Faculty Bibliography

Youth in northern Ghana experience high rates of unintended pregnancy due to limited access to and use of sexual and reproductive healthcare (SRH) services. Peer-led interventions are effective in increasing the youth uptake of SRH services, but limited peer-led interventions have been developed for Ghana. This study explores youth (ages 15-24 years) and clinical provider perspectives on youth SRH to inform the co-design of a peer-led SRH counseling program in northern Ghana. We conducted a qualitative study using semi-structured interviews with 22 SRH providers and 27 youth. We then conducted an inductive thematic analysis and mapped themes onto the COM-B (Capability-Opportunity-Motivation-Behavior) model. Results revealed that youth capability to make informed and confident SRH decisions is constrained by a fragmented information environment. Although access to SRH services is increasing in the region, logistical and privacy barriers limit adolescents' opportunities to engage in care. Religious and cultural norms stigmatize youth SRH care, though support for contraceptive use is growing among more educated sectors. Youth motivation to use SRH services is driven by a desire for autonomy but undermined by concerns about contraceptive side effects and anticipated stigma. This study supports the co-development of a contextually grounded peer counseling SRH intervention in northern Ghana.

The rapid pace of innovation in synthetic biology and genome engineering elicits a need to reevaluate systems of oversight to ensure that biosafety and biosecurity safeguards are keeping up. Accordingly, the regulation of nucleic acid synthesis, an enabling technology for synthetic biology and genome engineering, is a current focus of political debate in the United States. However, to develop appropriate governance that neither under- nor overregulates technological development, policy leaders must also appreciate how advances in synthetic biology and genome engineering are being employed in the interests of biosecurity to support human health, manufacturing, food security, ecosystems and the natural environment. Synthetic biology can support the development of new therapeutics and health technologies, alternative biomanufacturing methodologies, food and agricultural innovations, environmental biosensors for monitoring infectious and toxic agents, and interventions aimed at preserving and restoring our natural environment. This Perspective provides an overview of current and potential benefits of synthetic biology and genome engineering, aiming to balance the broader societal discussion of potential risks-particularly in this special issue of the journal-with potential social, economic, and environmental value to individuals and society at large.

OBJECTIVE/UNASSIGNED:Gender-diverse individuals often face a burden of poor mental health. This study examined whether gender-diverse experiences were associated with higher levels of loneliness in adolescents, over and above depression and anxiety, and how family environmental factors, including maladaptive parenting, being bullied by a sibling at home (victimization), and bullying a sibling at home (perpetration), moderate the associations between gender-diverse and loneliness experiences among 4,424 adolescents in a population-based cohort. METHOD/UNASSIGNED:This cross-sectional study was embedded in Generation R, a multiethnic population-based cohort from fetal life onward. Adolescents with information on self-reported or parent-reported gender diversity and loneliness at ages 13 to 15 years were included. RESULTS/UNASSIGNED:s > .10). CONCLUSION/UNASSIGNED:Gender diversity is associated with higher levels of loneliness in adolescents. Being a target of bullying modified the association of gender diversity with loneliness experiences, suggesting that gender-diverse adolescents who are bullied by siblings experience particularly higher levels of loneliness.

Food assistance recipients have high smoking rates. Mental health factors that may affect their smoking are understudied. This study examined psychological distress and mental health service use among food assistance recipients enrolled in a smoking cessation trial. The trial sample comprised N = 352 adults aged ≥18, earning below 200% of the federal poverty level, smoking ≥5 cigarettes daily, and receiving public food assistance (e.g. SNAP). Psychological distress was assessed via the Kessler-6. Recent mental health service use (yes/no), therapeutic satisfaction (scale of 1-10), and potential usefulness of mental health services (scale of 1-10) were also assessed. Overall, 23% of participants had severe distress, 53% moderate distress, and 24% no/mild distress. Severe psychological distress was associated with younger age, high levels of financial stress, and food insecurity, but not with tobacco behaviors or motivations. Recent mental health service use was more common among individuals with severe distress, while therapeutic satisfaction was high across all distress levels. Participants who had not received mental health services reported a high level of potential usefulness if they were to receive services, especially among participants with severe distress. Results suggest that food assistance recipients who smoke may have unmet mental health care needs.

BACKGROUND/UNASSIGNED:Multilevel interventions targeting patients, providers, and health systems improve hypertension outcomes, but little is known about how well they are implemented in resource-limited settings. This study evaluated the implementation fidelity of ALTA, a multilevel approach for hypertension management, supported by practice facilitation, across six primary care practices in a Federally Qualified Health Center (FQHC). METHODS/UNASSIGNED:patients' BP and goals. We used a multi-method approach to assess implementation fidelity (adherence, dose, quality, responsiveness, differentiation) guided by Proctor's Implementation Outcome's Framework. Data sources included a structured EHR-embedded tool, narrative reports, and interviews over 12 months. ALTA adaptations were tracked using the Framework for Reporting Adaptations and Modifications-Expanded. RESULTS/UNASSIGNED: = 46) highlighted the need for team support, ongoing practice facilitation, and feedback on patients' progress as factors affecting fidelity. CONCLUSIONS/UNASSIGNED:Implementation fidelity varied across the ALTA components and participating sites, with the greatest variability observed in delivery of the site-level components of identify and refer. Centralized components delivered by the nurse-led team (coach, document, monitor) were delivered consistently with high fidelity. Contextual factors like staffing and patient engagement shaped implementation success. CLINICAL TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov, NCT03713515.

BACKGROUND:Health care workers (HCWs) face sustained psychological demands that place them at heightened risk for burnout and posttraumatic stress disorder (PTSD). However, assessing psychological distress in this population remains challenging because of stigma, underreporting, and the limitations of self-report tools. Although nonverbal behaviors such as facial expressions and gaze hold diagnostic promise, most approaches overlook the fine-grained, temporal fluctuations in these signals. In this study, we focused on microbehavior intervals-brief, involuntary changes in multimodal nonverbal signals-that emerge during emotion-eliciting interviews. OBJECTIVE:This study aimed to determine whether microbehavior intervals improve the discrimination of psychological distress profiles among HCWs with symptoms of burnout and PTSD. METHODS:HCWs participated in a semistructured interview that included 5 work-related, emotionally charged questions and that was recorded via Webex (online video platform). Participants also completed validated questionnaires for burnout (Maslach Burnout Inventory General Survey 9-item) and PTSD (PTSD checklist for Diagnostic and Statistical Manual, 5th edition). Recordings were analyzed with computer vision models to generate time-series data of facial expressions, head movement, gaze, body posture, and hand gestures. An unsupervised anomaly detection model (MOMENT [a Family of Open Time-Series Foundation Models]) isolated microbehavior intervals without requiring manual labels. Features derived from these intervals were used to train a deep learning classifier that predicted 4 symptom classes of psychological distress: "moderate-severe burnout," "subthreshold-provisional PTSD," "burnout+PTSD," and "resilient." We conducted an ablation study by systematically removing one behavioral data stream at a time. Finally, we conducted an explainability analysis to characterize the features driving model predictions. RESULTS:-score. The explainability analysis revealed distinct temporal patterns across symptom classes, with irregularity and variability in microbehaviors emerging as key predictors. CONCLUSIONS:Focusing on microbehavior intervals yields a scalable, interpretable, and annotation-free framework for detecting psychological distress from nonverbal signals. By moving from whole-video features to fine-grained multimodal temporal modeling, we successfully captured subtle, involuntary fluctuations in nonverbal responses to emotion-eliciting questions. This multimodal approach enables an objective, robust, and explainable assessment of psychological distress and offers a promising complement to conventional psychometric assessments.

Local community populations ("survivors") exposed to the World Trade Center (WTC) disaster experienced complex exposures to mixtures of dust and combustion products with potential carcinogenic effects. Survivors with certifiable WTC-related conditions are eligible for inclusion in the federally funded WTC Health Program. We provide an updated description of cancers in the WTC Environmental Health Center (EHC), a program for WTC survivors, through 31 December 2024. Using data from the WTC EHC Pan Cancer Database, we summarized demographics, exposure history, and tumor characteristics among enrollees with pathologically confirmed primary cancers meeting WTC Health Program certification criteria. Among 17,449 members, 7274 had a certifiable cancer diagnosis; excluding non-melanoma skin cancers, 6588 patients with 7643 eligible cancers were analyzed. Women comprised 50.3% of the cohort and 47.5% of diagnoses. Solid tumors accounted for 87% of certifications, with breast (22%) and prostate (19%) cancers most frequent, followed by lung (8%), thyroid (6%), colorectal (6%), and melanoma (4.5%). Lymphoproliferative and hematopoietic malignancies represented 13% of cases. Fourteen percent developed multiple primary cancers, and median latency clustered around 14-16 years. Compared with our previous report in 2020, the enrolled number of cancers increased 2.5-fold. These findings support the need for sustained surveillance and additional epidemiologic studies to improve cancer prevention and survivorship in this uniquely exposed population.

PURPOSE/OBJECTIVE:Young adults with cancer (YAs) are rarely provided the necessary resources to make informed decisions about fertility preservation (FP) prior to beginning treatment. Digital decision aids are a promising strategy to ensure YAs receive timely, guideline-concordant information. We developed an alpha version Fertilit-e, a digital FP navigator, and conducted usability testing to obtain feedback from YAs. METHODS:We designed an alpha version of Fertilit-e that drew from existing evidence-based FP resources. Feedback was obtained from two waves of participants using a think-aloud framework, and modifications were made to the decision aid. RESULTS:Across waves, participants (n = 12) understood the purpose of Fertilit-e and thought modules were comprehensive and easy to understand. The usability of Fertilit-e was rated as excellent across waves and devices (iPad and computer). Participants suggested reducing the use of and better defining medical terminology and adding text to videos to enhance comprehensibility. CONCLUSIONS:YAs reported that Fertilit-e provided important information regarding FP in an understandable manner. Participants made suggestions for how to improve comprehensibility and usability that will guide future iterations of Fertilit-e. For example, tailoring algorithms and reorganization may direct users to the most relevant information. IMPLICATIONS FOR CANCER SURVIVORS/CONCLUSIONS:Digital decision aids may be a feasible and useful strategy for helping YAs navigate decisions regarding whether to pursue FP at the time of diagnosis. Additional research is needed to refine and evaluate such tools before integration into routine care.

PurposeTo estimate the effect of the culturally-adapted Greenlight intervention on parent activation and locus of control (LOC) among Chinese-American immigrant parents.DesignProspective, quasi-experimental study.SettingA New York City-based federally-qualified health center with a large patient population of low-income, ethnically Chinese immigrant individuals and families.Sample444 Immigrant Chinese-American parents of infants (267 cross-sectionally enrolled historical controls and 177 Greenlight recipients followed prospectively).InterventionA culturally-adapted version of Greenlight, a health literacy- and communication-informed early childhood obesity prevention intervention in primary care which promotes certain healthy infant feeding practices at 12 months in the present sample.MeasuresParent activation and LOC were measured at 6, 12, 24, and 36 month well child visits.AnalysisGeneralized estimating equations were used to examine the effects of the Greenlight intervention on the outcome measures.ResultsCompared to historical controls, parents receiving Greenlight were more likely to strongly agree with the activation statements: "I know how to prevent my child from becoming overweight" (adjusted odds ratio (aOR): 9.62 [4.70, 19.73]); "I have been able to help my child maintain recommended changes like eating right or exercising" (aOR: 6.42 [4.14, 9.97]); and "I am confident I can keep my child eating and exercising right, even when I am busy or stressed" (aOR: 8.44 [5.35, 13.31]). Greenlight recipients also demonstrated increased internal LOC (aOR: 2.02 [1.35, 3.03]) and decreased powerful others external LOC (aOR: 1.76 [1.23, 2.51]).ConclusionTo reduce disparities in child obesity, especially among immigrant families, interventions must also prioritize parent factors like parent activation and LOC to build upon their inherent assets and promote long-term change.

IMPORTANCE/UNASSIGNED:Buprenorphine-naloxone and extended-release (XR) naltrexone are both efficacious medications for opioid use disorder that reduce unregulated opioid use and improve opioid cravings and treatment retention. While prior comparative effectiveness studies demonstrated superiority of buprenorphine-naloxone over XR naltrexone for relapse and treatment retention, the comparative effectiveness of both treatments for all-cause mortality and nonfatal opioid overdose outcomes has not been rigorously tested. OBJECTIVE/UNASSIGNED:To compare the effectiveness of buprenorphine-naloxone vs XR naltrexone after medically managed opioid withdrawal (MMOW) treatment. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This observational comparative effectiveness study using a target trial emulation framework leveraged individually linked administrative data from the Massachusetts Public Health Data Warehouse to emulate the protocol of the Extended-Release Naltrexone vs Buprenorphine for Opioid Treatment randomized clinical trial. Participants included adults 18 years or older who were discharged from MMOW in Massachusetts between January 1, 2014, and December 31, 2018. Individuals could meet eligibility criteria more than once. Data were analyzed from December 22, 2023, to January 30, 2025. EXPOSURES/UNASSIGNED:Initiation of buprenorphine-naloxone or XR naltrexone therapy within 28 days of MMOW discharge. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Estimated 24-week cumulative incidence of all-cause mortality and nonfatal opioid overdose using inverse probability weighting to adjust for baseline and time-varying confounding. RESULTS/UNASSIGNED:A total of 36 752 unique individuals who met eligibility criteria were identified and contributed 106 052 MMOW discharge episodes; 79 089 (74.6%) episodes were among individuals who were male and 44 463 (42.1%) were among individuals aged 18 to 29 years. By 28 days after MMOW discharge, initiation of buprenorphine-naloxone was observed among 14 194 discharge episodes (13.4%) and initiation of XR naltrexone was observed among 4734 (4.5%) episodes. The adjusted 24-week cumulative incidence of all-cause mortality after MMOW discharge was 1.4% (95% CI, 1.2%-1.7%) for buprenorphine-naloxone and 1.4% (95% CI, 1.1%-1.8%) for XR naltrexone, corresponding to a risk difference of 0.0 percentage points (pp) (95% CI, -0.4 to 0.4 pp). The adjusted 24-week cumulative incidence of nonfatal opioid overdose after MMOW discharge was 11.6% (95% CI, 10.8%-12.3%) for buprenorphine-naloxone and 13.9% (95% CI, 12.9%-15.0%) for XR naltrexone, corresponding to a risk difference of 2.3 pp (95% CI, 1.2-3.6 pp). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this comparative effectiveness study of buprenorphine-naloxone vs XR naltrexone, initiating buprenorphine-naloxone after MMOW discharge was associated with a lower risk of nonfatal opioid overdose at 24 weeks than initiating XR naltrexone, but a similar risk of all-cause mortality.