Scott H. Frank

Tools, teamwork, and tenacity: an examination of family practice office system influences on preventive service delivery.

BACKGROUND Most research examining primary care office characteristics and preventive service delivery (PSD) has evaluated preventive service aids and equipment, while generally overlooking the complex interactions among multiple office systems where multiple factors influence the overall practice. We test a theoretical model of practice influences on PSD that accounts for Tools (preventive service aids/equipment), Teamwork (office organization), and Tenacity (prevention delivery attitudes). METHODS Office characteristics and 4454 patient visits were observed for 138 family physicians in northeast Ohio. Utilizing U.S. Preventive Services Task Force recommendations, age- and gender-specific PSD summary scores were computed for each patient and then averaged per physician. Multivariate analysis of variance tested office characteristic associations with PSD scores. RESULTS Tools were common, but most were not significantly associated with PSD scores. The Teamwork indicators of clear staff role expectations and shared vision among physician and staff existed, respectively, for 80 and 73% of physicians. A high average reported practice focus on prevention existed, despite low staff involvement in PSD (22.2%). Compared with Tools, more Teamwork and Tenacity characteristics were associated with the PSD scores. CONCLUSION Teamwork and Tenacity appear to be more important than Tools in delivering preventive services in primary care practices.

Capacity building for evidence-based decision making in local health departments: Scaling up an effective training approach

BackgroundThere are few studies describing how to scale up effective capacity-building approaches for public health practitioners. This study tested local-level evidence-based decision making (EBDM) capacity-building efforts in four U.S. states (Michigan, North Carolina, Ohio, and Washington) with a quasi-experimental design.MethodsPartners within the four states delivered a previously established Evidence-Based Public Health (EBPH) training curriculum to local health department (LHD) staff. They worked with the research team to modify the curriculum with local data and examples while remaining attentive to course fidelity. Pre- and post-assessments of course participants (n = 82) and an external control group (n = 214) measured importance, availability (i.e., how available a skill is when needed, either within the skillset of the respondent or among others in the agency), and gaps in ten EBDM competencies. Simple and multiple linear regression models assessed the differences between pre- and post-assessment scores. Course participants also assessed the impact of the course on their work.ResultsCourse participants reported greater increases in the availability, and decreases in the gaps, in EBDM competencies at post-test, relative to the control group. In adjusted models, significant differences (p < 0.05) were found in `action planning,’ `evaluation design,’ `communicating research to policymakers,’ `quantifying issues (using descriptive epidemiology),’ and `economic evaluation.’ Nearly 45% of participants indicated that EBDM increased within their agency since the training. Course benefits included becoming better leaders and making scientifically informed decisions.ConclusionsThis study demonstrates the potential for improving EBDM capacity among LHD practitioners using a train-the-trainer approach involving diverse partners. This approach allowed for local tailoring of strategies and extended the reach of the EBPH course.

Complexity of Measuring “Cigar Use” in Adolescents: Results From a Split Sample Experiment

INTRODUCTION Inclusion of brand-specific examples (BE) in health surveys assessing lifetime and current cigar use has been shown to impact response rates. A split sample experimental design was used to investigate whether these rates are consistent by race, gender, and geographic locale. METHODS The 2009 Cuyahoga County Youth Risk Behavior Survey was conducted among 20 randomly selected high schools. Two versions of the survey were created; the first included items assessing lifetime and current cigar use with no brand-specific examples (NBE) while the second included BE in the items assessing cigar use. Both survey versions were distributed randomly within selected classrooms in participating schools. RESULTS Within the City, both White and Black BE respondents reported higher lifetime cigar product use prevalence and current cigar product use compared to the NBE group; however, the difference was only significant among Black respondents (odds ratio [OR] = 1.45, 95% CI 1.02-2.06). In the Outer Ring, White BE respondents were significantly less likely to report lifetime cigar use (OR = 0.73, 95% CI: 0.54 - 0.98) and current cigar use (OR = 0.66, 95% CI: 0.44-0.99) when compared with White NBE respondents. CONCLUSIONS Inclusion of BE in current measures of cigar product use may improve product use estimates in at-risk groups. However, better estimation of cigar product use may be accomplished by creating additional items to assess the use of subtypes of cigars.

Consumption of alcoholic beverages among pregnant urban Ugandan women.

The World Health Organization estimated alcohol consumption in Uganda to be one of the highest in the world. We examined alcohol consumption among Ugandan women prior to and after learning of pregnancy. We developed a screening algorithm using factors that predicted alcohol consumption in this study. In 2006, we surveyed 610 women attending antenatal care at the national referral hospital in Kampala, Uganda about consumption of traditional and commercial alcoholic beverages before and after learning of pregnancy. Predictors of alcohol consumption during pregnancy were examined and a practical screening algorithm was developed for use in antenatal clinics. One hundred eighty women (30%) drank alcohol at least monthly before learning of their pregnancy. Among these women, almost one-third reported usual consumption of at least one beverage type at quantities that equal binging levels for women. Overall, 151 women (25%) consumed alcohol after learning of pregnancy. Commercial beverages, particularly beer, were consumed more often than traditional drinks. A two-stage screening algorithm asking women about their religion, male partner or friends’ drinking, and any lifetime drinking predicted self-reported consumption of alcohol during pregnancy with 97% sensitivity and 89% specificity. Alcohol consumption among pregnant Ugandan women attending antenatal care is high. A feasible screening algorithm can help providers target education and counseling to women who are likely drinking during pregnancy. Given the preference for commercial alcoholic beverages, it is recommended that labels be placed prominently on bottled alcoholic beverages warning of the adverse effects of consuming alcohol during pregnancy.

Cigars, Cigarettes, and Adolescents.

OBJECTIVE To examine public health implications of adolescent use of cigars only, cigarettes only, and both cigarettes and cigars. METHODS A cross-sectional health risk survey was administered to a random sample of 4486 high school students in a Midwestern county. RESULTS More adolescents reported using both cigarettes and cigars (10.6%) than cigar-only (7.4%) or cigarette-only (6.4%). Product of initiation was associated with current product use. Dual use was associated with more frequent use of both products, high stress, and susceptibility to future cigarette use. CONCLUSION Assessing cigarette use without examining cigar use overlooks a critical dimension of adolescent tobacco use.

A qualitative examination of secondary prophylaxis in rheumatic heart disease: factors influencing adherence to secondary prophylaxis in Uganda.

BACKGROUND Rheumatic heart disease (RHD) is the most common cause of heart disease among Ugandans age 15 to 49 years. Secondary prophylaxis with monthly injection of benzathine penicillin is effective in preventing recurrence of acute rheumatic fever and worsening of RHD, but adherence rates are poor in Uganda. OBJECTIVES This study sought to identify health behaviors, attitudes, and health care system factors that influence adherence to RHD secondary prophylaxis. METHODS We conducted 5 structured focus groups with 36 participants on monthly penicillin injections for RHD in Kamplala, Uganda. Transcripts were analyzed using qualitative description analysis and health behavior models. RESULTS Most participants were female (64%), from an urban area (81%), and had family income less than US

Polypharmacy in the elderly

1 daily (69%). Ages ranged from 14 to 58 years. Median prophylaxis duration was 1.42 years and 58% were adherent (≥80% of injections). Key facilitators include perceived worsening of disease with missing injections, personal motivation, a reminder system for injections, supportive family and friends, and a positive relationship with health care providers. Barriers to adherence include lack of resources for transportation and medications, fear of injection pain, poor patient-provider communication, and poor availability of clinics and providers able to give injections. CONCLUSIONS We identified key facilitators and barriers to secondary prophylaxis for RHD from the patient perspective framed within the socioecological model. Our findings provide direction for intervention development to improve national RHD secondary prophylaxis.

PREVENTIVE MEDICINE IN PRIMARY CARE : MOVING FROM THEORY TO PRACTICE

Objective: The objective was to assess the frequency of polypharmacy and potential complications among local seniors. Methods: A cross-sectional convenience sample of 59 adults aged above 65 years was interviewed at Cuyahoga county (U.S. state of Ohio) senior programs. Polypharmacy was defined as more than five prescribed medications. Primary outcomes were frequent missed doses, one or more duplicate drug/s, and equal or more than one contraindicated drug combinations. Findings: Among seniors with the mean age of 76.9 years (25.4% male), 40.6% used multiple pharmacies and 35.6% had polypharmacy. Of all seniors with polypharmacy, about 57% had contraindicated drug combinations. Polypharmacy was associated with duplication (P = 0.02), but not frequent missed doses (P = 0.20). Conclusion: As shown by this study, polypharmacy was associated with duplicated therapy and contraindicated drug combinations. Improved communications among seniors, physicians, and pharmacists is necessary to minimize adverse consequences of polypharmacy.

Principles for Authentic Population Health

Primary care physicians are in a unique position to offer preventive services. They have access to patients when intervention may be most successful, and they see most patients over a long period, which allows for adequate follow-up. The challenges are choosing the most effective interventions and organizing records and office staff to facilitate delivery of preventive services. Preventive medicine may not be as dramatic or as immediately successful as curative medicine, but it can have a tremendous long-term impact on health and well-being.

Health Risk Behaviors In A Unique Population-First Ring Suburban Adolescents

While there is broad agreement regarding the need to teach population health to all health professional students, and even substantial consensus about the content that should be included, the manner in which we engage student interest in this area of study is less than obvious. For the past 5 academic years, Case Western Reserve University (CWRU) has committed the first 5 weeks of medical education to innovative instruction in population health. In order to engage the students in this educational block, we undertake a detailed introduction to the social demographics and health characteristics of the population of patients from the Cleveland metropolitan area that they will both learn from and serve during their medical school tenure. Components of the presentation include national health rankings; national hospital ranking (pointing out the discrepancy between the two); and GIS mapping of characteristics such as poverty, mortality, crime, births to unwed mothers, and life expectancy. In addition, medical students are introduced to principles for authentic population health, a set of guidelines that cross boundaries between public health and medicine and seek to engage student interest in these population issues early in their careers. These principles, also provided to all public health students in the CWRU MPH handbook, are detailed here.