An asthma collaboration to reduce childhood asthma disparities on the Navajo Nation: Trial protocol for the Community Asthma Program.

Navajo children disproportionately experience poor asthma outcomes. Following a one-year community engagement period with key stakeholders from the Navajo Nation, the Community Asthma Program (CAP) was created using evidenced based programs with the goal of reducing asthma disparities among Navajo children. CAP is being evaluated with a six-year, multi-site step-wedge design in three Navajo communities: Tuba City, Chinle and Fort Defiance, Arizona. The primary outcome is asthma exacerbations defined as use of systemic oral corticosteroids, asthma hospitalizations, asthma related ED visits, and ICU admissions. Asthma exacerbations will be measured using data from the electronic medical records of the three community health care centers. Secondary outcomes include will changes in asthma-related events and asthma control. The RE-AIM ( R each and representativeness, 2) E ffectiveness, 3) A doption, 4) I mplementation, and 5) M aintenance) framework is being used to guide the implementation evaluation which includes iterative collection and analysis of process data to identify facilitators and barriers, describe relevant organizational contexts, and inform strategies for dissemination. The CAP intervention requires community engagement and participation, building community capacity, incorporating evidenced-based guidelines and practices while ensuring program strategies actively involve Navajo community members during all steps of the intervention. The outcome of this trial will allow us to determine the effectiveness of a multi-component, community-focused intervention to improve asthma in a tribal community.

Are prevention of mother-to-child HIV transmission service providers acquainted with national guideline recommendations? A cross-sectional study of primary health care centers in Lagos, Nigeria.

BACKGROUND: Implementation of interventions for the prevention of mother-to-child transmission (PMTCT) of HIV in low- and middle-income countries, faces several barriers including health systems challenges such as health providers' knowledge and use of recommended guidelines. This study assessed PMTCT providers' knowledge of national PMTCT guideline recommendations in Lagos, Nigeria. METHODS: This was a cross-sectional survey of a purposive sample of twenty-three primary health care (PHC) centers in the five districts of Lagos, Nigeria. Participants completed a self-administered 16-item knowledge assessment tool created from the 2016 Nigeria PMTCT guidelines. Research Electronic Data Capture (REDCap) was used for data entry and R statistical software used for data analysis. The Chi square test with a threshold of P < 0.05 considered as significant was used to test the hypothesis that at least 20% of service providers will have good knowledge of the PMTCT guidelines. RESULTS: One hundred and thirteen (113) respondents participated in the survey. Most respondents knew that HIV screening at the first prenatal clinic was an entry point to PMTCT services (97%) and that posttest counselling of HIV-negative women was necessary (82%). Similarly, most respondents (89%) knew that early infant diagnosis (EID) of HIV should occur at 6-8 weeks of life (89%). However, only four (3.5%) respondents knew the group counselling and opt-out screening recommendation of the guidelines; 63% did not know that haematocrit check should be at every antenatal clinic visit. Forty-eight (42.5%) service providers had good knowledge scores, making the hypothesis accepted. Knowledge score was not influenced by health worker cadre (p = 0.436), training(P = 0.537) and professional qualification of ≤5 years (P = 0.43). CONCLUSION: Service providers' knowledge of the PMTCT guidelines recommendations varied. The knowledge of group counselling and opt-out screening recommendations was poor despite the good knowledge of infant nevirapine prophylaxis. The findings highlight the need for training of service providers.

Use of beta blockers and the risk of death in hospitalised patients with acute exacerbations of COPD.

BACKGROUND: Cardiovascular disease is a major cause of death in patients with chronic obstructive pulmonary disease (COPD) and predicts hospitalisation for acute exacerbation, in-hospital death and post-discharge mortality. Although beta blockers improve cardiovascular outcomes, patients with COPD often do not receive them owing to concerns about possible adverse pulmonary effects. There are no published data about beta blocker use among inpatients with COPD exacerbations. A study was undertaken to identify factors associated with beta blocker use in this setting and to determine whether their use is associated with decreased in-hospital mortality. METHODS: Administrative data from the University of Alabama Hospital were reviewed and patients admitted between October 1999 and September 2006 with an acute exacerbation of COPD as a primary diagnosis or as a secondary diagnosis with a primary diagnosis of acute respiratory failure were identified. Demographic data, co-morbidities and medication use were recorded and subjects receiving beta blockers were compared with those who did not. Multivariate regression analysis was performed to determine predictors of in-hospital death after controlling for known covariates and the propensity to receive beta blockers. RESULTS: 825 patients met the inclusion criteria. In-hospital mortality was 5.2%. Those receiving beta blockers (n = 142) were older and more frequently had cardiovascular disease than those who did not. In multivariate analysis adjusting for potential confounders including the propensity score, beta blocker use was associated with reduced mortality (OR = 0.39; 95% CI 0.14 to 0.99). Age, length of stay, number of prior exacerbations, the presence of respiratory failure, congestive heart failure, cerebrovascular disease or liver disease also predicted in-hospital mortality (p<0.05). CONCLUSIONS: The use of beta blockers by inpatients with exacerbations of COPD is well tolerated and may be associated with reduced mortality. The potential protective effect of beta blockers in this population warrants further study.

Standardizing contact investigation protocols.

SETTING: The State of Alabama Department of Public Health Division of Tuberculosis Control. OBJECTIVE: To standardize contact investigation protocols and implement an intervention to increase TB field worker adherence to the protocols with the goal of promoting efficiency and effectiveness in contact investigations. DESIGN: A process evaluation of existing data collection and management systems and protocols was performed. Standardized protocols and an intervention to increase TB field worker adherence to the protocols were created and pilot tested. These were then implemented and formative evaluation data were collected. RESULTS: The process evaluation revealed considerable variance among field workers with regard to protocols and definitions of variables related to contact investigations. Protocols were standardized and an intervention targeted at TB field workers was developed. The intervention consisted of a training workshop and the development of a computer-based contact investigation module. This was successfully implemented throughout the state. CONCLUSIONS: To perform effective contact investigations and conduct studies to improve the effectiveness of these investigations, TB control programs must pay careful attention to precisely defining variables and concepts related to the contact investigation. Furthermore, protocols must be standardized and resources devoted to training of TB field workers to ensure adherence to protocols.

Experience of Black participants in the Lung Health Study smoking cessation intervention program.

This paper evaluates the hypothesis that Black smokers will respond differently than Whites to a smoking cessation intervention program where no adjustments are made in recognition of cultural differences. The responses of Black smokers who were recruited into the Lung Health Study (LHS) to the smoking cessation intervention are described. Black quit rates are compared with those of Whites. The LHS enrolled 5887 men and women smokers, aged 35-60 years, of whom 3923 were randomized to a group cessation intervention and 1964 to usual care. Blacks and Whites from six clinics who had complete covariate data (200 Blacks and 2868 Whites) were compared on baseline smoking characteristics and subsequent smoking cessation outcomes. Logistic models were constructed to adjust for baseline smoking variables and demographic characteristics to evaluate the effect of treatment group on smoking cessation among Blacks and Whites. At baseline, Blacks reported smoking fewer cigarettes than Whites, but had higher mean levels of salivary cotinine. The adjusted odds ratio of quitting at 1 year for the smoking intervention group vs. the usual care group was 1.48 for Blacks and 5.99 for Whites. This difference between Blacks and Whites was highly significant (p = 0.002). Across 5 years, the adjusted odds ratios of quitting were 1.87 for Blacks and 3.34 for Whites (p = 0.06). Although the treatment effect was stronger for Whites than for Blacks, over the 5 years of the study there was a significant treatment effect for Blacks. Indicators of physical dependence on nicotine at baseline were inconsistent in indicating whether Blacks were more dependent. We conclude that Blacks and Whites differed significantly in their response to the LHS group smoking intervention program.

Chronic obstructive pulmonary disease stage and 6-minute walk outcome.

PURPOSE: Although physicians generally reserve pulmonary rehabilitation (PR) referral for patients in later stages of chronic obstructive pulmonary disease (COPD), there is no evidence to suggest that PR programs are more effective for these persons than for those in earlier stages of the disease. This study examined the relationship between 6-minute walk change and COPD stage in patients completing PR. METHODS: The sample consisted of 76 patients who enrolled in the University of Alabama at Birmingham's Cardiopulmonary Rehabilitation Program with a primary diagnosis of COPD between January 1996 and June 2000. Data was collected on 6-minute walk upon entry into the program and upon program completion. Patients were stratified according to COPD stage using the American Thoracic Society staging system. RESULTS: There were significant differences among the three stages with regard to initial and ending 6-minute walk distances such that persons in later stages of the disease have shorter initial and ending 6-minute walk distances. However, all three stages show significant improvements in the 6-minute walk after PR. There were no significant differences in the median change among groups indicating that the median change was not better (or worse) for patients in any particular COPD stage. CONCLUSIONS: This study suggests that PR is equally effective in increasing physical performance for all patients regardless of COPD stage. This type of information can be used to support the recommendation of PR for patients early in the disease process.

Characteristics of participants who stop smoking and sustain abstinence for 1 and 5 years in the Lung Health Study.

BACKGROUND: This study describes baseline and Year 1 predictors of abstinence from smoking for the 3,523 intervention participants who had complete annual 5-year follow-up data in the Lung Health Study (LHS). METHODS: The LHS enrolled 5,887 smokers, aged 35 to 60 years, of whom 3,923 were offered a cessation intervention. Of these, 22% achieved biochemically verified abstinence for 5 years. Logistic regressions were performed. The first outcome variable was abstinence from smoking at 1 year. Then for those who were quit at 1 year, the outcome variable was 5 years of sustained abstinence. RESULTS: All participants who were not using nicotine gum after 1 year in the study were more likely to sustain cessation over 5 years than were gum users at year 1 (OR ranged from 0.31 to 0.44 for four age- and sex-specific groups). Baseline number of previous quit attempts was negatively associated with 5-year quitting success among younger and older men (OR = 0.82 and 0.83). Older participants who were less likely to associate smoking with emotional coping had higher abstinence rates at 5 years of follow-up (OR = 0.89 and 0.84). CONCLUSIONS: Different mechanisms may be responsible for achieving cessation in age/gender groups. These results have implications for planning successful interventions.

Advance directives in cardiac and pulmonary rehabilitation patients.

PURPOSE: Advance directives have been available in parts of the United States for more than 20 years, but research shows that only a small percentage of adults (5-25%) have some form of written advance directive. The purose of this study was to examine the presence of advance directives among persons entering cardiac and pulmonary rehabilitation, and identify characteristics of persons most likely to have advance directives. METHODS: The sample consisted of 336 cardiac patients and 181 pulmonary patients who enrolled in the University of Alabama at Birmingham's Cardiopulmonary Rehabilitation Program between January 1996 and December 1999. As part of the initial program assessment, patients were asked two questions: (1) Do you have a living will? (2) Do you have any advance directives? For the purposes of this study, the two questions were combined to examine the presence of either a living will or other type of advance directive. RESULTS: Results indicate that 25% of both subgroups (cardiac and pulmonary patients) report having written advance directives. Logistic regression analysis indicates that among cardiac patients whites and older persons were more likely to have advance directives. Among pulmonary patients, females and whites were more likely to have advance directives. CONCLUSIONS: These results indicate that only a minority of cardiopulmonary rehabilitation patients have advance directives upon entry into the program, and that the prevalence differs among gender, racial, and age groups. Cardiac and pulmonary rehabilitation programs may be valuable sites for educating patients about advance directives and efforts by rehabilitation personnel may increase the prevalence of advance directives among patients.

Asthma self-management: do patient education programs always have an impact?

BACKGROUND: During the past 15 years, programs to improve self-management practices in adults with asthma have reported improvement in functional status and reduction of inappropriate use of health care services. However, these programs usually represent an ideal approach, applying multiple patient education methods. Consequently, when these programs are found to be efficacious, it is important to replicate the programs as well as to evaluate less complex methods that may be more appropriate for nonacademic health care settings. METHODS: We compared the following 3 standardized self-management treatments in a randomized, controlled trial: (1) a replication of the self-management program developed at a university medical center that was previously shown to be efficacious; (2) a modified version of this program including only the core elements; and (3) a usual-care program. Outcome measures included medication and inhaler regimen adherence, asthma symptoms, respiratory illness, functional status, and use of health care resources. RESULTS: All 3 groups improved on measures of respiratory illnesses, use of health care services, and functional status. Patients in both education groups did no better than the usual-care group. CONCLUSIONS: The results are inconsistent with the results of the first asthma self-management study at this institution and with those of efficacy studies of similar programs. Two factors, selection of the patient population and historical changes in asthma treatment, most likely contributed to the lack of impact of the self-management programs. As a result of the improved standards for usual care due to both factors, the opportunity to effect patient outcomes was substantially reduced.

Social class, social support and obesity risk in children.

Selected characteristics of the social environment are tested as predictors of children's risk for obesity. Data were collected during the summer of 1991 at the University of South Alabama Springhill Paediatric Clinic (Mobile, AL, USA). Data were collected on 77 children, aged 2.5-5 years, and their primary caretaker. Obesity risk was measured by the child's weight for height score and calorie intake. Caretaker's socio-economic status, marital status, and social support predict children's obesity risk for this sample. Lower social class position, lower expressive social support, and unmarried status of the caretaker are associated with a higher calorie intake and a higher weight for height score in the child.

Paid family caregiving: a review of progress and policies.

Policymakers in the United States have begun to examine solutions that encourage increased sharing of caregiving responsibilities between government and family. Initiatives in Sweden and the United Kingdom are now in place. Support includes a care leave policy implemented at the federal level, paying salaries to family members when caregiving is a regular job, providing job training to salaried caregivers when their personal caregiving experience ends, community-based programs for caregivers, and allowances to be used for providing care to an elderly person. In the United States, 13 states pay caregivers as Medicaid providers. Policymakers have considered tax incentives and, in 1975, U.S. Senate Bill 1161 was introduced but failed as an attempt to provide cash subsidies to families caring for the elderly. A proposal has been made to expand the Temporary Disability Model to include care of family members of all ages by providing adequate wage replacement to assist caregivers. At present, 34 states provide some type of economic support for caregivers. Research is needed to determine what types of programs are most acceptable and beneficial to caregivers as well as cost effective for government.