Carol Woodell

Interventions to prevent post-traumatic stress disorder: a systematic review.

CONTEXT Traumatic events are prevalent worldwide; trauma victims seek help in numerous clinical and emergency settings. Using effective interventions to prevent post-traumatic stress disorder (PTSD) is increasingly important. This review assessed the efficacy, comparative effectiveness, and harms of psychological, pharmacologic, and emerging interventions to prevent PTSD. EVIDENCE ACQUISITION The following sources were searched for research on interventions to be included in the review: MEDLINE; Cochrane Library; CINAHL; EMBASE; PILOTS (Published International Literature on Traumatic Stress); International Pharmaceutical Abstracts; PsycINFO; Web of Science; reference lists of published literature; and unpublished literature (January 1, 1980 to July 30, 2012). Two reviewers independently selected studies, extracted data or checked accuracy, assessed study risk of bias, and graded strength of evidence. All data synthesis occurred between January and September 2012. EVIDENCE SYNTHESIS Nineteen studies covered various populations, traumas, and interventions. In meta-analyses of three trials (from the same team) for people with acute stress disorder, brief trauma-focused cognitive behavioral therapy was more effective than supportive counseling in reducing the severity of PTSD symptoms (moderate-strength); these two interventions had similar results for incidence of PTSD (low-strength); depression severity (low-strength); and anxiety severity (moderate-strength). PTSD symptom severity after injury decreased more with collaborative care than usual care (single study; low-strength). Debriefing did not reduce incidence or severity of PTSD or psychological symptoms in civilian traumas (low-strength). Evidence about relevant outcomes was unavailable for many interventions or was insufficient owing to methodologic shortcomings. CONCLUSIONS Evidence is very limited regarding best practices to treat trauma-exposed individuals. Brief cognitive behavioral therapy may reduce PTSD symptom severity in people with acute stress disorder; collaborative care may help decrease symptom severity post-injury.

Review and special articleInterventions to Prevent Post-Traumatic Stress Disorder: A Systematic Review

CONTEXT Traumatic events are prevalent worldwide; trauma victims seek help in numerous clinical and emergency settings. Using effective interventions to prevent post-traumatic stress disorder (PTSD) is increasingly important. This review assessed the efficacy, comparative effectiveness, and harms of psychological, pharmacologic, and emerging interventions to prevent PTSD. EVIDENCE ACQUISITION The following sources were searched for research on interventions to be included in the review: MEDLINE; Cochrane Library; CINAHL; EMBASE; PILOTS (Published International Literature on Traumatic Stress); International Pharmaceutical Abstracts; PsycINFO; Web of Science; reference lists of published literature; and unpublished literature (January 1, 1980 to July 30, 2012). Two reviewers independently selected studies, extracted data or checked accuracy, assessed study risk of bias, and graded strength of evidence. All data synthesis occurred between January and September 2012. EVIDENCE SYNTHESIS Nineteen studies covered various populations, traumas, and interventions. In meta-analyses of three trials (from the same team) for people with acute stress disorder, brief trauma-focused cognitive behavioral therapy was more effective than supportive counseling in reducing the severity of PTSD symptoms (moderate-strength); these two interventions had similar results for incidence of PTSD (low-strength); depression severity (low-strength); and anxiety severity (moderate-strength). PTSD symptom severity after injury decreased more with collaborative care than usual care (single study; low-strength). Debriefing did not reduce incidence or severity of PTSD or psychological symptoms in civilian traumas (low-strength). Evidence about relevant outcomes was unavailable for many interventions or was insufficient owing to methodologic shortcomings. CONCLUSIONS Evidence is very limited regarding best practices to treat trauma-exposed individuals. Brief cognitive behavioral therapy may reduce PTSD symptom severity in people with acute stress disorder; collaborative care may help decrease symptom severity post-injury.

Predictors of crop diversification: a survey of tobacco farmers in North Carolina (USA)

OBJECTIVE To assess the attitudes and behaviours of North Carolina tobacco farmers around crop diversification. DESIGN Cross-sectional telephone survey. PARTICIPANTS Active tobacco farmers in 14 North Carolina counties (n = 1236), interviewed between January and April 1997 (91% response rate). OUTCOME MEASURES Interest in, experience with, and perceived barriers to diversification. RESULTS Most farmers (95%) grew/raised a commodity other than tobacco (mean = 2.8). A total of 60% of farmers expressed interest in trying other on-farm activities to supplement their tobacco and 60% reported taking action in the past year around supplementation. Younger age and college education were positively associated with interest. College education, off-farm income, and larger farm size were associated with the number of actions taken. For perceived external barriers to diversification, use of tobacco, percent income from tobacco, lack of college education, and younger age were most strongly associated with the number of barriers. For internal barriers (personal factors), percent income from tobacco, use of tobacco, and lack of college education were most strongly associated with the number of barriers. CONCLUSIONS Most farmers were involved in diverse operations and expressed interest in continuing to diversify, although the breadth of diversification was narrow. Farmers noted many barriers to diversifying. If conventional production and marketing techniques are employed for non-tobacco alternatives, these alternatives may not provide the sustainable profitability that tobacco has afforded. Competition from foreign tobacco growers is the primary threat to the future of American growers and tobacco dependent communities.

Primary Care Screening and Treatment for Latent Tuberculosis Infection in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE Five to ten percent of individuals with latent tuberculosis infection (LTBI) progress to active tuberculosis (TB) disease. Identifying and treating LTBI is a key component of the strategy for reducing the burden of TB disease. OBJECTIVE To review the evidence about targeted screening and treatment for LTBI among adults in primary care settings to support the US Preventive Services Task Force in updating its 1996 recommendation. DATA SOURCES MEDLINE, Cochrane Library, and trial registries, searched through August 3, 2015; references from pertinent articles; and experts. Literature surveillance was conducted through May 31, 2016. STUDY SELECTION English-language studies of LTBI screening, LTBI treatment with recommended pharmacotherapy, or accuracy of the tuberculin skin test (TST) or interferon-gamma release assays (IGRAs). Studies of individuals for whom LTBI screening and treatment is part of public health surveillance or disease management were excluded. DATA EXTRACTION AND SYNTHESIS Two investigators independently reviewed abstracts and full-text articles. When at least 3 similar studies were available, random-effects meta-analysis was used to generate pooled estimates of outcomes. MAIN OUTCOMES AND MEASURES Sensitivity, specificity, reliability, active TB disease, mortality, hepatotoxicity, and other harms. RESULTS The review included 72 studies (n = 51 711). No studies evaluated benefits and harms of screening compared with no screening. Pooled estimates for sensitivity of the TST at both 5-mm and 10-mm induration thresholds were 0.79 (5-mm: 95% CI, 0.69-0.89 [8 studies, n = 803]; 10 mm: 95% CI, 0.71-0.87 [11 studies; n = 988]), and those for IGRAs ranged from 0.77 to 0.90 (57 studies; n = 4378). Pooled estimates for specificity of the TST at the 10-mm and 15-mm thresholds and for IGRAs ranged from 0.95 to 0.99 (34 studies; n = 23 853). A randomized clinical trial (RCT) of 24 weeks of isoniazid in individuals with pulmonary fibrotic lesions and LTBI (n = 27 830) found a reduction in absolute risk of active TB at 5 years from 1.4% to 0.5% (relative risk [RR], 0.35 [95% CI, 0.24-0.52]) and an increase in absolute risk for hepatoxicity from 0.1% to 0.5% (RR, 4.59 [95% CI, 2.03-10.39]) for 24 weeks of daily isoniazid compared with placebo. An RCT (n = 6886) found that 3 months of once-weekly rifapentine plus isoniazid was noninferior to 9 months of isoniazid alone for preventing active TB. The risk difference for hepatoxicity comparing isoniazid with rifampin ranged from 3% to 7%, with a pooled RR of 3.29 (95% CI, 1.72-6.28 [3 RCTs; n = 1327]). CONCLUSIONS AND RELEVANCE No studies evaluated the benefits and harms of screening compared with no screening. Both the TST and IGRAs are moderately sensitive and highly specific within countries with low TB burden. Treatment reduced the risk of active TB among the populations included in this review. Isoniazid is associated with higher rates of hepatotoxicity than placebo or rifampin.

Translating Evidence-Based Interventions Into Practice: The Design and Development of the Merck Childhood Asthma Network, Inc. (MCAN)

Pediatric asthma is a multifactorial disease, requiring complex, interrelated interventions addressing children, families, schools, and communities. The Merck Childhood Asthma Network, Inc. (MCAN) is a nonprofit organization that provides support to translate evidence-based interventions from research to practice. MCAN developed the rationale and vision for the program through a phased approach, including an extensive literature review, stakeholder engagement, and evaluation of funding gaps. The analysis pointed to the need to identify pediatric asthma interventions implemented in urban U.S. settings that have demonstrated efficacy and materials for replication and to translate the interventions into wider practice. In addition to this overall MCAN objective, specific goals included service and system integration through linkages among health care providers, schools, community-based organizations, patients, parents, and other caregivers. MCAN selected sites based on demonstrated ability to implement effective interventions and to address multiple contexts of pediatric asthma prevention and management. Selected MCAN program sites were mature institutions or organizations with significant infrastructure, existing funding, and the ability to provide services without requiring a lengthy planning period. Program sites were located in communities with high asthma morbidity and intended to integrate new elements into existing programs to create comprehensive care approaches.

Desired Attributes and Skills of Program Managers in Translation of Evidence-Based Interventions

Successful chronic disease project management, especially of multiyear initiatives using evidence-based interventions (EBIs), is of great importance to funders, health care decision makers, and researchers, particularly in light of limited funding. However, a gap in knowledge may exist regarding which attributes and skills are most desirable in a program manager to help him or her ensure successful implementation of EBIs. Although some literature examines the dynamics contributing to the success of community coalitions, public health leadership, and community health education, there is minimal literature exploring the significance of a program manager’s role in the conceptualization, implementation, and sustainability of initiatives to improve patient and community health. The authors present their experiences as participants in a large-scale asthma initiative implemented in priority communities, as well as results of a survey distributed among all personnel of the program sites. The survey aimed to assess the key skills and attributes, in addition to contextual factors, that contribute to the strength of a program manager overseeing EBIs in asthma initiatives. The results suggest that certain attributes and skills are desirable in recruiting and hiring of a program manager, especially when augmented by ongoing skill-building training, and can help ensure program and research success.

Media coverage of tobacco diversification: tradeoffs for community health:

As part of a tobacco farmer diversification randomized intervention study in 14 eastern North Carolina counties, a media content analysis of 16 local newspapers was conducted. All available issues of each of the newspapers from the period 1 November 1996, through 31 December 1999, were reviewed, and all relevant articles were clipped, coded, and entered into a database. Media coverage intensity was compared, qualitatively, with data from interviews with local civic, health, and religious leaders. There was, on average, only one tobacco diversification article in every 100 newspaper issues. The hypothesis that coverage of tobacco diversification and tobacco control would become more favorable in the intervention counties over time was not supported. Interview data showed that organizational leaders placed a higher priority on tobacco diversification policy issues than evidenced by media coverage.

The role of patient navigators in improving caregiver management of childhood asthma

Childhood asthma is a significant public health problem in the United States. Barriers to effective asthma management in children include the need for caregivers to identify and manage diverse environmental triggers and promote appropriate use of preventive asthma medications. Although health care providers may introduce asthma treatments and care plans, many providers lack the time and capacity to educate caregivers about asthma in an ongoing, sustained manner. To help address these complexities of asthma care, many providers and caregivers rely on patient navigators (defined as persons who provide patients with a particular set of services and who address barriers to care) (Dohan & Schrag, 2005). Despite growing interest in their value for chronic disease management, researchers and providers know little about how or what benefits patient navigators can provide to caregivers in managing asthma in children. To explore this issue, we conducted a mixed-method evaluation involving focus groups and a survey with caregivers of children with moderate-to-severe asthma who were enrolled in the Merck Childhood Asthma Network Initiative (MCAN). Findings suggest that patient navigators may support children’s asthma management by providing individualized treatment plans and hands-on practice, improving caregivers’ understanding of environmental triggers and their mitigation, and giving clear, accessible instructions for proper medication management. Study results may help to clarify and further develop the role of patient navigators for the effective management of asthma in children. Acknowledgments This research was supported under contract #35635 between the Merck Childhood Asthma Network and RTI International. RTI Press: Research Report Patient Navigators and Childhood Asthma Management 1 RTI Press Publication No. RR-0030-1704. Research Triangle Park, NC: RTI Press. https://doi.org/10.3768/rtipress.2017.rr.0030.1704 Introduction Childhood asthma is a critical public health problem in the United States (Akinbami, Centers for Disease Control, & Prevention National Center for Health Statistics, 2006; Akinbami et al., 2012; Eder, Ege, & von Mutius, 2006). The condition affects over 6 million children 0 to 17 years of age, and the prevalence of childhood asthma increased steadily at a rate of 1.4 percent annually between 2001 and 2010 (Centers for Disease Control & Prevention, 2013; Moorman et al., 2012). Rates of asthma attacks declined during this time, but only modestly, from 61.7 to 58.3 percent (Moorman et al., 2012). Recent reports on trends of asthma prevalence in children indicate a plateau from 2010 to 2013, though disparities among certain subgroups increased, including increased prevalence for 10-to-17-yearolds, poor children, and children living in the South (Akinbami, Simon, & Rossen, 2016). The findings demonstrate a great need for continued improvement in the management of childhood asthma. Caregivers must often assume the responsibility for managing childhood asthma. Caregivers of children with asthma need to understand the condition, identify and mitigate environmental triggers, and administer treatments appropriately—or help their child in taking these responsibilities. These tasks are difficult to remember, master, and carry out, however, and for these reasons, they are a major source of poor control of asthma (Akinbami et al., 2006; Modi & Quittner, 2006). Health care providers often lack the time or capacity to effectively coach and counsel caregivers in all the aspects of self-management for chronic illnesses like asthma (Wagner et al., 2001). To support the complex needs of chronic disease management, many patients, caregivers, and providers rely on patient navigators (Fischer, Sauaia, & Kutner, 2007; Fowler, Steakley, Garcia, Kwok, & Bennett, 2006; Viswanathan et al., 2009). Patient navigators provide patients with a particular set of services and address barriers to care (Dohan & Schrag, 2005). For asthma, patient navigators work with caregivers and their children to provide health education and to address the various responsibilities of and barriers to asthma management. In a 2010 study on patient navigators for minority and poor asthma patients, patient participants identified better asthma management through informational (education) and instrumental (physical) support that a patient navigator provided (Black et al., 2010). Adding to these perceived benefits, provider participants (nurses and physicians) argued that patient navigators may use knowledge of patients’ environment and social context to improve the effectiveness of asthma care plans. Overall research on patient navigators suggests that these professionals may augment the role of the health care provider, including provision of access to feasible, costeffective, and individualized care for caregivers and children with asthma (Black et al., 2010). The patient navigator’s facilitative function complements the goals of the Affordable Care Act (ACA), including the aim of improving population health and the individual patient care experience at reduced cost (Berwick, Nolan, & Whittington, 2008). Patient navigators may also advance the ACA’s goal of practicing transformation models, such as the use of Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs) that emphasize closely managing high-risk patients and engaging them in care decisions, treatment, and discussions about barriers to adherence (Meyers et al., 2010). From 2005 to 2009, the Merck Childhood Asthma Network, Inc. (MCAN) implemented evidencebased interventions to mitigate childhood asthma in five project sites: Chicago, Los Angeles, New York City, Philadelphia, and San Juan, Puerto Rico. All intervention communities had both significant pockets of poverty and high asthma morbidity. Each site had unique evidence-based interventions, and the details of these variations are described elsewhere (Malveaux & Butterfoss, 2011; Viswanathan et al., 2011a). Across all sites, however, interventions included established components for quality asthma care, including (1) education on asthma care; (2) control of environmental factors that affect or trigger asthma (e.g., animal dander, pollens); and (3) pharmacologic therapy (e.g., inhaled corticosteroids) (National Heart Lung and Blood Institute, 2007). 2 Smith et al., 2017 RTI Press: Research Report RTI Press Publication No. RR-0030-1704. Research Triangle Park, NC: RTI Press. https://doi.org/10.3768/rtipress.2017.rr.0030.1704 Each MCAN project also embraced key elements of successful community-based asthma programs by emphasizing community stakeholder partnerships and addressing or accounting for the physical and social environment (Clark, Lachance, Milanovich, Stoll, & Awad, 2009). Patient navigators were involved in all interventions to facilitate access to high-quality, community-based asthma care and to promote effective self-management. The individuals recruited to the patient navigator position had no formal health background, except in the Los Angeles intervention, which used school nurses. Most patient navigators lived or worked in the targeted communities. They led health education activities (in the clinic, the home, or both), performed environmental assessments of conditions in the home that could trigger or exacerbate asthma symptoms, and linked families to social services and other resources as needed. Despite research documenting the benefits of patient navigators for chronic disease management, we know little about how these benefits are actually realized, including assisting caregivers with asthma management in children (Crocker et al., 2011; Krieger, Song, & Philby, 2015; Krieger, Takaro, Song, Beaudet, & Edwards, 2009; Perez-Escamilla et al., 2015; Rodday et al., 2015). In this study we aim to help explore this issue by complementing MCAN evaluation findings with caregivers’ perceptions of the factors and conditions by which patient navigators support their effective management of their child’s asthma. This study addresses the MCAN initiative key evaluation question: Have MCAN programs improved caregiver knowledge of and positive behaviors toward asthma? And with regard to understanding the process behind these changes in knowledge and behavior, we ask: How has the role of the patient navigator in MCAN interventions supported caregivers’ capacity to (1) mitigate their children’s exposure to environmental triggers and (2) improve medication management? Findings from this study may help to identify key pathways and high-impact points for patient navigators to shape and improve caregivers’ understanding and management of children’s asthma. Methods To investigate how patient navigators may support caregivers’ management of their children’s asthma, we compared caregiver responses to a common survey with findings from caregiver focus groups conducted across MCAN intervention sites. Our goal was to assess the degree to which caregivers effectively addressed environmental triggers and medication management, and then to understand how patient navigators may have influenced these efforts. This approach follows a convergent parallel mixedmethod study design, in which both methods occur concurrently, with the aim of integrating the results in the analyses to more completely understand project outcomes. This mixed-method approach is ideal for the study of complex phenomenon in real-world settings requiring multiple sources and types of data to understand the context of the problem (Creswell & Plano Clark, 2011). Focus Groups A two-member team of independent investigators with knowledge of the MCAN initiative conducted six focus groups across the five MCAN communities. Eligible participants were caregivers (usually parents) of children with moderate-to-severe asthma who were enrolled in the MCAN initiative and who participated in an intervention (or program) in one of the five intervention sites. Program staff