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What Have PRCHN Faculty and Staff Been up To?
Awards and Honors            Publications             Presentations
PRCHN Director Elaine Borawski, PhD, has been named one of the American Academy of Health Behavior's (AAHB) 2017 Fellows. Fellow status in the AAHB is granted in recognition of significant contributions to the field of health behavior research and the advancement of knowledge in health behavior, health education, or health promotion through research, publications, and presentations. The 2017 AAHB Fellows were recognized during the Academy's Annual Meeting March 4-7, 2018, in Portland, Oregon. 
Congratulations to Associate Director Erika Trapl, PhD, who chaired the 2018 conference committee for American Academy of Health Behavior (AAHB). She states "It was an honor to organize a meeting that elevates the deep discussions about equity that we've been having locally within Cuyahoga County to a national group of exemplary health behavior researchers and deeply think about how we as researchers can best contribute to making real change in population health statistics." The recent AAHB conference in Portland, Oregon, went off without a hitch, in large part due to Dr. Trapl's vision, planning and organization. 
Congratulations to Associate Director Sue Flocke, PhD, co-author on the paper "Primary Care Resident Training for Obesity, Nutrition and Physical Activity Counseling: A Mixed Methods Study," is one of four papers selected in the inaugural collection "The Best of Health Promotion Practice."

This new annual recognition was established to elevate and celebrate particularly outstanding contributions to the Journal in a given volume year. Along with the longstanding Sara Mazelis Paper of the Year Award, Dr. Flocke's paper was one of four selected by the editorial leadership that together, "exemplify the power of health promotion scholarship" published in the journal in 2017. 
Moore, SM; Komton, V; Adegbite-Adeniyi, C; Dolansky, MA; Hardin, HK; Borawski EA.. Development of the Systems Thinking Scale for Adolescent Behavior ChangeWest J Nurs Res. 2018 Mar;40(3):375-387.  doi: 10.1177/0193945917697219
What is this article about?
This report describes the development and psychometric testing of the Systems Thinking Scale for Adolescent Behavior Change (STS-AB). Following item development, initial assessments of understandability and stability of the STS-AB were conducted in a sample of nine adolescents enrolled in a weight management program. Exploratory factor analysis of the 16-item STS-AB and internal consistency assessments were then done with 359 adolescents enrolled in a weight management program. Test-retest reliability of the STS-AB was .71, p = .03; internal consistency reliability was .87. Factor analysis of the 16-item STS-AB indicated a one-factor solution with good factor loadings, ranging from .40 to .67. Evidence of construct validity was supported by significant correlations with established measures of variables associated with health behavior change. We provide beginning evidence of the reliability and validity of the STS-AB to measure systems thinking for health behavior change in young adolescents. 
Freedman, DA; Lee, E; Ohri-Vachaspati, P; Trapl, E; Borawski, E; Bess, K; & Flocke, SPredictors of farmers' market shopping among people Receiving Supplemental Nutrition Assistance Program benefitsAmerican Journal of Community Psychology.  (2018) 0:1-12. DOI 10.1002/ajcp.12245
What is this article about?
Farmers ’ markets have the potential to increase access tofruits and vegetables in communities where healthy foodaccess is limited. Findings from this research provi de evi-dence to support a multicomponent approach to imp roveFM reach among low-income populations. Farmers’ mar-ket interventions that include strategies focused on indi-viduals, markets, and the community shoul d be tested tofurther the impact of these community-level interventions.
Zeliadt SB, Hoffman RM, Birkby G, Eberth JM, Brenner AT, Reuland DS, Flocke SA. Challenges Implementing Lung Cancer Screening in Federally Qualified Health Centers. American Journal of Preventive Medicine, 2018 Apr;54(4):568-575. https://www.ncbi.nlm.nih.gov/pubmed/29429 606
What is this article about?
The purpose of this study is to identify issues faced by Federally Qualified Health Centers (FQHCs) in implementing lung cancer screening in low-resource settings. FQHCs and other safety-net clinics, which predominantly serve low-socioeconomic populations with high proportions of smokers eligible for lung cancer screening, face significant economic and resource challenges to implementing lung cancer screening. Although these vulnerable patients are at increased risk for lung cancer, reducing patient financial burdens and appropriately managing abnormal findings are critical to ensure that offering screening does not inadvertently lead to harm and increase disparities. 

Sonya J. Jones, Carrie L. Draper, Bethany A. Bell, Michael P. Burke, Lauren Martini, Nicholas Younginer, Christine E. Blake, Jan Probst, Darcy Freedman. Child hunger from a family resilience perspective. January 2018  & Angela D. Liese.  Journal of Hunger & Environmental Nutrition. https://doi.org/10.1080/19320248.2017.1364189
What is this article about?
Eliminating food insecurity among children is a priority in the US, and research that focuses on the resilience and agency of families can help refocus our programs and policies. The Midlands Family Study was a cross-sectional study including 544 families that were food secure, food insecure, or experiencing food insecurity with child hunger that completed a survey interview between March 2012 and May 2013. Using the Family, Adjustment, Adaptation, and Response theory as our guide and multinomial logistic regression analyses, we found that negative life events, economic capabilities (income, Supplemental Nutrition Assistance Program benefit levels), and social capabilities (support) were associated with food security status. For every additional $100 of income or SNAP benefits, the odds of the family having a child that experienced hunger in the past year were reduced by 6% and 9%, respectively. The results suggest families dealing with negative life events with inadequate income and social support are particularly vulnerable to child hunger. We did not find evidence to support that changing attitudes, strengthening faith, or reducing already low financial obligations affected food security status. 

Joshi K, Smith S, Boeln SD, Osborne A, Benko M, Trapl ES. Implementing a produce prescription program for hypertensive patients in safety net clinics. Health Promotion Practice, January 2018.  https://doi.org/10.1177/1524839917754090
What is this article about?
Although community–clinical linkages can improve chronic disease management, little is known regarding strategies for program implementation. We describe implementation of a unique produce prescription program for patients with hypertension (PRxHTN) involving 3 safety net clinics and 20 farmers’ markets (FMs). Strategy. Safety net clinics were invited to participate, and provider-leads received assistance in (1) developing a process flow to screen for food insecurity among hypertensive adults for program referral, (2) integrating the program into their electronic health record for scheduling, and (3) counseling patients on PRxHTN/FM use. Research staff met with clinics twice monthly. FM managers were trained on maintaining PRxHTN voucher redemption logs. Discussion. A total of 7 diverse providers screened 266 patients over 3 months; 224 were enrolled. Twelve FM, including one newly established at a clinic through provider–FM manager collaboration, redeemed over $14,500 of the $10 PRxHTN vouchers. We describe several strategies that can be used to prepare for and overcome implementation challenges including organizational and staff selection, facilitative administration, and clinical training and consultation. Conclusion. The PRxHTN program offers a flexible implementation process allowing clinics to successfully adapt their workflow to suit their staffing and resources.

FreshLink: A Community Led Approach to Addressing Barriers Among Nutritious Food AccessRachael Sommer and Kara Bilkert, Cuyahoga County Conference on Social Welfare (National Association of Social Workers Ohio Chapter), Case Western Reserve University, March 9, 2018

What was this presentation about?
This presentation highlighted the community ambassador model as a method of addressing the social connection barrier in nutritious food access. Participants will learn about the FreshLink project and its aim to increase awareness of and social connection to local farmers’ market using community ambassadors. Participants will practice the various training approaches used in the model for training the FreshLink Ambassadors in the field. The session will conclude with a practical application of these concepts and practices to the participants own work in their respective fields.

Implementing a Produce Prescription Program for Hypertensive Patients in Safety Net ClinicsKakul Joshi. Population & Quantitative Health Science Departmental Seminar, Case Western Reserve University. February 19, 2018. 

What was this presentation about?
Although community-clinical linkages can improve chronic disease management, little is known regarding strategies for program implementation. This talk described the core components of implementation of a unique produce prescription program for patients with hypertension (PRxHTN) involving three safety net clinics and 20 farmers’ markets (FM), based on a recent published manuscript. A total of seven diverse providers screened 266 patients over three months; 224 were enrolled. Twelve farmers' markets, including one newly established at a clinic through provider-market manager collaboration, redeemed more than $14,500 in $10 PRxHTN vouchers. The presentation described several strategies that can be used to prepare for and overcome implementation challenges, including organizational and staff selection, facilitative administration, and clinical training and consultation. 

Using Design Sensitivity to Select between Competing Matched Sampling Algorithms in an Observational Study. David Ngendahimana. Population & Quantitative Health Science Departmental Seminar, Case Western Reserve University. February 19, 2018. 

What was this presentation about?
Increased computational power has led to the development of new, sophisticated design methods in observational studies that leverage matched sampling concepts. However, a key critique of observational studies is that any observed associations between a treatment and an exposure might be attributed to unobserved biases since observational study designs do not guarantee that treated and control groups are comparable on unmeasured variables. To address this criticism, a sensitivity analysis to unmeasured confounders is usually performed. Simulation studies have shown that some designs for observational studies are more resistant to unobserved biases than others. To determine which design will lead to results that are more robust to unmeasured confounders, it is useful to have a numerical quantity to appraise designs and a method to leverage this quantity during the design phase. The method we propose extends the concepts of split sampling and design sensitivity, which have been successfully used to select between competing outcomes, to select between competing matched sampling algorithms and also appraise impact of input from subject matter experts.

Measuring Nicotine Dependence among Adolescent and Young Adult Cigarillo and Multiple Tobacco Product UsersSusan Flocke, Erika Trapl, Elizabeth Antognoli, Rock Lim, Sarah Koopman-Gonzalez, David Cavallo, Maria Pagano, José Marino. Society for Research on Nicotine & Tobacco Annual Meeting, March 2018, Baltimore, MD. 

What was this presentation about?
Nicotine dependence (ND) is important for understanding smoking behavior and cessation, but existing measures of ND have been developed and validated only for cigarette smokers. We evaluate the psychometric properties of new and adapted items designed to assess ND among young adults who smoke cigarillos and multiple tobacco products.

Diversity of Cigarillo Packaging Designs and Visual Attention to Package Images. Erika Trapl, Elizabeth Klein, Michael Keating, Amanda Quisenberry. Society for Research on Nicotine & Tobacco Annual Meeting, March 2018, Baltimore, MD.

What was this presentation about?
Tobacco packaging is acknowledged as a critical vehicle to promote purchase and tobacco use. Despite shifting tobacco use trends highlighting use of cigarillos among youth and young adults, little attention has focused on understanding product packaging attributes that attract users. We present a summary of a comprehensive audit of cigarillo package attributes and discuss the visual attention given to various attributes of a cigarillo package as measured by an eye tracking study. 

Association of Nicotine Dependence with Groups of Multiple Tobacco Product Use Among Adolescent and Young Adult Cigarillo Users. Elizabeth Antognoli, Karen Ishler, Susan Flocke, Rock Lim, David Cavallo, Maria Pagano, Sarah Koopman Gonzalez, Erika Trapl. Society for Research on Nicotine & Tobacco Annual Meeting, March 2018, Baltimore, MD.

What was this presentation about?
Multiple tobacco product (MTP) use is a growing public health concern, particularly among adolescents and young adults. Examination of patterns of use of MTPs is important for understanding development of nicotine dependence. We identify subgroups of cigarillos smokers’ use of other tobacco products and test group associations with nicotine dependence. 

Love at First Puff: Positive First Experience of Cigarillo UseSarah Koopman Gonzalez, José Marino, Karen Ishler, Erika Trapl, Elizabeth Antognoli, Rock Lim, David Cavallo, Maria Pagano, Susan Flocke. Society for Research on Nicotine & Tobacco Annual Meeting, March 2018, Baltimore, MD.

What was this presentation about?
Research has shown that a positive experience of cigarette initiation is related to the development of nicotine dependence and current smoking behaviors. This relationship, however, has not been thoroughly examined for the use of little cigars and cigarillos (LCCs). We examine users’ descriptions of their initiation with LCCs and explore its relationship with product use. In this sample, 5%  expressed a positive first experience with LCCs. A deeper exploration of positive first experience and
perceptions of risk, nicotine dependence, and the trajectory of use patterns can provide insight into how messaging of the harms and addictiveness of LCC might be crafted to reduce initiation and use of these products.

A Comparison of Methods to Measure Consumption of Tobacco Products among Adolescent and Young Adult Cigarillo Users. Karen Ishler, Elizabeth Antognoli, Erika Trapl, Rock Lim, Susan Flocke. Society for Research on Nicotine & Tobacco Annual Meeting, March 2018, Baltimore, MD.

What was this presentation about?
Accurate assessment of cigarillo use is complicated by patterns of use that include sharing and multiple product use. In this study we compare a conventional tobacco use assessment to a more detailed measurement strategy that accounts for sharing. This study indicates that a compared to a detailed approach, a conventional measure of tobacco use for cigarillo users yields significantly higher daily consumption estimates for individuals that share products and those that smoke low amounts of cigarillos and significantly lower estimates for high level cigarillo users.

“Phantom Smokers”: Smoker Identity among Teen and Young Adult Users of Cigar Products. Rock Lim, Karen Ishler, Elizabeth Antognoli, David Cavallo, José Marino, Sarah Koopman Gonzalez, Maria Pagano, Erika Trapl, Susan Flocke. Society for Research on Nicotine & Tobacco Annual Meeting, March 2018, Baltimore, MD.

What was this presentation about?
There is a growing trend among young smokers to consume tobacco products mostly in social settings or to maintain consistent but nondaily smoking habits. These “phantom smokers” tend to underestimate their own health risks and feel less need to quit compared to self-identified smokers. Cigar, cigarillo, and little cigar (CCLC) use is associated with behaviors common to phantom smokers, suggesting these smokers may be particularly prone to phantom smoker beliefs and associated risks
Nearly a quarter of respondents did not self-identify as smokers, despite being regular cigarillo users. Phantom smokers’ lack of perceived addiction risk and high confidence in ability to quit implies that conventional quitting messages and smoking assessments may be less effective with these smokers.

Cigarettes, Little Cigars, and Cigarillos: Initiation, Motivation, and Decision Making. Elizabeth Antognoli, Sarah Koopman-Gonzalez, Erika Trapl, David Cavallo, Rock Lim, Susan Flocke. Society for Research on Nicotine & Tobacco Annual Meeting, March 2018, Baltimore, MD.

What was this presentation about?
Cigarettes and LCCs (little cigars/cigarillos) are the most prevalent dual use tobacco combination; one-third of cigarette smokers use LCCs. Risk factors for multiple tobacco product use have been reported, however, there is little understanding of why some individuals transition to and maintain multiple product use. This study examined narratives of tobacco product initiation and decision-making among LCC only and LCC/cigarette smokers. Among dual users, 60% began smoking LCCs before or at the same time as cigarettes, and 40% began smoking cigarettes first. Product initiation order was almost evenly split, but reasons for initiating the second product differed, with immediacy of reducing cravings as a key reason for LCC users to smoke a cigarette and social and financial reasons for cigarette users to smoke a LCC.

Nicotine Dependence among Adolescent Smokers: Application of a Brief, Product-Neutral Dependence MeasureErika Trapl, Sarah Koopman Gonzalez, Susan Flocke. Society for Research on Nicotine & Tobacco Annual Meeting, March 2018, Baltimore, MD.

What was this presentation about?
Nicotine dependence among youth who smoke cigar products is not well understood as measures of ND have been developed only for cigarette smokers. A novel, product-neutral measure of nicotine dependence was included in a surveillance survey conducted in Cuyahoga County, Ohio, which is known to have high rates of cigar product use and multiple tobacco product use. Data for this study were drawn from the 2017 Cuyahoga County Youth Risk Behavior Survey conducted in spring 2017 in 44 participating high schools in Cuyahoga County, Ohio. 13,907 youth completed the survey (overall response rate of 60%). Analysis was limited to youth who reported smoking cigarettes or cigars, cigarillos, and little cigars (CCLC) in the past month and completed the ND measure (n=702). Overall, 13.1% of students reported current CCLC use and 6.2% reported current cigarette smoking; 4.8% reported using both. Youth who smoke CCLC exhibit signs of nicotine dependence. Youth who consume (certain levels) of CCLC products have ND scores similar to those who consume (certain levels) of cigarettes. Youth use of CCLC put youth at increased risk for long-term ND and chronic disease.

School-Based Retail Environment Exposures and Adolescent Youth Cigar, Cigarillo, and Little Cigar UseErika Trapl, Andrew Anesetti-Rothermel, Stephanie Pike, Truth Initiative, DC, USA. Society for Research on Nicotine & Tobacco Annual Meeting, March 2018, Baltimore, MD.

What was this presentation about?
Rates of cigar, cigarillo and little cigar (CCLC) use among youth have been increasing, and increased use among African American youth are particularly alarming. Studies examining associations between retail tobacco availability (i.e., density and proximity) and tobacco use have been mixed. This study examined the associations between school-based retail environment exposures and CCLC  use among middle school youth in Cleveland, OH. Findings indicate that even after controlling for youth visits to corner stores, retail density is still significantly associated with CCLC use among 7th and 8th grade youth. This has potential policy implications for retailer licensing, zoning for tobacco retailers, and restrictions on exterior retail advertising.
Pass the khat: Bar groups, reciprocity and men’s HIV vulnerability in Kampala, Uganda. Megan Schmidt Sane. Society for Applied Anthropology's Annual Meeting, Philadelphia, PA. April 6, 2018. 

What was this presentation about?
Men in Uganda are “missing” across the HIV cascade, with low numbers testing and seeking treatment for HIV/AIDS (PEPFAR, 2017). The question remains: what about the social environment shapes men’s behavior? This research posits that “bar groups” play a role in men’s behavior and concomitant HIV vulnerability. “Bar groups” are a social mechanism with cultural and historical roots. Men form groups in various locations, sharing resources, alcohol, and drugs. These groups buffer against economic scarcity but may promote unhealthy behavior. This research explores the dualistic nature of “bar groups” as resilient and vulnerable social mechanisms, with implications for community-level programming. 

Creating Greater Destinies: A Community Health Engagement Framework for a Resident-informed Approach Towards Health Equity in Greater ClevelandAnna Thornton Matos and Briana L. McIntosh.  April 27, 2018. Special Health Services Research Seminar, MetroHealth Medical Center, Cleveland, OH.

What was this presentation about?
Creating Greater Destinies: A community health engagement framework for a resident-informed approach towards health equity in Greater Cleveland will highlight the resident engagement aspects of HIP-Cuyahoga's REACH (Racial and Ethnic Approaches to Community Health) grant.  This presentation will describe the community engagement framework that was developed, as well as, how the framework contributed to and amplified the success of the grant.  Lastly, we will discuss recommendations for how to continue to build and sustain equitable resident engagement post grant.

Malaria, Anemia, and Weight Status in Kisumu, Kenya: How Childhood Sex Bias Could Be Impacting Long-Term Health. Mary Bailey-Swanzy. Innovations Conference, Case Western Reserve University, April 20, 2018.

What was this presentation about?
Malnutrition, malaria, and anemia are all key contributors to high rates of child mortality globally. Malaria caused 445,000 deaths in 2016 and nearly half of all deaths in children under 5 years old are attributable to malnutrition annually. Nutrition also effects disease morbidity with 600 million children across the world estimated to be anemic. This project explored the association of a child’s sex with anemia and malaria frequency in a cohort of 392 children (aged 1-10, 201 males and 191 females, 1967 visits) residing in Western Kenya. Results: 84% of children presented over the two-year study period with acute malarial infection with an average of 2.4 positive blood smears over the 2 years. 65% of blood smears at baseline were anemic (Hgb < 10 g/dL). Girls in this study had more than twice the odds of wasting, underweight, and thin status by z-score as well as consistently lower mean Z-scores in weight for age, weight for height, and BMI categories. This disparity in nutrition status in the young girls compared to boys highlights a need in this community and those like it to increase nutritional support to reduce the burden of childhood malnutrition. The burden of disease associated with high rates of anemia as well as malaria present a need for diverse health interventions for this community.

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