The power of prevention and what it requires

Primary Prevention of Canine Atopic Dermatitis: Breaking the Cycle-A Narrative Review

Canine atopic dermatitis (cAD) is a common and distressing skin condition in dogs, affecting up to 30% of the canine population. It not only impacts their quality of life but also that of their owners. Like human atopic dermatitis (hAD), cAD has a complex pathogenesis, including genetic and environmental factors. Current treatments focus on managing clinical signs, but they can be costly and have limitations. This article emphasizes the importance of preventing cAD from developing in the first place. Understanding the role of the skin's protective barrier is crucial, as its dysfunction plays a vital role in both hAD and cAD. hAD prevention studies have shown promising results in enhancing the skin barrier, but more research is needed to support more robust conclusions. While hAD primary prevention is currently a focal point of intensive investigation in human medicine, research on cAD primary prevention remains under-researched and almost non-existent. Pioneering effective prevention strategies for cAD holds immense potential to enhance the quality of life for both dogs and their owners. Additionally, it bears the promise of a translational impact on human research. Hence, further exploration of this crucial topic is not only relevant but also timely and imperative, warranting support and encouragement.

Imaging in experimental models of diabetes

Translational medicine, experimental medicine and experimental animal models, in particular mice and rats, represent a multidisciplinary field that has made it possible to achieve, in the last decades, important scientific progress. In this review, we have summarized the most frequently used imaging animal models, such as ultrasound (US), micro-CT, MRI and the optical imaging methods, and their main implications in diagnostic and therapeutic fields, with a particular focus on diabetes mellitus, a multifactorial disease extremely widespread among the general population.

Preventing Leading Causes of Death: Systematic Review of Cost-Utility Literature

INTRODUCTION

Heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke are the 5 leading causes of death in the U.S. The objective of this review is to examine the economic value of prevention interventions addressing these 5 conditions.

METHODS

Tufts Medical Center Cost-Effectiveness Analysis Registry data were queried from 2010 to 2018 for interventions that addressed any of the 5 conditions in the U.S. Results were stratified by condition, prevention stage, type of intervention, study sponsorship, and study perspective. The analyses were conducted in 2020, and all costs were reported in 2019 dollars.

RESULTS

In total, 549 cost-effectiveness analysis studies examined interventions addressing these 5 conditions in the U.S. Tertiary prevention interventions were assessed in 61.4%, whereas primary prevention was assessed in 8.6% of the studies. Primary prevention studies were predominantly funded by government, whereas industry sources funded more tertiary prevention studies, especially those dealing with pharmaceutical interventions. The median incremental cost-effectiveness ratio for the 5 conditions combined was $68,500 per quality-adjusted life year. Median incremental cost-effectiveness ratios were lowest for primary prevention and highest for tertiary prevention.

DISCUSSION

Primary prevention may be more cost effective than secondary and tertiary prevention interventions; however, research investments in primary prevention interventions, especially by industry, lag in comparison. These findings help to highlight the gaps in the cost-effectiveness analysis literature related to the 5 leading causes of death and identify understudied interventions and prevention stages for each condition.

Health Recommender Systems: Systematic Review

Background

Health recommender systems (HRSs) offer the potential to motivate and engage users to change their behavior by sharing better choices and actionable knowledge based on observed user behavior.

Objective

We aim to review HRSs targeting nonmedical professionals (laypersons) to better understand the current state of the art and identify both the main trends and the gaps with respect to current implementations.

Methods

We conducted a systematic literature review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and synthesized the results. A total of 73 published studies that reported both an implementation and evaluation of an HRS targeted to laypersons were included and analyzed in this review.

Results

Recommended items were classified into four major categories: lifestyle, nutrition, general health care information, and specific health conditions. The majority of HRSs use hybrid recommendation algorithms. Evaluations of HRSs vary greatly; half of the studies only evaluated the algorithm with various metrics, whereas others performed full-scale randomized controlled trials or conducted in-the-wild studies to evaluate the impact of HRSs, thereby showing that the field is slowly maturing. On the basis of our review, we derived five reporting guidelines that can serve as a reference frame for future HRS studies. HRS studies should clarify who the target user is and to whom the recommendations apply, what is recommended and how the recommendations are presented to the user, where the data set can be found, what algorithms were used to calculate the recommendations, and what evaluation protocol was used.

Conclusions

There is significant opportunity for an HRS to inform and guide health actions. Through this review, we promote the discussion of ways to augment HRS research by recommending a reference frame with five design guidelines.

Design and Feasibility Study of the Mobile Application StopTheSpread

The emergence of recent disease outbreaks calls for the design of new educational games aimed at increasing awareness in disease prevention. This article presents StopTheSpread, an educational mobile application that seeks to improve awareness about the best practices to prevent the spreading of seasonal flu in the general public. StopTheSpread integrates concepts in network science and epidemiology, within a freely available mobile application that provides a unique learning experience for free-choice learners about flu prevention. StopTheSpread teaches users basic concepts about flu prevention, within a series of games of increasing difficulty that maintain user engagement and offers a user-friendly design. StopTheSpread provides a summary of the best practices to prevent flu spreading according to the guidelines of the Centers for Disease Control and Prevention, and the World Health Organization, while connecting users to citizen science projects aimed at worldwide flu tracking. Through Facebook, Twitter, and email we reached volunteers during the COVID-19 confinement, to conduct an online feasibility study, toward assessing learning outcome in playing with our mobile application. Our results indicate that the use of StopTheSpread increased by 20% the awareness about the spreading mechanism of flu, compared with the baseline population.

Community Gun Violence as a Social Determinant of Elementary School Achievement

The association of indirect exposure to firearm-related violence and standardized test scores among third grade elementary school children were analyzed using geospatial mapping of police department data for all gunshots in Syracuse, NY (n = 2, 127) and state standardized test scores from 2009-2015. Confirmed gunshots were geocoded and mapped across the city and neighborhood school catchment areas. Third grade standardized New York State test scores for English Language Arts (ELA) and math were coded as dichotomous variables of proficient and below proficient scores. State standardized test scores for ELA and math were found to be 50% lower in the elementary schools located within higher concentration gunshot areas, than in elementary schools in lower gunshot areas. Higher levels of gun violence within school catchment areas were significantly associated with higher rates of ELA and math failure (p ≤ .05). These findings suggest that community violence may be an important, though under recognized, social determinant of poor school performance.

Immunization Against Hepatitis A Virus and Hepatitis B Virus in Patients with Chronic Liver Disease: Are We Doing a Good Job?

Introduction: In the era of highly effective vaccines for Hepatitis A Virus (HAV) and Hepatitis B Virus (HBV), acute viral hepatitis in patients with a chronic liver disease remains a public health concern. Vaccination for HAV and HBV is endorsed by all liver society guidelines. The aim of our study was to determine the rates of immunization in an internal medicine resident clinic.

Methods: We identified patients with a chronic liver disease seen at the University of Oklahoma Internal Medicine resident clinic between June 2014 and May 2015. ICD-9 code 571 was used to identify patients with a chronic liver disease. Vaccination records and patient data were reviewed.

Results: A total of 141 patients with a chronic liver disease (mean age 54.1 years, 56% males) were identified. Almost half of the patients (47.5%) were also being seen in the gastroenterology clinic. During the internal medicine resident clinic visit, vaccination against HAV and HBV was addressed for 50% and 46% of the patients, respectively. Patients being seen by senior residents were more likely to be immunized against HAV (OR 2.7, p=0.009) and HBV (OR 2.1, p=0.03). Patients followed in the GI clinic were more likely to be immunized against HAV (OR 2.1, p= 0.02) and HBV (OR 2.0, p=0.02). The gender of the treating physician and etiology had no impact on vaccination rates.

Discussion: Immunization rates for HAV and HBV remain subpar despite clear guidelines for patients with a chronic liver disease. This provides an important avenue for improvement. Different strategies, including resident education, developing vaccination protocols, and referral to the gastroenterology clinic, are likely to improve vaccination status for patients with chronic liver diseases.

Sport Injuries Sustained by Athletes with Disability: A Systematic Review

Background

Fifteen percent of the world’s population live with disability, and many of these individuals choose to play sport. There are barriers to sport participation for athletes with disability and sports injury can greatly impact on daily life, which makes sports injury prevention additionally important.

Objective

The purpose of this review is to systematically review the definitions, methodologies and injury rates in disability sport, which should assist future identification of risk factors and development of injury prevention strategies. A secondary aim is to highlight the most pressing issues for improvement of the quality of injury epidemiology research for disability sport.

Methods

A search of NICE, AMED, British Nursing Index, CINAHL, EMBASE and Medline was conducted to identify all publications up to 16 June 2015. Of 489 potentially relevant articles and reference searching, a total of 15 studies were included. Wide study sample heterogeneity prevented data pooling and meta-analysis.

Results

Results demonstrated an evolving field of epidemiology, but with wide differences in sports injury definition and with studies focused on short competitions. Background data were generally sparse; there was minimal exposure analysis, and no analysis of injury severity, all of which made comparison of injury risk and injury severity difficult.

Conclusion

There is an urgent need for consensus on sports injury definition and methodology in disability sports. The quality of studies is variable, with inconsistent sports injury definitions, methodologies and injury rates, which prevents comparison, conclusions and development of injury prevention strategies. The authors highlight the most pressing issues for improvement of the quality in injury epidemiology research for disability sport.

An Ounce of Prevention: Deaths Averted From Primary Prevention Interventions

INTRODUCTION

The U.S. lags in the nationwide implementation of primary prevention interventions that have been shown to be efficacious. However, the potential population health benefit of widespread implementation of these primary prevention interventions remains unclear.

METHODS

The meta-analytic literature from October 2013 to March 2014 of primary prevention interventions published between January 2000 and March 2014 was reviewed. The authors then estimated the number of deaths that could have been averted in the U.S. in 2010 if all rigorously studied, efficacious primary prevention interventions for which population attributable risk proportions could be estimated were implemented nationwide.

RESULTS

A total of 372,054 (15.1%) of all U.S. deaths in 2010 would have been averted if all rigorously studied, efficacious primary prevention interventions were implemented. Two in three averted deaths would have been from cardiovascular disease or malignancy.

CONCLUSIONS

A substantial proportion of deaths in the U.S. in 2010 could have been averted if efficacious primary prevention interventions were implemented nationwide. Further investment in the implementation of efficacious interventions is warranted to maximize population health in the U.S.

Gamification for health and wellbeing: A systematic review of the literature

BACKGROUND

Compared to traditional persuasive technology and health games, gamification is posited to offer several advantages for motivating behaviour change for health and well-being, and increasingly used. Yet little is known about its effectiveness.

AIMS

We aimed to assess the amount and quality of empirical support for the advantages and effectiveness of gamification applied to health and well-being.

METHODS

We identified seven potential advantages of gamification from existing research and conducted a systematic literature review of empirical studies on gamification for health and well-being, assessing quality of evidence, effect type, and application domain.

RESULTS

We identified 19 papers that report empirical evidence on the effect of gamification on health and well-being. 59% reported positive, 41% mixed effects, with mostly moderate or lower quality of evidence provided. Results were clear for health-related behaviours, but mixed for cognitive outcomes.

CONCLUSIONS

The current state of evidence supports that gamification can have a positive impact in health and wellbeing, particularly for health behaviours. However several studies report mixed or neutral effect. Findings need to be interpreted with caution due to the relatively small number of studies and methodological limitations of many studies (e.g., a lack of comparison of gamified interventions to non-gamified versions of the intervention).

Vaccinating Adult Patients with Cirrhosis: Trends over a Decade in the United States

Introduction. The progression of chronic liver disease to cirrhosis involves both innate and adaptive immune system dysfunction resulting in increased risk of infectious complications. Vaccinations against pneumococcus, hepatitis A virus (HAV), and hepatitis B virus (HBV) are well tolerated and effective in disease prevention and reduction in morbidity and mortality. Prior studies assessing vaccination rates in patients with cirrhosis have specific limitations and to date no study has provided a comprehensive evaluation of vaccination rates in patients with cirrhosis in the United States. Aim. This study assessed vaccination rates for pneumococcus, HAV, and HBV in patients with cirrhosis. Results. Overall 59.7% of patients with cirrhosis received at least 1 vaccination during the study period. Vaccination rates within the same or following year of cirrhosis diagnosis were 19.9%, 7.7%, and 11.0% against pneumococcus, HAV, and HBV, respectively. Trend analysis revealed significant increases in vaccination rates for pneumococcus in all patients with cirrhosis and within subgroups based on age, gender, and presence of concomitant diabetes. Conclusion. The study demonstrated that vaccination rates in patients with cirrhosis remain suboptimal. Ultimately, the use of electronic medical record (EMR) reminders improved communication between healthcare professionals and public health programs to increase awareness are fundamental to reducing morbidity, mortality, and health-care related costs of vaccine preventable diseases in patients with cirrhosis.

Information diffusion, Facebook clusters, and the simplicial model of social aggregation: a computational simulation of simplicial diffusers for community health interventions

By integrating the simplicial model of social aggregation with existing research on opinion leadership and diffusion networks, this article introduces the constructs of simplicial diffusers (mathematically defined as nodes embedded in simplexes; a simplex is a socially bonded cluster) and simplicial diffusing sets (mathematically defined as minimal covers of a simplicial complex; a simplicial complex is a social aggregation in which socially bonded clusters are embedded) to propose a strategic approach for information diffusion of cancer screenings as a health intervention on Facebook for community cancer prevention and control. This approach is novel in its incorporation of interpersonally bonded clusters, culturally distinct subgroups, and different united social entities that coexist within a larger community into a computational simulation to select sets of simplicial diffusers with the highest degree of information diffusion for health intervention dissemination. The unique contributions of the article also include seven propositions and five algorithmic steps for computationally modeling the simplicial model with Facebook data.

Evaluating Feasible and Referable Behavioral Counseling Interventions

The U.S. Preventive Services Task Force (USPTF) recognizes that behaviors have a major impact on health and well-being. Currently, the USPSTF has 11 behavioral counseling intervention (BCI) recommendations. These BCIs can be delivered in a primary care setting or patients can be referred to other clinical or community programs. Unfortunately, many recommended BCIs are infrequently and ineffectually delivered, suggesting that more evidence is needed to understand which BCIs are feasible and referable. In response, the USPSTF convened an expert forum in 2013 to inform the evaluation of BCI feasibility. This manuscript reports on findings from the forum and proposes that researchers use several frameworks to help clinicians and the USPSTF evaluate which BCIs work under usual conditions. A key recommendation for BCI researchers is to use frameworks whose components can support dissemination and implementation efforts. These frameworks include the Template for Intervention Description and Replication (TIDieR), which helps describe the essential components of an intervention, and pragmatic frameworks like Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) or Pragmatic-Explanatory Continuum Indicator Summary (PRECIS), which help to report study design elements and outcomes. These frameworks can both guide the design of more-feasible BCIs and produce clearer feasibility evidence. Critical evidence gaps include a better understanding of which patients will benefit from a BCI, how flexible interventions can be without compromising effectiveness, required clinician expertise, necessary intervention intensity and follow-up, impact of patient and clinician intervention adherence, optimal conditions for BCI delivery, and how new care models will influence BCI feasibility.

Effects of a multidomain lifestyle modification on cognitive function in older adults: an eighteen-month community-based cluster randomized controlled trial

BACKGROUND

A healthy lifestyle may protect against cognitive decline. We examined outcomes in elderly individuals after 18 months of a five-group intervention program consisting of various modalities to prevent cognitive decline.

METHODS

We conducted a cluster randomized controlled trial assessing 460 community-dwelling individuals aged 60 years and older in a geriatric community mental health center in Suwon, Republic of Korea, between 2008 and 2010. We developed an intervention program based on the principles of contingency management, which could be delivered by ordinary primary health workers. Group A (n = 81) received standard care services. Group B (n = 80) received bimonthly (once every 2 months) telephonic care management. Group C (n = 111) received monthly telephonic care management and educational materials similar to those in group B. Group D (n = 93) received bimonthly health worker-initiated visits and counseling. Group E (n = 94) received bimonthly health worker-initiated visits, counseling, and rewards for adherence to the program.

RESULTS

The primary outcome was the change in Mini-Mental State Examination (MMSE) scores from baseline to the final follow-up visit at 18 months. Group E showed superior cognitive function to group A (adjusted coefficient β = 0.99, p = 0.044), with participation in cognitive activities being the most important determining factor among several health behaviors (adjusted coefficient β = 1.04, p < 0.01).

CONCLUSIONS

Engaging in cognitive activities, in combination with positive health behaviors, may be most beneficial in preserving cognitive abilities in community-dwelling older adults.

Old myths, new myths: challenging myths in public health

Myths are widely held beliefs and are frequently perpetuated through telling and retelling. We examined 10 myths in public health research and practice. Where possible, we traced their origins, interrogated their current framing in relation to the evidence, and offered possible alternative ways of thinking about them. These myths focus on the nature of public health and public health interventions, and the nature of evidence in public health. Although myths may have some value, they should not be privileged in an evidence-informed public health context.

"I Just Keep My Antennae Out": How Rural Primary Care Physicians Respond to Intimate Partner Violence

Women in rural communities who are exposed to intimate partner violence (IPV) have fewer resources when seeking help due to limited health services, poverty, and social isolation. Rural primary care physicians may be key sources of care for IPV victims. The objective of this study was to assess the opinions and practices of primary care physicians caring for rural women with regard to IPV identification, the scope and severity of IPV as a health problem, how primary care providers respond to IPV in their practices, and barriers to optimized IPV care in their communities. Semistructured interviews were conducted with 19 internists, family practitioners, and obstetrician-gynecologists in rural central Pennsylvania. Interview transcripts were analyzed for major themes. Most physicians did not practice routine screening for IPV due to competing time demands, lack of training, limited access to referral services as well as low confidence in their effectiveness, and concern that inquiry would harm the patient-doctor relationship. IPV was considered when patients presented with symptoms of mood, anxiety, or somatic disorders. Responses to IPV included validation, danger assessment, safety planning, referral, and follow-up planning. Perceived barriers to rural women seeking help for IPV included traditional gender roles, lower education, economic dependence on the partner, low self-esteem, and patient reluctance to discuss IPV. To overcome barriers, physicians created a "safe sanctuary" to discuss IPV and suggested improved public health education and referral services. Interventions to improve IPV-related care in rural communities should address barriers at multiple levels, including both physicians' and patients' comfort with discussing IPV. Provider training, community education, and improved access to referral services are key areas in which IPV-related care should be improved in rural communities. Our data support routine screening to better identify IPV and a more pro-active stance toward screening and counseling.

Effects of the Communities That Care system on cross-sectional profiles of adolescent substance use and delinquency

INTRODUCTION

Adolescent substance use and delinquency are major public health problems. Although community-based prevention strategies have been recommended to produce population-level reductions in rates of substance use and delinquency, few models show evidence of effectiveness.

PURPOSE

To test the efficacy of a community-based prevention system, Communities That Care (CTC), in reducing community rates of problem behaviors, particularly effects on specific profiles of adolescent substance use and delinquency in eighth- and tenth-graders.

METHODS

Twenty-four communities were randomized to CTC intervention or control groups. Data were collected from 14,099 8th- and 10th-grade students in these communities using anonymous cross-sectional surveys in 2004 and 2010 and analyzed in 2012. Outcomes were four different profiles of self-reported substance use and delinquency in 8th grade and five profiles in 10th grade.

RESULTS

In the cross-sectional 2010 data, there was no intervention effect on the probability of experimenting with substances or of substance use coupled with delinquent activities for either grade. However, tenth-graders in intervention communities were significantly less likely to be alcohol users than those in control communities (OR=0.69, CI=0.48, 1.00).

CONCLUSIONS

Cross-sectional population surveys showed evidence of CTC effects in reducing tenth-grade alcohol users but not experimenters. A community-wide reduction in adolescent alcohol use is important because alcohol is the most commonly used illicit substance during adolescence, and early initiation of alcohol use has been associated with alcohol-related disorders in adulthood. Failure to find hypothesized effects on experimenters qualifies these results.

What clinicians wish to know about benign colorectal polyps: an operative classification

INTRODUCTION

In recent years we assisted to a real "boom" of colorectal polyps, mainly due to the diffusion of screening procedures and of colonoscopy. This new "Polyp Epidemic" raises a series of problems and challenges. It became clear that many syndromes are defined by the number, histological type and location of polyps, together with extraintestinal manifestations and, in most cases, specific molecular changes. This paper discusses some of the above mentioned points, focusing on the relative role of endoscopists and pathologists. The objective is to reach an operative classification of the most common polyps observed in daily practice which might be of help for the identification of inherited syndromes.

METHODS AND RESULTS

Six main histological types of polyps are defined and underlined: Adenoma, hyperplastic/serrated, hamartoma, ganglioneuroma, mixed, inflammatory. The importance of a brief description, in pathology reports, of each type of polyps is fundamental for a correct diagnosis. Each of the defined polyps is associated with inherited syndromes whose genetic basis has recently been elucidated. Relevant information should be given, and separated from additional (and not strictly necessary) information.

RECOMMENDATIONS

A correct polyp analysis is a valuable element for identifying specific inherited syndromes. Polyps represent a precious tool for planning screening and follow-up in a given individual. In addition, these lesions focus the interest of clinicians toward syndrome which were considered as rare diseases; indeed, the explosion of molecular biology and the diffusion of colonoscopy revealed that these conditions are frequent and amenable of treatment.

Physicians infrequently adhere to hepatitis vaccination guidelines for chronic liver disease

Background and Goals

Hepatitis A (HAV) and hepatitis B (HBV) vaccination in patients with chronic liver disease is an accepted standard of care. We determined HAV and HBV vaccination rates in a tertiary care referral hepatology clinic and the impact of electronic health record (EHR)-based reminders on adherence to vaccination guidelines.

Methods

We reviewed the records of 705 patients with chronic liver disease referred to our liver clinic in 2008 with at least two follow-up visits during the subsequent year. Demographics, referral source, etiology, and hepatitis serology were recorded. We determined whether eligible patients were offered vaccination and whether patients received vaccination. Barriers to vaccination were determined by a follow-up telephone interview.

Results

HAV and HBV serologic testing prior to referral and at the liver clinic were performed in 14.5% and 17.7%; and 76.7% and 74% patients, respectively. Hepatologists recommended vaccination for HAV in 63% and for HBV in 59.7% of eligible patients. Patient demographics or disease etiology did not influence recommendation rates. Significant variability was observed in vaccination recommendation amongst individual providers (30–98.6%), which did not correlate with the number of patients seen by each physician. Vaccination recommendation rates were not different for Medicare patients with hepatitis C infection for whom a vaccination reminder was automatically generated by the EHR. Most patients who failed to get vaccination after recommendation offered no specific reason for noncompliance; insurance was a barrier in a minority.

Conclusions

Hepatitis vaccination rates were suboptimal even in an academic, sub-speciality setting, with wide-variability in provider adherence to vaccination guidelines.

Greater use of preventive services in U.S. health care could save lives at little or no cost

There is broad debate over whether preventive health services save money or represent a good investment. This paper analyzes the estimated cost of adopting a package of twenty proven preventive services--including tobacco cessation screening, alcohol abuse screening, and daily aspirin use--against the estimated savings that could be generated. We find that greater use of proven clinical preventive services in the United States could avert the loss of more than two million life-years annually. What's more, increasing the use of these services from current levels to 90 percent in 2006 would result in total savings of $3.7 billion, or 0.2 percent of U.S. personal health care spending. These findings suggest that policy makers should pursue options that move the nation toward greater use of proven preventive services.

A Cross-national Comparison of Risk and Protective Factors for Adolescent Drug Use and Delinquency in the United States and the Netherlands

The present study compared associations between risk and protective factors and adolescent drug use and delinquency in the Netherlands and the United States. Data were collected from students between the ages of 12 and 17 using the same school-administered survey instrument in both countries. Levels of exposure to risk and protective factors were generally similar in both countries. The same risk and protective factors shown to be associated with U.S. adolescents' drug use and delinquency were related significantly to Dutch youth's drug use and delinquency. One important exception was that Dutch students perceived their parents' attitudes to be more favorable toward alcohol use; these attitudes also were more predictive of adolescents' regular drinking in the Netherlands compared to the United States. The findings indicate that the risk and protective factors measured in this study can be important targets for prevention of health-compromising behaviors among young people in the Netherlands and the United States.

Self-determination theory: its application to health behavior and complementarity with motivational interviewing

Mounting evidence implicates health behaviors (e.g., nutrition, physical activity, tobacco abstinence) in various health outcomes. As the science of behavior change has emerged, increasing emphasis has been placed on the use of theory in developing and testing interventions. Self-determination theory (SDT)-a theoretical perspective-and motivational interviewing (MI)-a set of clinical techniques-have both been used in health behavior intervention contexts. Although developed for somewhat different purposes and in relatively different domains, there is a good deal of conceptual overlap between SDT and MI. Accordingly, SDT may offer the theoretical backing that historically has been missing from MI, and MI may offer SDT some specific direction with respect to particular clinical techniques that have not been fully borne out within the confines of health related applications of SDT. Research is needed to empirically test the overlap and distinctions between SDT and MI and to determine the extent to which these two perspectives can be combined or co-exist as somewhat distinct approaches.

Sustained decreases in risk exposure and youth problem behaviors after installation of the Communities That Care prevention system in a randomized trial

OBJECTIVE

To test whether the Communities That Care (CTC) prevention system reduced levels of risk and adolescent problem behaviors community-wide 6 years after installation of CTC and 1 year after study-provided resources ended.

DESIGN

A community randomized trial.

SETTING

Twenty-four small towns in 7 states, matched within state, randomly assigned to control or intervention condition in 2003.

PARTICIPANTS

A panel of 4407 fifth-grade students was surveyed annually through 10th grade from 2004 to 2009.

INTERVENTION

A coalition of community stakeholders received training and technical assistance to install CTC, used epidemiologic data to identify elevated risk factors and depressed protective factors in the community, and implemented programs to address their community's elevated risks from a menu of tested and effective programs for youths aged 10 to 14 years, their families, and schools.

OUTCOME MEASURES

Levels of risk and incidence and prevalence of tobacco, alcohol, and other drug use; delinquency; and violent behavior by grade 10.

RESULTS

Mean levels of targeted risks increased less rapidly between grades 5 and 10 in CTC than in control communities and were significantly lower in CTC than control communities in grade 10. The incidence of delinquent behavior, alcohol use, and cigarette use and the prevalence of current cigarette use and past-year delinquent and violent behavior were significantly lower in CTC than in control communities in grade 10.

CONCLUSIONS

Using the CTC system can produce enduring reductions in community-wide levels of risk factors and problem behaviors among adolescents beyond the years of supported implementation, potentially contributing to long-term public health benefits.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01088542.

Gender research in the National Institute on Drug Abuse National Treatment Clinical Trials Network: a summary of findings

BACKGROUND

The National Institute of Drug Abuse's National Drug Abuse Treatment Clinical Trials Network (CTN) was established to foster translation of research into practice in substance abuse treatment settings. The CTN provides a unique opportunity to examine in multi-site, translational clinical trials, the outcomes of treatment interventions targeting vulnerable subgroups of women; the comparative effectiveness of gender-specific protocols to reduce risk behaviors; and gender differences in clinical outcomes.

OBJECTIVES

To review gender-related findings from published CTN clinical trials and related studies from January 2000 to March 2010.

METHODS

CTN studies were selected for review if they focused on treatment outcomes or services for special populations of women with substance use disorders (SUDs) including those with trauma histories, pregnancy, co-occurring eating and other psychiatric disorders, and HIV risk behaviors; or implemented gender-specific protocols. The CTN has randomized 11,500 participants (41% women) across 200 clinics in 24 randomized controlled trials in community settings, of which 4 have been gender-specific.

RESULTS

This article summarizes gender-related findings from CTN clinical trials and related studies, focusing on trauma histories, pregnancy, co-occurring eating and other psychiatric disorders, and HIV risk behaviors.

CONCLUSIONS

These published studies have expanded the evidence base regarding interventions for vulnerable groups of women with SUDs as well as gender-specific interventions to reduce HIV risk behaviors in substance-using men and women. The results also underscore the complexity of accounting for gender in the design of clinical trials and analysis of results.

SCIENTIFIC SIGNIFICANCE

To fully understand the relevance of gender-specific moderators and mediators of outcome, it is essential that future translational studies adopt more sophisticated approaches to understanding and measuring gender-relevant factors and plan sample sizes that are adequate to support more nuanced analytic methods.

Designing a patient-centered personal health record to promote preventive care

BACKGROUND

Evidence-based preventive services offer profound health benefits, yet Americans receive only half of indicated care. A variety of government and specialty society policy initiatives are promoting the adoption of information technologies to engage patients in their care, such as personal health records, but current systems may not utilize the technology's full potential.

METHODS

Using a previously described model to make information technology more patient-centered, we developed an interactive preventive health record (IPHR) designed to more deeply engage patients in preventive care and health promotion. We recruited 14 primary care practices to promote the IPHR to all adult patients and sought practice and patient input in designing the IPHR to ensure its usability, salience, and generalizability. The input involved patient usability tests, practice workflow observations, learning collaboratives, and patient feedback. Use of the IPHR was measured using practice appointment and IPHR databases.

RESULTS

The IPHR that emerged from this process generates tailored patient recommendations based on guidelines from the U.S. Preventive Services Task Force and other organizations. It extracts clinical data from the practices' electronic medical record and obtains health risk assessment information from patients. Clinical content is translated and explained in lay language. Recommendations review the benefits and uncertainties of services and possible actions for patients and clinicians. Embedded in recommendations are self management tools, risk calculators, decision aids, and community resources--selected to match patient's clinical circumstances. Within six months, practices had encouraged 14.4% of patients to use the IPHR (ranging from 1.5% to 28.3% across the 14 practices). Practices successfully incorporated the IPHR into workflow, using it to prepare patients for visits, augment health behavior counseling, explain test results, automatically issue patient reminders for overdue services, prompt clinicians about needed services, and formulate personalized prevention plans.

CONCLUSIONS

The IPHR demonstrates that a patient-centered personal health record that interfaces with the electronic medical record can give patients a high level of individualized guidance and be successfully adopted by busy primary care practices. Further study and refinement are necessary to make information systems even more patient-centered and to demonstrate their impact on care.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT00589173.

Beyond the medical model: interdisciplinary programs of community-engaged health research

This report describes four diverse programs of community-engaged research, all of which demonstrated positive health outcomes. Three of the programs were focused on communities of people with diabetes, and one program targeted at-risk young families raising infants and young children. Brief descriptions of each research study and outcomes are presented as well as a discussion of the processes and lessons that were learned from each model of successful interdisciplinary community-university health research partnerships.

Regulatory approval of cancer risk-reducing (chemopreventive) drugs: moving what we have learned into the clinic

This article endeavors to clarify the current requirements and status of regulatory approval for chemoprevention (risk reduction) drugs and discusses possible improvements to the regulatory pathway for chemoprevention. Covering a wide range of topics in as much depth as space allows, this report is written in a style to facilitate the understanding of nonscientists and to serve as a framework for informing the directions of experts engaged more deeply with this issue. Key topics we cover here are as follows: a history of definitive cancer chemoprevention trials and their influence on the evolution of regulatory assessments; a brief review of the long-standing success of pharmacologic risk reduction of cardiovascular diseases and its relevance to approval for cancer risk reduction drugs; the use and limitations of biomarkers for developing and the approval of cancer risk reduction drugs; the identification of individuals at a high(er) risk for cancer and who are appropriate candidates for risk reduction drugs; business models that should incentivize pharmaceutical industry investment in cancer risk reduction; a summary of scientific and institutional barriers to development of cancer risk reduction drugs; and a summary of major recommendations that should help facilitate the pathway to regulatory approval for pharmacologic cancer risk reduction drugs.

Monitoring healthy people 2010 arthritis management objectives: education and clinician counseling for weight loss and exercise

PURPOSE

Our goal was to monitor the progress of 3 Healthy People 2010 (HP2010) objectives encouraging self-management education and clinician counseling for weight loss and physical activity among adults with doctor-diagnosed arthritis.

METHODS

Using the national 2002 and 2006 National Health Interview Survey (NHIS) and state-based 2003 and 2007 Behavioral Risk Factor Surveillance System (BRFSS), we estimated the change in proportion of persons counseled for each objective, overall and by selected characteristics.

RESULTS

Nationally, the proportion of overweight and obese adults with doctor-diagnosed arthritis who were counseled by their clinician to lose weight to lessen their arthritis symptoms increased significantly from 35.0% (95% confidence interval [CI], 32.8%-37.2%) in 2002 to 41.3% (95% CI, 38.7%-44.0%) in 2006 but have yet to reach the 2010 target of 46%. There was no change in the proportion of adults with doctor-diagnosed arthritis who had ever taken a self-management education class (approximately 11%) or who had been counseled to engage in physical activity (approximately 52%), whose targets for 2010 are 13% and 67%, respectively. States had variable findings.

CONCLUSIONS

Nationally, significant progress has been made by clinicians for weight counseling of overweight and obese adults with doctor-diagnosed arthritis but not for the other 2 arthritis management objectives. Because clinician counseling can have important effects on the latter, this discrepancy suggests a need to focus on barriers to physician counseling for these outcomes.

Office of National Drug Control Policy: a scientist in drug policy in Washington, DC

This essay describes how a basic scientist was thrust into the epicenter, the political cauldron of our national drug control policy, and how the experience altered her professional trajectory and perspective.

Results of a type 2 translational research trial to prevent adolescent drug use and delinquency: a test of Communities That Care

OBJECTIVE

To test whether the Communities That Care (CTC) prevention system reduces adolescent alcohol, tobacco, and other drug use and delinquent behavior communitywide.

DESIGN

The Community Youth Development Study is the first randomized trial of CTC.

SETTING

In 2003, 24 small towns in 7 states, matched within state, were randomly assigned to control or CTC conditions.

PARTICIPANTS

A panel of 4407 fifth-grade students was surveyed annually through eighth grade. Intervention A coalition of community stakeholders received training and technical assistance to install the CTC prevention system. They used epidemiological data to identify elevated risk factors and depressed protective factors in the community, and chose and implemented tested programs to address their community's specific profile from a menu of effective programs for families, schools, and youths aged 10 to 14 years.

MAIN OUTCOME MEASURES

Incidence and prevalence of alcohol, tobacco, and other drug use and delinquent behavior by spring of grade 8.

RESULTS

The incidences of alcohol, cigarette and smokeless tobacco initiation, and delinquent behavior were significantly lower in CTC than in control communities for students in grades 5 through 8. In grade 8, the prevalences of alcohol and smokeless tobacco use in the last 30 days, binge drinking in the last 2 weeks, and the number of different delinquent behaviors committed in the last year were significantly lower for students in CTC communities.

CONCLUSION

Using the CTC system to reduce health-risking behaviors in adolescents can significantly reduce these behaviors communitywide.

Physical activity advice to manage chronic conditions for adults with arthritis or hypertension, 2007

OBJECTIVE

To describe the prevalence and characteristics of persons with arthritis or hypertension who received advice from their health-care professional to manage their condition.

METHODS

Data from 9 states were obtained from the 2007 Behavioral Risk Factor Surveillance System. Two modules (Arthritis Management and Actions to Control High Blood Pressure) were analyzed (sample sizes: arthritis 29,698, hypertension 29,783).

RESULTS

Fifty-five percent of persons with arthritis and 75.8% of persons with hypertension reported that their health-care professional ever suggested physical activity or exercise to help manage their condition. Correlates for being less likely to receive advice were lower levels of education, longer time since last routine doctor visit, being physically inactive, and having lower body mass index. Among inactive, normal weight persons, 43.0% (95% CI: 38.7, 47.4) with arthritis and 50.0% (95% CI: 44.4, 55.6) with hypertension reported receiving advice; among inactive, obese patients, 59.1% (95% CI: 55.8, 62.3) with arthritis and 74.0% (95% CI: 70.5, 77.3) with hypertension reported receiving advice.

CONCLUSIONS

Findings suggest that health-care professionals may base physical activity counseling more on body mass index than a patient's activity level. To manage chronic health conditions, health-care professionals should assess patient's physical activity and offer all patients appropriate counseling.

Health economics in public health

BACKGROUND

Economic analysis is an important tool in deciding how to allocate scarce public health resources; however, there is currently a dearth of such analysis by public health researchers.

METHODS

Public health researchers and practitioners were surveyed to determine their current use of health economics and to identify barriers to use as well as potential strategies to decrease those barriers in order to allow them to more effectively incorporate economic analyses into their work. Data collected from five focus groups informed survey development. The survey included a demographic section and 14 multi-part questions. Participants were recruited in 2006 from three national public health organizations through e-mail; 294 academicians, practitioners, and community representatives answered the survey.

RESULTS

Survey data were analyzed in 2007. Despite an expressed belief in the importance of health economics, more than half of the respondents reported very little or no current use of health economics in their work. Of those using health economics, cost-benefit and cost-effectiveness analysis and determination of public health costs were cited as the measures used most frequently. The most important barriers were lack of expertise, funding, time, tools, and data, as well as discomfort with economic theory. The resource deemed most important to using health economics was collaboration with economists or those with economic training. Respondents indicated a desire to learn more about health economics and tools for performing economic analysis.

CONCLUSIONS

Given the importance of incorporating economic analysis into public health interventions, and the desire of survey respondents for more collaboration with health economists, opportunities for such collaborations should be increased.

Self-Monitoring of Blood Glucose (SMBG) in insulin- and non-insulin-using adults with diabetes: consensus recommendations for improving SMBG accuracy, utilization, and research

Current clinical guidelines for diabetes care encourage self-monitoring of blood glucose (SMBG) to improve glycemic control. Specific protocols remain variable, however, particularly among non-insulin-using patients. This is due in part to efficacy studies that neglect to consider (1) the performance of monitoring equipment under real-world conditions, (2) whether or how patients have been taught to take action on test results, and (3) the physiological, behavioral, and social circumstances in which SMBG is carried out. As such, a multidisciplinary group of specialists, including several endocrinologists, a health psychologist, a diabetes nurse practitioner, and a patient advocate (the Panel), discuss within this review article how the potential of SMBG might be fully realized in today's healthcare environment. The resulting recommendations cover technological, clinical, behavioral, and research considerations with the aim of achieving short- and long-term benefits, ranging from fewer hypoglycemic episodes to lower complication-related costs. The panel also made suggestions for designing future studies that increase the ability to discern optimal models of SMBG utilization for individuals with diabetes who may, or may not, use insulin.