Travis M. Loux

The acceptability of self-sampled screening for HPV DNA: a systematic review and meta-analysis.

Objective To examine whether or not self-sampled cervical screening for human papillomavirus (HPV) DNA is acceptable and if women prefer self-sampling to clinician-based sampling. Design Systematic review and meta-analysis. Data sources Thirty-seven primary studies obtained through a comprehensive search of six electronic bibliographic databases from 1986 to 2014 and other sources. Search keywords included HPV, screening, DNA testing, vaginal testing, self-collected specimen, self-collected sample, self-sampling, self-screening, preferences and acceptability. Review methods Studies eligible for analysis included those that had participants perform self-sampling, evaluated participant acceptance of or preference for self-sampled vaginal HPV DNA and reported data to calculate an effect size. There were no exclusion criteria for publication status or geographical location. Meta-analytic methods were used to quantitatively synthesise effect sizes across studies. Results The 37 studies included 18 516 female participants from 24 countries across five continents. Overall, there was a high level of acceptability of self-sampling among the participants. Participants reported preference for self-sampling over clinician sampling due to attractive characteristics such as ease and privacy. Conclusions The overall acceptability of self-sampled cervical screening, coupled with economic and effective care, provides opportunities for expanding screening services. Importantly, this can provide a creative screening alternative for women who do not participate in traditional cytological screening, and may ultimately reduce health disparities and prevent cervical disease.

Randomization, matching, and propensity scores in the design and analysis of experimental studies with measured baseline covariates

In many experimental situations, researchers have information on a number of covariates prior to randomization. This information can be used to balance treatment assignment with respect to these covariates as well as in the analysis of the outcome data. In this paper, we investigate the use of propensity scores in both of these roles. We also introduce a randomization procedure in which the balance of all measured covariates is approximately indexed by the variance of the empirical propensity scores and randomization is restricted to those permutations with the least variable propensity scores. This procedure is compared with recently proposed methods in terms of resulting covariate balance and estimation efficiency. Properties of the estimators resulting from each procedure are compared with estimates which incorporate the propensity score in the analysis stage. Simulation results show that analytical adjustment for the propensity score yields results on par with those obtained through restricted randomization procedures and can be used in conjunction with such procedures to further improve inferential efficiency.

A comparison of marginal odds ratio estimators.

Uses of the propensity score to obtain estimates of causal effect have been investigated thoroughly under assumptions of linearity and additivity of exposure effect. When the outcome variable is binary relationships such as collapsibility, valid for the linear model, do not always hold. This article examines uses of the propensity score when both exposure and outcome are binary variables and the parameter of interest is the marginal odds ratio. We review stratification and matching by the propensity score when calculating the Mantel–Haenszel estimator and show that it is consistent for neither the marginal nor conditional odds ratio. We also investigate a marginal odds ratio estimator based on doubly robust estimators and summarize its performance relative to other recently proposed estimators under various conditions, including low exposure prevalence and model misspecification. Finally, we apply all estimators to a case study estimating the effect of Medicare plan type on the quality of care received by African-American breast cancer patients.

Flipping Classrooms in a School of Public Health

Alternative course formats are gaining increasing attention in higher education. The literature provides a number of examples and studies of flipped classrooms in the medical sciences and liberal arts and sciences. However, fewer than five papers on flipped classes in graduate public health courses have been published, and none in health management. Because graduate public health education is competency based, it seems that a flipped approach with its applied nature would be an appropriate form of teaching public health courses. This paper describes three successfully flipped courses taught in a school of public health. We provide a rationale for flipping, description of each course, and lessons learned. Once some of the challenges are overcome, we believe flipping courses can provide an alternative approach that enhances active learning in applied, public health, and health management courses.

Factors associated with increased risk of suicide among survivors of head and neck cancer: A population-based analysis.

OBJECTIVES Cancer diagnosis is considered an independent predictor of suicide. We aimed to determine whether gender and human papillomavirus (HPV)-relatedness are associated with increased risks of suicide in the head and neck cancer (HNC) population. MATERIALS AND METHODS Adult patients ≥18 years with HNC were selected using the Surveillance, Epidemiology, and End Results (SEER) data from 1973 to 2014. Using anatomic sites as proxy, patients were grouped as HPV-related or not HPV-related. Standardized Mortality Ratios (SMRs) were calculated, and association between suicide, gender, HPV-relatedness were estimated as adjusted rate ratios (aRR) using multivariable Poisson regression model. RESULTS There were 1036 suicides among 287,901 HNC patients in the study period (63 suicides per 100,000 person-years). Male patients were six times more likely to commit suicide compared to female patients (aRR = 5.74, 95% CI 3.88, 8.50); however, HPV-relatedness did not increase risk of suicide (aRR = 0.87, 95% CI 0.58, 1.29). Compared with white patients, blacks (aRR = 0.20, 95% CI 0.12, 0.33) and Hispanics (aRR = 0.25, 95% CI 0.14, 0.43) were less likely to commit suicide. Additionally, increased risks of suicide were found among the widowed (aRR = 1.48, 95% CI 1.10, 1.99) and divorced/separated (aRR = 1.30, 95% CI 1.00, 1.69), compared with married patients. CONCLUSION Gender, not HPV-relatedness, was associated with risk of suicide in our study. We identified HNC patients more likely to commit suicide as: previously married, white, male, widowed, divorced or separated, ≥70 years. Our findings may be useful clinically in planning personalized cancer care and lifelong surveillance of HNC patients with higher risks of suicide.

Uptake and Beliefs Regarding Seasonal Influenza Vaccination Among Childcare Center Staff, Administrators, and Parents

Surveys were distributed to parents and childcare agency staff to determine seasonal influenza vaccine uptake. Multivariate logistic regressions identified vaccination determinants. Overall, 351 parents and staff participated (response rate, 32%). One-half (168 [48%]) received vaccine. Vaccination predictors included healthcare provider or employer recommendation, perceived seriousness, and no vaccine fear. Infect Control Hosp Epidemiol 2017;38:367-370.

A simple, flexible, and effective covariate-adaptive treatment allocation procedure.

We present a method for allocating treatment when subjects arrive in sequence. Based on the theory of propensity scores more commonly used in observational studies, the method balances both discrete and continuous covariates without assuming a model for the outcome. Although we allow for a number of possible specifications, we explore some specific instances in depth. The proposed method is compared with previously suggested sequential randomization and allocation procedures with relationships to some well-known methods highlighted. Through simulations, the deterministic version is shown to achieve both covariate balance and near optimum efficiency with minimal assumptions. We also investigate the properties of selected randomized versions with respect to both optimality and selection bias. We conclude with an application to a pilot study on weight loss. The proposed method is shown to be robust to the number of covariates balanced and the marginal and joint distributions of those covariates.

Pertussis Vaccination Among Childcare Center Staff, Administrators, and Parents: Uptake, Policies, and Beliefs

Introduction Little is known about childcare staff’s and parents’ uptake of and attitudes towards pertussis vaccine. Methods Questionnaires were distributed to St. Louis parents and childcare staff in fall, 2014. Parents versus staff and vaccinated versus unvaccinated individuals’ beliefs regarding pertussis vaccine were compared using chi square tests. Multivariate logistic regressions were run to develop predictive models for staff’s and parents’ vaccine uptake. Results Overall, 351 parents and staff from 23 agencies participated (response rate = 32%). Parents were more likely than staff to have received pertussis vaccine (66.5 vs. 45.8%, X2 = 12.5, p < .001). Predictors for staff vaccination included willingness to get vaccinated even if there was a cost (OR 6.6; CI 1.8–24.6; p < .01), awareness of vaccination recommendations (OR 5.2; CI 1.2–22.8; p < .05), and healthcare provider recommendation (OR 4.2; CI 1.2–15.1; p < .05). Parents’ predictors of vaccination included perceived importance of vaccination (OR 9.9; CI 4.1–23.8; p < .001), healthcare provider recommendation (OR 4.6; CI 1.7–12.6; p < .01), believing vaccination is effective (OR 4.4; CI 1.1–18.0; p < .05), and knowing where to get vaccine (OR 3.5; CI 1.5–8.1; p < .01). Among unvaccinated staff (n = 52), 74.5% (n = 38) and 70.0% (n = 35) would receive pertussis vaccine if it were offered free of charge and onsite, respectively. Conclusions for Practice Childcare staff’s and parents’ pertussis vaccine uptake was higher than overall U.S. rates, though significantly lower than the Global Pertussis Initiative target. Implementing an education campaign and providing free vaccine on-site are likely to result in increased vaccine uptake.

Variability in Weight Concern and Physical Activity Engagement Among African American Adolescent Girls

Lower rates of recreational physical activity (PA) among African American (AA) adolescent girls relative to other US age/race/gender groups are assumed to reflect within-race similarity in PA attitudes and practices. However, variability in PA attitudes and practices among AA adolescent girls is not well studied. To address this, a class-diverse sample of 51 AA adolescent girls’ responses to survey items querying weight concern (WC) and PA was examined for sub-groupings using cluster analysis. Three clusters were identified [L/H—low WC, high PA; H/L—high WC, low PA; and L/L—low WC and PA]. Survey item response means were examined by cluster. L/L differed visibly, but not significantly, from L/H and H/L on items assessing PA engagement. The same was true for H/L with WC items. Cluster identification and trends in response differences by cluster have potential implications for targeted PA promotion efforts. Further investigation with larger, representative samples is warranted.

Suicide risk among cancer survivors: Head and neck versus other cancers: Suicide Risks in Patients With Cancer

Cancer survivors face psychosocial issues that increase their risk of suicide. This study examined the risk of suicide across cancer sites, with a focus on survivors of head and neck cancer (HNC).