All Publications


  • Use of long-acting injectable buprenorphine in the correctional setting. Journal of substance abuse treatment Martin, R. A., Berk, J., Rich, J. D., Kang, A., Fritsche, J., Clarke, J. G. 2022; 142: 108851

    Abstract

    As overdoses due to opioids rise, medications for opioid use disorder (MOUD) continue to be underemployed, resulting in limited access to potentially life-saving treatment. Substance use disorders are prevalent in individuals who are incarcerated, and these individuals are at increased risk for death postrelease due to overdose. Few jails and prisons offer MOUD and most limit access. Extended-release buprenorphine (XR-BUP), a novel monthly injectable MOUD formulation, could be uniquely poised to address treatment access in correctional settings.This study linked a retrospective cohort design of statewide datasets to evaluate the real-world use of XR-BUP. The study included individuals (N = 54) who received XR-BUP while incarcerated from January 2019 through February 2022. The study was conducted at the Rhode Island Department of Corrections, with the nation's first comprehensive statewide correctional MOUD program.Fifty-four individuals received a combined total of 162 injections during the study period. The study found no evidence of tampering with the injection site, indicating no attempts by participants to remove, hoard, or divert the medication. Sixty-one percent reported at least one adverse effect after injections were received, with an average of 2.8 side effects. Sixty-one percent of those released on XR-BUP engaged in MOUD after release, 30 % continued with XR-BUP.XR-BUP is feasible and acceptable in correctional settings. XR-BUP addresses administrative concerns of diversion that obstruct lifesaving MOUD and offers another safe and effective treatment option. Further studies and trials should continue to assess this novel medication's ability to treat opioid addiction in the correctional setting and upon release to the community.

    View details for DOI 10.1016/j.jsat.2022.108851

    View details for PubMedID 35939914

  • Incongruence between Physician, Patient, and Medical Chart Report of Skin Cancer Prevention Counseling. International journal of environmental research and public health Matthews, N. H., Kang, A. W., Weinstock, M. A., Risica, P. M. 2022; 19 (11)

    Abstract

    Skin cancer incidence in the United States has risen rapidly in recent decades, underscoring the need for accessible and effective prevention practices. Skin cancer prevention counseling can lead to increased sun protective behavior and early detection; however, little is understood regarding the frequency and content of counseling among primary care providers (PCPs). We performed multi-center cross-sectional surveys among 53 providers and 3343 of their patients and chart review asking whether skin cancer prevention counseling occurred and details of that counseling. Only 10-25% of patients reported that counseling occurred. Among the providers who reported counseling, there were higher odds that their patients recollected they were advised to use sunscreen or protective clothing, on how to use sunscreen, on signs of skin cancer, to perform a self-skin exam (all p < 0.001), and were provided with written materials (p < 0.01). Eight percent of prevention counseling was chart documented despite being highly associated with patient and physician recollection of counseling (p < 0.001). These results highlight the need for consistent and clear delivery of skin cancer primary prevention.

    View details for DOI 10.3390/ijerph19116853

    View details for PubMedID 35682441

  • A multi-component tailored intervention in family childcare homes improves diet quality and sedentary behavior of preschool children compared to an attention control: results from the Healthy Start-Comienzos Sanos cluster randomized trial. The international journal of behavioral nutrition and physical activity Gans, K. M., Tovar, A., Kang, A., Ward, D. S., Stowers, K. C., von Ash, T., Dionne, L., Papandonatos, G. D., Mena, N., Jiang, Q., Risica, P. M. 2022; 19 (1): 45

    Abstract

    BACKGROUND: Childcare settings are important environments for influencing child eating and physical activity (PA). Family childcare homes (FCCH) care for many children of low-income and diverse racial/ethnic backgrounds who are at greater risk for poor diet quality, low PA, and obesity, but few interventions have targeted this setting. The aim of this study was to assess the efficacy of a multicomponent intervention conducted in FCCH on the diet quality and PA of 2-5year old children in their care.TRIAL DESIGN: Cluster randomized trial.METHODS: The cluster-randomized trial, Healthy Start/Comienzos Sanos (2015-2019) evaluated an 8-month nutrition and PA intervention that included four components: (1) monthly telephone calls from a support coach using brief motivational interviewing, (2) tailored reports, newsletters and videos, (3) group support meetings, and (4) active play toys. After completing baseline measurement, FCCH were randomized into intervention or comparison groups in matched pairs. Both groups received the same intervention components but on different topics (intervention: nutrition/PA vs. comparison: reading readiness/literacy). Evaluation staff were blinded to group assignment. Child primary outcome measures collected at baseline and 8-months included: 1) Healthy Eating Index (HEI-2015) scores calculated from diet observation, and 2) accelerometer measurement of PA. Process measures were collected from field data and provider surveys. Generalized Estimating Equation Models assessed changes in HEI-2015 scores and PA over time by experimental condition.RESULTS: Ethnically diverse FCCH providers (n=119) and 2-to-5-year-old children in their care (n=377) were included in the final analysis. Process evaluation showed high participation in all intervention components except for group meetings. Compared to children in comparison group FCCH, children in intervention FCCH increased total HEI-2015 scores by 7.2 points (p<.001) including improvement in component scores for vegetables (0.84 points, p=.025) and added sugar (0.94 points, p=.025). For PA, compared to children in the comparison group, children in intervention FCCH decreased sedentary time by 5.7% (p=.021).CONCLUSIONS: The multicomponent Healthy Start intervention was effective in improving diet quality and sedentary behavior of children in FCCH, which demonstrates the promise of obesity prevention interventions in this setting. Future research could include enhancing the Healthy Start intervention to strengthen the PA component, considering virtual peer support, and determining how to best translate and disseminate the intervention into FCCH nationally.TRIAL REGISTRATION: National Institutes of Health, NCT02452645 . Registered 5 May 2015.

    View details for DOI 10.1186/s12966-022-01272-6

    View details for PubMedID 35428298

  • Barriers and poor telephone counseling experiences among patients receiving medication for opioid use disorders. Patient education and counseling Kang, A. W., DeBritz, A. A., Hoadley, A., DelaCuesta, C., Walton, M., Hurley, L., Martin, R. 2022

    Abstract

    OBJECTIVE: The COVID-19 pandemic catalyzed the relaxation of regulations surrounding Medication for Opioid Use Disorders (MOUD) treatment, including a shift from in-person to telehealth counseling services adjunct to MOUD treatment. We examine how patient-level barriers impact their counseling experiences.METHODS: We examine data from n=264 participants who completed a cross-sectional survey regarding their experiences with telephone counseling adjunct to MOUD between July to November 2020. Variables examined include: convenience and satisfaction with telephone counseling, comfort and change in relationship with counselor, and how telephone counseling helped with anxiety, depression, anger, substance use, and recovery. Participants also listed the barriers they faced when using telephone counseling.RESULTS: Thirty-one percent of the sample (n=81) reported experiencing one or more barriers to telephone counseling. Satisfaction with counseling, perceived convenience, comfort, and beneficial effects of counseling on substance use were associated with increased odds of reporting no barriers (range of p.038 to <0.001).CONCLUSIONS: Many participants reported barriers to telehealth counseling, and these barriers were in turn associated with poorer counseling experiences.PRACTICE IMPLICATIONS: Many treatment providers plan to integrate telehealth service provision in their healthcare delivery model, but more research on patient-level barriers and its impact on treatment is needed.

    View details for DOI 10.1016/j.pec.2022.03.006

    View details for PubMedID 35279358

  • Physical Activity and Screen Time Practices of Family Child Care Providers: Do They Meet Best Practice Guidelines? Childhood obesity (Print) Gans, K. M., Jiang, Q., Tovar, A., Kang, A., McCardle, M., Risica, P. M. 2021

    Abstract

    Background: Child care settings significantly influence children's physical activity (PA) and screen time (ST) behaviors, yet less research has been conducted in family child care homes (FCCHs) than in child care centers. While a few studies have measured family child care providers' (FCCPs') PA practices, none have used observation to assess which specific evidence-based, best practice guidelines FCCPs met or did not meet, and no previous studies have included Latinx providers. This article examines FCCPs' adherence to PA and ST best practice guidelines using primarily observational methods with diverse FCCPs (including Latinx). Methods: We examined baseline data from a cluster randomized trial including surveys and observational data collected at the FCCH to assess whether providers met specific PA and ST best practices from the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) and the American Academy of Pediatrics. Results: Providers completed a telephone survey and participated in two full-day observations (n = 127; 72% Hispanic). Overall, only 4 of 14 PA and ST best practices were met by >50% of providers including: leading a planned PA class more than once a week; no ST during meal or snack; not modeling sedentary behavior; and providing families with information about children's ST. Best practices least likely to be met (<20% of providers) include: providing children with >60 minutes of outdoor play daily; providing children with >45 minutes of adult-led PA each day; participating in outdoor PA with children; participating in indoor PA with children; prompting and praising children for being active; and talking with children informally about the importance of PA. Conclusions: While FCCPs engage in some positive PA and ST practices, many providers do not meet best practice guidelines. There is a need for more research about how to overcome providers' personal and environmental barriers for meeting these guidelines as well as interventions and supports to overcome these barriers. Clinical Trial Registration Number NCT0245645.

    View details for DOI 10.1089/chi.2021.0094

    View details for PubMedID 34851731

  • Changes in Fathers' Body Mass Index, Sleep, and Diet From Prebirth to 12 Months Postbirth: Exploring the Moderating Roles of Parenthood Experience and Coparenting Support. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine Lo, B. K., Kang, A. W., Haneuse, S., Yu, X., Ash, T. v., Redline, S., Taveras, E. M., Davison, K. K. 2021; 55 (12): 1211-1219

    Abstract

    BACKGROUND: While research has examined prenatal to postnatal changes in women's weight, sleep, and diet, much less is known about these changes among fathers.PURPOSE: This study aimed to (a) examine changes in fathers' body mass index (BMI), sleep, and diet from 1 month before birth to 5-6 months following birth, and from 5-6 months to 11-12 months following birth and (b) explore the moderating roles of parenthood experience and coparenting support.METHODS: 169 fathers (mean age 35.5 years, 58.9% White) participated. Fathers completed an intake survey shortly after their infant's birth to recall their height and weight, nighttime sleep hours, fruit and vegetable intake, soda intake, and fast food intake for the month prior to birth. When their child was 6 and 12 months old, fathers reported their weight, sleep, and diet again for the past 4 weeks (i.e., 4 week periods spanning 5-6 months and 11-12 months following birth). Generalized estimating equations were used to answer our research questions.RESULTS: Fathers reported higher BMI (Delta = 0.22 kg/m2; 95% confidence interval [CI] = 0.06, 0.38; p = .008) and less nighttime sleep duration (Delta = -0.21 hr; 95% CI = -0.38, -0.05; p = .012) at 5-6 months following birth compared to 1 month prior to birth. Fathers' diet remained stable over the three timepoints. No evidence was found to support the moderating roles of parenthood experience and coparenting support on fathers' weight and behavior changes.CONCLUSIONS: 5-6 months following birth may be an important point of intervention for fathers to promote a return to prebirth BMI and sleep levels.

    View details for DOI 10.1093/abm/kaab013

    View details for PubMedID 33674862

  • Medication for Opioid Use Disorder Service Provision and Telephone Counseling: A Concurrent Mixed-Methods Approach. International journal of environmental research and public health Martin, R., Kang, A. W., DeBritz, A. A., Walton, M. R., Hoadley, A., DelaCuesta, C., Hurley, L. 2021; 18 (11)

    Abstract

    Using quantitative and qualitative evidence, this study triangulates counselors' perspectives on the use of telemedicine in the context of Opioid Use Disorder (OUD) treatment. A concurrent mixed-methods design examined counselors' experiences with telephone counseling during the COVID-19 pandemic. N = 42 counselors who provided OUD counseling services completed a close-ended, quantitative survey examining their experiences in addressing clients' anxiety, depression, anger, substance use, therapeutic relationship, and substance use recovery using telephone counseling. The survey also assessed comfort, convenience, and satisfaction with telephone counseling. Counselors also completed open-ended responses examining satisfaction, convenience, relationship with patients, substance use, and general feedback with telephone counseling. The synthesis of quantitative and qualitative evidence indicated that a majority of counselors had positive experiences with using telephone counseling to provide services to clients undergoing OUD treatment. Convenience, greater access to clients, and flexibility were among the reasons cited for their positive experience. However, counselors also expressed that the telephone counseling was impersonal, and that some clients may have difficulties accessing appropriate technology for telehealth adoption. Findings suggest that further research with counselors is needed to identify the key elements of an effective integration of telephone counseling with traditional in-person treatment approaches in the post-pandemic era.

    View details for DOI 10.3390/ijerph18116163

    View details for PubMedID 34200312

    View details for PubMedCentralID PMC8201197

  • Patient Experiences with the Transition to Telephone Counseling during the COVID-19 Pandemic. Healthcare (Basel, Switzerland) Kang, A. W., Walton, M., Hoadley, A., DelaCuesta, C., Hurley, L., Martin, R. 2021; 9 (6)

    Abstract

    Background: To identify and document the treatment experiences among patients with opioid use disorder (OUD) in the context of the rapid move from in-person to telephone counseling due to the COVID-19 pandemic. Methods: Participants (n = 237) completed a survey with open-ended questions that included the following domains: (1) satisfaction with telephone counseling, (2) perceived convenience, (3) changes to the therapeutic relationship, (4) perceived impact on substance use recovery, and (5) general feedback. Responses were coded using thematic analysis. Codes were subsequently organized into themes and subthemes (covering 98% of responses). Interrater reliability for coding of participants' responses ranged from 0.89 to 0.95. Results: Overall, patients reported that telephone counseling improved the therapeutic experience. Specifically, 74% of respondents were coded as providing responses consistently indicating "positive valency". "Positive valency" responses include: (1) feeling supported, (2) greater comfort and privacy, (3) increased access to counselors, and (4) resolved transportation barriers. Conversely, "negative valency" responses include: (1) impersonal experience and (2) reduced privacy. Conclusions: Telephone counseling presents its own set of challenges that should be investigated further to improve the quality of care and long-term patient outcomes.

    View details for DOI 10.3390/healthcare9060663

    View details for PubMedID 34199582

    View details for PubMedCentralID PMC8226454

  • Psychological Stress, Smoking, and Hazardous Drinking Behaviors among South Korean Adults: Findings from the Korean National Health and Nutrition Examination Survey. Journal of substance use Lee, H., Lee, H. H., Kang, A., Cha, Y., Operario, D. 2021; 26 (1): 13-20

    Abstract

    There is growing attention to mental health as a contributor to behavioral health in South Korea. We investigated the prevalence of psychological stress and its associations with cigarette smoking and drinking behaviors among a nationally representative sample of South Korean adults.Using data from 14,855 adults aged ≥19 years who participated in the 2013 to 2016 Korea National Health and Nutrition Examination Survey (KNHANES), we performed weighted logistic regression to examine the associations between stress and three binary outcome variables: cigarette smoking, heavy episodic drinking and frequent drinking.27.2% of participants reported high stress. Controlling for sociodemographic covariates, high stress was associated with 1.54 times the odds (p<0.001) of being a smoker, 1.25 times the odds (p<0.001) of being a heavy episodic drinker, and 1.23 times the odds (p<0.001) of being a frequent drinker. There was evidence of effect modification by gender and occupation, such that the effects of stress on these behaviors were particularly stronger among women and pink-collar (service industry) workers (compared to men and white-collar workers).Future policies that aim to address smoking and drinking behaviors in South Korea should consider stress reduction and coping strategies, especially among women and pink-collar workers.

    View details for DOI 10.1080/14659891.2020.1760379

    View details for PubMedID 33716570

    View details for PubMedCentralID PMC7954234

  • Physical Activity Levels among Preschool-Aged Children in Family Child Care Homes: A Comparison between Hispanic and Non-Hispanic Children Using Accelerometry. Children (Basel, Switzerland) Kang, A. W., Gans, K. M., von Ash, T., Castagneri, D., Dionne, L., Tovar, A., Risica, P. M. 2021; 8 (5)

    Abstract

    Obesity prevalence among Hispanic children is twice that of non-Hispanic white children; Hispanic children may also engage in less physical activity (PA) compared to non-Hispanic white children. A large number of U.S. preschool-aged children are cared for in Family Child Care Homes (FCCH), yet few studies have examined PA levels and ethnicity differences in PA levels among these children. We examine baseline data from a cluster-randomized trial (Healthy Start/Comienzos Sanos) to improve food and PA environments in FCCHs. Children aged 2-to-5-years (n = 342) wore triaxial accelerometers for two days in FCCHs. Variables examined include percentage of time (%) spent in sedentary, and light, moderate, and vigorous PA. The full dataset (n = 342) indicated sedentary behavior 62% ± 11% of the time and only 10% ± 5% of the time spent in moderate-to-vigorous PA. Among children in the upper-median half of wear-time (n = 176), Hispanic children had significantly greater % sedentary time vs. Non-Hispanic children (66.2% ± 8.3% vs. 62.6% ± 6.9%, p = 0.007), and lower % light PA (25.4% ± 6.3% vs. 27.7% ± 4.9%, p = 0.008) and moderate PA (5.5% ± 2.1% vs. 6.4% ± 2.2%, p = 0.018). Our results highlight that PA levels were lower among our sample compared to previous studies, and that Hispanic children were more sedentary and less active compared to non-Hispanic white children.

    View details for DOI 10.3390/children8050349

    View details for PubMedID 33924912

    View details for PubMedCentralID PMC8145521

  • Correlates of Objectively Measured Sleep and Physical Activity Among Latinx 3-To-5-Year Old Children. Journal of pediatric nursing Kang, A. W., Gans, K. M., Minkel, J., Risica, P. M. 2021; 60: 40-45

    Abstract

    Latinx children have the highest prevalence of obesity in the US. Physical activity (PA) and sleep are important risk factors for this health disparity, yet limited evidence exists examining objectively measured data among this population. We aim to identify correlates of sleep and PA, as well as the association between sleep and PA, among a sample of Latinx children.A cross-sectional study was conducted with thirty Latinx 3-to-5-year old children who wore GT3X+ triaxial accelerometers for five consecutive days, from which we examined sleep and PA constructs. Linear regression and ANOVA were used to examine study constructs.Sedentary behavior, light PA, and MVPA (moderate-to-vigorous PA) were 51.7, 5.6, and 2.6 min/h respectively. Total sleep duration averaged 9.6 h, sleep efficiency averaged 80.0%, and sleep variability averaged 1.30 h/night. Higher household income was associated with sleep variability (F = 7.240, p = .012) and lower sedentary behavior (F = 5.481, p = .027), and higher sleepiness was associated with lower MVPA (β = -0.503, p = .005) and higher child BMI (β = 0.531, p = .033). MVPA was associated with higher sleep efficiency (β = 0.441, p = .016).Household income emerged as a correlate of sleep variability and sedentary behavior in our study. In addition, we found that MVPA levels were associated with sleep efficiency.Our results signal an impetus for further research (particularly with larger, multi-site study designs) examining study constructs among Latinx children.

    View details for DOI 10.1016/j.pedn.2021.01.010

    View details for PubMedID 33618176

  • Ethnic Differences in Family Childcare Providers' Nutrition- and Activity-Related Attitudes and Barriers. Journal of obesity Jiang, Q., Tovar, A., Risica, P. M., Cooksey Stowers, K., Schwartz, M., Lombardi, C., Kang, A., Mena, N. Z., Gans, K. M. 2021; 2021: 6697006

    Abstract

    Objective: The aim of the study is to examine family childcare providers' (FCCPs) attitudes and perceived barriers related to nutrition, physical activity (PA), and screen time (ST) behaviors of preschool children, exploring differences by provider ethnicity.Design: Baseline survey data from a cluster-randomized trial. Participants. Around 168 FCCPs completed a telephone survey, and 126 completed both telephone and in-person surveys. Main Outcome Measures. Phone and in-person surveys include 44 questions to assess FCCPs attitudes and perceived barriers regarding nutrition, PA, and ST in the family childcare home. Analysis. Associations by ethnicity (Latinx vs. non-Latinx) were assessed by ANOVA, adjusting for provider education and Bonferroni correction.Results: Some FCCP attitudes were consistent with national obesity prevention guidelines; for example, most FCCPs agreed that they have an important role in shaping children's eating and PA habits. However, many FCCPs agreed with allowing children to watch educational TV and did not agree that children should serve themselves at meals. Adjusting for education, there were statistically significant differences in attitude and perceived barrier scores by provider ethnicity. For example, Latinx FCCPs were more likely to agree that they should eat the same foods as children(p < .001) but less likely to agree that serving the food at meal and snack time is the adult's responsibility (p < .001). Latinx FCCPs were more like to perceive barriers related to children's safety playing outside (p < .001). Conclusions and Implications. While FCCPs hold some nutrition-, PA-, and ST-related attitudes consistent with national guidelines, training opportunities are needed for FCCPs to improve knowledge and skills and overcome perceived barriers related to nutrition and PA. Latinx FCCPs, in particular, may need culturally tailored training and support to overcome misperceptions and barriers.

    View details for DOI 10.1155/2021/6697006

    View details for PubMedID 34659829

  • Association between sleep duration and differences between weekday and weekend sleep with body mass index & waist circumference among Black women in Sistertalk II. Sleep health Ash, T., Kang, A., Hom, C., Risica, P. M. 2020; 6 (6): 797-803

    Abstract

    Examine associations between sleep duration and differences between weekday and weekend sleep with body mass index and waist circumference in a sample of high-risk Black women from the SisterTalk II study.Cross-sectional analysis of baseline data from an intervention study targeting dietary and physical activity behaviors.Women were recruited from the Providence, RI, USA, area.The sample includes 569 middle-aged Black women who were hypertensive or at risk for hypertension.Participants self-reported their weekday and weekend sleep duration. Body mass index (BMI) and waist circumference (WC) were objectively measured. Associations between the sleep and anthropometric measures were examined using analysis of variance and multivariable regression models controlling for birthplace, educational attainment, employment status, and annual household income.25.5% of the sample were very short sleepers (≤6 hrs), 28.8% short sleepers (≥6 to <7 hrs), 40.4% recommended sleepers (≥7 to ≤9 hrs), and 5.3% long sleepers (>9 hrs); 70.7% had a consistent sleep duration (≤2-hour difference between weekday and weekend sleep duration), 21.6% were classified as "weekend snoozers" (>2-hours more sleep on weekends), and 7.7% were classified as "weekend warriors" (>2-hours less sleep on weekends). Compared to recommended sleepers, very short sleepers and long sleepers had significantly greater BMIs, while long sleepers had significantly larger WCs. Being a weekend snoozer was also associated with increased BMI and WC.In this sample of high-risk Black women, sleep duration and differences between weekday and weekend sleep were independently associated with excess weight and abdominal obesity.

    View details for DOI 10.1016/j.sleh.2020.05.005

    View details for PubMedID 32665187

    View details for PubMedCentralID PMC7749836

  • Effects of Coparenting Quality, Stress, and Sleep Parenting on Sleep and Obesity Among Latinx Children: A Path Analysis. Journal of pediatric health care : official publication of National Association of Pediatric Nurse Associates & Practitioners Kang, A. W., Gans, K. M., Minkel, J., Risica, P. M. 2020; 34 (6): e77-e90

    Abstract

    We sought to examine the associations among parent-level constructs, sleep-related parenting practices, and child sleep in Latinx families.A quantitative study was conducted with 101 Latinx parents of children aged 2-5 years. Key variables that were examined included parental stress, coparenting quality, bedtime routine consistency, parent-child sleep interactions, and child's sleep duration.Path analysis results indicated that (1) parent stress had a direct effect on child sleep duration (p =.005) and was mediated by parent-child sleep interactions (p =.021); (2) coparenting quality had a direct effect on child sleep duration (p =.001) and was mediated by bedtime routine consistency (p =.010); and (3) bedtime routine consistency had an indirect effect on child body mass index percentile and was mediated by sleep duration (p =.049).Coparenting quality and parental stress may be important constructs to consider when designing interventions to improve Latinx child sleep duration.

    View details for DOI 10.1016/j.pedhc.2020.06.010

    View details for PubMedID 32891498

  • Associations between health literacy and health care utilization and mortality in patients with coexisting diabetes and end-stage renal disease: A prospective cohort study. British journal of health psychology Griva, K., Yoong, R. K., Nandakumar, M., Rajeswari, M., Khoo, E. Y., Lee, V. Y., Kang, A. W., Osborne, R. H., Brini, S., Newman, S. P. 2020; 25 (3): 405-427

    Abstract

    Objectives Health literacy encompasses a broad skill set linked to patients' self-management ability and the complexity of their health care environments. Self-management in the context of multimorbidity is particularly challenging, placing patients at risk of poor clinical outcomes. This study aimed to explore the prognostic associations between health literacy domains, depression, and 12-month health care utilization and mortality in patients with diabetes and end-stage renal disease (DM-ESRD). Design Observational study. Methods Patients with DM-ESRD undergoing haemodialysis were recruited. Information on all-cause hospitalization/admission and mortality of participants was recorded. Negative binomial and Cox regressions were used to model risk factors for hospitalization and mortality. Results A total 221 participants [median age: 59 years, 61.6% men, 54.8% Chinese] were recruited. Differences in health literacy were found as a function of age, ethnicity, relationship status, and education. After adjusting for demographic and clinical factors, the HLQ domain Actively Managing My Health remained independently associated with lower rates of hospitalization (incidence rate ratio (IRR) = 0.674, 95% CI [0.490, 0.925], p = .02) and mortality (hazard ratio = 0.382, 95% CI [0.160, 0.848], p = .02). Cumulative hospitalization days were associated with employment status (IRR = 2.242, 95% CI [1.223, 4.113], p = .009), albumin (IRR = 0.918, 95% CI [0.854, 0.988], p = .02), HbA1c (IRR = 1.183, 95% CI [1.028, 1.360], p = .02), comorbidity burden (IRR = 1.137, 95% CI [1.003, 1.289], p = .04), and depression (IRR = 1.059, 95% CI [1.003, 1.118], p = .04) but no health literacy domains. Conclusions Health literacy skills related to Actively Managing My Health predict hospitalization and mortality independently of other risk factors. The HLQ provides an assessement of novel health literacy parameters which offer new insights into patients' status and behaviours and may strengthen interventions to improve clinical services, and patient outcomes in DM-ESRD. Statement of contribution What is already known on this subject? Patients with diabetes (DM) comprise the fastest growing segment of patients with end-stage renal disease (ESRD). Health literacy (HL) is pivotal for managing the complex treatment guidelines for DM-ESRD. Most prior work on HL focused on functional HL and shown significant associations with mortality and hospitalization. Limited research has investigated wider HL skills in relation to clinical outcomes. What does this study add? Supporting patients in Actively Managing my health liteacy skills is critical in decreasing probability of hospitalization and morbidity. The presence of symptoms of depression is associated with longer hospitalization period.

    View details for DOI 10.1111/bjhp.12413

    View details for PubMedID 32304286

  • Exploring Parenting Contexts of Latinx 2-to-5-Year Old Children's Sleep: Qualitative Evidence Informing Intervention Development. Journal of pediatric nursing Kang, A. W., Ash, T. R., Tovar, A., Gans, K. M., Minkel, J., Mena, N. Z., Risica, P. M. 2020; 54: 93-100

    Abstract

    Poor sleep quality is associated with childhood obesity, and Latinx children have the highest prevalence of obesity in the United States. Parents are key agents to ensuring good sleep quality among children, but limited research has examined sleep parenting among Latinx working parents who may have added responsibilities.Working Latinx parents of 2-to-5-year old children participated in in-depth interviews exploring parenting and familial contexts of child sleep. Main topics in the interview guide included sleep-related parenting practices, social support, cultural influences, and intervention service delivery and content preferences. Thematic analysis was used to analyze data.Twenty parents completed the interview. The following themes emerged: Sleep parenting, sleep knowledge, impact of familial structures, family commitments, child temperament, and broader contextual factors on sleep, and intervention content and design ideas. Across participants, employment was reported to be a barrier to effective sleep parenting. Parents also reported engaging in practices that may interfere with sleep quality such as using screen time as a distraction and reducing naptime during the weekends to increase the amount of family time. Family-level factors such as co-parenting and spousal support were reported to facilitate sleep parenting. Participants also indicated the need for more sleep parenting knowledge and a preference for mobile platforms and social media to deliver information.Results not only fill critical gaps in the literature, but also highlight the variability in parents' approaches to sleep parenting and an urgent need for intervention/programming efforts to target Latinx parent's sleep knowledge and parenting.

    View details for DOI 10.1016/j.pedn.2020.07.006

    View details for PubMedID 32801064

  • Physical activity and risk of cardiovascular events and all-cause mortality among kidney transplant recipients. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association Kang, A. W., Bostom, A. G., Kim, H., Eaton, C. B., Gohh, R., Kusek, J. W., Pfeffer, M. A., Risica, P. M., Garber, C. E. 2020; 35 (8): 1436-1443

    Abstract

    Insufficient physical activity (PA) may increase the risk of all-cause mortality and cardiovascular disease (CVD) morbidity and mortality among kidney transplant recipients (KTRs), but limited research is available. We examine the relationship between PA and the development of CVD events, CVD death and all-cause mortality among KTRs.A total of 3050 KTRs enrolled in an international homocysteine-lowering randomized controlled trial were examined (38% female; mean age 51.8 ± 9.4 years; 75% white; 20% with prevalent CVD). PA was measured at baseline using a modified Yale Physical Activity Survey, divided into tertiles (T1, T2 and T3) from lowest to highest PA. Kaplan-Meier survival curves were used to graph the risk of events; Cox proportional hazards regression models examined the association of baseline PA levels with CVD events (e.g. stroke, myocardial infarction), CVD mortality and all-cause mortality over time.Participants were followed up to 2500 days (mean 3.7 ± 1.6 years). The cohort experienced 426 CVD events and 357 deaths. Fully adjusted models revealed that, compared to the lowest tertile of PA, the highest tertile experienced a significantly lower risk of CVD events {hazard ratio [HR] 0.76 [95% confidence interval (CI) 0.59-0.98]}, CVD mortality [HR 0.58 (95% CI 0.35-0.96)] and all-cause mortality [HR 0.76 (95% CI 0.59-0.98)]. Results were similar in unadjusted models.PA was associated with a reduced risk of CVD events and all-cause mortality among KTRs. These observed associations in a large, international sample, even when controlling for traditional CVD risk factors, indicate the potential importance of PA in reducing CVD and death among KTRs.

    View details for DOI 10.1093/ndt/gfaa038

    View details for PubMedID 32437569

    View details for PubMedCentralID PMC7828582

  • Antenatal dietary concordance among mothers and fathers and gestational weight gain: a longitudinal study. BMC public health Figueroa, R., Saltzman, J. A., Kang, A., Mini, F. N., Davison, K. K., Taveras, E. M. 2020; 20 (1): 1071

    Abstract

    Parent-child dietary concordance is associated with child diet, but the clinical implications of mother-father dietary concordance during pregnancy are unknown. This study evaluates antenatal mother-father dietary concordance and associations with gestational weight gain (GWG).Mother-father (n = 111) dyads with low income reported their fruit/vegetable (FV), fast food (FF), and sugar-sweetened beverage (SSB) consumption frequency during the first trimester of pregnancy. From electronic health records, we collected height and self-reported pre-pregnancy weight and calculated pre-pregnancy body mass index (BMI). The primary outcome was excessive GWG for pre-pregnancy BMI. Dyads were categorized as healthy or unhealthy concordant (consuming similarly high or low amounts of FV, FF, or SSB), or mother-healthy or father-healthy discordant (consuming different amounts of FV, FF, or SSB). Multivariable and logistic regressions analyzed associations between dietary concordance and GWG.Mothers were Hispanic (25%), 43% White, 6% Black, and 23% Asian or Other. Most mothers were employed (62%) making <$50,000/year (64%). Average maternal GWG was 11.6 kg (SD = 6.40), and 36% had excessive GWG. Mothers in the mother-healthy discordant FV group (OR = 4.84; 95% CI = 1.29, 18.22) and the unhealthy concordant FF group (OR = 7.08; 95% CI = 2.08, 24.12) had higher odds for excessive GWG, compared to healthy concordant dyads. SSB concordance was associated with higher GWG in unadjusted, but not adjusted models.Mothers had higher risk for excessive GWG when both partners had unhealthy FF consumption frequency, and when fathers had unhealthy FV consumption frequency. These findings imply that fathers should be involved in educational opportunities regarding dietary intake during pregnancy.

    View details for DOI 10.1186/s12889-020-09182-7

    View details for PubMedID 32631291

    View details for PubMedCentralID PMC7339503

  • Changes in quality of life and sleep across the perinatal period in women with mood disorders. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation Kang, A. W., Pearlstein, T. B., Sharkey, K. M. 2020; 29 (7): 1767-1774

    Abstract

    The perinatal period represents a time of significant life changes associated with increases in sleep difficulties, depression, and potentially impaired quality of life (QoL). Associations between QoL and sleep among women with perinatal depression are poorly understood, and changes in QoL across the perinatal period have received little attention.Participants were the treatment-as-usual group (n = 23) from a clinical trial testing an intervention for perinatal mood disorders. They completed the WHOQOL-Bref, had depression assessed with the HAM-D-17, and wore wrist actigraphs to estimate sleep for 1 week during third trimester and at 6 weeks postpartum.Higher education level was associated with better environmental QoL during pregnancy (p = .044) and presence of older children was associated with worse social QoL postpartum (p = .045). Psychological health QoL worsened (p = .014) across the perinatal period. Total sleep time (p = .001) and sleep efficiency (p = .008) decreased from third trimester to postpartum week 6, but sleep measures were not associated with QoL at either time point. Depressive symptoms decreased from pregnancy to postpartum week 6 and were inversely associated with postpartum physical and social QoL (p = .031 and .048).Factors contributing to self-rated QoL are variable across multiple domains during the perinatal period. QoL among our participants was lower than population norms. In our sample of women with depression and/or anxiety, QoL was related to postpartum depressive symptoms, but not to objectively measured sleep quality, quantity, or timing. Links between QoL and sleep may be inherently complex in perinatal women.

    View details for DOI 10.1007/s11136-020-02437-1

    View details for PubMedID 32016680

    View details for PubMedCentralID PMC7299811

  • Cumulative Social Risk and Cardiovascular Disease Among Adults in South Korea: A Cross-Sectional Analysis of a Nationally Representative Sample. Preventing chronic disease Lee, H. H., Kang, A. W., Lee, H., Cha, Y., Operario, D. 2020; 17: E39

    Abstract

    The Framingham risk score (FRS) is widely used to predict cardiovascular disease (CVD), but it neglects to account for social risk factors. Our study examined whether use of a cumulative social risk score in addition to the FRS improves prediction of CVD among South Korean adults.We used nationally representative data on 19,147 adults aged 19 or older from the Korea National Health and Nutrition Examination Survey 2013-2016. We computed a cumulative social risk score (range, 0-3) based on 3 social risk factors: low household income, low level of education, and single-living status. CVD outcomes were stroke, myocardial infarction, and angina. Weighted logistic regression examined the associations between cumulative social risk, FRS, and CVD. McFadden pseudo-R2 and area under receiver operating characteristic curve (AUC) assessed model performance. We conducted mediation analyses to quantify the association between cumulative social risk score and CVD outcomes that is not mediated by the FRS.A unit increase in social risk was associated with 89.4% higher risk of stroke diagnosis, controlling for the FRS (P < .001). The FRS explained 8.0% of stroke diagnosis (R2) with fair discrimination (AUC = 0.728), and adding the cumulative social risk score enhanced R2 and AUC by 2.4% and 0.039. In the association between cumulative social risk and stroke, the proportion not mediated by the FRS was 65% (P < .001). We observed similar trends in myocardial infarction and angina, such that an increase in social risk was associated with increased relative risk of disease and improved disease diagnosis, and a large proportion of the association was not mediated by the FRS.Controlling for the FRS, cumulative social risks predicted stroke, myocardial infarction, and angina among adults in South Korea. Future research is needed to examine non-FRS mediators between cumulative social risk and CVD.

    View details for DOI 10.5888/pcd17.190382

    View details for PubMedID 32463785

    View details for PubMedCentralID PMC7279061

  • Society of Behavioral Medicine position statement: Support the updated hypertension guidelines and modify Medicare Part B to improve hypertension management. Translational behavioral medicine Kang, A. W., Freedland, K. E., Janke, A., Sumner, J. A., Hayman, L. L., Fitzgibbon, M., Buscemi, J., Dulin, A. 2020; 10 (2): 495-497

    Abstract

    Hypertension contributes to significant global health and economic burdens. The American College of Cardiology/American Heart Association's latest guideline lowers the blood pressure threshold for hypertension, and as a result, the number of adults with hypertension has increased. Hypertension is a major risk factor for cardiovascular morbidity, especially among older adults. Many individuals who are diagnosed with hypertension at the new, lower threshold may benefit from lifestyle counseling, but changes to existing Medicare policies are required to increase utilization of evidence-based lifestyle counseling approaches to hypertension management. We recommend appropriate funding for the reimbursement of evidence-based lifestyle counseling for hypertension management, the expansion of medical nutrition therapy counseling coverage as an option for Medicare beneficiaries with hypertension, the inclusion of home-based blood pressure monitoring devices in the list of Durable Medical Equipment Coverage, and modifications to the Medicare Benefit Policy Manual to prioritize evidence-based programs such as Dietary Approaches to Stop Hypertension, American Heart Association, and plant-predominant dietary programs.

    View details for DOI 10.1093/tbm/ibz104

    View details for PubMedID 31228195

  • The 'Check-It-Out' intervention increases confidence and practices of thorough skin self-examination. Journal of the European Academy of Dermatology and Venereology : JEADV Misitzis, A., Kang, A., Weinstock, M. A., Risica, P. M. 2020; 34 (2): e77-e78

    View details for DOI 10.1111/jdv.15969

    View details for PubMedID 31568597

  • Relationship between adherence to diet and physical activity guidelines and self-efficacy among black women with high blood pressure. Journal of health psychology Kang, A., Dulin, A., Risica, P. M. 2020: 1359105320967105

    Abstract

    Hypertension prevalence is highest among Black women in America. Understanding the relationship between adherence to diet and physical activity using socio-cognitive approaches (e.g. self-efficacy and social support) may be effective approaches in understanding hypertension management. This study found that dietary self-efficacy was associated with dietary adherence, and family social support was associated with both diet and physical activity self-efficacy. Social support mediated the relationship between dietary self-efficacy and dietary adherence. A paradoxical finding emerged where participants in the highest self-efficacy tertile also had higher measured systolic blood pressure. More research is necessary to explore culture-specific factors underlying hypertension treatment management among Black women.

    View details for DOI 10.1177/1359105320967105

    View details for PubMedID 33081506

  • Awareness and Acceptability of pre-exposure prophylaxis (PrEP) among gay, bisexual and other men who have sex with men (GBMSM) in Kenya. AIDS care Ogunbajo, A., Kang, A., Shangani, S., Wade, R. M., Onyango, D. P., Odero, W. W., Harper, G. W. 2019; 31 (10): 1185-1192

    Abstract

    Kenyan gay, bisexual, and other men who have sex with men (GBMSM) are significantly affected by HIV. Pre-exposure prophylaxis (PrEP) is an effective biomedical approach to HIV prevention. We conducted a cross-sectional survey of 459 HIV-negative Kenyan GBMSM to assess individual and interpersonal correlates of PrEP awareness/acceptability using univariate and hierarchical logistic regression modeling. We found that 64.3% of participants had heard of PrEP and 44.9% were willing to use PrEP. In hierarchical logistic regression models for PrEP awareness, condom use with regular partners, higher condom use self-efficacy, higher perceived ability to use PrEP, history of STI, and membership in LGBT organization were significantly associated with being aware of PrEP (χ2 = 69.6, p < .001). In hierarchical logistic regression models for PrEP acceptability, higher self-esteem, higher condom use self-efficacy, depression/anxiety, higher perceived ability to use PrEP, willingness to engage in PrEP follow-up visits, coercion at sexual debut, and family exclusion were significantly associated with being acceptable to PrEP (χ2 = 231.8, p < .001). Individual and interpersonal factors were significantly associated with PrEP awareness and acceptability. Our findings underscore the need to promote awareness and understanding of PrEP as an effective HIV prevention tool in combination with other safer-sex methods that are appropriate given an individual's personal circumstances.

    View details for DOI 10.1080/09540121.2019.1612023

    View details for PubMedID 31039628

    View details for PubMedCentralID PMC6663573

  • Therapy-seeking behavior among parents concerned about their adolescent's substance use. Substance abuse Kang, A. W., Escobar, K., Tavares, T., Helseth, S. A., Kelly, L. M., Becker, S. J. 2019; 40 (4): 489-495

    Abstract

    Background: Among the most persistent public health problems in the United States is the gap between adolescents who need therapy for a substance use (SU) disorder and those who seek therapy. The role of parental factors (e.g., impressions of the adolescent's symptoms, sociodemographic factors) has been well documented in work examining adolescent help-seeking from professionals and paraprofessionals but has not been evaluated in studies of therapy-seeking for adolescents with SU. This study's primary objective was to identify parental sociodemographic and parent-reported clinical factors associated with therapy-seeking among parents concerned about their adolescent's SU. A secondary objective was to explore reasons why parents reported not seeking therapy and whether these reasons were associated with sociodemographic and clinical variables. Methods: We conducted a survey of 411 parents of adolescents (age 12-19) who reported elevated concern about their adolescent's SU. Parents were asked whether their adolescent had a history of therapy, and those who reported no history were asked an open-ended question about reasons why they had not sought therapy. Responses were rated by 2 independent coders and used to sort parents into 3 groups: "treaters" (those who had sought therapy), "acknowledgers" (those who acknowledged their adolescent had SU problems but did not seek therapy), and "deniers" (those who denied their adolescent had SU problems). Multinomial logistic regression examined the relationship between sociodemographic and clinical factors and group membership. Results: Multivariate analyses revealed that parent-reported SU severity, internalizing distress, and externalizing behavior problems were all associated with therapy-seeking behavior, with internationalizing distress emerging as the strongest predictor. Additionally, non-Hispanic white parents were more likely to seek therapy than minority parents. Conclusions: Parent report of symptoms, especially internalizing distress, and parental race were associated with therapy-seeking behavior, highlighting opportunities for targeted outreach to engage parents in therapy.

    View details for DOI 10.1080/08897077.2019.1621240

    View details for PubMedID 31206349

    View details for PubMedCentralID PMC6918007

  • Physical Activity and Cardiovascular Risk among Kidney Transplant Patients. Medicine and science in sports and exercise Kang, A. W., Garber, C. E., Eaton, C. B., Risica, P. M., Bostom, A. G. 2019; 51 (6): 1154-1161

    Abstract

    Research examining the relationship between physical activity (PA) and cardiovascular disease (CVD) risk factors among kidney transplant recipients (KTR) is limited. Accordingly, we sought to 1) describe the levels of PA in KTR and 2) analyze the associations between PA levels and CVD risk factors in KTR.Baseline data from KTR participants in a large multiethnic, multicenter trial (the Folic Acid for Vascular Outcome Reduction in Transplantation) were examined. PA was categorized in tertiles (low, moderate, and high) derived from a modified PA summary score from the Yale Physical Activity Survey. CVD risk factors were examined across levels of PA by ANOVA, Kruskal-Wallis rank test, and hierarchical multiple regression.The 4034 participants were 37% female (mean ± SD = 51.9 ± 9.4 yr of age, 75% White, 97% with stage 2T-4T chronic kidney disease, and 20% with prevalent CVD. Participants in the "high" PA tertile reported more vigorous PA and walking, compared with participants in moderate and low tertiles (both P < 0.001). No differences were observed in daily household, occupational, or sedentary activities across PA tertiles. More participants in the "low" PA tertile were overweight/obese, had a history of prevalent diabetes, and/or had CVD compared with more active participants (all P < 0.001). Hierarchical modeling revealed that younger age (P = 0.002), cadaveric donor source (P = 0.006), shorter transplant vintage (P = 0.025), lower pulse pressure (P < 0.001), and no history of diabetes (P < 0.001) were associated with higher PA scores.The most active KTR engaged in more intentional exercise. Lower levels of PA were positively associated with more CVD risk factors. Higher PA levels were associated with younger age and with more positive KTR outcomes.

    View details for DOI 10.1249/MSS.0000000000001886

    View details for PubMedID 30629045

    View details for PubMedCentralID PMC6522300

  • Factors associated with contingency management adoption among opioid treatment providers receiving a comprehensive implementation strategy. Substance abuse Becker, S. J., Kelly, L. M., Kang, A. W., Escobar, K. I., Squires, D. D. 2019; 40 (1): 56-60

    Abstract

    Background: Contingency management (CM) is an evidence-based behavioral intervention for opioid use disorders (OUDs); however, CM adoption in OUD treatment centers remains low due to barriers at patient, provider, and organizational levels. In a recent trial, OUD treatment providers who received the Science to Service Laboratory (SSL), a multilevel implementation strategy developed by a federally funded addiction training center, had significantly greater odds of CM adoption than providers who received training as usual. This study examined whether CM adoption frequency varied as a function of provider sociodemographic characteristics (i.e., age, race/ethnicity, licensure) and perceived barriers to adoption (i.e., patient-, provider-, organization-level) among providers receiving the SSL in an opioid treatment program. Methods: Thirty-nine providers (67% female, 77% non-Hispanic white, 72% with specialty licensure, Mage = 42 [SD = 11.46]) received the SSL, which consisted of didactic training, performance feedback, specialized training of internal change champions, and external coaching. Providers completed a comprehensive baseline assessment and reported on their adoption of CM biweekly for 52 weeks. Results: Providers reported using CM an average of nine 2-week intervals (SD = 6.35). Hierarchical multiple regression found that providers identifying as younger, non-Hispanic white, and without addiction-related licensure all had higher levels of CM adoption frequency. Higher perceived patient-level barriers predicted lower levels of CM adoption frequency, whereas provider- and organization-level barriers were not significant predictors. Conclusions: The significant effect of age on CM adoption frequency was consistent with prior research on predictors of evidence-based practice adoption, whereas the effect of licensure was counter to prior research. The finding that CM adoption frequency was lower among racially/ethnically diverse providers was not expected and suggests that the SSL may require adaptation to meet the needs of diverse opioid treatment providers. Entities using the SSL may also wish to incorporate a more explicit focus on patient-level barriers.

    View details for DOI 10.1080/08897077.2018.1455164

    View details for PubMedID 29595403

    View details for PubMedCentralID PMC6163086

  • Nutrition-Related Practices of Family Child Care Providers and Differences by Ethnicity. Childhood obesity (Print) Gans, K. M., Tovar, A., Jiang, Q., Mello, J., Dionne, L., Kang, A., Mena, N. Z., Palomo, V., Risica, P. M. 2019; 15 (3): 167-184

    Abstract

    Child care settings play an important role in shaping children's eating behaviors; yet few studies have included family child care homes (FCCHs). We examined provider-reported nutrition-related practices in FCCHs and observed adherence to nutrition guidelines from the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC), exploring differences by provider ethnicity.We assessed baseline data from a cluster-randomized trial, including surveys with FCCH providers and observational data collected at the FCCH. We examined provider-reported nutrition-related practices and if providers met NAP SACC guidelines using observational data. Differences by ethnicity were assessed using chi-square and multivariate log-linear analysis adjusting for education.Providers completed a telephone survey (n = 166, 100% female and 72% Hispanic) and participated in 2 full-day observations (n = 119). Many providers reported engaging in positive nutrition-related practices. Significant differences by ethnicity included the following: Hispanic providers less likely to report feeding practices that were responsive to children's self-regulation, but also less likely to report eating and drinking unhealthy foods/beverages in front of children and having screens on during meals and more likely to report seeking nutrition trainings. Using observational data, only 10 of 26 NAP SACC practices were met by >60% of providers. Few ethnic differences in meeting guidelines were found (7 of 26 practices).While providers engage in some positive nutrition practices, improvement is needed to ensure that all providers actually meet evidence-based guidelines. Ethnic differences in certain practices underscore the need for culturally relevant trainings.NCT02452645.

    View details for DOI 10.1089/chi.2018.0083

    View details for PubMedID 30707598

    View details for PubMedCentralID PMC6909752

  • Evaluating Burden and Quality of Life among Caregivers of Patients Receiving Peritoneal Dialysis. Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis Kang, A., Yu, Z., Foo, M., Chan, C. M., Griva, K. 2019; 39 (2): 176-180

    Abstract

    Peritoneal dialysis (PD) is advocated as treatment of choice for most end-stage renal disease (ESRD) patients, including elderly and frail patients. It typically requires caregiver involvement to support care at home. The purpose of this study was to examine changes in burden and quality of life (QOL) in caregivers of prevalent PD patients over 12 months. Data were collected in 44 caregivers of PD patients (mean age 38.4 ± 6.3 years; 60% female) in Singapore at baseline and 12 months. Measures included demographics, the Lay Care-Giving for Adults Receiving Dialysis (LC-GAD), Zarit Burden Interview (ZBI), and the World Health Organization Quality of Life instrument (WHOQOL-BREF). Paired t-tests indicate a significant decrease in task-related aspects of caregiving (p = 0.04), particularly in relation to personal hygiene (p < 0.01), over time. Cognitive aspects of caregiving remained unchanged. Perceived burden, however, significantly increased (p < 0.01), with significantly more caregivers reporting moderate to severe caregiver burden at follow-up (28%) relative to baseline (13%; p < 0.01). There was a significant reduction in psychological health (under WHOQOL) (p = 0.01). Study findings indicate an increase in caregiver burden and a reduction in psychological health despite a reduction in task-related aspects of caregiving, supporting a further exploration of the "wear-and-tear" hypothesis among this population. Intervention strategies are needed.

    View details for DOI 10.3747/pdi.2018.00049

    View details for PubMedID 30858285

  • Stress, adherence, and blood pressure control: A baseline examination of Black women with hypertension participating in the SisterTalk II intervention. Preventive medicine reports Kang, A. W., Dulin, A., Nadimpalli, S., Risica, P. M. 2018; 12: 25-32

    Abstract

    The prevalence of hypertension is highest among Black women, but treatment adherence is reportedly low. Stress unique to the experiences of Black Americans may be associated with low adherence and poor blood pressure control, but few studies have examined the relationships between stress, adherence, and blood pressure control among hypertensive Black women. This study seeks to fill gaps in research by examining the association between stress, adherence, and blood pressure control. The baseline sample (n = 571) of at-risk or hypertensive Black women from the SisterTalk II RCT (Northeastern USA, 2004-2006) to improve adherence to recommendations for hypertension was analyzed. Participants self-reported stress, pharmacological adherence, non-pharmacological adherence (i.e. lifestyle management such as diet and exercise), and demographics. Blood pressure and anthropometrics (BMI and waist circumference) were measured. Statistical analysis included ANOVA, t-tests, linear regression. Tests of mediation examined if adherence mediated the relationship between stress and blood pressure control. This study found that stress was associated with lower age (p < .001) and being a single parent (p < .001). Stress was also associated with higher systolic blood pressure (p = .029), and poor blood pressure control (p = .043). Participants who reported higher stress also reported lower non-pharmacological adherence (p = .042). Non-pharmacological adherence was found to mediate the association between stress and blood pressure control. Hence, results document a relationship between stress with non-pharmacological adherence and blood pressure control among Black American women. More research is necessary to examine the relationship between stress and treatment adherence.

    View details for DOI 10.1016/j.pmedr.2018.08.002

    View details for PubMedID 30128268

    View details for PubMedCentralID PMC6098218

  • Prevalence and determinants of anxiety and depression in end stage renal disease (ESRD). A comparison between ESRD patients with and without coexisting diabetes mellitus. Journal of psychosomatic research Yoong, R. K., Mooppil, N., Khoo, E. Y., Newman, S. P., Lee, V. Y., Kang, A. W., Griva, K. 2017; 94: 68-72

    Abstract

    To compare anxiety and/or depressive symptoms between patients with end-stage renal disease with and without comorbid diabetes and identify factors associated with symptoms of distress in this population.Data from two studies (conducted between 2010 and 2014) were pooled. A total of 526 patients on hemodialysis (68.8% with diabetes) completed the Hospital Anxiety and Depression Scale (HADS). Elevated symptoms were defined as HADS-Anxiety or HADS-Depression≥8. Univariate and multivariate logistic regressions were used to estimate associations between diabetic status, and other socio-demographic and clinical factors with baseline clinical anxiety and depression.A total of 233 (45.4%) reported elevated anxiety symptoms and 256 (49.9%) reported elevated depressive symptoms sufficient for caseness. Rates were not different between patients with and without diabetes. Risk for clinical depression was higher in patients who were single/unpartnered (OR=1.828), Chinese vs. Malay (OR=2.05), or had lower albumin levels (OR=0.932). None of the parameters were associated with anxiety caseness.Sociocultural factors rather than comorbid burden may help identify patients at risk for depression. The high rates of anxiety and depression underlie the importance for monitoring and intervention in dialysis care.

    View details for DOI 10.1016/j.jpsychores.2017.01.009

    View details for PubMedID 28183405

  • Managing multiple chronic conditions in Singapore - Exploring the perspectives and experiences of family caregivers of patients with diabetes and end stage renal disease on haemodialysis. Psychology & health Lee, V. Y., Seah, W. Y., Kang, A. W., Khoo, E. Y., Mooppil, N., Griva, K. 2016; 31 (10): 1220-36

    Abstract

    Diabetes mellitus (DM) is the commonest cause of end stage renal disease (ESRD). Despite increasing DM-ESRD prevalence and high dependency on care, there is a lack of literature on DM-ESRD caregivers. We sought to explore the perspectives and experiences of caregivers of patients with DM undergoing haemodialysis in Singapore.This study employed an exploratory, qualitative design comprising in-depth interviews with caregivers of DM-ESRD patients.Semi-structured interviews were conducted with a sample of 20 family caregivers (54.2 ± 12.6 years; 75% female) of DM-ESRD patients. Data were analysed using Thematic Analysis.Key caregiving challenges identified were managing diet, care recipients' emotions and mobility dependence. Patients' emotional reactions caused interpersonal conflicts and hindered treatment management. Difficulties in dietary management were linked to patients' erratic appetite, caregivers' lack/poor understanding of the dietary guidelines and caregivers' low perceived competence. Limited resources in terms of social support and finances were also noted. Physical and psychological well-being and employment were adversely affected by caregiving role.This study highlights distinctive aspects of the DM-ESRD caregiving experience, which impact on caregivers' health and challenge care. Disease management programmes should be expanded to support caregivers in dealing with multimorbidity.

    View details for DOI 10.1080/08870446.2016.1203921

    View details for PubMedID 27356152

  • The Course of Quality of Life in Patients on Peritoneal Dialysis: A 12-month Prospective Observational Cohort Study. International journal of behavioral medicine Lim, H. A., Yu, Z., Kang, A. W., Foo, M. W., Griva, K. 2016; 23 (4): 507-14

    Abstract

    Quality of life (QOL) impairments are common in patients undergoing dialysis, and have been strongly associated with significant clinical outcomes like mortality and morbidity. Despite this, little is known about the course of QOL over time, especially for patients on peritoneal dialysis (PD).This prospective study was set to explore course and determinants of QOL over 12 months in PD patients.A total of 115 PD patients completed the SF-12 and Kidney Disease Quality of Life Short Form (KDQOL-SF) at baseline and 12 months later. Intra-individual changes in physical (physical component summary, PCS), mental (mental component summary, MCS), and Kidney Disease Component Summary scores (KDCS) were identified based on the minimally important clinical difference threshold. Clinical information was extracted from medical records.Of the patients, 74-80 % reported physical QOL impairments, as compared to 29-33 % who reported mental/emotional QOL impairments. PCS and MCS scores remained stable across 12 months. Significant deterioration was noted in the domains of patient satisfaction, staff encouragement, and social support, while there were significant increases in the perceived effects of kidney disease. Intra-individual trajectory analyses indicated that one in three patients reported deteriorating QOL. No sociodemographic or clinical variables were found to be associated with course of outcomes.Although PD offers the convenience of home-based care, it is associated with persisting QOL impairments and diminishing QOL over time, especially in domains related to quality of care and support. This highlights the need for improving or maintaining standards of care and support for PD patients as they become increasingly established on their regimes.

    View details for DOI 10.1007/s12529-015-9521-z

    View details for PubMedID 26538341

  • Predicting technique and patient survival over 12 months in peritoneal dialysis: the role of anxiety and depression. International urology and nephrology Griva, K., Kang, A. W., Yu, Z. L., Lee, V. Y., Zarogianis, S., Chan, M. C., Foo, M. 2016; 48 (5): 791-6

    Abstract

    Emotional distress is common in dialysis patients, but its role on clinical outcomes for patients on peritoneal dialysis (PD) is uncertain.To evaluate the effect of depression and anxiety on 1-year prognosis in PD patients.A total of N = 201 PD patients (58.9 ± 12.59 years) completed the Hospital Anxiety Depression Scale and measures of social support at baseline and were followed up for CC technique and actuarial patient survival.Mortality and technique failure rates were 9.9 and 5.97 %, respectively. Carer-assisted PD, anxiety, comorbid burden and albumin were significant univariate predictors. Multivariate proportional hazard model to adjust for confounders indicated that anxiety remained significant with HR of 2.145 [95 % CI 1.03, 4.49, p = 0.043] for death/technique failure.Anxiety is an important predictor of actuarial and technique survival in PD. Effective treatment for symptoms of anxiety may represent an easily achievable means of improving the clinical outcome of PD patients.

    View details for DOI 10.1007/s11255-015-1191-x

    View details for PubMedID 26725079

  • Rates of Intentional and Unintentional Nonadherence to Peritoneal Dialysis Regimes and Associated Factors. PloS one Yu, Z. L., Lee, V. Y., Kang, A. W., Chan, S., Foo, M., Chan, C. M., Griva, K. 2016; 11 (2): e0149784

    Abstract

    With increasing emphasis on expanding home-based dialysis, there is a need to understand adherence outcomes. This study set out to examine the prevalence and predictors of nonadherence among patients undergoing peritoneal dialysis. A cross sectional sample of 201 peritoneal dialysis patients recruited between 2010-2011 from Singapore General Hospital completed measures of quality of life, medication beliefs, self-efficacy and emotional distress. Nonadherence rates were high; 18% for dialysis, 46% for medication and 78% for diet. Intentional nonadherence was more common for dialysis (p = .03), whereas unintentional nonadherence was more common for medication (p = .002). Multivariate models indicated significant associations for higher education (intermediate vs low OR = 3.18, high vs low OR = 4.70), lower environment quality of life (OR = 0.79), dialysis self-efficacy (OR = 0.80) with dialysis nonadherence; higher education (OR = 2.22), self-care peritoneal dialysis (OR = 3.10), perceived necessity vs concerns over medication (OR = 0.90), self-efficacy (OR = 0.76) with nonadherence to medication. The odds for nonadherence to diet were higher among patients who were younger (OR = 0.96), of Chinese ethnicity (OR = 2.99) and those reporting better physical health (OR = 1.30) and lower self-efficacy (OR = 0.49). Nonadherence is common in peritoneal dialysis. Self-efficacy and beliefs about medication are promising targets for interventions designed to improve adherence.

    View details for DOI 10.1371/journal.pone.0149784

    View details for PubMedID 26919323

    View details for PubMedCentralID PMC4769138

  • Quality of life and emotional distress in patients and burden in caregivers: a comparison between assisted peritoneal dialysis and self-care peritoneal dialysis. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation Griva, K., Goh, C. S., Kang, W. C., Yu, Z. L., Chan, M. C., Wu, S. Y., Krishnasamy, T., Foo, M. 2016; 25 (2): 373-384

    Abstract

    Assisted peritoneal dialysis (PD) involving caregivers allows more patients to get started on home-based dialysis with good clinical outcomes, but evidence on patient-reported and caregiver-reported outcomes is lacking. This study aimed to compare assisted PD versus self-care PD on quality of life (QoL) and psychosocial outcomes for patients and caregivers. The effect of PD modality [automated PD (APD); continuous ambulatory PD (CAPD)] in relation to self-care or assisted care was also examined.A cross-sectional sample of 231 PD patients [142 self-care (57 APD/85 CAPD) and 89 assisted care PD (45 APD/44 CAPD)], 72 caregivers of assisted PD patients and 39 family members of self-care PD patients completed the Kidney Disease Quality of Life Short Form (KDQOL-SF), World Health Organisation Quality of Life Instrument-brief and the Hospital Anxiety and Depression Scale. Caregivers and family members completed the Lay Care-Giving for Adults Receiving Dialysis questionnaire and Zarit Burden Interview.Case-mix-adjusted comparisons indicated comparable QoL in all dimensions with the exception of physical SF-12 (p = .001) and the KDQOL effects of kidney disease in favour of self-care PD. Levels of anxiety (9.72 ± 4.90; 8.25 ± 5.22) and depression (8.63 ± 3.80; 6.35 ± 4.76) were equivalent in assisted PD and self-care PD, respectively. Assisted PD caregivers reported more task-orientated duties (p = .007), yet levels of perceived burden were equal to those reported by family members of self-care PD.Our findings of mostly comparable patient and caregiver outcomes in assisted PD and self-care PD suggest that caregiver burden and QoL should not be a barrier to using assisted PD.

    View details for DOI 10.1007/s11136-015-1074-8

    View details for PubMedID 26195319

  • An assessment of nutrition practices and attitudes in family child-care homes: implications for policy implementation. Preventing chronic disease Tovar, A., Risica, P., Mena, N., Lawson, E., Ankoma, A., Gans, K. M. 2015; 12: E88

    Abstract

    Family child-care homes (FCCHs) provide care and nutrition for millions of US children, including 28% in Rhode Island. New proposed regulations for FCCHs in Rhode Island require competencies and knowledge in nutrition. We explored nutrition-related practices and attitudes of FCCH providers in Rhode Island and assessed whether these differed by provider ethnicity or socioeconomic status of the enrolled children.Of 536 licensed FCCHs in Rhode Island, 105 randomly selected FCCH providers completed a survey about provider nutrition attitudes and practices, demographics of providers, and characteristics of the FCCH, including participation in the federal Child and Adult Care Food Program (CACFP). No differences between CACFP and non-CACFP participants were found; responses were compared by provider ethnicity using χ(2) tests and multivariate models.Nearly 70% of FCCHs reported receiving nutrition training only 0 to 3 times during the past 3 years; however, more than 60% found these trainings to be very helpful. More Hispanic than non-Hispanic providers strongly agreed to sitting with children during meals, encouraging children to finish their plate, and being involved with parents on the topics of healthy eating and weight. These differences persisted in multivariate models.Although some positive practices are in place in Rhode Island FCCHs, there is room for improvement. State licensing requirements provide a foundation for achieving better nutrition environments in FCCHs, but successful implementation is key to translating policies into real changes. FCCH providers need culturally and linguistically appropriate nutrition-related training.

    View details for DOI 10.5888/pcd12.140587

    View details for PubMedID 26043303

    View details for PubMedCentralID PMC4456854

  • Improving outcomes in patients with coexisting multimorbid conditions-the development and evaluation of the combined diabetes and renal control trial (C-DIRECT): study protocol. BMJ open Griva, K., Mooppil, N., Khoo, E., Lee, V. Y., Kang, A. W., Newman, S. P. 2015; 5 (2): e007253

    Abstract

    Diabetes mellitus (DM) is the most common cause of end-stage renal disease (ESRD). Patients with diabetes on dialysis have worse clinical outcomes and increased psychological burden. The need to manage the combined treatment demands for both conditions is particularly challenging yet there is paucity of data of the barriers preventing optimal management to combined therapy for diabetes and kidney failure. The study aims to explore needs of patients and develop an intervention to enable people with diabetes and ESRD to better manage both their conditions.A two-phase study comprising a mixed method observational study (phase I) and a feasibility trial (phase II). Phase I will seek to document outcomes and needs of the population (patients with DM-ESRD) and seek input on preferred delivery/implementation for the programme. Data will be collected with in-depth interviews with patients, caregivers and healthcare providers (N=50), and from a questionnaire-based survey (N=170). Phase 2 will build on these data to design and test the feasibility of a practical, low-intensity, clinic-integrated intervention using a self-management paradigm. The intervention will primarily seek to support behavioural change so as to improve adherence and clinical outcomes for DM as well as for ESRD. For the feasibility trial, we will be evaluating acceptability, retention and completion rates of the programme.The study protocol has been approved by the local ethics committee and written informed consent is required from every participant. Findings will be disseminated through journals, conferences and will be used to create a fully manualised intervention (materials) and training course for facilitators.

    View details for DOI 10.1136/bmjopen-2014-007253

    View details for PubMedID 25678545

    View details for PubMedCentralID PMC4330324

  • Double the trouble - the challenges around managing diabetes and end stage renal disease European Health Psychologist Bulletin Griva, K., Lee, V., Kang, A. 2015; 16 (6)
  • Quality of life and emotional distress between patients on peritoneal dialysis versus community-based hemodialysis. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation Griva, K., Kang, A. W., Yu, Z. L., Mooppil, N. K., Foo, M., Chan, C. M., Newman, S. P. 2014; 23 (1): 57-66

    Abstract

    Patient-reported outcomes are important endpoints to evaluate new models of renal delivery. This is the first study to compare Quality of Life (QOL) and emotional adjustment outcomes between patients on community-based hemodialysis (HD) and those on peritoneal dialysis (PD).Data were collected between 2009 and 2011 from a cross-sectional sample of 232 HD patients and 201 PD patients recruited through community dialysis centers and outpatient PD clinics in Singapore. Participants completed the Hospital Anxiety and Depression Scale, World Health Organization Quality of Life Brief and the Short form for the Kidney Disease Quality of Life. Measures of ESRD severity, comorbidity and biochemistry were also collected.Physical and emotional QOL impairments were noted for both dialysis groups. Case-mix-adjusted comparisons indicated higher symptoms of depression (p = 0.027), and poorer physical health yet higher satisfaction with care (p = 0.001) in PD relative to community-based HD.Peritoneal dialysis regimes offer flexibility and autonomy under the support of PD teams. Although outcomes for most QOL domains measured were equivalent, PD patients are more satisfied with care but are at risk for emotional distress and provide poor ratings of physical health. Further research is needed to explore the expansion of standards of care to address psychosocial needs in PD populations.

    View details for DOI 10.1007/s11136-013-0431-8

    View details for PubMedID 23689932