Black women's perspectives on bladder health: Social-ecological and life course contexts

AIMS

This paper explores Black women's perspectives on bladder health using a social-ecological conceptual framework and life course perspective.

METHODS

We conducted a directed content analysis of data from the Study of Habits, Attitudes, Realities, and Experiences (SHARE), a focus group study by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. Analysis was conducted on data from five focus groups and a member-checking session where all participants self-identified as Black or African American.

RESULTS

Forty-two participants aged 11-14 or 45+ years reported life course experiences with their bladder. The intersection of race and gender was the lens through which participants viewed bladder health. Participants' accounts of their perspectives on bladder health explicitly and implicitly revealed structural racism as an explanatory overarching theme. Participants described (a) historically-rooted and still pervasive practices of discrimination and segregation, engendering inequitable access to quality medical care and public facilities, (b) institutional barriers to toileting autonomy in educational and occupational settings, promoting unhealthy voiding habits, (c) internalized expectations of Black women's stereotyped role as family caregiver, compromising caregiver health, (d) lack of reliable information on bladder health, leading to unhealthy bladder behaviors, and (e) potentially stress-related comorbid chronic conditions and associated medication use, causing or exacerbating bladder problems.

CONCLUSIONS

Bladder health promotion interventions should address social-ecological and life course factors shaping Black women's bladder health, including social and structural barriers to accessing equitable health information and medical care.

Reducing Falls in Older Women with Urinary Incontinence

Urinary incontinence is common in older women and doubles the risk of falls in this population. The association between urinary incontinence, especially urgency urinary incontinence, and falls is multifactorial and likely the result of a complex interaction between physical, mental, social, and environmental factors. As a result of this multifactorial etiology and based on existing evidence, the integration of different fall prevention strategies including strength and resistance exercises, bladder training, and home hazard reduction have the potential to decrease the risk of falls in older women with urinary incontinence. Given the prevalence of urinary incontinence and the significant morbidity associated with falls, effective interventions to reduce fall risk in older women with urinary incontinence is of high public health significance.

Preferences for Public Health Messaging Related to Bladder Health in Adolescent and Adult Women

Objective: The purpose of this analysis was to explore adolescent and adult women's preferences for the content and delivery of public health messaging around bladder health. Materials and Methods: This was a directed content analysis of focus group data from the Study of Habits, Attitudes, Realities, and Experiences, which explored adolescent and adult women's experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health and function across the life course. This article reports an analysis of the "Public Health Messaging" code, which includes participants' views on what information is needed about bladder health, attributes of messaging, and preferred locations and delivery methods. Results: Forty-four focus groups were conducted with 360 participants (ages 11-93 years) organized into six age groups. Across age groups, participants wanted messaging on maintaining bladder health and preventing bladder problems. They offered suggestions for a wide variety of methods to deliver bladder health information. Ideas for delivery methods fell into three broad categories: (1) traditional in-person modes of delivery, which included individual communication with providers in clinical settings and group-based methods in schools and other community settings where adolescent and adult women naturally gather; (2) internet-based website and social media delivery methods; and (3) static (noninteractive) modes of delivery such as pamphlets. Participants recommended the development of multiple delivery methods to be tailored for specific audiences. Conclusions: These findings can inform development of broad ranging public health messaging tailored to audiences of all ages with a goal of engaging adolescent and adult women across the bladder health risk spectrum.

Trust and virtual communication during the COVID-19 pandemic for adults with asthma from low-income neighborhoods: What have we learned?

BACKGROUND

Low-income and marginalized adults disproportionately bear the burden of poor asthma outcomes. One consequence of the structural racism that preserves these inequities is decreased trust in government and health care institutions.

OBJECTIVE

We examined whether such distrust extended to health care providers during the pandemic.

METHODS

We enrolled adults living in low-income neighborhoods who had required a hospitalization, an emergency department visit, or a prednisone course for asthma in the prior year. Trust was a dichotomized measure derived from a 5-item questionnaire with a 5-point Likert scale response. The items were translated to the binary variable "strong" versus "weak" trust. Communication was measured using a 13-item questionnaire with a 5-point Likert scale. Logistic regression was used to examine the association between communication and trust, controlling for potential confounders.

RESULTS

We enrolled 102 patients, aged 18 to 78 years; 87% were female, 90% were Black, 60% had some post-high school education, and 57% were receiving Medicaid. Of the 102 patients, 58 were enrolled before the March 12, 2020, pandemic start date, and 70 (69%) named doctors as their most trusted source of health information. Strong trust was associated with a negative response to the statement "It is hard to reach a person in my doctor's office by phone." There was no evidence of an association between the overall communication scores and trust. Satisfaction with virtual messaging was weaker among those with less trust.

CONCLUSIONS

These patients trust their physicians, value their advice, and need to have accessible means of communication.

RISE FOR HEALTH: Rationale and protocol for a prospective cohort study of bladder health in women

INTRODUCTION

The spectrum of bladder health and the factors that promote bladder health and prevent lower urinary tract symptoms (LUTS) among women are not well understood. This manuscript describes the rationale, aims, study design, sampling strategy, and data collection for the RISE FOR HEALTH (RISE) study, a novel study of bladder health in women conducted by the Prevention of Lower Urinary Tract Symptom (PLUS) Research Consortium.

METHODS AND RESULTS

RISE is a population-based, multicenter, prospective longitudinal cohort study of community-dwelling, English- and Spanish-speaking adult women based in the United States. Its goal is to inform the distribution of bladder health and the individual factors (biologic, behavioral, and psychosocial) and multilevel factors (interpersonal, institutional, community, and societal) that promote bladder health and/or prevent LUTS in women across the life course. Key study development activities included the: (1) development of a conceptual framework and philosophy to guide subsequent activities, (2) creation of a study design and sampling strategy, prioritizing diversity, equity, and inclusion, and (3) selection and development of data collection components. Community members and cross-cultural experts shaped and ensured the appropriateness of all study procedures and materials. RISE participants will be selected by simple random sampling of individuals identified by a marketing database who reside in the 50 counties surrounding nine PLUS clinical research centers. Participants will complete self-administered surveys at baseline (mailed paper or electronic) to capture bladder health and LUTS, knowledge about bladder health, and factors hypothesized to promote bladder health and prevent LUTS. A subset of participants will complete an in-person assessment to augment data with objective measures including urogenital microbiome specimens. Initial longitudinal follow-up is planned at 1 year.

DISCUSSION

Findings from RISE will begin to build the necessary evidence base to support much-needed, new bladder health promotion and LUTS prevention interventions in women.

Need for Public Health Messaging Related to Bladder Health from Adolescence to Advanced Age

Objective: The purpose of this analysis was to explore adolescent and adult women's interest in public health messaging around bladder health and perceptions of its usefulness. Materials and Methods: Directed content analysis of focus group data from the Study of Habits, Attitudes, Realities, and Experiences, which explored adolescent and adult women's experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health across the life course. This article reports an analysis of the "Public Health Messaging" code, which included participants' desire or need for information about bladder health and recommendations for appropriate priority audiences. Results: Forty-four focus groups were conducted with 360 participants organized into six age groups (11-93 years). There was consensus across age groups that more information about the bladder is wanted and needed throughout the life course, as there is currently a lack of reliable educational resources. Information on bladder health was seen as useful and important because it enables people to anticipate negative changes in bladder health and act to prevent these. Several priority audiences were identified based on their risk of developing symptoms, but participants also saw value in educating the general public regardless of risk status. They also recommended education for parents and teachers who are in positions to control bathroom access. Conclusions: Results indicate a uniform desire for information on women's bladder health and a need for more research to develop individual prevention strategies and public health messaging for women of all ages, as well as guidance for organizations with a role in supporting bladder health.

Impact of Stigma on Clinician Training for Opioid Use Disorder Care: A Qualitative Study in a Primary Care Learning Collaborative

PURPOSE

We undertook a study to examine how stigma influences the uptake of training on medication for opioid use disorder (MOUD) in primary care academic programs.

METHODS

We conducted a qualitative study of 23 key stakeholders responsible for implementing MOUD training in their academic primary care training programs that were participants in a learning collaborative in 2018. We assessed barriers to and facilitators of successful program implementation and used an integrated approach to develop a codebook and analyze the data.

RESULTS

Participants represented the family medicine, internal medicine, and physician assistant fields, and they included trainees. Most participants described clinician and institutional attitudes, misperceptions, and biases that enabled or hindered MOUD training. Perceptions included concerns that patients with OUD are "manipulative" or "drug seeking." Elements of stigma in the origin domain (ie, beliefs by primary care clinicians or the community that OUD is a choice and not a disease), the enacted domain (eg, hospital bylaws banning MOUD and clinicians declining to obtain an X-Waiver to prescribe MOUD), and the intersectional domain (eg, inadequate attention to patient needs) were perceived as major barriers to MOUD training by most respondents. Participants described strategies that improved the uptake of training, including giving attention to clinician concerns, clarifying the biology of OUD, and ameliorating clinician fears of being ill equipped to provide care for patients.

CONCLUSIONS

OUD-related stigma was commonly reported in training programs and impeded the uptake of MOUD training. Potential strategies to address stigma in the training context, beyond providing content on effective evidence-based treatments, include addressing the concerns of primary care clinicians and incorporating the chronic care framework into OUD treatment.

Community-Based COVID-19 Vaccine Clinics in Medically Underserved Neighborhoods to Improve Access and Equity, Philadelphia, 2021-2022

Vaccination remains key to reducing the risk of COVID-19-related severe illness and death. Because of historic medical exclusion and barriers to access, Black communities have had lower rates of COVID-19 vaccination than White communities. We describe the efforts of an academic medical institution to implement community-based COVID-19 vaccine clinics in medically underserved neighborhoods in Philadelphia, Pennsylvania. Over a 13-month period (April 2021-April 2022), the initiative delivered 9038 vaccine doses to community members, a majority of whom (57%) identified as Black. (Am J Public Health. 2022;112(12):1721-1725. https://doi.org/10.2105/AJPH.2022.307030).

A community-engaged approach to the design of a population-based prospective cohort study to promote bladder health

INTRODUCTION

Community engagement is increasingly recognized as a critical component of research, but few studies provide details on how to successfully incorporate community perspectives in urological research. This manuscript describes the community engagement strategy used by the Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS) to design RISE FOR HEALTH (RISE), a multicenter, population-based, prospective cohort study to promote bladder health.

METHODS AND RESULTS

The PLUS Community Engagement Subcommittee, guided by a set of antiracist community engagement principles and practices, organized, implemented, and communicated findings for all RISE community engagement activities. Community engagement was conducted through a diverse network of community partners at PLUS clinical research centers called Rapid Assessment Partners (RAPs). Via online surveys (4), virtual discussion groups (14), and one-on-one interviews (12), RAPs provided input on RISE processes and materials, including in-person visit procedures, specimen collection instructions, survey data collection instruments, recruitment materials, the study website, and the study name. This process resulted in significant changes to these aspects of the study design with reciprocal benefits for the community partners.

DISCUSSION

Meaningful community engagement improved the design and implementation of RISE. PLUS will continue to engage community partners to interpret the RISE study results, disseminate RISE findings, and inform other PLUS studies toward the development of interventions to promote bladder health. Future urological studies would also benefit from community participation in determining priority research questions to address.

Design, Implementation, and Outcomes of a Volunteer-Staffed Case Investigation and Contact Tracing Initiative at an Urban Academic Medical Center

IMPORTANCE

The COVID-19 pandemic has claimed nearly 6 million lives globally as of February 2022. While pandemic control efforts, including contact tracing, have traditionally been the purview of state and local health departments, the COVID-19 pandemic outpaced health department capacity, necessitating actions by private health systems to investigate and control outbreaks, mitigate transmission, and support patients and communities.

OBJECTIVE

To investigate the process of designing and implementing a volunteer-staffed contact tracing program at a large academic health system from April 2020 to May 2021, including program structure, lessons learned through implementation, results of case investigation and contact tracing efforts, and reflections on how constrained resources may be best allocated in the current pandemic or future public health emergencies.

DESIGN, SETTING, AND PARTICIPANTS

This case series study was conducted among patients at the University of Pennsylvania Health System and in partnership with the Philadelphia Department of Public Health. Patients who tested positive for COVID-19 were contacted to counsel them regarding safe isolation practices, identify and support quarantine of their close contacts, and provide resources, such as food and medicine, needed during isolation or quarantine.

RESULTS

Of 5470 individuals who tested positive for COVID-19 and received calls from a volunteer, 2982 individuals (54.5%; median [range] age, 42 [18-97] years; 1628 [59.4%] women among 2741 cases with sex data) were interviewed; among 2683 cases with race data, there were 110 Asian individuals (3.9%), 1476 Black individuals (52.7%), and 817 White individuals (29.2%), and among 2667 cases with ethnicity data, there were 366 Hispanic individuals (13.1%) and 2301 individuals who were not Hispanic (82.6%). Most individuals lived in a household with 2 to 5 people (2125 of 2904 individuals with household data [71.6%]). Of 3222 unique contacts, 1780 close contacts (55.2%; median [range] age, 40 [18-97] years; 866 [55.3%] women among 1565 contacts with sex data) were interviewed; among 1523 contacts with race data, there were 69 Asian individuals (4.2%), 705 Black individuals (43.2%), and 573 White individuals (35.1%), and among 1514 contacts with ethnicity data, there were 202 Hispanic individuals (12.8%) and 1312 individuals (83.4%) who were not Hispanic. Most contacts lived in a household with 2 to 5 people (1123 of 1418 individuals with household data [79.2%]). Of 3324 cases and contacts who completed a questionnaire on unmet social needs, 907 (27.3%) experienced material hardships that would make it difficult for them to isolate or quarantine safely. Such hardship was significantly less common among White compared with Black participants (odds ratio, 0.20; 95% CI, 0.16-0.25).

CONCLUSIONS AND RELEVANCE

These findings demonstrate the feasibility and challenges of implementing a case investigation and contact tracing program at an academic health system. In addition to successfully engaging most assigned COVID-19 cases and close contacts, contact tracers shared health information and material resources to support isolation and quarantine, thus filling local public health system gaps and supporting local pandemic control.

Evaluation of a Contact Tracing Training Program and Field Experience

Introduction

The study objective was to evaluate a contact tracing training program and the role of contact tracing on volunteers' professional development.

Methods

A COVID-19 contact tracing program was conducted at an urban academic medical center, in collaboration with the local health department, between March 2020 and May 2021. Contact tracers, most of whom were health professions students, completed pretraining and post-training surveys to assess knowledge and self-efficacy to conduct contact tracing, plus an 18-month follow-up survey regarding career impacts.

Results

We observed statistically significant post-training increases in knowledge and self-efficacy to conduct contact tracing. Contact tracers described benefiting from training regarding cultural humility, empathy, and trauma-informed interviewing. They also expressed a deeper understanding of COVID-19 inequities and their structural causes and reported that the work was emotionally demanding.

Conclusions

Key to pandemic preparedness is having a trained and supported workforce. This study showed how contact tracing training and field experience strengthened students' education in the health professions by sharpening interpersonal skills and structural competency and by generating insights regarding current gaps in both public health infrastructure and support for vulnerable populations.

Clinic navigation and home visits to improve asthma care in low income adults with poorly controlled asthma: Before and during the pandemic

Asthma-related deaths, hospitalizations, and emergency visits are more numerous among low-income patients, yet management guidelines do not address this high-risk group's special needs. We recently demonstrated feasibility, acceptability, and preliminary evidence of effectiveness of two interventions to improve access to care, patient-provider communication, and asthma outcomes: 1) Clinic Intervention (CI): study staff facilitated patient preparations for office visits, attended visits, and afterwards confirmed patient understanding of physician recommendations, and 2) Home Visit (HV) by community health workers for care coordination and informing clinicians of home barriers to managing asthma. The current project, denominated "HAP3," combines these interventions for greater effectiveness, delivery of guideline-based asthma care, and asthma control for low-income patients recruited from 6 primary care and 3 asthma specialty practices. We assess whether patients of clinicians receiving guideline-relevant, real-time feedback on patient health and home status have better asthma outcomes. In a pragmatic factorial longitudinal trial, HAP3 enrolls 400 adults with uncontrolled asthma living in low-income urban neighborhoods. 100 participants will be randomized to each of four interventions: (1) CI, (2) CI with HVs, (3) CI and real-time feedback to asthma clinician of guideline-relevant elements of patients' current care, or (4) both (2) and (3). The outcomes are asthma control, quality of life, ED visits, hospitalizations, prednisone bursts, and intervention costs. The COVID-19 pandemic struck 6.5 months into recruitment. We describe study development, design, methodology, planned analysis, baseline findings and adaptions to achieve the original aims of improving patient-clinician communication and asthma outcomes despite the markedly changed pandemic environment.

Survey of lower urinary tract symptoms in United States women using the new lower urinary tract dysfunction research Network-Symptom Index 29 (LURN-SI-29) and a national research registry

PURPOSE

An online bladder health survey was administered to national registry volunteers to: (1) determine the feasibility of using ResearchMatch for studying lower urinary tract symptoms (LUTS); (2) pilot the new, comprehensive Lower Urinary Tract Dysfunction Research Network Symptom Index-29 (LURN-SI-29) and determine its ability to detect known associations with LUTS; and (3) explore novel areas of bladder health in community-based women.

METHODS

A cross-sectional web-based survey was administered to a random sample of ResearchMatch adult female, transgender and non-binary volunteers. Participant demographics, health characteristics, the LURN-SI-29, and LUTS-related experiences were collected.

RESULTS

A total of 1725 ReseachMatch volunteers with a mean age of 44.0 years completed the study and were eligible for the analysis. Participants were primarily white, cisgendered, highly educated, nulliparous, and premenopausal. The median LURN-SI-29 score was 17 (interquartile range: 11-26). More than half the sample reported urinary urgency (71.0%), nocturia (65.7%), and stress incontinence (52.3%) a "few times" or more in the last 7 days. Approximately half reported sensation of incomplete bladder emptying (49.6%) with one-third reporting urgency incontinence (37.6%); notably, 52.6% of respondents reported being at least "somewhat" bothered by LUTS. LURN-SI-29 scores increased with age, body mass index, decrements in self-reported health, medical comorbidity, parity, menopausal status, and urinary symptom bother, providing evidence of convergent validity. LURN-SI-29 scores varied by race and education, with the lowest scores in Asian and highly educated women.

CONCLUSION

Overall, the prevalence and spectrum of LUTS in an online research registry of women volunteers were high and comparable to other population-based samples. The new LURN-SI-29 demonstrated its ability to detect expected associations with demographic and health characteristics in a nonclinical population.

Acute pain and self-directed discharge among hospitalized patients with opioid-related diagnoses: a cohort study

Background

Patients with substance use disorders are more likely than those without to have a self-directed hospital discharge, putting them at risk for poor health outcomes including progressing illness, readmissions, and death. Inadequate pain management has been identified as a potential motivator of self-directed discharge in this patient population. The objective of this study was to describe the association between acute pain and self-directed discharges among persons with opioid-related conditions; the presence of chronic pain in self-directed discharges was likewise considered.

Methods

We employed a large database of all hospitalizations at acute care hospitals during 2017 in the city of Philadelphia to identify adults with opioid-related conditions and compare the characteristics of admissions ending with routine discharge versus those ending in self-directed discharge. We examined all adult discharges with an ICD-10 diagnoses related to opioid use or poisoning and inspected the diagnostic data to systematically identify acute pain for the listed primary diagnosis and explore patterning in chronic pain diagnoses with respect to discharge outcomes.

Results

Sixteen percent of the 7972 admissions involving opioid-related conditions culminated in self-directed discharge, which was more than five times higher than in the general population. Self-directed discharge rates were positively associated with polysubstance use, nicotine dependence, depression, and homelessness. Among the 955 patients with at least one self-directed discharge, 15.4% had up to 16 additional self-directed discharges during the 12-month observation period. Those admitted with an acutely painful diagnosis were almost twice as likely to complete a self-directed discharge, and for patients with multiple admissions, rates of acutely painful diagnoses increased with each admission coinciding with a cascading pattern of worsening infectious morbidity over time. Chronic pain diagnoses were inconsistent for those patients with multiple admissions, appearing, for the same patient, in one admission but not others; those with inconsistent documentation of chronic pain were substantially more likely to self-discharge.

Conclusions

These findings underscore the importance of pain care in disrupting a process of self-directed discharge, intensifying harm, and preventable financial cost and suffering. Each admission represents a potential opportunity to provide harm reduction and treatment interventions addressing both substance use and pain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-021-00581-6.

Primary language and the electronic health record patient portal: Barriers to use among Spanish-speaking adults with asthma

OBJECTIVES

To assess electronic health record patient portal use among Spanish-speaking patients with asthma compared to English-speaking patients and identify barriers to use.

METHODS

Using data collected for a PCORI-funded randomized controlled trial to increase patient portal use in low-income adults with uncontrolled asthma, we estimated the association between portal use, measured using surveys and actual user login data, and primary language. Open-ended survey responses were grouped into common themes.

RESULTS

Among 301 adults with asthma: age 18-87, 90% female, 17% Spanish speakers; 44% had no portal use during the study. Spanish speakers were less likely to have ever heard of the patient portal than English speakers (p=.001) and reported more difficulty navigating the portal (p<.001). Spanish speakers with low health literacy had less portal use (31%) than their English-speaking counterparts (51%) (p=.02). Compared to high-literacy English speakers, the odds of using the portal for low-literacy Spanish speakers were 0.34 (95% CI 0.14, 0.84) (p=.02). Three-quarters of Spanish speakers cited barriers to portal use compared to one-quarter of English speakers, and many suggested creating a Spanish version to improve user-friendliness.

CONCLUSIONS

English-only patient portals may not meet the needs of Spanish-speaking patients with uncontrolled asthma. Health systems serving Spanish-speaking communities should implement patient portals in Spanish.

Patient Advocates for Low-Income Adults with Moderate to Severe Asthma: A Randomized Clinical Trial

BACKGROUND

Few interventions have targeted low-income adults with moderate to severe asthma despite their high mortality.

OBJECTIVE

To assess whether a patient advocate (PA) intervention improves asthma outcomes over usual care (UC).

METHODS

This 2-armed randomized clinical trial recruited adults with moderate to severe asthma from primary care and asthma-specialty practices serving low-income neighborhoods. Patients were randomized to 6 months of a PA intervention or UC. PAs were recent college graduates anticipating health care careers, who coached, modeled, and assisted participants with preparations for asthma-related medical visits, attended visits, and confirmed participants' understanding of provider recommendations. Participants were followed for at least a year for patient-centered asthma outcomes: asthma control (primary outcome), quality of life, prednisone requirements, emergency department visits, and hospitalizations.

RESULTS

There were 312 participants. Their mean age was 51 years (range, 19-93 years), 69% were women, 66% African American, 8% Hispanic/Latino, 62% reported hospitalization for asthma in the year before randomization, 21% had diabetes, and 61% had a body mass index of 30 or more. Asthma control improved over 12 months, more in the intervention group (-0.45 [95% CI, -0.67 to -0.21]) than in the UC group (-0.26 [95% CI, -0.53 to -0.01]), and was sustained at 24 months but with no statistical difference between groups. The 6-month rate of emergency department visits decreased in the intervention (-0.90 [95% CI, -1.56 to -0.42]) and UC (-0.42 [95% CI, -0.72 to -0.06]) groups over 12 months. The cost of the PA program was $1521 per patient. Only 64% of those assigned had a PA visit.

CONCLUSIONS

A PA may be a promising intervention to improve and sustain outcomes in this high-risk population if expanded to address factors that make keeping appointments difficult.

Patient Portal Usage and Outcomes Among Adult Patients with Uncontrolled Asthma

BACKGROUND

Patient-clinician communication, essential for favorable asthma outcomes, increasingly relies on information technology including the electronic heath record-based patient portal. For patients with chronic disease living in low-income neighborhoods, the benefits of portal communication remain unclear.

OBJECTIVE

To describe portal activities and association with 12-month outcomes among low-income patients with asthma formally trained in portal use.

METHODS

In a longitudinal observational study within a randomized controlled trial, 301 adults with uncontrolled asthma were taught 7 portal tasks: reviewing upcoming appointments, scheduling appointments, reviewing medications, locating laboratory results, locating immunization records, requesting refills, and messaging. Half the patients were randomized to receive up to 4 home visits by community health workers. Patients' portal use by activities, rate of usage over time, frequency of appointments with asthma physicians, and asthma control and quality of life were assessed over time and estimated as of 12 months from randomization.

RESULTS

Fewer than 60% of patients used the portal independently. Among users, more than half used less than 1 episode per calendar quarter. The most frequent activities were reading messages and viewing laboratory results and least sending messages and making appointments. Higher rates of portal use were not associated with keeping regular appointments during follow-up, better asthma control, or higher quality of life at 12-month postintervention.

CONCLUSIONS

Patients with uncontrolled asthma used the portal irregularly if at all, despite in-person training. Usage was not associated with regular appointments or with clinical outcomes. Patient portals need modification to accommodate low-income patients with uncontrolled asthma.

Using a Community Workgroup Approach to Increase Access to Physical Activity in an Underresourced Urban Community

Background. Regular physical activity is associated with improved physical and psychosocial well-being. Increasing access to physical activity in underresourced communities requires collaborative, community-engaged methods. One such method is community workgroups. Purpose. The purpose of this article is to describe implementation, strengths, challenges, and results of the workgroup approach as applied to increasing access to physical activity, using our recent study as an illustrative example. Method. A 1-day conference was held in April 2017 for community leaders. The first half of the conference focused on disseminating results of a multifaceted community assessment. The second half entailed community workgroups. Workgroups focused on applying community assessment results to develop strategies for increasing access to physical activity, with plans for ongoing workgroup involvement for strategy refinement and implementation. A professional artist documented the workgroup process and recommendations via graphic recording. Results. Sixty-three community leaders attended the conference and participated in the workgroups. Workgroup participants reported that greater macrosystem collaboration was critical for sustainability of physical activity programming and that, particularly in underresourced urban communities, re-imagining existing spaces (rather than building new spaces) may be a promising strategy for increasing access to physical activity. Discussion. Considered collectively, the community workgroup approach provided unique insight and rich data around increasing access to physical activity. It also facilitated stakeholder engagement with and ownership of community health goals. With careful implementation that includes attention to strengths, challenges, and planning for long-term follow-up, the community workgroup approach can be used to develop health promotion strategies in underresourced communities.

Reconciling opposing perceptions of access to physical activity in a gentrifying urban neighborhood

OBJECTIVE

We sought to understand perspectives on access to physical activity in a gentrifying neighborhood.

DESIGN

This qualitative descriptive study used street intercept interviews and photo documentation.

SAMPLE

Participants included members (n = 19) of a gentrifying neighborhood in a northeastern city.

RESULTS

Participants held markedly different perceptions of opportunities for physical activity. Some participants, particularly area university students or those who are identified as White, perceived the neighborhood as favorable to physical activity, with high walkability and abundant resources. Other participants, particularly those who identified as Black or African-American, felt it was difficult to be physically active because neighborhood recreation facilities are scarce or unaffordable and parks are poorly maintained or unsafe. Multiple participants noted strategies to overcome neighborhood barriers to physical activity. Regardless of neighborhood perceptions, family and friends played an important role in influencing physical activity.

CONCLUSIONS

Nurses must consider how disparities in actual and perceived access to neighborhood resources influence participation in physical activity, particularly in gentrifying neighborhood. Public health nurses are embedded in the neighborhoods that they serve, providing a unique opportunity to understand and address the impact of neighborhood on health.

Engaging With the Community to Promote Physical Activity in Urban Neighborhoods

PURPOSE

To describe perceptions of physical activity, opinions, on intergenerational approaches to physical activity and a vision for increasing physical activity in an underresourced urban community.

APPROACH

Focus groups embedded in a large Community-Based Participatory Research Project.

SETTING

West and Southwest Philadelphia.

PARTICIPANTS

15 parents, 16 youth, and 14 athletic coaches; youth were 13 to 18 years old and attended West Philadelphia schools; parents' children attended West Philadelphia schools; and coaches worked in West Philadelphia schools.

METHODS

Six focus groups (2 youth, 2 parent, and 2 coach) were conducted guided by the Socio-Ecological Model; transcriptions were analyzed using a rigorous process of directed content analysis.

RESULTS

Factors on all levels of the Socio-Ecological Model influence the perception of and engagement in physical activity for youth and their families. Future strategies to increase engagement in physical activity need to be collaborative and multifaceted.

CONCLUSION

When physical activity is reframed as a broad goal that is normative and gender-neutral, a potential exists to engage youth and their families over their lifetimes; with attention to cross-sector collaboration and resource sharing, engaging and sustainable intergenerational physical activity interventions can be developed to promote health in underresourced urban communities.

Filling the patient-provider knowledge gap: a patient advocate to address asthma care and self-management barriers

Introduction: In an ongoing study, a new clinical role adapted from a patient navigator called the patient advocate (PA) met with patients before medical visits, attended appointments and afterwards reviewed provider instructions. This qualitative analysis examines the perspectives of PAs and providers regarding their experiences with patients to understand how a PA can help patients and providers achieve better asthma control. Methods: PAs recorded journal entries about their experiences with patients. Provider focus groups and interviews were conducted by researchers and transcribed. Analysis was based on the Grounded Theory approach for qualitative research, using open and then focused coding. Two researchers independently coded these sources until intercoder agreement was achieved. Results: Upon review of 31 journal entries on PA experiences with 24 patients and transcripts from 2 provider focus groups and 12 provider interviews, 5 themes emerged surrounding asthma care and self-management: medication adherence, follow-up, communication, social determinants of health and time. While patients shared with PAs specific socioeconomic barriers to medication adherence and follow-up, providers often did not know about these problems and cited barriers to communication. Time restrictions on medical visits further limited communication. Conclusions: Perspectives reported here illustrate a gap in knowledge and understanding between patients and providers. The PA's unique relationship with patients and presence inside and outside of medical visits allowed them to learn contextual patient information unknown to providers. PAs and providers cited numerous ways PAs can help to improve patient-provider mutual understanding.

Trauma-Informed Care Training in Family Medicine Residency Programs Results From a CERA Survey

BACKGROUND AND OBJECTIVES

Experiences of psychological trauma are common among primary care patient populations, and adversely affect patients' health and health care utilization. Trauma-informed care (TIC) is a framework for identifying and responding to patients' experiences of psychological trauma to avoid retraumatization. The purpose of this study was to evaluate the current state of TIC training in family medicine residency programs in the United States in order to identify opportunities for and barriers to TIC training.

METHODS

Items addressing the four core domains of TIC were incorporated into the 2017 Council of Academy Family Medicine Educational Research Alliance (CERA) survey of program directors. The items assessed the presence, content, and sufficiency of TIC curriculum, as well as barriers to further integration of TIC training.

RESULTS

Approximately 50% of programs responded to the survey. Of 263 respondents, 71 (27%) reported TIC training in their curriculum, but the majority devoted less than 5 hours annually to core content. The content most commonly addressed recognizing signs of trauma, most frequently using didactic formats. Overall, just over one-half of the programs reported that their curriculum met patients' TIC needs "somewhat" (48.5%) or "a great deal" (4.6%). Lack of a champion followed by lack of time were the most commonly cited barriers to integrating TIC training.

CONCLUSIONS

Despite the acknowledged importance of effects of trauma in health care, this study identified insufficient exposure to training in the core TIC domains in family medicine residency programs, underscoring a need for greater integration of TIC training during residency.

Public Libraries As Partners for Health

INTRODUCTION

Public libraries are free and accessible to all and are centers of community engagement and education, making them logical choices as partners for improving population health. Library staff members routinely assist patrons with unmet health and social needs.

METHODS

We used a 100-question, self-administered web survey sent to all library directors listed in the Pennsylvania Library Association database (N = 621), to investigate staff interactions with library patrons to address social determinants of health. We conducted statistical comparisons of quantitative responses and a content analysis of open-ended responses.

RESULTS

Respondents (N = 262) reported frequently interacting with patrons around health and social concerns - well beyond those related to literacy and education - including help with employment (94%), nutrition (70%), exercise (66%), and social welfare benefits (51%). Acute emergencies were not uncommon in Pennsylvania's public libraries, with nearly 12% of respondents having witnessed a drug overdose at the library in the past year. Most respondents felt that their professional training left them inadequately prepared to assist patrons with health and social issues. Although at least 40% of respondents offered some health programming at their library branch, their offerings did not meet the high level of need reflected in common patron inquiries.

CONCLUSION

The challenges library staff members experience in meeting their patrons' information needs suggest opportunities for public libraries to advance population health. Library staff members need additional training and resources and collaboration with public health and health care institutions to respond to community needs through effective, evidence-based public health programming.

A Monte Carlo simulation approach for estimating the health and economic impact of interventions provided at a student-run clinic

Background

Student Run Clinics (SRCs) are a common aspect of medical education, present at more than half of US medical schools, and noted for providing care to communities that might otherwise lack access, including the uninsured and underinsured. To date, few studies have rigorously quantified the health and economic benefits of SRCs, and the present study remedies that.

Methods and findings

We used Monte Carlo simulations to estimate the health impact of common preventive health interventions applied to individuals in quality-adjusted life-years (QALYs). We then used those measurements to estimate the health and economic impact of United Community Clinic (UCC), a student-run clinic in Philadelphia, PA. We found that with an annual operating budget of $50,000, UCC saves 6.5 QALYs, corresponding to over $850,000 saved.

Conclusions

Using Monte Carlo simulation methods, the health and economic impact of SRCs can be reasonably estimated to demonstrate the utility of SRCs and justify their growing importance in the healthcare delivery landscape of the US.

Exploring Patient Engagement: A Qualitative Analysis of Low-Income Urban Participants in Asthma Research

BACKGROUND

Uncontrolled asthma is a common highly morbid condition with worse outcomes in low-income and minority patients in part due to barriers accessing and engaging with health care. We developed a patient advocate to educate about and assist with navigating access to care and provider-patient communication. Participants completed an End of Study Questionnaire (ESQ) that was analyzed to assess experience and engagement with the protocol.

OBJECTIVE

This study uses qualitative analysis to evaluate participant experience with the patient advocate and control group interventions.

METHODS

The ESQ aimed to prompt an open-ended discussion of study experience. Questions were developed from patient focus groups about the patient advocate intervention (PAI), and were revised based on early responses. The questionnaire was administered after 12 months of study participation: 6 months of control or PAI, followed by 6 months of follow-up. Answers were evaluated using qualitative coding and a grounded theory analytical approach.

RESULTS

A total of 102 low-income and minority adults with moderate or severe asthma who had completed the study protocol at the time of publication (approximately one-third of total participants) found PAI and control group activities acceptable. Four themes emerged from both groups: (1) appreciation of interpersonal and educational interaction, (2) perception of improved health care adherence, (3) preparedness for physician appointments, (4) improved patient-provider communication. Attention from study personnel and review of asthma-related information was unanimously well received and empowered patients' active health care participation.

CONCLUSIONS

Patient engagement and empowerment were elicited by perceived education and personal attention. This study suggests a low-resource, feasible method to improve patient engagement.

A patient advocate to facilitate access and improve communication, care, and outcomes in adults with moderate or severe asthma: Rationale, design, and methods of a randomized controlled trial

Few interventions to improve asthma outcomes have targeted low-income minority adults. Even fewer have focused on the real-world practice where care is delivered. We adapted a patient navigator, here called a Patient Advocate (PA), a term preferred by patients, to facilitate and maintain access to chronic care for adults with moderate or severe asthma and prevalent co-morbidities recruited from clinics serving low-income urban neighborhoods. We describe the planning, design, methodology (informed by patient and provider focus groups), baseline results, and challenges of an ongoing randomized controlled trial of 312 adults of a PA intervention implemented in a variety of practices. The PA coaches, models, and assists participants with preparations for a visit with the asthma clinician; attends the visit with permission of participant and provider; and confirms participants' understanding of what transpired at the visit. The PA facilitates scheduling, obtaining insurance coverage, overcoming patients' unique social and administrative barriers to carrying out medical advice and transfer of information between providers and patients. PA activities are individualized, take account of comorbidities, and are generalizable to other chronic diseases. PAs are recent college graduates interested in health-related careers, research experience, working with patients, and generally have the same race/ethnicity distribution as potential participants. We test whether the PA intervention, compared to usual care, is associated with improved and sustained asthma control and other asthma outcomes (prednisone bursts, ED visits, hospitalizations, quality of life, FEV1) relative to baseline. Mediators and moderators of the PA-asthma outcome relationship are examined along with the intervention's cost-effectiveness.

A health care navigation tool assesses asthma self-management and health literacy

BACKGROUND

Self-management of moderate-to-severe asthma depends on the patient's ability to (1) navigate (access health care to obtain diagnoses and treatment), (2) use inhaled corticosteroids (ICSs) properly, and (3) understand ICS function.

OBJECTIVE

We sought to test whether navigation skills (medication recall, knowledge of copay requirements, and ability to provide information needed for a medical visit about a persistent cough unresponsive to medication) are related to other self-management skills and health literacy.

METHODS

A 21-item Navigating Ability (NAV2) questionnaire was developed, validated, and then read to adults with moderate-to-severe asthma. ICS technique was evaluated by using scales derived from instructions in national guidelines; knowledge of ICS function was evaluated by using a validated 10-item questionnaire. Spearman correlation was computed between NAV2 score and these questionnaires and with numeracy (Asthma Numeracy Questionnaire) and print literacy (Short Test of Functional Health Literacy in Adults).

RESULTS

Two hundred fifty adults participated: age, 51 ± 13 years; 72% female; 65% African American; 10% Latino; 50% with household income of less than $30,000/y; 47% with no more than a 12th-grade education; and 29% experienced hospitalizations for asthma in the prior year. A higher NAV2 score was associated with correct ICS technique (ρ = 0.24, P = .0002), knowledge of ICSs (ρ = 0.35, P < .001), better print literacy (ρ = 0.44, P < .001), and numeracy (ρ = 0.41, P < .001).

CONCLUSIONS

Patients with poor navigational ability are likely to have poor inhaler technique and limited understanding of ICS function, as well as limited numeracy and print literacy. Clinicians should consider these elements of self-management for their effect on asthma care and as a marker of more general health literacy deficits.

Resident Engagement in the Patient-Centered Medical Home

BACKGROUND AND OBJECTIVES

This study's objectives were to assess resident understanding and engagement with the patient-centered medical home (PCMH) model and to assess the impact of participation in a PCMH transformation collaborative on residents' experiences and perceptions related to their training environment.

METHODS

Residents from practices participating in the largest state-wide PCMH learning collaborative were asked to complete surveys describing their experiences with the collaborative and the PCMH transformation process. Residents from four representative participating residencies were recruited to participate in focus groups designed to provide qualitative data to augment our understanding of the quantitative survey results.

RESULTS

We had a reasonable average response rate (39%) with a total of 100 completed resident surveys. Quantitative data illustrated high levels of residents' endorsement of PCMH awareness, engagement, and PCMH-related skills acquisition. The analyses suggested higher levels of PCMH engagement, understanding, and sense of adequacy of preparation among residents who attended learning collaborative sessions compared to those who did not. While qualitative data validated many of the quantitative findings, they also illustrated a somewhat detached and peripheral description of resident experiences with the transformation process.

CONCLUSIONS

The presented data describe the complexities of preparing the next generation of providers for practice. Our mixed-methods study illustrated the strengths of participating in the learning collaborative but also areas of focus necessary for improving the experience and educational benefits of PCMH-related curricula involving residents.

The concentration of hospital care for black veterans in Veterans Affairs hospitals: implications for clinical outcomes

Where minorities receive their care may contribute to disparities in care, yet, the racial concentration of care in the Veterans Health Administration is largely unknown. We sought to better understand which Veterans Affairs (VA) hospitals treat Black veterans and whether location of care impacted disparities. We assessed differences in mortality rates between Black and White veterans across 150 VA hospitals for any of six conditions (acute myocardial infarction, hip fracture, stroke, congestive heart failure, gastrointestinal hemorrhage, and pneumonia) between 1996 and 2002. Just 9 out of 150 VA hospitals (6% of all VA hospitals) cared for nearly 30% of Black veterans, and 42 hospitals (28% of all VA hospitals) cared for more than 75% of Black veterans. While our findings show that overall mortality rates were comparable between minority-serving and non-minority-serving hospitals for four conditions, mortality rates were higher in minority-serving hospitals for acute myocardial infarction (AMI) and pneumonia. The ratio of mortality rates for Blacks compared with Whites was comparable across all VA hospitals. In contrast to the private sector, there is little variation in the degree of racial disparities in 30-day mortality across VA hospitals, although higher mortality among patients with AMI and pneumonia requires further investigation.

Short- and long-term mortality after an acute illness for elderly whites and blacks

OBJECTIVE

To estimate racial differences in mortality at 30 days and up to 2 years following a hospital admission for the elderly with common medical conditions.

DATA SOURCES

The Medicare Provider Analysis and Review File and the VA Patient Treatment File from 1998 to 2002 were used to extract patients 65 or older admitted with a principal diagnosis of acute myocardial infarction, stroke, hip fracture, gastrointestinal bleeding, congestive heart failure, or pneumonia.

STUDY DESIGN

A retrospective analysis of risk-adjusted mortality after hospital admission for blacks and whites by medical condition and in different hospital settings.

PRINCIPAL FINDINGS

Black Medicare patients had consistently lower adjusted 30-day mortality than white Medicare patients, but the initial survival advantage observed among blacks dissipated beyond 30 days and reversed by 2 years. For VA hospitalizations similar patterns were observed, but the initial survival advantage for blacks dissipated at a slower rate.

CONCLUSIONS

Racial disparities in health are more likely to be generated in the posthospital phase of the process of care delivery rather than during the hospital stay. The slower rate of increase in relative mortality among black VA patients suggests an integrated health care delivery system like the VA may attenuate racial disparities in health.

Is lower 30-day mortality posthospital admission among blacks unique to the Veterans Affairs health care system?

BACKGROUND

Several studies have reported lower risk-adjusted mortality for blacks than whites within the Veterans Affairs (VA) health care system, particularly for those age 65 and older. This finding may be a result of the VA's integrated health care system, which reduces barriers to care through subsidized comprehensive health care services. However, no studies have directly compared racial differences in mortality within 30 days of hospitalization between the VA and non-VA facilities in the US health care system.

OBJECTIVE

To compare risk-adjusted 30-day mortality for black and white males after hospital admission to VA and non-VA hospitals, with separate comparisons for patients younger than age 65 and those age 65 and older.

RESEARCH DESIGN

Retrospective observational study using hospital claims data from the national VA system and all non-VA hospitals in Pennsylvania and California.

SUBJECTS

A total of 369,155 VA and 1,509,891 non-VA hospitalizations for a principal diagnosis of pneumonia, congestive heart failure, gastrointestinal bleeding, hip fracture, stroke, or acute myocardial infarction between 1996 and 2001.

MEASURES

Mortality within 30 days of hospital admission.

RESULTS

Among those under age 65, blacks in VA and non-VA hospitals had similar odds ratios of 30-day mortality relative to whites for gastrointestinal bleeding, hip fracture, stroke, and acute myocardial infarction. Among those age 65 and older, blacks in both VA and non-VA hospitals had significantly reduced odds of 30-day mortality compared with whites for all conditions except pneumonia in the VA. The differences in mortality by race are remarkably similar in VA and non-VA settings.

CONCLUSIONS

These findings suggest that factors associated with better short-term outcomes for blacks are not unique to the VA.

Is thirty-day hospital mortality really lower for black veterans compared with white veterans?

OBJECTIVE

To examine the source of observed lower risk-adjusted mortality for blacks than whites within the Veterans Affairs (VA) system by accounting for hospital site where treated, potential under-reporting of black deaths, discretion on hospital admission, quality improvement efforts, and interactions by age group.

DATA SOURCES

Data are from the VA Patient Treatment File on 406,550 hospitalizations of veterans admitted with a principal diagnosis of acute myocardial infarction, stroke, hip fracture, gastrointestinal bleeding, congestive heart failure, or pneumonia between 1996 and 2002. Information on deaths was obtained from the VA Beneficiary Identification Record Locator System and the National Death Index.

STUDY DESIGN

This was a retrospective observational study of hospitalizations throughout the VA system nationally. The primary outcome studied was all-location mortality within 30 days of hospital admission. The key study variable was whether a patient was black or white.

PRINCIPAL FINDINGS

For each of the six study conditions, unadjusted 30-day mortality rates were significantly lower for blacks than for whites (p<.01). These results did not vary after adjusting for hospital site where treated, more complete ascertainment of deaths, and in comparing results for conditions for which hospital admission is discretionary versus non-discretionary. There were also no significant changes in the degree of difference by race in mortality by race following quality improvement efforts within VA. Risk-adjusted mortality was consistently lower for blacks than for whites only within the population of veterans over age 65.

CONCLUSIONS

Black veterans have significantly lower 30-day mortality than white veterans for six common, high severity conditions, but this is generally limited to veterans over age 65. This differential by age suggests that it is unlikely that lower 30-day mortality rates among blacks within VA are driven by treatment differences by race.