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1.  The role of health information sources in decision-making among Hispanic mothers during their children’s first 1000 days of life 
Maternal and child health journal  2015;19(11):2536-2543.
This qualitative research aimed to explore how health information sources inform decision-making among Hispanic mothers during their children’s first 1000 days of life (conception-age 24 months), and to generate appropriate health information sources and communication strategies for future interventions.
We conducted 7 focus groups with 49 Hispanic women who were pregnant or had children < 2 years old. Domains included interpersonal and media sources, source trustworthiness, dealing with contradictory information, and how information affects decision-making. We used immersion/crystallization process for analysis.
Trusted health information sources included health care providers, female and male family members, and other Internet sources, selected social media, and television. Some immigrant women reported preferring the Internet citing less established local support networks. Women highlighted the importance of validating health information through checking multiple sources for consistency and resolving contradictory information. Mothers expressed interest in receiving reliable website links from healthcare professionals and outreach to extended family.
Cultural factors, including immigration status, are important in understanding the use of health information sources and their role in decision-making about pregnancy and child health among Hispanic mothers. Healthcare providers and public health professionals should consider Hispanic mothers health information environment and provide culturally-relevant communication strategies and interventions during this high information-seeking time period.
PMCID: PMC4596758  PMID: 26122256
2.  Engaging children in the development of obesity interventions: exploring outcomes that matter most among obesity positive outliers 
Patient education and counseling  2015;98(11):1393-1401.
To explore outcomes and measures of success that matter most to 'positive outlier' children who improved their body mass index (BMI) despite living in obesogenic neighborhoods.
We collected residential address and longitudinal height/weight data from electronic health records of 22,657 children ages 6–12 years in Massachusetts. We defined obesity “hotspots” as zip codes where >15% of children had a BMI ≥95th percentile. Using linear mixed effects models, we generated a BMI z-score slope for each child with a history of obesity. We recruited 10–12 year-olds with negative slopes living in hotspots for focus groups. We analyzed group transcripts and discussed emerging themes in iterative meetings using an immersion/crystallization approach.
We reached thematic saturation after 4 focus groups with 21 children. Children identified bullying and negative peer comparisons related to physical appearance, clothing size, and athletic ability as motivating them to achieve a healthier weight, and they measured success as improvement in these domains. Positive relationships with friends and family facilitated both behavior change initiation and maintenance.
The perspectives of positive outlier children can provide insight into children’s motivations leading to successful obesity management. Practice implications: Child/family engagement should guide the development of patient-centered obesity interventions.
PMCID: PMC4609258  PMID: 26166630
obesity; overweight; positive deviance; children; attitude to health; qualitative
3.  Effects of adding a new PCMH block rotation and resident team to existing longitudinal training within a certified PCMH: primary care residents’ attitudes, knowledge, and experience 
Although the patient-centered medical home (PCMH) model is considered important for the future of primary care in the USA, it remains unclear how best to prepare trainees for PCMH practice and leadership. Following a baseline study, the authors added a new required PCMH block rotation and resident team to an existing longitudinal PCMH immersion and didactic curriculum within a Level 3-certified PCMH, aiming for “enhanced situated learning”. All 39 residents enrolled in a USA family medicine residency program during the first year of curricular implementation completed this new 4-week rotation. This study examines the effects of this rotation after 1 year.
A total of 39 intervention and 13 comparison residents were eligible participants. This multimethod study included: 1) individual interviews of postgraduate year (PGY) 3 intervention vs PGY3 comparison residents, assessing residents’ PCMH attitudes, knowledge, and clinical experience, and 2) routine rotation evaluations. Interviews were audiorecorded, transcribed, and analyzed using immersion/crystallization. Rotation evaluations were analyzed using descriptive statistics and qualitative analysis of free text responses.
Authors analyzed 23 interviews (88%) and 26 rotation evaluations (67%). Intervention PGY3s’ interviews revealed more nuanced understanding of PCMH concepts and more experience with system-level PCMH tasks than those of comparison PGY3s. More intervention PGY3s rated themselves “extremely prepared” to implement PCMH than comparison PGY3s; however, most self-rated “somewhat prepared”. Their reflections demonstrated deeper understanding of PCMH implementation and challenges than comparison PGY3s but inadequate experience to directly see the results of successful solutions. Rotation evaluations from PGY1, PGY2, and PGY3s revealed strengths and several areas for improvement.
Adding one 4-week block rotation to existing longitudinal training appears to improve residents’ PCMH knowledge, skills, and experience from “basic” to “intermediate”. However, this training level appears inadequate for PCMH leadership or for teaching junior learners. Further study is needed to determine the optimum training for different settings.
PMCID: PMC4978166  PMID: 27536169
primary care; new models of healthcare; curriculum; family medicine; population health; residency education
4.  Primary Care Providers’ Views on Using Lung Age as an Aid to Smoking Cessation Counseling for Patients with Chronic Obstructive Pulmonary Disease 
Lung  2015;193(3):321-327.
Smoking cessation is the primary goal for managing patients with chronic obstructive pulmonary disease (COPD) who smoke. However, previous studies have demonstrated poor cessation rates. The “lung age” concept (an estimate of the age at which the FEV1 would be considered normal) was developed to present spirometry data in an understandable format and to serve as a tool to encourage smokers to quit. Primary care physicians’ (PCPs) views of using lung age to help COPD patients to quit smoking were assessed.
Post-intervention interviews were conducted with PCPs in the U.S. who participated in the randomized clinical trial, “Translating the GOLD COPD Guidelines into Primary Care Practice.”
29 physicians completed the interview. Themes identified during interviews included: general usefulness of lung age for smoking cessation counseling, ease of understanding the concept, impact on patients’ thoughts of quitting smoking, and comparison to FEV1. Most providers found lung age easy to communicate. Moreover, some found the tool to be less judgmental for smoking cessation and others remarked on the merits of having a simple, tangible number to discuss with their patients. However, some expressed doubt over the long-term benefits of lung age and several others thought that there might be a potential backfire for healthy smokers if their lung age was ≤ to their chronological age.
This study suggests that lung age was well received by the majority of PCPs and appears feasible to use with COPD patients who smoke. However, further investigation in needed to explore COPD patients’ perspectives of obtaining their lung age to help motivate them to quit in randomized clinical trials.
PMCID: PMC4433592  PMID: 25791068
Chronic obstructive pulmonary disease; Smoking; Lung age
5.  Perspectives of Colorectal Cancer Risk and Screening among Dominicans and Puerto Ricans: Stigma and Misperceptions 
Qualitative health research  2009;19(11):1559-1568.
Colorectal cancer is the second most common cancer among Latinos, but a lower percentage of Latinos are screened than Whites and Blacks. Along with recognized economic barriers, differences in knowledge and perceptions might impede colorectal screening among Latinos. We conducted 147 individual, qualitative interviews with Dominicans and Puerto Ricans in the northeastern United States to explore their explanatory models for colorectal cancer and screening barriers. Many participants had not previously heard of colorectal cancer. The most commonly mentioned cause of colorectal cancer was anal sex. Also considered risks were “bad food,” digestion leading to constipation, and strained bowel movements. Screening barriers included stigma, misperceptions, embarrassment, and machismo. Progress toward increasing colorectal cancer screening requires normalization of this screening among Latinos. Higher patient familiarity, along with improved physician counseling and referral, might contribute to reducing stigma and other barriers, and to enhancing knowledge and Latino community support of colorectal cancer screening.
PMCID: PMC3584335  PMID: 19776255
cancer, screening; Caribbean people; communication, doctor-patient; ethnicity; health behavior; immigrants; interviews, semistructured; Latino/Hispanic people; lay concepts and practices; risk, perceptions
6.  Patients’ Reflections on Communication in the Second-Opinion Hematology-Oncology Consultation 
The nature of communication between patients and their second-opinion hematology consultants may be very different in these one-time consultations than for those that are within long-term relationships. This study explored patients’ perceptions of their second-opinion hematology oncology consultation to investigate physician-patient communication in malignant disease at a critical juncture in cancer patients’ care and decision-making.
In-depth telephone interviews with a subset of 20 patients from a larger study, following their subspecialty hematology consultations.
Most patients wanted to contribute to the consultation agenda, but were unable to do so. Patients sought expert and honest advice delivered with empathy, though most did not expect the consultant to directly address their emotions. They wanted the physician to apply his/her knowledge to the specifics of their individual cases, and were disappointed and distrustful when physicians cited only general prognostic statistics. In contrast, physicians’ consideration of the unique elements of patients’ cases, and demonstrations of empathy and respect made patients’ feel positively about the encounter, regardless of the prognosis.
Patients provided concrete recommendations for physician and patient behaviors to enhance the consultation.
Consideration of these recommendations may result in more effective communication and increased patient satisfaction with medical visits.
PMCID: PMC2812020  PMID: 19135824
physician-patient cancer communication; oncology consultations; qualitative research; focus groups; patients’ recommendations to patients; patients’ recommendations to physicians
7.  Reducing Hispanic Children's Obesity Risk Factors in the First 1000 Days of Life: A Qualitative Analysis 
Journal of Obesity  2015;2015:945918.
Objectives. Modifiable behaviors during the first 1000 days (conception age 24 months) mediate Hispanic children's obesity disparities. We aimed to examine underlying reasons for early life obesity risk factors and identify potential early life intervention strategies. Methods. We conducted 7 focus groups with 49 Hispanic women who were pregnant or had children < age 24 months. Domains included influences on childhood obesity risk factors and future intervention ideas. We analyzed data with immersion-crystallization methods until no new themes emerged. Results. Themes included coping with pregnancy may trump healthy eating and physical activity; early life weight gain is unrelated to later life obesity; fear of infant hunger drives bottle and early solids introduction; beliefs about infant taste promote early solids and sugary beverage introduction; and belief that screen time promotes infant development. Mothers identified physicians, nutritionists, and relatives as important health information sources and expressed interest in mobile technology and group or home visits for interventions. Conclusion. Opportunities exist in the first 1000 days to improve Hispanic mothers' understanding of the role of early life weight gain in childhood obesity and other obesity risk factors. Interventions that link health care and public health systems and include extended family may prevent obesity among Hispanic children.
PMCID: PMC4385595  PMID: 25874127
8.  Awakening is not a metaphor: the effects of Buddhist meditation practices on basic wakefulness 
Buddhist meditation practices have become a topic of widespread interest in both science and medicine. Traditional Buddhist formulations describe meditation as a state of relaxed alertness that must guard against both excessive hyperarousal (restlessness) and excessive hypoarousal (drowsiness, sleep). Modern applications of meditation have emphasized the hypoarousing and relaxing effects without as much emphasis on the arousing or alertness-promoting effects. In an attempt to counterbalance the plethora of data demonstrating the relaxing and hypoarousing effects of Buddhist meditation, this interdisciplinary review aims to provide evidence of meditation’s arousing or wake-promoting effects by drawing both from Buddhist textual sources and from scientific studies, including subjective, behavioral, and neuroimaging studies during wakefulness, meditation, and sleep. Factors that may influence whether meditation increases or decreases arousal are discussed, with particular emphasis on dose, expertise, and contemplative trajectory. The course of meditative progress suggests a nonlinear multiphasic trajectory such that early phases that are more effortful may produce more fatigue and sleep propensity, while later stages produce greater wakefulness as a result of neuroplastic changes and more efficient processing.
PMCID: PMC4054695  PMID: 24372471
Buddhist meditation; relaxation; sleep; arousal; alertness; wakefulness
9.  Physician Communication Styles in Initial Consultations for Hematological Cancer 
Patient education and counseling  2013;93(3):10.1016/j.pec.2013.08.023.
To characterize practices in subspecialist physicians’ communication styles, and their potential effects on shared decision-making, in second-opinion consultations.
Theme-oriented discourse analysis of 20 second-opinion consultations with subspecialist hematologist-oncologists.
Physicians frequently “broadcasted” information about the disease, treatment options, relevant research, and prognostic information in extended, often-uninterrupted monologues. Their communicative styles had one of two implications: conveying options without offering specific recommendations, or recommending one without incorporating patients’ goals and values into the decision. Some physicians, however, used techniques that encouraged patient participation.
Broadcasting may be a suboptimal method of conveying complex treatment information in order to support shared decision-making. Interventions could teach techniques that encourage patient participation.
Practice Implications
Techniques such as open-ended questions, affirmations of patients’ expressions, and pauses to check for patient understanding can mitigate the effects of broadcasting and could be used to promote shared decision-making in information-dense subspecialist consultations.
PMCID: PMC3852201  PMID: 24035463
US; Physician-patient communication; Oncology consultations; Information delivery; Patient participation; Shared decision-making; Physician-patient relationships; Second opinions
10.  “If it Tastes Good, I’m Drinking It”: Qualitative Study of Beverage Consumption among College Students 
This study examined how college students choose beverages and whether behavioral interventions might reduce their heavy consumption of sugar-sweetened beverages.
From April to June 2010, 90 students participated in 12 focus groups at 6 colleges in Massachusetts and Louisiana. The study team undertook a group content analysis of the verbatim focus group transcripts using the immersion-crystallization method.
The mean age of participants was 19 years. 50% were white, and 47% were black. Several themes emerged in focus groups: taste is paramount; price is important but secondary; health and nutritional content of beverages are of limited interest; juice has a “health halo”; and water is consumed primarily for hydration. Students were often highly fixated on favorite sugar-sweetened beverages. Price was uniquely important for good-tasting beverages costing less than one dollar. Some students reported calorie content as important for food choices, but most had no awareness of beverage calorie content. Students’ negative perceptions of sugar-sweetened beverages focused largely on the “dangers” of sugar and chemicals in sodas. They expressed particular concern about soda’s corrosive chemical properties or diet soda causing cancer. The health halo for juice persisted even with some recognition of high sugar content. Students thought shocking educational messages would be necessary to get them to reduce consumption of sugar-sweetened beverages.
Among college students, taste and price were the most important factors in choosing beverages. Interventions using shocking visual images or providing low-cost or free water may conquer taste and brand preference to reduce sugar-sweetened beverage intake.
PMCID: PMC3657589  PMID: 23415754
obesity; nutrition; soft drinks; adolescence; young adults; qualitative research
11.  Coping Styles, Health Status and Advance Care Planning in Patients with Hematologic Malignancies 
Leukemia & lymphoma  2011;52(12):2342-2348.
This study evaluated if measures of psychological well-being, including coping style are associated with advance care planning (ACP). Data were from the HEMA-COMM study, a prospective observational study of physician-patient communication in patients with hematologic malignancies. ACP was defined as having a living will, having a health care proxy, discussing life support with family or friends, and discussing life support with a doctor or nurse. 293 patients participated: only 45 (15%) had all the elements of ACP, 215 (73%) had at least 1 element of ACP, while 33 (11%) did not engage in ACP. In multivariate analysis, specific coping styles but not other measures of psychosocial well being were associated with having written ACP. Verbal ACP was associated with patient-reported health and physician estimate of life expectancy. Our study suggests that tailoring ACP discussions to a patient’s coping style may increase engagement in ACP.
PMCID: PMC3972814  PMID: 21851220
Advance care planning; Coping; Health Status; Hematological Cancer
12.  The study design and rationale of the randomized controlled trial: translating COPD guidelines into primary care practice 
BMC Family Practice  2013;14:56.
Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating disease associated with significant clinical burden and is estimated to affect 15 million individuals in the US. Although a large number of individuals are diagnosed with COPD, many individuals still remain undiagnosed due to the slow progression of the disorder and lack of recognition of early symptoms. Not only is there under-diagnosis but there is also evidence of sub-optimal evidence-based treatment of those who have COPD. Despite the development of international COPD guidelines, many primary care physicians who care for the majority of patients with COPD are not translating this evidence into effective clinical practice.
This paper describes the design and rationale for a randomized, cluster design trial (RCT) aimed at translating the COPD evidence-based guidelines into clinical care in primary care practices. During Phase 1, a needs assessment evaluated barriers and facilitators to implementation of COPD guidelines into clinical practice through focus groups of primary care patients and providers. Using formative evaluation and feedback from focus groups, three tools were developed. These include a computerized patient activation tool (an interactive iPad with wireless data transfer to the spirometer); a web-based COPD guideline tool to be used by primary care providers as a decision support tool; and a COPD patient education toolkit to be used by the practice team. During phase II, an RCT will be performed with one year of intervention within 30 primary care practices. The effectiveness of the materials developed in Phase I are being tested in Phase II regarding physician performance of COPD guideline implementation and the improvement in the clinically relevant outcomes (appropriate diagnosis and management of COPD) compared to usual care. We will also examine the use of a patient activation tool - ‘MyLungAge’ - to prompt patients at risk for or who have COPD to request spirometry confirmation and to request support for smoking cessation if a smoker.
Using a multi-modal intervention of patient activation and a technology-supported health care provider team, we are testing the effectiveness of this intervention in activating patients and improving physician performance around COPD guideline implementation.
Trial registration, NCT01237561
PMCID: PMC3651367  PMID: 23641803
COPD; Guidelines; Randomized Clinical Trial; Primary care
13.  Information giving and receiving in hematological malignancy consultations† 
Psycho-Oncology  2011;21(3):297-306.
Little is known about communication with patients suffering from hematologic malignancies, many of whom are seen by subspecialists in consultation at tertiary-care centers. These subspecialized consultations might provide the best examples of optimal physician–patient communication behaviors, given that these consultations tend to be lengthy, to occur between individuals who have not met before and may have no intention of an ongoing relationship, and which have a goal of providing treatment recommendations. The aim of this paper is to describe and quantify the content of the subspecialty consultation in regards to exchanging information and identify patient and provider characteristics associated with discussion elements.
Audio-recorded consultations between 236 patients and 40 hematologists were coded for recommended communication practices. Multilevel models for dichotomous outcomes were created to test associations between patient, physician and consultation characteristics and key discussion elements.
Discussions about the purpose of the visit and patient’s knowledge about their disease were common. Other elements such as patient’s preference for his/her role in decision-making, preferences for information, or understanding of presented information were less common. Treatment recommendations were provided in 97% of the consultations and unambiguous presentations of prognosis occurred in 81% of the consultations. Unambiguous presentations of prognosis were associated with non-White patient race, lower educational status, greater number of questions asked, and specific physician provider.
Although some communication behaviors occur in most consultations, others are much less common and could help tailor the amount and type of information discussed. Approximately half of the patients are told unambiguous prognostic estimates for mortality or cure.
PMCID: PMC3377472  PMID: 21294221
communication; physician–patient encounters; oncology; hematology; prognosis; cancer
14.  Racial Discrimination and Physical Activity Among Low Income–Housing Residents 
While discrimination has been identified as a potential determinant of existing racial/ethnic health disparities, no studies have investigated whether racial discrimination contributes to disparities in physical activity.
The primary aim of the current study was to examine the association between interpersonal racial discrimination and physical activity.
Baseline data were collected during 2004–2005 among a predominately black and Hispanic sample of adult residents living in 12 low income–housing sites in Boston, Massachusetts (n=1055). Residents reported experiences of lifetime racial discrimination during interview-administered surveys and wore a pedometer for 5 days to measure physical activity. For analyses, performed in 2009, linear regression models with a cluster design were conducted to predict physical activity, measured as steps per day.
Nearly 48% of participants reported ever experiencing racial discrimination, and discrimination was most commonly experienced on the street or in a public setting. No association was found between discrimination and physical activity, when examined in bivariate, multivariable, or race-stratified models.
The current results indicate that self-reported racial discrimination is not a key determinant of physical activity among residents living in lower-income housing. However, additional research is warranted to address current limitations of this study.
PMCID: PMC2818664  PMID: 19944922
15.  Effect of Language on Colorectal Cancer Screening Among Latinos and Non-Latinos 
Language barriers among some Latinos may contribute to the lower rates of colorectal cancer (CRC) screening between Latinos and non-Latino Whites. The purpose of this study was to examine the relationship between language and receipt of colorectal cancer screening tests among Latinos and non-Latinos using a geographically diverse, population-based sample of adults.
Cross-sectional analysis of the Behavioral Risk Factor Surveillance System (BRFSS) survey. Analysis included adults 50 years of age and older, who completed the 2006 BRFSS in a state that recorded data from English and Spanish-speaking participants.
The primary outcome measure was receipt of colorectal screening tests (fecal occult blood testing within prior 12 months and/or lower endoscopy within 10 years). Of the 99,895 respondents included in the study populations, 33% of Latinos responding-in-Spanish reported having had CRC testing, while 51% of Latinos responding-in-English and 62% of English-speaking non-Latinos reported test receipt. In multivariable analysis, compared to non-Latinos, Latinos responding-in-English were 16% less likely (OR,0.84, 95 % CI, 0.73-0.98), and Latinos responding-in-Spanish were 43% less likely to have received colorectal cancer testing (OR,0.57, 95% CI, 0.44-0.74). Additionally, compared to Latinos responding-in-English, Latinos responding-in-Spanish were 36% less likely to have received CRC testing (OR, 0.64; 95% CI, 0.48-0.84)
Latinos responding to the 2006 BRFSS survey in Spanish had a significantly lower likelihood of receiving CRC screening tests compared to non-Latinos and to Latinos responding-in-English. Based on this analysis, Spanish language use is negatively associated with CRC screening and may contribute to disparities in CRC screening.
PMCID: PMC2568081  PMID: 18708410
Colorectal cancer; Screening; Latino/Hispanic; Language; BRFSS

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