Effect of the Womens Health Initiative on Hormone Replacement Therapy Prescribing Practices in a Sin

1

Effect of the Womens Health Initiative on
Hormone Replacement Therapy
Prescribing Practices in a Single
Physician Ob-Gyn Office
in Northeast Florida

• Catherine Greenblum, MSN, APRN-BC
• PhD Student University of Florida

2
Background

• Since the results of the Womens Health
  Initiative study were published in July 2002,
  millions of women and their healthcare
  practitioners have had to re-examine decisions
  about the use of hormone replacement therapy

3

• The Womens Health Initiative, sponsored by the
  NIH, was an ambitious multicenter
  placebo-controlled study of the effects of HRT on
  16,608 healthy postmenopausal women aged 50-79
  (Beattie, 2003)
• WHI unexpectedly ended the study prematurely
  citing increased risks for breast cancer,
  pulmonary embolism, stroke, cardiac events, and
  dementia (NIH, 2004) contradicting years of
  observational studies
• A slight benefit of decreased fractures and
  colorectal cancer was also found in this study
  (NIH, 2004)

4
.

• Before the results of WHI were published in July
  2002, an estimated 6 million women were taking
  HRT. By May 2003, that number decreased to an
  estimated 2.7 million
• Within a year, millions of women stopped using
  HRT and many more did not start due to the
  findings published by WHI (Goldstein, 2004)
• The women who continued HRT despite the risks,
  did so primarily to reduce menopausal symptoms
  and maintain quality of life (Woodward, 2005)

5
.

• The average age of menopause today is 51.4 years
  and a healthy 50 year-old has a life expectancy
  of 91 years (Goldstein, 2004)
• Women live as many as 1/3rd of their years in the
  menopausal state
• ¾ of women report vasomotor symptoms at menopause
  and one-fourth of all menopausal women seek
  treatment for menopausal symptoms (Poindexter
  Wysocki, 2004)

6
.

• Menopause is a, normal transition that occurs in
  all women (Pearson, 2002, p.1). While some
  women become menopausal with little difficulty,
  other women have symptoms that disrupt their
  lives
• Discomfort from hot flashes is the most common
  reason women seek HRT and these vasomotor
  symptoms have been shown to have a significant
  negative impact on quality of life (Barton,
  Loprinzi, Waner-Roedler, 2001)
• HRT has been shown to be the most effective
  treatment for the vasomotor symptoms of menopause
  (ACOG, 2004 Woodward 2005)

7
Purpose

• The purpose of this study was to examine the
  effects of the WHI results published in July 2002
  on HRT prescribing practices in a single
  physician Ob-Gyn office in northeast Florida.

8
Method

• A total non-probability convenience sample of
  every medical record that met the inclusion
  criteria was used
• Inclusion criteria birth date in 1954 or earlier
• scheduled for gynecological care subsequent to
  July 2002 (the date of the cessation of the first
  arm of the WHI)
• A computer search on March 1, 2004 revealed
  approximately 1800 medical records that met the
  inclusion criteria

9

• A total of 1,783 charts were reviewed
• 301 were noted as no show for the scheduled
  office visit
• 19 were missing documented menopausal status
• 268 were seen for a non-gynecological
  appointment.
• N1,195.

10

Sample Demographic Data-
Nassau County Florida US
Census Bureau, 2006

11
.

• 41 of the population of Nassau County is age 45
  and older
• (Nassau County Economic Development Board, 2004).
  
• An investigation of 100 randomly chosen medical
  records at the practice site on April 11, 2004,
  showed a close match with the demographic data of
  the county

12
Demographic Characteristics of
Sample
13
Results
14
Effect of WHI on estrogen dose
and HRT use
15
.

• Based on physician recommendation, a significant
  portion of women (77.2) had discontinued HRT
• Of the women remaining on HRT, 54.7 changed
  either the dose or type of hormones taken
• Only 59.5 of women remained on the same estrogen
  dose both before and after the WHI results were
  published in 2002
• Only 29 women (4) initiated HRT use after July
  2002

16
.

• The average time on HRT for the sample as a whole
  was 8.3 years (range 0 to 46)
• 730 of the 1,195 women on whom charts were
  reviewed (61.1) had been on hormone replacement
  therapy prior to the release of the WHI results
  in July 2002
• 443 of the women on whom charts were reviewed
  (37.1) were on hormone replacement therapy at
  the time of data collection

17
.

• Of the women for whom both pre and post WHI data
  on HRT use were available (n 724), 254
  discontinued HRT on physician advice after July
  2002
• Of the 75 women remaining on HRT, 41 changed
  either the dose or type of hormones taken
• Only 59.5 of women taking HRT after July 2002
  remained on the same estrogen dose bother before
  and after WHI results were published
• Only 29 women (4) initiated HRT use after July
  2002.

18
.
19
Conclusions

• The application of the WHI results is limited
  because the study used only one oral preparation
  of HRT
• The average age of participants was 63 (ACOG,
  2004) with an average estrogen depletion of 10
  years (Chlebowski, n.d.)
• Nonetheless, recommendations to postmenopausal
  women changed radically. No longer the panacea
  for aging, millions of women were advised to
  abruptly discontinue HRT.
• Within two years, 1 in 4 of these women restarted
  hormone therapy to relieve menopausal symptoms
  (ACOG, 2004).

20
.

• Hormone therapy remains controversial and many
  questions remain unanswered. One thing experts
  agree on is HRT should be used for treating
  vasomotor symptoms and vaginal dryness at the
  lowest effective dose for the shortest amount
  time (ACOG, 2004 Woodward, 2005).

21
.

• ACOG stressed that each woman individually with
  her health care provider must evaluate use of
  hormone replacement therapy for risks and
  benefits.
• HRT should be used for management of menopausal
  symptoms only and not as a preventative for
  chronic disease.
• HRT use should be evaluated periodically and at
  least annually, the lowest dose for the least
  amount of time should be used, and alternative
  therapies considered.
• Current users of HRT are advised to taper doses
  toward discontinuation of HRT (ACOG, 2004)

22

• Since the results of the Womens Health
  Initiative study were published in 2002, millions
  of women and their healthcare practitioners have
  had to re-examine decisions about the use of
  hormone replacement therapy.
• Health care providers need to be current on the
  research and recommendations regarding HRT and
  treatment of menopausal symptoms and counsel
  their patients appropriately.
• Margaret Freda, editor of the American Journal of
  Maternal Child Nursing, stated that while the
  results of WHI were unexpected, health care
  providers now have evidence-based research on
  which to base their practices (Freda, 2003).

23
.
24
The Seven Dwarves of Menopause
25
References

• ACOG issues state-of-theart guide to hormone
  therapy. (2004). Retrieved February 7, 2006 from
  http//www.acog.org/from_home/publications/
  press_releases/nr09-30-04-2.cfm
• Barton, D., Loprinzi, C., Waner-Roedler, D.
  (2001). Hot flashes aetiology and management.
  Drugs Aging, 18, 597-606.
• Beattie, M. (2003). Current status of
  postmenopausal hormone therapy. Advanced Studies
  in Medicine, 3, 205-213.
• Chlebowski, R.T. (n. d.) Breast cancer in the
  womens health initiative trial of estrogen plus
  progestin. Retrieved February 7, 2006, from
  http//www.fda.gov/ohrms/ Dockets/ac/03/slides/
  3992S1_04_Chlebowski.ppt
• Freda, M. C. (2003). Surprise! HRT and the WHI.
  The American Journal of Maternal Child Nursing,
  28, 259.
• Goldstein, S. R. (2004). Clinical management
  after hormone therapy discontinuation. Menopause
  Management, 13, 45-47.

26
.

• Nassau County Economic Development Board. (2004).
  Nassau County Florida A Diverse, Growing
  Community. In Demographics. Fernandina Beach, FL
  Nassau County Economic Development Board.
  Retrieved February 7, 2006, from
  http/?/?www.nassaucountyfla.com/?demographics.htm
  
• National Institutes of Health. (March 2, 2004).
  NIH asks participants in women's health
  initiative estrogen-alone study to stop study
  pills, begin follow-up phase Electronic
  version. Washington, DC U.S. Government
  Printing Office.
• Pearson, C. (2002). The truth about hormone
  replacement therapy. A Friend Indeed for Women in
  the Prime of Life, 19, 1-3.
• Poindexter, A. N., Wysocki, S. (2004). WHI in
  perspective- focus on quality of life. The Forum
  a Working Group for Women's Healthcare, 1, 8-10.
• U.S. Census Bureau State and County Quick Facts
  Nassau County Florida. Retrieved February 7, 2006
  from http//quickfacts.census.gov/qfd/states/12/12
  080lk.html
• Woodward, J. (2005). Hormone therapy in
  menopause. Clinician Reviews, 15(4), 46-51.

27
EFFECTS OF CLUSTERED CARE ON PAIN IN THE PRETERM
INFANT-A DESCRIPTIVE STUDY

• Elizabeth A. Gyland, MSN, ARNP
• University of Florida
• College of Nursing
• November 3, 2006

28
The Problem

• The current standard of nursing care for preterm
  infants (clustered care) within the neonatal
  intensive care unit (NICU) may promote both
  structural and functional reorganization of pain
  pathways (plasticity) due to the windup
  phenomenon created by repetitive painful
  interventions.

29

• The result of this repetitive pain leads to a
  cumulative windup phenomenon that disrupts the
  normal development of the brain, with effects
  that potentially extend past postnatal brain
  development (Aynsley-Green, 1996 Anand, 1997).

30
This exposure to repetitive pain may promote
distinct behavioral phenotypes in the school-age
child, the adolescent, and the adult, which are
characterized by

• stress disorders
• decreased pain sensitivity
• hyperactivity/attention deficit disorder
• impaired social/cognitive skills and
• specific patterns of self-destructive behaviors
  

31
The purpose

• The purpose of this longitudinal, descriptive
  study is to explore relationships of pain scores
  in the 28-34 week postconceptional age neonate
  during clustered care (including both painful and
  nonpainful procedures) in the first seven days
  after birth and again at 34 weeks
  postconceptional age in a level III NICU.

32
Specific Aim 1

• To describe the within-subject differences in
  pain scores (using the Premature Infant Pain
  Profile or PIPP) before, during, and after
  clustered care of one test session from birth to
  seven days of age.

33
Hypothesis 1

• A statistically significant increase in pain
  scores will be noted within a session of
  clustered care, from pre-procedure to
  post-procedure, for sessions that include at
  least one painful intervention.

34
Specific Aim 2

• To describe between-group differences in
  pre-procedure, peri-procedure, and post-procedure
  pain scores (using the PIPP) between the two
  groups before, during, and after clustered care
  of one test session from birth to seven days of
  age and between both groups again at 34 weeks
  postconceptional age.

35
Hypothesis 2

• The pain scores in group 2 (those between 31-32
  6/7 weeks) will be higher than group 1 (those
  between 28-29 6/7 weeks) during sessions of
  clustered care that include at least one painful
  intervention.

36
Hypothesis 3

• The pain scores in group 1 (those between 28-29
  6/7 weeks) will be higher when tested again at 34
  weeks during sessions that include at least one
  painful intervention and there will be no
  significant difference in pain scores of group 2
  when tested again at 34 weeks during sessions
  that include at least one painful intervention.

37
Design

• Longitudinal, descriptive

38
Theoretical Framework

• Heidelise Als developed the Synactive Theory of
  Development in 1982 as a model for understanding
  the organization of neurobehavioral capabilities
  in the development of the fetus, infant, and
  young child.

39

• Her theory states that infants are in continual
  interaction with their environment via 5
  subsystems
• Autonomic/physiologic
• Motor
• State/organizational
• Attentional/interactive
• Self-regulatory

40
Diagram of theory

41

• The subsystems are interdependent and
  interrelated.
• The loss of integrity in one subsystem can
  influence the organization of other subsystems.

42

• Therefore, the burden and opportunity are on the
  identification and provision of developmentally
  appropriate and supportive environments to ensure
  normal developmental functioning and
  progression (Als, 1986).

43
Sample

• A convenience sample of 20 neonates 28-32 weeks
  postconceptional age admitted to a level III NICU
  will be recruited. The neonates will be divided
  into
• two groups
• 10 subjects between 28-29 6/7 weeks
  postconceptional age
• 10 subjects between 31 32 6/7 weeks
  postconceptional age

44
RECRUITMENT OF SAMPLE ACCORDING TO GROUP
ASSIGNMENT N20  (10 in Group1-28-29 6/7
weeks) (10 in Group 2-31-32 6/7 weeks)
45
RECRUITMENT AS PER COLUMN A
46
RECRUITMENT AS PER COLUMN B
47
RECRUITMENT AS PER COLUMN C
48
Inclusion criteria

• Confirmation of post-conceptional age by Dubowitz
• 5-minute Apgar score gt3 (cord pH gt7.0)
• Infants requiring intubation and placement on
  infant ventilator

49
Exclusion criteria

• Severe genetic and/or cardiac anomaly
• Severe intrapartum asphyxia (a 5-minute Apgar
  score lt/3 or a cord blood pH of lt7.0
• Use of a neuromuscular blocking agent that
  produces skeletal muscle paralysis

50
Parental consent

• To be obtained by primary investigator in a
  private room in the hospital within the first
  seven days of life.

51
Procedure

• Neonates will be observed during one session of
  clustered care during the first seven days of
  life.
• During each session, no research interventions
  will be performed.
• Pain scores will be calculated using the PIPP
  tool.
• Observational assessment of behavioral indicators
• Recording of the ECG to obtain heart rate and
  oxygen saturation

52
Premature Infant Pain Profile
53
Additional Behavioral Indicators of the PIPP

• Facial movements will be recorded onto a
  videotape during each session
• Brow bulge
• Eye squeeze
• Nasolabial furrow

54
Within Subject Session Comparison of Pain Scores

• Pain scores will be obtained during a session of
  clustered care as follows
• Before session begins
• During each procedures of clustered care (this
  will be variable as each infants care is
  individualized)
• After last procedure of clustered care
• 15-minutes post-procedure
• 30-minutes post-procedure
• 60-minutes post-procedure
• 90-minutes post-procedure
• 120-minutes post-procedure
• (as recommended by the Pain Assessment Guidelines
  of the National Association of Neonatal Nurses,
  2001)

55
WITHIN-IN SUBJECT SESSION COMPARISON
56
Statistical Analysis

• Specific Aim 1 To describe the within-subject
  differences between pain scores before, during,
  and after clustered care of one test session in
  the first seven days of life.
• Hypothesis 1 A statistically significant
  increase in pain scores will be noted within a
  session of clustered care, from pre-procedure to
  post-procedure, for sessions that include at
  least one painful intervention.

57

• The general linear mixed model (GLMM) will be
  used (SAS/STAT proc GENMOD software).
• The fixed effects in this model are
  post-conceptional age and pain scores

58

• Specific Aim 2 To describe between-group
  differences in pre-procedure, peri-procedure, and
  post-procedure pain scores (using the PIPP)
  between the two groups before, during, and
  after clustered care of one test session in the
  first seven days of life and between both groups
  again at 34 weeks postconceptional age.

59

• Hypothesis 2 The pain scores in group 2 (those
  between 30-32 6/7 weeks) will be higher than
  group 1 (those between 28-29 6/7 weeks) during
  sessions of clustered care that include at least
  one painful intervention.

60

• Hypothesis 3 The pain scores in group 1 (those
  between 28-29 6/7 weeks) will be higher when
  tested again 34 weeks during sessions that
  include at least one painful intervention and
  there will be no significant difference in pain
  scores of group 2 (those between 31-32 6/7 weeks)
  when tested again at 34 weeks during sessions
  that include painful interventions.

61

• The GLMM will be used (SAS/STAT pro GENMOD
  software). Each indicator will be analyzed
  separately.
• The three effects that will be analyzed will be
• brow bulge x gestational age
• eye squeeze score x gestational age
• nasolabial furrow score x gestational age.

62
Summary

• Determining the answers to these specific aims
  has the potential to provide the impetus for a
  change in the current standard of clustered care.
  It would promote an ongoing assessment of infant
  pain that would prevent or limit the windup
  phenomenon by guiding our caregiving and
  ultimately preventing permanent developmental
  changes to the pain pathways in the newborn that
  could lead to the distinct abnormal behavioral
  phenotypes (Anand Scalzo, 2000).

63
DissertationReady, Set, Go!?

• Andrea M. Boyd

64
Background and Significance

• Increase of CHF diagnosis during the past 20
  years of 150
• Average age of onset 65yrs
• 90 of CHF deaths occur in those over 65
• Aging population baby boomers
• CHF single most costly cardiovascular illness in
  the US
• Exercise is low cost, preventative AND feasible

65
Symptoms of CHF

• Dyspnea upon exertion (DOE)
• Shortness of breath when completing physical
  tasks (i.e. walking)
• Persistent cough or wheezing
• Edema in extremities, primarily in lower
  extremities
• Fatigue
• Decreased appetite, nausea
• Tachycardia (increased heart rate)
• Confusion, impaired thinking

66
Edema
67
Pitting Edema
68
Exercise and CHF

• Aerobic
• Increased VO2 max
• Improvement in Quality of Life Measures
• Decrease in inflammation markers (CRP, TNF-alpha,
  IL-6)
• Decrease in Depression measures

69
Exercise and CHF

• Anaerobic
• Improvement in Quality of Life measures
• Increased endothelial function
• Increase in strength

70
Why fluid status?

• Fluid balance has not been investigated with
  exercise.
• Fluid imbalance is the primary cause of edema.
• Edema (pulmonary and extremity) is the primary
  source of physical symptoms.
• Edema is directly related to quality of life for
  the CHF patient.

71
Purpose

• To determine if combination aerobic and anaerobic
  exercise alters the natural physiological
  processes that maintain fluid balance within the
  CHF patient.

72
Specific Aim

• To compare the combined effect of aerobic and
  anaerobic exercise to no exercise on the fluid
  balance status of the CHF patient.

73
Design

• Multiple Baseline across subjects with three
  subjects per study replicated at least once (6
  subjects) and a goal of 3 replications (12
  subjects).

74
Subjects

• Inclusion Criteria
• Diagnosis of CHF and staged according to the NYHA
  as Class I or II
• Over the age of 50 years
• Must be medically stable for the past 12 months
• Desire to use exercise as an adjunct to current
  treatment/therapy, have time for 1 hour of
  exercise 3 days per week and have transportation.
• Be ambulatory and able to conduct treadmill
  walking exercise
• Exclusion Criteria
• Can not be on transplant list
• Can not be staged as a NYHA III-IV
• Can not be medically unstable within last 12
  ,omths

75
Variables

• Fluid Status
• Daily Weights
• Urinalysis (Specific Gravity)
• BP
• Physical Assessment
• Serum Values (BUN, Na, Osmolality, Potassium,
  Creatinine)
• Self-report Symptom checklist

• Other
• Minnesota Living with Heart Failure Questionnaire
• RANDs Inventory
• Health Hardiness Scale
• Self-report on ADLs

76
Time Frame

• Baseline
• Until three point trend is established
• Exercise sessions
• Each session 1 hour long
• 3 sessions per week
• Performed until trend stabilizes
• Maintenance Probes
• At one month, three months, and six months

77
Exercise Protocol

• 5-10 min stretch
• Anaerobic (60 of max of one rep)
• 15 min lower extremity work (Knee extensor
  flexion/Hamstring curls/Toe raises) OR 15 min
  upper extremity work (Bicep Curls/Tri-cep
  extensions)
• Aerobic (40-60 of max heart rate)
• 35 min aerobic work (Treadmill walking or arm
  cycling)
• 5-10 min stretch

78
Treatment Integrity

• Heart rate will be continuously monitored via a
  Holter Monitor and adjustments to intensity will
  be done using this heart rate.
• Heart will be taken manually every five minutes
  to verify accuracy of Holter monitor.
• The data will be downloaded after every exercise
  session.
• Heart rate will be manually recorded every five
  minutes as a back up.

79
Holter monitor
80
Data Analysis Plan

• Visual Trend Analysis
• Time Series Analysis IF any of the following
  occur
• A trend in baseline is in the therapeutic
  direction.
• Variability is large.
• Treatment effects are neither rapid nor marked.

81
Social Validity

• Pre and post measures using visual analog and
  open-ended response format.

82
Social Significance

• Exercise is low cost to consumer.
• Decrease in acute exacerbations will decrease
  hospitalizations and subsequently overall
  healthcare resource consumption.
• Increase the quality of life of the CHF patient
  through decreased symptomology.
• The patient gains CONTROL of management of
  disease.

83
Limitations

• Generality (first study conducted)
• May be difficult to eliminate extraneous
  variables from effecting the study
• A new approach to exercise treatment in patient
  populations.
• No previous research demonstrating the effect of
  exercise on fluid status.

84
Strengths

• Ability to better assess exercise versus
  adherence on CHF.
• Ability to detect unknown effects due to
  intensity of assessment.
• Ability to detect unique or outlier behaviors
  that may be influential in the practical use of
  exercise in this population.
• No need to alter current care due to medication
  regime.
• Multiple baseline accounts for uncontrollable
  systematic changes (ie physician changes at
  facilities, systematic drug formula changes).

85
Great, Ready Set Go RIGHT?

• IRB here I come!!!!!

86
Lets Talk..
87
Need Help?

• amboyd_at_ufl.edu

88
Dissertation Proposal The Journey Tips for
Success along the Way.

• Judy Campbell,
• MSN, ARNP, PhD student

I am here!
UF Alumni Fellowship Recipient UF Gerontology
Research Trainee BAGNC Hartford Scholar
89
Background Interests

• Interest in Dementia syndromes began with nursing
  home background
• Masters thesis related to behaviors in dementia
• Taught gerontology content, including coverage
  regarding dementia, to beginning Nursing students

90
PhD program opportunity to work with Dr. Rowe on
CareWatch Study

• CareWatch is designed to improve sleep and
  related variables in caregivers of those with
  dementia
• No measures of effect of CareWatch on person with
  dementia included in study
• Opinion that caregiver mood/affect (which may
  change with CareWatch) may lead to changes in
  behaviors in PWD /or CG appraisal of behaviors
• During first semester Dr. Rowe allowed me to
  evaluate tools that measured behaviors
• chose tool and secured Dr. Rowe agreement to add
  tool
• assembled IRB revision as part of RA duties
  (approved)
• added to CareWatch study after a few subjects had
  begun

91
Dementia Caregiver Stress Health Process (as
conceptualized by Schulz Martire, 2004)
Primary Stressors Care recipient Disability,
Problem Behaviors, Loss
Secondary Stressors Family Conflict, Work
Difficulties
Appraisal of Demands Adaptive Capacities
Perceived Stress
Caregiver Model
Emotional/Behavioral Response
Morbidity/Mortality
92
Dementia Caregiver Stress-Health Process Outcomes
PWD Nighttime Awakenings
Primary Stressors Care recipient Disability,
Problem Behaviors, Loss
Secondary Stressors Family Conflict, Work
Difficulties

Care Watch System
Negative changes in sleep Objective actigraphy
Subjective sleep diary Daytime effect
Sleepiness Fatigue
Appraisal of Demands Adaptive Capacities
Dyadic Model

CG Worry, Burden, Intent to Institutionalize
Perceived Stress

CG Depressed mood (CES-D) CG Affect (PANAS)
Emotional/Behavioral Response
NPI PWD Behavior Non-cognitive Behavioral
Expression in the PWD
Dyad Out- Comes
PWD Out- comes
CG Health



KEY Increase will yield increase OR
decrease will yield decrease
NPI CG Distress Caregiver Appraisal of Behaviors

93
Outcome variables in original study

• Sleep in CG measured with actigraphy sleep
  diary
• Measures of CG sleepiness, fatigue, burden,
  worry, intent to institutionalize the PWD,
  depressed mood, and affect
• Measures specific to my study
• NeuroPsychiatric Inventory Questionnaire NPI-Q
  to measure PWD and CG Dyadic outcomes
• PWD behaviors CG distress

94
Design Methodology

• Retrospective secondary analysis using data
  collected in CareWatch Study including my tool
• CareWatch Study true experimental with repeated
  measures at 9 time points
• My proposed study will use CareWatch data and the
  added tool to determine whether CareWatch use
  changes behaviors in PWD /or CG appraisal of
  behaviors
• Additionally, to model certain CG variables to
  determine what factors explain any difference
  between the two dyad groups

95
Subjects from Original Study

• 55 Dementia Caregiving dyads in the north-central
  FL areacommunity-dwelling
• Caregiver English-speaking with concern about
  nighttime activity in the persons with dementia
• Care recipients with a CG-reported diagnosis of
  dementia

96
Statistical Measures

• Missing Data
• Longitudinal analyseschange in PWD behaviors and
  CG distress related to behaviors over time
• Group comparisons
• Multi-Level modeling

97
Post-Dissertation Plans

• Broader program of research to investigate dyadic
  interventions that may help delay nursing home
  placement as long as realistic for both CG PWD,
  most likely through improving behaviors
• Would like to utilize knowledge of actigraphy
  within future research endeavors

Hope to be Here
98
TIPS for Success

• Choose topic for dissertation early
• Choose primary mentor (for committee chair) with
  interests similar to yours, preferably with
  ongoing research in which you can be involved
• Negotiate for 7979 objectives that allow real
  research experience
• Develop a 10-year plan
• As possible, negotiate time to allow immersion
  into PhD (decrease or eliminate work and/or other
  responsibilities)
• Build relationships with fellow students