Linda Ciofu Baumann

Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement

DESCRIPTION Update of the 2009 US Preventive Services Task Force (USPSTF) recommendation on screening for depression in adults. METHODS The USPSTF reviewed the evidence on the benefits and harms of screening for depression in adult populations, including older adults and pregnant and postpartum women; the accuracy of depression screening instruments; and the benefits and harms of depression treatment in these populations. POPULATION This recommendation applies to adults 18 years and older. RECOMMENDATION The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B recommendation).

Screening for High Blood Pressure in Adults: U.S. Preventive Services Task Force Recommendation Statement

DESCRIPTION Update of the 2007 U.S. Preventive Services Task Force (USPSTF) reaffirmation recommendation statement on screening for high blood pressure in adults. METHODS The USPSTF reviewed the evidence on the diagnostic accuracy of different methods for confirming a diagnosis of hypertension after initial screening and the optimal rescreening interval for diagnosing hypertension. POPULATION This recommendation applies to adults aged 18 years or older without known hypertension. RECOMMENDATION The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. (A recommendation) The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

Peer Support For Self-Management Of Diabetes Improved Outcomes In International Settings

Self-management of diabetes is essential to reducing the risks of associated disabilities. But effective self-management is often short-lived. Peers can provide the kind of ongoing support that is needed for sustained self-management of diabetes. In this context, peers are nonprofessionals who have diabetes or close familiarity with its management. Key functions of effective peer support include assistance in daily management, social and emotional support, linkage to clinical care, and ongoing availability of support. Using these four functions as a template of peer support, project teams in Cameroon, South Africa, Thailand, and Uganda developed and then evaluated peer support interventions for adults with diabetes. Our initial assessment found improvements in symptom management, diet, blood pressure, body mass index, and blood sugar levels for many of those taking part in the programs. For policy makers, the broader message is that by emphasizing the four key peer support functions, diabetes management programs can be successfully introduced across varied cultural settings and within diverse health systems.

Screening for Vitamin D Deficiency in Adults: U.S. Preventive Services Task Force Recommendation Statement

DESCRIPTION New USPSTF recommendation on screening for vitamin D deficiency in adults. METHODS The USPSTF reviewed the evidence on screening for and treatment of vitamin D deficiency, including the benefits and harms of screening and early treatment. POPULATION This recommendation applies to community-dwelling, nonpregnant adults aged 18 years or older who are seen in primary care settings and are not known to have signs or symptoms of vitamin D deficiency or conditions for which vitamin D treatment is recommended. RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults. (I statement).

Screening for Oral Cancer: U.S. Preventive Services Task Force Recommendation Statement

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms. It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment. The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms. Summary of Recommendation and Evidence The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral cancer in asymptomatic adults. (I statement) See the Clinical Considerations section for additional information and suggestions for practice regarding the I statement. See the Figure for a summary of the recommendation and suggestions for clinical practice. Figure. Screening for oral cancer: clinical summary of U.S. Preventive Services Task Force recommendation. Appendix Table 1 describes the USPSTF grades, and Appendix Table 2 describes the USPSTF classification of levels of certainty about net benefit (both tables are available at www.annals.org). Appendix Table 1. What the USPSTF Grades Mean and Suggestions for Practice Appendix Table 2. USPSTF Levels of Certainty Regarding Net Benefit Supplement. Consumer Fact Sheet Rationale Importance Oral cavity cancer (or oral cancer) and pharyngeal cancer include cancer of the lip, oral cavity, and pharynx (nasopharynx, oropharynx, and laryngopharynx). Ninety percent of all cases of oral cavity and pharyngeal cancer are classified as squamous cell carcinoma (1). An estimated 41 380 new cases of and 7890 deaths from cancer of the oral cavity and pharynx will occur in 2013 (2). At the time of diagnosis, more than 50% of persons with oral and pharyngeal cancer have regional or distant metastases (3). Screening for oral cancer may be helpful if potentially malignant disorders can be identified earlier and treated successfully. Oral and oropharyngeal cancer have different causes. Oral cavity cancer is predominantly caused by tobacco and alcohol use. Oropharyngeal cancer, another subset of neck and head cancer, includes human papillomavirus (HPV) as an important risk factor. The incidence and mortality rate of oral cancer has been decreasing in the United States, presumably because of reduced tobacco and alcohol use. However, HPV-related oropharyngeal cancer is increasing in incidence. Oropharyngeal cancer includes lesions of the tonsil, oropharynx, and base of the tongue. The epidemiology of HPV-related oropharyngeal cancer is evolving and could have important implications for identifying high-risk populations that might benefit from screening. Detection The USPSTF found inadequate evidence that the oral screening examination accurately detects oral cancer. Benefits of Detection and Early Treatment The USPSTF found inadequate evidence that screening for oral cancer and treatment of screen-detected oral cancer improves morbidity or mortality. Harms of Detection and Early Treatment The USPSTF found inadequate evidence on the harms of screening. No study reported on harms from the screening test or from false-positive or false-negative results. Potential diagnostic harms are primarily related to the harms of biopsy for suspected oral cancer or its potential precursors. Harms of treatment for screen-detected oral cancer and its potentially malignant precursors (leukoplakia and erythroplakia) may result from complications of surgery (first-line treatment), radiation, and chemotherapy. The natural history of screen-detected oral cancer or potentially malignant disorders is unclear; thus, the magnitude of overdiagnosis due to screening is unknown. USPSTF Assessment The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of screening for oral cancer in asymptomatic adults by primary care providers. Clinical Considerations Patient Population Under Consideration This recommendation applies to asymptomatic adults aged 18 years or older who are seen by primary care providers. This recommendation focuses on screening (visual inspection and palpation) of the oral cavity performed by primary care providers and not dental providers or otolaryngologists. Assessment of Risk Tobacco and alcohol use are major risk factors for oral cancer. A total of 20% to 30% of cases of oral cancer worldwide are attributable to cigarette smoking (1). In the United States, up to 75% of cases of oral cancer may be attributable to tobacco and alcohol use (4). Additional risk factors include male sex, older age, use of betel quid, ultraviolet light exposure, infection with Candida or bacterial flora, and a compromised immune system (1). Sexually transmitted oral HPV infection (HPV-16) has recently been recognized as an increasingly important risk factor for oropharyngeal cancer. In the United States, the prevalence of oropharyngeal cancer due to oral HPV infection is probably as high as 80% to 95% (5). The prevalence of oral HPV infection is associated with age, sex, number of sexual partners, and number of cigarettes smoked per day. The effect of multifactorial risk assessment and screening for risk factors on oral cancer morbidity and mortality is unknown (1). Screening Tests The primary screening test for oral cancer is a systematic clinical examination of the oral cavity. According to the World Health Organization and the National Institute of Dental and Craniofacial Research, an oral cancer screening examination should include a visual inspection of the face, neck, lips, labial mucosa, buccal mucosa, gingiva, floor of the mouth, tongue, and palate. Mouth mirrors can help visualize all surfaces. The examination also includes palpating the regional lymph nodes, tongue, and floor of the mouth. Any abnormality that lasts for more than 2 weeks should be reevaluated and considered for biopsy (1, 6). Oropharyngeal cancer is difficult to visualize and is usually located at the base of the tongue (the back third of the tongue), the soft palate (the back part of the roof of the mouth), the tonsils, and the side and back walls of the throat. A comprehensive examination of the oropharynx may require referral to a dental provider or specialist, which is outside the scope of this recommendation. Additional tests proposed as adjuncts to the oral cancer screening examination include toluidine blue dye staining, chemiluminescent and autofluorescent lighting devices, and brush cytopathology. These screening and adjunct tests have not been adequately tested in primary care nondental settings. Although there is interest in screening for oral HPV infection, medical and dental organizations do not recommend it. Currently, no screening test for oral HPV infection has been approved by the U.S. Food and Drug Administration (FDA). Evaluating the accuracy of tests that detect oral HPV infection is a potentially promising area of research. Suggestions for Practice Regarding the I Statement This recommendation is intended for primary care providers and does not pertain to dental providers or otolaryngologists. Dental care providers and otolaryngologists may conduct a comprehensive examination of the oral cavity and pharynx during the clinical encounter. In deciding whether to screen for oral cancer, primary care providers should consider the following factors. Potential Preventable Burden Up to 75% of cases of oral cancer may be attributed to tobacco and alcohol use (4). Since 1979, the incidence rate of oral cavity cancer in the United States has been decreasing because of the reduced consumption of alcohol and smoking prevalence (1). During this period, the incidence of HPV-positive oropharyngeal squamous cell carcinoma has increased. Cancer registry data have shown that from 1988 to 2004, HPV-negative oropharyngeal cancer has decreased from 2.0 cases to 1.0 case per 100 000 persons and HPV-positive oropharyngeal cancer has increased more than 3-fold from 0.8 case to 2.6 cases per 100 000 persons (7). The overall prevalence of oral HPV infection is estimated to be 6.9% in adults aged 14 to 69 years in the United States. However, HPV prevalence can be as high as 20% for persons who have more than 20 lifetime sexual partners or currently use tobacco (more than 1 pack of cigarettes per day) (8). The prevalence of type-specific HPV-16 oral infection is estimated at 1% in adults aged 14 to 69 years (an estimated 2.13 million infected persons) (8). Human papillomavirus-16 is associated with approximately 85% to 95% of cases of HPV-positive oropharyngeal cancer (5). Therefore, the increasing role of oral HPV infection as a risk factor for oropharyngeal cancer may warrant future assessment of the independent effect of HPV-16 on incidence and outcomes of oropharyngeal cancer and the health effect of screening persons who are HPV-16positive. Potential Harms Suspected oral cancer or its precursors (such as erythroplakia, due to its high risk for transformation to cancer) detected through examination require confirmation by tissue biopsy, which may lead to harms. Harms of treatment of screen-detected oral cancer and its potential precursors (leukoplakia and erythroplakia) may result from complications of surgery, radiotherapy, and chemotherapy. The natural history of screen-detected oral cancer is not well-understood, and as a result, the harms from overdiagnosis and overtreatment are unknown. Current Practice In a 2008 survey of U.S. adults, 29.4% of those aged 18 years or older reported ever having an oral cancer examination in which a physician, dentist, or other health professional pulled on their tong

Screening for Autism Spectrum Disorder in Young Children: US Preventive Services Task Force Recommendation Statement

DESCRIPTION New US Preventive Services Task Force (USPSTF) recommendation on screening for autism spectrum disorder (ASD) in young children. METHODS The USPSTF reviewed the evidence on the accuracy, benefits, and potential harms of brief, formal screening instruments for ASD administered during routine primary care visits and the benefits and potential harms of early behavioral treatment for young children identified with ASD through screening. POPULATION This recommendation applies to children aged 18 to 30 months who have not been diagnosed with ASD or developmental delay and for whom no concerns of ASD have been raised by parents, other caregivers, or health care professionals. RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for ASD in young children for whom no concerns of ASD have been raised by their parents or a clinician. (I statement).

Applying a Health Behavior Theory to Explore the Influence of Information and Experience on Arsenic Risk Representations, Policy Beliefs, and Protective Behavior

The common sense model (CSM) shows how people process information to construct representations, or mental models, that guide responses to health threats. We applied the CSM to understand how people responded to information about arsenic-contaminated well water. Constructs included external information (arsenic level and information use), experience (perceived water quality and arsenic-related health effects), representations, safety judgments, opinions about policies to mitigate environmental arsenic, and protective behavior. Of 649 surveys mailed to private well users with arsenic levels exceeding the maximum contaminant level, 545 (84%) were analyzed. Structural equation modeling quantified CSM relationships. Both external information and experience had substantial effects on behavior. Participants who identified a water problem were more likely to reduce exposure to arsenic. However, about 60% perceived good water quality and 60% safe water. Participants with higher arsenic levels selected higher personal safety thresholds and 20% reported a lower arsenic level than indicated by their well test. These beliefs would support judgments of safe water. A variety of psychological and contextual factors may explain judgments of safe water when information suggested otherwise. Information use had an indirect effect on policy beliefs through understanding environmental causes of arsenic. People need concrete information about environmental risk at both personal and environmental-systems levels to promote a comprehensive understanding and response. The CSM explained responses to arsenic information and may have application to other environmental risks.

Predictors of fat intake behavior differ between normal-weight and obese WIC mothers.

Purpose. To determine whether predictors of fat intake behavior were the same for normal-weight and obese WIC mothers when applying the PRECEDE-PROCEED model and to identify predictors for each group. Design. Proportional stratified convenience sampling. Subjects. Five hundred eighty-one nonpregnant, black and white normal-weight (n = 180) or obese (n = 401) women. Settings. The Special Supplemental Nutrition Program for Women, Infants and Children in six counties in southern Wisconsin. Measures. The independent variables were predisposing, enabling, and reinforcing factors. Predisposing factors included beliefs in diet and health, beliefs in diet and body shape, health concerns in food choice, health concerns in nutrition, and eating habits. Enabling factors were cost of food, availability of time to prepare food, and accessibility to purchase food. Reinforcing factors were weight control intentions, sensory appeal, and mood. The dependent variable was fat intake behavior. Structural equation modeling was performed. Results. When controlling for covariates, certain factors affecting fat intake behavior differed between the normal-weight and the obese groups. For the normal-weight group, only reinforcing factors were positively associated with fat intake behavior. For the obese group, reinforcing and enabling, but not predisposing, factors were positively associated with fat intake behavior. Conclusions. Interventions to modify low-income womens fat intake behavior might benefit from targeting behavioral predictors that differ with body size. Messages that emphasize weight control intentions, sensory appeal, and mood are likely to affect both normal-weight and obese women. Information about cost of food, availability of time to prepare food, and accessibility to purchase food is likely to be more effective with obese women.

Development and Validation of a Self-Efficacy Measure for Fat Intake Behaviors of Low-Income Women

OBJECTIVE To develop a valid self-efficacy measure for eating low-fat diets in low-income women. DESIGN Cognitive interviews followed by self-administered questionnaires. PARTICIPANTS/SETTINGS 206 (6 + 200) nonpregnant black and white women participating in Head Start and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in Wisconsin. VARIABLES MEASURES: A 13-item self-efficacy measure for eating low-fat diets. ANALYSIS Content analysis and factor analyses. RESULTS After cognitive interviews, 3 items were removed from a draft instrument. Factor analyses were carried out using data from 200 questionnaires that were randomly selected from a pool of 487 respondents: 100 for exploratory factor analysis (EFA) and 100 for confirmatory factor analysis (CFA). Based on EFA, the 10-item pool was further reduced to 8 items, and 3 domains emerged: negative affect, positive affect, and availability. The results of CFA showed excellent model fit to the data (chi 2/df = 1.2, non-normed fit index = 1.0, comparative fit index = 1.0, incremental fit index = 1.0, root mean square error of approximate =.046). This measure demonstrated excellent reliabilities (Cronbach alpha : .82-.92; composite reliability: .92-.99) and construct and convergent validities. CONCLUSIONS AND IMPLICATIONS Information obtained from this revised instrument can be used among low-income women to measure self-efficacy for eating low-fat diets. This is an important step in developing more targeted and thus more effective education messages to help low-income women modify their fat intake behaviors.

Development of an Instrument to Assess Predisposing, Enabling, and Reinforcing Constructs Associated with Fat Intake Behaviors of Low-Income Mothers

OBJECTIVE To establish reliability and construct and discriminant validity of selected factors adapted from the Health and Taste Attitudes Questionnaire developed in Finland and the Food Choice Questionnaire developed in England for use with low-income mothers in the United States. DESIGN Cross-sectional. SETTING Head Start and the Special Supplemental Nutrition Program for Women, Infants and Children sites in south-central Wisconsin. PARTICIPANTS A convenience sample of 211 nonpregnant non-Hispanic black and white women. VARIABLES MEASURED Predisposing, enabling, and reinforcing constructs of the PRECEDE-PROCEED model. ANALYSIS Factor analyses. RESULTS After modification, the resulting measurement models of predisposing, enabling, and reinforcing constructs demonstrated good reliability and construct and discriminant validity. These models showed excellent model fit (chi-square/df range 1.5-2.0, root mean square error of approximate range.05-.07, non-normed fit index range.97-1.0, comparative fit index range.98-1.0, incremental fit index range.98-1.0), with all factor loadings significant (P <.001). Items previously developed with European adults demonstrated different pattern structures in predisposing and enabling constructs but the same structures for reinforcing construct when applied to low-income mothers in the United States. CONCLUSION AND IMPLICATION This modified instrument provides a tool for researchers and educators to further explore factors affecting fat intake behaviors in low-income mothers.