A Systems-Level Evaluation Framework for Virtual Care.

The virtual care landscape is significantly changing, largely due to an increased demand initiated by the COVID-19 pandemic and the evolution of technology. Complex questions about how to best leverage virtual care and its impact remain unanswered. Our team developed a systems-level evaluation framework to inform virtual care service design and evaluation to take a more comprehensive approach to planning and implementing virtual care. We designed the framework for application in Alberta Health Services (AHS) by engaging virtual care users (patients, families and healthcare providers), implementation staff and decision makers across the organization. Here we report our design process and key lessons learned. The framework received endorsement by AHS senior leadership for application across the system. Our next step is to test the framework. By sharing our design process and experiences, we aim to help inform other national and international jurisdictions plan virtual care evaluations within their context.

Moving toward a true depiction of tobacco behavior among Asian Indians in California: Prevalence and factors associated with cultural smokeless tobacco product use.

BACKGROUND: Asian Indians (AIs) in the United States exhibit disproportionate burdens of oral cancer and cardiovascular disease, which are potentially linked to smokeless tobacco. However, little is known about the use of cultural smokeless tobacco (CST) products in this population. METHODS: California Asian Indian Tobacco Use Survey data from 2004 (n = 1618) were used to investigate CST prevalence among California's AIs. CST products included paan, paan masala, and gutka. A multivariable logistic regression was conducted to examine factors (socioeconomic status, acculturation measures, and religious affiliation) associated with current CST use versus never use. RESULTS: The current CST prevalence was 13.0% (14.0% for men and 11.8% for women). In contrast, the prevalence of current cigarette use was 5.5% (8.7% for men and 1.9% for women), and the prevalence was lower for cultural smoked tobacco (0.1% for bidis and 0.5% for hookahs). Factors associated with CST use included the following: being male, being 50 years old or older, being an immigrant, speaking an AI language at home, having a higher level of education (adjusted odds ratio [AOR] for high school/some college, 2.6; 95% confidence interval [CI], 1.1-6.5; AOR for college degree or higher, 4.0; 95% CI, 1.7-9.5), having a higher income (AOR for $75,000-$100,000, 2.5; 95% CI, 1.3-4.7; AOR for ≥$100,000, 2.6; 95% CI, 1.4-5.0), identifying as non-Sikh (AOR for Hinduism, 10.0; 95% CI, 6.0-16.5; AOR for other faiths, 10.2; 95% CI, 5.9-17.7), and disagreeing that spiritual beliefs are the foundation of life (AOR, 2.1; 95% CI, 1.2-3.5). CONCLUSIONS: The current CST prevalence is relatively high among California's AIs in comparison with the prevalence of smoking, with narrower differences between sexes. The association with a higher socioeconomic status is contrary to typical cigarette smoking patterns. Acculturation and religious affiliation are important factors associated with current use. Health care providers and policymakers should consider such determinants for targeted interventions. Cancer 2018;124:1607-13. © 2018 American Cancer Society.

Testing antismoking messages for Air Force trainees.

INTRODUCTION: Young adults in the military are aggressively targeted by tobacco companies and are at high risk of tobacco use. Existing antismoking advertisements developed for the general population might be effective in educating young adults in the military. This study evaluated the effects of different themes of existing antismoking advertisements on perceived harm and intentions to use cigarettes and other tobacco products among Air Force trainees. METHODS: In a pretest-post-test experiment, 782 Airmen were randomised to view antismoking advertisements in 1 of 6 conditions: anti-industry, health effects+anti-industry, sexual health, secondhand smoke, environment+anti-industry or control. We assessed the effect of different conditions on changes in perceived harm and intentions to use cigarettes, electronic cigarettes, smokeless tobacco, hookah and cigarillos from pretest to post-test with multivariable linear regression models (perceived harm) and zero-inflated Poisson regression model (intentions). RESULTS: Antismoking advertisements increased perceived harm of various tobacco products and reduced intentions to use. Advertisements featuring negative effects of tobacco on health and sexual performance coupled with revealing tobacco industry manipulations had the most consistent pattern of effects on perceived harm and intentions. CONCLUSIONS: Antismoking advertisements produced for the general public might also be effective with a young adult military population and could have spillover effects on perceptions of harm and intentions to use other tobacco products besides cigarettes. Existing antismoking advertising may be a cost-effective tool to educate young adults in the military.

Paan (pan) and paan (pan) masala should be considered tobacco products.

Two products indigenous to the Indian subcontinent and popular among South Asians globally - paan and paan masala - are inconsistently categorised as tobacco by researchers, clinicians, program planners and policymakers. This article calls for a universally standard classification of these smokeless carcinogenic products as tobacco products and thus, subject to the same public health and clinical protections applied to other forms of tobacco. This recommendation is guided by scientific evidence strongly indicating the common presence of tobacco in paan and paan masala. Inclusion of these two products in population-level surveillance, clinical screening, as well as public health program planning and policy interventions may have considerable impact on preventing and reducing tobacco-related disparities among South Asians around the world.

Collaboration with behavioral health care facilities to implement systemwide tobacco control policies--California, 2012.

The California Tobacco Control Program (CTCP) administered 4 regional trainings in 2012 to staffers at CTCP-funded projects, tobacco control coalitions, several county departments of mental health and alcohol and drug, and administrators and providers from behavioral health care facilities. These trainings focused on the special tobacco use cessation needs and opportunities for cessation among persons with mental illness or substance abuse disorders, and they provided information about cessation and smoke-free policies. CTCP surveyed county and private behavioral health care programs to assess their readiness for adopting tobacco control strategies at treatment facilities. Between baseline and follow-up we found a decrease in the proportion of organizations at the precontemplation or contemplation stages of change and twice as many organizations at the action and maintenance stages of change. Significant obstacles remain to implementing policy: many agencies have concerns about going tobacco-free. But significant progress has been made, as evidenced by new policies and a growing number of tobacco-free coalitions consisting of public health agencies, behavioral health care agencies, and local hospitals.

Culturally specific tobacco use and South Asians in the United States: a review of the literature and promising strategies for intervention.

Over the past two decades, the United States has attracted large South Asian populations, who have imported tobacco products previously unique to the native subcontinent. South Asian cigarette use prevalence is consistently lower than other U.S. Asian subgroups; however, most surveys fail to capture smokeless products accurately. In part because of the pervasive use of popular smokeless cultural products resulting in greater population attributable risk of oral malignancies, many countries outside the United States have developed surveillance systems to capture these products and implemented effective population-level or community-based intervention strategies. This minority population in the United States continues to be "at risk" of suffering from a disproportionate burden of diseases, which are plausibly linked to the use of these products. The primary focus of this article is to provide an exhaustive literature review of tobacco use patterns and existing tobacco control strategies among South Asians in the United States. Framed within the social ecological model, the article suggests that there needs to be more detailed assessment of cultural tobacco products, a concurrent increase in cultural competencies of health care providers and provision of cessation resources outside the clinical setting. At the policy level, future efforts should adequately regulate these products and oversight must include such products in efforts to reduce rates of use. Concurrently, community-based efforts are needed to change social norms related to perceived health benefit and lack of stigma. This will help ensure that appropriately framed messages around use rates and burden of disease are addressed through culturally valued institutions and leaders.

Cost-effective smoke-free multiunit housing media campaigns: connecting with local communities.

Presented are cost-effective paid media strategies to educate Californians to advocate for stronger smoke-free multiunit housing (SF-MUH) policies between 2006 and 2008. Included is a summary of general market and specific ethnic market costs that correspond to SF-MUH attitudes and home smoking bans. Statewide questionnaires indicated that half of the intended general market saw an antitobacco TV ad and half of the intended ethnic markets heard radio ads. Analyses indicated that it cost $0.67 and $0.78 per person to see Caution Tape and Apartment TV ads, respectively. Slightly higher per capita costs corresponded with positive attitudes toward SF-MUH: $0.87 for Caution Tape and $1.00 for Apartment. Lessons learned from this campaign included effectiveness of specific ads in ethnic markets, impact on SF-MUH work plan policy objectives, and the need for collaborations among state and local partners throughout the message development process.

Assessing the relationship between ad volume and awareness of a tobacco education media campaign.

BACKGROUND: The relation between aided ad recall and level of television ad placement in a public health setting is not well established. We examine this association by looking back at 8 years of the California's Tobacco Control Program's (CTCP) media campaign. METHODS: Starting in July 2001, California's campaign was continuously monitored using five telephone series of surveys and six web-based series of surveys immediately following a media flight. We used population-based statewide surveys to measure aided recall for advertisements that were placed in each of these media flights. Targeted rating points (TRPs) were used to measure ad placement intensity throughout the state. RESULTS: Cumulative TRPs exhibited a stronger relation with aided ad recall than flight TRPs or TRP density. This association increased after log-transforming cumulative TRP values. We found that a one-unit increase in log-cumulative TRPs led to a 13.6% increase in aided ad recall using web-based survey data, compared to a 5.3% increase in aided ad recall using telephone survey data. CONCLUSIONS: In California, the relation between aided ad recall and cumulative TRPs showed a diminishing return after a large volume of ad placements These findings may be useful in planning future ad placement for CTCP's media campaign.

An evaluation of the California community intervention.

AIM: We conducted this study to determine key community-level factors associated with higher tobacco control programme performance. METHODS: A combination of surveys, administrative and fiscal data were collected to measure local county-level health department performance over a 7-year period. Longitudinal analyses were performed using generalised estimating equations to examine whether counties that exerted higher effort were successful in creating more tobacco retail licensing (TRL) and secondhand smoke policies. Several social, political and contextual factors were examined as confounders. RESULTS: Local county health departments (CHDs) that demonstrated high effort on their work plans increased the proportion of residents covered by TRL policies (7.2%; 95% CI -1.7 to 16.1%) compared to CHDs with lower levels of effort. Having legislators who voted in favour of tobacco control bills was found to significantly increase the passage of local TRL policies. CHDs demonstrating higher efforts also increased the proportion of residents covered by secondhand smoke policies (9.2%; 95% CI -3.5 to 21.9%). CONCLUSION: There was strong evidence that higher county-level efforts predicted an increasing number of local tobacco control policies. Evaluations using integrated designs are recommended as effective strategies to provide a more accurate assessment of how well community-level interventions catalyse community-wide change.

Features of hepatocellular carcinoma in Hispanics differ from African Americans and non-Hispanic Whites.

AIM: To compare features of hepatocellular carcinoma (HCC) in Hispanics to those of African Americans and Whites. METHODS: Patients treated for HCC at an urban tertiary medical center from 2005 to 2011 were identified from a tumor registry. Data were collected retrospectively, including demographics, comorbidities, liver disease characteristics, tumor parameters, treatment, and survival (OS) outcomes. OS analyses were performed using Kaplan-Meier method. RESULTS: One hundred and ninety-five patients with HCC were identified: 80.5% were male, and 22% were age 65 or older. Mean age at HCC diagnosis was 59.7 ± 9.8 years. Sixty-one point five percent of patients had Medicare or Medicaid; 4.1% were uninsured. Compared to African American (31.2%) and White (46.2%) patients, Hispanic patients (22.6%) were more likely to have diabetes (P = 0.0019), hyperlipidemia (P = 0.0001), nonalcoholic steatohepatitis (NASH) (P = 0.0021), end stage renal disease (P = 0.0057), and less likely to have hepatitis C virus (P < 0.0001) or a smoking history (P < 0.0001). Compared to African Americans, Hispanics were more likely to meet criteria for metabolic syndrome (P = 0.0491), had higher median MELD scores (P = 0.0159), ascites (P = 0.008), and encephalopathy (P = 0.0087). Hispanic patients with HCC had shorter OS than the other racial groups (P = 0.020), despite similarities in HCC parameters and treatment. CONCLUSION: In conclusion, Hispanic patients with HCC have higher incidence of modifiable metabolic risk factors including NASH, and shorter OS than African American and White patients.

Internet users' prior psychological and social difficulties.

This study addressed the hypothesis that frequent Internet use produces social and psychological difficulties. An Internet-administered survey was given to a sample of Internet users. Comparisons were made between this sample and general population norms on a selection of social and psychological variables. Internet users showed a more detrimental mean rating on 11 of 13 of the variables (two measures of social contact were more positive among the user sample). However, for those variables for which time of onset was available (n = 7), the disorder had begun 5-22 years before Internet use. These findings are not in accord with the theory that Internet use causes disorder or social difficulty, and suggest the possibility that the Internet may provide a particular benefit for certain individuals who have already displayed these personal and social difficulties.

Individual and family factors associated with intention to quit among male Vietnamese American smokers: implications for intervention development.

Smoking prevalence among Vietnamese American males remains higher than the U.S. general population. This study examined the associations of individual and family factors with quit intention among Vietnamese male smokers in California to guide intervention development to reduce their smoking prevalence. Data for Vietnamese male current smokers (n=234) in the 2008 California Vietnamese Adult Tobacco Use Survey (N=1101 males) were analyzed to describe quit intention and previous quit attempts. One-third of Vietnamese male smokers (33%) had no intention to quit at any time, 36% intended to quit soon (in the next 30 days), and 31% intended to quit later (beyond the next 30 days). Half (51.7%) of the sample was in "precontemplation," indicating no intention to quit within 6 months. Many (71%) had made a serious quit attempt in the past year, but 68% of those who tried to quit used no cessation assistance. Multivariate logistic regression adjusting for age, depression, smoking intensity, nicotine dependence, health knowledge, children in the household and home smoking ban revealed that having smoking-related family conflicts and a quit attempt in the past year with or without assistance were independently associated with an intention to quit either in the next 30 days or later. Higher education was associated with no intention to quit. Findings underscore the importance of designing strategic interventions that meet the needs of smokers at both individual and family levels to promote quit intention and to facilitate successful quitting in this population.

Cervical cancer disparities in South Carolina: an update of early detection, special programs, descriptive epidemiology, and emerging directions.

Through careful examination of cervical cancer incidence and mortality rates and current resources available in South Carolina, we have identified research and intervention priorities related to cervical cancer that would best serve the women of this state. Mortality rates due to cervical cancer are largely explained by the lack of early detection among women rarely and never screened and non-adherence to recommended follow-up care of cervical dysplasia; however, other factors less well explained are determinants of observed disparities between AA and EA women. Efforts are underway to implement strategies recommended by the NCI to eliminate cervical cancer disparities through improved efforts to reach out to rarely and never-screened women and prepare health care providers for implementation of HPV vaccines.

Prostate cancer disparities in South Carolina: early detection, special programs, and descriptive epidemiology.

Available evidence suggests that there may be qualitative differences in the natural history of PrCA by race. If this is true then additional etiologic research is needed to identify places in the causal chain where we can intervene to lower PrCA rates in AA men. South Carolina may prove to be a useful context in which to study prostate cancer etiology, because of the presence of unique environmental exposures. For example, soil selenium and cadmium concentrations unique to South Carolina might have a differential affect in the rural areas of the state where ground water use is more common and where AAs are more likely to live. These metals are important in terms of prostate metabolism and cancer. The possible interaction of geological factors with underlying biological factors such as metal transporter gene expression by race needs to be explored in South Carolina. Diet and exercise are consistently seen as possible primary prevention strategies for prostate and other cancers, as noted above. There may be very good reasons to intervene on diet and physical activity, but if the intention is to make a health claim with real, specific meaning for PrCA prevention and control then studies must be designed to test the effect of these modalities in rigorous ways at specific points in the natural history of prostate carcinogenesis. Nutrition and exercise programs need to be developed in South Carolina that are seen as acceptable by people at risk of PrCA; and they will need to focus on effective ways to prevent the development of PrCA, other cancers, and other health outcomes. Implementing diet and nutrition programs in rural parts of the state, possibly through schools or churches, offer benefit to both youth and adults alike. So, it would be possible, indeed it would be desirable, to create programs that may be used for research in one part of the population (e.g., men with PrCA), but are equally beneficial for others (e.g., their spouses and children). Organizing studies that can focus on promising new areas of research and changing the paradigms under which the research community currently operates probably will require re-conceptualizing research strategies employing methods that entail CBPR approaches. Because much of South Carolina's African-American population resides in rural parts of the state, outreach presents a challenge for both researchers and clinicians. Individuals living in rural areas are more likely than urban residents to live in poverty, report poorer health status, and not have private health insurance. Americans living in rural areas face disparities in access to basic public health services compared to those living in metropolitan areas. In very practical ways, local public health departments are absent in many rural communities, and rural hospitals continue to close, removing needed services. Closing of public hospitals has been shown to significantly increase the percentage of people without a primary health care provider as well as the percentage of people denied care. Public health departments are of particular importance to rural residents as they serve as the main avenue for public health and clinical care for this group. Issues such as access to care, lack of frequent physician's visits and quality of medical care have a negative impact on outcomes for men with PrCA, particularly in relationship to staging. If better outcomes are to be achieved in South Carolina, then more must be done to reach the community and provide better access to care in more rural areas of the state. Small media interventions, such as those presented in churches and barbershops may be an effective means for reaching the rural AA population. Our ability to reach out to and interact with the high-risk pockets in the state will be necessary for screening, treatment, and research (which, if conducted competently, will affect screening efficacy, treatment effectiveness, and primary prevention). It is believed that currently available decision-making materials for PrCA screening may not be appropriate due to socioeconomic as well as health literacy differences present in all male groups. It is unclear whether men in the lower socioeconomic groups are given appropriate information that allows them to make educated, informed decisions around PrCA screenings. Considering the number of males in the lower socioeconomic groups in South Carolina and the large AA male population, research evaluating the appropriateness of the existing materials could have an impact --both within the state and in national efforts. Patient education is a promising strategy, but educating the patient in the context of his family seems to be a more effective strategy for this population. Family networks and faith-based networks offer a strong support base for the patient when making health-related decisions, particularly for the African-American male. In collaboration with the SCCDCN, the South Carolina Cancer Alliance (SCCA) is currently developing a proposal to create a decision guide for prostate screening that is targeted toward the African-American male. The SCCA plans to pilot test new, culturally appropriate materials in the Low Country of South Carolina because of its comparatively large African-American population and its high rate of residential stability. South Carolina is one of only a few states to adopt expanded Medicaid coverage for the treatment of breast cancer. PrCA needs to receive equal recognition. This year alone in South Carolina 3,290 women will be diagnosed with breast cancer and 630 will die from the disease. Likewise, the American Cancer Society estimated 3,770 men in South Carolina would be diagnosed with prostate cancer and 440 will die from the disease in 2006. The 1 million dollars set aside in South Carolina budget by lawmakers for treatment of breast and cervical cancer patients makes no mention of prostate cancer, which is an unfair omission. Finally, there currently exists a number of high-quality PrCA treatment, research, and referral resources in the state. Collaborations across agencies, institutes and organizations throughout South Carolina would prove to be beneficial in reaching the most rural (and therefore hardest to reach) populations. Collaborative arrangements will be pursued to increase positive outcomes and better futures for South Carolinians.

Breast cancer disparities in South Carolina: early detection, special programs, and descriptive epidemiology.

A discrepancy exists between mortality and incidence rates between African-American and European-American women in South Carolina. The relationship between tumor grade and the estrogen/ progesterone receptor status is different in African-American and European-American women. African-American women with breast cancer should be encouraged to participate in clinical trials, with the goal of identifying biological factors that might facilitate the detection of tumors at an earlier stage and the development of more effective therapies. The most important of our goals is to design studies to reduce the incidence of the disease and interventions to improve survival and quality of life. The importance of participation in research cannot be overstated. Reproductive factors such as early pregnancy and multiple pregnancies are strongly related to breast cancer risk, however, promotion of these factors as a "prevention strategy," clearly does not lead to cogent, comprehensive public health messages. Data from ecological and migrant studies point clearly to other factors that may be important such as diet. Additional research around primary prevention strategies is needed. In addition, yearly mammograms (secondary prevention) are recommended for women over 50 years old or those with relatives who have developed breast cancer. The Best Chance Network, as a provider of screenings to low-income, uninsured women, has helped to narrow the racial gap in screening that otherwise might exist (see Figures 3 and 4) to a large extent. The determination for timing of surgery after diagnosis needs additional consideration. For example, factors such as effective screening in younger women, timing of screening and surgery in relationship to the ovulatory cycle, and season of screening and surgery may have a great impact on outcomes and may offer some insight into the process of carcinogenesis and therapeutic efficacy. Research into this area is so novel that the impact on possible ethnic disparities is completely unknown. The South Carolina Cancer Disparities Community Network (SCCDCN) has identified the following areas as potential research foci: Identification of small media interventions as an effective strategy to motivate targeted populations, especially those least likely to seek screening for breast cancer and those least likely to participate in research programs (African-Americans). Utilization of breast cancer survivors, self-identified as community natural helpers, can share their experiences with their church congregation. A replication of such a program in South Carolina has great potential because of the strong presence of the church, especially in rural parts of the state. Programs that closely integrate religion with screening women for breast cancer are promising in this state. Development of a mammography registry whereby information on all mammography procedures would be collected within a single database system (much like a central cancer registry). This would aid in identifying population groups that could be targeted for special programs and in the examination and exploration of the most appropriate modalities of detection. Such a resource could also be a useful tool to encourage screening. Thus, this focus area has the potential to benefit epidemiologic and health promotion research on many different levels. Additional breast cancer screening methods should not be overlooked as a potential research focus. Mammography is not the only valid screening method for breast cancer. Magnetic resonance imaging has shown some promise for screening among women with a genetic predisposition for cancer. Another promising avenue is thermography. Because detection rates may depend on age, ethnicity, and breast mammographic characteristics, women for whom regular screening methods do not detect their cancers (e.g. older age, African-American ethnicity, dense breasts) must be identified and other screening methods promoted within these populations. The above-mentioned mammography registry would support this type of research.