Person:

Goldman, Roberta

Objectives:. Modifiable behaviors during the first 1000 days (conception age 24 months) mediate Hispanic children's obesity disparities. We aimed to examine underlying reasons for early life obesity risk factors and identify potential early life intervention strategies. Methods:. We conducted 7 focus groups with 49 Hispanic women who were pregnant or had children < age 24 months. Domains included influences on childhood obesity risk factors and future intervention ideas. We analyzed data with immersion-crystallization methods until no new themes emerged. Results:. Themes included coping with pregnancy may trump healthy eating and physical activity; early life weight gain is unrelated to later life obesity; fear of infant hunger drives bottle and early solids introduction; beliefs about infant taste promote early solids and sugary beverage introduction; and belief that screen time promotes infant development. Mothers identified physicians, nutritionists, and relatives as important health information sources and expressed interest in mobile technology and group or home visits for interventions. Conclusion:. Opportunities exist in the first 1000 days to improve Hispanic mothers' understanding of the role of early life weight gain in childhood obesity and other obesity risk factors. Interventions that link health care and public health systems and include extended family may prevent obesity among Hispanic children.

Objective

To characterize practices in subspecialist physicians’ communication styles, and their potential effects on shared decision-making, in second-opinion consultations.

Methods

Theme-oriented discourse analysis of 20 second-opinion consultations with subspecialist hematologist-oncologists.

Results

Physicians frequently “broadcasted” information about the disease, treatment options, relevant research, and prognostic information in extended, often-uninterrupted monologues. Their communicative styles had one of two implications: conveying options without offering specific recommendations, or recommending one without incorporating patients’ goals and values into the decision. Some physicians, however, used techniques that encouraged patient participation.

Conclusions

Broadcasting may be a suboptimal method of conveying complex treatment information in order to support shared decision-making. Interventions could teach techniques that encourage patient participation.

Practice Implications

Techniques such as open-ended questions, affirmations of patients’ expressions, and pauses to check for patient understanding can mitigate the effects of broadcasting and could be used to promote shared decision-making in information-dense subspecialist consultations.

Introduction: Primary care providers are needed who provide cost-effective, comprehensive care that is teambased and patient-centered (i.e., Patient-Centered Medical Homes-PCMH). Although PCMH implementation is underway in a variety of settings across the U.S, adopting the PCMH model can be challenging even in motivated and efficient practices. The purpose of this study was to help facilitate Patient-Centered Medical Home and other practice transformation initiatives in the state of Rhode Island. The objectives of the Brown Primary Care Transformation Initiative were to: train medical students, residents, and faculty/community family physicians in practice transformation; convene a series of Think Tanks with PCMH experts to discuss domains and data collection tools that could be used in the development of a comprehensive and feasible evaluation methodology for identifying how transformation within the practice environment occurs; and helping with practice transformation of 8 primary care practices. Method: This paper describes the development and delivery of a curriculum utilizing PCMH principles to train medical students and residents in practice transformation; convening three Think Tanks with PCMH experts to address theoretical and practical problems associated with PCMH; the transformation of 8 primary care teaching practices; the development of a methodology for measuring transformation and evaluation of curriculum change; and dissemination of the findings. Discussion: This study provides insights into how and why a diverse group of family medicine practices transform and how training of primary care residents and providers prepares them to implement and/or teach the principles of PCMH.

To explore colorectal cancer risk perceptions among Latinos. Focus groups discussions among Spanish-speaking Latinos conducted between February and July 2007 with 37 men and women who were age-eligible for colorectal cancer screening. Predominant themes of perceived colorectal cancer risk included: general cancer risks, risks related to nutrition and the digestive tract, and risks related to sexual practices. Participants frequently referred to the role of diet in keeping the colon “clean,” suggesting that retained feces increase colorectal cancer risk. Among both men and women, rectal sex was commonly associated with increased colorectal cancer risk. Some Latinos may hold misperceptions about colorectal cancer risks, including an association between rectal sex and colon cancer, that may impact their screening behaviors. Clinicians and public health officials should consider these potential risk misperceptions and explore for other risk misperceptions when counseling and educating patients about colorectal cancer screening.

This study evaluated if measures of psychological well-being, including coping style are associated with advance care planning (ACP). Data were from the HEMA-COMM study, a prospective observational study of physician-patient communication in patients with hematologic malignancies. ACP was defined as having a living will, having a health care proxy, discussing life support with family or friends, and discussing life support with a doctor or nurse. 293 patients participated: only 45 (15%) had all the elements of ACP, 215 (73%) had at least 1 element of ACP, while 33 (11%) did not engage in ACP. In multivariate analysis, specific coping styles but not other measures of psychosocial well being were associated with having written ACP. Verbal ACP was associated with patient-reported health and physician estimate of life expectancy. Our study suggests that tailoring ACP discussions to a patient’s coping style may increase engagement in ACP.

Understanding factors that promote or prevent adherence to recommended health behaviors is essential for developing effective health programs, particularly among lower-income populations who carry a disproportionate burden of disease. We conducted in-depth qualitative interviews (n=64) with low-income Black and Latina women who shared the experience of requiring diagnostic follow-up after having an abnormal screening mammogram. In addition to holding negative and fatalistic cancer-related beliefs, we found that the social context of these women was largely defined by multiple challenges and major life stressors that interfered with their ability to attain health. Factors commonly mentioned included competing health issues, economic hardship, demanding caretaking responsibilities and relationships, insurance-related challenges, distrust of healthcare providers, and inflexible work policies. Black women also reported discrimination and medical mistrust, while Latinas experienced difficulties associated with immigration and social isolation. These results suggest that effective health interventions not only address change among individuals, but must also change healthcare systems and social policies in order to reduce health disparities.

Purpose

Little is known about communication with patients suffering from hematologic malignancies, many of whom are seen by subspecialists in consultation at tertiary-care centers. These subspecialized consultations might provide the best examples of optimal physician–patient communication behaviors, given that these consultations tend to be lengthy, to occur between individuals who have not met before and may have no intention of an ongoing relationship, and which have a goal of providing treatment recommendations. The aim of this paper is to describe and quantify the content of the subspecialty consultation in regards to exchanging information and identify patient and provider characteristics associated with discussion elements.

Methods

Audio-recorded consultations between 236 patients and 40 hematologists were coded for recommended communication practices. Multilevel models for dichotomous outcomes were created to test associations between patient, physician and consultation characteristics and key discussion elements.

Results

Discussions about the purpose of the visit and patient’s knowledge about their disease were common. Other elements such as patient’s preference for his/her role in decision-making, preferences for information, or understanding of presented information were less common. Treatment recommendations were provided in 97% of the consultations and unambiguous presentations of prognosis occurred in 81% of the consultations. Unambiguous presentations of prognosis were associated with non-White patient race, lower educational status, greater number of questions asked, and specific physician provider.

Conclusion

Although some communication behaviors occur in most consultations, others are much less common and could help tailor the amount and type of information discussed. Approximately half of the patients are told unambiguous prognostic estimates for mortality or cure.

Colorectal cancer screening (CRC) disparities between non-Latino Whites and Latinos remain, and may have increased. The goal of this analysis was to examine the association between Latino race/ethnicity, gender, and English-proficiency and CRC screening. Analysis of the CDC’s BRFSS 2008 survey. We estimated crude and adjusted screening rates and odds ratios of respondents’ reported CRC test receipt stratified by self-reported Latino ethnicity, gender, and limited English proficiency (LEP) as determined by language of survey response (English vs Spanish). Of 99,883 respondents included in the study populations, LEP Latino men had the lowest adjusted screening rates (48.2 %) which were lower that all other Latinos subgroups including Latina women with LEP (56.2 %). Compared to non-Latino White men, LEP Latino men were 0.47 times as likely to report receiving CRC screening tests (AOR 0.47; 95 % CI 0.35–0.63). Disparities in CRC screening are most dramatic for LEP Latino men.

Objective

New approaches for obesity prevention and management can be gleaned from 'positive outliers', i.e., individuals who have succeeded in changing health behaviors and reducing their body mass index (BMI) in the context of adverse built and social environments. We explored perspectives and strategies of parents of positive outlier children living in high risk neighborhoods.

Methods

We collected up to five years of height/weight data from the electronic health records of 22,443 Massachusetts children, ages 6-12 years, seen for well-child care. We identified children with any history of BMI ≥95th percentile (n=4007) and generated a BMI z-score slope for each child using a linear mixed effects model. We recruited parents for focus groups from the sub-sample of children with negative slopes who also lived in zip codes where >15% of children were obese. We analyzed focus group transcripts using an immersion/crystallization approach.

Results

We reached thematic saturation after 5 focus groups with 41 parents. Commonly cited outcomes that mattered most to parents and motivated change were child inactivity, above-average clothing sizes, exercise intolerance, and negative peer interactions; few reported BMI as a motivator. Convergent strategies among positive outlier families were family-level changes, parent modeling, consistency, household rules/limits, and creativity in overcoming resistance. Parents voiced preferences for obesity interventions that include tailored education and support that extend outside clinical settings and are delivered by both health care professionals and successful peers.

Conclusions

Successful strategies learned from positive outlier families can be generalized and tested to accelerate progress in reducing childhood obesity.

Osteoarthritis (OA) is a leading cause of disability in the United States and globally, [14; 39] and the burdens it causes are expected to increase as the world’s population ages [14; 23]. Non-pharmacological treatments are a recommended component of current guidelines for treating OA pain [53]. Although evidence is mixed that people benefit from non-pharmacological treatments such self-management interventions and patient education [e.g., 17; 25; 38; 45], one non-pharmacological therapy—pain coping skills training (PCST)—has demonstrated more consistently positive outcomes [38]. PCST focuses specifically on educating people about cognitive and behavioral pain coping skills and helping them master those skills so they can become more actively involved in managing their pain--the most common and debilitating OA symptom [33]. It includes two main components: 1) a rationale linking pain to patterns of cognitive, emotional, and behavioral pain responses, and 2) training in skills such as attention diversion (e.g., relaxation), cognitive restructuring (to address catastrophizing and other maladaptive cognitive patterns), and activity patterns (e.g., activity-rest cycling). It has traditionally been delivered in-person by a trained therapist over 10-12 weeks. Randomized controlled trials demonstrate that PCST significantly improves pain and other outcomes [e.g., 24; 29; 30; 31; 63]. Moreover, interventions such as PCST have fewer adverse effects than pharmacological pain treatments and are well-received by patients.

Thus, research supports the efficacy of in-person PCST. However, access to this intervention is limited by barriers such as lack of trained therapists, the substantial resources needed to deliver it, and the need for people to travel to in-person training held at scheduled times [22; 59] There is a clear need for an approach that makes PCST more accessible. The Internet—a proven method for delivering behavioral interventions—provides an avenue for meeting this need [15; 42; 58; 65], especially given older adults’ increasing use of the Internet [69].

The present pilot study was a two-arm randomized controlled trial conducted to evaluate the potential efficacy and acceptability of an eight-week, automated, Internet-based version of PCST called PainCOACH. This program was designed to retain key therapeutic features of the in-person PCST protocol, simulating in-person PCST while presenting training in an easy-to-use format with guided instruction, individualized feedback, interactive exercises, and animated demonstrations [57]. We hypothesized that: (1) PainCOACH would reduce pain (primary outcome) and improve pain-related interference with functioning, pain-related anxiety, self-efficacy for pain management, and positive and negative affect; and (2) acceptability would be high. Our overarching goal was to use findings from this early-stage research to refine the program and study protocol in preparation for a larger-scale trial.

Additionally, we explored sex differences in responses to PainCOACH, based on evidence in our own lab and others showing significant sex differences in pain, pain responses, pain behavior, and pain coping in people with OA [e.g., 1; 19; 27; 32; see 54; 62; 67]. The potential for men and women to respond differently to pain interventions is important but rarely evaluated in research.