Faculty Bibliography

PURPOSE Effective strategies are needed to increase the implementation and sustainability of evidence-based tobacco dependence treatment (TDT) in public health systems in low- and middle-income countries. Our cluster randomized controlled trial (VQuit) found that a multicomponent implementation strategy was effective in increasing provider adherence to TDT guidelines in community health centers (CHCs) in Vietnam. In this paper, we present findings from a postimplementation qualitative assessment of factors that influence implementation effectiveness and program sustainability. METHODS We conducted semistructured qualitative interviews (N = 52) with 13 CHC medical directors (ie, physicians), 25 CHC health care providers, and 14 village health workers (VHWs) in 13 study sites. Interviews were transcribed and translated into English. RESULTS Facilitators of implementation effectiveness included training that increased confidence and skill, satisfaction with point-of-service tools, increasing patient demand for TDT, and, for the intervention arm, the value of a VHW referral system that reduced provider burden. The primary challenge to sustainability is the competing priorities driven by the Vietnam Ministry of Health, which may result in fewer resources for TDT compared with other health programs. However, providers and VHWs described several options for adapting the implementation strategies to address challenges and increase the engagement of local government committees and other sectors to sustain gains. CONCLUSION Our findings offer insight into how a multicomponent implementation strategy influenced changes in the delivery of evidence-based TDT. In addition, these results illustrate the dynamic interplay between barriers to and facilitators of sustaining TDT at the policy and community/practice level, particularly in the context of centralized public health systems, like that of Vietnam. Sustaining gains in practice improvement and clinical outcomes will require strategies that include ongoing engagement with policymakers and other stakeholders at the national and local level, as well as planning for adaptations and subsequent resource allocations, to meet Article 14 goals

Importance/UNASSIGNED:Secondhand smoke (SHS) exposure is associated with many health conditions in children and adults. Millions of individuals in the US are currently exposed to SHS in their homes. Objective/UNASSIGNED:To investigate whether a federal ban on smoking in public housing settings was associated with a decrease in indoor SHS levels in New York City public housing developments 12 months after the policy's implementation. Design, Setting, and Participants/UNASSIGNED:This cohort study tracked indoor air quality longitudinally from April 2018 to September 2019 and used difference-in-differences analysis to examine SHS exposure before vs after implementation of the 2018 federal smoke-free housing (SFH) policy in 10 New York City Housing Authority (NYCHA) buildings vs 11 matched low-income buildings not subject to the SFH policy (ie, Section 8 buildings). Exposures/UNASSIGNED:Federal SFH policy implementation, beginning July 30, 2018. Main Outcomes and Measures/UNASSIGNED:Comparison of nicotine concentration levels from passive, bisulfate-coated filters before vs 12 months after implementation of the federal SFH policy. Secondary outcomes included changes in particulate matter less than 2.5 μm in diameter, measured with low-cost particle monitors, and counts of cigarette butts in common areas. Results/UNASSIGNED:Air quality was measured repeatedly in a total of 153 NYCHA and 110 Section 8 nonsmoking households as well as in 91 stairwells and hallways. Before the SFH policy implementation, air nicotine was detectable in 19 of 20 stairwells (95.0%) in NYCHA buildings and 15 of 19 stairwells (78.9%) in Section 8 buildings (P = .19) and in 17 of 19 hallways (89.5%) in NYCHA buildings and 14 of 23 hallways (60.9%) in Section 8 buildings (P = .004). Nicotine was detected less frequently inside nonsmoking apartments overall (26 of 263 [9.9%]) but more frequently in NYCHA apartments (20 of 153 [13.1%]) than in Section 8 apartments (6 of 110 [5.5%]) (P = .04). One year after policy implementation, there was no differential change over time in nicotine concentrations measured in stairwells (DID, 0.03 μg/m3; 95% CI, -0.99 to 1.06 μg/m3) or inside nonsmoking households (DID, -0.04 μg/m3; 95% CI, -0.24 to 0.15 μg/m3). Larger decreases in nicotine concentration were found in NYCHA hallways than in Section 8 hallways (DID, -0.43 μg/m3; 95% CI, -1.26 to 0.40 μg/m3). Conclusions and Relevance/UNASSIGNED:The findings suggest that there was no differential change in SHS in NYCHA buildings 12 months after SFH policy implementation. Additional support may be needed to ensure adherence to SFH policies.

INTRODUCTION/BACKGROUND:Smoking rates remain disproportionately high among Chinese immigrants in the US, particularly in males. Community-based smoking cessation services and quitlines have low engagement rates. Social media and text messaging programs can be effective in promoting quit rates and improving treatment engagement. This study examined Chinese immigrant smokers' barriers to accessing available smoking cessation services and patterns of using social media platforms and mobile phone text messaging. METHODS:We conducted in-depth interviews (n=30) and a brief survey (n=49) with adult Chinese immigrant smokers leaving in New York City in 2018. Qualitative interviews explored smokers' challenges with smoking cessation, barriers to accessing and using smoking cessation services, and experience using social media and text messaging. The quantitative survey assessed smoking and quitting behaviors, and social media and text messaging use patterns. RESULTS:Qualitative data revealed that participants faced various barriers to accessing cessation services, including the lack of awareness about services, skepticism about treatment effects, reliance on willpower for cessation, and time constraints. WeChat was mainly used to maintain social networking and acquire information. Participants rarely used text messaging or other social media platforms. Quantitative data showed that 55% of participants had no plan to quit smoking. Among those who reported past-year quit attempts (45%), 55% used cessation assistance. WeChat was the most frequently used platform with 94% users. CONCLUSIONS:WeChat has potential to serve as an easily accessible platform for delivering smoking cessation treatment among Chinese immigrant populations. Research is warranted to explore the feasibility and efficacy of employing WeChat in smoking cessation treatment.

Few studies have assessed the fidelity of practice facilitation (PF) as an implementation strategy, and none have used an a priori definition or conceptual framework of fidelity to guide fidelity assessment. The authors adapted the Conceptual Framework for Implementation Fidelity to guide fidelity assessment in HealthyHearts NYC, an intervention that used PF to improve adoption of cardiovascular disease evidence-based guidelines in primary care practices. Data from a web-based tracking system of 257 practices measured fidelity using 4 categories: frequency, duration, content, and coverage. Almost all (94.2%) practices received at least the required 13 PF visits. Facilitators spent on average 26.3 hours at each site. Most practices (95.7%) completed all Task List items, and 71.2% were educated on all Chronic Care Model strategies. The majority (65.8%) received full coverage. This study provides a model that practice managers and implementers can use to evaluate fidelity of PF, and potentially other implementation strategies.

BACKGROUND:Effective strategies are needed to increase implementation and sustainability of evidence-based tobacco dependence treatment (TDT) in public health systems in low- and middle-income countries (LMICs). Our two-arm cluster randomized controlled trial (VQuit) found that a multicomponent implementation strategy was effective in increasing provider adherence to TDT guidelines in commune health center (CHCs) in Vietnam. In this paper, we present findings from a post-implementation qualitative assessment of factors influencing effective implementation and program sustainability. METHODS:We conducted semi-structured qualitative interviews (n = 52) with 13 CHC medical directors (i.e., physicians), 25 CHC health care providers (e.g., nurses), and 14 village health workers (VHWs) in 13 study sites. Interviews were transcribed and translated into English. Two qualitative researchers used both deductive (guided by the Consolidated Framework for Implementation Research) and inductive approaches to analysis. RESULTS:Facilitators of effective implementing of TDT included training and point-of-service tools (e.g., desktop chart with prompts for offering brief counseling) that increased knowledge and self-efficacy, patient demand for TDT, and a referral system, available in arm 2, which reduced the provider burden by shifting more intensive cessation counseling to a trained VHW. The primary challenges to sustainability were competing priorities that are driven by the Ministry of Health and may result in fewer resources for TDT compared with other health programs. However, providers and VHWs suggested several options for adapting the intervention and implementation strategies to address challenges and increasing engagement of local government committees and other sectors to sustain gains. CONCLUSION/CONCLUSIONS:Our findings offer insights into how a multicomponent implementation strategy influenced changes in the delivery of evidence-based TDT. In addition, the results illustrate the dynamic interplay between barriers and facilitators for sustaining TDT at the policy and community/practice level, particularly in the context of centralized public health systems like Vietnam's. Sustaining gains in practice improvement and clinical outcomes will require strategies that include ongoing engagement with policymakers and other stakeholders at the national and local level, and planning for adaptations and subsequent resource allocations in order to meet the World Health Organization's goals promoting access to effective treatment for all tobacco users. TRIAL REGISTRATION/BACKGROUND:NCT02564653 , registered September 2015.

HealthyHearts New York City (HHNYC), one of 7 cooperatives funded through the Agency for Healthcare Research and Quality's EvidenceNOW initiative, evaluated the impact of practice facilitation on implementation of the Million Hearts guidelines for cardiovascular disease prevention and treatment. Tracking the intervention required a system to facilitate process data collection that was also user-friendly and flexible. Coupled with protocols and training, a strategically planned and customizable customer relationship management system (CRMS) was implemented to support the quality improvement intervention with 257 small independent practices. Features of the CRMS and implementation protocols were customized to optimize program management, practice facilitation tracking and supervision, and data collection for performance feedback to practices and research. The CRMS was a valuable tool for tracking and managing the intervention systematically. Successful implementation of the HHNYC protocol also required an articulated implementation plan and adoption process.

BACKGROUND:Most hookah use studies have not included racial and ethnic minorities which limits our understanding of its use among these growing populations. This study aimed to investigate the individual characteristics of hookah use patterns and associated risk behaviors among an ethnically diverse sample of college students. METHODS:A cross-sectional survey of 2460 students (aged 18-25) was conducted in 2015, and data was analyzed in 2017. Descriptive statistics were used to present the sociodemographic characteristics, hookah use-related behavior, and binge drinking and marijuana use according to the current hookah use group, including never, exclusive, dual/poly hookah use. Multivariate logistic regression was conducted to examine how hookah related behavior and other risk behaviors varied by sociodemographics and hookah use patterns. RESULTS:Among current hookah users (n = 312), 70% were exclusive hookah users and 30% were dual/poly hookah users. There were no statistically significant differences in sociodemographic characteristics except for race/ethnicity (p < 0.05). Almost half (44%) of the exclusive hookah users reported having at least five friends who also used hookah, compared to 30% in the dual/poly use group. Exclusive users were less likely to report past year binge drinking (17%) and past year marijuana use (25%) compared to those in the dual/poly use group (44 and 48% respectively); p < 0.001. CONCLUSIONS:The socialization aspects of hookah smoking seem to be associated with its use patterns. Our study calls for multicomponent interventions designed to target poly tobacco use as well as other substance use that appears to be relatively common among hookah users.

OBJECTIVE:Understanding barriers and facilitators to engaging with implementation science (IS) research can provide insight into how to improve efforts to encourage more researchers to participate in IS research. STUDY DESIGN/METHODS:The study design used is a grounded theory qualitative study. METHODS:We conducted semistructured telephone interviews with 20 health researchers familiar with IS that both report engaging in IS research and those that do not. We explored perceptions of barriers and facilitators to engaging in IS research. Themes surrounding difficulties defining IS, lack of training availability, and obstacles to forming research partnerships were discussed as barriers to engaging IS research. Interview topics were informed by the result of an online survey of health researchers in the US. RESULTS:Themes surrounding difficulties defining IS, lack of training availability, and obstacles to forming research partnerships were discussed as barriers to engaging IS research. While accessible mentorship, exposure to formative experiences that develop interest in IS research and an increasing IS visibility were described as motivators for engaging in IS research. CONCLUSIONS:These results highlight the importance of mentorship and exposure to IS ideas in motivating engagement in IS research and the presence of training and methodological barriers to engagement. Future research should expand this line of inquiry to include the perspectives of more junior researchers and students to better reflect the current IS environment.

STUDY OBJECTIVE/OBJECTIVE:Housing instability is prevalent among emergency department (ED) patients and is known to adversely affect health. We aim to determine the incidence and timing of homeless shelter entry after an ED visit among patients who are not currently homeless. METHODS:We conducted a random-sample survey of ED patients at an urban public hospital from November 2016 to September 2017. Patients provided identifying information and gave informed consent for us to link their survey data with the New York City Department of Homeless Services shelter database. Shelter use was followed prospectively for 12 months after the baseline ED visit. We examined timing of shelter entry in the 12 months after the ED visit, excluding patients who were homeless at baseline. RESULTS:Of 1,929 unique study participants who were not currently homeless, 96 (5.0%) entered a shelter within 12 months of their baseline ED visit. Much of the shelter entry occurred in the first month after the ED visit, with continued yet slower rates of entry in subsequent months. Patients in our sample who entered a shelter were predominantly men and non-Hispanic black, and commonly had past shelter and frequent ED use. CONCLUSION/CONCLUSIONS:In this single-center study, 5.0% of urban ED patients who were not currently homeless entered a homeless shelter within the year after their ED visit. Particularly if replicated elsewhere, this finding suggests that ED patients may benefit from efforts to identify housing instability and direct them to homelessness prevention programs.