Research and Scholarship

The National Network to Innovate for COVID-19 and Adult Vaccine Equity (NNICE) is a partnership of Michigan State University, Michigan Public Health Institute, the Community Foundation of Greater Flint and Community Campus Partnerships for Health. These organizations reflect the ‘pillars’ for a network of organizations that represent four important sectors of society, including: 1) academic institutions; 2) the national network of Public Health Institutes that support public health practice and translation; 3) local community foundations/philanthropy (whose legacy and mission is to lead local fund raising, grant-making and sustainability efforts); and 4) grass roots community organizations. The bringing together of these four pillars to form a network of partners to mitigate the disparate impact of COVID-19 and boost confidence in and receipt of COVID-19 and other adult vaccinations, is timely and relevant to the current pandemic and adult vaccine disparities and inequities more broadly in the nation.

Cardiovascular disease (CVD) complications are the leading cause of diabetes mellitus (DM)-related morbidity and mortality, creating a significant burden on the public health system. This burden is in part attributable to poor medication adherence, with 21-42% of patients failing to properly adhere to their care. Importantly, this issue is especially pronounced in minority and low-income populations, which show higher rates of chronic illness and lower medication adherence. Interventions that foster and reinforce patient-centered communication between clinicians and patients show promise in improving health outcomes. However, they have not been widely implemented, in part due to a lack of compelling evidence for their effectiveness in real primary care settings. Project Objective: We propose to evaluate the impact of our patient activation program: Office Guidelines Applied to Practice (Office-GAP) combined with mobile phone text messaging reinforcement (Care4life) on medication adherence, in minority and low-income patients with DM compared to mobile texting alone. Office-GAP incorporates shared decision-making and a decision/support checklist to be completed during office visits, to foster patients’ investment in their own care. Care4life is a cell phone messaging service that informs and encourages patients to adhere to goals and improve communication. Our long-term goal is to develop a model that can reliably improve and sustain adherence and can be successfully implemented in primary care clinics to close the morbidity and mortality gap for minority/low-income DM patients. We hypothesize that the combined face-to-face patient activation and mobile phone delivered reinforcement methods will facilitate communication between patients and care providers, improving the frequency, accuracy, and timeliness of communication while reinforcing shared goals and engendering mutual respect more than mobile phone texting alone. Improved communication between patients and physicians may improve medication adherence, blood sugar, cholesterol, blood pressure control, and patient satisfaction with providers, and ultimately decrease burden of illness. Research Strategy: We will conduct a randomized community-based clinical trial in Federally-Qualified Health Clinics (FQHCs) in Michigan. We will enroll 378 patients in 16 teams in clinics serving low-income and minority patients. All patients will receive usual care and medication for DM and CVD prevention. Eight teams will be randomly chosen to use mobile phone texting alone, and 8 teams will combine Office-GAP with Care4life. We will evaluate the impact of these shared decision-making strategies for patients and providers in the clinics. Impact: If successfully translated to clinical practice, these interventions have the potential to significantly impact patient care in FQHCs, improving outcomes for DM and CVD. This research also paves the way for shifting clinical practice across a spectrum of chronic disease where medication non-adherence is an issue.

Both colorectal (CRC) and cervical cancers are major causes of death in the US; colorectal cancer is the third leading cause of cancer deaths among men and women in Michigan; while deaths from cervical cancer in Michigan have been declining, in 2019, the ACS estimated 360 new cases, despite an effective vaccine against HPV, the primary cause of cervical cancer. Both cancers have effective screening approaches (colonoscopy, the gold standard for colorectal cancer), and clinician-directed speculum exam (the gold standard for cervical cancer). Follow-up after a positive screening test is key to survival from both cancers; there is consistent evidence that time to follow-up diagnostic testing after a positive screen is suboptimal, and unequally distributed. Thus, both cancers are still likely to be diagnosed after symptoms develop. The initial diagnosis is most likely to take place in the primary care setting. With both types of cancer, residents in rural areas experience a higher incidence of these cancers than urban residents. Multi-level screening approaches—with individuals, clinical teams, and health care institutions—have been found effective in increasing screening for both cancers, but are rarely implemented conjointly for CRC and cervical cancer screening in the primary care setting. The goal of the project is to advance understanding of the multi-level healthcare policy, institution, provider team, and patient factors that contribute to colorectal and cervical cancer-related health disparities in incidence and mortality among rural populations, and the implications of these inequities. One of our specific aims is to recruit 40 primary care sites from networks serving rural patients, yielding letters of support or MOU’s for the long-term conduct of long-term research within these settings. The project, a planned center grant application (P01), will contain four novel R01’s, one focused on practice-level shared decision-making and patient navigation interventions, another, implementing an SMS-based program at the healthcare and patient levels, a third, on self-screening for cervical cancer at the provider workflow and patient levels, and a fourth, on disseminating multilevel HPV vaccination approaches to rural primary care practices.

While Asian American (AA) mothers are described as high initiators of breastfeeding, no previous studies have conducted a randomized trial of AA mothers’ breastfeeding and formula use behaviors and whether these mothers continue to breastfeed exclusively for the recommended six months. Using an online Qualtrics customized panel, we will conduct a systematic investigation of the breastfeeding behaviors and timing of the introduction of complementary foods, and use of formula of AA mothers over a one-year period. We will recruit 1200 women between the ages of 18 and 35, as follows: 400 AA mothers with children one-year or younger; 400 pregnant AA women; and 400 American mothers from all race/ethnic groups will serve as the control group. This longitudinal study will track pregnant AA women through the birth of their babies, and will assess breastfeeding support and behaviors after the initial data collection, at 3-months, 6-months, and at one-year.

When patients come into the intensive care unit, it is important to establish not only what medical treatments will be necessary, but also the goals of those treatments. The goals for medical treatment ought to reflect the patient’s own goals and values. Intensive communication about goals of care has been shown to reduce ICU length of stay and the duration of use of non-beneficial advanced life support in critically ill patients as well as a lower prevalence of posttraumatic stress symptoms, anxiety, and depressive symptoms in family members. Unfortunately, few physicians are trained in how to have goals of care discussions with patients or their family members. To respond to this challenge, Drs. Stahl and Tomlinson are creating teaching modules which will enhance providers’ skills and confidence in having productive conversations with families about medically and ethically complex plans of care for seriously ill, incapacitated patients in the ICUs. They will evaluate the effectiveness of this education and assess the impact and effectiveness providers’ goals of care communication skills.

Improving health care services for low income women continues to be a challenge in Michigan and across the nation. This demonstration project aims to develop and test a system of care for pregnant women. The demonstration aims to coordinate services throughout pregnancy and in the early phase of the family’s life. It focuses on Kent County, and brings together primary community partners Spectrum Health, Cherry Street Health Services, Kent County Health Department, Arbor Circle (mental health), Priority Health Plan, and the Michigan Department of Community Health. The system aims to help providers share information and to help patients actively participate in their care. The project will test the impact on the health of the population of women eligible to participate.

This project examines mechanisms underlying coworkers’ stigma towards lactating mothers in the workplace and the impact of coworker disapproval on the duration of breastfeeding. While benefits and barriers to breastfeeding have been studied extensively, less is known about the role coworkers play in the continuation of breastfeeding after maternity leave. Around 57% of mothers with young children in the U.S. work (Rojjanasrirat, Wambach, Sousa, & Gajewski, 2010). While private space and break time is a right under the Affordable Care Act (2010), frequent breaks challenge timely completion of work tasks and the ability to meet deadlines; coworkers may have to do more work to compensate for a missing team member. This could cause resentment and the perception of unfairness.

Publications:

• Zhuang J, Bresnahan M, Zhu Y, Yan X, Bogdan-Lovis E, Goldbort J, Haider S. The impact of coworker support and stigma on breastfeeding after returning to work. Journal of Applied Communication Research. Available online July 19, 2018. doi.org/10.1080/00909882.2018.1498981
• Zhuang J, Bresnahan MJ, Yan X, Zhu Y, Goldbort J, Bogdan-Lovis E. Keep Doing the Good Work: Impact of Coworker and Community Support on Continuation of Breastfeeding. Health Communication. Available online May 17, 2018. doi.org/10.1080/10410236.2018.1476802
• From MSU Today: Here's Why It's Important to Support Your Breastfeeding Co-Workers
• From Quartz: Why it’s so crucial to support colleagues who pump breast milk at work
• From Moneyish: Why breastfeeding moms are trying to normalize pumping at work

This project is a collaboration with colleagues at the Center for Bioethics and Social Science in Medicine at University of Michigan, and continues the line of research started by the earlier R25, Ethics and Public Attitudes Concerning the Use of Archived Biological Samples. The first component is a large, nationally representative survey designed to answer two questions: What effects will presentation of possible future projects that might worry some donors have on the public’s willingness to give a blanket consent to all future research using their de-identified donations? And, once made aware of the possibility research that might affect their “non-welfare interests”, what degree of information and control does the public want regarding future research uses of biobank donations. Since the policy trade-offs are complex and not easily presented in a survey, the second component will be a set of democratic deliberations that enlist ordinary citizens in discussions leading to a set of policy recommendations for balancing respect for individual values with the need to conduct large-scale biobank research efficiently and economically.

Publications:

• De Vries RG, Tomlinson T, Kim HM, Krenz C, Haggerty D, Ryan KA, et al. Understanding the Public’s Reservations about Broad Consent and Study-By-Study Consent for Donations to a Biobank: Results of a National Survey. PLoS ONE. July 14 2016; 11(7). doi: 10.1371/journal.pone.0159113. PMC4944938.
• De Vries RG, Tomlinson T, Kim HM, et al. The moral concerns of biobank donors: the effect of non-welfare interests on willingness to donate. Life Sciences, Society and Policy. March 11 2016;12(3). doi: 10.1186/s40504-016-0036-4. PMC4788662.
• Tomlinson T, De Vries R, Ryan K, Kim HM, Lehpamer N, Kim SYH. Moral Concerns and the Willingness to Donate to a Research Biobank. Journal of the American Medical Association. January 27 2015;313(4):417-419. doi: 10.1001/jama.2014.16363. PMC4443895.

There are numerous potential contributors to the disparate burden of CRC on African Americans including clinician counseling practices, patient perceptions, access to care, and financial considerations. There are recent studies identifying a CRC screening barrier that is unique to men in general, but may be especially pertinent for African American men; that barrier is a perceived threat to masculinity and male sexuality. This is a secondary data analysis (DATES, M. Jimbo, PI, R01CA152413) of transcribed clinical encounters of men discussing colorectal cancer screening options with their primary care physicians. It will describe what men say about masculinity and male sexuality in the context of decision making about CRC screening in real world clinic visits with their primary care physicians. It will provide an enhanced understanding of what is important to men in determining their participation in screening for colorectal cancer. The insights gained from this study will not only have important implications for CRC screening but can also be applied to other health behaviors among men where discussions about masculinity and male sexuality inform screening and/or treatment decisions.

Informed decision making is the standard of care in preference sensitive clinical decisions like localized prostate cancer, where patient survival is similar across competing treatments, including no treatment or watchful waiting. However, little is known about the quality of informing physicians provide in routine practice. This study aims to describe and evaluate the nature and completeness of informing for patients and physicians making treatment decisions when patients receive a diagnosis of localized prostate cancer.
In this study we will analyze previously audio-recorded encounters of 252 men with localized prostate cancer (PSA<20; Gleason 6 or 7) seen in outpatient urology clinics in four Veterans Affairs Medical Centers. Data collected from a randomized trial of two patient decision aids. Treating physicians were urology residents and fellows who received no intervention. Results will allow description of the state-of-the art of informed decision making and identify areas for improvement.

The Specific Aims of this study are 1) to describe physician communication about colorectal cancer screening (CRCS) options and assess the impact of shared decision making (SDM) on patient screening decisions and 2) to perform an exploratory interview analysis to describe how patients perceive use and acceptability of interactive technology (IT) to improve clinical care, such as decision aids (DAs), within and outside the clinical encounter. Aim 1 will be achieved through qualitative content analysis of transcribed audio-recorded clinical encounters coming from the DATES parent grant (M. Jimbo, PI, R01CA152413) affording an in-depth description of what happens between the physician and patient and how information is conveyed, received, and acted upon. Aim 2 is a pilot study achieved through patient interviews with DATES study participants. The long-term goal of this research is to help describe communication patterns surrounding informing and collaborative discussion in the clinical encounter in order to design appropriate interventions to facilitate shared decision-making, decrease health disparities and ultimately to lead to better patient outcomes.

Biobanks—collections of various kinds of biological specimens like blood and tissues—are an increasingly important platform for advancing knowledge about human health and disease. These specimens are usually donated under a “blanket consent,” in which donors agree that their specimen can be used in any future research without any further consent from them. Since the specimens are provided to researchers with no personal information attached, the research done on them poses no real risk to the donors. So do donors care at all about what might later be done with their tissue? Conducted with Stan Kaplowitz and Meghan Faulkner, this project aimed to find out. The research team used a survey of Michigan residents designed to test whether disclosure of possible research uses that might raise moral, cultural or religious concerns for some donors would have an effect on people’s willingness to give a blanket consent. The results showed that these “non-welfare interests” do affect the willingness to give a blanket consent, although perhaps not as much as would be expected. The magnitude of this effect is related to several factors, including individuals’ trust in the medical profession and in researchers.

Publications:

• Tomlinson T, Kaplowitz SA, Faulkner M. Do People Care What’s Done with Their Biobanked Samples? IRB: Ethics & Human Research. July 2014;36(4):8-15. PMID: 25219068.
• Tomlinson T. Respecting Donors to Biobank Research. Hastings Center Report. Jan-Feb 2013;43(1):41-47. PMID: 23254911.