A local health department's journey to the summit: a case study of a decade of quality improvement.

As the interest in quality improvement (QI) efforts in public health agencies gathers momentum, organizations looking to initiate or strengthen QI processes may benefit from learning about existing programs. This article serves as a case study for other agencies to consider as they embark upon their QI journey. Specifically, this article reviews more than a decade of QI efforts in a mid-sized local health department and highlights areas of success (including an annual QI summit), barriers to implementation of QI, and areas needing improvement.

Is use of the human papillomavirus vaccine among female college students related to human papillomavirus knowledge and risk perception?

BACKGROUND: Few studies have examined factors associated with the actual use of the human papillomavirus (HPV) vaccine since licensure in 2006. The aims of this study were to assess HPV vaccination rates and to examine whether knowledge and risk perceptions regarding HPV were associated with the reported use of the HPV vaccine among female college students. METHODS: Using a cross-sectional design, 406 women aged 18-26 years were recruited at two public universities and completed a self-administered survey. Respondents who reported having received at least one dose of HPV vaccine were classified as 'vaccinated' (n=177, 43.6%). Responses, stratified by the receipt of HPV vaccine, were compared using descriptive statistics and multivariate models. RESULTS: Based on multivariate logistic regression modelling, 18-year-old women were approximately four times more likely to report use of the HPV vaccine compared with respondents aged 19-26 years. Respondents who correctly indicated that HPV caused genital warts were 1.85 times more likely (adjusted odds ratio (OR) 1.85, 95% CI 1.20 to 2.93) to have received at least one HPV vaccine. African American and Asian women were each less likely to be vaccinated compared with white women. Risk perception was not significantly associated with vaccine uptake, however, the majority of respondents failed accurately to recognise their high risk of both acquiring and transmitting HPV. CONCLUSIONS: These findings suggest knowledge deficits and misperceptions about HPV risk as potential themes for educational campaigns encouraging the greater use of the preventive HPV vaccine among this subgroup.

Changes in cigarette smoking, purchase patterns, and cessation-related behaviors among low-income smokers in New York State from 2002 to 2005.

OBJECTIVE: This study characterized longitudinal changes in cigarette smoking and purchase and cessation patterns among low-income smokers in New York State. DESIGN: Longitudinal tobacco use surveys were conducted in 2002 and 2005. Responses from the 2002 and 2005 surveys were compared among participants who completed both surveys. SETTING: New York State. PARTICIPANTS: Adult low-income smokers (n = 274) were recruited from the Department of Social Services office in Erie County, New York, in 2002 and recontacted in 2005. MAIN OUTCOME MEASURES: These included cigarette smoking, cessation and purchase behaviors, awareness and use of the Quitline, and participation in tobacco industry promotions during the 3-year follow-up period. RESULTS: During the 3-year follow-up period, 37 participants (13.5%) stopped smoking. Among smokers, the average number of daily cigarettes smoked decreased from 16.1 to 13.7 cigarettes (P < .01). There were significant increases in the proportion of smokers who reported that they had ever used a stop smoking medication (26.6% to 51.9%), had ever heard of the Quitline (32.5% to 73.0%), or had ever called the Quitline (4.2% to 11.0%). There was an increase in the use of tobacco industry coupons (41.1% to 59.3%). CONCLUSIONS: Findings suggest that state and local tobacco control policies and programs are being increasingly utilized by this population; however, tobacco company price promotions are also being increasingly used, offsetting the public health benefit of the tobacco control policies and programs in this low-income population.

A Phase II study of St. John's Wort for smoking cessation.

OBJECTIVES: To examine the feasibility and efficacy of St. John's Wort (SJW) for smoking cessation. DESIGN: This one-arm Phase II study utilized an exact two-stage group sequential design with a 1-week run-in period between the start of SJW treatment and the designated quit date. A total of 37 smokers (ages 18-65 years, smoking > or = 10 cigarettes/day) were started on SJW. Thirteen failed to make a verified quit attempt on the predesignated date and were taken off study resulting in 24 evaluable subjects. SETTING: Smokers completed clinic visits at a cancer center with interval telephone calls and mailings. INTERVENTION: Standardized SJW, 450 mg capsules taken orally twice daily along with cessation counseling messages. MAIN OUTCOME MEASURES: Subjects completed validated surveys and a focused physical examination at baseline. Evaluable subjects were defined as those subjects who made a confirmed quit attempt on their "quit date" 1 week following initiation of SJW. Smoking status was determined through self-report and bioverification using carbon monoxide (CO) testing. RESULTS: Among evaluable subjects, the 12-week quit rate was 37.5% (9/24). Quitters had no significant change in weight from baseline to 12-weeks cessation. Use of SJW was generally well tolerated. CONCLUSIONS: Based upon these results (which suggest that SJW may be effective in maintaining smoking cessation) and the high compliance and few AEs, we conclude that SJW demonstrates feasibility for use in smoking cessation. If SJW proves to be effective in larger controlled studies, it could represent a less expensive, more readily accessible and well-tolerated agent to promote tobacco cessation.

Sex differences among college students in awareness of the human papillomavirus vaccine and vaccine options.

OBJECTIVES: To explore awareness of human papillomavirus (HPV) and use of HPV vaccines (Gardasil and Cervarix) by college students. PARTICIPANTS: The sample was composed of 817 undergraduates at 2 northeastern US universities; they participated between February and May 2010. METHODS: Students were provided with a link to an anonymous, self-administered, Web-based survey comprised of 76 questions. The survey included questions about health behaviors, awareness, and knowledge of HPV and the 2 HPV vaccines, and vaccine uptake. RESULTS: Results indicate high levels of awareness of HPV as well as marked sex differences related to vaccine awareness and uptake. Both sexes are largely unaware of Cervarix and the differences between Cervarix and Gardasil. CONCLUSION: The study affirms the importance of a clinician's recommendation for HPV vaccination. Public health messaging should become more inclusive of adolescent and young adult males. College students' awareness of HPV vaccine options mirrors Gardasil's market dominance in the United States.

Nurse practitioners' knowledge, practice and attitudes about tobacco cessation & lung cancer screening.

PURPOSE: To determine nurse practitioners' (NPs') knowledge, practice, and attitudes about tobacco cessation counseling and lung cancer early detection. DATA SOURCE: A descriptive, cross-sectional survey design was used to examine NPs' approaches to primary and secondary prevention of tobacco use among patients in western New York. CONCLUSIONS: Among the 175 respondents, NPs appropriately counseled tobacco users on tobacco cessation. However, there was limited understanding of first-line pharmacological agents used for tobacco cessation and of how to manage treatment for a patient at high risk for lung cancer. IMPLICATIONS FOR PRACTICE: These findings suggest the need to implement professional educational programs aimed at conveying not only the importance of tobacco cessation counseling but also information on the most effective first-line pharmacological agents and appropriate management options for patients at increased risk of developing lung cancer.

Disparity in the use of smoking cessation pharmacotherapy among Medicaid and general population smokers.

BACKGROUND: The prevalence of smoking remains higher among the Medicaid population compared with the general population. To reduce this disparity, the majority of state Medicaid programs now provide coverage for smoking cessation pharmacotherapy. The objectives of this study were to (1) assess awareness of this benefit among Medicaid smokers and (2) compare the use of pharmacotherapy among a sample of Medicaid smokers with smokers in the general population of western New York. METHODS: This report summarizes findings from two cross-sectional studies conducted in western New York State during 2002 to 2003: (1) Medicaid smokers (n = 1,174) completed an interviewer-administered questionnaire in the Office of Medicaid Management and (2) smokers from the general population (n = 852) completed a telephone survey. RESULTS: The majority of Medicaid smokers (54%) remain unaware of the program benefit providing coverage for smoking cessation pharmacotherapies. Medicaid smokers were much less likely (odds ratio = 0.33, 95% confidence interval = 0.25-0.44) than the general population to report having ever used pharmacotherapies. CONCLUSIONS: Highlighting the availability of the smoking cessation pharmacotherapy benefit to Medicaid program participants may be one strategy to enhance quit attempts among this population. Future research should identify other potential barriers to the use of effective pharmacotherapies among poorer smokers.

A randomized trial to promote pharmacotherapy use and smoking cessation in a Medicaid population (United States).

OBJECTIVE: To evaluate the impact of three different intervention conditions designed to increase use of the Medicaid smoking cessation pharmacotherapy benefit and promote smoking cessation among Medicaid clients. METHODS: In 2002, 608 current smokers receiving Medicaid benefits were recruited from the reception areas at the Department of Social Services in Erie County, New York, USA. Participants were randomized to one of three interventions: Minimal (verbal information on the Medicaid pharmacotherapy benefit), Self Help (verbal information plus self-help information materials), or Case Management (verbal information, self-help information, plus case management assistance to facilitate access to the pharmacotherapy benefit). Outcomes included (a) use of a stop-smoking medication during the three month follow-up period, (b) self-reported 7-day point prevalence abstinence at three months and (c) bioverified non-smoking status at three months (bio-chemically validated by expired Carbon Monoxide (CO) < or =8 ppm). RESULTS: 14.6% reported using a stop-smoking medication and staying off cigarettes for 24 h, 4.6% self-reported being smoke-free at three months, and 1.8% were bioverified as smoke-free. There were no differences by intervention group for these outcomes. CONCLUSIONS: An intensive intervention designed to promote pharmacotherapy use and smoking cessation among Medicaid smokers was no more effective than less intensive interventions.

Impact of economic policies on reducing tobacco use among Medicaid clients in New York.

BACKGROUND: New York State (NYS) recently implemented Medicaid coverage for prescription pharmacologic adjuncts for cessation and a 55-cent excise tax on a pack of cigarettes. This study examined awareness and use of stop smoking medications and changes in smoking/purchasing behavior among Medicaid clients. METHODS: Participants (n = 173) were English-speaking Medicaid clients ages 18-64 years who currently smoked cigarettes and volunteered to be interviewed while waiting to reregister with the NYC Medicaid Office during early 2001. Data were collected using a brief (10-min) interviewer-administered questionnaire. RESULTS: Over 80% of Medicaid clients reported some desire to stop smoking and 40% intended to stop smoking in the next 6 months. Awareness of Medicaid coverage for tobacco cessation pharmacotherapy was 7% for nicotine replacement therapy and 13% for bupropion. Use of these stop smoking medications varied across products but in general was low (<10%). Half of the Medicaid clients reported changing their smoking behavior as a result of the cigarette tax increase. CONCLUSIONS: The majority of Medicaid clients report a desire to stop smoking, but these economic influences alone are insufficient to substantially reduce smoking in this population. These findings emphasize the importance of allocating a portion of tobacco tax revenue to promote both expanded awareness of this prescription benefit among Medicaid clients and to support programs to further assist low-income smokers in their attempts to stop smoking.