Faculty Bibliography

INTRODUCTION: The goal of this project was to use the Consolidated Framework for Implementation Research (CFIR) as the theoretical foundation for developing a web-based clinical decision support system (CDSS) for primary care screening and care coordination by dental hygienists at chairside. METHODS: First, we appraised New York State education and scope of practice requirements for dental hygienists with input from health experts who constituted a Senior Advisory Board for the project, and reviewed current professional guidelines and best practices for tobacco use, hypertension and diabetes screening, and nutrition counseling at chairside. Second, we created algorithms for these four health issues (tobacco, hypertension, diabetes, and nutrition) using evidence-based guidelines endorsed by authoritative professional bodies. Third, an information technology specialist incorporated the algorithms into a tool using an iterative process to refine the CDSS, with input from dental hygienists, dentists, Senior Advisory Board members and research staff. RESULTS: An evidence-based CDSS for use by dental hygienists at chairside for tobacco use, hypertension and diabetes screening, and nutrition counseling was developed with the active participation of the individuals involved in the implementation process. CONCLUSIONS: CDSS technology may potentially be leveraged to enhance primary care screening and coordination by dental hygienists at chairside, leading to improved patient care. Using the CFIR as a pragmatic structure for implementing this intervention across multiple settings, the developed CDSS is available for downloading and adaptation to diverse dental settings and other primary care sensitive conditions.

BACKGROUND: Vietnam has a smoking prevalence that is the second highest among Southeast Asian countries (SEACs). According to the World Health Organization (WHO), most reductions in mortality from tobacco use in the near future will be achieved through helping current users quit. Yet, largely due to a lack of research on strategies for implementing WHO-endorsed treatment guidelines in primary care settings, services to treat tobacco dependence are not readily available to smokers in low middle-income countries (LMICs) like Vietnam. The objective of this study is to conduct a cluster randomized controlled trial that compares the effectiveness of two system-level strategies for implementing evidence-based guidelines for the treatment of tobacco use in 26 public community health centers (CHCs) in Vietnam. METHODS/DESIGN: The current study will use a cluster-randomized design and multiple data sources (patient exit interviews, provider and village health worker (VHW) surveys, and semi-structured provider/VHW interviews) to study the process of adapting and implementing clinical practice guidelines in Vietnam and theory-driven mechanisms hypothesized to explain the comparative effectiveness of the two strategies for implementation. CHCs will be randomly assigned to either of the following: (1) training plus clinical reminder system (TC) or (2) TC + referral to a VHW (TCR) for three in person counseling sessions. The primary outcome is provider adherence to tobacco use treatment guidelines. The secondary outcome is 6-month biochemically verified smoking abstinence. DISCUSSION: The proposed implementation strategies draw on evidence-based approaches and a growing literature that supports the effectiveness of integrating community health workers as members of the health care team to improve access to preventive services. We hypothesize that the value of these implementation strategies is additive and that incorporating a referral resource that allows providers to delegate the task of offering counseling (TCR) will be superior to TC alone in improving delivery of cessation assistance to smokers. The findings of this research have potential to guide large-scale adoption of promising strategies for implementing and disseminating tobacco use treatment guidelines throughout the public health system in Vietnam and will serve as a model for similar action in other LMICs. TRIAL REGISTRATION: NCT01967654.

Korean men and women have the highest current smoking rates across all Asian ethnic subgroups in the United States. This is a 2-arm randomized controlled study of a culturally adapted smoking cessation intervention. The experimental condition received eight weekly 40-min individualized counseling sessions that incorporated Korean-specific cultural elements, whereas the control condition received eight weekly 10-min individualized counseling sessions that were not culturally adapted. All participants also received nicotine patches for 8 weeks. One-hundred nine Korean immigrants (91 men and 18 women) participated in the study. The rate of biochemically verified 12-month prolonged abstinence was significantly higher for the experimental condition than the control condition (38.2 vs. 11.1 %, chi (2) = 10.7, p < 0.01). Perceived family norm significantly mediated the effect of cessation intervention on abstinence. Smoking cessation intervention for Korean Americans should be culturally adapted and involve family members to produce a long-term treatment effect.

INTRODUCTION: Low rates of adherence to smoking cessation pharmacotherapy may limit the effectiveness of treatment. However, few studies have examined adherence in smoking cessation trials thus, there is a limited understanding of factors that influence adherence behaviors. This brief report analyzes correlates of adherence to varenicline among people living with HIV/AIDS. METHODS: Study participants were recruited from three HIV care centers in New York City and enrolled in a three-arm randomized controlled pilot study in which all subjects received varenicline. At the 1-month study visit, there were no significant differences in adherence by study condition, therefore we combined treatment arms to examine correlates of adherence (n = 127). We used pill counts to assess varenicline adherence, defined as taking at least 80% of the prescribed dose. We conducted a multivariate path analysis to assess factors proposed by the information-motivation-behavioral skills model to predict adherence. RESULTS: Only 56% of smokers were at least 80% adherent to varenicline at 1 month. Adherence-related information, self-efficacy, a college degree, and non-Hispanic white race/ethnicity were associated with increased varenicline adherence. In path analysis, information and motivation were associated with increased adherence self-efficacy, and adherence self-efficacy was associated with increased adherence, but with marginal significance. These associations with adherence were no longer significant after controlling for race/ethnicity and education. CONCLUSIONS: Further exploration of the role of a modifiable correlates of adherence, such as adherence-related information, motivation and self-efficacy is warranted. Interventions are needed that can address disparities in these and other psychosocial factors that may mediate poor medication adherence.

INTRODUCTION: The purpose of this study was to explore the relationship between social norms and attitudes towards ENDS and hookah and use of these products. METHODS: We conducted surveys with hookah and ENDS users who regularly used the Internet and social media and analyzed the primary social media account (e.g. Facebook) of each participant, coding all references to nicotine or tobacco products. The survey included domains on perceived favorability, perceived vulnerability and subjective norms. RESULTS: We surveyed 21 ENDS users and 20 hookah users. Both groups used the Internet to look up information about their respective tobacco product (95% for hookah vs. 90% for ENDS). Seventy percent of hookah users had references to hookah on their social media profiles while 43% of ENDS users had references to ENDS on their page. The majority of both groups were exposed to content posted by friends in their social media network about their respective products online. Those who posted on social media about hookah and those who read about ENDS online had lower perceived vulnerability to the health risks associated with tobacco products. CONCLUSIONS: Hookah and ENDS users actively use the Internet and social media to obtain and share information about nicotine/tobacco products. Study participants who use hookah were more likely to share photos and discuss hookah related activities via social media than those who use ENDS. Social networks also represent valuable and untapped potential resources for communicating with this group about risks and harm reduction related to emerging nicotine/tobacco products.

Few published studies describe processes in the development of mobile health interventions. This study reports data from a formative evaluation of a text messaging intervention being developed to increase adherence to smoking cessation medication (varenicline) among tobacco-dependent persons with HIV/AIDS. Four focus groups were conducted (N = 29) using a mixed-methods approach to assess: (a) beliefs and preferences regarding the use of varenicline, (b) preferences for receiving tobacco-related texts, and (c) the acceptability of draft text messages. Themes that emerged from the focus groups were that (a) participants were cautious and wanted to discuss varenicline carefully with health care providers, (b) participants preferred simple messages that were positive and encouraging, (c) messages should emphasize tobacco cessation and not varenicline adherence, and (d) texts would serve as a reminder about goals and foster support and connectedness with the health care team. Overall, 47 out of the 100 messages received a grade of C or less (rated on a 5-point grade scale: A, B, C, D, or F), the majority of which focused on medication adherence. All participants reported that they were likely to read the messages. The majority (64%) indicated that they preferred receiving 2 or more messages per day. Gathering systematic participant feedback provides critical input in intervention planning.