Research Scientist | Implementation and Social Science
INTRODUCTION: U.S. reductions in smoking have not been experienced equally. Smoking prevalence is greater among persons of lower education, lower income, and unemployed. We evaluated whether a cessation intervention for job-seekers would result in significantly fewer cigarettes smoked per day and a greater likelihood of tobacco abstinence and re-employment, compared to the control condition at 6-months follow-up.METHODS: Unemployed, job-seekers who smoked daily were recruited from five employment development departments in the San Francisco Bay Area, October 2015 to February 2018. Intention to quit smoking was not required. Participants were randomized to a brief motivationally-tailored, computer-assisted counseling intervention or referred to a toll-free quitline. Midstudy, 8-weeks of combination nicotine replacement was added to the intervention. Expired carbon monoxide and cotinine testing verified abstinence. Data were analyzed fall 2019.RESULTS: Participants (N?=?360; 70% men; 43% African American, 27% non-Hispanic Caucasian; 19% unhoused) averaged 12 cigarettes/day (SD?=?6), 67% smoked within 30?min of wakening; 27% were in preparation stage to quit. During the 6-month study period, intervention participants were more likely to make a quit attempt (71% vs. 58%, p?=?.021) and reported significantly greater reduction in cigarettes/day than control participants (median reduction: 6.9 vs. 5.0, p?=?.038); however, bioconfirmed abstinence (3%) and re-employment (36%) did not differ by treatment group.CONCLUSIONS: In a diverse sample with economic hardships, quit attempts and smoking reduction were greater in the intervention group; however, few achieved abstinence, and neither abstinence nor re-employment differed by condition. A priority group, further research is needed on smoking and re-employment.
View details for DOI 10.1016/j.ypmed.2020.106259
View details for PubMedID 33022318
INTRODUCTION: Reports from patients and healthcare workers dealing with COVID-19 underscore experiences of isolation and fear. Some of this experience results from the distancing effect of masks, gloves, and gowns known as Personal Protective Equipment (PPE). One approach to bridging the divide created by PPE is the use of PPE Portraits, postcard-sized pictures affixed to PPE.OBJECTIVE: Our confidential, email-based survey aimed to quantify provider attitudes towards PPE Portraits.METHODS: PPE Portraits were piloted at an academic, safety-net health system experiencing a COVID-19 patient surge in April-May 2020, necessitating use of full PPE for COVID-positive patients and surgical masks in all hospital settings. Our survey assessed staff exposure to PPE Portraits, attitudes towards PPE Portraits, and potential program expansion. For staff wearing PPE Portraits, we also assessed perceptions of interactions with other staff and patients/families and impact on personal wellbeing. The University of Massachusetts Medical School's IRB designated this a quality improvement project (#H00020279).RESULTS: Over half of survey respondents (n=111/173, 64%) reported exposure to PPE Portraits. Attitudes towards PPE Portraits were positive overall, with agreement that PPE Portraits were a good idea (89%), improved provider mood (79%), enhanced perception of team connection (72%) and more positive among those who reported exposure. Open-ended responses (n=41) reinforced positive survey data, and also raised concerns about infection control (n=6), cost/logistics (n=5), and provider vulnerability (n=3).CONCLUSIONS: Providers report that PPE Portraits may represent a positive, patient-centered idea that helps reassure patients, is well-received by interdisciplinary staff, and may enhance patient and team interactions. Potential adaptations to address concerns include "photo pins," and donor/ patient and family experience department support for costs.KEY MESSAGE: This article describes a cross-sectional study that investigated provider perceptions on the use of PPE Portraits, an intervention that addresses the barrier to patient-provider connection presented by the use of PPE. The results suggest that implementation of the PPE Portrait Project is feasible, acceptable, and effective.
View details for DOI 10.1016/j.jpainsymman.2020.08.038
View details for PubMedID 32911039
The COVID-19 pandemic has rapidly moved telemedicine from discretionary to necessary. Here we describe how the Stanford Neurology Department: 1) rapidly adapted to the COVID-19 pandemic, resulting in over 1000 video visits within four weeks and 2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to: equipment/software, provider engagement, workflow/triage, and training. Upon reflection, the key drivers of our success were provider engagement and a supportive physician champion. The physician champion played a critical role understanding stakeholder needs, including staff and physicians' needs, and creating workflows to coordinate both stakeholder groups. Prior to COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated post-pandemic era.
View details for DOI 10.1212/WNL.0000000000010015
View details for PubMedID 32611634
The use of personal protective equipment (PPE) has skyrocketed, as providers don masks, glasses, and gowns to protect their eyes, noses, and mouths from COVID-19. Yet these same facial features express human individuality, and are crucial to nonverbal communication. Isolated ICU patients may develop "post intensive-care syndrome," which mimics PTSD with sometimes debilitating consequences. While far from a complete solution, PPE Portraits (disposable portrait picture stickers- 4" * 5") have the potential to humanize care. Preparing for a larger effectiveness evaluation on patient and provider experience, we collected initial qualitative implementation insights during Spring 2020's chaotic surge preparation. Front-line providers reported more comfort with patient interactions while wearing PPE Portraits: "It makes it feel less like a disaster zone [for the patient]." A brief pilot showed signs of significant adoption: a participating physician requested PPE Portraits at their clinic, shift nurses had taken PPE Portraits with them to inpatient services, and masked medical assistant team-members requested PPE Portraits to wear over scrubs. We believe PPE Portraits may support patient care and health, and even potentially healthcare team function and provider wellness. While we await data on these effects, we hope hospitals can use our findings to speed their own implementation testing.
View details for DOI 10.1007/s11606-020-05875-2
View details for PubMedID 32410125
View details for Web of Science ID 000533323500064
The Consolidated Framework for Implementation Research (CFIR) is a commonly used implementation science framework to facilitate design, evaluation, and implementation of evidence-based interventions. Its comprehensiveness is an asset for considering facilitators and barriers to implementation and also makes the framework cumbersome to use. We describe adaptations we made to CFIR to simplify its pragmatic application, for use in a learning health system context, in the evaluation of a complex patient-centered care transformation.We conducted a qualitative study and structured our evaluation questions, data collection methods, analysis, and reporting around CFIR. We collected qualitative data via semi-structured interviews and observations with key stakeholders throughout. We identified and documented adaptations to CFIR throughout the evaluation process.We analyzed semi-structured interviews with key stakeholders (n = 23) from clinical observations (n = 5). We made three key adaptations to CFIR: (a) promoted "patient needs and resources," a subconstruct of the outer setting, to its own domain within CFIR during data analysis; (b) divided the "inner setting" domain into three layers that account for the hierarchy of health care systems (i. pilot clinic, ii. peer clinics, and iii. overarching health care system); and (c) tailored several construct definitions to fit a patient-centered, primary care setting. Analysis yielded qualitative findings concentrated in the CFIR domains "intervention characteristics" and "outer setting," with a robust number of findings in the new domain "patient needs and resources."To make CFIR more accessible and relevant for wider use in the context of patient-centered care transformations within a learning health system, a few adaptations are key. Specifically, we found success by teasing apart interactions across the inner layers of a health system, tailoring construct definitions, and placing additional focus on patient needs.
View details for DOI 10.1002/lrh2.10201
View details for PubMedID 31989028
View details for PubMedCentralID PMC6971122
Current evaluation methods are mismatched with the speed of health care innovation and needs of health care delivery partners. We introduce a qualitative approach called the lightning report method and its specific product-the "Lightning Report." We compare implementation evaluation results across four projects to explore report sensitivity and the potential depth and breadth of lightning report method findings.The lightning report method was refined over 2.5 years across four projects: team-based primary care, cancer center transformation, precision health in primary care, and a national life-sustaining decisions initiative. The novelty of the lightning report method is the application of Plus/Delta/Insight debriefing to dynamic implementation evaluation. This analytic structure captures Plus ("what works"), Delta ("what needs to be changed"), and Insights (participant or evaluator insights, ideas, and recommendations). We used structured coding based on implementation science barriers and facilitators outlined in the Consolidated Framework for Implementation Research (CFIR) applied to 17 Lightning Reports from four projects.Health care partners reported that Lighting Reports were valuable, easy to understand, and they implied reports supported "corrective action" for implementations. Comparative analysis revealed cross-project emphasis on the domains of Inner Setting and Intervention Characteristics, with themes of communication, resources/staffing, feedback/reflection, alignment with simultaneous interventions and traditional care, and team cohesion. In three of the four assessed projects, the largest proportion of coding was to the clinic-level domain of Inner Setting-ranging from 39% for the cancer center project to a high of 56% for the life-sustaining decisions project.The lightning report method can fill a gap in rapid qualitative approaches and is generalizable with consistent but flexible core methods. Comparative analysis suggests it is a sensitive tool, capable of uncovering differences and insights in implementation across projects. The Lightning Report facilitates partnered evaluation and communication with stakeholders by providing real-time, actionable insights in dynamic health care implementations.
View details for DOI 10.1002/lrh2.10210
View details for PubMedID 32313836
View details for PubMedCentralID PMC7156867
Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n?=?27 encounters); and qualitative interviews with physicians (n?=?10), patients (n?=?27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n?=?30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their "top 5" practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.The systematic literature review (n?=?73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient's story (consider life circumstances that influence the patient's health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient's emotions).This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.
View details for DOI 10.1001/jama.2019.19003
View details for PubMedID 31910284
Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient-provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience).We sourced data from PubMed, EMBASE, and PsycInfo (January 1997-August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient-provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider-patient dyad), and quadruple aim outcomes.Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands.Simple, low-demand patient-provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.
View details for DOI 10.1007/s11606-019-05525-2
View details for PubMedID 31919725
View details for DOI 10.1007/s11606-020-06219-w
View details for PubMedID 32935312
The Veterans Health Administration (VA) National Center for Ethics in Healthcare (NCEHC) implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI) including policy and practice standards, clinician communication training, a documentation template, and central implementation support to foster advance care planning (ACP) via goals of care conversations for seriously ill Veterans in 2014, spreading nationally to other Veterans Health Affairs (VA) sites in 2017.We conducted semi-structured interviews with 31 key stakeholders from 11 sites to identify cross-site best practices and pitfalls related to implementation.Three primary implementation themes emerged: organizational readiness for transformation, importance of champions, and time and resources needed to achieve implementation. Each theme's barriers and facilitators highlighted variability in success based on complexity in terms of vertical hierarchy and horizontal cross-role/cross-clinic relationships.Learning healthcare systems need multi-level interdisciplinary implementation approaches to support communication about serious illness, from broad-based system-level training and education in order to build communication skills, to focusing on characteristics of successful individual champions who listen to critics and are tenacious in addressing concerns.This study of a national implementation of ACP demonstrates that the route to success is variable, with flexible core components of leaders/advisors, champions, and resources that can be instantiated at various levels in a highly complex organization.
View details for DOI 10.1016/j.jpainsymman.2020.07.040
View details for PubMedID 32781166
Telemedicine has been used for decades; yet, despite its many advantages, its uptake and rigorous evaluation of feasibility across neurology's ambulatory subspecialties has been sparse. The SARS-CoV-2 (COVID-19) pandemic however, prompted healthcare systems worldwide to reconsider traditional healthcare delivery. To safeguard healthcare workers and patients many healthcare systems quickly transitioned to telemedicine, including across neurology subspecialties, providing a new opportunity to evaluate this modality of care.To evaluate the accelerated implementation of video visits in ambulatory neurology during the COVID-19 pandemic, we used mixed methods to assess the adoption, acceptability, appropriateness, and perceptions of potential sustainability.Video visits were launched rapidly in ambulatory neurology clinics of a large academic medical center. To assess adoption, we analyzed clinician-level scheduling data collected between March 22 and May 16, 2020. We assessed acceptability, appropriateness, and sustainability via a clinician survey (n=48) and semi-structured interviews with providers (n=30) completed between March and May 2020.Video visits were adopted rapidly; 65 (98%) clinicians integrated video visits into their workflow within the first 6 implementation weeks and 92% of all visits were conducted via video. Video visits were largely considered acceptable by clinicians, although various technological issues impacted satisfaction. Video visits were reported to be more convenient for patients, families, and/or caregivers than in-person visits; however, access to technology, the patient's technological capacity, and language difficulties were considered barriers. Many clinicians expressed optimism about future utilization of video visits in neurology. They believed that video visits promote continuity of care and can be incorporated into their practice long-term, although several insisted that they can never replace the in-person examination.Video visits are an important addition to clinical care in ambulatory neurology and are anticipated to remain a permanent supplement to in-person visits, promoting patient care continuity, and flexibility for patients and clinicians alike.
View details for DOI 10.2196/24328
View details for PubMedID 33245699
Prior to national spread, the Department of Veterans Affairs implemented a pilot of the life-sustaining treatment decisions initiative (LSTDI) to promote proactive goals of care conversations (GoCC) with seriously ill patients, including policy and practice standards, an electronic documentation template and order set, and implementation support.To describe a 2-year pilot of the LSTDI at 4 demonstration sites.Prospective observational study.A total of 6664 patients who had at least one GoCC.Descriptive statistics characterized patient demographics, goals of care, LST decisions, and risk of hospitalization or mortality among patients with at least one GoCC. Participants were on average 71.4 years old, 93.2% male, 87.1% white, and 64.7% urban; 27.3% died by the end of the pilot period. Fifteen percent lacked decision-making capacity (DMC). Nonmutually exclusive goals included to be cured (7.6%), to prolong life (34%), to improve/maintain quality of life (61.5%), to be comfortable (53%), to obtain support for family/caregiver (8.4%), to achieve life goals (2.1%), and other (10.5%). Many GoCCs resulted in a do not resuscitate (DNR) order (58.8%). Patients without DMC were more likely to have comfort-oriented goals (77.3% vs 48.8%) and a DNR (84% vs 52.6%). Chart abstraction supported content validity of GoCC documentation.The pilot demonstrated that standardizing practices for eliciting and documenting GoCCs resulted in customized documentation of goals of care and LST decisions of a large number of seriously ill patients and established the feasibility of spreading standardized practices throughout a large integrated health care system.
View details for DOI 10.1177/1049909120923595
View details for PubMedID 32383388
Research has documented higher smoking prevalence with unemployment and greater difficulty with gaining re-employment for those who smoke. Using photo elicitation methods, we sought to gain a deeper understanding of the connection between job-seeking and tobacco use.Unemployed daily smokers (18 men, 1 woman) were recruited from the San Francisco Employment Development Department (EDD) and provided disposable cameras with 27 exposures and a list of 20 photo prompts related to job-seeking and tobacco. Study staff reviewed the photos with the participants and audio-recorded their narratives. The photos and narratives were coded for themes.Of 363 photos, the most frequent photo imagery related to transportation (n?=?56, 15.4%), work or education (n?=?39, 10.7%), and littered cigarettes (n?=?39, 10.7%). Narrated themes centered on motivators to quit smoking (255 mentions from 15 participants); people, places, and things associated with smoking (248 mentions, 16 participants); and motivators to secure work (157 mentions, 13 participants). The intersection of smoking and unemployment received 92 mentions from 11 participants, with 60 mentions (8 participants) identifying smoking as a barrier to re-employment.Both motivators to quit and associated smoking cues were salient in the environments of job-seeking smokers. Struggles with quitting and perceptions that smoking is harming re-employment success suggest the potential for offering tobacco treatment in EDD settings. With permission, the photos and themes have been incorporated into a tobacco treatment intervention for job-seeking smokers.
View details for DOI 10.1177/1179173X20921446
View details for PubMedID 32669882
View details for PubMedCentralID PMC7338730
View details for DOI 10.1002/lrh2.10210
View details for Web of Science ID 000503760600001
PURPOSE: Patients with cancer face daunting coordination problems at a vulnerable time. Lay navigation programs offer 1 approach to address these problems, but how to best implement these programs presents challenges. We sought to describe those implementation challenges at 1 academic cancer center to inform future efforts.METHODS: We performed a mixed methods study using standard implementation outcomes 1 year after program initiation. Quantitative data from the electronic medical record and qualitative data from in-depth interviews, focus groups, and ethnographic observations were included in analyses. The study took place at a National Cancer Institute-designated comprehensive cancer center across 12 tumor-specific clinics.RESULTS: Supportive care concerns, scheduling, and clinical-related issues were the most frequent issues navigators encountered. Effective navigation required continuous, time-consuming, invisible work, including building and maintaining a broad knowledge base of resources and health system processes, as well as cultivating relationships with diverse and changing clinical teams. The acceptability and appropriateness of lay navigator activities were mixed among clinic and social work staff, related to negotiating lines between clinical and nonclinical care.CONCLUSION: After 1 year of implementation, lay navigators still found it difficult to interpret and prioritize complex patient needs in a way that all clinical staff found appropriate. Negotiating these issues has made it difficult to develop the strong relationships with clinical teams that are needed for an integrated approach to patient care. To successfully coordinate patient care, it seems that lay navigation programs should be integrated with clinical teams to provide more seamless patient care.
View details for DOI 10.1200/JOP.19.00339
View details for PubMedID 31693450
View details for DOI 10.1002/lrh2.10201
View details for Web of Science ID 000487784900001
Purpose: Implementing team-based care into existing primary care is challenging; understanding facilitators and barriers to implementation is critical. We assessed adoption and acceptability of new roles in the first 6months of launching a team-based care model focused on preventive care, population health, and psychosocial support.Methods: We conducted qualitative rapid ethnography at a community-based test clinic, including 74hours of observations and 28 semi-structured interviews. We identified implementation themes related to team-based care and specifically the integration of three roles purposively designed to enhance coordination for better patient outcomes, including preventive screening and mental health: (1) medical assistants as care coordinators; (2) extended care team specialists, including clinical pharmacist and behavioral health professional; and (3) advanced practice providers (APPs)-ie, nurse practitioners and physician assistants.Results: All stakeholders (ie, patients, providers, and staff) reported positive perceptions of care coordinators and extended care specialists; these roles were well defined and quickly implemented. Care coordinators effectively managed care between visits and established strong patient relationships. Specialist colocation facilitated patient access and well-supported diabetes services and mental health care. We also observed unanticipated value: Care coordinators relayed encounter-relevant chart information to providers while scribing; extended care specialists supported informal continuing medical education. In contrast, we observed uncertain definition and expectations of the APP role across stakeholders; accordingly, adoption and acceptability of the role varied.Conclusions: Practice redesign can redistribute responsibility and patient connection throughout a team but should emphasize well-defined roles. Ethnography, conducted early in implementation with multistakeholder perspectives, can provide rapid and actionable insights about where roles may need refinement or redefinition to support ultimate physical and mental health outcomes for patients.
View details for DOI 10.1002/lrh2.10188
View details for PubMedID 31317071
View details for DOI 10.1177/1062860618802365
View details for Web of Science ID 000476540300004
View details for Web of Science ID 000456406900215
Patients are asking health care providers about e-cigarettes, vaping, and other electronic nicotine delivery systems (ENDS). Provider advice on ENDS has varied greatly, suggesting a need for evidence-based continuing medical education (CME).A novel free online CME course was developed on ENDS risks and benefits, product types (e.g., vape pens, pods), and screening and counseling best practices for adults, adolescents, and different smoker profiles (e.g., daily, social).From January 2017 through June 2018, 1061 individuals accessed the course: 46% physicians, 7% physician assistants, 7% nurse practitioners, 15% nurses, 4% pharmacists, and 28% allied health/student/other; 41% were international.The course was built from observed online patient-provider interactions. Through video role-plays, expert interviews, and interactive activities, the course engaged learners in the evidence on ENDS. Completers earned 1.5 CME units.A total of 555 health care providers earned 832.5 CME units. Pre- to post-test scores significantly increased from 57 to 90%; 76% rated the course as above average (41%) or outstanding (35%); 99% indicated the course was free of commercial bias.Addressing the growing need for balanced provider education on ENDS, this interactive online CME engaged learners and increased knowledge on devices and evidence-based cessation approaches.
View details for DOI 10.1007/s11606-019-05388-7
View details for PubMedID 31630366
While barriers to physician wellness have been well detailed, concrete solutions are lacking.We looked to professionals across diverse fields whose work requires engagement and interpersonal connection with clients. The goal was to identify effective strategies from non-medical fields that could be applied to preserve physician wellness.We conducted semi-structured interviews with 30 professionals outside the field of clinical medicine whose work involves fostering effective connections with individuals.Professionals from diverse professions, including the protective services (e.g., police officer, firefighter), business/finance (e.g., restaurateur, salesperson), management (e.g., CEO, school principal), education, art/design/entertainment (e.g., professional musician, documentary filmmaker), community/social services (e.g., social worker, chaplain), and personal care/services (e.g., massage therapist, yoga instructor).Interviews covered strategies that professionals use to initiate and maintain relationships, practices that cultivate professional fulfillment and preserve wellness, and techniques that facilitate emotional presence during interactions. Data were coded using an inductive thematic analysis approach.Professionals identified self-care strategies at both institutional and individual levels that support wellness. Institutional-level strategies include scheduling that allows for self-care, protected time to connect with colleagues, and leadership support for debriefing after traumatic events. Individual strategies include emotionally protective distancing techniques and engagement in a bidirectional exchange that is central to interpersonal connection and professional fulfillment.In this exploratory study, the purposive sampling technique and single representative per occupation could limit the generalizability of findings.Across diverse fields, professionals employ common institutional and personal wellness strategies that facilitate meaningful engagement, support collegiality, and encourage processing after intense events. The transdisciplinary nature of these wellness strategies highlights universal underpinnings that support wellbeing in those engaging in people-oriented professions.
View details for PubMedID 31037542
While barriers to physician wellness have been well detailed, concrete solutions are lacking.We looked to professionals across diverse fields whose work requires engagement and interpersonal connection with clients. The goal was to identify effective strategies from non-medical fields that could be applied to preserve physician wellness.We conducted semi-structured interviews with 30 professionals outside the field of clinical medicine whose work involves fostering effective connections with individuals.Professionals from diverse professions, including the protective services (e.g., police officer, firefighter), business/finance (e.g., restaurateur, salesperson), management (e.g., CEO, school principal), education, art/design/entertainment (e.g., professional musician, documentary filmmaker), community/social services (e.g., social worker, chaplain), and personal care/services (e.g., massage therapist, yoga instructor).Interviews covered strategies that professionals use to initiate and maintain relationships, practices that cultivate professional fulfillment and preserve wellness, and techniques that facilitate emotional presence during interactions. Data were coded using an inductive thematic analysis approach.Professionals identified self-care strategies at both institutional and individual levels that support wellness. Institutional-level strategies include scheduling that allows for self-care, protected time to connect with colleagues, and leadership support for debriefing after traumatic events. Individual strategies include emotionally protective distancing techniques and engagement in a bidirectional exchange that is central to interpersonal connection and professional fulfillment.In this exploratory study, the purposive sampling technique and single representative per occupation could limit the generalizability of findings.Across diverse fields, professionals employ common institutional and personal wellness strategies that facilitate meaningful engagement, support collegiality, and encourage processing after intense events. The transdisciplinary nature of these wellness strategies highlights universal underpinnings that support wellbeing in those engaging in people-oriented professions.
View details for DOI 10.1007/s11606-019-04913-y
View details for DOI 10.1200/JCO.2018.36.34_suppl.180
View details for Web of Science ID 000464876100171
A new transformational model of primary care is needed to address patient care complexity and provider burnout. An 18-month design effort (2015-2016) included the following: (1) Needs Finding, (2) Integrated Facility Design, (3) Design Process Assessment, and (4) Development of Evaluation. Initial outcome metrics were assessed. The design team successfully applied Integrated Facility Design to primary care transformation design; qualitative survey results suggest that design consensus was facilitated by team-building activities. Initial implementation of Quadruple Aim-related outcome metrics showed positive trends. Redesign processes may benefit from emphasis on team building to facilitate consensus and increased patient involvement to incorporate patient voices successfully.
View details for PubMedID 30409021
View details for Web of Science ID 000442641400264
BACKGROUND: Modern technology (ie, websites and social media) has significantly changed social mores in health information access and delivery. Although mass media campaigns for health intervention have proven effective and cost-effective in changing health behavior at a population scale, this is best studied in traditional media sources (ie, radio and television). Digital health interventions are options that use short message service/text messaging, social media, and internet technology. Although exposure to these products is becoming ubiquitous, electronic health information is novel, incompletely disseminated, and frequently inaccurate, which decreases public trust. Previous research has shown that audience trust in health care providers significantly moderates health outcomes, demographics significantly influence audience trust in electronic media, and preexisting health behaviors such as smoking status significantly moderate audience receptivity to traditional mass media. Therefore, modern health educators must assess audience trust in all sources, both media (traditional and digital) and interpersonal, to balance pros and cons before structuring multicomponent community health interventions.OBJECTIVE: We aimed to explore current trust and moderators of trust in health information sources given recent changes in digital health information access and delivery to inform design of future health interventions in Oklahoma.METHODS: We conducted phone surveys of a cross-sectional sample of 1001 Oklahoma adults (age 18-65 years) in spring 2015 to assess trust in seven media sources: traditional (television and radio), electronic (online and social media), and interpersonal (providers, insurers, and family/friends). We also gathered information on known moderators of trust (sociodemographics and tobacco use status). We modeled log odds of a participant rating a source as "trustworthy" (SAS PROC SURVEYLOGISTIC), with subanalysis for confounders (sociodemographics and tobacco use).RESULTS: Oklahomans showed the highest trust in interpersonal sources: 81% (808/994) reported providers were trustworthy, 55% (550/999) for friends and family, and 48% (485/998) for health insurers. For media sources, 24% of participants (232/989) rated the internet as trustworthy, followed by 21% of participants for television (225/998), 18% for radio (199/988), and only 11% for social media (110/991). Despite this low self-reported trust in social media, 40% (406/991) of participants reported using social media for tobacco-related health information. Trust in health providers did not vary by subpopulation, but sociodemographic variables (gender, income, and education) and tobacco use status significantly moderated trust in other sources. Women were on the whole more trusting than men, trust in media decreased with income, and trust in friends and family decreased with education.CONCLUSIONS: Health education interventions should incorporate digital media, particularly when targeting low-income populations. Utilizing health care providers in social media settings could leverage high-trust and low-cost features of providers and social media, respectively.
View details for DOI 10.2196/publichealth.6260
View details for PubMedID 29434015
Latinos are the largest minority group in the United States, and in California they outnumber non-Hispanic whites. Smoking cessation programs tailored for Latino culture, and this population's specific smoking patterns, are needed. Online social networks for smoking cessation have high potential for Latinos, but have not been tested to date.Building a research program on social media apps for cancer prevention in diverse populations, this qualitative study assessed acceptability of tobacco treatment that was distributed via social media for Latino smokers.We conducted three focus groups with Latino adults who were former and current smokers recruited from Santa Clara County, California in 2015 (N=32). We assessed participants' smoking histories, attempts to quit, social media exposure, and receptivity to a social media-based smoking cessation intervention. Audio transcripts were translated and coded for themes.Participants reported factors driving their tobacco use and motivations to quit, and emphasized the importance of community and family in influencing their smoking initiation, cravings and triggers, attempts to quit, and abstinence. Participants valued the communal aspect of social media and suggested strategically tailoring groups based on key features (eg, age, gender, language preference). Participants reported preferring visual, educational, and motivational messages that were connected with existing services.Participants generally voiced acceptability of a social media-delivered intervention to help them quit smoking, viewed the intervention as well-equipped for catering to the strong community orientation of Latinos, and suggested that the platform was able to address variation within the population through strategic group creation. As a group member reflected, "Podemos hacerlo juntos" (We can do it together).
View details for DOI 10.2196/mhealth.6684
View details for PubMedID 28179217
View details for PubMedCentralID PMC5322200
With attention to the rapidly growing market of electronic nicotine delivery systems (ENDS/e-cigarettes) and the fastest growing US ethnic minority group, the current study explored associations between awareness, perceived risks, and use of ENDS among Asian American and Pacific Islander (AAPI) young adults. AAPI young adults (ages 18-25) in California were recruited via social media, college classes, listservs for AAPI-serving non-profits, and snowball sampling to complete an anonymous survey between 2014 and 2015. The sample (N = 501) was 57% women, 15% LGBTQIA; with a mean age of 21; 26% foreign-born; identifying as Filipino (29%), Chinese (24%), Vietnamese (14%), mixed-AAPI heritage (13%), or 21% other. Nearly half the sample (44%) reported ever ENDS use; 11% were current users. Current ENDS use was twofold greater for: Filipino and Vietnamese compared to Chinese respondents; men versus women; LGBTQIA-identified respondents; those vocationally trained; and employed. Awareness of ENDS from peers/friends was most common and was associated with ever though not current ENDS use. Most respondents perceived ENDS as harmful (62%); low compared to high risk perception was associated with a three-fold greater likelihood of ever use and six-fold greater likelihood of current use. Popular flavors were fruit (49%, e.g., lychee, taro) and candy/sweets (26%). Current users viewed ENDS as a healthier alternative or quit aid for conventional cigarettes (42%); recreation/social use (33%) also was common. Findings indicate ENDS visibility among AAPI young adults in California with affinity for flavors and many engaging in trial and current use for harm reduction and recreational/social aims.
View details for DOI 10.1016/j.pmedr.2016.05.011
View details for PubMedID 27413658
View details for PubMedCentralID PMC4929057
E-cigarettes are popular and unregulated. Patient-provider communications concerning e-cigarettes were characterized to identify patient concerns, provider advice and attitudes, and research needs.An observational study of online patient-provider communications was conducted January 2011-June 2015 from a network providing free medical advice, and analyzed July 2014-May 2016. Patient and provider themes, and provider attitudes toward e-cigarettes (positive, negative, or neutral) were coded qualitatively. Provider attitudes were analyzed with cumulative logit modeling to account for clustering. Patient satisfaction with provider responses was expressed via a Thank function.An increase in e-cigarette-related questions was observed over time. Patient questions (N=512) primarily concerned specific side effects and harms (34%); general safety (27%); e-cigarettes as quit aids (19%); comparison of e-cigarette harms relative to combusted tobacco (18%); use with pre-existing medical conditions (18%); and nicotine-free e-cigarettes (14%). Half of provider responses discussed e-cigarettes as a harm reduction option (48%); 26% discussed them as quit aids. Overall, 47% of providers' responses represented a negative attitude toward e-cigarettes; 33% were neutral (contradictory or non-committal); and 20% were positive. Attitudes did not differ statistically by medical specialty; provider responses positive toward e-cigarettes received significantly more Thanks.Examination of online patient-provider communications provides insight into consumer health experience with emerging alternative tobacco products. Patient concerns largely related to harms and safety, and patients preferred provider responses positively inclined toward e-cigarettes. Lacking conclusive evidence of e-cigarette safety or efficacy, healthcare providers encouraged smoking cessation and recommended first-line cessation treatment approaches.
View details for DOI 10.1016/j.amepre.2016.06.018
View details for PubMedID 27576005
View details for PubMedCentralID PMC5118131
There is an emerging standard to provide patients rapid electronic access to elements of their medical records. Although surveys of patients generally support it, this practice is controversial among oncologists, because few empiric data are available for scenarios of potentially life-threatening conditions like cancer. We report the views of oncologists about patient electronic access to radiology and pathology results that could potentially indicate disease progression.Four months before oncologists were surveyed, final results of radiology/pathology reports were routinely made available to patients online through a secure portal after a 7-day, hold to provide clinicians time to review and communicate results with the patients. Mixed methods were used to assess physician attitudes and experiences toward this change.One hundred twenty-nine oncologists were surveyed, and 82 (64%) responded. A small majority (54%) responded that the release of reports was somewhat or very beneficial for patients who received normal radiology/pathology results before discussion with a physician, but 87% said it was somewhat or very harmful for patients to receive abnormal results before discussion. Forty-nine percent reported that release of reports had a somewhat or very negative impact on communication with their patients.Almost half of oncologists reported that sharing digital radiology and pathology records had a negative impact on their communication with patients. Patient surveys in similar cancer populations would complement the physician perspective. Efforts are needed to improve consensus among oncologists and patients on how to best communicate such results in a timely fashion.
View details for DOI 10.1200/JOP.2016.011098
View details for PubMedID 27382001
Investigate smoking stigma among different tobacco user types.US adults (N=1,812) responded to an online survey, including non-smokers, smokeless tobacco users, exclusive smokers, and smokeless and cigarette "dual users".Dual users perceived the highest smoking stigma. Stigma was higher for smokers open to quitting by switching to smokeless. E-cigarette users (smokers) reported higher stigma than non-users. Making a past-year quit attempt was predicted by smoking stigma, and smokeless and/or e-cigarette use.Smoking stigma and dual use of smokeless tobacco and/or e-cigarettes with cigarettes predict quit attempts. However, smoking stigma might prevent smokers from consulting doctors and induce use of alternative tobacco products as cessation aids.
View details for PubMedID 27088103
View details for PubMedCentralID PMC4829360
We examined the understanding of the harms of secondhand smoke (SHS) exposure among low-income, hospitalized adults with cardiovascular disease. Participants were 15 nonsmokers reporting daily SHS exposure and 15 light or nondaily cigarette smokers. We coded responses from audiotaped semistructured interviews for themes. No participant spontaneously identified heart risks related to SHS exposure. Strategies to avoid SHS included verbal requests to not smoke and physically avoiding smoke; both smokers and nonsmokers prioritized politeness over urgency. Most participants thought a blood test quantifying SHS exposure would be clinically useful. Health education, assertiveness communication training, and protective policies (eg, smoke-free multiunit housing) also were supported.
View details for DOI 10.5888/pcd13.150593
View details for PubMedID 27560724
View details for PubMedCentralID PMC5003531
De-normalization of smoking as a public health strategy may create shame and isolation in vulnerable groups unable to quit. To examine the nature and impact of smoking stigma, we developed the Internalized Stigma of Smoking Inventory (ISSI), tested its validity and reliability, and explored factors that may contribute to smoking stigma.We evaluated the ISSI in a sample of smokers with mental health diagnoses (N?=?956), using exploratory and confirmatory factor analysis, and assessed construct validity.Results reduced the ISSI to eight items with three subscales: smoking self-stigma related to shame, felt stigma related to social isolation, and discrimination experiences. Discrimination was the most commonly endorsed of the three subscales. A multivariate generalized linear model predicted 21-30% of the variance in the smoking stigma subscales. Self-stigma was greatest among those intending to quit; felt stigma was highest among those experiencing stigma in other domains, namely ethnicity and mental illness-based; and smoking-related discrimination was highest among women, Caucasians, and those with more education.Smoking stigma may compound stigma experiences in other areas. Aspects of smoking stigma in the domains of shame, isolation, and discrimination were related to modeled stigma responses, particularly readiness to quit and cigarette addiction, and were found to be more salient for groups where tobacco use is least prevalent.The ISSI measure is useful for quantifying smoking-related stigma in multiple domains. (Am J Addict 2015;24:410 -418).
View details for DOI 10.1111/ajad.12215
View details for Web of Science ID 000358620400006
Social media, such as Twitter, have become major channels of communication and commentary on popular culture, including conversations on our nation's leading addiction: tobacco. The current study examined Twitter conversations following two tobacco-related events in the media: (1) President Obama's doctor announcing that he had quit smoking and (2) the release of a photograph of Miley Cyrus (a former Disney child star) smoking a cigarette. With a focus on high-profile individuals whose actions can draw public attention, we aimed to characterise tobacco-related conversations as an example of tobacco-related public discourse and to present a novel methodology for studying social media.Tweets were collected 11-13 November 2011 (President Obama) and 1-3 August 2011 (Miley Cyrus) and analysed for relative frequency of terms, a novel application of a linguistic methodology.The President Obama data set (N=2749 tweets) had conversations about him quitting tobacco as well as a preponderance of information on political activity, links to websites, racialised terms and mention of marijuana. Websites and terms about Obama's smoke-free status were most central to the conversation. In the Miley Cyrus data (N=4746 tweets), terms that occurred with the greatest relative frequency were positive, emotional and supportive of quitting (eg, love, and please), with words such as 'love' most central to the conversation.People are talking about tobacco-related issues on Twitter, and semantic network analysis can be used to characterise on-line conversations. Future interventions may be able to harness social media and major current events to raise awareness of smoking-related issues.
View details for DOI 10.1136/tobaccocontrol-2013-051243
View details for Web of Science ID 000350337500013
View details for PubMedID 24227540
View details for PubMedCentralID PMC4103964
To test the feasibility and usability of mHealth TLC, an interactive, immersive 3-dimensional iPad health game that coaches lung cancer patients toward assertive communication strategies during first-person virtual clinics visits.We observed players and conducted semi-structured interviews. Research questions focused on scenario believability, the impact of technical issues, transparency of game goals, and potential of mHealth TLC to decrease lung cancer stigma (LCS) and improve patient-clinician communication.Eight users confirmed mHealth TLC to be: (1) believable, (2) clinic-appropriate, and (3) helpful in support of informed healthcare consumers. Concerns were expressed about emotionally charged content and plans to use mHealth TLC in clinic settings as opposed to at home.Although the dialog and interactions addressed emotionally charged issues, players were able to engage, learn, and benefit from role-play in a virtual world. Health games have the potential to improve patient-clinician communication, and mHealth TLC specifically may decrease LCS, and promote optimal self-management.Process reflection revealed the need for health games to be created by experienced game developers in collaboration with health care experts. To prepare for this best practice, research institutions and game developers interested in health games should proactively seek out networking and collaboration opportunities.
View details for PubMedID 25620075
View details for PubMedCentralID PMC4451946
De-normalization of smoking as a public health strategy may create shame and isolation in vulnerable groups unable to quit. To examine the nature and impact of smoking stigma, we developed the Internalized Stigma of Smoking Inventory (ISSI), tested its validity and reliability, and explored factors that may contribute to smoking stigma.We evaluated the ISSI in a sample of smokers with mental health diagnoses (N?=?956), using exploratory and confirmatory factor analysis, and assessed construct validity.Results reduced the ISSI to eight items with three subscales: smoking self-stigma related to shame, felt stigma related to social isolation, and discrimination experiences. Discrimination was the most commonly endorsed of the three subscales. A multivariate generalized linear model predicted 21-30% of the variance in the smoking stigma subscales. Self-stigma was greatest among those intending to quit; felt stigma was highest among those experiencing stigma in other domains, namely ethnicity and mental illness-based; and smoking-related discrimination was highest among women, Caucasians, and those with more education.Smoking stigma may compound stigma experiences in other areas. Aspects of smoking stigma in the domains of shame, isolation, and discrimination were related to modeled stigma responses, particularly readiness to quit and cigarette addiction, and were found to be more salient for groups where tobacco use is least prevalent.The ISSI measure is useful for quantifying smoking-related stigma in multiple domains. (Am J Addict 2015;24:410 -418).
View details for PubMedID 25930661
View details for PubMedID 26293382
View details for DOI 10.1136/oemed-2014-102145
View details for PubMedID 24759972