A qualitative analysis of smokers' perceptions about lung cancer screening.

BACKGROUND: In 2013, the US Preventive Services Task Force (USPSTF) began recommending lung cancer screening for high risk smokers aged 55-80 years using low-dose computed tomography (CT) scan. In light of these updated recommendations, there is a need to understand smokers' knowledge of and experiences with lung cancer screening in order to inform the design of patient education and tobacco cessation programs. The purpose of this study is to describe results of a qualitative study examining smokers' perceptions around lung cancer screening tests. METHODS: In 2009, prior to the release of the updated USPSTF recommendations, we conducted 12 120-min, gender-specific focus groups with 105 current smokers in Charlotte, North Carolina and Cincinnati, Ohio. Focus group facilitators asked participants about their experience with three lung cancer screening tests, including CT scan, chest x-ray, and sputum cytology. Focus group transcripts were transcribed and qualitatively analyzed using constant comparative methods. RESULTS: Participants were 41-67 years-old, with a mean smoking history of 38.9 pack-years. Overall, 34.3% would meet the USPSTF's current eligibility criteria for screening. Most participants were unaware of all three lung cancer screening tests. The few participants who had been screened recalled limited information about the test. Nevertheless, many participants expressed a strong desire to pursue lung cancer screening. Using the social ecological model for health promotion, we identified potential barriers to lung cancer screening at the 1) health care system level (cost of procedure, confusion around results), 2) cultural level (fatalistic beliefs, distrust of medical system), and 3) individual level (lack of knowledge, denial of risk, concerns about the procedure). Although this study was conducted prior to the updated USPSTF recommendations, these findings provide a baseline for future studies examining smokers' perceptions of lung cancer screening. CONCLUSION: We recommend clear and patient-friendly educational tools to improve patient understanding of screening risks and benefits and the use of best practices to help smokers quit. Further qualitative studies are needed to assess changes in smokers' perceptions as lung cancer screening with CT scan becomes more widely used in community practice.

Program Implementation Approaches to Build and Sustain Health Care Coordination for Type 2 Diabetes.

BACKGROUND: As more people enter the U.S. health care system under the Affordable Care Act (ACA), it is increasingly critical to deliver coordinated, high-quality health care. The ACA supports implementation and sustainability of efficient health care models, given expected limits in available resources. This article highlights implementation strategies to build and sustain care coordination, particularly ones consistent with and reinforced by the ACA. It focuses on disease self-management programs to improve the health of patients with type 2 diabetes, exemplified by grantees of the Alliance to Reduce Disparities in Diabetes. METHOD: We conducted interviews with grantee program representatives throughout their 5-year programs and conducted a qualitative framework analysis of data to identify key themes related to care coordination. RESULTS: The most promising care coordination strategies that grantee programs described included establishing clinic-community collaborations, embedding community health workers within care management teams, and sharing electronic data. Establishing provider buy-in was crucial for these strategies to be effective. DISCUSSION: This article adds new insights into strategies promoting effective care coordination. The strategies that grantees implemented throughout the program align with ACA requirements, underscoring their relevance to the changing U.S. health care environment and the likelihood of further support for program sustainability.

A content analysis of electronic health record (EHR) functionality to support tobacco treatment.

Government regulations have created new incentives for health systems to implement changes in electronic health records (EHRs) to reduce tobacco use among patients. The purpose of this study is to conduct a content analysis of EHR modifications aimed at supporting tobacco cessation and to document these modifications using a 5 A's framework (i.e., Ask, Advise, Assess, Assist, Arrange). Fourteen trials were identified that met inclusion criteria. A content analysis of EHR functionality in these trials was conducted by two independent reviewers between February and June 2015. For "Ask," all trials provided for the documentation of smoking status in the EHR. For "Advise," 35.7 % of EHRs provided functionality related to helping a clinician provide advice to quit. For "Assess," more than half (57.1 %) of EHRs included a feature to document a patient's willingness to quit. For "Assist," EHRs offered features for medication prescribing (78.6 %), providing educational materials to patients (57.1 %), referring a patient to the quitline (50.0 %), referring a patient to a tobacco treatment specialist (42.9 %), and documenting the provision of counseling (35.7 %). Finally, for "Arrange," EHRs supported the following up of patients (35.7 %) and allowed tobacco treatment specialists to "pass back" patient notes to primary care providers (28.6 %). Studies that have modified EHRs for tobacco treatment have done so across the steps in the 5 As model, with most modifications occurring to support documenting smoking status (Ask) and assisting with medication prescribing (Assist). As health systems attempt to comply with Meaningful Use regulations, an understanding of the range of EHR modifications to support tobacco treatment is warranted.

Text2Quit: an analysis of participant engagement in the mobile smoking cessation program.

BACKGROUND: Text2Quit, an interactive text-messaging program aimed at smoking cessation, has been shown to increase quit rates, but engagement has not been thoroughly explored. Understanding the program features associated with engagement and behavior change is integral for effective program design. OBJECTIVES: This study explored participants' interaction with the Text2Quit text-messaging program and associations between engagement and smoking cessation. METHODS: The study included the 262 participants who received the Text2Quit intervention. Self-reported engagement measures, primarily usage of Text2Quit keywords and survey responses, were collected through computer records of participant use. Demographic variables and self-reported smoking abstinence were recorded in surveys at baseline and 6-month assessment. RESULTS: The majority of participants (73%) maintained their subscription during the 6-month intervention. On average, participants received 210.51 text messages, 23.75 emails, and logged into the web portal 1.94 times. Being female was predictive of engagement with the program (ß = 15.39). Program engagement, measured by the keyword PLEDGE (p = .002) and the Smokefree Status at 7 Days survey (p < .001) were associated with 6-month abstinence; use of keywords SMOKED (p < .001), RELAPSE (p = .007), and STOP (p = .023) were inversely related to abstinence. While abstainers (N = 83, 31%) stayed enrolled longer and engaged with the program more frequently, program "dose" was not predictive of smoking cessation. CONCLUSIONS: Using interactive tools such as pledges and reporting on smoking status were predictive of cessation. Further study of program features is required to understand how to optimally design text messaging programs.

Smoking cessation support for pregnant women: role of mobile technology.

BACKGROUND: Smoking during pregnancy has deleterious health effects for the fetus and mother. Given the high risks associated with smoking in pregnancy, smoking cessation programs that are designed specifically for pregnant smokers are needed. This paper summarizes the current landscape of mHealth cessation programs aimed at pregnant smokers and where available reviews evidence to support their use. METHODS: A search strategy was conducted in June-August 2015 to identify mHealth programs with at least one component or activity that was explicitly directed at smoking cessation assistance for pregnant women. The search for text messaging programs and applications included keyword searches within public health and medical databases of peer-reviewed literature, Google Play/iTunes stores, and gray literature via Google. RESULTS: Five unique short message service programs and two mobile applications were identified and reviewed. Little evidence was identified to support their use. Common tools and features identified included the ability to set your quit date, ability to track smoking status, ability to get help during cravings, referral to quitline, and tailored content for the individual participant. The theoretical approach utilized was varied, and approximately half of the programs included pregnancy-related content, in addition to cessation content. With one exception, the mHealth programs identified were found to have low enrollment. CONCLUSION: Globally, there are a handful of applications and text-based mHealth programs available for pregnant smokers. Future studies are needed that examine the efficacy of such programs, as well as strategies to best promote enrollment.

Quit4baby: results from a pilot test of a mobile smoking cessation program for pregnant women.

BACKGROUND: Text messaging (short message service, SMS) programs have been shown to be effective in helping adult smokers quit smoking. This study describes the results of a pilot test of Quit4baby, a smoking cessation text messaging program for pregnant smokers that was adapted from Text2quit. OBJECTIVE: The study aimed to demonstrate the feasibility and acceptability of Quit4baby for women currently enrolled in Text4baby, a perinatal health text messaging program. METHODS: Pregnant women enrolled in Text4baby and who were current smokers or had quit within the last 4 weeks (n=20) were enrolled in Quit4baby. Those under the age of 18, not pregnant, not current smokers, those using nicotine replacement therapy, and those not interested in participating were ineligible. Participants were surveyed at baseline and at 2 and 4 weeks postenrollment. RESULTS: Most participants responded to the program favorably. Highly rated aspects included the content of the program, skills taught within the program, and encouragement and social support provided by the program. Participants reported that the program was helpful in quitting, that the program gave good ideas on quitting, and that they would recommend the program to a friend. Suggestions for improvement included increasing the message dose and making the quitpal more interactive. CONCLUSIONS: This pilot test provides support for the feasibility and acceptability of Quit4baby. Future studies are needed to assess whether Quit4baby is effective for smoking cessation during pregnancy.

Improving the implementation of diabetes self-management: findings from the Alliance to Reduce Disparities in Diabetes.

To enhance the health and well-being of patients managing type 2 diabetes, the five grantees comprising the Alliance to Reduce Disparities in Diabetes implemented evidence-based approaches to patient self-management education as part of their programs. This article describes strategies implemented by the grantees that may help explain program success, defined as improvement in clinical values and patient-reported outcomes. A process evaluation of grantee programs included interviews and document review at the beginning, midpoint, and end of the Alliance initiative. A total of 97 interviews were conducted over time with 65 program representatives. The Alliance programs served 2,328 people from diverse racial and ethnic backgrounds and provided 36,826 diabetes self-management sessions across the intervention sites. Framework analysis of the interviews identified four key themes that emerged across time and program sites that may help account for program success: empowerment, increasing access and support, addressing local needs and barriers, and care coordination. The overall evaluation findings may help other diabetes self-management programs seeking to translate and implement evidence-based approaches to reduce disparities and enhance patient well-being.

Integrating stages of change models to cast new vision on interventions to improve global retinoblastoma and childhood cancer outcomes.

BACKGROUND: Retinoblastoma, the most common intraocular tumor globally, represents a curable cancer when diagnosed early and treated promptly. Delay to diagnosis, lag time prior to treatment initiation, and abandonment of treatment including upfront treatment refusal, represent stark causes of high retinoblastoma mortality rates in low- and middle- income settings, particularly regions in Africa. While a health delivery-based approach has been a historic focus of retinoblastoma treatments globally and is essential to quality care, this is necessary but not adequate. Retinoblastoma is a compelling disease model to illustrate the potential insights afforded in theory-informed approaches to improve outcomes that integrate public health and oncology perspectives, prioritizing both health service delivery and social efficacy for cure. DISCUSSION: Given that barriers to appropriate and timely diagnosis and treatment represent main contributors to mortality in children with retinoblastoma in resource-limited settings such as certain areas in Africa, an important priority is to overcome barriers to cure that may be predominantly socially influenced, alongside health delivery-based improvements. While Stages of Change models have been effectively utilized in cancer screening programs within settings of economic and cultural barriers, this application of health behavior theory has been limited to cancer screening rather than a comprehensive framework for treatment completion. Using retinoblastoma as a case example, we propose applying stage-based intervention models in critical stages of care, such as the Precaution Adoption Process Model to decrease delay to diagnosis and a Transtheoretical Model to increase treatment completion rates in resource-limited settings. SUMMARY: Stage-based theories recognize that improved cure and survival outcomes will require supportive strategies to progress households, communities, and social and economic institutions from being unaware and unengaged to committed and sustained in their respective roles. Applying a stage-based model lens to programmatic interventions in resource-limited settings has potential for visible improvement in outcomes for children with retinoblastoma and other cancers.