Jeannette E. South-Paul

Obesity as a risk factor for premenstrual syndrome.

Purpose: To determine the association between obesity and Premenstrual Syndrome (PMS). Methods: A cross-sectional study was conducted using a random-digit dialing method. The sampling frame consisted of all possible area codes, exchanges, and 4-digit suffixes in Virginia. A total of 874 women between the ages of 18–44 residing in the state of Virginia between August 1 and September 15, 1994 were interviewed. Cases were defined as women who reported severe or extreme PMS symptom changes using the Shortened Premenstrual Assessment Form. The main exposure variable was obesity as measured by Body Mass Index. Results: The prevalence of PMS in Virginia was 10.3 percent. Obese women (BMI ⩾ 30) had nearly a three-fold increased risk for PMS than non-obese women OR = 2.8 (95% CI = 1.1, 7.2). PMS was more prevalent among whites, younger women, and smokers. Conclusion: This data provided evidence that obesity is strongly associated with PMS. Since obesity is a modifiable risk factor, PMS management strategies should not only consider factors such as, high stress, and smoking but also obesity.

The Effects of Barriers on Health Related Quality of Life (HRQL) and Compliance in Adult Asthmatics who are Followed in an Urban Community Health Care Facility

This cross sectional descriptive study sought to identify perceived barriers to follow-up care for adult asthmatics who are followed in two community health care facilities. A second purpose of the study was to determine the effect of any barriers to Health Related Quality of Life (HRQL) and compliance in the sample. Thirty-four adults completed a demographic and health status survey, the MiniAQLQ and the EWash Access to Health Care Survey. “Long waiting time in provider’s office,” “someone had to miss work,” “cost of care too much, “and “long wait for an appointment” were the most prevalent perceived barriers in the sample. “Lack of transportation” was significantly associated with study participants who receive health care at one site or who stated the emergency room as their usual place of care. “Someone had to miss work” was significantly correlated with the following variables: employment, a higher annual household income, 1–2 daily medications for asthma, no overnight hospitalizations for asthma and no psychological co-morbidities. A higher reported HQOL was significantly correlated with study participants whose medical care needs were met and found access to local health care services. The only perceived barrier that was significantly correlated with compliance was study participants who “sometimes” had to reschedule an appointment with a health care provider due to “lack of transportation.” The present study suggests that strategies designed to decrease the perceived barriers might improve compliance with the treatment regime, thus decreasing costs, absenteeism, and lack of continuity.

Using the 4 Pillars™ Practice Transformation Program to increase adult Tdap immunization in a randomized controlled cluster trial

INTRODUCTION National adult Tdap vaccination rates are low, reinforcing the need to increase vaccination efforts in primary care offices. The 4 Pillars™ Practice Transformation Program is an evidence-based, step-by-step guide to improving primary care adult vaccination with an online implementation tracking dashboard. This study tested the effectiveness of an intervention to increase adult Tdap vaccination that included the 4 Pillars™ Program, provider education, and one-on-one coaching of practice-based immunization champions. METHODS 25 primary care practices participated in a randomized controlled cluster trial (RCCT) in Year 1 (6/1/2013-5/31/2014) and a pre-post study in Year 2 (6/1/2014-1/31/2015). Baseline year was 6/1/2012-5/31/2013, with data analyzed in 2016. Demographic and vaccination data were derived from de-identified electronic medical record (EMR) extractions. The primary outcomes were vaccination rates and percentage point (PP) changes/year. RESULTS The cohort consisted of 70,549 patients ⩾18years who were seen in the practices ⩾1 time each year, with a baseline mean age=55years; 35% were men; 56% were non-white; 35% were Hispanic and 20% were on Medicare. Baseline vaccination rate averaged 35%. In the Year 1 RCCT, cumulative Tdap vaccination increased significantly in both intervention and control groups; in both cities, the percentage point increases in the intervention groups (7.7 PP in Pittsburgh and 9.9 PP in Houston) were significantly higher (P<0.001) than in the control groups (6.4 PP in Pittsburgh and 7.6 PP in Houston). In the Year 2 pre-post study, in both cities, active intervention groups increased rates significantly more (6.2 PP for both) than maintenance groups (2.2 PP in Pittsburgh and 4.1 PP in Houston; P<0.001). CONCLUSIONS An intervention that includes the 4 Pillars™ Practice Transformation Program, staff education and coaching is effective for increasing adult Tdap immunization rates within primary care practices. Clinical Trial Registry Name/Number: NCT01868334.

Pain and Depression in a Cohort of Underserved, Community-Dwelling Primary Care Patients

Purpose: Almost 17% of the US population exhibits a major depressive disorder in their lifetimes. Prevalence data show that whites experience depression earlier than African Americans, and women have a higher prevalence than men. Less is known regarding depression among underserved minority populations. The goal of our study was to examine the relationship of depression and associated self-reported conditions in participants enrolled in a community-based research registry, a substantial number of whom were underrepresented minorities. Methods: This study used a research registry of community members who had expressed interest in participating in health education projects conducted by the Center for Primary Care Community-Based Research. The patients received care at 10 family health centers. Participants were surveyed regarding family history of depression/anxiety and associated symptoms. Descriptive analyses, univariate analyses, and logistic regressions were used. Results: The population (N = 2421) included women (72.2%), African Americans (54.9%), and reported good or very good general health (68.9%). Comorbid pain was found, with headache as the predominant complaint. Compared with nonwhites, whites had a significantly higher prevalence of current depression (26.3% vs. 23.8%; P = .01), current anxiety (25.5% vs. 16.6%), and current headache (14.2% vs. 11.2%). Whites also had a higher prevalence of a family history of depression (38.4% vs. 32.1%) and anxiety (8.9% vs. 7.7%) and of taking depression (22.4% vs. 14.8%) and anxiety (15.8% vs. 7.8%) medications. However, nonwhites had a higher prevalence of leg pain (18.8% vs. 14.9%) but a lower prevalence of headache (11.2% vs. 14.2%). Conclusions: Pain was common in patients with comorbid behavioral conditions. Headache was more common in whites, whereas leg pain was more common in nonwhites. Physicians should screen for depression and anxiety in patients with headache and other pain symptoms.

Disparities in Health Care for Minorities: An Ecological Perspective

Disparities in health and health care for minorities have existed in the United States for decades and result from an interconnected array of factors. Potential sources of disparities relate to institutional-level, patient-level, and provider-level factors. Institutional-level factors that disproportionately affect African American and Hispanic American patients are lack of access to quality healthcare facilities and variations in insurance status. Patient behaviors (such as tobacco use, diet, and exercise patterns) impact risk for many chronic diseases for which there are significant disparities (such as cardiovascular disease, diabetes, and hypertension). Provider-level factors such as variations in treatments related to patient characteristics have been well-described. Quality care is based upon matching patients with a patient-centered medical home where the patient is known, the patient can name his/her provider, and first-contact, continuous, compassionate, collaborative, and comprehensive care is available. That care should address physical, behavioral, oral, and preventive health components of the patient’s needs.

Sociocultural Issues in Health Care

The world is facing movements of peoples unparalleled in history. Even the heartland of the American continent, which has seen few new population groups since the European immigration of the nineteenth century, has felt the effects of this restive population shift during the late 1980s and 1990s. Physicians who themselves have had little experience outside their own cultural environment are now dealing with health and social issues of patients who approach their surroundings in profoundly different ways than they might themselves. Yet the differences have always been present.

Negotiation with Patients

A 49-year-old woman presents to the emergency room with multiple rib fractures and a displaced, pathologic, subtrochanteric fracture of the left hip. She is 4 years post right radical mastectomy for breast cancer. She is in severe pain and wants treatment. On obtaining a history, completing a physical examination, and obtaining radiographs of the affected areas, the patient notes that she is a Jehovah’s Witness and will not allow blood transfusions. She notes that if family or friends see her receiving a transfusion, they will think she has betrayed her faith.