt of a visual notification for habit formation. Barriers included challenges with school nurses reaching parents, poor understanding of program expectations, and lack of reimbursement structure. Participant-proposed solutions to barriers included utilizing alternate communication methods (eg, social media), educational sessions, and meeting with payors to consider reimbursement models. Conclusion: RAL is a school-linked text-message intervention demonstrating promise in improving outcomes and equity in asthma care. Key implementation facilitators, barriers, and proposed solutions will inform protocol adaptations to promote successful implementation of this and other text-message interventions into clinical practice.
  • The impact of a lifestyle intervention on postpartum weight retention among US Hispanic women with overweight and obesity

    Wagner, Kathryn A; Whitcomb, Brian W; Marcus, Bess; Pekow, Penelope; Rosal, Milagros C; Leidy Sievert, Lynnette; Tucker, Katherine L; Manson, JoAnn E; Chasan-Taber, Lisa (2024-01-28)
    Introduction: To evaluate the effect of a culturally-modified, motivationally-targeted, individually-tailored lifestyle intervention on postpartum weight retention among Hispanic women with overweight/obesity. Materials and methods: Proyecto Mamá was a randomized controlled trial conducted in western Massachusetts (2014-2020). Hispanic women with overweight/obese pre-pregnancy BMI (n = 148) were randomized in early pregnancy to a Lifestyle Intervention (LI) or a Health & Wellness (HW) comparison arm. The LI was based upon theoretical concepts, used a low-cost, high-reach strategy, and focused on healthy exercise and diet with follow-up through 12-months postpartum. The primary outcome of change in weight was calculated as the difference between pre-pregnancy weight and 6-week, 6-month, and 12-month postpartum weight. The secondary outcome was achievement of 5 % weight reduction from pre-pregnancy weight. Retention was 68.2 % in the overall postpartum period and 31.0 % at 12-months. Results: In intent-to-treat analyses, compared to the HW arm, there was no difference in postpartum weight retention at 6-weeks (0.0 kg, 95 % CI: -3.4, 3.5), 6-months (-1.8 kg, 95 % CI: -5.6, 2.0), or 12-months (-2.0 kg, 95 % CI: -7.0, 3.1). In a secondary complete case analysis, compared to the HW arm, the LI arm had 5.5 times higher odds of meeting the postpartum weight reduction goal (aOR = 5.5, 95 % CI: 1.7, 17.9) adjusting for pre-pregnancy weight. Conclusions: A lifestyle intervention among at-risk Hispanic women with overweight/obesity had no overall impact on postpartum weight, but a beneficial impact among those who completed the trial. Future studies should focus on increasing the feasibility and acceptability of the intervention in this at-risk population.
  • Experiences of cisgender youth with a transgender and/or nonbinary sibling

    Godwin, Eli G; Moore, Lb M; Sansfaçon, Annie Pullen; Nishman, Melissa MacNish; Rosal, Milagros C; Katz-Wise, Sabra L (2024-01-03)
    While recent research has begun to address the effects of family support on transgender and/or nonbinary youth (TNY), almost no studies have directly examined how cisgender siblings in families with TNY navigate their sibling's gender disclosure and affirmation within both their families and their larger communities. We conducted an exploratory secondary analysis of in-person, semi-structured interviews with 15 adolescent and young adult siblings (age 13-24 years) of TNY from the northeastern United States from the baseline wave of the community-based, longitudinal, mixed methods Trans Teen and Family Narratives Project. Interview transcripts were analyzed using immersion/crystallization and template organizing approaches. Analyses yielded three main themes: gender-related beliefs and knowledge, peri- and post-disclosure family dynamics, and assessing responses to their sibling. Subthemes included anticipation of their sibling's TN identity, expectations post-disclosure, participants' level of involvement in gender-related family processes, perceptions of changes in family relationships, concern for their sibling (including a high degree of attunement to gender-affirming name and pronoun usage), and concern for themselves. Findings from this study suggest the need to engage directly with siblings of TNY to further elucidate their intrapersonal, intra-familial, and extra-familial experiences related to having a TN sibling and determine their unique support needs. Implications for families, clinicians, and communities are discussed.
  • Shift-and-persist strategies as a potential protective factor against symptoms of psychological distress among young adults in Puerto Rico

    López-Cepero, Andrea A; Spruill, Tanya; Suglia, Shakira F; Lewis, Tené T; Mazzitelli, Natalia; Pérez, Cynthia M; Rosal, Milagros C (2023-12-12)
    Objective: Residents of Puerto Rico are disproportionately exposed to social and environmental stressors (e.g., Hurricane María and the 2020 sequence of tremors) known to be associated with psychological distress. Shift-and-persist (SP), or the ability to adapt the self to stressors while preserving focus on the future, has been linked with lower psychological distress, but no study has evaluated this in Puerto Rico. This study examined the association between SP and psychological distress (including that from natural disasters) in a sample of young adults in Puerto Rico. Methods: Data from the Puerto Rico-OUTLOOK study (18-29 y) were used. Participants (n = 1497) completed assessments between September 2020 and September 2022. SP was measured with the Chen scale and categorized into quartiles (SPQ1-SPQ4). Psychological distress included symptoms of depression (CESD-10), anxiety (STAI-10), post-traumatic stress disorder (Civilian Abbreviated Scale PTSD checklist), and ataque de nervios (an idiom of distress used by Latinx groups). Outcomes were dichotomized according to clinical cutoffs when available, otherwise used sample-based cutoffs. Two additional items assessed the perceived mental health impact of Hurricane María and the 2020 sequence of tremors (categorized as no/little impact vs. some/a lot). Adjusted prevalence ratios (PR) and their 95% confidence intervals (CI) were estimated. Results: The most commonly reported psychological distress outcome was PTSD (77%). In adjusted models, compared to SP Q1, persons in SP Q2-Q4 were less likely to have elevated symptoms of depression (PR Q2 = 0.79, 95% CI = 0.72-0.85; PR Q3 = 0.65, 95% CI = 0.58-0.73; and PR Q4 = 0.41, 95% CI = 0.35-0.48), PTSD (PR Q2 = 0.92, 95% CI = 0.87-0.98; PR Q3 = 0.86, 95% CI = 0.80-0.93; and PR Q4 = 0.76, 95% CI = 0.70-0.83), anxiety (PR Q2 = 0.39, 95% CI = 0.31-0.48; PR Q3 = 0.27, 95% CI = 0.20-0.37; and PR Q4 = 0.11, 95% CI = 0.07-0.17) and experiences of ataque de nervios (PR Q2 = 0.85, 95% CI = 0.76-0.94; PR Q3 = 0.79, 95% CI = 0.70-0.90; and PR Q4 = 0.68, 95% CI = 0.60-0.78). Compared to persons in SP Q1, persons in SP Q3-Q4 were less likely to report adverse mental health impacts from Hurricane María (PR Q3 = 0.66, 95% CI = 0.55-0.79; and PR Q4 = 0.53, 95% CI = 0.44-0.65) and the 2020 sequence of tremors (PR Q3 = 0.77, 95% CI = 0.61-0.98; and PR Q4 = 0.74, 95% CI = 0.59-0.94). Conclusion: SP was associated with lower psychological distress. Studies are needed to confirm our findings and evaluate potential mechanisms of action.
  • Prioritizing a research agenda on built environments and physical activity: a twin panel Delphi consensus process with researchers and knowledge users

    Prince, Stephanie A; Lang, Justin J; de Groh, Margaret; Badland, Hannah; Barnett, Anthony; Littlejohns, Lori Baugh; Brandon, Nicholas C; Butler, Gregory P; Casu, Géna; Cerin, Ester; et al. (2023-12-07)
    Background: The growth of urban dwelling populations globally has led to rapid increases of research and policy initiatives addressing associations between the built environment and physical activity (PA). Given this rapid proliferation, it is important to identify priority areas and research questions for moving the field forward. The objective of this study was to identify and compare research priorities on the built environment and PA among researchers and knowledge users (e.g., policy makers, practitioners). Methods: Between September 2022 and April 2023, a three-round, modified Delphi survey was conducted among two independent panels of international researchers (n = 38) and knowledge users (n = 23) to identify similarities and differences in perceived research priorities on the built environment and PA and generate twin 'top 10' lists of the most important research needs. Results: From a broad range of self-identified issues, both panels ranked in common the most pressing research priorities including stronger study designs such as natural experiments, research that examines inequalities and inequities, establishing the cost effectiveness of interventions, safety and injuries related to engagement in active transportation (AT), and considerations for climate change and climate adaptation. Additional priorities identified by researchers included: implementation science, research that incorporates Indigenous perspectives, land-use policies, built environments that support active aging, and participatory research. Additional priorities identified by knowledge users included: built environments and PA among people living with disabilities and a need for national data on trip chaining, multi-modal travel, and non-work or school-related AT. Conclusions: Five common research priorities between the two groups emerged, including (1) to better understand causality, (2) interactions with the natural environment, (3) economic evaluations, (4) social disparities, and (5) preventable AT-related injuries. The findings may help set directions for future research, interdisciplinary and intersectoral collaborations, and funding opportunities.
  • Maintaining Program Fidelity in a Changing World: National Implementation of a School-Based HIV Prevention Program

    Schieber, Elizabeth; Deveaux, Lynette; Cotrell, Lesley; Li, Xiaoming; Lemon, Stephenie C; Ash, Arlene S.; MacDonell, Karen; Ghosh, Samiran; Poitier, Maxwell; Rolle, Glenda; et al. (2023-11-18)
    Large-scale, evidence-based interventions face challenges to program fidelity of implementation. We developed implementation strategies to support teachers implementing an evidence-based HIV prevention program in schools, Focus on Youth in The Caribbean (FOYC) and Caribbean Informed Parents and Children Together (CImPACT) in The Bahamas. We examined the effects of these implementation strategies on teachers' implementation in the subsequent year after the initial implementation during the COVID-19 pandemic. Data were collected from 79 Grade 6 teachers in 24 government elementary schools. Teachers completed training workshops and a pre-implementation questionnaire to record their characteristics and perceptions that might affect their program fidelity. School coordinators and peer mentors provided teachers with monitoring, feedback, and mentoring. In Year 1, teachers on average taught 79.3% of the sessions and 80.8% of core activities; teachers in Year 2 covered 84.2% of sessions and 72.9% of the core activities. Teachers with "good" or "excellent" school coordinators in the second year taught significantly more sessions on average (7.8 vs. 7.0, t = 2.04, P < 0.05) and more core activities (26.3 vs. 23.0, t = 2.41, P < 0.05) than teachers with "satisfactory" coordinators. Teachers who had a "good" or "satisfactory" mentor taught more sessions than teachers who did not have a mentor (7.9 vs. 7.3; t = 2.22; P = 0.03). Two-level mixed-effects model analysis indicated that teachers' program fidelity in Year 1, confidence in the execution of core activities, and school coordinators' performance were significantly associated with Year 2 implementation dose. Implementation of FOYC + CImPACT was significantly associated with improved student outcomes. Teachers maintained high fidelity to a comprehensive HIV prevention program over 2 years during the COVID-19 pandemic. Future program implementers should consider additional implementation support to improve the implementation of school-based programs.
  • Locations of COVID-19 vaccination provision: Urban-rural differences

    Ryan, Grace W; Kahl, Amanda R; Callaghan, Don; Kintigh, Bethany; Askelson, Natoshia M (2023-11-13)
    Purpose: Our goal was to compare locations of COVID-19 vaccine provision in urban and rural communities over the course of the pandemic. Methods: We used the Iowa Immunization Registry Information System (IRIS) to identify the organizations providing COVID-19 vaccines (eg, pharmacies, public health departments, and medical providers). Proportions of first-dose vaccines by organization type and patient census-based statistical area were generated. We calculated Chi-square tests to assess differences among metropolitan, micropolitan, and noncore communities. Findings: IRIS data revealed that 64% (n = 2,043,251) of Iowans received their first COVID-19 vaccine between December 14, 2020, and December 31, 2022. For metropolitan-dwelling individuals, most first doses were administered at pharmacies (53%), with similar trends observed for micropolitan (49%) and noncore (42%) individuals. The second most common location for metropolitan individuals was medical practices (17%); public health clinics and departments were the second most common provider for micropolitan (26%) and noncore (33%) individuals. These trends shifted over time. In December 2020, hospitals were the most common vaccine provider for everyone, but by December 2022, medical providers were the most common source for metropolitan individuals, and pharmacies were most common for micropolitan and noncore individuals. Conclusions: Trends in the type of vaccine provider differentiated metropolitan residents from micropolitan and noncore residents. For the latter groups, local public health departments played a more significant role. Across all groups, pharmacists emerged as a critical vaccine provider. Our findings can be used to plan for seasonal vaccine campaigns as well as potential future mass vaccination campaigns.
  • Screening and Preventive Interventions for Oral Health in Children and Adolescents Aged 5 to 17 Years: US Preventive Services Task Force Recommendation Statement

    Barry, Michael J; Nicholson, Wanda K; Silverstein, Michael; Chelmow, David; Coker, Tumaini Rucker; Davis, Esa M; Donahue, Katrina E; Jaén, Carlos Roberto; Li, Li; Ogedegbe, Gbenga; et al. (2023-11-07)
    Importance: Oral health is fundamental to health and well-being across the lifespan. Oral health conditions affect the daily lives of school-age children and adolescents, leading to loss of more than 51 million school hours every year. Untreated oral health conditions in children can lead to serious infections and affect growth, development, and quality of life. Objective: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate screening and preventive interventions for oral health conditions in children and adolescents aged 5 to 17 years. Population: Asymptomatic children and adolescents aged 5 to 17 years. Evidence assessment: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral health conditions (eg, dental caries) performed by primary care clinicians in asymptomatic children and adolescents aged 5 to 17 years. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions for oral health conditions (eg, dental caries) performed by primary care clinicians in asymptomatic children and adolescents aged 5 to 17 years. Recommendations: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening performed by primary care clinicians for oral health conditions, including dental caries, in children and adolescents aged 5 to 17 years. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions performed by primary care clinicians for oral health conditions, including dental caries, in children and adolescents aged 5 to 17 years. (I statement).
  • Screening and Preventive Interventions for Oral Health in Adults: US Preventive Services Task Force Recommendation Statement

    Barry, Michael J; Nicholson, Wanda K; Silverstein, Michael; Chelmow, David; Coker, Tumaini Rucker; Davis, Esa M; Donahue, Katrina E; Jaén, Carlos Roberto; Li, Li; Ogedegbe, Gbenga; et al. (2023-11-07)
    Importance: Oral health is fundamental to health and well-being across the life span. Dental caries (cavities) and periodontal disease (gum disease) are common and often untreated oral health conditions that affect eating, speaking, learning, smiling, and employment potential. Untreated oral health conditions can lead to tooth loss, irreversible tooth damage, and other serious adverse health outcomes. Objective: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate screening and preventive interventions for oral health conditions in adults. Population: Asymptomatic adults 18 years or older. Evidence assessment: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral health conditions (eg, dental caries or periodontal disease) performed by primary care clinicians in asymptomatic adults. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions for oral health conditions (eg, dental caries or periodontal disease) performed by primary care clinicians in asymptomatic adults. Recommendations: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening performed by primary care clinicians for oral health conditions, including dental caries or periodontal-related disease, in adults. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions performed by primary care clinicians for oral health conditions, including dental caries or periodontal-related disease, in adults. (I statement).
  • Trends in COVID-19 vaccine administration across visit types in a safety net pediatric practice during the first year of authorization

    Ryan, Grace W; Goulding, Melissa; Beeler, Angela L; Nazarian, Beverly L; Pbert, Lori; Rosal, Milagros C; Lemon, Stephenie C (2023-11-06)
    We explored patterns of COVID-19 vaccination across pediatric visit types using electronic health record data from 7/1/2021 through 7/25/2022 in a pediatric safety-net clinic. We generated frequencies and descriptive statistics for patient demographic and vaccine administration variables. Analyses were stratified into age subgroups of 5-to-11-year-olds and 12- to-17-year-olds. 1,409 children received at least one dose of the COVID-19 vaccine and 2,197 doses were administered in this first year of vaccine delivery. Most vaccines given were first doses in the series (45%), followed by second doses (38%), and then booster doses (17%). First doses tended to be given at well-child (42%) or nurse visits (48%), while second doses were almost entirely given at nurse visits (87%) and booster doses at well-child visits (58%). Efforts to optimize COVID-19 vaccination could leverage clinic workflow systems to provide reminder prompts for vaccination for scheduling future doses and identify strategies to facilitate vaccination at non-well child visits, particularly for booster doses.
  • The Impact of a Lifestyle Intervention on Postpartum Cardiometabolic Risk Factors Among Hispanic Women With Abnormal Glucose Tolerance During Pregnancy: Secondary Analysis of a Randomized Trial

    Wagner, Kathryn A; St Laurent, Christine W; Pekow, Penelope; Marcus, Bess; Rosal, Milagros C; Braun, Barry; Manson, Joann E; Whitcomb, Brian W; Sievert, Lynnette Leidy; Chasan-Taber, Lisa (2023-10-27)
    Background: Women with abnormal glucose tolerance during pregnancy are at risk for cardiovascular disease (CVD), with higher rates among Hispanics. However, studies on the impact of lifestyle interventions on postpartum CVD profiles are sparse. Methods: This is a secondary analysis of a controlled trial among a subsample of Hispanic women with abnormal glucose tolerance participating in Estudió PARTO (Project Aiming to Reduce Type twO diabetes; mean age = 28.2 y, SD: 5.8) who were randomized to a culturally modified Lifestyle intervention (n = 45) or a comparison Health and Wellness intervention (n = 55). Primary endpoints were biomarkers of cardiovascular risk (lipids, C-reactive protein, fetuin-A, and albumin-to-creatinine ratio) and insulin resistance (fasting insulin, glucose, HbA1c, homeostasis model assessment, leptin, tumor necrosis factor-alpha, and adiponectin) measured at baseline (6-wk postpartum) and 6 and 12 months. Results: In intent-to-treat analyses, there were no significant differences in changes in biomarkers of CVD risk or insulin resistance over the postpartum year. In prespecified sensitivity analyses, women adherent with the Lifestyle Intervention had more favorable improvements in insulin (intervention effect = -4.87, SE: 1.93, P = .01) and HOMA-IR (intervention effect = -1.15, SE: 0.53, P = .03) compared with the Health and Wellness arm. In pooled analyses, regardless of intervention arm, women with higher postpartum sports/exercise had greater increase in HDL-cholesterol (intervention effect = 6.99, SE: 1.72, P = .0001). Conclusions: In this randomized controlled trial among Hispanic women with abnormal glucose tolerance, we did not observe a significant effect on postpartum biomarkers of CVD risk or insulin resistance. Women adherent to the intervention had more favorable changes in insulin and HOMA-IR.
  • Implementing Shared Decision-Making for Multiple Sclerosis: The MS-SUPPORT Tool

    Col, Nananda F; Solomon, Andrew J; Alvarez, Enrique; Pbert, Lori; Ionete, Carolina; BerriosMorales, Idanis; Chester, Jennifer; Kutz, Christen; Iwuchukwu, Crystal; Livingston, Terrie; et al. (2023-10-21)
    Background: Disease modifying therapies (DMTs) offer opportunities to improve the course of multiple sclerosis (MS), but decisions about treatment are difficult. People with multiple sclerosis (pwMS) want more involvement in decisions about DMTs, but new approaches are needed to support shared decision-making (SDM) because of the number of treatment options and the range of outcomes affected by treatment. We designed a patient-centered tool, MS-SUPPORT, to facilitate SDM for pwMS. We sought to evaluate the feasibility and impact of MS-SUPPORT on decisions about disease modifying treatments (DMTs), SDM processes, and quality-of-life. Methods: This multisite randomized controlled trial compared the SDM intervention (MS-SUPPORT) to control (usual care) over a 12-month period. English-speaking adults with relapsing MS were eligible if they had an upcoming MS appointment and an email address. To evaluate clinician perspectives, participants' MS clinicians were invited to participate. Patients were referred between November 11, 2019 and October 23, 2020 by their MS clinician or a patient advocacy organization (the Multiple Sclerosis Association of America). MS-SUPPORT is an online, interactive, evidence-based decision aid that was co-created with pwMS. It clarifies patient treatment goals and values and provides tailored information about MS, DMTs, and adherence. Viewed by patients before their clinic appointment, MS-SUPPORT generates a personalized summary of the patient's treatment goals and preferences, adherence, DMT use, and clinical situation to share with their MS clinician. Outcomes (DMT utilization, adherence, quality-of-life, and SDM) were assessed at enrollment, post-MS-SUPPORT, post-appointment, and quarterly for 1 year. Results: Participants included 501 adults with MS from across the USA (84.6% female, 83% white) and 34 of their MS clinicians (47% neurologists, 41% Nurse Practitioners, 12% Physician Assistants). Among the 203 patients who completed MS-SUPPORT, most (88.2%) reported they would recommend it to others and that it helped them talk to their doctor (85.2%), understand their options (82.3%) and the importance of taking DMTs as prescribed (82.3%). Among non-users of DMTs at baseline, the probability ratio of current DMT use consistently trended higher over one-year follow-up in the MS-SUPPORT group (1.30 [0.86-1.96]), as did the cumulative probability of starting a DMT within 6-months, with shorter time-to-start (46 vs 90 days, p=0.24). Among the 222 responses from 34 participating clinicians, more clinicians in the MS-SUPPORT group (vs control) trended towards recommending their patient start a DMT (9 of 108 (8%) vs 5 of 109 (5%), respectively, p=0.26). Adherence (no missed doses) to daily-dosed DMTs was higher in the MS-SUPPORT group (81.25% vs 56.41%, p=.026). Fewer patients forgot their doses (p=.046). The MS-SUPPORT group (vs control) reported 1.7 fewer days/month of poor mental health (p=0.02). Conclusions: MS-SUPPORT was strongly endorsed by patients and is feasible to use in clinical settings. MS-SUPPORT increased the short-term probability of taking and adhering to a DMT, and improved long-term mental health. Study limitations include selection bias, response bias, social desirability bias, and recall bias. Exploring approaches to reinforcement and monitoring its implementation in real-world settings should provide further insights into the value and utility of this new SDM tool.
  • Equitable reach: Patient and professional recommendations for interventions to prevent perinatal depression and anxiety

    Zimmermann, Martha; Peacock-Chambers, Elizabeth; Merton, Catherine; Pasciak, Katarzyna; Thompson, Azure; Mackie, Thomas; Clare, Camille A; Lemon, Stephenie C; Byatt, Nancy (2023-10-09)
    Objective: Perinatal depression and anxiety are the most common complications in the perinatal period and disproportionately affect those experiencing economic marginalization. Fewer than 15% of individuals at risk for perinatal depression are referred for preventative counseling. The goal of this study was to elicit patient and perinatal care professionals' perspectives on how to increase the reach of interventions to prevent perinatal depression and anxiety among economically marginalized individuals. Methods: We conducted qualitative interviews with perinatal individuals with lived experience of perinatal depression and/or anxiety who were experiencing economic marginalization (n = 12) and perinatal care professionals and paraprofessionals (e.g., obstetrician/gynecologists, midwives, doulas; n = 12) serving this population. Three study team members engaged a "a coding consensus, co-occurrence, and comparison," approach to code interviews. Results: Perinatal individuals and professionals identified prevention intervention delivery approaches and content to facilitate equitable reach for individuals who are economically marginalized. Factors influential included availability of mental health counselors, facilitation of prevention interventions by a trusted professional, digital health options, and options for mental health intervention delivery approaches. Content that was perceived as increasing equitable intervention reach included emphasizing stigma reduction, using cultural humility and inclusive materials, and content personalization. Conclusions: Leveraging varied options for mental health intervention delivery approaches and content could reach perinatal individuals experiencing economic marginalization and address resource considerations associated with preventative interventions.
  • Integrating Equity Into Bicycle Infrastructure, Planning, and Programming: A Mixed Methods Exploration of Implementation Among Participants in the Bicycle Friendly Community Program

    Lemon, Stephenie C; Neptune, Amelia; Goulding, Melissa; Pendharkar, Jyothi Ananth; Dugger, Roddrick; Chriqui, Jamie F (2023-10-05)
    Introduction: Integrating equity considerations into bicycle infrastructure, planning, and programming is essential to increase bicycling and reduce physical inactivity-related health disparities. However, little is known about communities' experiences with activities that promote equity considerations in bicycle infrastructure, planning, and programming or about barriers and facilitators to such considerations. The objective of this project was to gain in-depth understanding of the experiences, barriers, and facilitators that communities encounter with integrating equity considerations into bicycle infrastructure, planning, and programming. Methods: We administered a web-based survey in 2022 to assess communities' experiences with 31 equity-focused activities in 3 areas: 1) community engagement, education, events, and programming (community engagement); 2) data collection, evaluation, and goal setting (data); and 3) infrastructure, facilities, and physical amenities (infrastructure). Respondents were people who represented communities in the US that participated in the League of American Bicyclists' Bicycle Friendly Community (BFC) Program. We then conducted 6 focus groups with a subset of survey respondents to explore barriers and facilitators to implementing equity-focused activities. Results: Survey respondents (N = 194) had experience with a mean (SD) of 5.9 (5.7) equity-focused activities. Focus group participants (N = 30) identified themes related to community engagement (outreach to and engagement of underrepresented communities, cultural perceptions of bicycling, and funding and support for community rides and programs); data (locally relevant data); and infrastructure (political will, community design, and infrastructure). They described barriers and facilitators for each. Conclusion: Communities are challenged with integrating equity into bicycle infrastructure, planning, and programming. Multicomponent strategies with support from entities such as the BFC program will be required to make progress.
  • Adolescent cancer prevention in rural, pediatric primary care settings in the United States: A scoping review

    Ryan, Grace W; Whitmire, Paula; Batten, Annabelle; Goulding, Melissa; Baltich Nelson, Becky; Lemon, Stephenie C; Pbert, Lori (2023-09-29)
    Adolescence is a critical period for establishing habits and engaging in health behaviors to prevent future cancers. Rural areas tend to have higher rates of cancer-related morbidity and mortality as well as higher rates of cancer-risk factors among adolescents. Rural primary care clinicians are well-positioned to address these risk factors. Our goal was to identify existing literature on adolescent cancer prevention in rural primary care and to classify key barriers and facilitators to implementing interventions in such settings. We searched the following databases: Ovid MEDLINE®; Ovid APA PsycInfo; Cochrane Library; CINAHL; and Scopus. Studies were included if they reported on provider and/or clinic-level interventions in rural primary care clinics addressing one of these four behaviors (obesity, tobacco, sun exposure, HPV vaccination) among adolescent populations. We identified 3,403 unique studies and 24 met inclusion criteria for this review. 16 addressed obesity, 6 addressed HPV vaccination, 1 addressed skin cancer, and 1 addressed multiple behaviors including obesity and tobacco use. 10 studies were either non-randomized experimental designs (n = 8) or randomized controlled trials (n = 2). The remaining were observational or descriptive research. We found a dearth of studies addressing implementation of adolescent cancer prevention interventions in rural primary care settings. Priorities to address this should include further research and increased funding to support EBI adaptation and implementation in rural clinics to reduce urban-rural cancer inequities.
  • Effects of Teacher Training and Continued Support on the Delivery of an Evidence-Based HIV Prevention Program: Findings From a National Implementation Study in the Bahamas

    Wang, Bo; Deveaux, Lynette; Guo, Yan; Schieber, Elizabeth; Adderley, Richard; Lemon, Stephenie C; Allison, Jeroan J.; Li, Xiaoming; Forbes, Nikkiah; Naar, Sylvie (2023-09-02)
    Background: Few studies have investigated the effects of teacher training and continued support on teachers' delivery of evidence-based HIV prevention programs. We examined these factors in a national implementation study of an evidence-based HIV risk reduction intervention for adolescents in the sixth grade in the Bahamas. Methods: Data were collected from 126 grade 6 teachers and 3,118 students in 58 government elementary schools in the Bahamas in 2019-2021. This is a Hybrid Type III implementation study guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) model. Teachers attended 2-day training workshops. Trained school coordinators and peer mentors provided biweekly monitoring and mentorship. We used mixed-effects models to assess the effects of teacher training and continued support on implementation fidelity. Results: Teachers who received training in-person or both in-person and online taught the most core activities (27.0 and 27.2 of 35), versus only online training (21.9) and no training (14.9) (F = 15.27, p < .001). Teachers with an "excellent" or "very good" school coordinator taught more core activities than those with a "satisfactory" coordinator or no coordinator (29.2 vs. 27.8 vs. 19.3 vs. 14.8, F = 29.20, p < .001). Teachers with a "very good" mentor taught more core activities and sessions than those with a "satisfactory" mentor or no mentor (30.4 vs. 25.0 vs. 23.1; F = 7.20; p < .01). Teacher training, implementation monitoring, peer mentoring, teachers' self-efficacy, and school-level support were associated with implementation fidelity, which in turn was associated with improved student outcomes (HIV/AIDS knowledge, preventive reproductive health skills, self-efficacy, and intention to use protection). Conclusion: Teachers receiving in-person training and those having higher-rated school coordinator and mentor support taught a larger number of HIV prevention core activities. Effective teacher training, implementation monitoring, and peer mentoring are critical for improving implementation fidelity and student outcomes.
  • Toward a more comprehensive understanding of organizational influences on implementation: the organization theory for implementation science framework

    Birken, Sarah A; Wagi, Cheyenne R; Peluso, Alexandra G; Kegler, Michelle C; Baloh, Jure; Adsul, Prajakta; Fernandez, Maria E; Masud, Manal; Huang, Terry T-K; Lee, Matthew; et al. (2023-08-31)
    Introduction: Implementation is influenced by factors beyond individual clinical settings. Nevertheless, implementation research often focuses on factors related to individual providers and practices, potentially due to limitations of available frameworks. Extant frameworks do not adequately capture the myriad organizational influences on implementation. Organization theories capture diverse organizational influences but remain underused in implementation science. To advance their use among implementation scientists, we distilled 70 constructs from nine organization theories identified in our previous work into theoretical domains in the Organization Theory for Implementation Science (OTIS) framework. Methods: The process of distilling organization theory constructs into domains involved concept mapping and iterative consensus-building. First, we recruited organization and implementation scientists to participate in an online concept mapping exercise in which they sorted organization theory constructs into domains representing similar theoretical concepts. Multidimensional scaling and hierarchical cluster analyses were used to produce visual representations (clusters) of the relationships among constructs in concept maps. Second, to interpret concept maps, we engaged members of the Cancer Prevention and Control Research Network (CPCRN) OTIS workgroup in consensus-building discussions. Results: Twenty-four experts participated in concept mapping. Based on resulting construct groupings' coherence, OTIS workgroup members selected the 10-cluster solution (from options of 7-13 clusters) and then reorganized clusters in consensus-building discussions to increase coherence. This process yielded six final OTIS domains: organizational characteristics (e.g., size; age); governance and operations (e.g., organizational and social subsystems); tasks and processes (e.g., technology cycles; excess capacity); knowledge and learning (e.g., tacit knowledge; sense making); characteristics of a population of organizations (e.g., isomorphism; selection pressure); and interorganizational relationships (e.g., dominance; interdependence). Discussion: Organizational influences on implementation are poorly understood, in part due to the limitations of extant frameworks. To improve understanding of organizational influences on implementation, we distilled 70 constructs from nine organization theories into six domains. Applications of the OTIS framework will enhance understanding of organizational influences on implementation, promote theory-driven strategies for organizational change, improve understanding of mechanisms underlying relationships between OTIS constructs and implementation, and allow for framework refinement. Next steps include testing the OTIS framework in implementation research and adapting it for use among policymakers and practitioners.

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