Applying Publicly Available Contextual Factors to Predict Smoking Relapse in a National Sample

Background: The ecological fallacy is broadly understood, though its complimentary problem, the individualistic or atomistic fallacy, isless often considered. Multilevel models offer the statistical tools needed to avoid both errors by allowing simultaneous considerationof individual, contextual, and policy factors. This study applies such methods to smoking cessation data. Tobacco control is of particularconcern in Ohio where the adult smoking prevalence remains around 22%.Methods: Data from the 1,785 participants in the Technology Enhanced Quitline Study were used to test the theory that contextualfactors impact relapse rates and program effectiveness, employing a mixed-effects model to account for the nested nature of the datawhile testing for the relationship between contextual factors and relapse, controlling for individual characteristics.Results: No contextual factors or policy variables were significant predictors of smoking relapse in the sample, nor were any associated with the success of the intervention.Conclusions: While this work could not identify specific influences of contextual and policy factors on smoking outcomes in our sample, it demonstrates the feasibility of adding such predictors to future clinical trials. This project clearly does not rule out the possibility that contextual and policy factors may influence smoking even after controlling for individual characteristics, but does not provide strong evidence of such a link. It is possible that these negative findings may be due to geocoded mailing addresses being a poor proxy for relevant contextual factors, use of the wrong geographic unit of analysis (modifiable areal unit problem), or a lack of temporal resolution in contextual variables

Hypothesis Generation Using Network Structures on Community Health Center Cancer-Screening Performance

RESEARCH OBJECTIVES: Nationally sponsored cancer-care quality-improvement efforts have been deployed in community health centers to increase breast, cervical, and colorectal cancer-screening rates among vulnerable populations. Despite several immediate and short-term gains, screening rates remain below national benchmark objectives. Overall improvement has been both difficult to sustain over time in some organizational settings and/or challenging to diffuse to other settings as repeatable best practices. Reasons for this include facility-level changes, which typically occur in dynamic organizational environments that are complex, adaptive, and unpredictable. This study seeks to understand the factors that shape community health center facility-level cancer-screening performance over time. This study applies a computational-modeling approach, combining principles of health-services research, health informatics, network theory, and systems science. METHODS: To investigate the roles of knowledge acquisition, retention, and sharing within the setting of the community health center and to examine their effects on the relationship between clinical decision support capabilities and improvement in cancer-screening rate improvement, we employed Construct-TM to create simulated community health centers using previously collected point-in-time survey data. Construct-TM is a multi-agent model of network evolution. Because social, knowledge, and belief networks co-evolve, groups and organizations are treated as complex systems to capture the variability of human and organizational factors. In Construct-TM, individuals and groups interact by communicating, learning, and making decisions in a continuous cycle. Data from the survey was used to differentiate high-performing simulated community health centers from low-performing ones based on computer-based decision support usage and self-reported cancer-screening improvement. RESULTS: This virtual experiment revealed that patterns of overall network symmetry, agent cohesion, and connectedness varied by community health center performance level. Visual assessment of both the agent-to-agent knowledge sharing network and agent-to-resource knowledge use network diagrams demonstrated that community health centers labeled as high performers typically showed higher levels of collaboration and cohesiveness among agent classes, faster knowledge-absorption rates, and fewer agents that were unconnected to key knowledge resources. Conclusions and research implications: Using the point-in-time survey data outlining community health center cancer-screening practices, our computational model successfully distinguished between high and low performers. Results indicated that high-performance environments displayed distinctive network characteristics in patterns of interaction among agents, as well as in the access and utilization of key knowledge resources. Our study demonstrated how non-network-specific data obtained from a point-in-time survey can be employed to forecast community health center performance over time, thereby enhancing the sustainability of long-term strategic-improvement efforts. Our results revealed a strategic profile for community health center cancer-screening improvement via simulation over a projected 10-year period. The use of computational modeling allows additional inferential knowledge to be drawn from existing data when examining organizational performance in increasingly complex environments

Automated Telephone Monitoring for Relapse Risk among Recent Quitters Enrolled in Quitline Services

poster abstractThis study is part of a randomized controlled trial to test the efficacy of interactive voice response (IVR) technology for enhancing existing quitline services (Free & Clear’s Quit for Life® program) to prevent smoking relapse and achieve abstinence. The IVR system screens for six indicators of risk for relapse including smoking lapse, physical withdrawal symptoms, depressive symptoms, perceived stress, decreased self-efficacy for quitting, and decreased motivation to quit. Participants can screen positive on any one or more risks, resulting in a rollover call to a telephone counselor. There are two intervention arms that differ in timing and frequency of IVR screening. In the Technology Enhanced Quitline arm (TEQ-10), 10 automated calls are placed at decreasing frequency for 8 weeks post-quit (twice a week for the first two weeks, then weekly). The High Intensity Technology-Enhanced Quitline arm (TEQ-20) includes 20 IVR calls (daily for the first 2 weeks, then weekly). This preliminary analysis includes IVR data collected on calls from 4/12/2010 to 10/31/2010. 2620 calls were made to 98 participants in the two intervention arms, TEQ-10 (n=44) and TEQ-20 (n=54). The two arms did not differ significantly on demographics or comorbid conditions. Three outcomes were analyzed: completed screening assessments, positive screen for relapse risk, and smoking lapse (i.e., smoking even a puff since the last call). 136 of the 736 (18.5%) completed assessments were positive for relapse risk: 66 for smoking lapse (49%), 42 craving (31%), 32 depressive symptoms (24%), 27 lack of confidence (20%), 8 stress (6%), and 8 lack of motivation (6%). Logistic regression models (adjusted for age and gender), with GEE estimation to account for withinperson correlation, showed that compared to the TEQ-10 study group, participants in the TEQ-20 study group were more likely to complete assessments (OR=1.7; 95% CI=1.2-2.4), less likely to screen positive for relapse risk (OR=.3; 95% CI=.2-.6), and less likely to have smoked (OR=.2; 95% CI=.09-.4). These results indicate that frequent IVR monitoring during the immediate postquit period may have a positive effect on relapse risk

Using computational modeling to assess the impact of clinical decision support on cancer screening improvement strategies within the community health centers

AbstractOur conceptual model demonstrates our goal to investigate the impact of clinical decision support (CDS) utilization on cancer screening improvement strategies in the community health care (CHC) setting. We employed a dual modeling technique using both statistical and computational modeling to evaluate impact. Our statistical model used the Spearman’s Rho test to evaluate the strength of relationship between our proximal outcome measures (CDS utilization) against our distal outcome measure (provider self-reported cancer screening improvement). Our computational model relied on network evolution theory and made use of a tool called Construct-TM to model the use of CDS measured by the rate of organizational learning. We employed the use of previously collected survey data from community health centers Cancer Health Disparities Collaborative (HDCC). Our intent is to demonstrate the added valued gained by using a computational modeling tool in conjunction with a statistical analysis when evaluating the impact a health information technology, in the form of CDS, on health care quality process outcomes such as facility-level screening improvement. Significant simulated disparities in organizational learning over time were observed between community health centers beginning the simulation with high and low clinical decision support capability

Understanding the Personal and Clinical Utility of Psychiatric Advance Directives: A Qualitative Perspective

Psychiatric advance directives (PADs) are legal tools that allow competent individuals to declare preferences for future mental health treatment when they may not be capable of doing so as a result of a psychiatric crisis. PADs allow individuals to maintain self–determination during times when they are most vulnerable to loss of autonomy and in need of assistance to make their preferences known and honored. This article describes the content of twenty–eight open–ended, semi–structured qualitative interviews of adults with PADs who have experienced psychiatric crises. The qualitative analysis revealed three major themes from the interviews: (1) PADs as tools for empowerment and self–determination, (2) limited knowledge of PADs among service providers; and (3) difficulties communicating PADs to inpatient staff. In general, many participants expressed enthusiasm of the implementation of PADs but concern regarding clinicians’ general lack of awareness about them. Additionally, some consumers discussed discomfort in even mentioning that they had a PADto clinicians for fear of a negative response from them, or some type of involuntary treatment during their hospitalization. However, participants consistently viewed PADs as a positive tool to promote autonomy with the potential to facilitate stronger patient–provider relationships. Therefore, when working with individuals in psychiatric crisis who have a PAD, and who have never before experienced a sense of control over their own treatment, clinicians must recognize the potential troubling disequilibrium this sense of control may engender. In sum, though the most significant challenges facing the implementation of PADs involve clinicians’ familiarity with and education about PADs, much promise for the future growth of PADs lies in the benefits perceived by the patients

An integrated computer-based system to support nicotine dependence treatment in primary care

The purpose of this study was to develop, implement, and evaluate the feasibility of an integrated computer-based system for tobacco-user identification and smoking cessation intervention for primary care patients in a medically indigent, managed care population. Interactive voice response (IVR) technology was used to screen for tobacco use prior to scheduled primary care visits at two inner-city clinics. The IVR system placed calls to 2,039 patients scheduled for clinic visits, and 1,086 (53%) patients completed the automated tobacco-use question set. Current smokers were identified in 421 (39%) of the calls. Computer-generated reminders for clinicians that incorporated information obtained from the automated calls were placed on all smokers' encounter forms. In a postvisit interview of 120 smokers, 58 participants (48%) reported that they discussed smoking cessation with their provider. Some 71% of participants agreed that use of the IVR system to obtain information was a ''good way for patients to give information about their health to doctors.'' Automated capture of patient-reported data via IVR technology is a potentially useful strategy for tobacco-use screening in primary care

Cognitive tests used in chronic adult human randomised controlled trial micronutrient and phytochemical intervention studies

In recent years there has been a rapid growth of interest in exploring the relationship between nutritional therapies and the maintenance of cognitive function in adulthood. Emerging evidence reveals an increasingly complex picture with respect to the benefits of various food constituents on learning, memory and psychomotor function in adults. However, to date, there has been little consensus in human studies on the range of cognitive domains to be tested or the particular tests to be employed. To illustrate the potential difficulties that this poses, we conducted a systematic review of existing human adult randomised controlled trial (RCT) studies that have investigated the effects of 24 d to 36 months of supplementation with flavonoids and micronutrients on cognitive performance. There were thirty-nine studies employing a total of 121 different cognitive tasks that met the criteria for inclusion. Results showed that less than half of these studies reported positive effects of treatment, with some important cognitive domains either under-represented or not explored at all. Although there was some evidence of sensitivity to nutritional supplementation in a number of domains (for example, executive function, spatial working memory), interpretation is currently difficult given the prevailing 'scattergun approach' for selecting cognitive tests. Specifically, the practice means that it is often difficult to distinguish between a boundary condition for a particular nutrient and a lack of task sensitivity. We argue that for significant future progress to be made, researchers need to pay much closer attention to existing human RCT and animal data, as well as to more basic issues surrounding task sensitivity, statistical power and type I error

Corporate philanthropy, political influence, and health policy

Background The Framework Convention of Tobacco Control (FCTC) provides a basis for nation states to limit the political effects of tobacco industry philanthropy, yet progress in this area is limited. This paper aims to integrate the findings of previous studies on tobacco industry philanthropy with a new analysis of British American Tobacco's (BAT) record of charitable giving to develop a general model of corporate political philanthropy that can be used to facilitate implementation of the FCTC. Method Analysis of previously confidential industry documents, BAT social and stakeholder dialogue reports, and existing tobacco industry document studies on philanthropy. Results The analysis identified six broad ways in which tobacco companies have used philanthropy politically: developing constituencies to build support for policy positions and generate third party advocacy; weakening opposing political constituencies; facilitating access and building relationships with policymakers; creating direct leverage with policymakers by providing financial subsidies to specific projects; enhancing the donor's status as a source of credible information; and shaping the tobacco control agenda by shifting thinking on the importance of regulating the market environment for tobacco and the relative risks of smoking for population health. Contemporary BAT social and stakeholder reports contain numerous examples of charitable donations that are likely to be designed to shape the tobacco control agenda, secure access and build constituencies. Conclusions and Recommendations Tobacco companies' political use of charitable donations underlines the need for tobacco industry philanthropy to be restricted via full implementation of Articles 5.3 and 13 of the FCTC. The model of tobacco industry philanthropy developed in this study can be used by public health advocates to press for implementation of the FCTC and provides a basis for analysing the political effects of charitable giving in other industry sectors which have an impact on public health such as alcohol and food

Ambivalence toward men: comparing sexism among Polish, South African and British university students

This study extends the literature on attitudes toward gender roles by exploring whether the nature of sexism (i.e., benevolence and hostility directed at men) differs among university students from two under-researched countries, Poland (n = 190) and South Africa (n = 188), in a comparison with students in the United Kingdom (n = 166). Based on empirical literature applying Ambivalent Sexism Theory, and in the light of the socio-political context, it was hypothesized that: (1) both hostile and benevolent attitudes toward men in Poland would be more liberal than in South Africa and more conservative than in the United Kingdom, and (2), women would exhibit more hostile but less benevolent attitudes than men in relatively more conservative South Africa. The Ambivalence to Men Inventory was used to measure the two types of sexist attitudes about men. Findings supported the first hypothesis for hostile attitudes and partially for benevolent attitudes. South African and Polish students were more benevolent and hostile to men than British students, and students from South Africa were more hostile than those from Poland. Moreover, as predicted, a significant country-by-gender interaction revealed that South African women had more hostile and less benevolent attitudes to men than South African men. No such gender gap was present in the case of hostile attitudes in Poland and benevolent attitudes in the United Kingdom. Findings are discussed in terms of Ambivalent Sexism Theory and the countries’ socio-cultural context

How does the tobacco industry attempt to influence marketing regulations? A systematic review

BACKGROUND: The Framework Convention on Tobacco Control makes a number of recommendations aimed at restricting the marketing of tobacco products. Tobacco industry political activity has been identified as an obstacle to Parties' development and implementation of these provisions. This study systematically reviews the existing literature on tobacco industry efforts to influence marketing regulations and develops taxonomies of 1) industry strategies and tactics and 2) industry frames and arguments. METHODS: Searches were conducted between April-July 2011, and updated in March 2013. Articles were included if they made reference to tobacco industry efforts to influence marketing regulations; supported claims with verifiable evidence; were written in English; and concerned the period 1990-2013. 48 articles met the review criteria. Narrative synthesis was used to combine the evidence. RESULTS: 56% of articles focused on activity in North America, Europe or Australasia, the rest focusing on Asia (17%), South America, Africa or transnational activity. Six main political strategies and four main frames were identified. The tobacco industry frequently claims that the proposed policy will have negative unintended consequences, that there are legal barriers to regulation, and that the regulation is unnecessary because, for example, industry does not market to youth or adheres to a voluntary code. The industry primarily conveys these arguments through direct and indirect lobbying, the promotion of voluntary codes and alternative policies, and the formation of alliances with other industrial sectors. The majority of tactics and arguments were used in multiple jurisdictions. CONCLUSIONS: Tobacco industry political activity is far more diverse than suggested by existing taxonomies of corporate political activity. Tactics and arguments are repeated across jurisdictions, suggesting that the taxonomies of industry tactics and arguments developed in this paper are generalisable to multiple jurisdictions and can be used to predict industry activity