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Fortmann SP, Bailey SR, Brooks NB, Hitsman B, Rittner SS, Gillespie SE, Hill CN, Leo MC, Crawford PM, Hu W, King DS, O'Cleirigh C, Puro J, Ann McBurnie M. Trends in smoking documentation rates in safety net clinics. Health Serv Res 2020; 55:170-177. [PMID: 31930738 DOI: 10.1111/1475-6773.13259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To assess the impact of provider incentive policy on smoking status documentation. DATA SOURCES Primary data were extracted from structured electronic medical records (EMRs) from 15 community health centers (CHCs). STUDY DESIGN This was an observational study of data from 2006 to 2013, assessing changes in documentation of smoking status over time. DATA EXTRACTION METHODS We extracted structured EMR data for patients age 18 and older with at least one primary care visit. PRINCIPAL FINDINGS Rates of documented smoking status rose from 30 percent in 2006 to 90 percent in 2013; the largest increase occurred from 2011 to 2012 following policy changes (21.3% [95% CI, 8.2%, 34.4%] from the overall trend). Rates varied by clinic and across patient subgroups. CONCLUSIONS Documentation of smoking status improved markedly after introduction of new federal standards. Further improvement in documentation is still needed, especially for males, nonwhite patients, those using opioids, and HIV + patients. More research is needed to study whether changes in documentation lead to improvements in counseling, cessation, and patient outcomes.
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Affiliation(s)
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon
| | - Neon B Brooks
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Brian Hitsman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | | | - Weiming Hu
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | | | - Conall O'Cleirigh
- The Fenway Institute, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jon Puro
- Research Informatics and Analytics, OCHIN, Inc., Portland, Oregon
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Latkin CA, Kennedy RD, Davey-Rothwell MA, Tseng TY, Czaplicki L, Baddela A, Edwards C, Chander G, Moran MB, Knowlton AR. The Relationship Between Neighborhood Disorder and Barriers to Cessation in a Sample of Impoverished Inner-City Smokers in Baltimore, Maryland, United States. Nicotine Tob Res 2019; 20:1451-1456. [PMID: 29126121 DOI: 10.1093/ntr/ntx252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 11/08/2017] [Indexed: 11/13/2022]
Abstract
Introduction Economic disparities in rates of smoking have been well documented in many countries. These disparities exist on an individual and geographic or neighborhood level. This cross-sectional study examined the relationship between neighborhood physical and social disorder and barriers to smoking cessation among an impoverished urban sample. Methods A sample of current smokers were recruited through street outreach, posted advertisements, and word of mouth from impoverished neighborhoods in Baltimore, Maryland, USA for a study of psychosocial factors and smoking behaviors. Neighborhood disorder was assessed with a 10-item scale from the Block Environmental Inventory and barriers to cessation with a 9-item scale. Results In the multiple logistic regression model, perceived stress (aOR = 1.60, 95% CI = 1.32 to 1.95), neighborhood disorder (aOR= 1.34, 95% CI = 1.11 to 1.63), and level of nicotine dependence (aOR = 1.97), 95% CI = 1.62 to 2.40) were all strongly associated with barriers to cessation. Conclusion The results of this study suggest that neighborhood disorder may lead to barriers to cessation among low-income populations. The findings also indicate that tobacco control interventions should examine and address social and physical aspects of impoverished neighborhoods. Implications In many countries, tobacco control programs and policies have been less effective among low-income populations as compared to more affluent populations. Little is known about how neighborhood factors influence smoking cessation. This study examined the relationship between neighborhood disorder and barriers to cessation among a low-income population. We recruited a convenience sample of hard-to-reach cigarette smokers from low-income neighborhoods. Even after controlling for level of nicotine dependence and stress, neighborhood disorder was found to be associated with barriers to cessation. The findings suggest the important role of neighborhood disorder as a barrier to smoking cessation.
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Affiliation(s)
- Carl A Latkin
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ryan D Kennedy
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Melissa A Davey-Rothwell
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Tuo-Yen Tseng
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Lauren Czaplicki
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Anirudh Baddela
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Catie Edwards
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Geetanjali Chander
- Division of Infectious diseases, Johns Hopkins School of Medicine, Baltimore, MD
| | - Meghan B Moran
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Amy R Knowlton
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Ahsan A, Zimmerman E, Rodriguez EM, Widman C, Erwin DO, Saad-Harfouche FG, Mahoney MC. Examining Lung Cancer Screening Behaviors in the Primary Care Setting: A Mixed Methods Approach. JOURNAL OF CANCER TREATMENT AND RESEARCH 2019; 7:1-8. [PMID: 31179379 PMCID: PMC6554719 DOI: 10.11648/j.jctr.20190701.11] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
While the National Lung Screening Trials (NLST) demonstrated the efficacy of low dose chest computed tomography (LDCT) for lung cancer early detection, utilization of LDCT remains suboptimal. The purpose of this formative study was to understand attitudes and beliefs among primary care clinicians regarding LDCT lung cancer screening as well as to assess gaps in knowledge to identify opportunities for reinforcing personalized lung cancer screening that is accessible and evidence-based. A 20-item closed and open-ended interview was conducted with a targeted group of primary care clinicians (38 respondents; 33 physicians and 5 NPs/PAs). Quantitative data were analyzed using descriptive statistics while qualitative data was analyzed thematically. Although 50.0% of clinicians characterized LDCT as "very effective", only 47.4% of clinicians reported that they frequently or often recommend LDCT as a lung cancer screening tool. Respondents were generally unconcerned with the high rate of false positive test results. The majority of clinicians were referring patients for LDCT based on smoking history, however other factors were also considered (e.g., health status, sex, family history, past medical history, and occupational exposures.) The majority of respondents were knowledgeable about the use of LDCT as a lung screening tool but were unsure about its effectiveness for lung cancer early detection. Some clinicians are recommending patients for LDCT based on factors which are inconsistent with evidence-based guidelines.
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Affiliation(s)
- Alvie Ahsan
- Jacobs School of Medicine and Biomedical Sciences, State University at New York at Buffalo, Buffalo, USA
| | - Eva Zimmerman
- Jacobs School of Medicine and Biomedical Sciences, State University at New York at Buffalo, Buffalo, USA
| | - Elisa Marie Rodriguez
- Department of Cancer Prevention & Control, Roswell Park Comprehensive Cancer Center, Buffalo, USA
| | - Christy Widman
- Department of Cancer Prevention & Control, Roswell Park Comprehensive Cancer Center, Buffalo, USA
| | - Deborah Oates Erwin
- Department of Cancer Prevention & Control, Roswell Park Comprehensive Cancer Center, Buffalo, USA
| | | | - Martin Christopher Mahoney
- Department of Cancer Prevention & Control, Roswell Park Comprehensive Cancer Center, Buffalo, USA
- Department of Internal Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, USA
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Flocke SA, Vanderpool R, Birkby G, Gullett H, Seaman EL, Land S, Zeliadt S. Addressing Tobacco Cessation at Federally Qualified Health Centers: Current Practices & Resources. J Health Care Poor Underserved 2019; 30:1024-1036. [PMID: 31422986 PMCID: PMC6724530 DOI: 10.1353/hpu.2019.0071] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This study assesses the current practices of Federally Qualified Health Centers (FQHCs) to address tobacco cessation with patients. A national sample of 112 FQHC medical directors completed the web-based survey. Frequently endorsed barriers to providing tobacco cessation services were: patients lacking insurance coverage (35%), limited transportation (27%), and variance in coverage of cessation services by insurance type (26%). Nearly 50% indicated that two or more tobacco cessation resources met the needs of their patients; 25% had one resource, and the remaining 25% had no resources. There were no differences among resource groups in the use of electronic health record (EHR) best-practice-alerts for tobacco use or in the perceived barriers to providing tobacco cessation assistance. Systems changes to harmonize coverage of tobacco assistance, such as broader accessibility to evidence-based cessation services could have a positive impact on the efforts of FQHCs to provide tobacco cessation assistance to their patients.
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Mahoney MC, Erwin DO, Twarozek AM, Saad-Harfouche FG, Rodriguez EM, Sun X, Underwood W, Fox C. Leveraging technology to promote smoking cessation in urban and rural primary care medical offices. Prev Med 2018; 114:102-106. [PMID: 29953897 PMCID: PMC6082685 DOI: 10.1016/j.ypmed.2018.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/04/2018] [Accepted: 06/24/2018] [Indexed: 10/28/2022]
Abstract
We examined the use of automated voice recognition (AVR) messages targeting smokers from primary care practices located in underserved urban and rural communities to promote smoking cessation. We partnered with urban and rural primary care medical offices (n = 7) interested in offering this service to patients. Current smokers, 18 years and older, who had completed an office visit within the previous 12 months, from these sites were used to create a smoker's registry. Smokers were recruited within an eight county region of western New York State between June 2012 and August 2013. Participants were contacted over six month intervals using the AVR system. Among 5812 smokers accrued 1899 (32%) were reached through the AVR system and 55% (n = 1049) continued to receive calls. Smokers with race other than white or African American were less likely to be reached (OR = 0.71, 0.57-0.90), while smokers ages 40 and over were more likely to be reached. Females (OR = 0.78, 0.65-0.95) and persons over age 40 years were less likely to opt out, while rural smokers were more likely to opt out (OR = 3.84, 3.01-4.90). Among those receiving AVR calls, 30% reported smoke free (self-reported abstinence over a 24 h period) at last contact; smokers from rural areas were more likely to report being smoke free (OR = 1.41, 1.01-1.97). An AVR-based smoking cessation intervention provided added value beyond typical tobacco cessation efforts available in these primary care offices. This intervention required no additional clinical staff time and served to satisfy a component of patient center medical home requirements for practices.
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Affiliation(s)
- Martin C Mahoney
- Department of Medicine, Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA.
| | - Deborah O Erwin
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | | | - Frances G Saad-Harfouche
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Elisa M Rodriguez
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Xiaoxi Sun
- State University of New York at Buffalo, Department of Biostatistics, Buffalo, New York, USA
| | - Willie Underwood
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Chester Fox
- State University of New York at Buffalo, Department of Family Medicine, Buffalo, New York, USA
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6
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Bailey SR, Heintzman JD, Marino M, Jacob RL, Puro JE, DeVoe JE, Burdick TE, Hazlehurst BL, Cohen DJ, Fortmann SP. Smoking-Cessation Assistance: Before and After Stage 1 Meaningful Use Implementation. Am J Prev Med 2017; 53:192-200. [PMID: 28365090 PMCID: PMC5522621 DOI: 10.1016/j.amepre.2017.02.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 01/10/2017] [Accepted: 02/02/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Brief smoking-cessation interventions in primary care settings are effective, but delivery of these services remains low. The Centers for Medicare and Medicaid Services' Meaningful Use (MU) of Electronic Health Record (EHR) Incentive Program could increase rates of smoking assessment and cessation assistance among vulnerable populations. This study examined whether smoking status assessment, cessation assistance, and odds of being a current smoker changed after Stage 1 MU implementation. METHODS EHR data were extracted from 26 community health centers with an EHR in place by June 15, 2009. AORs were computed for each binary outcome (smoking status assessment, counseling given, smoking-cessation medications ordered/discussed, current smoking status), comparing 2010 (pre-MU), 2012 (MU preparation), and 2014 (MU fully implemented) for pregnant and non-pregnant patients. RESULTS Non-pregnant patients had decreased odds of current smoking over time; odds for all other outcomes increased except for medication orders from 2010 to 2012. Among pregnant patients, odds of assessment and counseling increased across all years. Odds of discussing or ordering of cessation medications increased from 2010 compared with the other 2 study years; however, medication orders alone did not change over time, and current smoking only decreased from 2010 to 2012. Compared with non-pregnant patients, a lower percentage of pregnant patients were provided counseling. CONCLUSIONS Findings suggest that incentives for MU of EHRs increase the odds of smoking assessment and cessation assistance, which could lead to decreased smoking rates among vulnerable populations. Continued efforts for provision of cessation assistance among pregnant patients is warranted.
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Affiliation(s)
- Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.
| | - John D Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | | | | | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Tim E Burdick
- Department of Community and Family Medicine, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | | | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
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Dziadkowiec O, Jenniges R. Using flow diagrams to improve tobacco cessation programs. Int J Health Care Qual Assur 2017; 30:436-444. [DOI: 10.1108/ijhcqa-05-2016-0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to understand how the Wyoming Quit Tobacco Program (WQTP) is used by its subscribers and to better understand how WQTP might be connected to WQTP outcomes.
Design/methodology/approach
Provider intake and program use data corresponding to the May 2010 to March 2012 enrollment period (n=6,168) were used. All program flows were constructed using frequencies and crosstabs, based on an initial theoretical model prepared by the program provider. Data were adjusted based on analysis that explored all possible uses beyond those specified by the provider’s theoretical model.
Findings
Although the authors could replicate the structure – the theoretical model constructed by the provider – the authors were not able to replicate all relationships between program components. The authors also found that most individuals signed up and used web-based services. Only a few individuals finished their treatment regimens in the way they were designed to be used by the program.
Originality/value
This is the first case study to use a program flow method to investigate an entire comprehensive tobacco cessation program structure and delivery.
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Cohen JK, Bakamjian A, Leng L, Adhikari M, Flattery D, Berry L. No Ifs, Ands, or Buts: Leveraging Population Health to Focus on the Care of Patients Who Smoke. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2017; 4:2382120517735010. [PMID: 29349342 PMCID: PMC5736277 DOI: 10.1177/2382120517735010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 07/06/2017] [Indexed: 06/07/2023]
Abstract
We developed a multidisciplinary curriculum to improve our residents' proficiency with smoking cessation counseling and prescribing of nicotine replacement therapy (NRT). The curriculum included a didactic portion, informational handouts, and a panel management component during which residents did telephone outreach and clinic in-reach to address high rates of smoking among patients. Residents rated their confidence with smoking cessation counseling and clinical knowledge before and after the intervention. We also tracked the number of patients flagged in the electronic medical record as smokers, the number of patients contacted, and the number of patients who received counseling. Although we did not make statistically significant improvements in perceived confidence with prescribing NRT, we found that there is an urgent need to address smoking cessation in the primary care setting and that working with a clinical pharmacist and psychologist offered a comprehensive approach. Furthermore, by anchoring the intervention with a population health component, almost 200 patients benefited from outreach efforts.
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Affiliation(s)
- Jenny K Cohen
- Division of Primary Care, Highland Hospital, Oakland, CA, USA
| | - Allison Bakamjian
- Division of Primary Care, Highland Hospital, Oakland, CA, USA
- University of California, Berkeley School of Public Health, Berkeley, CA, USA
| | - Lisa Leng
- Division of Primary Care, Highland Hospital, Oakland, CA, USA
| | - Mili Adhikari
- University of California, Berkeley School of Public Health, Berkeley, CA, USA
| | - Davida Flattery
- Division of Primary Care, Highland Hospital, Oakland, CA, USA
| | - Lyn Berry
- Division of Primary Care, Highland Hospital, Oakland, CA, USA
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9
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Twarozek AM, Eggert T, Puca ZG, DuPont N, Erwin DO, Fox CH, Mahoney MC. Promoting Tobacco Cessation in a Community-Based Women's Health Centre. JOURNAL OF WOMEN'S HEALTH CARE 2016; 4. [PMID: 27127729 PMCID: PMC4846304 DOI: 10.4172/2167-0420.1000225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Objective This report assesses the impact of a series of education sessions delivered to office staff on the delivery of smoking cessation services among patients seeking care at a community-based women’s health center. Methods A quasi-experimental design was used to examine the delivery of smoking cessation services to patients in a medical office before and after office staff attended a series of 3 educational sessions intended to increase their knowledge and self-efficacy to address cessation. Delivery of smoking cessation services was documented through a systematic review of medical records using a structured abstraction form. Results While nearly all smokers (93%) were asked about smoking status at their last office visit, few smokers at baseline or follow-up were assessed for interest in setting a quit date or offered pharmacotherapy. Referrals to the smokers quit line increased from <1% at baseline to 8% at follow-up (p<0.001) and “any assistance” also showed a modest but significant increase (<1% baseline, 9% follow-up, p<0.001). Conclusion This evaluation failed to identify clinical meaningful changes in the delivery of smoking cessation services in this women’s health office before and after completion of a series of educational interventions for office staff. It is anticipated that the implementation of patient centered medical homes, and EMR systems, will help to enhance the delivery of smoking cessation services to women seeking medical care.
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Affiliation(s)
| | - Thomas Eggert
- State University of New York at Buffalo, School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Zachary G Puca
- State University of New York at Buffalo, School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Nefertiti DuPont
- Doctor of Oncology, Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, New York
| | - Deborah O Erwin
- Director, Office of Cancer Health Disparities Research, Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, New York
| | - Chester H Fox
- Department of Family Medicine, State University of New York at Buffalo, 77 Goodell Street, Buffalo New York
| | - Martin C Mahoney
- Departments of Medicine & Health Behaviour, Roswell Park Cancer Institute, Elm & Carlton Streets, Buffalo, New York
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duPont NC, Mahoney MC, Kahn LS, Vest BM, Widman CA, Clark-Hargrave NS, Erwin DO. Developing a Smoking Cessation Intervention for Low Income and Minority Women. JOURNAL OF WOMEN'S HEALTH CARE 2016; 5:309. [PMID: 28824830 PMCID: PMC5558895 DOI: 10.4172/2167-0420.1000309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this qualitative pilot study was to elicit patient and provider feedback on how to develop a smoking cessation program for low income women with cervical dysplasia in an urban Women's Health Center. METHODS A community-based participatory research project incorporating a focus group and structured interviews was utilized to elicit feedback on how to develop a culturally appropriate smoking cessation program appealing to low-income and minority women smokers. RESULTS Qualitative data from 13 patients, 4 nurses, and 6 staff members collected between January 2012-August 2012 described the challenges of finding effective mechanisms for cessation interventions that met the schedules and needs of low income and minority patients. Input from office staff indicated insufficient educational resources to offer patients, limited skills to assist patients and the importance of perceived patient readiness to quit as barriers to creating an effective smoking cessation program. CONCLUSION Smoking cessation services targeting low-income and minority female smokers can be enhanced by providing clinic staff with patient education materials and smoking cessation training.
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Affiliation(s)
- Nefertiti C duPont
- Department of Gynecologic Oncology, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Martin C Mahoney
- Departments of Medicine and Health Behavior, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, New York, USA
| | - Linda S Kahn
- Department of Family Medicine, University at Buffalo, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Bonnie M Vest
- Department of Family Medicine, University at Buffalo, The State University of New York at Buffalo, Buffalo, New York, USA
| | - Christy A Widman
- Division of Cancer Prevention and Control, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, New York, USA
| | - Nikia S Clark-Hargrave
- Division of Cancer Prevention and Control, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, New York, USA
| | - Deborah O Erwin
- Division of Cancer Prevention and Control, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, New York, USA
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