acase@tulane.edu

<p> Sickle cell disease (SCD) is a major healthcare and societal problem that affects millions of people worldwide. Sickle cell pain is the hallmark feature of SCD and includes manageable and unmanageable persistent pain that affects every aspect of an individual's life. Most of the research on pain in SCD has focused on children with acute vaso-occlusive episodes. Consequently, significant gaps exist in our knowledge of the occurrence and characteristics of manageable and unmanageable persistent pain in adults with SCD. </p><p> The specific aims of this study in a sample of adults with SCD were to: 1) determine the occurrence of persistent SCD pain and compare those with manageable and unmanageable persistent SCD pain on demographic and clinical characteristics, as well as, pain-related measures; 2) compare those with manageable and unmanageable persistent SCD pain on coping strategies; and 3) determine which factors influence quality of life (QOL) in these patients. </p><p> One hundred and three patients who were &ge;18 years with SCD completed questionnaires on demographic, clinical, and pain characteristics, as well as, the Pain Catastrophizing Scale (PCS), the Duke Religious Index (DRI), and the Medical Outcomes Study Short-Form (SF-36). Patients were divided into those with manageable (average pain intensity &le;5) and unmanageable pain (average pain intensity >5) based on established cutpoints. Final analyses were done on 94 patients. </p><p> Seventy percent of patients had manageable pain and 30% had unmanageable pain. Patients with unmanageable pain reported higher ratings for all of the items on the Pain Quality Assessment Scale (PQAS); were more likely to be taking only a short-acting opioid; reported less relief from analgesic medications, and reported significantly lower SF-36 scores. Significant negative correlations were found between pain catastrophizing and religiosity/spirituality, and physical and mental health. Several variables were found to have an influence on QOL. These findings suggest that persistent pain in adults with SCD is a significant problem. More research needs to evaluate how adults with SCD cope with persistent pain and its impact on their QOL.</p>

<p> Puerto Rico has the highest prevalence of type 2 diabetes, low birth-weight, and the second highest prevalence of preterm-birth in all the U.S. and its non-incorporated territories. These conditions are related. Birth-weight at both ends of the spectrum and preterm-birth are associated with an increased risk for developing type 2 diabetes and immune-inflammatory dysregulations. Maternal psychosocial stressors during pregnancy have also been recognized as potential risk factors for type 2 diabetes, and have been consistently associated with preterm-birth and low birth-weight across populations. Current evidence points toward epigenetic fetal metabolic-programming as the mechanism that underlies the increased risk for the previously mentioned morbidities. However, the particular psychosocial stressors that may contribute to the high prevalence of low birth-weight and preterm-birth in the population of Puerto Rico have not been well studied.</p><p> The present study assesses the relationships between particular psychosocial stressors, socioeconomic status, food insecurity, and birth outcomes. The results of this study show that low-risk pregnancy women were more likely to have babies with a higher ponderal index if they were exposed to stressors during gestation months 5, 6, and 7, or if exposed to "relationship stress" at any time during pregnancy. Women exposed to "financial difficulties" at any time during pregnancy were more likely to deliver babies at an earlier gestational age. Differences in birth outcomes between the exposed and non-exposed women were independent of maternal anthropometric measurements, maternal age at birth, number of previous births, and sex of the baby. Significant differences in birth outcomes were found between categories of father's self-identified and identified by others ethnicity, but sample size within categories was small. Although mothers with children at home had higher levels of food insecurity, and the level of food insecurity was correlated with higher levels of stress, no birth outcome measure was associated with food insecurity.</p><p> Some results are atypical in comparison with other populations, and therefore these findings may contribute to the understanding of population differences in the relationship between maternal stress during pregnancy and birth outcomes. The relatively small sample size and strict exclusion criteria of this study may limit the generalizability of the findings. Epidemiological similarities between Puerto Rico and other populations, and the possibility of a higher ponderal index increasing the risk for type 2 diabetes in the population of Puerto Rico need to be examined in future research.</p>

<p><b>Background:</b> In settings such as rural Bangladesh, where the majority of births occur at home, population-based data are lacking on the burden and risk factors for obstetric complications, as well as care-seeking behavior. This dissertation seeks to describe the prevalence and risk factors for obstetric complications, explore factors affecting care seeking for complications, and describe the availability of obstetric care among health facilities in rural Bangladesh. </p><p> <b>Methods:</b> We used extant data from a community-randomized maternal micronutrient supplementation trial which ascertained reported morbidities and care seeking among 42,214 pregnant women between 2007 and 2011 in rural northwest Bangladesh. Multivariate multinomial logistic regression was used to analyze the association of biological, socioeconomic, and psychosocial factors with reported obstetric complications and near misses. Multivariate logistic regression of socioeconomic, demographic, perceived need, and service factors on care seeking was performed. Primary data on availability and readiness to provide obstetric services at 14 health facilities was collected through surveys. </p><p> <b>Results:</b> Of the 42,214 married women of reproductive age, 73% (n=30,830) were classified as having non-complicated pregnancies, 25% (n=10,380) as having obstetric complications, and 2% (n=1,004) with reported near misses. In multivariate analysis, women's age less than 18 years (Relative Risk Ratio 1.26 95% CI 1.14-1.39), obstetric history of stillbirth or abortion (RRR 1.15 CI 1.07-1.22), and neither partner wanting the pregnancy (RRR 1.33 CI 1.20-1.46) significantly increased the risk of obstetric complications. Out of 9,576 women with data on care seeking, 77% sought any care, with only 23% seeking at least one formal provider. Socioeconomic factors and service factors, such as facility availability of comprehensive obstetric services (OR 1.25 CI 1.16- 1.34), improved care seeking from formal providers. Average facility readiness for emergency obstetric care was 81% in private clinics compared to 67% in public facilities (p=0.045). </p><p> <b>Conclusions:</b> These analyses indicate a high burden of obstetric morbidity, with a quarter of women reporting obstetric complications. Policies to reduce early marriage and unmet need for contraception may address risk factors including adolescent pregnancy and unwanted pregnancies. Improvements in socioeconomic factors, coupled with strategies to increase service availability at health facilities, could increase care seeking from formal providers. </p>

<p> Type 1 diabetes (T1D) is a chronic and lifelong condition, often diagnosed in childhood. Patients with T1D are at elevated risks of associated health complications, comorbidities, and mortality. Occurrence, clinical presentation, and complications related to T1D differ by age of onset, ethnicity, and gender. The last reported population-based estimates regarding the burden of T1D in children using the National Health and Nutrition Examination Survey (NHANES) were published in 2008, and these estimates were not well stratified by age of onset, ethnicity, and gender. The purpose of this study was to examine these demographics within the conceptual framework of the hygiene hypothesis using data from NHANES from 1999 to 2012. A cross-sectional study design was used to determine the average age of onset of T1D with respect to ethnicity and gender and to assess if age of onset is associated with ethnicity and gender. The average age of onset was 10.5 years for males and 11.8 years for females. The average age of onset was 13.0 years for Hispanics, 12.7 years for Non-Hispanic Blacks, and 10.6 years for Non-Hispanic Whites. Regression analysis indicated that there was no significant association between age of onset and gender (&beta; = 1.1, <i>p</i> = 0.386) and between age of onset and ethnicity (&beta; = 2.1, <i>p</i> = 0.070 for Hispanic White; &beta; = 1.9, <i>p</i> = 0.101 for Non-Hispanic Black) having considered the Non-Hispanic White as the reference population. The result of this study may contribute to positive social change by providing better insight on demographic determinants of the risk of T1D, which is crucially important in the planning and implementation of prevention measures in highly susceptible populations.</p>

<p> <b>Background:</b> HIV testing saves lives. It is fundamental to combating the global HIV epidemic. Key populations at higher risk for HIV in Mozambique, including Men who have Sex with Men (MSM), Female Sex Workers (FSW) and mineworkers, are in urgent need of effective HIV prevention strategies. This is the first analysis ever conducted in Mozambique to identify levels of HIV testing and associated factors that inform these strategies. </p><p> <b>Methods:</b> This analysis used data from seven cross-sectional surveys conducted between 2011-2012 among MSM, FSW and Mineworkers in Mozambique. Participants completed a questionnaire and provided blood samples for HIV testing. MSM and FSW were recruited used Respondent Driven Sampling in Maputo, Beira and Nampula. Mineworkers were recruited using Time Location Sampling in Ressano-Garcia. Participants with previous HIV-positive tests or missing HIV test histories were excluded (&lt;5% overall). Weighted logistic regression was used to measure associations with recent HIV testing (&lt;12 months). Theory-driven multivariate logistic regression was conducted in R v2.15 using the Health Behavior Model as a conceptual framework. </p><p> <b>Results:</b> The prevalence of recent testing for HIV ranged from 29.8-59.5%, yet 4.4-25.0% had HIV and did not know it. Between 11.9-57.4% had never been tested, and fear was given as the primary barrier. Recent HIV testing was positively associated with knowledge of ARV drugs, knowing the HIV status of a sexual partner, knowing where to go to get tested, and having had contact with a peer educator. It was negatively associated with having had a genital sore or ulcer and unprotected sex. Between 32.1-90.0% of HIV-positive undiagnosed, key population members had used a healthcare service in the previous 12 months and 23.4-47.5% had tested negative for HIV in that time period. </p><p> <b>Conclusion:</b> Routine testing with strengthened post-test counseling encouraging key populations to have annual HIV screenings need to be implemented in Mozambique.</p>

<p> Congestive heart failure (CHF) afflicts millions of Americans, and accounts for the largest share of rehospitalization of patients. Readmission rates for CHF patients have been high for more than a decade, resulting in unfavorable outcomes for patients and hospitals. One potential solution element is telemonitoring in the home. Allowing cardiologists to monitor patients with chronic diseases remotely has been shown to reduce hospital readmissions. This observational research (OR) study was based on anonymous secondary data from a CardioNet telemonitoring study conducted by a community teaching hospital in New England. The study was designed to answer the research question of whether telemonitoring can predict an imminent heart failure episode and, upon initiation of an intervention, reduce the number of hospital readmissions. The OR study also reported the effect telemonitoring had on the number of emergency department visits, medication changes, home healthcare visits, and visits to cardiologists or primary care physicians. The study did not have a sufficient number of participants to gain statistical power, but it highlighted the opportunity to learn more about the population of CHF patients in the community. The study also identified an opportunity for the use of mobile healthcare devices, big data, and analytics. </p>

<p> <b>BACKGROUND:</b> Children with Special Health Care Needs (CSHCN) increasingly live into adulthood, and every year approximately 500,000 American youth transition from pediatric to adult health care system. Health Care Transition (HCT) for Youth with Special Health Care Needs (YSHCN) has emerged as a significant event in the life course of this population. The overarching goal for HCT is to provide high quality, coordinated, uninterrupted health care which is responsive to the needs and desires of the patient. Although improvements have been seen in health care quality of the general population, differences still persist in health care quality among CSHCN in racial and ethnic minority groups. Children with Intellectual and Developmental Disabilities (ID-DD) are an important subpopulation of CSHCN because of their increasing prevalence due to autism and attention deficit hyperactivity disorder, high service needs, cost, and societal impact. A few researchers have focused on transition preparation for all YSHCN, but not on racial and ethnic (e.g., African American, Latino) disparities in health care transition and quality for youth ages 12-17 with ID-DD. <b>OBJECTIVE:</b> The purpose of this study was to explore the racial and ethnic disparities in transition to adult health care and quality of care for youth ages 12-17 with ID-DD. <b>METHODS:</b> The 2009&ndash;2010 National Survey of Children with Special Health Care Needs is a nationally representative sample with 17, 114 respondents (parents of CSHCN) ranging in age from 12 to 17 years old. They were asked about transitioning to an adult provider, changing health care needs, maintaining insurance needs, and increasing responsibility for self-care. They were also asked about having a personal doctor or nurse, doctors spending enough time with them, doctors listening carefully to the parent, providers showing sensitivity about family values; the parent receiving enough information from the doctor, and the doctor making the parent feel like a partner. The researcher analyzed the association of selected characteristics with successful transition and quality of health care for White, Black, and Latino children ages 12-17 with ID-DD. The study was guided by Andersen&rsquo;s (1995) <i>Behavioral Model of Health Care Use.</i> Bivariate analyses were conducted and consisted of seven chi-square analyses. For each chi-square analysis, the data split to include only children with ID-DD. <b>RESULTS:</b> The study was comprised of youth with ID-DD ranging in age from 12 to 17 years old, with an average mean age of 14.55 years old (M=14.55, SD=1.74). Results of the chi-square analysis indicated the proportions of children transitioning to adult health care for each ethnic group were not significantly different than expected (&chi;²(3) = 5.41, <i>p</i> = 0.144). Results also indicated that only four percent of children with ID-DD successfully transitioned to adult health care. Four of the six chi-square analyses related to the quality of health care were indicative of significant deviations from expected responses (doctors and other health care providers spending enough time with the child &chi;²(12) = 79.74, <i>p</i> &lt; 0.001; listening carefully (&chi;²(15) = 63.42, <i>p</i> &lt; 0.001); showing sensitivity to family values (&chi;²(15) = 34.44, <i> p</i> = 0.003); and making the family feel like a partner in care (&chi;²(12) = 33.89, <i>p</i> &lt;0 .001). A multiple linear regression was conducted to determine the relationship between the occurrence of an intellectual or developmental disability and the transition to adult health care, while controlling for predisposing (e.g., race and ethnicity, gender, parents education, and family structure), enabling factors (e.g., family income, health insurance status, and patient-centered medical home). A preliminary <i>F</i> test on the regression indicated a significant model fit (<i>F</i>(12, 10,387) = 67.76, <i>p</i> &lt; 0.001). Furthermore, a multiple linear regression was conducted to determine the relationship between the occurrence of a disability and the quality of health care, while controlling for predisposing and enabling factors. The preliminary <i>F</i> test indicated a significant model (<i>F</i>(12, 17,101) = 328.62, <i>p</i> &lt; .001). <b>CONCLUSIONS:</b> Youth with ID-DD, particularly those who are Latino and Black, face greater challenges in transitioning to adult health care and receiving a quality of care compared to other children with special health care needs in the United States. Addressing specific medical home components might reduce racial and ethnic disparities. Future research that examines the association between the HCT and family/professional partnerships in family-to-family health information centers (ACA 5507(b)) will be needed to ensure quality outcomes for youth with ID-DD.</p>

<p> <b>Background:</b> Dengue prevention for U.S. travelers focuses on compliance with mosquito avoidance practices (MAP) and passive surveillance. Understanding determinants of MAP among high-risk travelers can improve Dengue prevention strategies. In travel medicine, a risk assessment framework of social determinants of health and travel purpose of visiting friends and relatives (VFR) determines risk of travel-associated diseases. This risk assessment framework is subject to bias and inaccuracy because it fails to account for factors of influence on travel behaviors from a social-ecological perspective. A mixed methods approach identified and characterized determinants of MAP in U.S. West-Indian American VFR travelers. Two pilot studies revealed travelers' decision-making processes for MAP and outlined determinants of intended MAP through a qualitative interview and cross-sectional survey. Survey analyses included an exploratory factor analysis, Chi-squared/ Fisher's exact test, logistic regression and qualitative coding for development of an `Intended MAP International Travel Behavior' (IMAP-ITB) model. </p><p> <b>Methods:</b> To expand the IMAP-ITB model and describe factors of influence on actual MAP, 2 subsequent qualitative studies were conducted. A multi-case ethnographic study of travel cohorts to Trinidad, Brazil and Thailand identified social/physical environmental influences on actual MAP in a cross-case content analysis of field observations data. An interpretive phenomenological analysis of semi-structured interviews yielded similarities and differences in MAP by revealing the meaning of `going home' in VFR travelers versus another travel destination. </p><p> <b>Results:</b> A '<i>Cultural Embeddedness and MAP</i>' model extends the IMAP-ITB, using a social-ecological perspective, including factors of influence on intended and actual MAP. MAP during international travel was associated with travel logistics, social interactions, risk perceptions and cues to action. The concept of '<i>Cultural Embeddedness</i>' may explain compliance behaviors with MAP, irrespective of VFR status. </p><p> <b>Discussion:</b> Prevention strategies at each level of influence within a social-ecological framework would address Dengue emergence because individual level prevention using MAP is capricious by individual, type of travel and social/physical environmental influences. Findings demonstrate that VFR terminology does not accurately depict high-risk travelers. Next steps should include more research on the concept of '<i>Cultural Embeddedness </i>' and CEMAP. Furthermore, improvements to current Dengue surveillance are needed to prevent to prevent and monitor imported Dengue.</p>

<p> Objectives: The purpose of this secondary data analysis was to examine "stage of change" as a predictor of attrition among participants in a worksite wellness program. A Conceptual Model of Attrition was developed to examine health screening, health risk appraisal (HRA), and demographic predictors of attrition as well. Methods: Data for this study were drawn from a worksite wellness program which was sponsored by an integrated rural healthcare system. The sample consisted of 1058 individuals for whom valid demographic, health screening, and HRA data were available. Of the total sample, 414 did not participate in a subsequent year (39.1% attrition). This research was conducted as a predictive correlational study using binary logistic regression analysis. Results: Significant associations between stage of change and attrition were found for the physical activity, nutrition, weight, stress, and overall healthy lifestyle health behavior areas. The stage of change with the highest odds of attrition was the preparation stage across these health behavior areas. In the Conceptual Model of Attrition, significant associations with attrition were found for emotional symptoms, emotional health limitations, health view, and overall healthy lifestyle stage of change. Conclusions: This research has shown that the stage of change construct is useful for predicting attrition. Identification of participants' stage of change offers a leverage point for engagement in worksite wellness programs and for prevention of program attrition. For employers, retention of these employees in their worksite wellness program could yield a greater return on investment resulting in lower health care costs, fewer missed work days, and higher productivity on the job.</p>