The Role of Home Practice Engagement in a Mindfulness-Based Intervention

Over the last three decades, there has been a precipitous rise in curiosity regarding the clinical use of mindfulness meditation for the self-management of a broad range of chronic health conditions. Despite the ever-growing body of evidence supporting the use of mindfulness-based therapies for both medical and psychological concerns, data on the active ingredients of these mind-body interventions are relatively scarce. Regular engagement in formal mindfulness practice is considered by many to be requisite for generating therapeutic change; however, previous investigations of at-home practice in MBIs have produced mixed results. The equivocal nature of these findings has been attributed to significant methodological limitations, including the lack of standardized, systematic practice monitoring tools, and a singular focus on practice time, with little attention paid to the nature and quality of one’s practice. The present study used a prospective, observational design to assess the effects of home-based practice on dispositional mindfulness, self-compassion, and psychological functioning in twenty-eight people enrolled in an MBSR or MBCT program. To address some of the aforementioned limitations, the present study collected detailed weekly accounts of participants’ home-based practice engagement, including information about practice time (i.e., frequency and duration), exercise type, perceived effort and barriers to participation, and practice quality. Hierarchical multiple regression was used to examine the relative contribution of practice time and practice quality on treatment outcomes, and to explore possible predictors of adherence to at-home practice recommendations. As anticipated, practice quality and perceived effort improved with time; however, rather unexpectedly, practice quality was not a significant predictor of treatment-related improvements in psychological health. Home practice engagement, however, was predictive of change in dispositional mindfulness, in the expected direction. Results of our secondary analyses demonstrated that employment status was predictive of home practice engagement, with those who were unemployed completing more at-home practice on average. Mindfulness self-efficacy at baseline and previous experience with meditation or other contemplative practices were independently predictive of mean practice quality. The results of this study suggest that home practice helps generate meaningful change in dispositional mindfulness, which is purportedly a key mechanism of action in mindfulness-based interventions.

Migration and Perception of Health Status: a Qualitative Study in Kazakh Chinese

This qualitative study explored the rural to urban migration’s effect and its related factors on later life health status and health perception among Kazakh Chinese. The participants were same sex sibling pairs, of which one moved from rural to urban areas in early life and the other stayed in rural areas. Rural participants tend to have more selected chronic diseases conditions and other self-reported conditions than urban participants but less physical limitations in older age. There is no clear difference on the health perceptions between rural and urban participants. Health care access and environmental factors are the major differences that may affect health in later life for rural participants.

Health events and the smoking cessation of middle aged Americans.

This study investigates the effect of serious health events including new diagnoses of heart attacks, strokes, cancers, chronic lung disease, chronic heart failure, diabetes, and heart disease on future smoking status up to 6 years postevent. Data come from the Health and Retirement Study, a nationally representative longitudinal survey of Americans aged 51-61 in 1991, followed every 2 years from 1992 to 1998. Smoking status is evaluated at each of three follow-ups, (1994, 1996, and 1998) as a function of health events between each of the four waves. Acute and chronic health events are associated with much lower likelihood of smoking both in the wave immediately following the event and up to 6 years later. However, future events do not retrospectively predict past cessation. In sum, serious health events have substantial impacts on cessation rates of older smokers. Notably, these effects persist for as much as 6 years after a health event.

The Political Economy of Climate Adaptation and Environmental Health: The Case of Ethiopia

The environment affects our health, livelihoods, and the social and political institutions within which we interact. Indeed, nearly a quarter of the global disease burden is attributed to environmental factors, and many of these factors are exacerbated by global climate change. Thus, the central research question of this dissertation is: How do people cope with and adapt to uncertainty, complexity, and change of environmental and health conditions? Specifically, I ask how institutional factors, risk aversion, and behaviors affect environmental health outcomes. I further assess the role of social capital in climate adaptation, and specifically compare individual and collective adaptation. I then analyze how policy develops accounting for both adaptation to the effects of climate and mitigation of climate-changing emissions. In order to empirically test the relationships between these variables at multiple levels, I combine multiple methods, including semi-structured interviews, surveys, and field experiments, along with health and water quality data. This dissertation uses the case of Ethiopia, Africa’s second-most populous nation, which has a large rural population and is considered very vulnerable to climate change. My fieldwork included interviews and institutional data collection at the national level, and a three-year study (2012-2014) of approximately 400 households in 20 villages in the Ethiopian Rift Valley. I evaluate the theoretical relationships between households, communities, and government in the process of adaptation to environmental stresses. Through my analyses, I demonstrate that water source choice varies by individual risk aversion and institutional context, which ultimately has implications for environmental health outcomes. I show that qualitative measures of trust predict cooperation in adaptation, consistent with social capital theory, but that measures of trust are negatively related with private adaptation by the individual. Finally, I describe how Ethiopia had some unique characteristics, significantly reinforced by international actors, that led to the development of an extensive climate policy, and yet with some challenges remaining for implementation. These results suggest a potential for adaptation through the interactions among individuals, communities, and government in the search for transformative processes when confronting environmental threats and climate change.

Non-Pharmacological Approaches for Pain Management in Sickle Cell Disease: Development of a Mindfulness-Based Intervention

Background: Sickle Cell Disease (SCD) is a genetic hematological disorder that affects more than 7 million people globally (NHLBI, 2009). It is estimated that 50% of adults with SCD experience pain on most days, with 1/3 experiencing chronic pain daily (Smith et al., 2008). Persons with SCD also experience higher levels of pain catastrophizing (feelings of helplessness, pain rumination and magnification) than other chronic pain conditions, which is associated with increases in pain intensity, pain behavior, analgesic consumption, frequency and duration of hospital visits, and with reduced daily activities (Sullivan, Bishop, & Pivik, 1995; Keefe et al., 2000; Gil et al., 1992 & 1993). Therefore effective interventions are needed that can successfully be used manage pain and pain-related outcomes (e.g., pain catastrophizing) in persons with SCD. A review of the literature demonstrated limited information regarding the feasibility and efficacy of non-pharmacological approaches for pain in persons with SCD, finding an average effect size of .33 on pain reduction across measurable non-pharmacological studies. Second, a prospective study on persons with SCD that received care for a vaso-occlusive crisis (VOC; N = 95) found: (1) high levels of patient reported depression (29%) and anxiety (34%), and (2) that unemployment was significantly associated with increased frequency of acute care encounters and hospital admissions per person. Research suggests that one promising category of non-pharmacological interventions for managing both physical and affective components of pain are Mindfulness-based Interventions (MBIs; Thompson et al., 2010; Cox et al., 2013). The primary goal of this dissertation was thus to develop and test the feasibility, acceptability, and efficacy of a telephonic MBI for pain catastrophizing in persons with SCD and chronic pain.

Methods: First, a telephonic MBI was developed through an informal process that involved iterative feedback from patients, clinical experts in SCD and pain management, social workers, psychologists, and mindfulness clinicians. Through this process, relevant topics and skills were selected to adapt in each MBI session. Second, a pilot randomized controlled trial was conducted to test the feasibility, acceptability, and efficacy of the telephonic MBI for pain catastrophizing in persons with SCD and chronic pain. Acceptability and feasibility were determined by assessment of recruitment, attrition, dropout, and refusal rates (including refusal reasons), along with semi-structured interviews with nine randomly selected patients at the end of study. Participants completed assessments at baseline, Week 1, 3, and 6 to assess efficacy of the intervention on decreasing pain catastrophizing and other pain-related outcomes.

Results: A telephonic MBI is feasible and acceptable for persons with SCD and chronic pain. Seventy-eight patients with SCD and chronic pain were approached, and 76% (N = 60) were enrolled and randomized. The MBI attendance rate, approximately 57% of participants completing at least four mindfulness sessions, was deemed acceptable, and participants that received the telephonic MBI described it as acceptable, easy to access, and consume in post-intervention interviews. The amount of missing data was undesirable (MBI condition, 40%; control condition, 25%), but fell within the range of expected missing outcome data for a RCT with multiple follow-up assessments. Efficacy of the MBI on pain catastrophizing could not be determined due to small sample size and degree of missing data, but trajectory analyses conducted for the MBI condition only trended in the right direction and pain catastrophizing approached statistically significance.

Conclusion: Overall results showed that at telephonic group-based MBI is acceptable and feasible for persons with SCD and chronic pain. Though the study was not able to determine treatment efficacy nor powered to detect a statistically significant difference between conditions, participants (1) described the intervention as acceptable, and (2) the observed effect sizes for the MBI condition demonstrated large effects of the MBI on pain catastrophizing, mental health, and physical health. Replication of this MBI study with a larger sample size, active control group, and additional assessments at the end of each week (e.g., Week 1 through Week 6) is needed to determine treatment efficacy. Many lessons were learned that will guide the development of future studies including which MBI strategies were most helpful, methods to encourage continued participation, and how to improve data capture.

Reduction of quantity smoked predicts future cessation among older smokers.

AIM: To examine whether smokers who reduce their quantity of cigarettes smoked between two periods are more or less likely to quit subsequently. STUDY DESIGN: Data come from the Health and Retirement Study, a nationally representative survey of older Americans aged 51-61 in 1991 followed every 2 years from 1992 to 1998. The 2064 participants smoking at baseline and the first follow-up comprise the main sample. MEASUREMENTS: Smoking cessation by 1996 is examined as the primary outcome. A secondary outcome is relapse by 1998. Spontaneous changes in smoking quantity between the first two waves make up the key predictor variables. Control variables include gender, age, education, race, marital status, alcohol use, psychiatric problems, acute or chronic health problems and smoking quantity. FINDINGS: Large (over 50%) and even moderate (25-50%) reductions in quantity smoked between 1992 and 1994 predict prospectively increased likelihood of cessation in 1996 compared to no change in quantity (OR 2.96, P<0.001 and OR 1.61, P<0.01, respectively). Additionally, those who reduced and then quit were somewhat less likely to relapse by 1998 than those who did not reduce in the 2 years prior to quitting. CONCLUSIONS: Reducing successfully the quantity of cigarettes smoked appears to have a beneficial effect on future cessation likelihood, even after controlling for initial smoking level and other variables known to impact smoking cessation. These results indicate that the harm reduction strategy of reduced smoking warrants further study.

Teaching yoga to seniors: essential considerations to enhance safety and reduce risk in a uniquely vulnerable age group.

BACKGROUND: Seniors age 65 and older represent the fastest-growing sector of the population and, like many Americans, are increasingly drawn to yoga. This presents both an extraordinary opportunity and a serious challenge for yoga instructors who must be both a resource and guardians of safety for this uniquely vulnerable group. A typical class of seniors is likely to represent the most diverse mix of abilities of any age group. While some may be exceedingly healthy, most fit the profile of the average older adult in America, 80% of whom have at least one chronic health condition and 50% of whom have at least two. OBJECTIVES: This article discusses the Therapeutic Yoga for Seniors program, offered since 2007 at Duke Integrative Medicine to fill a critical need to help yoga instructors work safely and effectively with the increasing number of older adults coming to yoga classes, and explores three areas that pose the greatest risk of compromise to older adult students: sedentary lifestyle, cardiovascular disease, and osteoporosis. To provide a skillful framework for teaching yoga to seniors, we have developed specific Principles of Practice that integrate the knowledge gained from Western medicine with yogic teachings.

Small molecule dual-inhibitors of TRPV4 and TRPA1 for attenuation of inflammation and pain.

TRPV4 ion channels represent osmo-mechano-TRP channels with pleiotropic function and wide-spread expression. One of the critical functions of TRPV4 in this spectrum is its involvement in pain and inflammation. However, few small-molecule inhibitors of TRPV4 are available. Here we developed TRPV4-inhibitory molecules based on modifications of a known TRPV4-selective tool-compound, GSK205. We not only increased TRPV4-inhibitory potency, but surprisingly also generated two compounds that potently co-inhibit TRPA1, known to function as chemical sensor of noxious and irritant signaling. We demonstrate TRPV4 inhibition by these compounds in primary cells with known TRPV4 expression - articular chondrocytes and astrocytes. Importantly, our novel compounds attenuate pain behavior in a trigeminal irritant pain model that is known to rely on TRPV4 and TRPA1. Furthermore, our novel dual-channel blocker inhibited inflammation and pain-associated behavior in a model of acute pancreatitis - known to also rely on TRPV4 and TRPA1. Our results illustrate proof of a novel concept inherent in our prototype compounds of a drug that targets two functionally-related TRP channels, and thus can be used to combat isoforms of pain and inflammation in-vivo that involve more than one TRP channel. This approach could provide a novel paradigm for treating other relevant health conditions.

Inter-Species Microbial Sharing in Rural Madagascar: A Study of Environmental Influences on the Skin Microbiome

The skin is home to trillions of microbes, many of which are recently implicated in immune system regulation and various health conditions (33). The skin is continuously exposed to the outside environment, inviting microbial transfer between human skin and the people, animals, and surfaces with which an individual comes into contact. Thus, the aim of this study is to assess how different environmental exposures influence skin microbe communities, as this can strengthen our understanding of how microbial variation relates to health outcomes. This study investigated the skin microbial communities of humans and domesticated cattle living in rural Madagascar. The V3 region of the 16S rRNA gene was sequenced from samples of zebu (the domesticated cattle of Madagascar), zebu owners, and non-zebu owners. Overall, human armpits were the least diverse sample site, while ankles were the most diverse. The diversity of zebu samples was significantly different from armpits, irrespective of zebu ownership (one-way ANOVA and Tukey’s HSD, p<0.05). However, zebu owner samples (from the armpit, ankle forearm, and hand) were more similar to other zebu owner samples than they were to zebu, yet no more similar to other zebu owner samples than they were to non-zebu owner samples (unweighted UniFrac distances, p<0.05). These data suggest a lack of a microbial signature shared by zebu owners and zebu, though further taxonomic analysis is required to explain the role of additional environmental variables in dictating the microbial communities of various samples sites. Understanding the magnitude and directionality of microbial sharing has implications for a breadth of microbe-related health outcomes, with the potential to explain mosquito host preference and mitigate the threats of vector-borne diseases.

Potassium Measures and Their Associations with Glucose and Diabetes Risk: The Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND: Recent studies have found low-normal potassium (K) to be associated with increased diabetes risk. We sought to verify these associations in a multi-ethnic US cohort; and to determine if these associations extend to US Hispanics and Asian-Americans. METHODS: We analyzed data from Multi-Ethnic Study of Atherosclerosis (MESA) participants who were free-of-diabetes at baseline. We examined cross-sectional associations between measures of K-serum, dietary, and urine-with fasting glucose and HOMA-IR. We examined longitudinal associations between K and diabetes risk over 8 years. FINDINGS: In multivariable models, compared to those with higher serum K (≥4.5mmol/L), those with lower serum K (<4.0mmol/L) had significantly higher fasting glucose [1.3 mg/dL (95%CI 0.2, 2.4), P-value = 0.03]. Incident diabetes developed in 1281 of 5415 at-risk participants. In minimally-adjusted models, we found inverse associations between serum and dietary K and diabetes risk. Compared to those with higher serum K, those with lower serum K had an HR (95% CI) of incident diabetes of 1.23 (1.04, 1.47), P-value = 0.02. However, these associations were attenuated in fully-adjusted models. We found no significant interaction between potassium and ethnicity. CONCLUSIONS: In this multi-ethnic cohort, we found a significant inverse association between serum K and fasting glucose but no significant association with longer-term diabetes risk. This inverse association between potassium and glucose must be studied further to understand the physiology and its potential impact on chronic health.

Mobile Clinics & Bundled Healthcare: An Exploration of Patient Perceptions of the SughaVazhvu Approach to Chronic Care Management

As the burden of non-communicable diseases increases worldwide, it is imperative that health systems adopt delivery approaches that will enable them to provide accessible, high-quality, and low-cost care to patients that need consistent management of their lifelong conditions. This is especially true in low- and middle-income country settings, such as India, where the disease burden is high and the health sector resources to address it are limited. The subscription-based, managed care model that SughaVazhvu Healthcare—a non-profit social enterprise operating in rural Thanjavur, Tamil Nadu—has deployed demonstrates potential for ensuring continuity of care among chronic care patients in resource-strained areas. However, its effectiveness and sustainability will depend on its ability to positively impact patient health status and patient satisfaction with the care management they are receiving. Therefore, this study is not only a program appraisal to aid operational quality improvement of the SughaVazhvu Healthcare model, but also an attempt to identify the factors that affect patient satisfaction among individuals with chronic conditions actively availing services.