CD07-005 Abstracts
1 R18 CE001341-01 - High Impact Interventions for Employee Health Promotion
BINGHAM, C. RAYMOND
DESCRIPTION (provided by applicant): The overall goal of this study is to improve teen driver safety by increasing parental involvement in helping their teens' learn to drive. A qualitative/quantitative method will be used to examine three issues: achieving more complete implementation of GDL programs by increasing parental involvement with and supervision of their teens as they learn to drive; introducing the Checkpoints program into existing GDL programs as a means of improving parental supervision of their teens as they learn to drive; and, increasing parental involvement in their teens' driver training by identifying disparities in access to licensure through GDL programs, and investigating solutions to increase equal access. Research has consistently shown that GDL is effective in reducing crashes involving teen drivers, including fatal and non-fatal injury crashes. However, the effectiveness of GDL could be improved by better adherence to its requirements. Research has also shown the promise of Checkpoints in enhancing parental limits set on teens' early driving, and on reducing their risky driving. Developing an understanding of how these two evidence-based, complementary approaches could be more effectively and widely implemented should accelerate their adoption, and contribute to a substantial reduction in teen crashes. Disparities in access to driver licensure through GDL results in teens postponing licensure until they are 18 years of age. However, there is significant evidence that unlicensed teens are driving in spite of not being licensed. As a result, they are placing themselves and others at risk, and driving without the safety benefit of GDL. This study will examine these issues using a combination of qualitative methods to understand barriers to and facilitators of GDL licensure and the introduction of Checkpoints into GDL, and to identify disparities in access to GDL and ways to enhance equal access. The results of the qualitative data collection will be used, with the assistance of an expert panel, to develop a survey that will be administered to a nationally representative sample of parents with teens aged 15-17 years. The results of the survey will be presented to the expert panel, and the panel will assist the research team in developing guidelines and recommendations that address the research issues related to GDL, Checkpoints, and disparities in access to GDL. These recommendations will be disseminated to state and federal driver safety departments and offices, and through presentations and peer reviewed publication.
1 R18 DP001139-01 - Understanding and Enhancing Dissemination among US Chronic Disease Practitioners
BROWNSON, ROSS C
DESCRIPTION (provided by applicant): Background. Existing knowledge on chronic disease prevention is not systematically disseminated and applied. State-level public health practitioners are in positions to implement programs and services related to chronic disease control. To do so, evidence-based interventions are available within the Guide to Community Preventive Services (the Community Guide). Goal and aims. Our primary goal is to increase the dissemination of evidence-based interventions to prevent and control chronic diseases. The first set of specific aims seeks to identify:1) essential competencies for dissemination of evidence-based interventions for chronic disease prevention, 2) barriers for dissemination, and 3) how the stage of dissemination varies by agency size, capacity, and risk factor/disease. A second set of aims builds on these to: 1) conduct a prioritization process, 2) refine a menu of dissemination activities for implementation in the six dissemination states, and 3) implement and evaluate a menu-driven, active dissemination approach. Methods and evaluation. To advance dissemination science, we will evaluate how and why dissemination is occurring and will actively disseminate the Community Guide. This project will occur in two parts. Phase 1 research involves a nationwide survey of state-level practitioners in chronic disease prevention and control. The survey will rate the importance of and proficiency in dissemination-related competencies, barriers to evidence-based decision making, and the extent to which evidence-based interventions are used. Phase 2 builds on Phase 1, using a quasi-experimental design (pre-test/post-test with a comparison group) to evaluate the active dissemination of evidence-based chronic disease control interventions in six states. Qualitative interviews will supplement quantitative data to help us understand contextual factors. State selection will be based on chronic disease burden (a measure of health disparity), size of state, and geographic dispersion. Dissemination activities in Phase 2 include tool and skill development (e.g., issue briefs, dissemination workshops) to enhance uptake of evidence-based interventions. Evaluation of Phase 2 interventions will rely on two data sources: 1) measures of dissemination based on surveys of practitioners and 2) review and abstraction of state-level chronic disease control records. We will also conduct process evaluation and will pay particular attention to external validity. Dissemination and innovations. Concurrent with Phase 2, we will begin efforts to design for dissemination. The intent of these activities is to ensure that findings from our grant are useful, informative, relevant, and ready for widespread dissemination when funding ends. We will assemble and work with two advisory groups and capture project costs. Practice-relevant dissemination of evidence-based interventions is highly innovative yet is an area that remains largely uncharted. This project is relevant to public health because it addresses behaviors that lead to significant premature chronic disease morbidity and mortality. Sparse knowledge exists regarding effective approaches for dissemination of research-tested interventions among real world practice audiences. Upon completion, our study will provide feasible evidence-based dissemination strategies that can be adapted to other settings and risk factors.
1 R18 CE001334-01 - Cascading Diffusion of an Evidence-Based Child Maltreatment Intervention
CHAFFIN, MARK J
DESCRIPTION (provided by applicant): Project Abstract Child neglect is the dominant referral problem among families entering the child welfare service system, comprising two-thirds of all entering cases nationally. Neglect cases are characterized by high recidivism, and relatively high negative impact on children with respect to health, mental health, and behavioral outcomes. Most neglect cases are served by in-home family preservation/family reunification (FP/FR) service systems. Many FP/FR services-as-usual are based on a loose social support and case management model, and more effective models with stronger scientific support, such as the SafeCare model, have not yet penetrated into FP/FR service systems. How to diffuse evidence-based models throughout these systems, and maintain sustained fidelity, is an open question. Results from two ongoing NIMH-funded studies of a statewide SafeCare controlled-trail implementation in Oklahoma have yielded initial findings that some implementation features (e.g. in vivo provider coaching) are critical. In this proposal, we will test a new and promising implementation and diffusion approach developed for transporting SafeCare into an existing FP/FR service network in San Diego County California. The proposed study will take advantage of a new, recently funded implementation project, scheduled to begin in September, 2007. The proposed study will use this already funded implementation as a vehicle for expanding scientific knowledge about the implementation and diffusion project. The diffusion model involves a cascading approach, first developing a small seed program of exceptionally high quality, then using providers from the seed program as in vivo coaches and implementation agents for sequential implementations at other provider agencies in the system. This study will examine whether or not the planned diffusion model can develop a network of services with self-sustaining levels of model fidelity and provider competency across cascading waves of individual agency implementation. Also, using a mixed-methods (quantitative/qualitative) approach, we will examine and describe the relationship between individual provider staff, system, and organizational factors, and their impact on the implementation process. The anticipated results of the study will be a rich data set systematically describing key factors and issues involved in diffusion of an EBT within a child welfare FP/FR service system along with data on the effectiveness of the diffusion model in achieving sustained model uptake.
1 R18 CK000102-01 - Translating efficacy into effectiveness of insecticide-treated nets (ITNs)
EISELE, THOMAS P
DESCRIPTION (provided by the applicant): Insecticide-treated bed nets (ITNs) have been shown to significantly reduce malaria related morbidity and all cause child mortality across a range of transmission settings. Zambia has recently launched an unprecedented scale-up of free ITN distribution with the target of distributing 3 million long-lasting ITNs by the end of 2007. However, the impact of ITNs on preventing malaria morbidity and mortality will be minimized if they are not properly and consistently used, especially among children and pregnant women. Our long-term goal is to provide public health scientists and officials with an effective intervention to optimize ITN uptake and use among children and pregnant women as they become more widely available through the scale-up of national distribution programs. It is hypothesized that a village-based interpersonal communication (IPC) intervention will increase ITN use among households already possessing them within the context of a national ITN distribution program currently underway in Zambia. The focus of this application is to: 1) test if a village based IPC intervention increases the proportion of children using ITNs within households possessing them within the context of a large-scale ITN distribution program in the Luangwa District of Zambia; 2) determine the costs associated with achieving such increased ITN use; and 3) identify household, community and policy-level factors that facilitate or impede ITN use among children. A group randomized controlled trial will be used to assess the effectiveness of the IPC intervention at increasing ITN use among children within households possessing at least one ITN, relative to children within households possessing at least one ITN within non-IPC intervention villages in the Luangwa District of Zambia. The primary outcome measure will be the proportion of children under five years old using an ITN within households possessing at least one ITN. The IPC intervention will be delivered by community health workers face-to-face in villages, and will focus primarily on: 1) repeated demonstrations of proper ITN deployment and use; and 2) written, verbal and video communication as to the health-related benefits of ITNs to children. An incremental cost-effectiveness analysis will be conducted to determine the ratio of costs to effectiveness of the IPC intervention at increasing ITN use relative to the control of non-IPT villages. Immediate ways that our research will have a direct and significant scientific and societal impact include: 1) Our IPC activities to increase ITN use will provide a basis for determining when, where and what types of messages should be used to achieve the greatest impact on ITN use in similar setting in Africa; 2) Positive results can potentially lead to the development of behavioral interventions strategies to increase adoption of other efficacious malaria control interventions in Africa; and 3) Our project emphasizes the identification of impediments and facilitators to ITN adherence and the translation of results into public health policy; the methods employed can serve as a model to promote interdisciplinary approaches for research and problem solving in Africa.
1 R18 DP001146-01 - Fax to Quit: Linking Smokers Visiting Clinics to State Quitlines
FIORE, MICHAEL C
DESCRIPTION (provided by applicant): In America today, tobacco use stands out as a condition of unique lethality, prevalence, and neglect, despite the availability of effective interventions. This troubling set of circumstances highlights the need to disseminate effective interventions so as to meaningfully reduce tobacco use prevalence. Among available evidence-based treatment options, telephone quitlines may offer the greatest unrealized promise to help a large proportion of U.S. smokers to successfully quit. Telephone quitlines are effective treatments for tobacco dependence. As a result of strong empirical support, all 50 states now provide statewide quitline services. Yet the reach, or population penetrance, of quitlines has been low (1-3% of smokers annually) and traditional means of boosting quitline use - paid media campaigns and medication give-aways linked to quitline use - are often prohibitively expensive for states struggling with declining tobacco control funding. Fax to Quit - a strategy to link state quitlines to the 70% of smokers who visit a primary care physician each year - has been identified as a means of increasing quitline reach at potentially lower cost. Operationally, every tobacco user making a primary care visit is asked if s/he is interested in quitting and receiving quitline counseling. If s/he agrees, a referral is faxed (or transmitted electronically) to the state quitline, which then proactively contacts the tobacco user. The potential of this strategy has led more than 40 states to implement some form of Fax to Quit. Yet, this promising approach has not been adequately evaluated and some evidence indicates that Fax to Quit referral and connection rates are often low. This proposal is designed to systematically evaluate two forms of Fax to Quit: Fax to Quit alone (FQ) and Fax to Quit plus Enhanced Academic Detailing (FQ + EAD) with EAD comprising ongoing training/technical assistance and performance feedback. After collecting baseline rates of quitline referrals, 40 clinics will be randomized to receive either FQ or FQ + EAD. Clinic referral rates, quitline-patient contacts, and "quality contacts" (when referrals result in the individual enrolling in quitline counseling services) will be measured. In addition, a qualitative research component will evaluate key aspects of the two interventions and an economic analysis will compare the cost of the two Fax to Quit interventions to the costs of media and other current quitline promotional strategies. The proposal is designed to meet the research objectives of this RFA; to conduct translational research using an evidence-based intervention that has the potential to foster the Healthy People 2010 goals of enhanced health promotion and disease prevention.
1 R18 DP001147-01 - Translating a nutrition intervention thru WIC & Minority Health Promotion Centers
GANS, KIM M
DESCRIPTION (provided by the applicant): The purpose of the proposed research is to conduct translational research to study the process of disseminating a tailored nutrition intervention that has been shown to be efficacious in improving fruit and vegetable (FV) intake in diverse low income audiences as part of a NCI-funded efficacy study entitled Your Healthy Life/Su Vida Saludable (YHS/SVS). The proposed research will systematically study and characterize the process of successfully translating the YHL/SVS intervention into the established practice of two different types of sites: Minority Health Promotion Centers (MHPC) and WIC clinics in RI in partnership with the Rhode Island Department of Health (RIDH). The research will ascertain optimal diffusion strategies to enable this intervention program to be disseminated to similar settings throughout and beyond RI. Primary aims of the proposed research are: 1. To conduct formative research including focus groups and focused interviews with key stakeholders including the target audience, key RIDH officials, MHPC and WIC staff to inform adaptations of the content and format of the YHL/SVS intervention so that it meets the needs of these audiences/settings, and to inform the intervention and evaluation protocols and tools for the translational pilot; 2. To conduct a translational pilot with 20 sites (and their clients) to evaluate the process of dissemination including reach, adoption, implementation, fidelity, etc. using a variety of qualitative and quantitative evaluation measures; 3. To compile data from the translational pilot and use it to create a plan for disseminating the intervention throughout RI and into other states. Secondary aims will be to 1. To compare the effectiveness of the adapted YHL/SVS intervention to the effectiveness of a comparison intervention (traditional self help material) in terms of change in FV intake (and psychosocial mediators) of participants; 2. To compare the effect size achieved in the translational pilot study with the effect size achieved in the previous YHL/SVS randomized efficacy trial; and 3. To measure the public health impact of the adapted YHL/SVS intervention. The three year study will have three phases. Phase 1 in YO1 will include formative research with key stakeholders to inform adaptations of the content and format of the YHL/SVS intervention so that it meets the needs of these audiences/settings, to inform the plans for intervention implementation, and the evaluation methods, tools and measures so they meet the needs/priorities of the stakeholders. Phase II beginning in YO2 will be a translational pilot study with 6 MHPC and 14 WIC sites (half randomized to receive the tailored intervention and half randomized to receive the comparison intervention) and 1400 of their clients to study and evaluate the translation of the intervention. Phase III will be a continuation of the translation study with all sites receiving the tailored intervention. at the end of YO3, we will compile data from the translation research pilot study and use it to create a plan for disseminating the intervention throughout RI and into other states.
1 R18 CE001339-01 - Dissemination Research in Child Safety
GIELEN, ANDREA C
DESCRIPTION (provided by applicant): This proposal utilizes proven effective interventions to reduce home injuries caused by fires, scalds, and carbon monoxide. Using participatory methods, we propose to study the dissemination of lithium smoke alarms, hot water safety, and carbon monoxide detectors in census tracts at high risk in East Baltimore. The proposal is specifically responsive to research requested by the CCEHIP in its focus on unintentional injury prevention and healthy homes as well as that requested by the NCHM in its focus on the utilization of effective partnerships to improve dissemination to high risk populations. The proposed research builds on the ongoing community work of four organizations: 1) The CARES Mobile Safety Resource Center; 2) The Baltimore City Fire Department; 3) The Center for Community Health Education, Advocacy, Leadership, and Training; and 4) The Environmental Justice Partnership. Together, this team proposes dissemination research to: 1) Describe the implementation of a community program promoting adoption of effective injury prevention interventions in low income, urban neighborhoods by completing a) in depth interviews with community partners and stakeholders and b) a process evaluation of the program; 2) Determine the diffusion of the program among families in the selected neighborhoods by conducting household surveys in two communities (intervention and comparison) to measure program awareness, participation, knowledge and adoption of the injury prevention interventions; 3) Determine the maintenance of injury prevention interventions among families who participated in the program by conducting a six-month follow up visit with a cohort of program participants; and 4) Identify the mechanisms through which the program could be scaled-up and institutionalized to address the needs of all high-risk communities throughout the city by conducting key informant interviews with selected policy makers and other leaders. A combination of qualitative and quantitative methods is proposed, including interviews, document reviews, and home observations. Utilization of multiple types of research methods will help advance the scientific approach to dissemination research. Results will also yield new knowledge about how best to disseminate effective interventions to reduce burns and carbon monoxide poisoning among children and families living in high risk, urban communities.
1 R18 DD000345-01 - Translating Evidence-Based Developmental Screening into Pediatric Primary Care
GUEVARA, JAMES P
DESCRIPTION (provided by the applicant): Developmental problems in early childhood are common and often go undetected, leading to significant disability. Developmental screening using standardized instruments can improve the detection of developmental delays and allow for referral to early intervention services. Unfortunately, few clinicians utilize standardized screening instruments to identify developmental problems. The American Academy of Pediatrics (AAP) recently issued a recommendation that health care providers conduct developmental surveillance at all well child visits and institute developmental screening at 9, 18, and 30 months of age. This application will address the adaptability, feasibility, and effectiveness of the AAP's evidence-based policy statement regarding developmental screening in an urban primary care setting serving primarily low income African American families. The specific aims of this application are (1) to identify barriers and facilitators to the use of guideline based standardized developmental screening in primary care practice, (2) to assess the feasibility of implementation of two different developmental screening protocols compared with a control condition: standardized developmental screening at 9, 18, and 30 months with support for the implementation of the protocol (Intervention 1) vs. standardized developmental screening at 9, 18, and 30 months with no additional support for the implementation of the protocol (Intervention 2) vs. developmental surveillance alone (control condition), and (3) to determine the relative effectiveness of two different developmental screening protocols compared with a control condition: standardized developmental screening at 9, 18, and 30 months with support for the implementation of the protocol (Intervention 1) vs. standardized developmental screening at 9, 18, and 30 months with no additional support for the implementation of the protocol (Intervention 2) vs. developmental surveillance alone (control condition). The application will employ a mixed methods study design that combines qualitative and quantitative methodologies. In year 1 of the application, urban primary care pediatric practices affiliated with a large children's hospital will be recruited. Focus groups of health care providers and office staff at participating practices will be conducted to identify attitudes, social norms, and perceived behavioral controls including facilitators and barriers to developmental screening. Information obtained from these meetings will be used to adapt a developmental screening protocol for implementation. In years 2-3 of the application, health care providers will be randomized to one of three developmental screening protocols: targeted screening by primary care support staff, targeted screening by health care providers, or surveillance alone. Eligible children will be followed in the intervention for 18 months, and outcome data on identification and referral of developmental problems and enrollment in early intervention will be obtained from electronic health records and early intervention service providers. Surveys of participating health care providers and families will be used to obtain information on the feasibility of the various screening protocols.
1 R18 DP001148-01 - A Model Statewide Trial to Detect and Treat Maternal Hypothyroidism in Pregnancy
HADDOW, JAMES E
DESCRIPTION (provided by applicant): We propose a model community-based trial in Rhode Island (RI), aimed at avoiding or minimizing morbidity from overt maternal hypothyroidism by systematic detection and treatment, beginning at the 1st prenatal visit. This model can be superimposed on existing prenatal screening programs and is intended ultimately to replace "case-finding", which has recently been shown ineffective. Three aspects of maternal and child health are compromised when a pregnant woman is thyroid deficient: 1) the woman's own health and well-being; 2) her baby's brain de- velopment; and 3) overall health of the pregnancy (e.g., fetal death, prematurity, preeclampsia). Thyroid stimulating hormone (TSH) measurement, a well accepted indicator of thyroid dysfunc- tion, will serve as the primary test for both diagnosis and monitoring. A TSH value >10 mU/L indicates overt hypothyroidism. Among the state's 14,000 annual pregnancies, 42 women (0.3%) will be overtly hypothyroid early in gestation (32 undiagnosed, and 10 under-treated). TSH values between 4.5 mU/L (98th centile) and 9.9 mU/L indicate subclinical hypothyroidism. The 240 women in this category will also receive treatment, and information will be gathered about disease progression to inform future practice. Approximately half of all RI's pregnancies are cared for by practices in Greater Providence, and TSH testing will initially be introduced, there. The research component is also within that area. Testing will subsequently be extended to the entire state. The program will be centrally managed by three units at Women and Infants Hospital, in consultation with RI's Birth Defects Program Director. Program goals are to: provide TSH testing to at least 70% of pregnant women in Greater Providence provide TSH testing to at least 50% of pregnant women elsewhere in RI test 70% of screened women by 12 weeks' gestation, and 90% by 18 weeks' gestation begin treatment in Greater Providence by 13 weeks' in 70%, and by 19 weeks' in 90% document successful treatment during pregnancy in 90% (TSH >0.1 mU/L and < 2.0 mU/L) retain 95% treated women to end of pregnancy, and 90% for up to 1 year postpartum obtain pregnancy complications and birth outcomes for the entire cohort (Vital Records) Data will be collected on participation by practices and women, % of women with undiagnosed thyroid deficiency, compliance with follow-up and treatment during pregnancy and for up to one year afterwards, outcomes of their pregnancies, % of hypothyroid women with postpartum thy- roid dysfunction, % of women with subclinical hypothyroidism who remain hypothyroid one year postpartum, physician attitudes, and program costs. There is general agreement that thyroid gland function should be assessed in pregnant women. When the gland produces too little thyroid hormone (hypothyroidism), all of the woman's bodily functions slow down, and there are problems with her baby's development. Until now, physicians have identified this problem on an individual basis (case-finding), but this approach misses many of the cases. Our trial aims to replace case-finding with a routine blood test that is highly effective at detecting hypothyroidism, thereby allowing treatment to correct the deficiency. This approach can eventually be implemented throughout the United States.
1 R18 CI000583-01 - Statewide Implementation of Guidelines to Control MRSA
HERWALDT, LOREEN A
DESCRIPTION (provided by applicant): Methicillin (oxacillin)-resistant Staphylococcus aureus (MRSA) is by far the most common resistant bacterial pathogen. Despite concerted efforts to decrease transmission, the prevalence of this organism continues to increase in healthcare facilities and in the community. Moreover, this organism now causes serious infections in persons who do not have the traditional risk factors for MRSA infections and it can spread silently in the healthcare setting and in the community. Few hospitals have implemented all components of the evidence-based guidelines for preventing spread of MRSA. The purpose of the proposed study is to 1) encourage all Iowa hospitals to implement the Institute for Healthcare Improvement's (IHI) MRSA bundle and to report data on nosocomial MRSA infections to Iowa's unique voluntary reporting system for healthcare-associated infections; 2) identify impediments and/or facilitators to successful translation of this evidence-based public health guideline; 3) identify optimal strategies for enhancing widespread adoption and institutionalization of this effective public health intervention. A robust coalition of specialists in implementation of evidence-based guidelines, quality improvement, infectious diseases, microbiology, molecular epidemiology, hospital epidemiology, public health, healthcare delivery, and healthcare policy will study the implementation of this evidence-based guideline to control MRSA. This proposal has 6 specific aims: 1) Assess knowledge, current preventive practices, and needs regarding MRSA control in acute-care hospitals, long-term-care facilities, and in the outpatient setting; 2) Implement IHI's MRSA bundle at the University of Iowa Hospitals and Clinics, the Iowa City Veterans Affairs Medical Center, and at acute care hospitals across Iowa; 3) Determine whether MRSA carriage at sites other than the nares, carriage by healthcare workers, and environmental contamination decreases the effectiveness of IHI's MRSA Bundle; 4) Assess the implementation of IHI's MRSA Bundle in individual hospitals and in Iowa's hospitals in general; 5) Assess the effectiveness of IHI's MRSA bundle at individual hospitals and in Iowa's hospitals in general; 6) Develop resources to help the community prevent spread of MRSA; control of MRSA in the community might enhance the effectiveness of IHI's MRSA bundle in hospitals. The methods will involve observing practice, calculating rates of nosocomial MRSA bloodstream infections and of MRSA transmission, feeding these rates back to the clinicians, evaluating progress, implementing more change, and measuring rates again (rapid-cycle change). Statistical analysis will be done by time series analysis methods adapted for data with frequent zeros to assess whether implementing the evidence-based guideline was successful. Summative surveys and focus groups, using methods from appreciative inquiry, positive deviance, and critical incident analysis, will be conducted to identify facilitators and obstacles to implementation. Methicillin-resistant Staphylococcus aureus (MRSA), which is the most common resistant bacteria causing serious infections in both healthy people and people whose immune systems are impaired, continues to spread in healthcare facilities and in the community. Yet numerous studies have demonstrated that concerted efforts, particularly in hospitals, can decrease MRSA infections and prevent spread of this organism. The goal of this proposal is to implement these effective practices in hospitals and in high risk areas of the community across Iowa to prevent MRSA infections and to learn how best to translate medical knowledge into everyday medical practice.
1 R18 DP001140-01 - Fit and Strong!: Translating an Evidence-Based Multi-component Exercise Program
HUGHES, SUSAN L
DESCRIPTION (provided by applicant): Abstract Osteoarthritis (OA) is the most common chronic condition among older adults, is a major barrier to their participation in physical activity, and is a known risk factor for disability and institutionalization. Fit and Strong! is an evidence-based physical activity/behavior change program that targets this high risk group. It addresses documented strength and aerobic deficits in this population and is inexpensive and simple to replicate. Results from a randomized trial show that Fit and Strong! has significantly decreased participants' lower extremity joint pain and stiffness while increasing their self efficacy for exercise and their maintenance of exercise over time (Hughes et al, 2004 and Hughes et al., 2006). Fit and Strong! is currently being replicated in Chicago, in Charlotte, NC and in WVA. It is ready for broad, community-based diffusion to persons who can benefit from it. Because little is currently known about the most effective ways of translating and diffusing physical activity programs for older adults, this study will examine the effectiveness of partnering with existing Area Agencies on Aging (AAAs) in two states (IL and NC) to translate and diffuse the program to senior centers within two AAA catchment areas per state. This translation study will use Glasgow's Re-Aim model and Greene et al.'s work on evaluation (Glasgow, Vogt and Bowles, 1999; Green and Glasgow, 2006) to identify facilitators and barriers to the reach, effectiveness, adoption, implementation and maintenance of Fit and Strong!. We will train a T Trainer and Master Trainers and will work with them to train certified exercise instructors to conduct Fit and Strong at senior centers in 4 AAA catchment areas (target Ns = 1 T trainer, 2 master trainers, 30 sites, 30 certified instructors and a minimum of 1,200 participants). The study will use mixed methods including secondary analyses of census and BRFS data (reach), pre-postest participant outcome measures (effectiveness), surveys of all senior centers in each catchment area (adoption), site visits to all participating Centers to develop and refine fidelity/adaptation checklists and procedures (implementation), and in-depth interviews with upper level senior center managers at the conclusion of each iteration of Fit and Strong! (maintenance) to evaluate the effectiveness of this diffusion process along with facilitators and barriers experienced within and across the two states. Study funds will also be used to develop a Fit and Strong! website and an interactive web-based support hotline, to finalize training materials, to support the cost of the trainings and to provide financial incentives for participation among the first sites that sign up to participate. Study activities will both advance the development of Fit and Strong as a high quality, turnkey evidence based program and also obtain new data on factors that facilitate the adoption, implementation, and maintenance of PA programs for older adults.
1 R18 TP000102-01 - Assessing the Impact of Federal and State Law on Public Health Preparedness
JACOBSON, PETER D
DESCRIPTION (provided by applicant): The purpose of this project is to assess and evaluate how the law shapes the public health system's preparedness activities and its response to public health threats, such as infectious disease outbreaks, pandemic flu, and all hazards (including bioterrorism preparedness). The specific objectives are to examine: 1) the link between law and public health preparedness activities; 2) the extent and scope of legal mandates on state and local public health systems and whether those mandates facilitate or impede public health preparedness efforts; 3) how variations in state laws affect the use of federal and state funding streams to meet public health preparedness objectives; 4) how public health practitioners interpret and respond to federal and state laws affecting public health preparedness; and 5) to translate the findings into concrete policy recommendations for public health officials and legislators to implement. To meet these objectives, the investigators will first examine federal laws regarding public health preparedness, such as bioterrorism and infectious disease threats (including an examination of funding streams and performance measures). Then we will conduct a series of case studies of state and local public health systems to determine how state and federal law affects the public health system's ability to respond more effectively to public health threats and other public health preparedness needs. The project's primary contribution will be to provide policymakers with the first systematic empirical information to understand how law shapes the public health system's disease preparedness activities, and how public health officials are adjusting to the changing legal environment. Another project goal is to bridge the gap between academic research and the issues public health practitioners face. Translating the research findings to the practitioner community is an important element of our overall strategy, an aspect of the research that we view as both crucial to the project's success and an important contribution of this effort. Thus, we plan to recommend concrete strategies states and local health departments can use to address the implications of federal and state law and funding on their public health preparedness activities.
1 R18 DP001143-01 - Policies to Restrict High Alcohol Content Beverages
JONES-WEBB, RHONDA J
DESCRIPTION (provided by applicant): This application is in response to RFA-CD-07-005, Improving Public Health Practice Through Translation Research. Translation research characterizes the process by which proven interventions or polices are successfully adopted, implemented, and adapted in other settings. A major goal of our research is to examine the adoption, implementation, and diffusion of policies to restrict malt liquor sales in the U.S. Our three -year study has three primary objectives: (1) Determine whether the sale and consumption of malt liquor is perceived as a problem by city officials and document what has been done at the local level to restrict it. Specifically, we are interested in learning which cities have tried successfully or unsuccessfully to adopt policies to restrict malt liquor sales and consumption over the last 13 years (1995- 2007). This aim will be accomplished by conducting a telephone survey of city officials and staff responsible for alcohol policy-making and enforcement in the 100 largest U.S. cities. (2) Compare six cities' efforts to adopt policies to restrict malt liquor sales and determine what factors were critical to their success or failure. This aim will be achieved by conducting a retrospective, comparative case study of three cities that successfully adopted policies that restrict malt liquor sales and three cities that were unsuccessful. Study cities will be selected based on results of the telephone survey. Special attention will be given to barriers and facilitators of passage and compromises made to adopt these policies. Multiple data collection strategies will be used, including key informant interviews, documentation review, and media tracking. (3) Create a national database that provides summaries of key features of local policies that have been successfully adopted to restrict malt liquor sales on our Alcohol Epidemiology website, which is accessible to local policy makers, law enforcement officials, community groups, and researchers. The database will also include a summary of the literature on malt liquor consumption and policies to restrict its use, model ordinances that cities may wish to adapt to their communities, a summary of factors that may facilitate or impede adoption of these policies, and examples of measures that can be used to evaluate these policies. This is the first study we know to explore local efforts to reduce malt liquor sales at a national level. Results will have immediate and real-world implications for cities wishing to alleviate alcohol-related problems in inner cities.
1 R18 HK000057-01 - A Study of an EHR to Translate Public Health Practices
KUKAFKA, RITA
DESCRIPTION (provided by applicant): Ample evidence demonstrates that public health elements such as preventive care reminders, quality measurement, immunization registries, and patient education materials provide public health value, yet dissemination is poor. Electronic health records (EHRs) may provide a solution, but poor EHR adoption and poor incorporation of public health elements into EHRs limit their broad use. The New York City government is carrying out a unique project to improve the health of the city, investing over $27 million to implement a public health enabled EHR (PHEEHR) to providers who treat underserved patients throughout the city. Our project is to study this PHEEHR New York City implementation with the goal of discovering strategies that can enhance PHEEHR adoption and impact. Specific aims are 1) to study the implementation process by examining across practice settings the contextual factors that contribute to the adoption and impact of the PHEEHR; 2) to study how the complex relationships between public health elements and environmental task elements facilitate or hamper adoption and impact of the PHEEHR and 3) to develop and disseminate generalizable conclusions based on the results of aims 1 and 2. We will use the DeLone and McLean Information System Model to evaluate the causal paths that begin with the PHEEHR system itself, and incorporate user satisfaction, adoption, and impact. Impact in this study is multifaceted measured in part by an increase in the proportion of provider sites that perform preventative services and public health reporting based on Healthy People 2010 and the U.S. Preventive Services Task Force guidelines. The DeLone and McLean model and an extended model with a task-technology fit construct will be empirically tested with quantitative qualitative and relational data collected from 327 practice settings. Multilevel structural equation modeling (ML-SEM) will be used to evaluate both models. To maximize the generalizability of our findings, we will adhere to standardized multidimensional reporting metrics from the RE-AIM framework specifically designed to improve the translatability of research findings. Our goal is to extend what we learn from this unprecedented New York City PHHEHR implementation research study to inform others that are likely to engage in similar PHEEHR implementations in the future.
1 R18 DP001141-01 - Implementation of a Mammography Reminder System in a Healthcare Network
LUCKMANN, ROGER S
DESCRIPTION (provided by applicant): Substantial evidence supports the effectiveness of screening mammography in reducing breast cancer mortality and the effectiveness of mailed and telephone reminders and counseling in increasing timely screening. Widespread adoption of mammography reminder and counseling systems (MRCS) designed to reach and meet the needs of the older women, minority women has the potential to decrease breast cancer mortality nationwide. However, MRCS adoption faces many barriers including uncertainty about the roles of primary care practices, managed care organizations, and integrated healthcare networks (IHN), fragmentation of information systems, and absence of model system components ready for implementation. In many areas, IHNs are in an ideal position to adopt MRCSs because of their connections to primary care (PCP) and mammography providers, and their access to information systems. We propose to 1) demonstrate the feasibility and effectiveness of implementing and institutionalizing a comprehensive MRCS within a large, IHN and at 2) document the barriers we encounter along with strategies for overcoming them. The system would use aggregated MCO claims data and IHN clinical scheduling and mammography data systems to track mammography use among women >=40 years who are patients of PCPs affiliated with the IHN. Women deemed eligible by their PCPs and overdue for a mammogram would be mailed tailored reminders in the patient's preferred language, and a second reminder if necessary. Nonresponders would get a telephone call that includes a verbal reminder and an offer to schedule a mammogram. Counseling would be provided for those hesitant to schedule. Building on 10 year's experience in developing and evaluating MRCSs and on the educational materials and computer-assisted telephone counseling protocols we have developed, we propose to implement a model MRCS in the IHN. Following implementation we would engage key stakeholders within and outside the IHN in a process aimed at institutionalizing the MRCS. We would evaluate system reach for targeted women and practices, effectiveness in increasing timely mammography, acceptance of the system by the PCPs and women, and fidelity of intervention delivery. We would prepare an implementation manual and a package of print materials and software to facilitate dissemination of the effective components of the MRCS model. 7. Project Narrative Research has shown that mailing reminders and calling women who are due or overdue for a screening mammogram can increase the chances that these women will get a mammogram. The goal of this project is to study the implementation of a program in a large healthcare network that systematically provides mailed reminders and calls to women age 40 and older who are patients of primary care providers in the network and are due or overdue for a mammogram. We will also work with the leaders of the healthcare network and health insurance plans to make the program a permanent service provided by the network.
1 R18 DD000344-01 - Implementing Newborn Screening for Duchenne Muscular Dystrophy in the Community
MENDELL, JERRY
DESCRIPTION (provided by the applicant): In a cooperative agreement with the CDC, the critical groundwork for a newborn screening program (NBS) for Duchenne muscular dystrophy (DMD) was established and included: the range of creatine kinase (CK) observed on > 30,000 anonymous samples, a successful method to measure CK isoenzymes, with particular emphasis on CK-MB, and a reliable method of DNA analysis of the dystrophin gene, with validation from known DMD mutations. These laboratory approaches permit us to do all NBS for DMD from the initial dried blood spot samples taken at birth without obtaining additional blood at a later time. These achievements have made it possible to propose a more extended program to cover the majority of the birthing hospitals in the State of Ohio, fulfilling the true spirit of translating a laboratory-based program to the community. Compelling reasons for making this a reality include: 1) DMD is the most common devastating muscle disease of childhood; 2) NBS will have a major impact on the disease and community offering early intervention and treatment (including the use of corticosteroids and exciting molecular and pharmacologic approaches reviewed in this application); 3) excessive expense and anxiety of the later diagnostic challenge faced by many families; 4) genetic counseling to families at risk for having more sons with DMD (multiple boys with DMD leads to overwhelming financial expenses, guilt-laden parents, and increased incidence of divorce). In this application, NBS will be extended throughout the State of Ohio, reaching 75,000 newborn males. The first year will be focused on organization and will permit us to: 1) establish an Administrative Core to manage a network of participating hospitals (AIM1); 2) establish a Laboratory Core for evaluation of CK and DNA for the dystrophin gene (AIM2); and 3) establish the network of hospitals participating in this program (AIM3). Starting in year 1 and continuing in years 2 and 3 will be the implementation of the NBS of 75,000 males for DMD (AIM4). The success of this program will provide a template for expanding NBS for DMD to other States with the potential of making this a national voluntary screening program. Such a program will make a difference for this disease.
1 R18 IP000166-01 - Influenza Vaccine Delivery to Adolescents: two multicomponent interventions
ORENSTEIN, WALTER A
DESCRIPTION (provided by applicant): There is a critical need to better control the current burden of influenza. Despite the availability of vaccines and vaccination strategies targeted to those most at risk of complications from the disease, approximately 36,000 deaths and more than 200,000 hospitalizations occur annually. This proposal addresses two potential delivery systems for a new control strategy currently under consideration by national policy makers for annual vaccination of all school children. Specifically, we will determine whether vaccinating adolescents at school as compared to their usual source of medical care (i.e., doctor's office or health department clinic) leads to higher immunization coverage. The focus on adolescents is particularly important because many do not make the recommended preventive care visits, and determining the best means of reaching them for vaccination has relevance for a number of new vaccines recommended for this age group. We will conduct a three- armed controlled trial using a systematic replication design to compare influenza vaccination rates in three racially diverse rural counties of southeast Georgia, specifically, Warren, Lincoln and Jenkins counties. In Lincoln and Warren counties we will implement two cycles of the multicomponent interventions designed to motivate parents and adolescents to be vaccinated and distribute vouchers for free vaccine. In Warren County (N=437 middle- and high-school students), we also will conduct vaccination clinics in the school. In contrast, in Lincoln County (N = 783), we will ask parents to take their child, along with the voucher, to their usual source of care where vaccine will be provided, free. Providers will also be reimbursed for vaccine administration at the Medicare fee, $17.05 per dose. Jenkins (N = 869) will serve as a control county where we will implement no intervention. As a secondary outcome we will assess the delivery of other recommended preventive health services to determine whether bringing adolescents to their usual source of medical care for vaccination (provider-based intervention) can improve the overall delivery of preventive healthcare compared to the school-based intervention and the control condition. Other outcomes will include the effect of the two interventions on mediators of vaccine acceptance. Findings from this study could have important health policy implications, laying the foundation for recommendations on how best to implement a universal influenza vaccination strategy of adolescents.
1 R18 CE001340-01 - Population-Level Parenting Interventions to Reduce Prevalence of Child Abuse
PRINZ, RONALD J
DESCRIPTION (provided by applicant): This project focuses on improving public health practice through translation research in the context of a population trial aimed at the prevalence reduction of child maltreatment. This trial, called the U.S. Triple P System Population Trial, is the only known study on prevention of child maltreatment that has randomly assigned geographical areas (in this case 18 counties) to condition and is examining impact on population indicators of child maltreatment. The public-health-based intervention is the Triple P (Positive Parenting Program) system for which efficacy and effectiveness has been well established through over 30 previous RCTs. The key aims are: (1) to identify and better understand facilitators and impediments to maintenance of service-provider implementation of evidence-based parenting interventions for prevention of child maltreatment; (2) to evaluate how well the translation of the evidence-based parenting interventions into a broad-scale dissemination strategy has succeeded with respect to the sustaining the prevention of child maltreatment over multiple years with respect to child out-of-home placements, child hospitalizations and emergency-room visits for maltreatment-related injuries, and child maltreatment cases; (3) to evaluate the cost effectiveness of the population-wide dissemination over multiple years; and (4) to characterize variation in child-maltreatment prevention outcomes across counties and explore associations with implementation and socio-demographic variables. The methodology includes randomization and experimental control at the level of county (controlling for prior rates of child abuse), repeated field assessments with 400 service providers, and ecological dissemination of the public health intervention.
1 R18 DP001144-01 - Intensive Behavioral Weight Management in Public Health Settings
SAMUEL-HODGE, CARMEN D
DESCRIPTION (provided by the applicant): Low-income women in the US have the highest rates of overweight and obesity, putting them at increased risk for diabetes, heart disease, and other chronic illnesses. Because mean BMI gradually increases during adult life and peaks at 50-59 years of age, low income women between 40-64 years are a group deserving of special attention. While there is sufficient evidence that some behavioral weight management interventions are effective in producing clinically meaningful levels of weight loss with reductions in cardiovascular risk factors and delayed onset of diabetes, there is a research gap in translating these efficacious interventions to real life settings and diverse population groups. Research that seeks to translate effective behavioral weight management interventions from resource-intensive efficacy trials to long-term adoption and implementation by public health settings serving a diverse low-income population is timely and of great public health significance. This translational research can provide important information to decision-makers about evidence-based intervention delivery, resource allocation, and workforce preparation. The overall goal of the proposed research is to evaluate the processes and outcomes of translating from research to practice an intense, evidence-based behavioral weight loss intervention with demonstrated effectiveness among midlife low-income women. Originally studied in a single coordinated community health care center/church setting and delivered by research staff, we will evaluate the translation of and test the effectiveness of this intervention as implemented by existing staff in a range of county health departments supported by local community resources. To evaluate the translation process, we will use the RE-AIM framework, diffusion of innovation theory, and systematic models of adaptation to assess: 1) factors related to reach; contextual or setting-specific factors necessary for successful adoption and implementation; 2) effectiveness of facilitator training and stakeholder collaborations; 3) adaptation and fidelity during implementation; and 4) costs associated with the implementation and outcomes. To test the intervention's effectiveness, we will enroll 240 overweight or obese low-income women, 40-64 years of age, at 6 representative public health agencies. Participants will be randomized to receive a 16-week behavioral weight loss intervention or usual care (wait listed control group). The primary study outcome at 5 month follow-up is weight change; secondary outcomes include change in blood pressure, dietary intake, physical activity, and quality of life measures. After 5-month follow-up, the wait listed control group will receive a 10-week intervention, refined by lessons learned during the 16-week implementation. For this group, we will conduct a second round of process and outcome evaluations. Also, for both groups, we will evaluate maintenance of weight loss 6 months post intervention.
1 R18 DP001149-01 - From Guideline to Practice: A Nursing Intervention to Help Smokers Quit
SARNA, LINDA P
DESCRIPTION (provided by applicant): Tobacco use is the leading cause of preventable death and illness in the US. Despite its availability, the Guideline for evidence-based smoking cessation interventions is underutilized by healthcare professionals. The purpose of this proposal is to translate the Guideline into nursing practice by using an innovative web- based intervention, Helping Smokers Quit (HSQ). The HSQ includes a validated web-based educational program tailored for nurses working in acute care hospitals, a toolkit of printed materials, including the HSQ Pocket Guide for Nurses, web-resources in a special tab on the Tobacco Free Nurses website www.tobaccofreenurses.org, and technical support to the Directors of Nursing (DN). The control group (HSQ- m) will only receive the toolkit. The primary aims are to: 1) Evaluate the effectiveness of the HSQ in improving self-reported nursing performance on smoking cessation interventions with hospitalized patients 6-months after the intervention as compared to the HSQ-m group; 2) Determine the adoption and maintenance of changes in a) nurse performance on cessation interventions 12-months after the intervention; and b) hospital practices 24-months after the intervention in the HSQ as compared to the HSQ-m group; and 3) Determine the variables (nurse- and hospital-level) on the effectiveness of the HSQ and HSQ-m in nursing performance at 6- and 12- months after the intervention. Also, we will: 4) Examine improvement in hospital performance in smoking cessation (based on ratings by the Joint Commission, JC) on interventions offered to patients with the target diagnoses (heart attack, heart failure, and pneumonia), at 12- and 24-months post-intervention in the HSQ as compared to the HSQ-m group; and 5) Evaluate implementation (utilization and satisfaction) of the HSQ and HSQ-m. Six hundred (n = 300 HSQ and n = 300 HSQ-m) nurses from two states with high smoking prevalence (West Virginia, WV, Indiana, IN) and one with low prevalence (California, CA) are the focus of this program. Using an intervention-control, two-group, pre-post design, based upon the RE-AIM model, the HSQ will be delivered to nurses in 15 JC accredited hospitals in WV, IN, and CA (5 in each state). Nurses in 15 other hospitals (5 per state) will serve as controls (HSQ-m). We will partner with nurse experts and tobacco control consultants who will provide community support. The RX for Change(c) curriculum will be delivered via webcast. Data on self-reported nursing performance in smoking cessation will be collected via the web using a valid and reliable questionnaire. Publicly available data from the JC will be used to monitor changes in hospital performance. Interviews with the DNs 24-months after the intervention will identify maintenance of changes in hospitals. Regression models will evaluate effectiveness of the HSQ, adoption/ maintenance of changes in nursing performance; multiple linear regression will examine correlates of nurse performance. Content analysis will be used to evaluate interview responses. This project will provide information about translation of the Guideline to clinical practice and the link between a training program and changes in hospital performance. Statement Despite the availability of proven ways to help patients help stop smoking, the leading cause of preventable death and illness in the US, these interventions are not a routine part of nursing care. The purpose of this application is to translate smoking cessation interventions into clinical nursing practice using a web-based program in three states. Two of these states have smoking prevalence >25%, twice the 12% goal set by Healthy People 2010, and the rate in one state is the second lowest in the country. This project has potential to decrease smoking and improve health outcomes of Americans.
1 R18 DP001150-01 - PEARLS Dissemination
SNOWDEN, MARK B
DESCRIPTION: Depression Care Management is a model of depression treatment demonstrating effectiveness in diverse settings and studies. The Program to Encourage Active and Rewarding Lives for Seniors (PEARLS) is a specific, multi-component, depression care management intervention that effectively treats minor depression and dysthymia in homebound elders. Despite its effectiveness, successful translation into everyday practice has been slow and incomplete. Use of an implementation consultant has been shown to effectively overcome organizational barriers. The purpose of this research application is to study the effects of adding consultation by an implementation management team to usual PEARLS implementation through case manager referral. The investigators hypothesize that the consultation team will facilitate greater reach of PEARLS to homebound elderly depressed patients across a county-wide region as compared to current referral-based implementation efforts. The Seattle Aging and Disabilities Services program has 50 case managers serving over 2000 homebound elderly clients, of whom 400 have depression scores consistent with dysthymia or minor depression. 25 case managers will be randomly allocated to work with PEARLS referral-based care augmented by an implementation management team and the remaining 25 will continue with usual referral-based care. One of the specific aims is to develop an implementation management team to improve PEARLS implementation. The team will include a geriatric psychiatrist, a person with PEARLS intervention expertise, and a case manager. A second aim is to develop an implementation plan for organizational assessment, staff education and training, monitoring of outcomes, and collaborative problem solving. The third aim is to conduct the trial testing the implementation methods to usual implementation and the fourth aim is to evaluate the trial. The evaluation plan will use mixed methods including both qualitative and quantitative methods to determine the reach, effectiveness, adoption, implementation fidelity, and maintenance of this implementation approach to determine the benefits of using an implementation management team.
1 R18 PS000830-01 - Translating Research into the Jade Ribbon Campaign
SO, SAMUEL K S
DESCRIPTION (provided by the applicant): Major gaps exist in the timely identification and immunization of infants born to women infected with hepatitis B virus (HBV). Timely identification of such newborns is critical because immunoprophylaxis at birth can prevent HBV transmission in over 90% of newborns. In contrast, more than 90% of newborns infected with HBV will develop chronic hepatitis B, which confers a 200-fold increased risk of liver cancer. To address this critical public health issue, the Advisory Committee on Immunization Practices (ACIP) issued recommendations in 2005 to improve nationwide prevention of perinatal HBV transmission. The next step in the widespread adoption of these guidelines is to translate them into a public health strategy that fosters rapid uptake of the recommended actions. Therefore, this research project aims both to understand the factors that impede or facilitate the adoption of perinatal hepatitis B prevention guidelines, and to translate the ACIP recommendations into concrete implementation of prevention services for pregnant women infected with HBV, their newborn infants, and other household and sexual contacts. Our specific aims are as follows: 1) to increase by at least 300% the number of obstetricians that provide timely antenatal reporting of pregnant women infected with HBV; 2) to increase by at least 10% the enrollment of exposed newborns in case management services; 3) to improve to over 80% the rate of post-vaccination serologic testing among exposed newborns; 4) to increase to over 75% the proportion of delivery hospitals that adopt standardized procedures for management of HBV-positive pregnant women, their newborns, and their household and sexual contacts; and 5) to improve knowledge about hepatitis B among HBV-positive pregnant women. Our project will be based in two California counties where at least one-quarter of the population is composed of Asian and Pacific Islander Americans-the racial/ethnic group at highest risk of perinatal HBV transmission. Our strategy focuses on education of health care providers, pregnant women, and their household contacts through the dissemination of culturally tailored educational materials; provision of standardized "provider packet for HBsAg positive pregnant women" to facilitate the adoption of case reporting and management guidelines by hospital personnel; and informational support for pregnant women infected with HBV. We will assess pre- and post-intervention practices, knowledge, and barriers and facilitators to care among stakeholders, and will evaluate the cost effectiveness of our intervention to address its future sustainability. The ultimate goal of our study is to develop a comprehensive program for perinatal hepatitis B prevention that can be disseminated widely and integrated seamlessly into existing public health service programs to result in a more effective, efficient, and sustainable strategy for long-term reduction of disease and death due to hepatitis B.
1 R18 HK000058-01 - Electronic Medical Records to Improve Patient Care & Public Health in Rural Kenya
TIERNEY, WILLIAM M
DESCRIPTION (provided by applicant): Health care is an information-intensive, complex set of processes. Integrating care between providers and sites requires integrating health care information. Health care in developing countries has been inadequately sup- ported with electronic medical record systems (EMRs), being on the far side of the digital divide. As a result, data are not available to enhance the quality and efficiency of care. Developers from Indiana University, the Regenstrief Institute, and their collaborators at Moi University in Kenya created sub-Saharan Africa's first ambulatory electronic medical record system that served (and still serves) a rural health centre in western Kenya. This system then gave birth to what has become the most widely implemented, comprehensive electronic medical record system used in HIV/AIDS clinics throughout sub-Saharan Africa: OpenMRS. Although in western Kenya most of the HIV/AIDS clinics are in public health facilities that also contain primary care clinics, the HIV/AIDS information system does not contain data from these primary care clinics, and therefore primary care and HIV/AIDS care happens separately, without integration. Yet both primary care and HIV/AIDS clinics in these health centres are caring for the same patients, and each visit in developing countries where access to care is always challenging is an opportunity to provide patient-focused primary and specialty care. This project will merge the Mosoriot Medical Record System, from which OpenMRS was originally created, back into OpenMRS. It will demonstrate that a single integrated EMR can support both primary and HIV/AIDS care and become an effective tool for care in both types of clinics. Once integrated, the developers will demonstrate that simple decision-support tools such as computer reminders will increase adherence to both primary care and HIV/AIDS care guidelines, such as (a) preventing transmission of HIV from pregnant mothers to their infants (specifically, increasing the number of women and their infants appropriately screened for HIV), (b) ensuring that HIV-infected children receive appropriate preventive care (specifically, receiving appropriate immunizations), and (c) coordinating care for adults and children co-infected with HIV and tuberculosis (specifically, increasing the number of co-infected patients completing appropriate treatment and follow-up). The effect of the merged primary/HIV/AIDS EMR on provider productivity and time management will also be measured. The agencies funding HIV/AIDS care in developing countries have realized that paying for care requires paying for the collection and management of high-quality electronic data. This project will discern whether such EMRs can also be used to support primary care at minimal additional cost (and perhaps be cost-saving if preliminary evidence of increased productivity of Mosoriot's health care providers can be demonstrated on a larger scale). If so, then such EMRs will be sustainable as long as HIV/AIDS care is funded, and the use of EMRs to manage and improve HIV/AIDS and primary care can be maintained.
1 R18 DP001142-01 - Prevention of Ovarian Cancer in Women Participating in Mammography
URBAN, NICOLE D
DESCRIPTION (provided by applicant): Prevention of Ovarian Cancer in Women Participating in Mammography Abstract: The evidence-based policy that we seek to promote is risk-reducing salpingo-oophorectomy (RRSO) in women at high risk (HR) for ovarian cancer. Impediments to the successful translation of this policy are that some women are not aware of their risk, and that the appropriate timing of the surgery remains unclear. Our strategy to enhance widespread adoption and institutionalization of this policy is to take advantage of the availability of family history (FH) data in mammography systems in order to systematically identify HR women for referral to risk/genetic counseling (R/GC). In addition we will explore the use of serum markers as risk prediction tools to complement FH. Our long-term goal is prevention of ovarian cancer. An intervention has been demonstrated to work well: prophylactic removal of the ovaries and fallopian tubes once child-bearing is completed. While it would be inappropriate to recommend this surgery for all women, it is recommended for women with a strong FH suggestive of an inherited susceptibility, especially for those with a documented mutation in BRCA1 or BRCA2. The first impediment, that there is no systematic identification of HR women, can be addressed using available data and systems. The additional impediments, that most ovarian cancer occurs in women without a mutation or FH and that the timing of RRSO in these women is uncertain, require a novel approach. We will explore the use of serum markers to predict diagnosis of ovarian cancer in the HR population. We will identify women at HR based on FH at the time of their annual mammogram for referral to a genetic counselor (GC). A randomized controlled trial (RCT) will be performed at the Swedish Breast Cancer Center (SBCC) to evaluate the efficacy of this strategy in increasing rates of RRSO. An effectiveness study of the same strategy will be conducted at Group Health (GH) of Puget Sound to learn how guidelines for receipt of R/GC are adopted in practice. In addition we will explore the novel use of risk prediction serum markers to predict the diagnosis of malignancy or pre-invasive cancer in HR women enrolled in the study. This work will provide the evidence needed to optimize strategies for widespread adoption and institutionalization of systematic identification of HR women for appropriate intervention to prevent ovarian cancer incidence and mortality. Keywords: ovarian cancer, prevention, prophylactic surgery, risk, biomarkers, screening, symptoms STATEMENT We will evaluate a system-wide strategy to routinely identify women with a significant family history of breast and ovarian cancer, so that they can be informed by genetic counselors of their high risk for these cancers. Our goal is to promote surgical removal of ovaries and fallopian tubes in women who are at very high risk for these cancers, because there is clear evidence that this surgery can reduce the risk for ovarian cancer by over 90%, as well as the risk of breast cancer by 50% if the procedure is performed prior to menopause. A novel aspect of our work is that we will also evaluate a panel of serum markers for its ability to predict ovarian malignancy within the next two years, to assist high-risk women in their decision-making about the timing of preventive actions.
1 R18 PS000829-01 - Translating Effective Health Behavior Strategies Into Practice for HIV+ Women
WEISS, STEPHEN M.
DESCRIPTION: This multi-site application for a controlled "translational" trial proposes to test a dissemination strategy for an evidence-based behavioral intervention designed to reach poor women of color living with HIV. Over the past ten years, this multidisciplinary research team (University of Miami and Clinical Directors Network, New York) has conducted two behavioral clinical trials with poor women of color living with HIV/AIDS (the SMART/EST Women's Program) SWP. These trials demonstrated significant improvements in antiretroviral medication adherence, nutrition, self-efficacy, coping skills, and quality of life, accompanied by significant reductions in viral load, depression, anxiety, sexual risk and substance use. The applicants propose to test whether Community Health Center staff can be trained to implement the SMART/EST Women's Program in CHCs in New York, New Jersey and south Florida, three locales with the highest HIV rates for women in the U.S. Beginning with a six month "pilot phase" to refine the dissemination strategy, the study will provide intensive training and follow-up support for CHC health care staff to deliver the entire 16 session manualized intervention in English, Spanish and Creole, as appropriate. Organizational and clinical variables will be assessed to determine the effectiveness of this strategy for the adoption, implementation and maintenance of this program by the participating CHCs.
1 R18 DP001145-01 - Translation of Obesity and Cognition Research in a Rural State via Senior Centers
WEST, DELIA SMITH
DESCRIPTION (provided by the applicant): Obesity is a major public health problem among older adults, with 31% of non-institutionalized older persons (60 years+) in the US obese and projections indicating that this will rise to 40% by 2010. A second public health challenge on the horizon for the aging US population is the increasing number of individuals experiencing cognitive decline, dementia or Alzheimer's disease. Recent clinical trials have demonstrated efficacy in reducing risks associated with both of these significant and increasingly pervasive health problems, which are more common among rural, low income and ethnic minority populations. The Diabetes Prevention Program (DPP) Lifestyle Intervention produced sustained weight losses in a large, diverse population of high-risk individuals and dramatically reduced rates of type 2 diabetes onset, particularly among older adults. The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) produced long-term improvements in memory, reasoning and processing speed, as well as protected against declines in health-related quality of life and functional decline in instrumental activities of daily living in community dwelling older persons. Transferring these exciting technologies to community settings where they can benefit older adults is a pressing public health need. Therefore, the current project seeks to transfer these two evidence-based interventions to older adults in a rural state using senior centers as the venue for dissemination and lay health educators to deliver the interventions. Senior centers are a particularly attractive context for translation of evidence-based health promotion technologies in predominantly rural states like Arkansas because they have a well-established infrastructure in communities and share a common goal of promoting healthy aging and reducing health care costs. The 3-year randomized, controlled trial will evaluate translation of the interventions by randomizing senior centers (N=16) across Arkansas to implement either (1) the DPP Lifestyle Weight Loss Program or (2) the ACTIVE Cognitive Training Program. Older (age > 60) adults (N=288) nested within senior centers will receive the programs delivered in a group format by a trained lay health educator. Primary outcomes are changes in body weight and cognitive functioning at 12 months. The multi-level evaluation plan will characterize reach, effectiveness, adoption, implementation and maintenance of the interventions, with a strong cost effectiveness component.
1 R18 OH009396-01 - Translating a Weight Management Program to Worksites
WILSON, MARK G
DESCRIPTION (provided by the applicant): This project proposes to evaluate the implementation of the Diabetes Prevention Program (DPP) adapted to fit the unique characteristics of work organizations. Implementation research is an important step in the translation of research to practice because it examines how a set of intervention strategies can be used to integrate an evidence-based intervention within a specific setting, without the tightly controlled research infrastructure frequently associated with efficacy and effectiveness trials. DPP, which has been proven efficacious in clinical trials and effective in the worksite as well, is a 24 week weight management program designed to reduce caloric intake and increase caloric expenditure. The implementation of DPP in this study will be supported with strategies designed to bolster work and home environmental supports which, based on the ecological model and previous research, are key strategies for supporting health promotion programs in work settings. The corporate partner for the study will be Union Pacific Railroad (UPRR) which has very high levels of overweight and obesity that have been costly to the organization. Using a non-equivalent control group design, after matching sites, we will randomly assign four sites to treatment and control (n=1150 per condition). The primary outcome is BMI with secondary outcomes including healthy eating behaviors and physical activity levels. Other very important outcomes include changes in the work and home environmental supports, organizational measures measuring workplace improvement, and financial outcomes including health care utilization and ROI. Data will be collected at baseline, end of program, and six months post program. Statistical methods will be used to control for baseline differences and examine change over time. This study will not only provide the opportunity to test the implementation of a proven intervention in a high risk population, it will also enable us to test worksite specific implementation strategies (work and home environmental supports) about which there is considerable anecdotal, but little empirical evidence. This will provide valuable evidence on effective strategies for translating a proven intervention program to worksites.
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Page last modified: July 22, 2008
Content source: Office of the Chief Science Officer (OCSO)
