Nonparametric scanning tests of homogeneity for hierarchical models with continuous covariates.

In many applications of hierarchical models, there is often interest in evaluating the inherent heterogeneity in view of observed data. When the underlying hypothesis involves parameters resting on the boundary of their support space such as variances and mixture proportions, it is a usual practice to entertain testing procedures that rely on common heterogeneity assumptions. Such procedures, albeit omnibus for general alternatives, may entail a substantial loss of power for specific alternatives such as heterogeneity varying with covariates. We introduce a novel and flexible approach that uses covariate information to improve the power to detect heterogeneity, without imposing unnecessary restrictions. With continuous covariates, the approach does not impose a regression model relating heterogeneity parameters to covariates or rely on arbitrary discretizations. Instead, a scanning approach requiring continuous dichotomizations of the covariates is proposed. Empirical processes resulting from these dichotomizations are then used to construct the test statistics, with limiting null distributions shown to be functionals of tight random processes. We illustrate our proposals and results on a popular class of two-component mixture models, followed by simulation studies and applications to two real datasets in cancer and caries research.

Effect of a pediatric fruit and vegetable prescription program on child dietary patterns, food security, and weight status: a study protocol.

BACKGROUND: Although nutrients in fruits and vegetables are necessary for proper development and disease prevention, most US children consume fewer servings than recommended. Prescriptions for fruits and vegetables, written by physicians to exchange for fresh produce, address access and affordability challenges while emphasizing the vital role of diet in health promotion and disease prevention. Michigan's first fruit and vegetable prescription program (FVPP) exclusively for children was introduced in 2016 at one large pediatric clinic in Flint and expanded to a second clinic in 2018. The program provides one $15 prescription for fresh produce to all pediatric patients at every office visit. Prescriptions are redeemable at a year-round farmers' market or a local mobile market. The current study will assess the impact of this FVPP on diet, food security, and weight status of youth. METHODS: Demographically similar pediatric patient groups with varying levels of exposure to the FVPP at baseline will be compared: high exposure (> 24 months), moderate exposure (12-24 months), and no previous exposure. Data collection will focus on youth ages 8-16 years. A total of 700 caregiver-child dyads (one caregiver and one child per household) will be enrolled in the study, with approximately 200 dyads at clinic 1 (high exposure); 200 dyads at clinic 2 (moderate exposure), and 300 dyads at clinic 3 (no previous exposure). Children with no previous exposure will be introduced to the FVPP, and changes in diet, food security, and weight status will be tracked over two years. Specific aims are to (1) compare baseline diet, food security, and weight status between pediatric patients with varying levels of exposure to the FVPP; (2) measure changes in diet, food security, and weight status before and after never-before-exposed children are introduced to the FVPP; and (3) compare mean 12- and 24-month follow-up measures of diet, food security, and weight status in the initial no exposure group to baseline measures in the high exposure group. DISCUSSION: Completion of study aims will provide evidence for the effectiveness of pediatric FVPPs and insights regarding the duration and intensity of exposure necessary to influence change. TRIAL REGISTRATION: The study was registered through clinicaltrials.gov [ID: NCT04767282] on February 23, 2021.

Gestational Antibodies to C. pneumoniae, H. pylori and CMV in Women with Preeclampsia and in Matched Controls.

OBJECTIVES: Some research has suggested a possible role for past infection in the development of preeclampsia. The objective of this study was to explore the role of Helicobacter pylori, cytomegalovirus, and Chlamydophila pneumoniae in the development of preeclampsia in a prospective pregnancy sample. METHODS: We conducted a nested case-control study in The Archive for Child Health (ARCH), a pregnancy cohort of 867 unselected women enrolled at the first prenatal visit with archived blood and urine in pregnancy. We matched 21 cases of preeclampsia to 52 unaffected controls on maternal age (±4 years), race, parity, and gestational age at blood draw. Using conditional logistic regression, we examined the association between preeclampsia status and immunoglobulins G (IgG) tested by indirect ELISA to each of the three microorganisms, adjusting for potential confounders. RESULTS: No significant difference was found between cases and controls. The unadjusted odds ratio was 1.5 (95%CI: 0.2-9.1), 0.6 (95%CI: 0.2-1.9), and 1.9 (95%CI: 0.6-5.6) for H. pylori, cytomegalovirus and C. pneumoniae respectively. After controlling for confounders analysis found increased odds of H. pylori IgG (AOR: 1.9; 95% CI: 0.2-15.3) and C. pneumoniae IgG (AOR: 2.3; 95% CI: 0.6-9.2) for preeclampsia, albeit being not significant. Conversely, cytomegalovirus IgG had lower odds for preeclampsia (AOR: 0.4; 95% CI: 0.1-1.7). CONCLUSIONS: Past infection with H. pylori, and C. pneumoniae in early pregnancy showed a higher risk of preeclampsia, but the findings failed to achieve statistical significance. Cytomegalovirus was not associated with preeclampsia in these data. These preliminary findings encourage future research in populations with high prevalence of these infections.

On testing for homogeneity with zero-inflated models through the lens of model misspecification.

In many applications of two-component mixture models such as the popular zero-inflated model for discrete-valued data, it is customary for the data analyst to evaluate the inherent heterogeneity in view of observed data. To this end, the score test, acclaimed for its simplicity, is routinely performed. It has long been recognized that this test may behave erratically under model misspecification, but the implications of this behavior remain poorly understood for popular two-component mixture models. For the special case of zero-inflated count models, we use data simulations and theoretical arguments to evaluate this behavior and discuss its implications in settings where the working model is restrictive with regard to the true data generating mechanism. We enrich this discussion with an analysis of count data in HIV research, where a one-component model is shown to fit the data reasonably well despite apparent extra zeros. These results suggest that a rejection of homogeneity does not imply that the underlying mixture model is appropriate. Rather, such a rejection simply implies that the mixture model should be carefully interpreted in the light of potential model misspecifications, and further evaluated against other competing models.

Adherence to Mammography and Pap Screening Guidelines Among Medically Underserved Women: the Role of Family Structures and Network-Level Behaviors.

Poor adherence to screening recommendations is an important contributing factor to disparities in breast and cervical cancer outcomes among women in the USA. Screening behaviors are multifactorial, but there has been limited focus on how family network beliefs and behaviors influence individual's likelihood to complete screening. This research aims to fill this gap by evaluating the role of family network composition and screening behaviors on women's likelihood to adhere to mammogram and pap screening recommendations. We used an ego network approach to analyze data from 137 families and their networks. Primary outcomes were whether an individual had received a mammogram in the past year and whether she had received a pap screening in the past 3 years. Network-level predictors included network composition (size of network, average age of network members, satisfaction with family communication) and network screening behaviors. We conducted multivariable logistic regressions to assess the influence of network-level variables on both mammogram and pap smears, adjusting for potential individual-level confounders. Each network had an average age of 47.9 years, and an average size of 3.05 women, with the majority of members being sisters (57.7%). We found differences in network screening behaviors by race, with Arab networks being less likely to have completed self-breast exams (OR = 0.21, 95%CI = 0.05-0.76, p = 0.02), ever a gotten pap screen (OR = 0.11, 95%CI = 0.01-0.85, p = 0.04), and gotten pap screening in the last 3 years (OR = 0.31, 95%CI = 0.10-0.99, p = 0.04) compared with African American networks. Network screening behaviors also strongly influenced the likelihood of an individual completing a similar screening behavior. This analysis sheds light on family network characteristics that influence screening behaviors among medically underserved women. These findings support the development and dissemination of screening interventions among female's family networks.

Maternal Socioeconomic Mobility and Preterm Delivery: A Latent Class Analysis.

Objective Growing evidence suggests that maternal socioeconomic mobility (SM) is associated with pregnancy outcomes. Our study investigated the association between maternal SM from childhood to adulthood and the risk of preterm delivery (PTD), and examined heterogeneity of associations by race/ethnicity. Methods In this study, 3019 pregnant women enrolled from 5 Michigan communities at 16-27 weeks' gestation (1998-2004) provided their parents' socioeconomic position (SEP) indicators (education, occupation, receipt of public assistance) and their own and child's father's SEP indicators (education, occupation, Medicaid status, and household income) at the time of enrollment. Latent class analysis was used to identify latent classes of childhood SEP indicators, adulthood SEP indicators, and SM from childhood to adulthood, respectively. A model-based approach to latent class analysis with distal outcome assessed relations between latent class and PTD, overall and within race/ethnicity groups. Results Three latent classes (low, middle, high) were identified for childhood SEP indicators and adulthood SEP indicators, respectively; while four latent classes (static low, upward, downward, and static high) best described SM. Women with upward SM had decreased odds of PTD (Odds ratio = 0.60, 95% confidence interval: 0.42, 0.87), compared to those with static low SEP. This SM advantage was true for all women and most pronounced in white/others women. Conclusions Maternal experiences of upward SM may be important considerations when assessing PTD risk. Our results support the argument that policies and programs aimed at improving women's SEP could lower PTD rates.

Assisted reproduction and risk of preterm birth in singletons by infertility diagnoses and treatment modalities: a population-based study.

PURPOSE: The purpose of this study is to examine the spectrum of infertility diagnoses and assisted reproductive technology (ART) treatments in relation to risk of preterm birth (PTB) in singletons. METHODS: Population-based assisted reproductive technology surveillance data for 2000-2010 were linked with birth certificates from three states: Florida, Massachusetts, and Michigan, resulting in a sample of 4,370,361 non-ART and 28,430 ART-related singletons. Logistic regression models with robust variance estimators were used to compare PTB risk among singletons conceived with and without ART, the former grouped by parental infertility diagnoses and treatment modalities. Demographic and pregnancy factors were included in adjusted analyses. RESULTS: ART was associated with increased PTB risk across all infertility diagnosis groups and treatment types: for conventional ART, adjusted relative risks ranged from 1.4 (95% CI 1.0, 1.9) for male infertility to 2.4 (95% CI 1.8, 3.3) for tubal ligation. Adding intra-cytoplasmic sperm injection and/or assisted hatching to conventional ART treatment did not alter associated PTB risks. Singletons conceived by mothers without infertility diagnosis and with donor semen had an increased PTB risk relative to non-ART singletons. CONCLUSIONS: PTB risk among ART singletons is increased within each treatment type and all underlying infertility diagnosis, including male infertility. Preterm birth in ART singletons may be attributed to parental infertility, ART treatments, or their combination.

A sup-score test for the cure fraction in mixture models for long-term survivors.

The evaluation of cure fractions in oncology research under the well known cure rate model has attracted considerable attention in the literature, but most of the existing testing procedures have relied on restrictive assumptions. A common assumption has been to restrict the cure fraction to a constant under alternatives to homogeneity, thereby neglecting any information from covariates. This article extends the literature by developing a score-based statistic that incorporates covariate information to detect cure fractions, with the existing testing procedure serving as a special case. A complication of this extension, however, is that the implied hypotheses are not typical and standard regularity conditions to conduct the test may not even hold. Using empirical processes arguments, we construct a sup-score test statistic for cure fractions and establish its limiting null distribution as a functional of mixtures of chi-square processes. In practice, we suggest a simple resampling procedure to approximate this limiting distribution. Our simulation results show that the proposed test can greatly improve efficiency over tests that neglect the heterogeneity of the cure fraction under the alternative. The practical utility of the methodology is illustrated using ovarian cancer survival data with long-term follow-up from the surveillance, epidemiology, and end results registry.

Marginal mean models for zero-inflated count data.

Zero-inflated regression models have emerged as a popular tool within the parametric framework to characterize count data with excess zeros. Despite their increasing popularity, much of the literature on real applications of these models has centered around the latent class formulation where the mean response of the so-called at-risk or susceptible population and the susceptibility probability are both related to covariates. While this formulation in some instances provides an interesting representation of the data, it often fails to produce easily interpretable covariate effects on the overall mean response. In this article, we propose two approaches that circumvent this limitation. The first approach consists of estimating the effect of covariates on the overall mean from the assumed latent class models, while the second approach formulates a model that directly relates the overall mean to covariates. Our results are illustrated by extensive numerical simulations and an application to an oral health study on low income African-American children, where the overall mean model is used to evaluate the effect of sugar consumption on caries indices.

In utero exposure to polychlorinated biphenyls is associated with decreased fecundability in daughters of Michigan female fisheaters: a cohort study.

BACKGROUND: Multiple studies have suggested a relationship between adult exposures to environmental organochlorines and fecundability. There is a paucity of data, however, regarding fetal exposure to organochlorines via the mother's blood and fecundability of adult female offspring. METHODS: Data from a two-generation cohort of maternal fisheaters was investigated to assess female offspring fecundability. Serum concentrations of polychlorinated biphenyls (PCBs) and 1,1-bis-(4-chlorophenyl)-2,2-dichloroethene (DDE) in Michigan female anglers were serially measured between 1973 and 1991 and used to estimate in utero exposure in their female offspring using two different methods. The angler cohort included 391 women of whom 259 provided offspring information. Of 213 daughters aged 20-50, 151 participated (71 %) and provided information for time intervals of unprotected intercourse (TUI). The daughters reported 308 TUIs (repeated observations), of which 288 ended in pregnancy. We estimated the fecundability ratio (FR) for serum-PCB and serum-DDE adjusting for confounders and accounting for repeated measurements. An FR below one indicates a longer time to pregnancy. RESULTS: Compared to serum-PCB of <2.5 µg/L, the FR was 0.60 for serum-PCB between 2.5-7.4 µg/L [95 % confidence intervals (CI) 0.36, 0.99], and 0.42 [95 % CI 0.20, 0.88] for serum-PCB >7.4 µg/L. Similar results were obtained using the alternative statistical method to estimate in utero serum-PCB. The association was stronger for TUIs when women planned a baby; FR = 0.50 for serum-PCB between 2.5-7.4 µg/L, [95 % CI 0.29, 0.89], and 0.30 [95 % CI 0.13, 0.68] for serum-PCB >7.4 µg/L. There was no relationship between in utero exposure to DDE and fecundability in daughters. CONCLUSIONS: Decreased fecundability in female offspring of fisheaters was found to be associated with PCB exposure in utero, possibly related to endocrine disruption in the oocyte and/or other developing organs influencing reproductive capacity in adulthood.

A score-type test for heterogeneity in zero-inflated models in a stratified population.

We propose a score-type statistic to evaluate heterogeneity in zero-inflated models for count data in a stratified population, where heterogeneity is defined as instances in which the zero counts are generated from two sources. Evaluating heterogeneity in this class of models has attracted considerable attention in the literature, but existing testing procedures have primarily relied on the constancy assumption under the alternative hypothesis. In this paper, we extend the literature by describing a score-type test to evaluate homogeneity against general alternatives that do not neglect the stratification information under the alternative hypothesis. The limiting null distribution of the proposed test statistic is a mixture of chi-squared distributions that can be well approximated by a simple parametric bootstrap procedure. Our numerical simulation studies show that the proposed test can greatly improve efficiency over tests of heterogeneity that ignore the stratification information. An empirical application to dental caries data in early childhood further shows the importance and practical utility of the methodology in using the stratification profile to detect heterogeneity in the population.

DDE and PCB serum concentration in maternal blood and their adult female offspring.

BACKGROUND: Dichlorodiphenyl dichloroethylene (DDE) and polychlorinated biphenyls (PCBs) can be passed from mother to offspring through placental transfer or breastfeeding. Unknown is whether maternal levels can predict concentrations in adult offspring. OBJECTIVES: To test the association between maternal blood levels of DDE and PCBs and adult female offspring levels of these compounds using data from the Michigan Fisheaters'Cohort. METHODS: DDE and PCB concentrations were determined in 132 adult daughters from 84 mothers. Prenatal exposures were estimated based on maternal DDE and PCB serum levels measured between 1973 and 1991. Levels in adult daughters were regressed on maternal and estimated prenatal exposure levels, adjusting for potential confounders using linear mixed models. Confounders included daughter's age, birth order, birth weight, number of pregnancies, the length of time the daughter was breast-fed, the length of time the daughter breast-fed her own children, last year fish-eating status, body mass index, and lipid weight. RESULTS: The median age of the participants was 40.4 years (range 18.4-65.4, 5-95 percentiles 22.5-54.6%, respectively). Controlling for confounders and intra-familial associations, DDE and PCB concentrations in adult daughters were significantly positively associated with estimated prenatal levels and with maternal concentrations. The proportion of variance in the adult daughters' organochlorine concentrations explained by the maternal exposure levels is approximately 23% for DDE and 43% for PCBs. The equivalent of a median of 3.67 µg/L prenatal DDE and a median of 2.56 µg/L PCBs were 15.64 and 10.49 years of fish consumption, respectively. When controlling for effects of the shared environment (e.g., fish diet) by using a subsample of paternal levels measured during the same time frames (n=53 and n=37), we determined that the direct maternal transfer remains important. CONCLUSIONS: Estimated intra-uterine DDE and PCB levels predicted concentrations in adult female offspring 40 years later. Interpretation of adverse health effects from intra-uterine exposures of persistent pollutants may need to consider the sustained impact of maternal DDE and PCB levels found in their offspring.

Transient hypothyroidism at 3-year follow-up among cases of congenital hypothyroidism detected by newborn screening.

OBJECTIVE: To investigate the rate of transient thyroid deficiency and treatment compliance among cases with congenital hypothyroidism diagnosed and followed-up after age 3 years by newborn screening (NBS). STUDY DESIGN: Cases detected by Michigan NBS between October 1, 2003, and December 31, 2007, and followed-up after age 3 years were included. The χ(2) and Fisher exact tests were used to test differences among followed and lost cases. Logistic regression models were used to investigate predictors of treatment cessation. RESULTS: Roughly 45% of eligible cases were lost to follow-up, and disease state (transient or permanent congenital hypothyroidism) could not be determined for 12 cases (7.9%). Of the 72 followed cases, 34 (47%) were considered permanent congenital hypothyroidism based on thyroid imaging findings (n = 7) or an increase in medication dosage over time (n = 27). One-quarter of followed cases with congenital hypothyroidism were no longer being treated, and of these, just over 83% stopped treatment without medical supervision. Of 23 cases that underwent a medically supervised trial without thyroid hormone medication, treatment was reinstated in 20. Laboratory confirmation of euthyroidism was available for 6 of 18 cases clinically deemed transient. After adjustment, black race was the strongest predictor of treatment cessation (OR, 9.86; 95% CI, 1.82-53.31). Treatment cessation was also more common among low birth weight infants and those admitted to the neonatal intensive care unit at birth. CONCLUSION: We recommend that NBS programs include long-term follow-up through at least age 3 years to determine treatment compliance and disease permanence. Further research is needed to determine ideal follow-up program operations and reassessment methods for congenital hypothyroidism disease permanence. Guidelines that provide evidence-based reassessment methods would be beneficial for the healthcare providers of children with congenital hypothyroidism.

The Antidiabetic Activity of Combining the Aqueous Extracts of Vernonia amygdalina Leaves and Tamarindus indica Fruit Pulp in Streptozotocin-Induced Wistar Rats.

Background Many plants are used to reduce the side effects of diabetes mellitus. These plants (including Vernonia amygdalina and Tamarindus indica) are rich in phytochemical compounds that have the ability to reduce glycemia and the effect of diabetes-related oxidative stress. In this study, we aimed to investigate the antioxidant and antidiabetic activities of combining V. amygdalina leaves and T. indica pulp extracts. Methodology We prepared a mixture by combining V. amygdalina leaves and T. indica pulp extracts, and we assessed antioxidant properties via the capacity of both extracts to reduce ferric ions, 2,2-diphenyl-1-picryl-hydrazyl (DPPH) radicals, and hydroxyl radicals. We also assessed antidiabetic properties through the capacity of the extracts' combination to inhibit alpha-amylase. We evaluated crude fiber, total phenols content (TPC), and total flavonoid content (TFC). Results From our findings, the combination at a concentration of 200 µg/mgE showed that a percentage of 55.17±1.2 could reduce DPPH radicals, 0.366±0.012 could scavenge ferric ions, and 0.233±0.0022 could reduce hydroxyl radicals. With regard to secondary metabolites, we obtained 16.96±0.17 mEGA/gE for total phenol content, 1.74±0.045 mECAT/gE for total flavonoid content, and crude fiber content in our combination at 6.87±1%. These results were obtained with a significant difference at the 5% threshold. The extract combination also showed an alpha-amylase inhibitory percentage of 23.56±4.6% at the concentration of 200 µg/mgE. Daily administration of the combination of extracts significantly lowered the fasting blood glucose, triglycerides, total cholesterol, LDL cholesterol, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, creatinine, and malondialdehyde. However, there was a significant increase in serum proteins and HDL cholesterol. We did not observe an antagonistic effect between our combination and glybenclamide. Conclusion Our formulation, therefore, presents antioxidant and antidiabetic activity and could be used for the management of diabetic patients.

On the efficiency of score tests for homogeneity in two-component parametric models for discrete data.

In many applications of two-component mixture models for discrete data such as zero-inflated models, it is often of interest to conduct inferences for the mixing weights. Score tests derived from the marginal model that allows for negative mixing weights have been particularly useful for this purpose. But the existing testing procedures often rely on restrictive assumptions such as the constancy of the mixing weights and typically ignore the structural constraints of the marginal model. In this article, we develop a score test of homogeneity that overcomes the limitations of existing procedures. The technique is based on a decomposition of the mixing weights into terms that have an obvious statistical interpretation. We exploit this decomposition to lay the foundation of the test. Simulation results show that the proposed covariate-adjusted test statistic can greatly improve the efficiency over test statistics based on constant mixing weights. A real-life example in dental caries research is used to illustrate the methodology.

Spline Confidence Bands for Functional Derivatives.

We develop in this paper a new procedure to construct simultaneous confidence bands for derivatives of mean curves in functional data analysis. The technique involves polynomial splines that provide an approximation to the derivatives of the mean functions, the covariance functions and the associated eigenfunctions. We show that the proposed procedure has desirable statistical properties. In particular, we first show that the proposed estimators of derivatives of the mean curves are semiparametrically efficient. Second, we establish consistency results for derivatives of covariance functions and their eigenfunctions. Most importantly, we show that the proposed spline confidence bands are asymptotically efficient as if all random trajectories were observed with no error. Finally, the confidence band procedure is illustrated through numerical simulation studies and a real life example.

Simultaneous Inference For The Mean Function Based on Dense Functional Data.

A polynomial spline estimator is proposed for the mean function of dense functional data together with a simultaneous confidence band which is asymptotically correct. In addition, the spline estimator and its accompanying confidence band enjoy oracle efficiency in the sense that they are asymptotically the same as if all random trajectories are observed entirely and without errors. The confidence band is also extended to the difference of mean functions of two populations of functional data. Simulation experiments provide strong evidence that corroborates the asymptotic theory while computing is efficient. The confidence band procedure is illustrated by analyzing the near infrared spectroscopy data.

Validating a geospatial healthfulness index with self-reported chronic disease and health outcomes.

Leveraging community engagement from past research may yield frameworks on which to build new inquiries. We previously integrated community voice into the development of a healthfulness index to increase awareness of social determinants of health in the built environment and inform deployment of public health interventions in the Flint (Michigan, USA) Center for Health Equity Solutions. Here we combine the healthfulness index with self-reported chronic disease and health outcomes (n = 12,279) from a community-based healthcare entity, the Genesee Health Plan. The healthfulness index purports to predict how health-promoting a neighborhood is based on many spatially varying characteristics; by linking our health plan data to this index, we validate the effectiveness of the healthfulness index. After geocoding all enrollees and joining their healthfulness scores, we conducted a series of logistic regressions to compare the relationship between self-reported outcomes and healthfulness. Matching the two intervention projects of our center (revolving around healthy eating & physical activity in project 1 and mental health sustainment & substance use prevention in project 2), our analyses also focused on classes of outcomes related to a) cardiovascular disease and b) mental health. In only select cases, higher (better) healthfulness scores from each project were independently associated with better cardiovascular and mental health outcomes, controlling for age, race, and sex. Generally, however, healthfulness did not add predictive strength to the association between health and sociodemographic covariates. Even so, the use of composite healthfulness indices to describe the health-promoting or degrading qualities of a neighborhood could be valuable in identifying differences in health outcomes. Future researchers could further explore healthcare claims datasets to increase understanding of the links between healthfulness and health outcomes. This and future work will be valuable in advocacy toward additional healthfulness indices to aid other communities in enriching understanding between the built environment and health.

Impact of patient and family engagement in improving continuous positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial.

STUDY OBJECTIVES: The aim of the Improving CPAP Adherence Program was to assess the impact of a multidimensional treatment framework based on shared decision-making, patient activation, and caregiver engagement on improving long-term positive airway pressure (PAP) adherence in patients newly diagnosed with obstructive sleep apnea. METHODS: In this pilot study, patients aged ≥ 18 years with a new obstructive sleep apnea diagnosis who qualified for PAP treatment and lived with a caregiver were randomly assigned to receive either the multidimensional treatment (intervention, n = 28) or unrelated education (control group, n = 32). All patients and their caregiver participated in a group visit. The intervention group attended 4 structured sessions: interactive education, peer coaching, hands-on experience, and a semistructured motivational interview. The control group was educated on physical activity and lifestyle only. Objective PAP adherence data were obtained at baseline (day that they received PAP machine to group visit), group visit to 3 months, and 3-6 months. RESULTS: In an age-adjusted model, the mean daily use of PAP increased significantly over the 3 time periods (P = .03). Intervention-arm participants gained a mean 1.23 hours (95% confidence interval, 0.33-2.13) in PAP mean daily use between 3 and 6 months vs those in the control arm (P = .008). We saw no difference in the percentage of PAP adherence across time between the 2 arms. CONCLUSIONS: A multifaceted patient-centered intervention with caregiver engagement improved PAP adherence vs control levels, a beneficial effect sustained for the 6 months. Our findings suggest that caregivers, with the appropriate training, can improve patients' PAP adherence by providing a socially supportive environment. CITATION: Khan NNS, Todem D, Bottu S, Badr MS, Olomu A. Impact of patient and family engagement in improving continuous positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial. J Clin Sleep Med. 2022;18(1):181-191.

Differences in knowledge of breast cancer screening among African American, Arab American, and Latina women.

INTRODUCTION: We examined differences in knowledge and socioeconomic factors associated with 3 types of breast cancer screening (breast self-examination, clinical breast examination, and mammogram) among African American, Arab, and Latina women. METHODS: Community health workers used a community-based intervention to recruit 341 women (112 Arab, 113 Latina, and 116 African American) in southeastern Michigan to participate in a breast cancer prevention intervention from August through October 2006. Before and after the intervention, women responded to a previously validated 5-item multiple-choice test on breast cancer screening (possible score range: 0 to 5) in their language of preference (English, Spanish, or Arabic). We used generalized estimating equations to analyze data and to account for family-level and individual correlations. RESULTS: Although African American women knew more about breast cancer screening at the baseline (pretest median scores were 4 for African American, 3 for Arab and 3 for Latina women), all groups significantly increased their knowledge after participating in the breast cancer prevention intervention (posttest median scores were 5 for African American and 4 for Arab and Latina women). Generalized estimating equations models show that Arab and Latina women made the most significant gains in posttest scores (P < .001). CONCLUSION: Racial/ethnic differences in knowledge of breast cancer screening highlight the need for tailored information on breast cancer screening for African American, Arab, and Latina women to promote adherence to breast cancer screening guidelines.