Perceived Barriers and Facilitators in Accessing Cervical Cancer Screening: The Voices of Women in a Low-Income Urban Community.

Although advancements in cervical cancer prevention have helped reduce the incidence, mortality, and prevalence, access to these preventive services has not been experienced equally by all women in the United States. The purpose of this study was to learn about the factors that affect access to preventive services in a low-income, primarily Black community. Using a community-based participatory research approach, women were recruited to participate in 7 focus groups, with 6 to 8 women per group (N = 45). Participants were mainly Black (64%), with a mean age of 46 years, and 60% reporting completing at least some college. The discussions were transcribed, and text data were organized using Dedoose software. Guided by qualitative content analysis, the data were analyzed through an iterative process of coding and condensing the codes into themes. Ten types of barriers and 11 facilitators relating to cervical cancer screening access were identified and grouped into 7 themes. Participants provided suggestions for promoting cervical cancer screening in their community. On the basis of the findings of the data, the researchers conceptualized and mapped culturally and geographically appropriate interventions to promote cervical cancer screening within the community of interest.

Cost-effectiveness Analysis of Contralateral Prophylactic Mastectomy Compared to Unilateral Mastectomy with Routine Surveillance for Unilateral, Sporadic Breast Cancer.

BACKGROUND: Contralateral prophylactic mastectomy (CPM) rates in younger women with unilateral breast cancer have more than doubled. Studies of cost and quality of life of the procedure remain inconclusive. METHODS: A cost-effectiveness analysis using a decision-tree model in TreeAge Pro 2015 was used to compare long-term costs and quality of life following unilateral mastectomy (UM) with routine surveillance versus CPM for sporadic breast cancer in women aged 45 years. A 10-year risk period for contralateral breast cancer (CBC), reconstruction, wound complications, cost of routine surveillance, and treatment for CBC were used to estimate accrued costs. In addition, a societal perspective was used to estimate quality-adjusted life years (QALYs) following either treatment for a period of 30 years. Medical costs were obtained from the 2014 Medicare physician fee schedule and event probabilities were taken from recent literature. RESULTS: The mean cost of UM with surveillance was $14,141 and CPM was $20,319. Treatment with CPM resulted in $6178 more in costs but equivalent QALYs (17.93) compared with UM over 30 years of follow-up. Even with worst-case scenario and varying assumptions, CPM is dominated by UM in terms of cost and quality. CONCLUSIONS: From this refined model, UM with routine surveillance costs less and provides an equivalent quality of life. Patients undergoing CPM may eliminate the anxiety of routine surveillance, but they face the burden of higher lifetime medical costs.

Prehabilitation and quality of life three months after total knee arthroplasty: a pilot study.

Knee osteoarthritis (OA), which affects over 27 million Americans, decreases the individual's quality of life through decreasing mobility, deconditioning, reducing functional ability, and increasing knee pain. The present aim was to assess whether such patients engaging in exercise prior to surgery ("prehabilitation"; preoperative exercise intervention) rate higher quality of life 3 mo. after their surgery compared with ratings by patients who did not engage in prehabilitation. Standard populations consist of OA patients that do not participate in any preoperative exercise programs, such as a prehabilitation exercise intervention. 18 knee osteoarthritis patients were randomly assigned to a control or a prehabilitation group. The latter group participated in an exercise intervention three times per week, once at home and twice at the physical therapy lab, for 8 wk. prior to their surgery. The control group participated in their usual preoperative care prescribed by the physician for all patients. Eight health-related quality of life domains were assessed at 3 mo. post surgery. These preliminary findings suggest efficacy of prehabilitation in facilitating quality of life of total knee arthroplasty (TKA) patients 3 mo. after surgery.

Nationwide public perceptions regarding the acceptance of using wastewater for community health monitoring in the United States.

To assess the levels of infection across communities during the coronavirus disease 2019 pandemic, researchers have measured severe acute respiratory syndrome coronavirus 2 RNA in feces dissolved in sewer water. This activity is colloquially known as sewer monitoring and is referred to as wastewater-based epidemiology in academic settings. Although global ethical principles have been described, sewer monitoring is unregulated for health privacy protection when used for public health surveillance in the United States. This study used Qualtrics XM, a national research panel provider, to recruit participants to answer an online survey. Respondents (N = 3,083) answered questions about their knowledge, perceptions of what is to be monitored, where monitoring should occur, and privacy concerns related to sewer monitoring as a public health surveillance tool. Furthermore, a privacy attitude questionnaire was used to assess the general privacy boundaries of respondents. Participants were more likely to support monitoring for diseases (92%), environmental toxins (92%), and terrorist threats (88%; e.g., anthrax). Two-third of the respondents endorsed no prohibition on location sampling scale (e.g., monitoring single residence to entire community was acceptable); the most common location category respondents wanted to prohibit sampling was at personal residences. Sewer monitoring is an emerging technology, and our study sheds light on perceptions that could benefit from educational programs in areas where public acceptance is comparatively lower. Respondents clearly communicated guard rails for sewer monitoring, and public opinion should inform future policy, application, and regulation measures.

Undressing "health fashion": an examination of health-cause clothing and accessories.

Today, fashion items such as rubber wristbands in various colors, pink ribbons, and red dresses represent different health-related causes and can be seen frequently across demographic groups. Complete with pithy slogans (e.g., "Go Red for Women"), these items are part of a larger "health fashion" trend--one that involves wearing, using, and displaying health-cause clothing and accessories. In this article, the authors explore recent interest in "health fashion," examining in particular its origins, effectiveness, and implications.

Type 2 Diabetes Mellitus (T2DM) "Remission" in Non-bariatric Patients 65 Years and Older.

Objective: To analyze the factors associated with type 2 diabetes mellitus (T2DM) "remission" in non-bariatric Medicare patients 65 years and older. Research Design and Methods: A retrospective cohort analysis of a Medicare Advantage health plan was conducted using administrative data. An individual was identified as T2DM if the individual had: ≥ 2 medical claims for T2DM coded 250.xx excluding type 1 diabetes; or ≥ 2 pharmacy claims related to T2DM; or ≥ 2 combined medical claims, pharmacy claims for T2DM in 12 months. A T2DM individual was in "remission" if they had no T2DM related claims for more than 12 months continuously. This is different from the standard American Diabetes Association (ADA) definition of remission which includes HbA1c values and hence is represented in quotation (as "remission"). 10,059 T2DM individuals were evaluated over a period of 8 years from 2008 to 2015. Cox proportional hazards was used to identify significant variables associated with T2DM "remission." Results: 4.97% of patients studied met the definition of T2DM "remission" in the study cohort. After adjusting for covariates this study found a number of variables associated with T2DM "remission" that were not previously reported: no statin use; low diabetes complications severity index score; no hypertension; no neuropathy; no retinopathy; race (non-white and non-African American); presence of other chronic ischemic heart disease (IHD) and females (p < 0.05). Conclusion: T2DM "remission" in Medicare patients 65 years and older is observed in a community setting in a small proportion of non-bariatric patients.

Influence of Built Environment Quality and Social Capital on Mental Health of Residents of Assisted Living Communities in Louisville, Kentucky.

Objectives: Prior research has shown social capital and built environment quality are associated with overall health status and the incidence of mental illness. This study explores the relationship between social capital, built environment, and quality of life specifically for assisted living residents, currently a gap in the literature. Method: A total of 76 assisted living residents were interviewed for the study using researcher-administered questionnaires. In addition, site audits were conducted to quantitatively evaluate the built environment surrounding 12 assisted living communities in the Louisville Metro region. Results: There was a moderate, positive correlation between social capital and mental health, r = .473, p < .001. Built environment quality for the neighborhood immediately surrounding the assisted living community was not significantly correlated with quality of life for assisted living residents. Other population characteristics, including demographic characteristics, self-rated health status, and instrumental activities of daily living were not significantly predictive of mental health scores. Conclusion: This study demonstrates that social capital is associated with happiness and self-rated quality of life. Specifically, increased social capital is associated with increased mental well-being for older adults residing in assisted living communities, with social capital explaining about 20% of the variation in quality of life scores.

Influencers and preference predictors of HPV vaccine uptake among US male and female young adult college students.

OBJECTIVE: The purpose of the study was to assess the knowledge, attitudes and beliefs of male and female college students in Kentucky about HPV associated diseases and vaccines, and to determine which parameters predicted self-reported uptake of HPV vaccination. MATERIALS AND METHODS: A self-selected cross-sectional sample of college students completed an evidence-based online survey. RESULTS: Of approximately 1200 potential respondents, 585 completed the survey. The average age was 20.6 (SD 3.15) and 78% were female; 84% of the population had had one or more sexual partners. Concern for HPV vaccine safety and potential need for boosters did not significantly deter vaccine uptake. Likewise, knowledge about HPV associated cancers was not predictive of vaccine uptake. On the other hand, parental influence for vaccination was a strong predictor for vaccine uptake (aOR = 5.32, 2.71-13.03), and free vaccine nearly doubled the likelihood of being vaccinated (aOR 1.90, 1.05-3.41). In addition, the strong preference for the respondent's partner to be HPV vaccinated predicted vaccine uptake (aOR = 4.04, 95% CI: 2.31-7.05), but the lack of preference for partner vaccination predicted an unvaccinated self (aOR = 0.50, 0.27-0.93). CONCLUSIONS: HPV vaccination has been successful in young adult college students in Kentucky. Young adults prefer their partners to be HPV vaccinated regardless of whether they themselves are vaccinated. Parental influence and free vaccine were positive predictors for vaccine uptake in this population.

Cost-effectiveness of Strategies for Offering Influenza Vaccine in the Pediatric Emergency Department.

Importance: Influenza is a significant public health burden, causing morbidity and mortality in children, yet vaccination rates remain low. Vaccination in the pediatric emergency department (PED) setting may be beneficial but, to date, has not been proven to be cost-effective. Objective: To compare the cost-effectiveness of 4 strategies for PED-based influenza vaccine: offering vaccine to all patients, only to patients younger than 5 years, only to high-risk patients (all ages), or to no patients. Design, Setting, and Participants: Using commercial decision analysis software, a cost-effectiveness analysis was performed from January 1, 2016, to June 1, 2017, to compare influenza vaccine strategies at a tertiary, urban, freestanding PED with an estimated 60 000 visits per year among a hypothetical cohort of children visiting the above PED during influenza season. Sensitivity analyses estimated the effect of uncertainties across a variety of input variables (eg, influenza prevalence, vaccine price and effectiveness, and costs of complications). Main Outcomes and Measures: The primary outcomes were cost and incremental cost-effectiveness ratio in dollars per influenza case averted. Secondary outcomes included total societal costs, hospitalizations and deaths averted, and quality-adjusted life-years gained. Results: Offering influenza vaccine to all eligible patients has the lowest cost, at $114.45 (95% CI, $55.48-$245.45) per case of influenza averted. This strategy saves $33.51 (95% CI, $18-$62) per case averted compared with no vaccination, and averages 27 fewer cases of influenza per 1000 patients. Offering vaccine to all patients resulted in 0.72 days (95% CI, 0.18-1.78 days) of quality-adjusted life-years lost, whereas offering to none resulted in 0.91 days (95% CI, 0.25-2.2 days) of quality-adjusted life-years lost. In sensitivity analyses, this strategy remains robustly cost-effective across a wide range of assumptions. In addition to being the most cost-effective strategy regardless of age or risk status, routine vaccination in the PED results in a net societal monetary benefit under many circumstances. In Monte Carlo analysis, offering vaccine to all patients was superior to other strategies in at least 99.8% of cases. Conclusions and Relevance: Although few PEDs routinely offer influenza vaccination, doing so appears to be cost-effective, with the potential to significantly reduce the economic (and patient) burden of pediatric influenza.

Parents' adherence to pediatric health and safety guidelines: Importance of patient-provider relationships.

OBJECTIVE: To examine 1) parent-provider communication about pediatric health/safety guidelines, 2) trust in child's provider, 3) comfort discussing guidelines, 4) agreement with guideline advice, 5) self-efficacy following guidelines, and their impact on guideline adherence. METHOD: 256 parents of children ages 0-6 completed an online survey about sunscreen use, newborn Vitamin K injections, influenza vaccination, routine vaccination, car seats, infant safe sleep, furniture anchoring, large trampoline use, and firearm safety. Multivariable models regressed: 1) communication about each guideline on parents' corresponding guideline adherence; 2) trust, comfort discussing guidelines, agreement with guideline advice, self-efficacy, on parents' total guideline adherence. RESULTS: Communication about furniture anchoring (OR = 2.26), sunscreen (OR = 5.28), Vitamin K injections (OR = 3.20), influenza vaccination (OR = 13.71), routine vaccination (OR = 6.43), car seats (OR = 6.15), and infant safe sleep (OR = 3.40) related to corresponding guideline adherence (ps < 0.05). Firearm safety communication was not related to adherence (OR = 1.11, n.s.). Trampoline communication related to lower likelihood of trampoline guideline adherence (OR = 0.24, p = 0.001). Agreement with guideline advice (ß = 0.35), trust (ß = 0.34), self-efficacy (ß = 0.45), comfort discussing guidelines (ß = 0.35) positively related to total guideline adherence (ps < 0.001). CONCLUSION: Findings underscore the importance of provider communication about health/safety guidelines. PRACTICE IMPLICATIONS: Providers should respectfully engage and build relationships with parents to support health/safety guideline adherence.

Correction: Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization.

[This corrects the article DOI: 10.1371/journal.pone.0140212.].

Validity of self-reported smoking status among participants in a lung cancer screening trial.

Lung cancer remains a devastating disease associated with substantial morbidity and mortality. Recent research has suggested that lung cancer screening with spiral computed tomography scans might reduce lung cancer mortality. Studies of lung cancer screening have also suggested that significant numbers of participants quit smoking after screening. However, most have relied solely on self-reported smoking behavior, which may be less accurate among participants in lung cancer screening. To assess the validity of self-reported smoking status among participants in a lung cancer screening trial, this study compared self-reported smoking status against urinary cotinine levels. The sample included 55 consecutive participants enrolled in a randomized clinical trial comparing annual spiral computed tomography and chest X-ray for lung cancer screening. Participants were a mean of 59 years of age and predominantly Caucasian (96%) and male (55%). Self-reported smoking status was assessed before and after participants learned of the purpose of the biochemical verification study. Using urinary cotinine as the "gold standard," the sensitivity and specificity of self-reported smoking status were 91% and 95%, respectively (kappa = 0.85, P < 0.001, 95% confidence interval = 0.71-0.99). Total misclassification rate was 7%. However, three of the four misclassified participants reported concurrent use of nicotine replacement strategies. Eliminating these cases from the analysis revealed sensitivity of 100% and specificity of 95% (kappa = 0.96, P < 0.001, 95% confidence interval = 0.88-1.00). In conclusion, self-reported smoking status among participants in a lung cancer screening trial was highly consistent with urinary cotinine test results.

Health information and risk behaviors among lesbian, gay, and bisexual college students.

PURPOSE: To describe differences in alcohol use, marijuana use, and smoking behaviors between lesbian, gay, and bisexual (LGB) and heterosexual college students, and determine whether there was a difference in the health information each group received. DATA SOURCES: A random sample of 3000 college students aged 18-24 years who were currently enrolled at a southeastern metropolitan university on a full-time basis were invited to participate. The final sample (n = 772) consisted of heterosexuals (n = 731) and LGB (n = 41) college students. Gay and bisexual men (n = 20) and lesbian and bisexual women (n = 21) were compared to heterosexual college students. CONCLUSIONS: Lesbian/bisexual women were 4.9 times more likely to smoke, 10.7 times more likely to drink, and 4.9 times more likely to use marijuana than heterosexual women. Gay/bisexual men did not significantly differ from heterosexual men. There was no difference in the health information on alcohol and drug prevention the groups received. Gay/bisexual men were less likely (p = .02) compared to heterosexual men to have received tobacco prevention information. IMPLICATION FOR PRACTICE: Advanced practice nurses must ensure that every patient receives preventive services and anticipatory guidance at every visit. LGB clients in particular need health assessments and interventions appropriate to their individual risk profiles.

Antibiotic therapy of hospitalized patients with community-acquired pneumonia: an international perspective from the CAPO Cohort Study.

The American Thoracic Society and the Infectious Diseases Society of America have developed evidence-based guidelines for the therapy of hospitalized patients with community-acquired pneumonia (CAP). In an attempt to evaluate if the care provided to hospitalized patients with CAP is in compliance with the care recommended by national guidelines, an international network of investigators has been collecting data from 40 hospitals in 13 countries. The care provided in the following areas of antibiotic therapy was analyzed: empiric antibiotic therapy, timing of initial antibiotic therapy, and switch from intravenous to oral antibiotic therapy. Lack of compliance with national guidelines was identified in all areas of antibiotic therapy. Compliance at the local level can be improved with the implementation of a hospital-based pneumonia quality improvement team. Improving compliance with national guidelines recommendations will produce a beneficial effect in CAP clinical and economic outcomes.

Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization.

BACKGROUND: Poor psychological and physical resilience in response to stress drives a great deal of health care utilization. Mind-body interventions can reduce stress and build resiliency. The rationale for this study is therefore to estimate the effect of mind-body interventions on healthcare utilization. OBJECTIVE: Estimate the effect of mind body training, specifically, the Relaxation Response Resiliency Program (3RP) on healthcare utilization. DESIGN: Retrospective controlled cohort observational study. SETTING: Major US Academic Health Network. SAMPLE: All patients receiving 3RP at the MGH Benson-Henry Institute from 1/12/2006 to 7/1/2014 (n = 4452), controls (n = 13149) followed for a median of 4.2 years (.85-8.4 yrs). MEASUREMENTS: Utilization as measured by billable encounters/year (be/yr) stratified by encounter type: clinical, imaging, laboratory and procedural, by class of chief complaint: e.g., Cardiovascular, and by site of care delivery, e.g., Emergency Department. Subgroup analysis by propensity score matched pre-intervention utilization rate. RESULTS: At one year, total utilization for the intervention group decreased by 43% [53.5 to 30.5 be/yr] (p <0.0001). Clinical encounters decreased by 41.9% [40 to 23.2 be/yr], imaging by 50.3% [11.5 to 5.7 be/yr], lab encounters by 43.5% [9.8 to 5.6], and procedures by 21.4% [2.2 to 1.7 be/yr], all p < 0.01. The intervention group's Emergency department (ED) visits decreased from 3.6 to 1.7/year (p<0.0001) and Hospital and Urgent care visits converged with the controls. Subgroup analysis (identically matched initial utilization rates-Intervention group: high utilizing controls) showed the intervention group significantly reduced utilization relative to the control group by: 18.3% across all functional categories, 24.7% across all site categories and 25.3% across all clinical categories. CONCLUSION: Mind body interventions such as 3RP have the potential to substantially reduce healthcare utilization at relatively low cost and thus can serve as key components in any population health and health care delivery system.

Tethered Cord Syndrome in the Pediatric-Adolescent Gynecologic Patient.

STUDY OBJECTIVE: To describe how pediatric and adolescent patients present to the gynecologist when they have tethered cord syndrome (TCS). DESIGN: We conducted a retrospective chart review on all patients suspected by the gynecologist of having TCS. SETTING: Single pediatric and adolescent gynecology clinic in a mid-sized city in the midwest. PARTICIPANTS: Thirty-two patients, first seen between 2005 and 2012, suspected of having TCS and for whom follow-up information was available. INTERVENTIONS AND MAIN OUTCOME MEASURES: Patient characteristics, including patient history, gynecologic clinical indicators, clinical outcomes, indications for surgery, and postoperative resolution of symptoms, were reviewed. RESULTS: The initial review of systems indicated stress urinary incontinence, back pain, and constipation as common markers in the 32 patients who were suspected of having TCS. All 32 patients underwent lumbar magnetic resonance imaging without contrast and evaluation by neurosurgery. Of the 32 patients with suspected TCS, 18 were later confirmed and 14 were shown to not have TCS. Of the 18 patients with sufficient information to justify a detethering procedure, 14 patients were followed and 93% (13 patients) had complete resolution of symptoms. Final diagnosis in the non-TCS group varied, including vulvovaginitis, enuresis, chronic constipation, and lichen sclerosis. Symptoms improved with the treatment of each primary condition. CONCLUSIONS: TCS symptoms overlap with gynecologic conditions; therefore, patients with TCS may present initially to the gynecologist. In pediatric/adolescent patients, TCS should be considered when stress urinary incontinence, back pain, and constipation are discovered in the review of systems. Because possible irreversible ischemic and neurologic changes are believed to be involved, early diagnosis and surgery are crucial for resolution. Providers should be aware of TCS in these pediatric and adolescent settings, because quick assessment may result in complete resolution of a chronic progressive disease.

Use of the levonorgestrel intrauterine system in adolescents with endometriosis.

STUDY OBJECTIVE: The purpose of this study was to evaluate our adolescent patient population who had received a levonorgestrel intrauterine system (LNG-IUS) at or after the time of endometriosis diagnosis, and determine efficacy of the LNG-IUS in regards to pain and bleeding on follow-up exam. DESIGN: Retrospective cohort study. SETTING: Pediatric Adolescent Gynecology Clinic and Children's Hospital in a metropolitan area. PARTICIPANTS: Adolescent patients age 14-22 with pathology-proven endometriosis who had the LNG-IUS placed during the course of their treatment for this disease. Patients were divided into LNG-IUS placement at the time of surgical diagnosis versus placement some time after diagnosis. MAIN OUTCOME MEASURES: Pain and bleeding were assessed by follow-up exam. Pain was classified at each follow-up visit as either none, minimal, moderate, or severe. Bleeding was classified as none, irregular spotting, irregular bleeding, or daily bleeding. RESULTS: The majority of patients (67%) required additional hormonal therapy for pain and bleeding suppression. Time to bleeding suppression and pain suppression was sooner in the group with interval time between surgical diagnosis and LNG-IUS placement, compared to LNG-IUS placement at the time of surgery (2.4 months vs 5.3 months until bleeding suppression, and 3.8 months vs 4.8 months until pain suppression), although statistical significance was not achieved. CONCLUSIONS: The LNG-IUS is an option for treatment of endometriosis in adolescents. As pain is the main problem associated with endometriosis, LNG-IUS placement is beneficial at the time of surgery when it is diagnosed. A prospective study is needed for further assessment of outcomes.

Gender differences in diabetes self-management among African American adults.

The rising incidence of diabetes complications among African Americans is a major health concern. Few studies have addressed gender differences in diabetes self-management in this population. The purpose of this study was to determine whether gender differences in facilitators and barriers to self-management exist among African American adults with type 2 diabetes. Thirty-eight participants were recruited from community agencies and each participated in one of seven audio-recorded focus group sessions. Regular health care visits, positive outlook, prioritization of health, and independence facilitated self-management behaviors in men, whereas acceptance of diabetes was a facilitator for women. Lack of time at work, lack of family support, and lack of knowledge were barriers for men, whereas lack of finances, embarrassment, negative outlook, perceived lack of disease control, and adverse effects of medications were barriers for women. Further research is necessary to design and test gender-specific tailored interventions to improve diabetes self-management in this population.

Intention to seek mental health treatment for adolescent girls: comparison of predictors in mothers and daughters.

PROBLEM: To examine predictors of intention to seek mental health treatment for adolescent girls in mothers and daughters. METHODS: In this cross-sectional study, mothers and adolescent daughters (n = 71) completed measures of behavioral attitudes, subjective norms, perceived behavioral control, and intention to seek mental health treatment for the adolescent daughter. FINDINGS: Behavioral attitude and perceived behavioral control predicted intention to seek mental health treatment among mothers. Behavioral attitude predicted intention among daughters. There were no associations between mothers and daughters on study variables. CONCLUSIONS: To promote shared decision making and engagement in mental health treatment, clinicians may target interventions to the mother's perceived behavioral control and behavioral attitudes of daughters and mothers. Based upon study results, clinicians should promote shared decision making and concordance between mothers and daughters on attitudes toward mental health treatment.