Faculty Bibliography

PurposeTo evaluate the association between demographic characteristics and weight-loss in response to financial incentives designed using behavioral economics.DesignRetrospective analysis of randomized clinical trial (RCT).SettingFIReWoRk RCT (NCT03157713), which found that financial incentives were more effective than provision of weight-management resources only for weight-loss.Subjects668 adults with obesity (221 in resources-only group, 447 in incentive groups) living in low-income neighborhoods.MeasuresDemographic characteristics and weight-loss.AnalysisLinear mixed-effects models with interaction terms to examine effect of incentives on weight-loss in different demographic groups.ResultsMean age of participants was 47.69 years, 81.0% were women, 72.6% were Hispanic, and mean BMI was 37.95 kg/m². Financial incentives increased percent weight loss at 6 months (difference in percent weight loss between financial incentive and resources-only group = -2.41%; 95% CI -3.23% to -1.58%). In fully adjusted models, participants who were Black lost less weight than participants who were White (difference in percent weight loss = 2.12%; 95% CI 0.25% to 3.99%). Differences in percent weight loss by sex, age, education and neighborhood income were absent. Models that tested for interactions between group assignment and percent weight loss did not demonstrate evidence of a heterogenous effect of incentives in sociodemographic subgroups.ConclusionBlack participants in the FIReWoRk intervention lost less weight than White participants, but effectiveness of financial incentives generally did not vary significantly by sociodemographic characteristics. However, it remains important to evaluate potential impacts of financial incentive programs on health disparities.

BACKGROUND:Black men are underrepresented in hypertension trials, even though this population has higher prevalence and more adverse sequelae from hypertension, compared to other groups. In this article we present recruitment and community engagement strategies for the Community-to-Clinic Linkage Implementation Program (CLIP), a cluster-randomized trial on hypertension prevention among Black men. METHODS:Using a 2-stage recruitment process: 1) we enrolled Black-owned barbershops from zip-codes with high hypertension prevalence; and 2) recruited Black male participants who fulfilled the eligibility criteria and were customers of the barbershops. Barbershop and participant recruitment was conducted by a partner community-based organization. RESULTS:The study met the recruitment goals for barbershop enrollment (N=22) and individual participants. Of eligible individuals (N=461), 430 enrolled in the study (93% consent rate, exceeding the original enrollment goal of N=420 participants). Throughout recruitment, the study team conducted 101 unique engagements (41 prior to recruitment, 60 during recruitment), totaling engagement with180 partners across all events, including individual and group meetings, attendance at community events, and educational presentations. In addition to a primary partner community organization, the study team collaborated with a Community Advisory Council, comprised of residents, and civic and community leaders, and with the local health department and varied other organizations. CONCLUSIONS:In CLIP, a high number of academic-community engagement encounters and close collaboration with community partners contributed to successful recruitment of Black men at risk for hypertension and with adverse social determinants. Our experience may serve as to inform investigators focused on recruiting underserved populations in hypertension research trials.

IMPORTANCE/UNASSIGNED:In the context of the US opioid crisis, factors associated with the prevalence of opioid use disorder (OUD) must be identified to aid prevention and treatment. State medical cannabis laws (MCL) and recreational cannabis laws (RCL) are potential factors associated with OUD prevalence. OBJECTIVE/UNASSIGNED:To examine changes in OUD prevalence associated with MCL and RCL enactment among veterans treated at the Veterans Health Administration (VHA) and whether associations differed by age or chronic pain. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Using VHA electronic health records from January 2005 to December 2022, adjusted yearly prevalences of OUD were calculated, controlling for sociodemographic characteristics, receipt of prescription opioids, other substance use disorders, and time-varying state covariates. Staggered-adoption difference-in-difference analyses were used for estimates and 95% CIs for the relationship between MCL and RCL enactment and OUD prevalence. The study included VHA patients aged 18 to 75 years. The data were analyzed in December 2023. MAIN OUTCOME AND MEASURES/UNASSIGNED:International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) OUD diagnoses. RESULTS/UNASSIGNED:From 2005 to 2022, most patients were male (86.7.%-95.0%) and non-Hispanic White (70.3%-78.7%); the yearly mean age was 61.9 to 63.6 years (approximately 3.2 to 4.5 million patients per year). During the study period, OUD decreased from 1.12% to 1.06% in states without cannabis laws, increased from 1.13% to 1.19% in states that enacted MCL, and remained stable in states that also enacted RCL. OUD prevalence increased significantly by 0.06% (95% CI, 0.05%-0.06%) following MCL enactment and 0.07% (95% CI, 0.06%-0.08%) after RCL enactment. In patients aged 35 to 64 years and 65 to 75 years, MCL and RCL enactment was associated with increased OUD, with the greatest increase after RCL enactment among older adults (0.12%; 95% CI, 0.11%-0.13%). Patients with chronic pain had even larger increases in OUD following MCL (0.08%; 95% CI, 0.07%-0.09%) and RCL enactment (0.13%; 95% CI, 0.12%-0.15%). Consistent with overall findings, the largest increases in OUD occurred among patients with chronic pain aged 35 to 64 years following the enactment of MCL and RCL (0.09%; 95% CI, 0.07%-0.11%) and adults aged 65 to 75 years following RCL enactment (0.23%; 95% CI, 0.21%-0.25%). CONCLUSIONS AND RELEVANCE/UNASSIGNED:The results of this cohort study suggest that MCL and RCL enactment was associated with greater OUD prevalence in VHA patients over time, with the greatest increases among middle-aged and older patients and those with chronic pain. The findings did not support state cannabis legalization as a means of reducing the burden of OUD during the ongoing opioid epidemic.

OBJECTIVE:The objective of this study is to examine real-world dose titration patterns of semaglutide for weight management (Wegovy, Novo Nordisk A/S) in US adults and identify characteristics associated with early discontinuation. METHODS:We identified 15,811 commercially insured adults who started semaglutide for weight management (administrated through single-dose prefilled pens) between June 2021 and December 2023. We depicted dose-titration patterns over 5 months and identified factors associated with discontinuation using multivariable Cox regression. Sensitivity analyses examined patterns after supply shortage resolution (after October 2023). RESULTS:Most semaglutide users deviated from the recommended monthly dose-escalation schedule within the first 5 months. By the fifth month, nearly one-half (46%) had discontinued the treatment, with similar rates (48%) among those initiating after supply stabilization. Discontinuation was strongly associated with copayment amount, with rates increased from 41% in the lowest quintile ($1-$54 per month) to 51% in the highest quintile ($161-$1460 per month). Higher discontinuation rates were also associated with lower household income and education level. CONCLUSIONS:The deviations from the recommended dose-escalation schedule and high discontinuation rate among real-world semaglutide users indicate important challenges in the delivery of evidence-based care. Policy interventions that reduce financial barriers to the persistence of semaglutide are needed.

BACKGROUND:E-cigarettes may serve as a safer alternative to combustible cigarettes and may be more effective than currently available nicotine replacement therapy (NRT). Little is known about the perceptions of using e-cigarettes as part of a smoking treatment program. The objective of this study was to gain insight into patient-level factors to consider when developing smoking treatment programs that incorporate e-cigarettes. METHODS:Qualitative analysis of in-depth interviews with 14 participants enrolled in the e-cigarette treatment arm of a tobacco treatment intervention pilot randomized trial comparing the impact of behavioral counseling paired with e-cigarettes or NRT on smoking outcomes. Participants were prompted to share their experiences with the products and the study overall. Transcripts were coded according to the principles of framework analysis for applied research. Codes were organized into themes using the principles of grounded theory. RESULTS:Themes suggest that while there is an eagerness to try e-cigarettes as a new tool for smoking cessation, there is apprehension regarding what it means to "quit" if switching to e-cigarettes. Reflecting on the transitional purpose of e-cigarettes and potential health concerns associated with their use, many participants differentiated between the short-term goal to quit combustible cigarettes and the long-term goal to quit e-cigarettes. CONCLUSIONS:Including e-cigarettes as an option in smoking treatment regimens may be an opportunity to re-engage people who smoke who have tried and failed to quit with other forms of treatment. Participants found it challenging to establish what it means to quit cigarettes with e-cigarettes due to addiction and other health concerns. Clear guidelines are needed for integrating e-cigarettes into smoking cessation programs. TRIAL REGISTRATIONS/BACKGROUND:ClinicalTrials.gov Identifier: NCT04465318.

BACKGROUND:While a growing body of scientific literature suggests that evidence-based interventions may improve health outcomes in diverse settings, little is known about the best strategies for large-scale implementation. In Africa, music-an important positive social determinant of health-leverages existing cultural values, which may effectively enhance the reach, uptake, and long-term sustainability of evidence-based interventions in the region. To understand how music interventions work, why they are effective, and with whom they resonate, this systematic review aims to evaluate the quality and empirical application of music as an implementation strategy for adopting evidence-based interventions in Africa using the RE-AIM framework as a guide. METHODS:A comprehensive librarian-assisted search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five major electronic databases, EBSCOhost, PubMed, Web of Science, Embase, and MEDLINE, were searched for empirical studies focused on using music as an implementation strategy to improve health outcomes in Africa. Two independent investigators extracted components of retrieved papers using the RE-AIM framework as a guide. RESULTS:From 981 citations, eight studies met the inclusion criteria, each reporting a unique music intervention. The interventions were conducted in West Africa (n = 3), South African regions (n = 4), and East Africa (n = 1) and included seven observational studies and one randomized controlled trial (RCT). Using the RE-AIM scoring criteria, we summarize the RE-AIM dimensions reported from selected studies - Adoption (72.5%) being the highest, followed by Reach (62.5%), Implementation (41.7%), and Efficacy/Effectiveness (20.0%). All eight studies (100%) described the intervention location, the expertise of delivery agents, the target population, and the participant characteristics. Moreover, our analysis highlighted the effectiveness of music interventions in enhancing health outcomes, particularly in improving knowledge and awareness (62.5%), facilitating behavioral change (50%), and promoting mental health (25%). CONCLUSION/CONCLUSIONS:Music interventions adapted to the sociocultural context in Africa have the potential to help prevent diseases, improve well-being, and enhance health outcomes. Our review emphasizes the importance of customizing music-based interventions to fit the cultural context, which can enhance the programs' effectiveness, acceptance, and sustainability. Clinical trials are necessary to confirm the efficacy of music interventions in specific medical conditions and from a public health promotion perspective.

INTRODUCTION/BACKGROUND:Forms of combustible tobacco, such as shisha and pipe tobacco, are popular in the Middle East. Poly use of combustible tobacco products increases exposure to the harmful toxicants in them. Little is known about patterns of tobacco use behaviors in Middle Eastern countries and the potential harms due to particular types and concurrent versus single-use. METHODS:We analyzed data on tobacco use from 7,535 Emirati adults as part of the UAE Healthy Future Study, a longitudinal cohort study in the United Arab Emirates. We examined associations between single, dual, or poly combustible tobacco use and sociodemographic and clinical factors, including markers of cardiovascular disease (CVD). We also examined associations between the type of tobacco used and markers of CVD. RESULTS:Age-adjusted prevalence of combustible tobacco use was 34%. Single, dual, and poly use were 47%, 35%, and 18%, respectively. Parental tobacco use was associated with any kind of combustible tobacco use, and was strongly associated with poly use (RRRp=4.4, 95% CI=1.2, 16.8). Those who used one or more combustible tobacco products had higher levels of some CVD markers, notably HDL and Apolipoprotein A. Use of any type of tobacco was associated with increased risk for markers of CVD. CONCLUSIONS:Any amount of tobacco used was associated with differences in CVD markers. Associations were strongest for poly tobacco users. Future studies are needed to understand relationships between single, dual and poly combustible tobacco use, different combustible tobacco types, and disease risk. IMPLICATIONS/CONCLUSIONS:All forms of tobacco were associated with markers of CVD, signaling that there is no safer form of combustible tobacco. The study is one of the largest to characterize tobacco use behaviors in a Middle Eastern population, and should provide an important benchmark for further research on different, and sometimes co-occurring, forms of tobacco use.

PURPOSE/OBJECTIVE:To evaluate outcomes from the Trainers in Oncofertility Reproductive Communication and Health (TORCH) program, which trains Allied Health Professionals (AHPs) to become leaders in counseling AYA cancer patients on reproductive health. METHODS:ECHO-TORCH was developed for alumni of the Enriching Communication Skills for Health Professionals in Oncofertility (ECHO) program. It included web-based modules on evidence-based content, adult learning principles, and a simulation exercise for skill practice. Evaluation involved pre/post-tests, skills assessments during simulation via standardized learners (SLs) and faculty observers, and online focus groups. RESULTS:ECHO-TORCH learners (n = 10) showed improved knowledge, from 76% on pre-test to 86% on post-test (p < 0.01). Both SLs (86%) and faculty observers (90%) showed high likelihood of inviting learners back for future presentations. In online focus groups, participants described the modules as clear, relevant, and highly satisfying. Learners appreciated the opportunity for practice and structured review of the ECHO content. CONCLUSIONS:The ECHO-TORCH program improved AHPs' knowledge and skills in teaching reproductive health content to AYA cancer patients. The train-the-trainer model empowers AHPs to disseminate knowledge within their institutions, ultimately improving care quality and empowering AYA patients to make informed decisions about reproductive health. IMPLICATIONS FOR CANCER SURVIVORS/CONCLUSIONS:Continued development of professionals in reproductive healthcare will significantly enhance cancer survivors' quality of life by supporting informed decision-making regarding their reproductive health.

INTRODUCTION/BACKGROUND:Delayed Emergency Medical Services (EMS) response and transport (time from injury occurrence to hospital arrival) are associated with increased injury mortality. Inequities in accessing EMS care for injured patients are not well characterized. We sought to evaluate the association between the area deprivation index (ADI), a measure of geographic socioeconomic disadvantage, and timely access to EMS care within the United States. METHODS:The Homeland Infrastructure Foundation Level Data open-source database from the National Geospatial Intelligence Agency was used to evaluate the location of EMS stations across the United States using longitude and latitude coordinates. The ADI was obtained from Neighborhood Atlas at the census block group level. An ambulance desert (AD) was defined as populated census block groups with a geographic center outside of a 25-minute ambulance service area. The total population (urban and rural) located within an AD and outside an AD (non-ambulance desert [NAD]) and the ADI index distribution within those areas were calculated with their statistical significance derived from χ2 testing. Spearman correlations between the number of EMS stations available within 25-minutes service areas and ADI were calculated, and statistical significance was derived after accounting for spatial autocorrelation. RESULTS:A total of 42,472 ground EMS stations were identified. Of the 333,036,755 people (current US population), 2.6% are located within an AD. When stratified by type of population, 0.3% of people within urban populations and 8.9% of people within rural populations were located within an AD (p < 0.01). When compared with NADs, ADs were more likely to have a higher ADI (ADIAD, 53.13; ADINAD, 50.41; p < 0.01). The number of EMS stations available per capita was negatively correlated with ADI (rs = -0.25, p < 0.01), indicating that people living in more disadvantaged neighborhoods are likely to have fewer EMS stations available. CONCLUSION/CONCLUSIONS:Ambulance deserts are more likely to affect rural versus urban populations and are associated with higher ADIs. The impact of inequities in access to EMS care on outcomes deserves further study. LEVEL OF EVIDENCE/METHODS:Prognostic and Epidemiological; Level III.

INTRODUCTION/BACKGROUND:Spending on tobacco products may exacerbate health-related financial hardship experienced by low-income older adults. This study examined tobacco spending and the relationship between tobacco use and non-tobacco spending among low-income older adults in the U.S. METHODS:Using pooled 2021-2023 Consumer Expenditure Survey data, 1,983 single-person households (aged ≥65, with income <200% of the federal poverty level) were analyzed. Descriptive statistics summarized quarterly expenditures and budget shares for tobacco and non-tobacco goods. Generalized linear and fractional logit models compared non-tobacco expenditures and budget shares between people who use (versus do not use) tobacco, controlling for sociodemographic covariates. RESULTS:Overall, 10.6% of respondents reported tobacco spending. Respondents who used tobacco spent an average of $305.0 (SD = 303.4) per quarter on tobacco (7.8% of their total budget). Compared to respondents that did not use tobacco, respondents that used tobacco spent significantly more per quarter on alcohol ($54.8 vs. $22.0, P<0.001) and significantly less per quarter on food ($783.9 vs. $837.0, P<0.01), housing ($1,754.5 vs. $2,189.7, P<0.05), health care ($564.0 vs. $720.2, P<0.05), and clothing ($47.8 vs. $64.7, P<0.05). Similarly, respondents that used tobacco spent a significantly greater portion of their budget on alcohol (1.3% vs. 0.4%, P<0.001) and a significantly lower portion on food (19.6% vs. 19.7%, P<0.05), housing (38.8% vs. 43.4%, P<0.01), health care (14.7% vs. 16.8%, P<0.01), and other expenses (2.0% vs. 3.9%, P<0.01). CONCLUSIONS:Tobacco spending and its complementary alcohol spending may reduce low-income older adults' expenditures on food, housing and health care.