Racial disparities in clinic follow-up early in life among survivors of congenital heart disease.

OBJECTIVE: The current study aims to identify the rates of lapses in care and loss to follow-up before age one through age five for white and nonwhite congenital heart disease (CHD) survivors. Nonwhite CHD survivors were hypothesized to experience an earlier lapse in care and be lost to follow-up than whites. DESIGN: Patients were from a large pediatric hospital and had (1) at least one outpatient cardiology clinic visit or cardiac surgery visit before the age of one and (2) a diagnosis of moderate or complex structural CHD. Cardiology outpatient utilization rates were tracked from before age one through age five. Lapse in follow-up was defined as not having at least one outpatient cardiology visit per year, and loss to follow-up was not returning after a lapse in care by age five. Race was categorized as white and nonwhite. Covariates included sex, insurance type, noncardiology inpatient and outpatient hospital utilization, and CHD severity. RESULTS: The sample included 1034 patients. Overall, 75.7% experienced a lapse in care with only 41.6% of those returning by age five. Nonwhites experienced lapses in care at younger ages than whites. Nonwhites had a 53% increased risk of lapse in care. Medicaid patients and those with moderate CHD diagnoses also had an increased risk for lapse in care. CONCLUSIONS: Lapse in care appears prevalent among CHD survivors by age five, with nonwhites demonstrating elevated risk. Future multisite prospective studies should include the assessment of parental knowledge, barriers to accessing care, and satisfaction with care.

Evaluation of Pediatric Human Papillomavirus Vaccination Provider Counseling Written Materials: A Health Literacy Perspective.

BACKGROUND AND OBJECTIVES: Despite recommendations supporting human papillomavirus (HPV) vaccination, pediatric vaccination rates remain suboptimal in the United States; lack of tools to support provider counseling is one barrier. We sought to evaluate HPV-related counseling materials for readability, suitability, and content, and assess parent perceptions of materials, using a health literacy perspective. METHODS: A systematic search was conducted for written materials developed for HPV vaccination counseling by examining state Department of Health Web sites and associated links to local and national organizations. Materials were assessed for the following: 1) readability (Flesch Reading Ease, Flesch-Kincaid, Gunning Fog, Simple Measure of Gobbledygook, Fry), 2) suitability (understandability and actionability) (Suitability Assessment of Materials; Patient Education Materials Assessment Tool for Printable Materials), and 3) coverage of 8 key content areas (recommended by Centers for Disease Control and Prevention). Semistructured interviews were conducted with English-speaking parents or caregivers of children 9 to 17 years of age from 3 pediatric clinics (New York, Ohio, Illinois) serving predominantly low-income families to assess perceptions and usefulness of 4 handouts selected for review. RESULTS: Thirty-eight documents were assessed. Mean ± standard deviation (SD) reading grade level was 9.4 ± 2; 10.5% (n = 4) had a reading level of 6th grade or below; 68.4% (n = 26) were considered not suitable. Mean understandability was 41.7% and mean actionability was 20.7%. Only 5.3% (n = 2) addressed all 8 content areas mean ± SD (number of areas = 6.7 ± 1.2). Brochure comprehensiveness and inclusion of a personal story were cited as factors that would be helpful in influencing parents to vaccinate against HPV. CONCLUSIONS: Few written materials for HPV vaccination counseling were optimal from a health literacy best practices perspective. Content comprehensiveness was important for informed decision making.

A feasibility study of home-based contingency management with adolescent smokers of rural Appalachia.

Cigarette smoking among adolescents remains a significant public health concern. This problem is compounded in regions such as rural Appalachia where rates of smoking are consistently higher than national averages and access to treatments is limited. The current research evaluated a home-based contingency management program completed over the Internet with adolescent smokers recruited from rural Appalachia. Participants (N = 62) submitted 3 video recordings per day showing their breath carbon monoxide (CO) levels using a handheld CO monitor. Participants were assigned to either an active treatment condition (AT; n = 31) in which reductions in breath CO were reinforced or a control treatment condition (CT; n = 31) in which providing timely video recordings were reinforced with no requirement to reduce breath CO. Results revealed that participants in the AT condition reduced their breath CO levels significantly more so during treatment than participants in the CT condition. Within-group comparisons revealed that participants in both conditions significantly reduced their breath CO, self-reported smoking, and nicotine dependence ratings during treatment. However, only participants in the AT condition significantly reduced urinary cotinine levels during treatment, and only participants in this condition maintained all reductions until 6-week post treatment. Participants in the CT condition only maintained self-reported smoking reductions until posttreatment assessments. These results support the feasibility and initial efficacy of this incentive-based approach to smoking cessation with adolescent smokers living in rural locations.

Delay discounting and self-reported impulsivity in adolescent smokers and nonsmokers living in rural Appalachia.

Background and Objectives This study evaluated whether impulsivity (delay discounting and BIS-11-A) is associated with adolescent smoking status in a region with strong environmental risk factors for smoking. Methods Forty-two adolescent smokers and nonsmokers from rural Appalachia completed discounting and self-reported impulsivity assessments. Results The BIS-11-A, but not the measure of discounting, was associated with smoking status; however, neither assessment predicted smoking status once parent/best-friend smoking variables were statistically accounted for. Discussion and Conclusions In regions with strong environmental risk factors for smoking, delay discounting may play a more limited role in risk of initiation. Scientific Significance Helps to better define impulsivity as risk factors for smoking in relation to familial and broader cultural variables.

A pilot study of home-based smoking cessation programs for rural, appalachian, pregnant smokers.

OBJECTIVE: To evaluate a web-based contingency management program (CM) and a phone-delivered cessation counseling program (Smoking Cessation for Healthy Births [SCHB]) with pregnant smokers in rural Appalachia who were ≤12 weeks gestation at enrollment. DESIGN: Two group randomized design. SETTING: Home-based cessation programs in rural Appalachia Ohio and Kentucky. PARTICIPANTS: A community sample of pregnant smokers (N = 17). METHODS: Participants completed demographic and smoking-related questionnaires and were assigned to CM (n = 7) or SCHB (n = 10) conditions. Smoking status was assessed monthly using breath carbon monoxide and urinary cotinine. RESULTS: For CM, two of seven (28.57%) of the participants achieved abstinence, and three of 10 (30%) of those enrolled in SCHB were abstinent by late in pregnancy. Participants in CM attained abstinence more rapidly than those in SCHB. However, those in SCHB experienced less relapse to smoking, and a greater percentage of these participants reduced their smoking by at least 50%. CONCLUSION: Based on this initial evaluation, the web-based CM and SCHB programs appeared to be feasible for use with rural pregnant smokers with acceptable program adherence for both approaches. Future researchers could explore combining these programs to capitalize on the strengths of each, for example, rapid smoking cessation based on CM incentives and better sustained cessation or reductions in smoking facilitated by the counseling support of SCHB.

Dimensions of impulsive behavior and treatment outcomes for adolescent smokers.

Adolescent cigarette smoking rates remain a significant public health concern, and as a result there is a continued need to understand factors that contribute to an adolescent's ability to reduce or quit smoking. Previous research suggests that impulsive behavior may be associated with treatment outcomes for smoking. The current research (N = 81) explored 3 dimensions of impulsive behavior as predictors of treatment response from a social-cognitive type program for adolescent smokers (i.e., Not On Tobacco; N-O-T). Measures included laboratory assessments of delay discounting, sustained attention, and behavioral disinhibition. A self-report measure of impulsivity was also included. Adolescent smokers who had better sustained attention were more likely to reduce or quit smoking by the end of treatment. No other measures of impulsivity were significantly associated with treatment response. From these findings, an adolescent smoker's ability to sustain attention appears to be an important behavioral attribute to consider when implementing smoking cessation programs such as N-O-T.

Delay discounting by depressed and non-depressed adolescent smokers and non-smokers.

BACKGROUND: Both delay discounting and depression are risk factors for cigarette smoking during adolescence. However, very little research has explored associations between these variables in adolescent smokers and non-smokers. METHODS: Eighty adolescents were recruited based on depression status (depressed and non-depressed) and smoking status (smokers and non-smokers) to form four groups (n=20 per group). All participants completed a computerized monetary delay discounting task and a measure of depression. RESULTS: Delay discounting and depression were significantly correlated. Also, smokers (both depressed and non-depressed) and depressed non-smokers all discounted significantly more than non-smokers who were not depressed. Depressed non-smokers and both groups of smokers did not differ in rate of delay discounting. CONCLUSIONS: Adolescent non-smokers who are depressed discount similarly to adolescents who smoke and more than non-smokers who are not depressed. Future research should explore the unique versus shared roles of delay discounting and depression as risk factors for smoking during adolescence.