Faculty Bibliography

BACKGROUND: Obesity disproportionately affects Latina women, but few targeted, technology-assisted interventions that incorporate tailored health information exist for this population. The Veterans Health Administration (VHA) uses an online weight management tool (MOVE!23) which is publicly available, but was not designed for use in non-VHA populations. METHODS: We conducted a qualitative study to determine how interactions between the tool and other contextual elements impacted task performance when the target Latina users interacted with MOVE!23. We sought to identify and classify specific facilitators and barriers that might inform design changes to the tool and its context of use, and in turn promote usability. Six English-speaking, adult Latinas were recruited from an inner city primary care clinic and a nursing program at a local university in the United States to engage in a "Think-Aloud" protocol while using MOVE!23. Sessions were recorded, transcribed, and coded to identify interactions between four factors that contribute to usability (Tool, Task, User, Context). RESULTS: Five themes influencing usability were identified: Technical Ability and Technology Preferences; Language Confusion and Ambiguity; Supportive Tool Design and Facilitator Guidance; Relevant Examples; and Personal Experience. Features of the tool, task, and other contextual factors failed to fully support participants at times, impeding task completion. Participants interacted with the tool more readily when its language was familiar and content was personally relevant. When faced with ambiguity and uncertainty, they relied on the tool's visual cues and examples, actively sought relevant personal experiences, and/or requested facilitator support. CONCLUSIONS: The ability of our participants to successfully use the tool was influenced by the interaction of individual characteristics with those of the tool and other contextual factors. We identified both tool-specific and context-related changes that could overcome barriers to the use of MOVE!23 among Latinas. Several general considerations for the design of eHealth tools are noted.

OBJECTIVE: This study sought to identify rates and predictors of obesity counseling performed by outpatient psychiatrists in the United States. METHODS: The 2005-2010 National Ambulatory Medical Care Surveys provided data from 7,309 outpatient psychiatry visits. Logistic regression was used to examine associations between patient, visit, and practice characteristics and outcomes. RESULTS: Most (81%) visits occurred in a private practice setting. Nine percent (N=657) of visits included measurement of patient body mass index (BMI); 30% of these visits were with patients who met the obesity criterion (BMI >/=30.0 kg/m2). Among visits with obese patients, 16% included exercise counseling, 22% included weight reduction counseling, and 24% included diet or nutrition counseling. Patients with obesity were more likely than patients without obesity to receive diet or nutrition counseling (p<.05) and weight reduction counseling (p<.05), but not exercise counseling. Black patients were significantly less likely to receive any form of counseling (p<.05). CONCLUSIONS: There is a significant need to improve psychiatrists' obesity counseling.

Early childhood is a critical stage for the foundation and development of both the microbiome and host. Early-life antibiotic exposures, cesarean section, and formula feeding could disrupt microbiome establishment and adversely affect health later in life. We profiled microbial development during the first 2 years of life in a cohort of 43 U.S. infants and identified multiple disturbances associated with antibiotic exposures, cesarean section, and formula feeding. These exposures contributed to altered establishment of maternal bacteria, delayed microbiome development, and altered alpha-diversity. These findings illustrate the complexity of early-life microbiome development and its sensitivity to perturbation.

BACKGROUND: Obesity is highly prevalent among Veterans. In the United States, the Veterans Health Administration (VHA) offers a comprehensive weight management program called MOVE!. Yet, fewer than 10 % of eligible patients ever attend one MOVE! visit. The VHA has a patient-centered medical home (PCMH) model of primary care (PC) called Patient-Aligned Care Teams (PACT) at all Veterans Affairs (VA) Medical Centers. PACT teamlets conduct obesity screening, weight management counseling, and refer to MOVE!. As part of a needs assessment to improve delivery of weight management services, the purpose of this study was to assess PACT teamlet and MOVE! staff: 1) current attitudes and perceptions regarding obesity care; 2) obesity-related counseling practices 3) experiences with the MOVE! program; and 4) targets for interventions to improve implementation of obesity care in the PC setting. METHODS: We recruited 25 PACT teamlet members from a single VA study site-11 PC physicians, 5 registered nurses, 5 licensed practical nurses, 1 clerical assistant, and 3 MOVE! staff (2 dietitians, 1 psychologist)-for individual interviews using a combination of convenience and snowball sampling. Audio recorded interviews were professionally transcribed and iteratively coded by two independent reviewers. The analytic process was guided by discourse analysis in order to discover how the participants perceived and provided weight management care and what specific attitudes affected their practices, all as bounded within the organization. RESULTS: Emerging themes included: 1) role perceptions, 2) anticipated outcomes of weight management counseling and programs, and 3) communication and information dissemination. Perceived role among PCPs was influenced by training, whereas personal experience with their own weight management impacted role perception among LPNs/RNs. Attitudes about whether or not they could impact patients' weight outcomes via counseling or referral to MOVE! varied. System-level communication about VHA priorities through electronic health records and time allocation influenced teams to prioritize referral to MOVE! over weight management counseling. CONCLUSION: We found a diversity of attitudes, and practices within PACT, and identified factors that can enhance the MOVE! program and inform interventions to improve weight management within primary care. Although findings are site-specific, many are supported in the literature and applicable to other VA and non-VA sites with PCMH models of care.

We have previously proposed that by identifying a set of Educationally Sensitive Patient Outcomes (ESPOs), medical education outcomes research becomes more feasible and likely to provide meaningful guidance for medical education policy and practice. ESPOs are proximal outcomes that are sensitive to provider education, measurable, and linked to more distal health outcomes. Our previous model included Patient Activation and Clinical Microsystem Activation as ESPOs. In this paper, we discuss how Health Literacy, defined as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions," is another important ESPO. Between one-third and one-half of all US adults have limited health literacy skills. Providers can be trained to adopt a "universal precautions approach" to addressing patient health literacy, through the acquisition of specific skills (e.g., teachback, "chunking" information, use of plain language written materials) and by learning how to take action to improve the "health literacy environment." While there are several ways to measure health literacy, identifying which measurement tools are most sensitive to provider education is important, but challenging and complex. Further research is needed to test this model and identify additional ESPOs.