Student Publications

Explore a wide variety of topics, methodologies, and perspectives as our students engage with the world through their work.

Each publication is not just a culmination of research, but a testament to their intellectual curiosity, creativity, and pursuit of excellence.

A citation analysis and scoping systematic review of the operationalization of the Practical, Robust Implementation and Sustainability Model

Group:

Caitlin Golden, MPH, PhD Candidate, Department of Health Promotion

Abstract:

Background: The Practical, Robust Implementation and Sustainability Model was developed in 2008 as a contextually expanded version of the broadly used Reach, Adoption, Effectiveness, Implementation, and Maintenance framework. PRISM provides researchers a pragmatic and intuitive model to improve translation of research interventions into clinical and community practice. Since 2008, the use of PRISM increased across diverse topics, populations, and settings. This citation analysis and scoping systematic review aimed to assess the use of the PRISM framework and to make recommendations for future research.

Methods: A literature search was conducted using three databases (PubMed, Web of Science, Scopus) for the period of 2008 and September 2020. After exclusion, reverse citation searches and invitations to experts in the field were used to identify and obtain recommendations for additional articles not identified in the original search. Studies that integrated PRISM into their study design were selected for full abstraction. Unique research studies were abstracted for information on study characteristics (e.g., setting/population, design), PRISM contextual domains, and RE-AIM outcomes.

Results: A total of 180 articles were identified to include PRISM to some degree. Thirty-two articles representing 23 unique studies integrated PRISM within their study design. Study characteristics varied widely and included studies conducted in diverse contexts, but predominately in high-income countries and in clinical out-patient settings. With regards to use, 19 used PRISM for evaluation, 10 for planning/development, 10 for implementation, four for sustainment, and one for dissemination. There was substantial variation across studies in how and to what degree PRISM contextual domains and RE-AIM outcomes were operationalized and connected. Only two studies directly connected individual PRISM context domains with RE-AIM outcomes, and another four included RE-AIM outcomes without direct connection to PRISM domains.

Conclusions: This is the first systematic review of the use of PRISM in various contexts. While there were low levels of ‘integrated’ use of PRISM and few reports on linkage to RE-AIM outcomes, most studies included important context domains of implementation and sustainability infrastructure and external environment. Recommendations are provided for more consistent and comprehensive use of and reporting on PRISM to inform both research and practice on contextual factors in implementation.

Mentor: Paul Estabrooks, PhD

Journal: Implementation Science

Longitudinal Effects of Maternal Tobacco Use during Pregnancy upon Child Neurocognitive Development

Group:

Troy Puga, MPH Student, Department of Health Promotion

Abstract:

Importance: Maternal tobacco usage during pregnancy persists across the globe. Longitudinal assessment of the neurocognitive development of offspring at late childhood development is limited.

Objectives: This cohort study examined whether MTDP exhibits effects on the neurocognitive development of children.

Design, Setting, and Participants: Children aged 9 and 10 years old at Wave 1(October 2016-October 2018, n=11,448) and children aged 11-12 at 2-year follow-up (Wave 2, August 2018-January 2021, n=9,846) across 21 US sites in the Adolescent Brain Cognitive Development Study.

Exposure: MTDP.

Main outcomes and measures: 1) neurocognition measured by the NIH Toolbox Cognition Battery and 2) morphometric brain measures through region of interest analysis from structural magnetic resonance imaging.

Results: Among 11,448 participants at Wave 1 (age, mean[SD]=9.9[0.6] years-old; 48.4% females, 52.8% non-Hispanic Whites, 12.5% NH Blacks, 24.9% Hispanics), 1,607 children were identified with MTDP. In NIH Toolbox Cognition Battery, children with MTDP (vs. no MTDP) exhibited lower scores on the Oral Reading Recognition at wave 1 (mean [SE] b=-1.2 [0.2]; P<.001) and wave 2 (b=-1.6 [0.3]; P<.001), Picture Sequence Memory at wave 1 (b=-2.3[0.6];P<.0001) and 2 (b=-2.3 [0.8]; P=.005), Picture Vocabulary Tests at wave 1 (b=-1.2 [0.3]; P<.001) and wave 2 (b=-1.5 [0.4]; P=.001), and Crystalized Cognition Composite Score at wave 1(b=-1.3 [0.3]; P<.00101) and wave 2 (b=-1.5 [0.3]; P<.00101). At wave 1, children with MTDP demonstrated decreased area in significant areas such as inferior parietal (b=-153.9 [SE 43.4]; P<.001) and entorhinal (b=-25.1 [SE 5.8]; P<.001), and the precentral (b=-141.2 [SE 38.9]; P<.001) at wave 1 and 2. At wave 1, children with MTDP demonstrated decreased volume in critical regions such as precentral (b=-474.4 [SE 98.2]; P<.001), inferior parietal (b=-523.7 [SE 136.7]; P<.001), supramarginal (b=-330.0 [SE 120.0]; P=.006) posterior cingulate (b=-72.2 [SE 31.3]; P=.021), entorhinal (b=-94.1 [SE 24.5]; P<.001), and parahippocampal (b=-82.6 [SE 18.7]; P<.001). At wave 2, children with MTDP demonstrated decreased volume in regions of the precentral (b=-717.3 [SE 120.8]; P<.001), inferior parietal (b=-485.6 [SE 164.3]; P=.003), supramarginal (b=-364.0 [SE 148.1]; P=.014), entorhinal (b=-95.7 [SE 28.2]; P=.001), and parahippocampal (b=-93.9 [SE 23.0]; P<.001).

Conclusions and Relevance: In this cohort study, MTDP was associated with persistent adverse impacts on childhood neurocognition. Continued research for influence on cognitive performance and brain structure related to language processing skills and episodic memory is needed.

Mentor: Daisy Dai, PhD

Journal: JAMA Network Open

Addressing and evaluating health literacy in mHealth: a scoping review

Group:

Louis Fok, MPH, PhD Student, Department of Epidemiology & Maria S. Mickles, MPH, PhD Student, Department of Health Services Research and Administration 

Abstract:

Background: Recent surveys have revealed many adults have basic or below basic health literacy, which is linked to medical errors, increased illness, and compromised public health. Health literacy as a concept is multi-faceted extending beyond the individual to include social structures and the context in which health information is being accessed. Delivering health information via mobile devices expands the amount of information available while presenting challenges to ensuring these materials are suitable for a variety of literacy needs. The aims of this study are to discover how health literacy is addressed and evaluated in mHealth app development.

Methods: A scoping review of 5 peer-reviewed databases was conducted. Eligible articles were written in English, addressed general literacy or mHealth/digital/eHealth literacy, and collected literacy information in order to incorporate literacy into the design and/or modification of an app or collected literacy information to describe the population being studied. The “Health Literacy Online” United States government guide was used as a framework.

Results: Thirty-two articles were reviewed. Articles included health literacy recommendations for all HLO categories and some recommendations not aligned with these categories. Most articles addressed health literacy using specific HLO categories though none incorporated every HLO category. The most common categories addressed engagement and testing of mHealth content. Though several studies addressed health literacy through a formal assessment tool, most did not. Evaluation of health literacy in mHealth was end-user focused and did not extensively evaluate content for fit to a variety of individuals with limited health literacy.

Conclusions: The recommendations seen consistently in our results in conjunction with formal HLO categories can act as beginning steps towards development of a health literacy evaluation tool for mHealth apps themselves. It is clear efforts are being made to reduce barriers to using mHealth for those with literacy deficits, however, it was also clear that this space has room to be more pragmatic in evaluation of mHealth tools for literacy. End user engagement in design and testing is necessary in future mHealth literacy tool development.

Mentor: Shinobu Watanabe-Galloway, PhD

Journal: mHealth

Identification of Multimorbidity Patterns in Rheumatoid Arthritis Through Machine Learning

Group:

Harlan R Sayles, PhD Student, Department of Biostatistics 

Abstract:

Objective: Recognizing that the interrelationships between chronic conditions that complicate rheumatoid arthritis are poorly understood, we aimed to identify patterns of multimorbidity and to define their prevalence in RA through machine learning.

Methods: We constructed RA and age- and sex-matched (1:1) non-RA cohorts within a large commercial insurance database (MarketScan) and the Veterans Health Administration. Chronic conditions (n = 44) were identified from diagnosis codes from outpatient and inpatient encounters. Exploratory factor analysis was performed separately in both databases, stratified by RA diagnosis and sex, to identify multimorbidity patterns. The association of RA with different multimorbidity patterns was determined using conditional logistic regression.

Results: We studied 226,850 patients in MarketScan (76% female) and 120,780 patients in the VHA (89% male). The primary multimorbidity patterns identified were characterized by the presence of cardiopulmonary, cardiometabolic, and mental health and chronic pain disorders. Multimorbidity patterns were similar between RA and non-RA patients, female and male patients, and patients in MarketScan and the VHA. RA patients had higher odds of each multimorbidity pattern (odds ratios [ORs] 1.17–2.96), with mental health and chronic pain disorders being the multimorbidity pattern most strongly associated with RA (ORs 2.07–2.96).

Conclusion: Cardiopulmonary, cardiometabolic, and mental health and chronic pain disorders represent predominant multimorbidity patterns, each of which is overrepresented in RA. The identification of multimorbidity patterns occurring more frequently in RA is an important first step in progressing toward a holistic approach to RA management and warrants assessment of their clinical and predictive utility.

Mentor: Fanh Yu, PhD

Journal: Arthritis Care & Research

Exploring First Responders' Use and Perceptions on Continuous Health and Environmental Monitoring

Group:

Sarah Tucker, PhD Student, Department of Environmental, Agricultural & Occupational Health

Abstract:

First responders lose their lives in the line of duty each year, and many of these deaths result from strenuous physical exertion and exposure to harmful environmental agents. Continuous health monitoring may detect diseases and alert the first responder when vital signs are reaching critical levels. However, continuous monitoring must be acceptable to first responders. The purpose of this study was to discover first responders' current use of wearable technology, their perceptions of what health and environmental indicators should be monitored, and who should be permitted to monitor them. The survey was sent to 645 first responders employed by 24 local fire department stations. A total of 115 (17.8%) first responders answered the survey and 112 were used for analysis. Results found first responders perceived a need for health and environmental monitoring. The health and environmental indicators that respondents perceived as most important for monitoring in the field were heart rate (98.2%) and carbon monoxide (100%), respectively. Overall, using and wearing monitoring devices was not age-dependent and health and environmental concerns were important for first responders at any stage of their career. However, current wearable technology does not seem to be a viable solution for first responders due to device expense and durability issues.

Mentor: Aaron Yoder, PhD

Acceptability of Intergenerational Physical Activity Programming: A Mixed Methods Study of Latino Aging Adults in Nebraska

Group:

Marcela Carvajal-Suarez, MPH, BS, PhD Student, Department of Health Promotion 

Abstract:

Objective: This study explored Hispanic/Latino aging adults’ interest in and preferences for intergenerational physical activity programming.

Methods: We used an exploratory sequential (Qual-QUAN) mixed methods design consisting of three focus groups (N = 13 participants; M age = 62.5 years old) and a quantitative survey (N = 105 participants; M age = 57.3 years old).

Results: We found that most participants were interested in intergenerational physical activity programs: (1) to promote overall health and well-being, (2) increase opportunities for socialization and relationships, and (3) foster motivation and energy. Preferences for programming included cultural tailoring, bilingual and Spanish-language offerings, and being conducted in-person. Barriers to physical activity included cost, scheduling, transportation, and limited awareness of community resources. Discussion: Innovative public health initiatives incorporating an intergenerational approach may promote physical activity among aging adults. This study has implications for developing and refining intergenerational programming with Hispanic/Latino communities.

Mentor: Athena Ramos, PhD, MBA, MS, CPM

Biomarkers of Toxic Exposure and Oxidative Stress Among U.S. Adult Users of Premium Cigar Versus Other Cigar Subtypes: 2013–2019

Group:

James Buckley, MPH, PhD Student, Department of Epidemiology 

Abstract:

Introduction: Cigars are currently the second-highest-used combustible tobacco product among U.S. adults, but knowledge about health effects of premium cigars versus other cigar subtype use is limited.

Aims and Methods: This study analyzed the biospecimen data (n = 31 875) from Waves 1-5 of the Population Assessment of Tobacco and Health Study, collected during 2013–2019. Multivariable generalized estimation equations, accounting for within-person clustering, were conducted to examine differences in urine biomarkers of exposure (BOE) from five classes of harmful and potentially harmful constituents along with a biomarker of oxidative stress (urine 8-isoprostane) among exclusive users of premium cigars versus other exclusive cigar subtypes (ie, non-premium large cigars, cigarillos, and filtered cigars), cigarettes, and non-tobacco users.

Results: In comparison to non-tobacco users, exclusive premium cigar users had higher geometric mean concentrations of the nicotine metabolite cotinine (5.8 vs. 0.5ng/mg, p < .0001), tobacco-specific nitrosamine (TSNA) (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL): 7.8 vs. 1.3pg/mg, p < .0001), and volatile organic compound (VOC) (N-Acetyl-S-(2-cyanoethyl)-L-cysteine (CYMA, acrylonitrile): 4.7 vs. 1.6ng/mg, p < .0001). Exclusive premium cigar users were less likely to be daily users than other tobacco user groups and had comparable BOEs with exclusive non-premium large cigar users but generally lower BOEs than exclusive cigarillo, filtered cigar, and cigarette smokers. Daily exclusive premium cigar users had similar nicotine and TSNA exposure but lower exposure to polycyclic aromatic hydrocarbons and volatile organic compounds than exclusive cigarillo and filtered cigar users.

Conclusions: Premium cigar use exhibits different exposure to toxicants from other cigar subtype users. Regulations of premium cigars need to formalize product definition and take the population’s health effects into consideration.

Implications: This population study provides important information on BOE and potential harm with premium cigar use and its potential health effects. At present, premium cigars appear to pose a relatively low overall population health risk due to low frequency of use. However, future regulation of other tobacco products might change the landscape of premium cigar use and alter the overall health impact.

Mentor: Daisy Dai, PhD

System Redesign: The Value of a Primary Care Liaison Model to Address Unmet Social Needs among Older Primary Care Patients.

Group:

Vaibhavi Mone, MPH, PhD Student, Department of Health Services Research and Administration 

Abstract:

Assessing and addressing social determinants of health can improve health outcomes of older adults. The Nebraska Geriatrics Workforce Enhancement Program implemented a primary care liaison model of care, including training primary care staff to assess and address unmet social needs, patient counseling to identify unmet needs, and mapping referral services through cross-sectoral partnerships. A PCL worked with three patient-centered medical homes that are part of a large integrative health system. A mixed-methods approach using a post-training survey and a patient tracking tool, was used to understand the reach, adoption, and implementation of the PCL model. From June 2020 to May 2021, the PCL trained 61 primary care staff to assess and address unmet social needs of older patients. A total of 327 patients, aged 65 years and older and within 3–5 days of acute-care hospital discharges, were counseled by the PCL. For patients with unmet needs, support services were arranged through community agencies: transportation (37%), in-home care (33%), food (16%), caregiver support (2%), legal (16%), and other (16%). Our preliminary results suggest that the PCL model is feasible and implementable within PCMH settings to address unmet social needs of older patients to improve their health outcomes.

Mentor: Jungyoon Kim, PhD