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Seidler ZE, Benakovic R, Wilson MJ, McGee MA, Fisher K, Smith JA, Oliffe JL, Sheldrake M. Approaches to Engaging Men During Primary Healthcare Encounters: A scoping review. Am J Mens Health 2024; 18:15579883241241090. [PMID: 38606788 PMCID: PMC11010769 DOI: 10.1177/15579883241241090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 04/13/2024] Open
Abstract
Gender-responsive healthcare is critical to advancing men's health given that masculinities intersect with other social determinants to impact help-seeking, engagement with primary healthcare, and patient outcomes. A scoping review was undertaken with the aim to synthesize gender-responsive approaches used by healthcare providers (HCPs) to engage men with primary healthcare. MEDLINE, PubMed, CINAHL, and PsycINFO databases were searched for articles published between 2000 and February 2024. Titles and abstracts for 15,659 citations were reviewed, and 97 articles met the inclusion criteria. Data were extracted and analyzed thematically. Thirty-three approaches were synthesized from across counseling/psychology, general practice, social work, nursing, psychiatry, pharmacy, and unspecified primary healthcare settings. These were organized into three interrelated themes: (a) tailoring communication to reach men; (b) purposefully structuring treatment to meet men's health needs, and (c) centering the therapeutic alliance to retain men in care. Strength-based and asset-building approaches focused on reading and responding to a diversity of masculinities was reinforced across the three findings. While these approaches are recommended for the judicious integration into health practitioner education and practice, this review highlighted that the evidence remains underdeveloped, particularly for men who experience health inequities. Critical priorities for further research include intersectional considerations and operationalizing gender-responsive healthcare approaches for men and its outcomes, particularly at first point-of-contact encounters.
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Affiliation(s)
- Zac E. Seidler
- Movember, Melbourne, Victoria, Australia
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Ruben Benakovic
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Michael J. Wilson
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | | | - Krista Fisher
- Orygen, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - James A. Smith
- Rural and Remote Health, College of Medicine and Public Health, Flinders University, Darwin, Northern Territory, Australia
| | - John L. Oliffe
- School of Nursing, The University of British Columbia, Vancouver, British Columbia, Canada
- Department of Nursing, The University of Melbourne, Parkville, Victoria, Australia
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Martínez-Angulo P, Rich-Ruiz M, Ventura-Puertos PE, López-Quero S. Integrating shared decision-making, expressing preferences and active participation of older adults in primary care nursing: a systematic review of qualitative studies and qualitative meta-synthesis. BMJ Open 2023; 13:e071549. [PMID: 37344120 DOI: 10.1136/bmjopen-2022-071549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023] Open
Abstract
OBJECTIVES To systematically synthesise the results of primary qualitative studies on how community-dwelling older adults experience shared decision-making processes, express preferences and actively participate in care. DESIGN Systematic review of qualitative studies and qualitative meta-synthesis. METHODS We focused on studies about community-dwelling participants aged ≥65 undergoing a health-disease process circumscribed to a primary healthcare setting, and the central theme should focus on either shared decision-making, expressing preferences or patient participation. We searched the following databases: MEDLINE, CINAHL, Web of Science, Scopus and PsycINFO (time publication frame 2012-2022). We excluded studies in those cases where the qualitative results were not analysed or unrelated to the phenomenon addressed, phenomena were not clear enough to be included or the setting did not occur in the community. RESULTS A total of 12 studies were included in this meta-synthesis. We appraised the quality of the selected studies through Critical Appraisal Skills Programme (CASP) Checklist. The metasummary comprised the frequency and intensity of qualitative patterns across the included studies. The meta-synthesis revealed four influential elements in their interaction: recognising personal qualities, facing professional characteristics, experiences of discrimination and a double-edged context. CONCLUSIONS The phenomena studied were influenced by how older people approached their role in their binomial relationship with healthcare professionals. Those with a reinforced self-concept were better aware of health-disease-related situations regarding shared decision-making and the importance of being communicatively assertive. Professional characteristics were also crucial in how older people modulated their acting ability through their personality, communication skills and the approach healthcare professionals used towards older adults. Situations of discrimination generated through an imbalance of power inhibited the expression of preferences and hindered the active participation of older people. The context surrounding the participants influenced all these situations, key in tipping the balance between a therapeutic and a harmful side. PROSPERO REGISTRATION NUMBER CRD42022363515.
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Affiliation(s)
- Pablo Martínez-Angulo
- Department of Nursing, Pharmacology and Physiotherapy, Faculty of Medicine and Nursing, University of Córdoba (UCO), Córdoba, Andalucía, Spain
- Interdisciplinary Research Group in Discourse Analysis (HUM380), University of Córdoba (UCO), Córdoba, Andalucía, Spain
| | - Manuel Rich-Ruiz
- Department of Nursing, Pharmacology and Physiotherapy, Faculty of Medicine and Nursing, University of Córdoba (UCO), Córdoba, Andalucía, Spain
- Nursing and Healthcare Research Unit (Investén-isciii), Instituto de Salud Carlos III, Madrid, Spain
- Ciber Fragility and Healthy Aging (CIBERFES), Madrid, Spain
| | - Pedro E Ventura-Puertos
- Department of Nursing, Pharmacology and Physiotherapy, Faculty of Medicine and Nursing, University of Córdoba (UCO), Córdoba, Andalucía, Spain
- Interdisciplinary Research Group in Discourse Analysis (HUM380), University of Córdoba (UCO), Córdoba, Andalucía, Spain
| | - Salvador López-Quero
- Interdisciplinary Research Group in Discourse Analysis (HUM380), University of Córdoba (UCO), Córdoba, Andalucía, Spain
- Department of Language Sciences, Faculty of Philosophy and Letters, University of Córdoba (UCO), Córdoba, Andalucía, Spain
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Carson SL, Hong C, Behforouz H, Chang E, Dixon LZ, Factor D, George SM, Lewis J, Majeno A, Morales M, Porter C, Shah A, Vassar S, Brown AF. Mechanisms for Community Health Worker Action on Patient-, Institutional-, and Community-Level Barriers to Primary Care in a Safety-Net Setting. J Ambul Care Manage 2022; 45:22-35. [PMID: 34812754 PMCID: PMC8622376 DOI: 10.1097/jac.0000000000000405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Medically and socially complex patients disproportionately face barriers to primary care, contributing to health inequities and higher health care costs. This study elicited perspectives on how community health workers (CHWs) act upon barriers to primary care in 5 patient (n = 25) and 3 CHW focus groups (n = 17). Participants described how CHWs acted on patient-level barriers through social support, empowerment, and linkages, and system-level barriers by enhancing care team awareness of patient circumstances, optimizing communication, and advocating for equitable treatment. Limitations existed for influencing entrenched community-level barriers. CHWs, focusing on patient preferences, motivators, and circumstances, intervened on multilevel barriers to primary care, including advocacy for equitable treatment. These mechanisms have implications for existing CHW conceptual models.
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Affiliation(s)
- Savanna L. Carson
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California Los Angeles, 1100 Glendon Ave, Suite 1820, Los Angeles, CA, 90095
| | - Clemens Hong
- Los Angeles County, Department of Health Services, 241 N. Figueroa Street Los Angeles, CA 90012
| | - Heidi Behforouz
- Los Angeles County, Department of Health Services, 241 N. Figueroa Street Los Angeles, CA 90012
| | - Emily Chang
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California Los Angeles, 1100 Glendon Ave, Suite 1820, Los Angeles, CA, 90095
| | - Lydia Z. Dixon
- Health Science Program, California State University, Channel Islands, 1 University Dr, Camarillo, CA 93012
| | - Diane Factor
- Worker Education & Resource Center, Inc, 1545 Wilshire Blvd #500, Los Angeles, CA 90017
| | - Sheba M. George
- Department of Urban Public Health, Charles R Drew University of Medicine and Science, College of Science and Health, 1731 E 120th St, Los Angeles, CA 90059
| | - Jenebah Lewis
- USC Suzanne Dworak-Peck School of Social Work, 669 W 34th St, Los Angeles, CA 90089
| | - Angelina Majeno
- Department of Psychological Science, University of California Irvine, 510 E Peltason Dr. Irvine, California 92697
| | - Maria Morales
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California Los Angeles, 1100 Glendon Ave, Suite 1820, Los Angeles, CA, 90095
| | - Courtney Porter
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California Los Angeles, 1100 Glendon Ave, Suite 1820, Los Angeles, CA, 90095
- Worker Education & Resource Center, Inc, 1545 Wilshire Blvd #500, Los Angeles, CA 90017
| | - Ami Shah
- Los Angeles County, Department of Health Services, 241 N. Figueroa Street Los Angeles, CA 90012
| | - Stefanie Vassar
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California Los Angeles, 1100 Glendon Ave, Suite 1820, Los Angeles, CA, 90095
- Olive View-UCLA Medical Center, 14445 Olive View Dr, Sylmar, CA 91342
| | - Arleen F. Brown
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California Los Angeles, 1100 Glendon Ave, Suite 1820, Los Angeles, CA, 90095
- Olive View-UCLA Medical Center, 14445 Olive View Dr, Sylmar, CA 91342
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Holt JM, Cusatis R, Winn A, Asan O, Spanbauer C, Williams JS, Flynn KE, Somai M, Talsma A, Laud P, Makoul G, Crotty BH. Impact of Pre-visit Contextual Data Collection on Patient-Physician Communication and Patient Activation: a Randomized Trial. J Gen Intern Med 2021; 36:3321-3329. [PMID: 33559067 PMCID: PMC8606508 DOI: 10.1007/s11606-020-06583-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 12/29/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patient contextual data (PCD) are often missing from electronic health records, limiting the opportunity to incorporate preferences and life circumstances into care. Engaging patients through tools that collect and summarize such data may improve communication and patient activation. However, differential tool adoption by race might widen health care disparities. OBJECTIVE Determine if a digital tool designed to collect and present PCD improves communication and patient activation; secondarily, evaluate if use impacts outcomes by race. DESIGN, SETTING, AND PARTICIPANTS A pragmatic, two-armed, non-blinded, randomized controlled trial conducted during 2019 in a primary care setting. INTERVENTION The PCD tool (PatientWisdom) invited patients to identify preferences, values, goals, and barriers to care. Patients were randomized to a standard pre-visit email or facilitated enrollment with dedicated outreach to encourage use of the tool. MAIN OUTCOMES AND MEASURES Outcomes of interest were post-visit patient communication and patient activation measured by the Communication Assessment Tool (CAT) and Patient Activation Measure (PAM), respectively. Outcomes were evaluated using treatment-on-the-treated (TOT) and intention-to-treat (ITT) principles. KEY RESULTS A total of 301 patients were enrolled. Facilitated enrollment resulted in a five-fold increase in uptake of the PCD tool. TOT analysis indicated that the PCD tool was associated with notable increases in specific CAT items rated as excellent: "treated me with respect" (+ 13 percentage points; p = 0.04), "showed interest in my ideas" (+ 14 percentage points; p = 0.03), "showed care and concern" (+ 16 percentage points; p = 0.02), and "spent about the right amount of time with me" (+ 11 percentage points; p = 0.05). There were no significant pre/post-visit differences in PAM scores between arms (- 4.41 percentage points; p = 0.58). ITT results were similar. We saw no evidence of the treatment effect varying by race in ITT or TOT analyses. CONCLUSIONS AND RELEVANCE The inclusion of PCD enhanced essential aspects of patient-provider communication but did not affect patient activation. Outcomes did not differ by race. TRIAL REGISTRATION Clincaltrials.gov identifier: NCT03766841.
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Affiliation(s)
- Jeana M Holt
- University of Wisconsin-Milwaukee, College of Nursing, Milwaukee, WI, USA.
| | - Rachel Cusatis
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aaron Winn
- School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Onur Asan
- Stevens Institute of Technology, School of Systems & Enterprises, Hoboken, NJ, USA
| | - Charles Spanbauer
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joni S Williams
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kathryn E Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Melek Somai
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - AkkeNeel Talsma
- University of Wisconsin-Milwaukee, College of Nursing, Milwaukee, WI, USA
| | - Purushottam Laud
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Gregory Makoul
- PatientWisdom, Inc. and Yale School of Medicine, New Haven, CT, USA
| | - Bradley H Crotty
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Mitchell J, Perry T, Rorai V, Ilardo J, Lichtenberg PA, Jackson JS. Building and Sustaining a Community Advisory Board of African American Older Adults as the Foundation for Volunteer Research Recruitment and Retention in Health Sciences. Ethn Dis 2020; 30:755-764. [PMID: 33250622 DOI: 10.18865/ed.30.s2.755] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Older African Americans' participation in health-related research is severely limited; they are not involved in sufficient numbers to ensure the applicability of advancements in medical and behavioral health. This research participation gap exacerbates older African Americans' vulnerability to poor health outcomes and disparities. The Michigan Center for Urban African American Aging Research employs a progressive community-based participatory model that utilizes a structured community advisory board (CAB) of African American older adults in metro Detroit, Michigan to oversee the research recruitment and retention of fellow minority older adult research participants. CAB members develop and support community health programming that provides free resources to older adults and also serves as fertile ground for recruiting participants in a volunteer research registry. CAB members are also provided ongoing training on social and behavioral health research and are supported in acting as a consultancy to outside researchers where they can be compensated for their expertise and engagement. This community-engaged model of sustaining a CAB of African American older adults offers key lessons learned on building relationships and trust, valuing and leveraging community members' expertise and time, sharing decision-making, and fostering genuine community all while promoting research recruitment and retention among underserved populations.
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Affiliation(s)
- Jamie Mitchell
- School of Social Work, University of Michigan, Ann Arbor, MI
| | - Tam Perry
- School of Social Work, Wayne State University, Detroit, MI
| | - Vanessa Rorai
- Healthier Black Elders Center and the Institute of Gerontology, Wayne State University, Detroit, MI
| | - Joan Ilardo
- Michigan State University, College of Human Medicine, Lansing, MI
| | - Peter A Lichtenberg
- Institute of Gerontology and Merrill Palmer Skillman Institute, Wayne State University, Detroit, MI
| | - James S Jackson
- Institute for Social Research, University of Michigan, Ann Arbor, MI
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Mitchell JA, Perry R. Disparities in patient-centered communication for Black and Latino men in the U.S.: Cross-sectional results from the 2010 health and retirement study. PLoS One 2020; 15:e0238356. [PMID: 32991624 PMCID: PMC7523955 DOI: 10.1371/journal.pone.0238356] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 08/14/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND A lack of patient-centered communication (PCC) with health providers plays an important role in perpetuating disparities in health care outcomes and experiences for minority men. This study aimed to identify factors associated with any racial differences in the experience of PCC among Black and Latino men in a nationally representative sample. METHODS We employed a cross-sectional analysis of four indicators of PCC representative of interactions with doctors and nurses from (N = 3082) non-Latino White, Latino, and Black males from the 2010 Health and Retirement Study (HRS) Core and the linked HRS Health Care Mail in Survey (HCMS). Men's mean age was 66.76 years. The primary independent variable was Race/Ethnicity (i.e. Black and Hispanic/Latino compared to white males) and covariates included age, education, marital status, insurance status, place of care, and self-rated health. RESULTS Bivariate manova analyses revealed racial differences across each of the four facets of PCC experience such that non-Hispanic white men reported PC experiences most frequently followed by black then Hispanic/Latino men. Multivariate linear regressions predictive of PCC by race/ethnicity revealed that for Black men, fewer PCC experiences were predicted by discriminatory experiences, reporting fewer chronic conditions and a lack of insurance coverage. For Hispanic/Latino men, access to a provider proved key where not having a place of usual care solely predicted lower PCC frequency. IMPLICATIONS Researchers and health practitioners should continue to explore the impact of inadequate health care coverage, time-limited medical visits and implicit racial bias on medical encounters for underrepresented patients, and to advocate for accessible, inclusive and responsive communication between minority male patients and their health providers.
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Affiliation(s)
- Jamie A Mitchell
- School of Social Work, University of Michigan, Ann Arbor, MI, United States of America
| | - Ramona Perry
- School of Social Work, University of Michigan, Ann Arbor, MI, United States of America
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Lor M, Vang X, Rabago D, Brown RL, Backonja M. “It Hurts as If…”: Pain-Associated Language, Visual Characterization, and Storytelling in Hmong Adults. PAIN MEDICINE 2019; 21:1690-1702. [DOI: 10.1093/pm/pnz268] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
AbstractObjectivePain is challenging to diagnose and manage in primary care, especially when patients have limited English proficiency (LEP). Little is known about whether LEP patients can provide pain information that is consistent with the process and the content that providers expect in a clinical interaction. We explore how LEP Hmong patients communicate their pain to providers in primary care settings.MethodsA qualitative study with 67 Hmong participants (63% female and x̄ age = 53.7 years) were recruited from a Midwestern state. Semistructured interviews on pain communication were conducted, audio-recorded, transcribed, and analyzed using directed content analysis.ResultsThe Hmong participants described pain using stories that generally had the same dimensions of information that providers require for pain assessment. These included references to time, causality, associated symptoms or related experiences, intensity, and consequences of pain. However, the participants expressed some pain dimensions in language that was not shared by providers: visual metaphors that were generally in reference to pain quality and fewer words for pain location, intensity, and some qualities. Participants used two strategies to decide whether they should tell their pain story: assessing the provider and determining whether their story was appreciated. The perception that providers underappreciated their stories resulted in dissatisfaction and undertreatment of pain. Ultimately, this resulted in having less frequent contact with providers or changing providers.ConclusionsFindings demonstrate a discordance in the expected process and content of the clinical interaction between LEP Hmong patients and providers, suggesting the need for culturally appropriate pain assessments in this population.
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Affiliation(s)
- Maichou Lor
- Columbia University School of Nursing, University of Wisconsin-Madison, School of Nursing, Madison, Wisconsin
| | - Xia Vang
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - David Rabago
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Roger L Brown
- School of Nursing, University of Wisconsin-Madison, Madison, Wisconsin
| | - Miroslav Backonja
- Department of Neurology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Holt JM, Cusatis R, Asan O, Williams J, Nukuna S, Flynn KE, Moore J, Crotty BH. Incorporating patient-generated contextual data into care: Clinician perspectives using the Consolidated Framework for Implementation Science. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2019; 8:100369. [PMID: 31445878 DOI: 10.1016/j.hjdsi.2019.100369] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/17/2019] [Accepted: 08/04/2019] [Indexed: 01/17/2023]
Abstract
Patient contextual data (PCD), defined as patient's values, environment, or behavior influencing health, are essential to the proper care of patients, yet often are missing in the electronic health record (EHR). The current EHR structures and practice demands produce barriers to document PCD systemically. We sought to understand clinicians' perceived facilitators and barriers to use PCD using a consumer informatics technology integrated into the EHR. The PCD components include patient perceived pressures; joys; preferred approach to care; perceived health; health-goals; and visit agenda. We conducted semi-structured interviews of twenty primary care clinicians from an academic health system implementing a PCD initiative. The analysis included an inductive approach and a deductive a priori framework, the Consolidated Framework for Implementation Research (CFIR). Clinicians identified the following facilitators of adoption: reinforcement of patient engagement; a focus on enhancing team-based care; and communication around how the tool can be incorporated for individualized care. Clinicians identified barriers as: challenges incorporating PCD into the time-compressed visit and reviewing the tool involved another click in the EHR. The deductive results spanned four domains and seven constructs of CFIR, principally finding intervention source, relative advantage, organizational needs, and relative priority as facilitators with a need for ongoing leadership for the culture change. Overall, clinicians supported the adoption of a consumer informatics technology, as they reflected on the perceived value of a new data source to enhance patient-centered care and involvement in the development process. User-focused optimization efforts aided in the improved functionality and adoption of the application.
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Affiliation(s)
- Jeana M Holt
- Medical College of Wisconsin, Department of Family & Community Medicine, HUB A2360-7 8701, Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - Rachel Cusatis
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Onur Asan
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, USA
| | - Joni Williams
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sandile Nukuna
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kathryn E Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Bradley H Crotty
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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