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Zoran Bursac

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King's College London

Vladimir Janković

The University of Manchester

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Papers by Zoran Bursac

The comparative effectiveness of two brief tobacco interventions in the U.S. Air Force: Perceived harm and intentions-to-use of tobacco products

Tobacco Induced Diseases, 2018

INTRODUCTION Tobacco use causes 480 000 deaths each year in the United States 1. It increases the... more INTRODUCTION Tobacco use causes 480 000 deaths each year in the United States 1. It increases the risk of coronary heart disease and stroke up to 4 times, and lung cancer by a staggering 25 times 1,2. Young adults (age 18-25 years) are at high risk for tobacco use due to targeting by tobacco companies 3. In 2013, 37% of 18-25 year olds used some form of tobacco in the past month, compared to 7.8% of 12-17 year olds and 25.7% of 26 years old and older 4. Young adults comprise the largest age demographic in the US military 5. Tobacco prevalence rates are

Lessons Learned From Miami-Dade County's COVID-19 Epidemic: Making Surveillance Data Accessible for Policy Makers

Journal of Public Health Management and Practice, 2021

Introduction: COVID-19 represents an unprecedented challenge to policy makers as well as those en... more Introduction: COVID-19 represents an unprecedented challenge to policy makers as well as those entrusted with capturing, monitoring, and analyzing COVID-19 data. Effective public policy is data-informed policy. This requires a liaison between public health scientists and public officials. Objective: This article details the experience, challenges, and lessons learned advising public officials in a large metropolitan area from March to October 2020. Methods: To effectively do this, an R Markdown report was created to iteratively monitor the number of COVID-19 tests performed, positive tests obtained, COVID-19 hospitalization census, intensive care unit census, the number of patients with COVID-19 on ventilators, and the number of deaths due to COVID-19. Results: These reports were presented and discussed at meetings with policy makers to further comprehension. Discussion: To facilitate the fullest understanding by both the general public and policy makers alike, we advocate for greater centralization of public health surveillance data, objective operational definitions of metrics, and greater interagency communication to best guide and inform policy makers. Through consistent data reporting methods, parsimonious and consistent analytic methods, a clear line of communication with policy makers, transparency, and the ability to navigate unforeseen externalities such as “data dumps” and reporting delays, scientists can use information to best support policy makers in times of crises.

Running Title: Motivational Interviewing and Obesity Treatment

OBJECTIVE-We sought to determine whether adding motivational interviewing to a behavioral weight ... more OBJECTIVE-We sought to determine whether adding motivational interviewing to a behavioral weight control program improves weight loss outcomes and glycemic control for overweight women with type 2 diabetes. RESEARCH DESIGN AND METHODS-We conducted a randomized, controlled, clinical trial in which participants all received an 18-month, group-based behavioral obesity treatment and were randomized to individual sessions of motivational interviewing or attention control (total of five sessions) as an adjunct to the weight control program. Overweight women with type 2 diabetes treated by oral medications who could walk for exercise were eligible. Primary outcomes were weight and A1C, assessed at 0, 6, 12, and 18 months. RESULTS-A total of 217 overweight women (38% African American) were randomized (93% retention rate). Women in motivational interviewing lost significantly more weight at 6 months (P ϭ 0.01) and 18 months (P ϭ 0.04). Increased weight losses with motivational interviewing were mediated by enhanced adherence to the behavioral weight control program. African-American women lost less weight than white women overall and appeared to have a diminished benefit from the addition of motivational interviewing. Significantly greater A1C reductions were observed in those undergoing motivational interviewing at 6 months (P ϭ 0.02) but not at 18 months. CONCLUSIONS-Motivational interviewing can be a beneficial adjunct to behavioral obesity treatment for women with type 2 diabetes, although the benefits may not be sustained among African-American women.

594: Cesarean section reduces the odds of morbidity and mortality among very low birthweight infants

American Journal of Obstetrics and Gynecology, 2018

exposure. Magnesium sulfate did not appear to protect from severe IVH (OR¼ 0.20; 95% CI 0.01-2.4;... more exposure. Magnesium sulfate did not appear to protect from severe IVH (OR¼ 0.20; 95% CI 0.01-2.4; p¼0.21). CONCLUSION: Maternal magnesium appears to be an independent predictor of survival from 12 hours after birth until discharge among neonates who are born weighing less than 500g. This is the first study that has found a survival benefit in these periviable birth weights.

BMI and related risk factors among U.S. Marshallese with diabetes and their families

Ethnicity & Health, 2019

Objective: Examine cross-sectional associations between body mass index (BMI) and related health ... more Objective: Examine cross-sectional associations between body mass index (BMI) and related health behaviors, barriers and facilitators to health care, and perceived health status among a sample of U.S. Marshallese adults with Type 2 diabetes and evaluate associations of interest between participants and their family members. Design: Cross-sectional baseline data were analyzed from participants in a diabetes self-management education intervention trial. Setting: Data collection took place in home or community settings through a community-academic partnership in Arkansas. Participants: Study participants consisted of U.S. Marshallese adults with Type 2 diabetes (N = 221) and their family members (N = 211) recruited through community settings. Intervention(s): N/A. Main Outcome Measure(s): Participants' height and weight were measured using standard protocols to calculate BMI (kg/m 2). Diet, physical activity, health care access, financial strain related to health care, perceived health status, and health care satisfaction were measured using self-report surveys. Results: Participants' mean BMI was 31.0 (95% CI: 30.2-31.7), with over half of study participants and their family members' BMI falling in the obese category. Participants' BMI was positively associated with spreading health care bill payments over time (β = 1.75 (SE = 0.87); p = 0.045). Positive associations between participants and their family members were observed for self-reported health status conditions, health care coverage, health care utilization, and health care satisfaction. Conclusion: Study findings highlight the high prevalence of obesity and related risk factors among U.S. Marshallese adults with Type 2 diabetes and emphasize the need for intervention strategies that ARTICLE HISTORY

How stakeholder engagement influenced a randomized comparative effectiveness trial testing two Diabetes Prevention Program interventions in a Marshallese Pacific Islander Community

Journal of Translational Medicine, 2019

Background: Marshallese face significant health disparities, with particularly high rates of type... more Background: Marshallese face significant health disparities, with particularly high rates of type 2 diabetes. Engaging stakeholders in the research process is essential to reduce health inequities. Methods: A community-and patient-engaged research approach was used to involve community Marshallese stakeholders in a randomized comparative effectiveness trial testing two Diabetes Prevention Program interventions. Results: The article outlines the engagement process and the specific influence that stakeholders had on the research planning and implementation, discussing the areas of agreement and disagreement between community and patient stakeholders and academic investigators and documenting changes to the research protocol. Conclusion: The article provides an example of methods that can be used to design and conduct a randomized controlled trial testing with a population who has been underrepresented in research and suffered significant historical trauma.

Fetal pulmonary artery acceleration/ejection time prognostic accuracy for respiratory complications in preterm prelabor rupture of membranes

The Journal of Maternal-Fetal & Neonatal Medicine, 2018

The Mediating Role of Sleep Quality and Quantity in the Link Between Food Insecurity and Obesity Across Race and Ethnicity

Obesity (Silver Spring, Md.), 2018

The objective of the study was to examine the mediating role of sleep quality and quantity in the... more The objective of the study was to examine the mediating role of sleep quality and quantity in the relationship between food insecurity and obesity across races/ethnicities. Bivariate negative binomial regression and multinomial logistic regression were used to examine direct associations between food insecurity and sleep quality and quantity among non-Hispanic Native Hawaiian and other Pacific Islanders (NHPI) relative to non-Hispanic White, Black, Asian, and Hispanic individuals with obesity. The potential outcomes approach and adjusted Wald test were used to explore the mediating role of sleep quality and quantity and the moderating role of race/ethnicity, respectively. Among adults with obesity, the study found a positive and direct relationship between food insecurity and trouble falling asleep in each racial/ethnic group. Trouble staying asleep was associated with food insecurity in each racial/ethnic group, except in the Asian group. Positive and direct associations were obser...

Fit & quit: An efficacy trial of two behavioral post-cessation weight gain interventions

Contemporary Clinical Trials, 2018

While smoking cessation leads to significant improvements in both mortality and morbidity, postce... more While smoking cessation leads to significant improvements in both mortality and morbidity, postcessation weight gain partially attenuates this benefit. Even though post-cessation weight gain is small (4.7 kg on average), it is a stated reason to delay cessation attempts and is associated with smoking relapse. Fit & Quit is a randomized, controlled efficacy trial that aims to examine the ability of a weight stability intervention and a weight loss intervention to reduce post-cessation weight gain. For this purpose, Fit & Quit will randomize participants to three conditions: (a) Small Changes, a weight gain prevention intervention; (b) Look AHEAD Intensive Lifestyle Intervention; and (c) a lower-intensity bibliotherapy intervention. All conditions will receive a highly efficacious behavioral (i.e., rate reduction skills, motivational interviewing) and pharmacological (i.e., varenicline) smoking cessation program. A total of 400 participants will be recruited and randomized to the three interventions. Participants will be recruited in waves, with 10 waves of approximately 40 participants per wave. The primary outcomes of this study include post-cessation weight gain and cessation status at 12-month follow-up. Fit & Quit will integrate and adapt the strongest evidence-based interventions available for weight management and smoking cessation. Fit & Quit is highly innovative in the areas of the target population, study design, and use of technology. For these reasons, we expect that Fit & Quit will make a significant public health contribution to curtailing the important cessation barrier of post-cessation weight gain.

Effect of Weight on Indwelling Catheter Use among Long-Term Care Facility Residents

Urologic Nursing, 2013

This study examined the effect of obesity on the use of indwelling urinary catheters among long-t... more

Frequency and predictors of health services use by Native Hawaiians and Pacific Islanders: evidence from the U.S. National Health Interview Survey

BMC health services research, Jan 21, 2018

Native Hawaiians and Pacific Islanders (NHPIs) are one of the fasting growing racial groups in th... more Native Hawaiians and Pacific Islanders (NHPIs) are one of the fasting growing racial groups in the United States (US). NHPIs have a significantly higher disease burden than the US population as a whole, yet they remain underrepresented in research. The purpose of this study is to examine factors associated with health care utilization among NHPIs. Drawing from the 2014 NHPI-National Health Interview Survey, we used stereotype logistic regressions to examine utilization of emergency department (ED) and outpatient services among 2172 individuals aged 18 and older. NHPIs with chronic diseases were twice as likely to be multiple ED users and nearly four times as likely to be frequent-users of outpatient services. Social support played a protective role in preventing multiple use of ED. Having a usual source of care made it more than eight times as likely to be a frequent-user of outpatient services. Use of eHealth information increased the odds of using ED and outpatient services. Abili...

Insurance coverage mandates: Impact of physician utilization in moderating colorectal cancer screening rates

American journal of surgery, Jan 2, 2018

Precision public health requires research that supports innovative systems and health delivery ap... more Precision public health requires research that supports innovative systems and health delivery approaches, programs, and policies that are part of this vision. This study estimated the effects of health insurance mandate (HiM) variations and the effects of physician utilization on moderating colorectal cancer (CRC) screening rates. A time-series analysis using a difference-in-difference-in-differences (DDD) approach was conducted on CRC screenings (1997-2014) using a multivariate logistic framework. Key variables of interest were HiM, CRC screening status, and physician utilization. The adjusted average marginal effects from the DDD model indicate that physician utilization increased the probability of being "up-to-date" vs. non-compliance by 9.9% points (p = 0.007), suggesting that an estimated 8.85 million additional age-eligible persons would receive a CRC screening with HiM and routine physician visits. Routine physician visits and mandates that lower out-of-pocket exp...

Design of a comparative effectiveness randomized controlled trial testing a faith-based Diabetes Prevention Program (WORD DPP) vs. a Pacific culturally adapted Diabetes Prevention Program (PILI DPP) for Marshallese in the United States

Medicine, 2018

Pacific Islander populations, including Marshallese, face a disproportionately high burden of hea... more Pacific Islander populations, including Marshallese, face a disproportionately high burden of health disparities relative to the general population. A community-based participatory research (CBPR) approach was utilized to engage Marshallese participants in a comparative effectiveness trial testing 2 Diabetes Prevention Program (DPP) interventions designed to reduce participant's weight, lower HbA1c, encourage healthy eating, and increase physical activity. To compare the effectiveness of the faith-based (WORD) DPP to the culturally adapted (Pacific Culturally Adapted Diabetes Prevention Program [PILI]) DPP, a clustered randomized controlled trial (RCT) with 384 Marshallese participants will be implemented in 32 churches located in Arkansas, Kansas, Missouri, and Oklahoma. Churches will be randomly assigned to WORD DPP arm or to PILI DPP arm. WORD DPP focuses on connecting faith and health to attain a healthy weight, eat healthy, and be more physically active. In contrast, PILI D...

Substance Use and Psychological Distress Before and After the Military to Civilian Transition

Military medicine, Jan 6, 2018

Those currently serving in the military constitute a vulnerable population given their high-risk ... more Those currently serving in the military constitute a vulnerable population given their high-risk status for substance use, and population data suggest that veterans continue to engage in significant substance use long after their military service ends. Recent research suggests that the separation transition from active duty to civilian life may be critical in terms of the future functioning of the veteran. We sought to explore substance use prevalence, as well as potential emotional distress among veterans by retrospectively assessing substance use during active duty and following separation to examine possible changes in use over this period. This study assessed substance use and emotional distress in veterans (N = 80; 90% male) across the military to civilian transition. Repeated measures tests indicated that endorsement of alcohol use, cigarette use, and prescription drug misuse was similar during active duty and post-separation, and marijuana and hard drug use endorsement increa...

Cost-related Nonadherence to Medication Treatment Plans: Native Hawaiian and Pacific Islander National Health Interview Survey, 2014

Medical care, Jan 9, 2018

Adherence to medication treatment plans is important for chronic disease (CD) management. Cost-re... more Adherence to medication treatment plans is important for chronic disease (CD) management. Cost-related nonadherence (CRN) puts patients at risk for complications. Native Hawaiians and Pacific Islanders (NHPI) suffer from high rates of CD and socioeconomic disparities that could increase CRN behaviors. Examine factors related to CRN to medication treatment plans within an understudied population. Using 2014 NHPI-National Health Interview Survey data, we examined CRN among a nationally representative sample of NHPI adults. Bonferroni-adjusted Wald test and multivariable logistic regression were performed to examine associations among financial burden-related factors, CD status, and CRN. Across CD status, NHPI engaged in CRN behaviors had, on an average, increased levels of perceived financial stress, financial insecurity with health care, and food insecurity compared with adults in the total NHPI population. Regression analysis indicated perceived financial stress [adjusted odds ratio...

The Effect of Prenatal Alcohol Exposure on Fetal Growth and Cardiovascular Parameters in a Baboon Model of Pregnancy

Reproductive sciences (Thousand Oaks, Calif.), Jul 1, 2017

Prenatal alcohol exposure often results in an array of fetal developmental abnormalities termed f... more Prenatal alcohol exposure often results in an array of fetal developmental abnormalities termed fetal alcohol spectrum disorders (FASDs). Despite the high prevalence of FASDs, the pathophysiology of fetal damage by alcohol remains poorly understood. One of the major obstacles in studying fetal development in response to alcohol exposure is the inability to standardize the amount, pattern of alcohol consumption, and peak blood alcohol levels in pregnant mothers. In the present study, we used Doppler ultrasonography to assess fetal growth and cardiovascular parameters in response to alcohol exposure in pregnant baboons. Baboons were subjected to gastric alcohol infusion 3 times during the second trimester equivalent to human pregnancy, with maternal blood alcohol levels reaching 80 mg/dL within 30 to 60 minutes following alcohol infusion. The control group received a drink that was isocaloric to the alcohol-containing one. Doppler ultrasonography was used for longitudinal assessment o...

Family Planning Provider Referral, Facilitation Behavior, and Patient Follow-up for Abnormal Pap Smears

Public Health Reports, 2009

Objectives. Family planning (FP) clinics are important access points for cervical cancer screenin... more Objectives. Family planning (FP) clinics are important access points for cervical cancer screening and referrals for follow-up care for abnormal Papanicolaou (Pap) smears for a substantial number of U.S. women. Because little is known about referral and facilitation practices in these clinics or client action based on referrals, we sought to determine FP provider referral and facilitation practices when seeing FP clients with abnormal Pap smear results, and FP client follow-up for abnormal Pap smears due to FP provider referrals. Methods. We conducted a mail survey of Medicaid-enrolled FP providers in Arkansas and Alabama, and conducted a telephone survey with a sample of FP clients of those providers responding to the provider survey. Results. Major provider factors associated with referral included rural location, health department and clinic institutional setting, large Title X practice/clinic size, and high FP clinic focus. Major factors associated with facilitation included rur...

Design of a randomized, controlled, comparative-effectiveness trial testing a Family Model of Diabetes Self-Management Education (DSME) vs. Standard DSME for Marshallese in the United States

Contemporary Clinical Trials Communications, 2017

Background: Type 2 diabetes (T2D) is a significant public health problem, with U.S. Pacific Islan... more Background: Type 2 diabetes (T2D) is a significant public health problem, with U.S. Pacific Islander communitiesdsuch as the Marshallesedbearing a disproportionate burden. Using a community-based participatory approach (CBPR) that engages the strong family-based social infrastructure characteristic of Marshallese communities is a promising way to manage T2D. Objectives: Led by a collaborative community-academic partnership, the Family Model of Diabetes Self-Management Education (DSME) aimed to change diabetes management behaviors to improve glycemic control in Marshallese adults with T2D by engaging the entire family. Design: To test the Family Model of DSME, a randomized, controlled, comparative effectiveness trial with 240 primary participants was implemented. Half of the primary participants were randomly assigned to the Standard DSME and half were randomly assigned to the Family Model DSME. Both arms received ten hours of content comprised of 6e8 sessions delivered over a 6e8 week period. Methods: The Family Model DSME was a cultural adaptation of DSME, whereby the intervention focused on engaging family support for the primary participant with T2D. The Standard DSME was delivered to the primary participant in a community-based group format. Primary participants and participating family members were assessed at baseline and immediate post-intervention, and will also be assessed at 6 and 12 months. Summary: The Family Model of DSME aimed to improve glycemic control in Marshallese with T2D. The utilization of a CBPR approach that involves the local stakeholders and the engagement of the familybased social infrastructure of Marshallese communities increase potential for the intervention's success and sustainability.

Comparison of Office-Based Versus Outsourced Immunization Recall Services

Clinical Pediatrics, 2016

Given poor use of recall in primary care practices, we compared outsourced versus office-based re... more Given poor use of recall in primary care practices, we compared outsourced versus office-based recall systems. From 2011 to 2013, we enrolled 87 individual Arkansas providers in distinct practices treating their own patients &amp;amp;lt;24 months of age which were randomized to usual care (A), office-based (B), or outsourced (C) recall groups. At the end of study, recall activity was 19.4%, 55.0%, and 92.6% for Groups A, B, and C, respectively (B and C vs A: P &amp;amp;lt; .001). Only 68 Group B patients were identified as needing immunizations versus 826 in Group C. The majority of successful contacts were made through mobile phone (41.3%) or text message (32.6%). The total cost per practice per week was significantly lower for Group C versus Group B ($39.50 and $53.00, respectively; P = .004). With limited electronic health record use, an outsourced recall system is more sustainable and less costly than an office-based system.

Impact of a Smoke-Free Hospital Campus Policy on Employee and Consumer Behavior

Public Health Reports, 2007

Objective. Although smoke-free hospital campuses can provide a strong health message and protect ... more Objective. Although smoke-free hospital campuses can provide a strong health message and protect patients, they are few in number due to employee retention and public relations concerns. We evaluated the effects of implementing a clean air policy on employee attitudes, recruitment, and retention; hospital utilization; and consumer satisfaction in 2003 through 2005. Methods. We conducted research at a university hospital campus with supplemental data from an affiliated hospital campus. Our evaluation included (1) measurement of employee attitudes during the year before and year after policy implementation using a cross-sectional, anonymous survey; (2) focus group discussions held with supervisors and security personnel; and (3) key informant interviews conducted with administrators. Secondary analysis included review of employment records and exit interviews, and monitoring of hospital utilization and patient satisfaction data. Results. Employee attitudes toward the policy were suppo...

The comparative effectiveness of two brief tobacco interventions in the U.S. Air Force: Perceived harm and intentions-to-use of tobacco products

Tobacco Induced Diseases, 2018

INTRODUCTION Tobacco use causes 480 000 deaths each year in the United States 1. It increases the... more INTRODUCTION Tobacco use causes 480 000 deaths each year in the United States 1. It increases the risk of coronary heart disease and stroke up to 4 times, and lung cancer by a staggering 25 times 1,2. Young adults (age 18-25 years) are at high risk for tobacco use due to targeting by tobacco companies 3. In 2013, 37% of 18-25 year olds used some form of tobacco in the past month, compared to 7.8% of 12-17 year olds and 25.7% of 26 years old and older 4. Young adults comprise the largest age demographic in the US military 5. Tobacco prevalence rates are

Lessons Learned From Miami-Dade County's COVID-19 Epidemic: Making Surveillance Data Accessible for Policy Makers

Journal of Public Health Management and Practice, 2021

Introduction: COVID-19 represents an unprecedented challenge to policy makers as well as those en... more Introduction: COVID-19 represents an unprecedented challenge to policy makers as well as those entrusted with capturing, monitoring, and analyzing COVID-19 data. Effective public policy is data-informed policy. This requires a liaison between public health scientists and public officials. Objective: This article details the experience, challenges, and lessons learned advising public officials in a large metropolitan area from March to October 2020. Methods: To effectively do this, an R Markdown report was created to iteratively monitor the number of COVID-19 tests performed, positive tests obtained, COVID-19 hospitalization census, intensive care unit census, the number of patients with COVID-19 on ventilators, and the number of deaths due to COVID-19. Results: These reports were presented and discussed at meetings with policy makers to further comprehension. Discussion: To facilitate the fullest understanding by both the general public and policy makers alike, we advocate for greater centralization of public health surveillance data, objective operational definitions of metrics, and greater interagency communication to best guide and inform policy makers. Through consistent data reporting methods, parsimonious and consistent analytic methods, a clear line of communication with policy makers, transparency, and the ability to navigate unforeseen externalities such as “data dumps” and reporting delays, scientists can use information to best support policy makers in times of crises.

Running Title: Motivational Interviewing and Obesity Treatment

OBJECTIVE-We sought to determine whether adding motivational interviewing to a behavioral weight ... more OBJECTIVE-We sought to determine whether adding motivational interviewing to a behavioral weight control program improves weight loss outcomes and glycemic control for overweight women with type 2 diabetes. RESEARCH DESIGN AND METHODS-We conducted a randomized, controlled, clinical trial in which participants all received an 18-month, group-based behavioral obesity treatment and were randomized to individual sessions of motivational interviewing or attention control (total of five sessions) as an adjunct to the weight control program. Overweight women with type 2 diabetes treated by oral medications who could walk for exercise were eligible. Primary outcomes were weight and A1C, assessed at 0, 6, 12, and 18 months. RESULTS-A total of 217 overweight women (38% African American) were randomized (93% retention rate). Women in motivational interviewing lost significantly more weight at 6 months (P ϭ 0.01) and 18 months (P ϭ 0.04). Increased weight losses with motivational interviewing were mediated by enhanced adherence to the behavioral weight control program. African-American women lost less weight than white women overall and appeared to have a diminished benefit from the addition of motivational interviewing. Significantly greater A1C reductions were observed in those undergoing motivational interviewing at 6 months (P ϭ 0.02) but not at 18 months. CONCLUSIONS-Motivational interviewing can be a beneficial adjunct to behavioral obesity treatment for women with type 2 diabetes, although the benefits may not be sustained among African-American women.

594: Cesarean section reduces the odds of morbidity and mortality among very low birthweight infants

American Journal of Obstetrics and Gynecology, 2018

exposure. Magnesium sulfate did not appear to protect from severe IVH (OR¼ 0.20; 95% CI 0.01-2.4;... more exposure. Magnesium sulfate did not appear to protect from severe IVH (OR¼ 0.20; 95% CI 0.01-2.4; p¼0.21). CONCLUSION: Maternal magnesium appears to be an independent predictor of survival from 12 hours after birth until discharge among neonates who are born weighing less than 500g. This is the first study that has found a survival benefit in these periviable birth weights.

BMI and related risk factors among U.S. Marshallese with diabetes and their families

Ethnicity & Health, 2019

Objective: Examine cross-sectional associations between body mass index (BMI) and related health ... more Objective: Examine cross-sectional associations between body mass index (BMI) and related health behaviors, barriers and facilitators to health care, and perceived health status among a sample of U.S. Marshallese adults with Type 2 diabetes and evaluate associations of interest between participants and their family members. Design: Cross-sectional baseline data were analyzed from participants in a diabetes self-management education intervention trial. Setting: Data collection took place in home or community settings through a community-academic partnership in Arkansas. Participants: Study participants consisted of U.S. Marshallese adults with Type 2 diabetes (N = 221) and their family members (N = 211) recruited through community settings. Intervention(s): N/A. Main Outcome Measure(s): Participants' height and weight were measured using standard protocols to calculate BMI (kg/m 2). Diet, physical activity, health care access, financial strain related to health care, perceived health status, and health care satisfaction were measured using self-report surveys. Results: Participants' mean BMI was 31.0 (95% CI: 30.2-31.7), with over half of study participants and their family members' BMI falling in the obese category. Participants' BMI was positively associated with spreading health care bill payments over time (β = 1.75 (SE = 0.87); p = 0.045). Positive associations between participants and their family members were observed for self-reported health status conditions, health care coverage, health care utilization, and health care satisfaction. Conclusion: Study findings highlight the high prevalence of obesity and related risk factors among U.S. Marshallese adults with Type 2 diabetes and emphasize the need for intervention strategies that ARTICLE HISTORY

How stakeholder engagement influenced a randomized comparative effectiveness trial testing two Diabetes Prevention Program interventions in a Marshallese Pacific Islander Community

Journal of Translational Medicine, 2019

Background: Marshallese face significant health disparities, with particularly high rates of type... more Background: Marshallese face significant health disparities, with particularly high rates of type 2 diabetes. Engaging stakeholders in the research process is essential to reduce health inequities. Methods: A community-and patient-engaged research approach was used to involve community Marshallese stakeholders in a randomized comparative effectiveness trial testing two Diabetes Prevention Program interventions. Results: The article outlines the engagement process and the specific influence that stakeholders had on the research planning and implementation, discussing the areas of agreement and disagreement between community and patient stakeholders and academic investigators and documenting changes to the research protocol. Conclusion: The article provides an example of methods that can be used to design and conduct a randomized controlled trial testing with a population who has been underrepresented in research and suffered significant historical trauma.

Fetal pulmonary artery acceleration/ejection time prognostic accuracy for respiratory complications in preterm prelabor rupture of membranes

The Journal of Maternal-Fetal & Neonatal Medicine, 2018

The Mediating Role of Sleep Quality and Quantity in the Link Between Food Insecurity and Obesity Across Race and Ethnicity

Obesity (Silver Spring, Md.), 2018

The objective of the study was to examine the mediating role of sleep quality and quantity in the... more The objective of the study was to examine the mediating role of sleep quality and quantity in the relationship between food insecurity and obesity across races/ethnicities. Bivariate negative binomial regression and multinomial logistic regression were used to examine direct associations between food insecurity and sleep quality and quantity among non-Hispanic Native Hawaiian and other Pacific Islanders (NHPI) relative to non-Hispanic White, Black, Asian, and Hispanic individuals with obesity. The potential outcomes approach and adjusted Wald test were used to explore the mediating role of sleep quality and quantity and the moderating role of race/ethnicity, respectively. Among adults with obesity, the study found a positive and direct relationship between food insecurity and trouble falling asleep in each racial/ethnic group. Trouble staying asleep was associated with food insecurity in each racial/ethnic group, except in the Asian group. Positive and direct associations were obser...

Fit & quit: An efficacy trial of two behavioral post-cessation weight gain interventions

Contemporary Clinical Trials, 2018

While smoking cessation leads to significant improvements in both mortality and morbidity, postce... more While smoking cessation leads to significant improvements in both mortality and morbidity, postcessation weight gain partially attenuates this benefit. Even though post-cessation weight gain is small (4.7 kg on average), it is a stated reason to delay cessation attempts and is associated with smoking relapse. Fit & Quit is a randomized, controlled efficacy trial that aims to examine the ability of a weight stability intervention and a weight loss intervention to reduce post-cessation weight gain. For this purpose, Fit & Quit will randomize participants to three conditions: (a) Small Changes, a weight gain prevention intervention; (b) Look AHEAD Intensive Lifestyle Intervention; and (c) a lower-intensity bibliotherapy intervention. All conditions will receive a highly efficacious behavioral (i.e., rate reduction skills, motivational interviewing) and pharmacological (i.e., varenicline) smoking cessation program. A total of 400 participants will be recruited and randomized to the three interventions. Participants will be recruited in waves, with 10 waves of approximately 40 participants per wave. The primary outcomes of this study include post-cessation weight gain and cessation status at 12-month follow-up. Fit & Quit will integrate and adapt the strongest evidence-based interventions available for weight management and smoking cessation. Fit & Quit is highly innovative in the areas of the target population, study design, and use of technology. For these reasons, we expect that Fit & Quit will make a significant public health contribution to curtailing the important cessation barrier of post-cessation weight gain.

Effect of Weight on Indwelling Catheter Use among Long-Term Care Facility Residents

Urologic Nursing, 2013

This study examined the effect of obesity on the use of indwelling urinary catheters among long-t... more

Frequency and predictors of health services use by Native Hawaiians and Pacific Islanders: evidence from the U.S. National Health Interview Survey

BMC health services research, Jan 21, 2018

Native Hawaiians and Pacific Islanders (NHPIs) are one of the fasting growing racial groups in th... more Native Hawaiians and Pacific Islanders (NHPIs) are one of the fasting growing racial groups in the United States (US). NHPIs have a significantly higher disease burden than the US population as a whole, yet they remain underrepresented in research. The purpose of this study is to examine factors associated with health care utilization among NHPIs. Drawing from the 2014 NHPI-National Health Interview Survey, we used stereotype logistic regressions to examine utilization of emergency department (ED) and outpatient services among 2172 individuals aged 18 and older. NHPIs with chronic diseases were twice as likely to be multiple ED users and nearly four times as likely to be frequent-users of outpatient services. Social support played a protective role in preventing multiple use of ED. Having a usual source of care made it more than eight times as likely to be a frequent-user of outpatient services. Use of eHealth information increased the odds of using ED and outpatient services. Abili...

Insurance coverage mandates: Impact of physician utilization in moderating colorectal cancer screening rates

American journal of surgery, Jan 2, 2018

Precision public health requires research that supports innovative systems and health delivery ap... more Precision public health requires research that supports innovative systems and health delivery approaches, programs, and policies that are part of this vision. This study estimated the effects of health insurance mandate (HiM) variations and the effects of physician utilization on moderating colorectal cancer (CRC) screening rates. A time-series analysis using a difference-in-difference-in-differences (DDD) approach was conducted on CRC screenings (1997-2014) using a multivariate logistic framework. Key variables of interest were HiM, CRC screening status, and physician utilization. The adjusted average marginal effects from the DDD model indicate that physician utilization increased the probability of being "up-to-date" vs. non-compliance by 9.9% points (p = 0.007), suggesting that an estimated 8.85 million additional age-eligible persons would receive a CRC screening with HiM and routine physician visits. Routine physician visits and mandates that lower out-of-pocket exp...

Design of a comparative effectiveness randomized controlled trial testing a faith-based Diabetes Prevention Program (WORD DPP) vs. a Pacific culturally adapted Diabetes Prevention Program (PILI DPP) for Marshallese in the United States

Medicine, 2018

Pacific Islander populations, including Marshallese, face a disproportionately high burden of hea... more Pacific Islander populations, including Marshallese, face a disproportionately high burden of health disparities relative to the general population. A community-based participatory research (CBPR) approach was utilized to engage Marshallese participants in a comparative effectiveness trial testing 2 Diabetes Prevention Program (DPP) interventions designed to reduce participant's weight, lower HbA1c, encourage healthy eating, and increase physical activity. To compare the effectiveness of the faith-based (WORD) DPP to the culturally adapted (Pacific Culturally Adapted Diabetes Prevention Program [PILI]) DPP, a clustered randomized controlled trial (RCT) with 384 Marshallese participants will be implemented in 32 churches located in Arkansas, Kansas, Missouri, and Oklahoma. Churches will be randomly assigned to WORD DPP arm or to PILI DPP arm. WORD DPP focuses on connecting faith and health to attain a healthy weight, eat healthy, and be more physically active. In contrast, PILI D...

Substance Use and Psychological Distress Before and After the Military to Civilian Transition

Military medicine, Jan 6, 2018

Those currently serving in the military constitute a vulnerable population given their high-risk ... more Those currently serving in the military constitute a vulnerable population given their high-risk status for substance use, and population data suggest that veterans continue to engage in significant substance use long after their military service ends. Recent research suggests that the separation transition from active duty to civilian life may be critical in terms of the future functioning of the veteran. We sought to explore substance use prevalence, as well as potential emotional distress among veterans by retrospectively assessing substance use during active duty and following separation to examine possible changes in use over this period. This study assessed substance use and emotional distress in veterans (N = 80; 90% male) across the military to civilian transition. Repeated measures tests indicated that endorsement of alcohol use, cigarette use, and prescription drug misuse was similar during active duty and post-separation, and marijuana and hard drug use endorsement increa...

Cost-related Nonadherence to Medication Treatment Plans: Native Hawaiian and Pacific Islander National Health Interview Survey, 2014

Medical care, Jan 9, 2018

Adherence to medication treatment plans is important for chronic disease (CD) management. Cost-re... more Adherence to medication treatment plans is important for chronic disease (CD) management. Cost-related nonadherence (CRN) puts patients at risk for complications. Native Hawaiians and Pacific Islanders (NHPI) suffer from high rates of CD and socioeconomic disparities that could increase CRN behaviors. Examine factors related to CRN to medication treatment plans within an understudied population. Using 2014 NHPI-National Health Interview Survey data, we examined CRN among a nationally representative sample of NHPI adults. Bonferroni-adjusted Wald test and multivariable logistic regression were performed to examine associations among financial burden-related factors, CD status, and CRN. Across CD status, NHPI engaged in CRN behaviors had, on an average, increased levels of perceived financial stress, financial insecurity with health care, and food insecurity compared with adults in the total NHPI population. Regression analysis indicated perceived financial stress [adjusted odds ratio...

The Effect of Prenatal Alcohol Exposure on Fetal Growth and Cardiovascular Parameters in a Baboon Model of Pregnancy

Reproductive sciences (Thousand Oaks, Calif.), Jul 1, 2017

Prenatal alcohol exposure often results in an array of fetal developmental abnormalities termed f... more Prenatal alcohol exposure often results in an array of fetal developmental abnormalities termed fetal alcohol spectrum disorders (FASDs). Despite the high prevalence of FASDs, the pathophysiology of fetal damage by alcohol remains poorly understood. One of the major obstacles in studying fetal development in response to alcohol exposure is the inability to standardize the amount, pattern of alcohol consumption, and peak blood alcohol levels in pregnant mothers. In the present study, we used Doppler ultrasonography to assess fetal growth and cardiovascular parameters in response to alcohol exposure in pregnant baboons. Baboons were subjected to gastric alcohol infusion 3 times during the second trimester equivalent to human pregnancy, with maternal blood alcohol levels reaching 80 mg/dL within 30 to 60 minutes following alcohol infusion. The control group received a drink that was isocaloric to the alcohol-containing one. Doppler ultrasonography was used for longitudinal assessment o...

Family Planning Provider Referral, Facilitation Behavior, and Patient Follow-up for Abnormal Pap Smears

Public Health Reports, 2009

Objectives. Family planning (FP) clinics are important access points for cervical cancer screenin... more Objectives. Family planning (FP) clinics are important access points for cervical cancer screening and referrals for follow-up care for abnormal Papanicolaou (Pap) smears for a substantial number of U.S. women. Because little is known about referral and facilitation practices in these clinics or client action based on referrals, we sought to determine FP provider referral and facilitation practices when seeing FP clients with abnormal Pap smear results, and FP client follow-up for abnormal Pap smears due to FP provider referrals. Methods. We conducted a mail survey of Medicaid-enrolled FP providers in Arkansas and Alabama, and conducted a telephone survey with a sample of FP clients of those providers responding to the provider survey. Results. Major provider factors associated with referral included rural location, health department and clinic institutional setting, large Title X practice/clinic size, and high FP clinic focus. Major factors associated with facilitation included rur...

Design of a randomized, controlled, comparative-effectiveness trial testing a Family Model of Diabetes Self-Management Education (DSME) vs. Standard DSME for Marshallese in the United States

Contemporary Clinical Trials Communications, 2017

Background: Type 2 diabetes (T2D) is a significant public health problem, with U.S. Pacific Islan... more Background: Type 2 diabetes (T2D) is a significant public health problem, with U.S. Pacific Islander communitiesdsuch as the Marshallesedbearing a disproportionate burden. Using a community-based participatory approach (CBPR) that engages the strong family-based social infrastructure characteristic of Marshallese communities is a promising way to manage T2D. Objectives: Led by a collaborative community-academic partnership, the Family Model of Diabetes Self-Management Education (DSME) aimed to change diabetes management behaviors to improve glycemic control in Marshallese adults with T2D by engaging the entire family. Design: To test the Family Model of DSME, a randomized, controlled, comparative effectiveness trial with 240 primary participants was implemented. Half of the primary participants were randomly assigned to the Standard DSME and half were randomly assigned to the Family Model DSME. Both arms received ten hours of content comprised of 6e8 sessions delivered over a 6e8 week period. Methods: The Family Model DSME was a cultural adaptation of DSME, whereby the intervention focused on engaging family support for the primary participant with T2D. The Standard DSME was delivered to the primary participant in a community-based group format. Primary participants and participating family members were assessed at baseline and immediate post-intervention, and will also be assessed at 6 and 12 months. Summary: The Family Model of DSME aimed to improve glycemic control in Marshallese with T2D. The utilization of a CBPR approach that involves the local stakeholders and the engagement of the familybased social infrastructure of Marshallese communities increase potential for the intervention's success and sustainability.

Comparison of Office-Based Versus Outsourced Immunization Recall Services

Clinical Pediatrics, 2016

Given poor use of recall in primary care practices, we compared outsourced versus office-based re... more Given poor use of recall in primary care practices, we compared outsourced versus office-based recall systems. From 2011 to 2013, we enrolled 87 individual Arkansas providers in distinct practices treating their own patients &amp;amp;lt;24 months of age which were randomized to usual care (A), office-based (B), or outsourced (C) recall groups. At the end of study, recall activity was 19.4%, 55.0%, and 92.6% for Groups A, B, and C, respectively (B and C vs A: P &amp;amp;lt; .001). Only 68 Group B patients were identified as needing immunizations versus 826 in Group C. The majority of successful contacts were made through mobile phone (41.3%) or text message (32.6%). The total cost per practice per week was significantly lower for Group C versus Group B ($39.50 and $53.00, respectively; P = .004). With limited electronic health record use, an outsourced recall system is more sustainable and less costly than an office-based system.

Impact of a Smoke-Free Hospital Campus Policy on Employee and Consumer Behavior

Public Health Reports, 2007

Objective. Although smoke-free hospital campuses can provide a strong health message and protect ... more Objective. Although smoke-free hospital campuses can provide a strong health message and protect patients, they are few in number due to employee retention and public relations concerns. We evaluated the effects of implementing a clean air policy on employee attitudes, recruitment, and retention; hospital utilization; and consumer satisfaction in 2003 through 2005. Methods. We conducted research at a university hospital campus with supplemental data from an affiliated hospital campus. Our evaluation included (1) measurement of employee attitudes during the year before and year after policy implementation using a cross-sectional, anonymous survey; (2) focus group discussions held with supervisors and security personnel; and (3) key informant interviews conducted with administrators. Secondary analysis included review of employment records and exit interviews, and monitoring of hospital utilization and patient satisfaction data. Results. Employee attitudes toward the policy were suppo...