Forgotten clientele: A systematic review of patient-centered pathology reports

CONTEXT

Patient portals, designed to give ready access to medical records, have led to important improvements in patient care. However, there is a downside: much of the information available on portals is not designed for lay people. Pathology reports are no exception. Access to complex reports often leaves patients confused, concerned and stressed. We conducted a systematic review to explore recommendations and guidelines designed to promote a patient centered approach to pathology reporting.

DESIGN

In consultation with a research librarian, a search strategy was developed to identify literature regarding patient-centered pathology reports (PCPR). Terms such as "pathology reports," "patient-centered," and "lay-terms" were used. The PubMed, Embase and Scopus databases were searched during the first quarter of 2023. Studies were included if they were original research and in English, without date restrictions.

RESULTS

Of 1,053 articles identified, 17 underwent a full-text review. Only 5 studies (≈0.5%) met eligibility criteria: two randomized trials; two qualitative studies; a patient survey of perceived utility of potential interventions. A major theme that emerged from the patient survey/qualitative studies is the need for pathology reports to be in simple, non-medical language. Major themes of the quantitative studies were that patients preferred PCPRs, and patients who received PCPRs knew and recalled their cancer stage/grade better than the control group.

CONCLUSION

Pathology reports play a vital role in the decision-making process for patient care. Yet, they are beyond the comprehension of most patients. No framework or guidelines exist for generating reports that deploy accessible language. PCPRs should be a focus of future interventions to improve patient care.

Empowering Family Glaucoma Risk Communication Using QR-Code-Mediated Online Intervention

PURPOSE

Attempts at engaging relatives of glaucoma patients in education and screening have had limited success. This study explores the feasibility of an electronic intervention to facilitate direct yet reliable glaucoma risk communication between open-angle glaucoma patients (probands) and their first-degree relatives (FDRs).

DESIGN

Prospective survey and assessment of intervention.

PARTICIPANTS

Fifty adult probands, engaging 140 FDRs.

METHODS

Phase I was an iterative process involving creating a customized website and Quick Response (QR)-code-based intervention designed with input from probands, FDRs of patients, community members, and researchers. In phase II, the intervention was deployed in a clinical setting; this involved recruiting probands who had a smartphone and were willing to use the QR-code to message their FDRs a standard message, including a website link about glaucoma risk in FDRs and the importance of getting examined. Follow-up interviews were conducted with probands 1 to 2 weeks after their clinic visit to assess the impact of the intervention. Demographic data, website analytics, and participant feedback were collected and analyzed.

MAIN OUTCOME MEASURES

Increased awareness of glaucoma risk among FDRs and enhanced discussions.

RESULTS

At the time of the first interview, probands reported that 70% of the FDRs were aware of the probands' glaucoma diagnosis, but only 26% had undergone glaucoma screening. Ninety percent of probands had no issues using the QR-codes. Website analytics recorded 73 visits from 51 distinct internet protocol addresses (IPs). After receiving the standard message, 95% of FDRs followed up with the probands, actively discussing glaucoma. Of the probands, 84% completed the follow-up interview 1 to 2 weeks after enrollment. Fifty-nine percent of the FDRs were reported to have scheduled screening appointments. The collected feedback revealed that 96% of probands found the intervention helpful, fostering glaucoma discussions with their FDRs and improving probands' comfort level in discussing health issues with FDRs from baseline (very comfortable: 88%, comfortable: 8%, neutral: 2%, and very uncomfortable: 2%) to the follow-up interview (very comfortable: 98% and comfortable: 2%).

CONCLUSIONS

This innovative online method of communicating the risk of glaucoma to FDRs of probands prompted and increased the comfort level of familial discussions of glaucoma. More than half of FDRs reported making an appointment to get screened for glaucoma.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Freelisting: A Technique for Enhancing the Community Health Needs Assessment

US health systems are required to conduct community health needs assessments (CHNAs). These assessments often rely solely on publicly reported disease prevalence data. The objective of this study was to identify a feasible qualitative method that can be implemented into CHNAs to confirm existing information and enhance them with new data and community narrative. Freelisting interviews were conducted in 2017 throughout a county in Pennsylvania. Individuals listed (1) things that improve health, (2) health problems, and (3) health barriers. Responses were grouped into like terms, Smith's salience index was calculated for each, subgroup variation was assessed. Community-reported health priorities were identified by salient terms juxtaposed with publicly reported disease prevalence data. 98 respondents throughout the county participated in freelisting interviews. Demographics resembled the population: median age 55, 46% female, 88% Caucasian, 9% uninsured. Salient terms that improve health included: "physical activity", "healthy eating", and "health services". Salient terms describing health problems included: "cardiovascular disease" and "spine and joint disease". Centers for Disease Control and Prevention (CDC)-reported chronic disease prevalence in the county included heart disease mortality (22% of deaths) and arthritis (26% of adults). Salient barriers to health included: "weight, physical activity, and dietary concerns", as well as "occupational concerns". This is in line with 2017 County Health Rankings related to obesity (reported 29%), however, while 10% were uninsured in the community, this was not a salient term. Freelisting can augment and inform CHNAs. In this single-county study, freelisting responses supported publicly available disease/mortality prevalence data and provided insight into community perceptions of health issues.

Exposing the disability-related hidden curriculum in case-based learning: A qualitative study

BACKGROUND

People with disabilities face significant health disparities. Studies show that healthcare professionals harbor negative attitudes towards disability, compromising the quality of care. These attitudes, in unwritten, unofficial, and even unintended ways can be passed from providers to learners in the medical education setting.

OBJECTIVE

Using a Critical Disability Studies (CDS) paradigm, the authors uncovered the disability-related hidden curriculum within Case-Based Learning (CBL) and proposed guidelines for promoting a disability-conscious medical education that resists ableism.

METHODS

The study team conducted a qualitative analysis of all CBL cases from the pre-clerkship curriculum (n = 53) at Sidney Kimmel Medical College. The authors employed a directed content analysis approach to develop a codebook based on case examination, literature review, and CDS concepts. Two researchers coded all cases and assessed intercoder reliability. The results informed the development of an explanatory model.

RESULTS

Only four of 53 cases overtly mentioned disability, none of which defined disability according to CDS. Coding did not identify content challenging stereotypical views of disability. Additionally, two cases included content fueling negative attitudes of disability.

CONCLUSION

By inadequately addressing disability from a CDS perspective, harmful assumptions of disability may go unchallenged, driving a hidden curriculum within CBL. This phenomenon leaves medical students ill-prepared to care for people with disabilities and creates physicians ill-equipped to teach the next generation. Since many health professions utilize CBL to educate students, these cases provide an untapped opportunity to resist ableism and better prepare students to address the negative attitudes driving health disparities experienced by people with disabilities.

Is Artificial Intelligence the Cost-Saving Lens to Diabetic Retinopathy Screening in Low- and Middle-Income Countries?

Diabetes is a rapidly growing global health crisis disproportionately affecting low- and middle-income countries (LMICs). The emergence of diabetes as a global pandemic is one of the major challenges to human health, as long-term microvascular complications such as diabetic retinopathy (DR) can lead to irreversible blindness. Leveraging artificial intelligence (AI) technology may improve the diagnostic accuracy, efficiency, and accessibility of DR screenings across LMICs. However, there is a gap between the potential of AI technology and its implementation in clinical practice. The main objective of this systematic review is to summarize the currently available literature on the health economic assessments of AI implementation for DR screening in LMICs. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We conducted an extensive systematic search of PubMed/MEDLINE, Scopus, and the Web of Science on July 15, 2023. Our review included full-text English-language articles from any publication year. The Joanna Briggs Institute's (JBI) critical appraisal checklist for economic evaluations was used to rate the quality and rigor of the selected articles. The initial search generated 1,423 records and was narrowed to five full-text articles through comprehensive inclusion and exclusion criteria. Of the five articles included in our systematic review, two used a cost-effectiveness analysis, two used a cost-utility analysis, and one used both a cost-effectiveness analysis and a cost-utility analysis. Across the five articles, LMICs such as China, Thailand, and Brazil were represented in the economic evaluations and models. Overall, three out of the five articles concluded that AI-based DR screening was more cost-effective in comparison to standard-of-care screening methods. Our systematic review highlights the need for more primary health economic analyses that carefully evaluate the economic implications of adopting AI technology for DR screening in LMICs. We hope this systematic review will offer valuable guidance to healthcare providers, scientists, and legislators to support appropriate decision-making regarding the implementation of AI algorithms for DR screening in healthcare workflows.

Reflections of Graduating Medical Students: A Photo-Elicitation Study

Medical school is associated with increased mental health morbidity that can result in professional burnout. To explore the sources of stress and means of coping for medical students, the photo-elicitation method was utilized, with interviews being conducted. The commonly discussed stressors included the presence of academic stress, difficulty relating to peers outside of medicine, frustration, feelings of helplessness and under-preparedness, imposter syndrome, and competition. Coping themes included camaraderie, interpersonal relationships, and wellness activities such as diet and exercise. Medical students are exposed to unique stressors, and as a result, students develop coping strategies throughout their studies. Further research is needed to identify how to better support students.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01758-3.

Genitourinary and Sexual Symptoms and Treatments in Transfeminine Individuals: A Qualitative Exploration of Patients' Needs

Introduction

Medical providers may not be familiar with the genitourinary and sexual symptoms of transgender and non-binary (TGNB) individuals. This lack of familiarity may hinder a provider's ability to address these issues as patients may hesitate to report symptoms due to fear of stigma, misgendering, and being treated disrespectfully.

Aim

To describe the array of genitourinary and sexual symptoms in transfeminine individuals.

Methods

Upon institutional review board approval, researchers used semi-structured interviews with 25 transfeminine individuals assigned male at birth to explore urinary and sexual symptoms on a sample of convenience. Participants were recruited and interviews were conducted until saturation was achieved. Two research assistants independently coded all de-identified transcripts and resolved discrepancies.

Outcomes

Thematic codes pertaining to genitourinary and sexual symptoms were defined and assessed in this study.

Results

Some genitourinary symptoms unrelated to hormone therapy or genital gender-affirming surgery (GGAS) included frequency, urgency, nocturia, and incontinence, while those attributed to GGAS included slow stream, spraying, and retention. Sexual symptoms unrelated to hormone therapy or GGAS included sexually transmitted infections, erectile dysfunction, and low libido. Sexual symptoms related to GGAS included delayed ejaculation, penile pain, scar tissue pain, and pain with receptive vaginal penetration.

Clinical Implications

Increased provider awareness of and accountability for the treatment of genital and sexual symptoms of transfeminine individuals.

Strengths and Limitations

Open-ended questions were used to generate a range of responses and perspectives through conversation instead of quantifiable data. Findings are not applicable to all TGNB people since participants were limited to transfeminine adults assigned male at birth only. Recruitment was limited by the sensitive nature of the topic and hard-to-reach populations and relied on convenience through flyers and a chain-referral sampling approach.

Conclusion

Transfeminine individuals experience a wide array of genitourinary and sexual symptoms both similar and different to their cis gender counterparts.

Chung PH, Swaminathan V, Spigner S, et al. Genitourinary and Sexual Symptoms and Treatments in Transfeminine Individuals: A Qualitative Exploration of Patients’ Needs. Sex Med 2022;10:100566.

Mental health-related stigma and attitudes toward patient care among providers of mental health services in a rural Chinese county

BACKGROUND AND AIMS

The increasing prevalence of mental illness and low treatment rate presents a pressing public health issue in China. Pervasive stigma is a significant barrier to mental health recovery and community inclusion. In particular, stigmatizing or supportive attitudes held by healthcare providers could either perpetuate or mitigate self-stigma of people with mental illness. Moreover, mental health resources are unevenly distributed in China, with most of them concentrated in urban centers and provincial capitals. This study explores healthcare providers' attitudes toward mental illness and the challenges they faced at work in a rural Chinese county.

METHOD

Four focus groups were conducted with 36 healthcare providers from a three-tier mental healthcare system in a rural county in southwestern China. Focus group discussions were recorded and transcribed verbatim. The team employed a conventional content analysis approach for data analysis. All transcripts were double-coded by three bilingual team members who are native Chinese speakers. Coding discrepancies were resolved by consensus.

RESULTS

Healthcare providers recruited from the county, township, and village levels varied in educational background, professional qualification, and experience of working with people with mental illness. Five thematic categories identified across four groups include (1) barriers to mental healthcare delivery, (2) keys to mental health recovery, (3) providers' attitudes toward providing care, (4) providers' perception toward patients and family members, and (5) providers' perception of training needs.

CONCLUSIONS

This is a unique study that included healthcare providers from a three-tier healthcare system. Findings signal the importance of understanding healthcare practitioners' experiences and views to inform the design of training initiatives in rural or low-resource communities.

'Even a smile helps': Exploring the interactions between people experiencing homelessness and passersby in public spaces

BACKGROUND

Many people experiencing homelessness dwell, panhandle, or congregate in public spaces where they frequently cross paths with others. In these spaces, they can be recipients of acts of kindness or emotional and physical insult, but there is little research on the quality, nature, or value of interactions between people living on the street and those who pass them by.

AIM

This study explored the lived experiences of unhoused people who panhandle and their interactions with passersby in Philadelphia, Pennsylvania.

METHODS

Forty semi-structured interviews were conducted with participants who were approached while panhandling and asked to describe their experiences asking for help in public and accessing homelessness services, as well as what they wished to share with passersby. Interviews were coded and analyzed using a directed content analysis approach.

RESULTS

Participants described being ignored and subjected to violence, leading them to crave meaningful interaction with passersby. They also described experiences of receiving kindness and support while panhandling. Many shared personal histories of tragedy and called for greater empathy and compassion from passersby, as well as society as a whole, for people experiencing homelessness.

CONCLUSION

Participants' experiences were consistent with loneliness, as characterized in the literature as distress at lack of social connection, and were also notable for the verbal and physical violence endured in public spaces. Social isolation and trauma are detrimental to mental health in this vulnerable group, so interventions to support this population should provide opportunities for consistent, supportive social connections and focus on providing low-barrier, stable housing.

Impact of penile prostheses and intracavernosal injections on psychosocial functioning

INTRODUCTION

Prior studies evaluating the efficacy of penile prostheses (PP) and intracavernosal injections (ICI) have focused predominantly on sexual function, not psychosocial health. We utilized the freelisting technique and the Self-Esteem and Relationship (SEAR) questionnaire to evaluate the impact of PP and ICI treatments on psychosocial functioning.

MATERIALS AND METHODS

IRB-approval was obtained to perform an evaluation of patients who underwent PP or ICI treatment for erectile dysfunction (ED). Using a modified freelisting approach, participants were asked to give three one-word responses to questions about sexual function and relationships. Participants also completed the SEAR questionnaire and results were calculated based on the previously described formulas.

RESULTS

Fifty patients agreed to participate in the study (25 ICI, 25 PP). In the freelisting portion of the study, PP patients had more positive responses than ICI patients in 2 out of 3 questions. The freelisting study also identified important areas of concern for ED patients such as self-esteem, confidence, and treatment reliability. PP patients reported numerically higher SEAR total scores than ICI patients (63.9 vs. 53.9, p = 0.12), especially in confidence with duration of (p = 0.003), satisfaction with sexual performance (p = 0.06), and confidence with sexual performance (p = 0.02). SEAR confidence domain (p = 0.83), self-esteem subscale (p = 0.68), and overall relationship sub-scales (p = 0.90) were similar between PP and ICI patients.

CONCLUSIONS

PP appears to have a stronger psychosocial impact compared to ICI; however, both PP and ICI patients continue to struggle with self-esteem, confidence, and treatment reliability. Further patient counseling before and after treatment may help to address these concerns and improve patient satisfaction.

Risk Factors for Poor Outcomes Among Patients with Extensively Drug-Resistant Tuberculosis (XDR-TB): A Scoping Review

In recent years, there has been an upsurge in cases of drug-resistant TB, and strains of TB resistant to all forms of treatment have begun to emerge; the highest level of resistance is classified as extensively drug-resistant tuberculosis (XDR-TB). There is an urgent need to prevent poor outcomes (death/default/failed treatment) of XDR-TB, and knowing the risk factors can inform such efforts. The objective of this scoping review was to therefore identify risk factors for poor outcomes among XDR-TB patients. We searched three scientific databases, PubMed, Scopus, and ProQuest, and identified 25 articles that examined relevant risk factors. Across the included studies, the proportion of patients with poor outcomes ranged from 8.6 to 88.7%. We found that the most commonly reported risk factor for patients with XDR-TB developing poor outcomes was having a history of TB. Other risk factors were human immunodeficiency virus (HIV), a history of incarceration, low body mass, being a smoker, alcohol use, unemployment, being male, and being middle-aged. Knowledge and understanding of the risk factors associated with poor outcomes of XDR-TB can help policy makers and organizations in the process of designing and implementing effective programs.

Perspectives on Breastfeeding from Mothers with Postpartum Depression Symptoms: A Qualitative Assessment of Antecedents, Barriers, Facilitators, and Intervention Suggestions

Background: Postpartum depression (PPD) is one of the most common birthing complications, and studies negatively associate PPD with breastfeeding initiation and continuation. However, little is known about either the breastfeeding experience of mothers with PPD or what resources mothers need for sustained breastfeeding from their perspectives. This study aimed to identify the antecedents, barriers, and facilitators to breastfeeding for mothers with PPD, understand the relationship between self-efficacy and emergent themes, and generate suggestions to inform supportive interventions. Materials and Methods: Birth mothers who screened positive for PPD and reported breastfeeding were recruited to participate in semistructured interviews. Interviews were transcribed verbatim, and inter-coder discrepancies from double coding were resolved through consensus. Thematic analysis was facilitated using immersion-crystallization methods. Results: Participants identified five antecedent themes that encourage initiation (professional support, infant health, mother's health, cost-effectiveness, and faith), four facilitator themes for sustained breastfeeding (infant connection, decreased stress, personal attributes, and logistical strategies), and seven barrier themes (physical pain, infant nutrition, negative feelings, latching difficulties, medical conditions, public breastfeeding, and sleep). Participants' suggestions fell into three primary themes: supportive services, managing expectations, and respecting self-determination. Conclusion: Antecedent and facilitator themes did not overlap, indicating that factors encouraging breastfeeding initiation differ from sustaining factors. Participant suggestions, barriers, and facilitators did not largely differ from mothers without PPD in other qualitative studies. Therefore, interventions should tailor support to specific breastfeeding phase and may not need to be markedly different for mothers with PPD, in addition to depression management.

The efficacy of insecticide-treated window screens and eaves against Anopheles mosquitoes: a scoping review

Background

Female mosquitoes serve as vectors for a host of illnesses, including malaria, spread by the Plasmodium parasite. Despite monumental strides to reduce this disease burden through tools such as bed nets, the rate of these gains is slowing. Ongoing disruptions related to the COVID-19 pandemic may also negatively impact gains. The following scoping review was conducted to examine novel means of reversing this trend by exploring the efficacy of insecticide-treated window screens or eaves to reduce Anopheles mosquito bites, mosquito house entry, and density.

Methods

Two reviewers independently searched PubMed, Scopus, and ProQuest databases on 10 July, 2020 for peer-reviewed studies using insecticide-treated screens or eaves in malaria-endemic countries. These articles were published in English between the years 2000–2020. Upon collection, the reports were stratified into categories of biting incidence and protective efficacy, mosquito entry and density, and mosquito mortality.

Results

Thirteen out of 2180 articles were included in the final review. Eaves treated with beta-cyfluthrin, transfluthrin or bendiocarb insecticides were found to produce vast drops in blood-feeding, biting or mosquito prevalence. Transfluthrin-treated eaves were reported to have greater efficacy at reducing mosquito biting: Rates dropped by 100% both indoors and outdoors under eave ribbon treatments of 0.2% transfluthrin (95% CI 0.00–0.00; p < 0.001). Additionally, co-treating window screens and eaves with polyacrylate-binding agents and with pirimiphos-methyl has been shown to retain insecticidal potency after several washes, with a mosquito mortality rate of 94% after 20 washes (95% CI 0.74–0.98; p < 0.001).

Conclusions

The results from this scoping review suggest that there is value in implementing treated eave tubes or window screens. More data are needed to study the longevity of screens and household attitudes toward these interventions.

RAPIDIRON: Reducing Anaemia in Pregnancy in India-a 3-arm, randomized-controlled trial comparing the effectiveness of oral iron with single-dose intravenous iron in the treatment of iron deficiency anaemia in pregnant women and reducing low birth weight deliveries

Background

Anaemia is a worldwide problem and iron deficiency is the most common cause. In pregnancy, anaemia increases the risk of adverse maternal, foetal and neonatal outcomes.

India’s anaemia rate is among the highest in the world with India’s National Family Health Survey indicating over 50% of pregnant women were affected by anaemia.

India’s Anaemia Mukt Bharat-Intensified National Iron Plus Initiative aims to reduce the prevalence of anaemia among reproductive-age women, adolescents and children by 3% per year and facilitate the achievement of a Global World Health Assembly 2025 objective to achieve a 50% reduction of anaemia among women of reproductive age.

However, preliminary results of the NFHS-5 survey completed in 2020 indicate that anaemia rates are increasing in some states and these targets are unlikely to be achieved. With oral iron being the first-line treatment for iron deficiency anaemia (IDA) in pregnancy, these results are likely to be impacted by the side effects, poor adherence to tablet ingestion and low therapeutic impact of oral iron. These reports suggest a new approach to treating IDA, specifically the importance of single-dose intravenous iron infusions, may be the key to India effectively reaching its targets for anaemia reduction.

Methods

This 3-arm, randomized controlled trial is powered to report two primary outcomes. The first is to assess whether a single dose of two different intravenous formulations administered early in the second trimester of pregnancy to women with moderate IDA will result in a higher percentage of participants achieving a normal for pregnancy Hb concentration at 30–34 weeks’ gestation or just prior to delivery when compared to participants taking standard doses of oral iron. The second is a clinical outcome of low birth weight (LBW) (< 2500 g), with a hypothesis that the risk of LBW delivery will be lower in the intravenous iron arms when compared to the oral iron arm.

Discussion

The RAPIDIRON trial will provide evidence to determine if a single-dose intravenous iron infusion is more effective and economically feasible in reducing IDA in pregnancy than the current standard of care.

Trial registration

Clinical Trials Registry – India CTRI/2020/09/027730. Registered on 10 September 2020, http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=46801&EncHid=&userName=anemia%20in%20pregnancy

Does Age-Related Macular Degeneration (AMD) Treatment Influence Patient Falls and Mobility? A Systematic Review

Purpose: Age-related macular degeneration (AMD), a leading cause of irreversible blindness, increases fall risk through impaired central vision. Falls place an enormous economic burden on healthcare systems. We hypothesized that AMD treatments may reduce patients' falls risk. This systematic review (ID #: 172623) synthesized the current understanding of wet and dry AMD treatments' impact on patient falls and mobility, connecting these two public health issues.Methods: On April 17, 2020, PubMed, Scopus, CINAHL, and the Cochrane Central Register of Controlled Trials were queried. Clinical trials and observational studies were included, while non-English and non-primary studies were excluded. Two authors screened, extracted data, and assessed bias using RoB-2 and ROBINS-I. A third author served as a tie breaker.Results: This database search resulted in 3,525 studies, with an additional 112 identified through bibliography review. Ten articles met eligibility criteria. Most studies featured the outcome of interest as a secondary outcome (n = 4) and patient-reported adverse events (n = 5), rather than a primary focus (n = 2). Ten out of the 11 outcomes had a moderate to serious risk of bias. No two studies used the same instrument to measure falls or mobility.Conclusion: Despite the potential positive impact of AMD treatments on patient falls and mobility, quality data on this relationship are lacking. This work underscores the need to broaden ophthalmologic research outcomes beyond visual parameters to include patient-centred, functional measures. Incorporating standardized methods to track falls and screen for difficulty with walking and balance would enable evaluation of AMD treatments on functional outcomes, potentially helping guide management.

813 Patient and Provider Experiences with CBT-I Administered In-Person or via Telemedicine

Introduction

CBT-I is the gold standard treatment for insomnia, but access to in-person care is limited, which has worsened due to the recent COVID-19 pandemic. While providers across spheres of care have rapidly pivoted to telehealth there have been few systematic comparisons of in-person treatments to telemedicine approaches. The current study, launched pre-COVID, aimed to examine the perspectives of patients who were randomly assigned to receive CBT-I in-person or via telemedicine. Additionally, provider reflections were collected.

Methods

Individuals with DSM5 Insomnia Disorder (n=60) were randomized to in-person CBT-I, telemedicine CBT-I or a wait-list control group. CBT-I was delivered over 6–8 weekly sessions by video telemedicine or in-person. This nested qualitative study addressed patient and provider perspectives on treatment approaches. A sample of participants from each group (n=36) were interviewed 3 months post-treatment. Phone interviews were audio recorded, transcribed and analyzed using a directed content analysis approach. Results were organized into thematic categories including 1) participant experience with CBT-I, 2) access issues and 3) accountability issues related to delivery approach. Additionally, participating providers (n=7) were interviewed and shared their reflections on delivering CBT-I in-person vs. telemedicine.

Results

Patients reflected positively on CBT-I, and this did not vary across treatment groups. Patients and providers noted telemedicine benefits related to access that included, but were not limited to, reducing transportation barriers to treatment and improved continuity of care (e.g. not having to cancel an appointment if a patient was traveling). Patients and providers shared concerns they had anticipated pre-treatment about possible telemedicine related technological hurdles and barriers to establishing meaningful rapport on-line. However, they reported that these concerns did not prove to be barriers to effective telemedicine visits.

Conclusion

This qualitative study allowed patients and their providers to reflect on their experience delivering in-person vs telemedicine CBT-I. CBT-I was accepted well regardless of delivery approach. Telemedicine is currently being deployed widely and this study provides a systematic comparison between approaches.

Support (if any)

This study was supported by the American Sleep Medicine Foundation.

Life during the pandemic: an international photo-elicitation study with medical students

BACKGROUND

The SARS-CoV-2 (COVID-19) pandemic is a global event with unprecedented impact on individuals and communities around the world. The purpose of this study is to use a modified photo-elicitation methodology to examine the impact of the COVID-19 pandemic on the lives of medical students and their communities around the world.

METHODS

Participating medical students were asked to take photographs for 14 days. In lieu of an interview, which is customary for photo-elicitation projects, participants were asked to share a reflection (a paragraph or two) for each photograph they contributed to the study.

RESULTS

Between April 27th, 2020 and May 11th, 2020 26 students from 19 medical schools across 13 countries shared photographs and reflections. Qualitative analysis of written reflections revealed that medical students felt the impact of the pandemic on several levels 1) individual, 2) interpersonal, 3) educational, and 4) societal.

CONCLUSIONS

The COVID-19 pandemic has impacted the lives of medical students on multiple levels. As individuals, students felt emotional distress but found resilience through physical activity and the establishment of new routines. Many students felt isolated as their interpersonal relationships were confined due to social distancing measures. These feelings could be combated with new educational initiatives focused on group collaboration. Lastly, students reflecting on the larger societal implications were concerned with the economic ramifications of the virus and its impact on their future. This study brought together students from several different countries to engage in an applied learning program as a model for equitable global health research.

Practical Guidance for Studies Using Freelisting Interviews

Freelisting is a qualitative interviewing technique that has recently grown in popularity. It is an excellent tool for rapidly exploring how groups of people think about and define a particular health-related domain and is well suited for engaging communities and identifying shared priorities. In this article, we outline 7 practical considerations for conducting freelisting studies summarized from 16 articles conducted by the authors at the University of Pennsylvania and Thomas Jefferson University in partnership with community-based organizations and students. Our recommendations can inform study design, data collection, and data analysis for investigators who are interested in using freelisting interviews in their research.

Educational programs implemented for pharmacists after state passage of a standing order for naloxone: A systematic review of current practices

OBJECTIVE

This review describes the current educational interventions that have been created for pharmacists after the implementation of a standing order for naloxone.

METHODS

Search strategies were constructed for 3 databases (PubMed, SCOPUS, and CINAHL), which were queried between February 1, 2019, and March 5, 2019. Two reviewers independently screened 224 titles and abstracts from these databases. The descriptive criteria of each study, such as rationale, design, study location, population, and method of intervention, were included.

RESULTS

Eight articles met the inclusion criteria; 4 were delivered in person, 2 were online programs, and 2 used combined in-person and online methodologies. Of the 8 studies, 4 were delivered to practicing pharmacists, and 4 were designed for student pharmacists.

CONCLUSION

Pharmacists seem to engage in more overdose prevention behaviors after participating in the novel educational program as compared with taking the state-mandated training alone. Both student pharmacists and practicing pharmacists had promising postintervention results, with post-test scores indicating a statistically significant increase in knowledge or improvement in naloxone-relevant skills. The results of this review indicate the need to critically analyze the implementation of standing order laws for naloxone, specifically how pharmacists are being trained. The next steps include publication of existing best practices for educational interventions for pharmacists that may not currently be in the literature.

Needs of Individuals Living With Hepatitis Delta Virus and Their Caregivers, 2016-2019

Introduction

Hepatitis delta virus (HDV) is a serious coinfection of the hepatitis B virus (HBV) that is estimated to affect between 48 to 72 million people worldwide. Data are limited on the informational needs of people living with HDV. The Hepatitis B Foundation, a US-based nonprofit organization that provides support to people living with HBV and HDV, receives emails (queries) as part of a helpline, a service to provide information, resources, and support to people affected by HBV and HDV.

Methods

Query content was analyzed to assess the impact of HDV at the individual level. A total of 65 HDV-related queries from 17 countries were received from October 2016 to January 2019, and all were analyzed for this study.

Results

Thematic analysis of queries indicated 4 dominant themes. Three were related to a need for information about 1) the disease and prevention of it, 2) disease symptoms and outcomes, and 3) treatment options. The fourth theme was related to barriers and quality of life. Individuals requested information on treatment options, medication access, diagnostic test interpretation, and clinical trials.

Conclusion

Our study highlights the needs and lived experience of patients with HDV and summarizes critical information gaps. Findings can inform health care providers, public health professionals, and the pharmaceutical and biotechnology industries about the informational needs and lived experiences of individuals living with HDV and help create future HDV-related educational resources, care, and clinical trials.

Perspectives and Experiences of Transgender and Non-binary Individuals on Seeking Urological Care

OBJECTIVE

To describe perspectives and experiences related to urology care-seeking of transgender and non-binary (TGNB) individuals assigned male at birth.

MATERIALS AND METHODS

This HIPAA-compliant study was IRB approved and followed Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines. Through semistructured interviews, perspectives, and experiences of individuals related to urology care-seeking were explored. Open-ended questions were designed to elicit a range of responses rather than quantifiable data. Thematic codes were developed and explicitly defined. Codes pertaining to patient experiences were assessed and described.

RESULTS

Twenty-five TGNB individuals assigned male at birth were interviewed. Participants reported an array of factors that informed and inhibited care-seeking, factors that framed individual urologic care experiences, and their overall impression of the healthcare system's ability to effectively and respectfully serve the TGNB population. Specifically, participants reported that prior negative healthcare experiences dissuaded them from seeking care such as feeling discriminated against and having a lack of trust in providers. Additionally, participants reported feeling a need and responsibility to "educate" providers on both their medical needs and psychosocial experiences. Participants were also unclear how best to identify "trans-friendly" urologists who are culturally competent and have appropriate medical knowledge.

CONCLUSION

TGNB individuals face significant barriers to care for unique healthcare needs. TGNB participants described care avoidance and reported experiences of healthcare discrimination. These data highlight the importance for urologists to understand the perspectives and historical experiences of these individuals who may seek urological care.

Health Design Thinking: An Innovative Approach in Public Health to Defining Problems and Finding Solutions

Current trends in the United States health care landscape call for innovative and adaptive approaches to improve outcomes and reduce inefficiencies. Design Thinking is an innovative approach to problem-solving that leverages insights from the end-users of new products, services, and experiences in order to develop best-fit solutions that are rapidly prototyped and iteratively refined. When compared to traditional problem-solving methods in health care and other public health adjacent fields, Design Thinking leads to more successful and sustainable interventions. Design Thinking has facilitated improvements in patient, provider, and community satisfaction, and in public health, has increased efficiency and collaboration in intervention development. Given the promising nature of Design Thinking as an effective problem-solving method, it follows that Design Thinking training would prove a beneficial addition to public health education. The integration of Design Thinking in public health education may equip public health leaders with essential skills necessary to understand and more effectively approach historically intractable challenges. This article describes the development and evaluation of a hands-on Design Thinking workshop, piloted with Master of Public Health (MPH) students in April, 2019 at Thomas Jefferson University. Preceding and following the workshop, evaluation forms were used to assess participants' knowledge about Design Thinking concepts and attitudes towards the workshop experience. Metrics were aligned with established learning objectives related to process, impact, and outcomes of the workshop. We hypothesized that the workshop intervention would increase participants understanding of Design Thinking concepts and applications in public health. Evaluations demonstrated that after attending the workshop, participants were able to understand and apply Design Thinking concepts in a public health context. Following the evaluation of pilot data, the workshop was refined and embedded in the MPH curriculum at Thomas Jefferson University in Philadelphia, PA.

Tiny or Tall, Mighty or Small-Music for All! Developing an Interactive Online Storybook to Promote Body Positivity in Children

Body dissatisfaction and dietary restraint have been demonstrated in children as young as 5 years. Internalization of a thin-ideal is theorized to occur before the onset of body dissatisfaction and both have the potential to influence self-worth and impact multiple aspects of life. Across childhood, body dissatisfaction tends to increase while there is a parallel decline in positive self-concepts. Social comparisons also become more critical after the age of 7 years. Research suggests that early childhood (aged 3-8 years) may be the ideal time to expose children to content that counters unhealthy, unrealistic media ideals about body shape and size. This Practice Note describes the process of creating an evidence-based online storybook, Tiny or Tall, Mighty or Small-Music for All!, written to promote positive body image in children. Multiple steps were taken to complete this project, which required collaboration among experts across fields of public health, children's literature, and music. The storybook can be downloaded as a PDF file for free, online, and integrates sound clips for each instrument to more fully engage readers. We hope that this electronic platform overcomes potential logistical and financial barriers of accessing a print copy and therefore allows the message of body positivity to reach a wider audience.

Where there's smoke, there's fire: what current and future providers do and do not know about electronic cigarettes

Background

Health care providers play a pivotal role as educators on health-related matters ranging from vaccination to smoking cessation. With the rising popularity of electronic cigarettes (e-cigarettes), providers face a new challenge. To date, studies have identified a general lack of knowledge among providers regarding e-cigarettes and discomfort with counseling patients on e-cigarette use. This study aims to systematically explore the perspectives of different health care providers on e-cigarettes and their health implications. With a growing availability of research on the health consequences of e-cigarette use, our study also aims to assess the familiarity of our participants with this literature.

Methods

From July to October 2018, a sample of attendings (n = 15), residents (n = 15), medical students (n = 33), and nursing students (n = 28) from Thomas Jefferson University participated in a freelisting interview and survey.

Results

Our study found that perceptions of e-cigarettes vary across different participant groups, as evidenced by the range of responses when asked to think about e-cigarettes and their health implications. We identified gaps in knowledge among students regarding FDA regulation of e-cigarettes and found that attending physicians are less aware than junior trainees of the prevalence of use. Familiarity with evidence-based health consequences was variable and low across all groups. Finally, participants most commonly reported learning about e-cigarettes from news outlets and social media rather than professional platforms.

Conclusion

This study highlights the need for curricular development in nursing and medical schools, residency training, and continuing medical education regarding e-cigarette use and their impact on human health.

Natural Disasters in the Americas, Dialysis Patients, and Implications for Emergency Planning: A Systematic Review

Introduction

Natural hazards are elements of the physical environment caused by forces extraneous to human intervention and may be harmful to human beings. Natural hazards, such as weather events, can lead to natural disasters, which are serious societal disruptions that can disrupt dialysis provision, a life-threatening event for dialysis-dependent people. The adverse outcomes associated with missed dialysis sessions are likely exacerbated in island settings, where health care resources and emergency procedures are limited. The effect of natural disasters on dialysis patients living in geographically vulnerable areas such as the Cayman Islands is largely understudied. To inform predisaster interventions, we systematically reviewed studies examining the effects of disasters on dialysis patients and discussed the implications for emergency preparedness in the Cayman Islands.

Methods

Two reviewers independently screened 434 titles and abstracts from PubMed, Scopus, CINAHL, and Cochrane Library. We included studies if they were original research articles published in English from 2009 to 2019 and conducted in the Americas.

Results

Our search yielded 15 relevant articles, which we included in the final analysis. Results showed that disasters have both direct and indirect effects on dialysis patients. Lack of electricity, clean water, and transportation, and closure of dialysis centers can disrupt dialysis care, lead to missed dialysis sessions, and increase the number of hospitalizations and use of the emergency department. Additionally, disasters can exacerbate depression and lead to posttraumatic stress disorder among dialysis patients.

Conclusion

To our knowledge, this systematic review is the first study that presents a synthesis of the scientific literature on the effects of disasters on dialysis populations. The indirect and direct effects of disasters on dialysis patients highlight the need for predisaster interventions at the patient and health care system levels. Particularly, educating patients about an emergency renal diet and offering early dialysis can help to mitigate the negative effects of disasters.

Analysis of Unregulated Sale of Lifesaving Prescription Drugs Online in the United States

This cross-sectional analysis examines the prevalence of unregulated resale of insulin, albuterol, and epipenephrin online in the United States.

Perspectives of adolescents with severe obesity on social Media in Preparation for weight-loss surgery: a qualitative study

Background

Currently the most effective treatment for severe obesity in adolescents is weight-loss surgery coupled with lifestyle behavior change. In preparation for weight-loss surgery, adolescents are required to make changes to eating and activity habits (lifestyle changes) to promote long term success. Social media support groups, which are popular among adolescents, have the potential to augment preoperative lifestyle changes. The purpose of this study was to qualitatively assess the perceived role of social media as a support tool for weight-loss, and to identify motivators and constraints to lifestyle changes and social media use in adolescents preparing for weight-loss surgery.

Methods

Thematic analysis of social media comments from 13 (3 male, 10 female) adolescents aged 16 ± 1.3 years with a body mass index (BMI) 45 ± 7.3 kg/m² enrolled in a weight-management program preparing for bariatric surgery and who participated in a 12-week pilot social media intervention was performed. Participants commented on moderator posts and videos of nutrition, physical activity, and motivation that were shared three to four times per week. Social media comments were coded using NVivo 11.0 to identify recurrent themes and subthemes.

Results

1) Social media provided accountability, emotional support, and shared behavioral strategies. 2) Motivators for lifestyle changes included family support, personal goals, and non-scale victories. 3) Challenges included negative peers, challenges with planning and tracking, and time constraints.

Conclusion

Adolescents considering bariatric surgery identified social media as a tool for social support and reinforcement of strategies for successful behavior change. Important motivators and challenges to lifestyle changes were identified.

Comparing Patient, Clinician, and Caregiver Perceptions of Care for Early Psychosis: A Free Listing Study

Models for early psychosis intervention often involve shared decision-making among patients, their caregivers, and clinicians. However, this process rests on a shared understanding of constructs, experiences, and language. This study examined how various aspects of early psychosis care were conceptualized by those involved in the help-seeking process, and the extent to which their perceptions aligned with one another. We conducted a free listing study to systematically explore perceptions of the help-seeking process and management of psychosis-related symptoms among a sample of 65 patients, caregivers, and clinicians at an early psychosis intervention clinic. Results indicated varying levels of agreement between different roles on getting or giving help, taking medications, factors influencing symptom management, and thoughts regarding the future. These findings highlight important differences and emphasize a need for further exploration of how stakeholder perceptions may influence decisions surrounding the care of individuals experiencing early psychosis.

Social Determinants of Health and What Mothers Say They Need and Want After Release From Jail

Identifying the biopsychosocial needs of mothers who have been released from jail is critical to understanding the best ways to support their health and stability after release. In May through August 2014, we interviewed 15 mothers who had been released from an urban jail about their reentry experiences, and we analyzed transcripts for themes. Eight domains of community reentry emerged through analysis: behavioral health services, education, employment, housing, material resources, medical care, relationships with children, and social support. Participants defined barriers to successful reentry, which paralleled the social determinants of health, and shared suggestions that could be used to mitigate these barriers.

Youth Speak Out on School Food Environments

In Philadelphia, over 40% of youth are overweight or obese. The objective in this assessment was to learn about urban residents' perspectives regarding the local food environment and its impact on eating behaviors. Using photo-elicitation, 20 adolescents reflected on their food environments through photographs and corresponding interviews. Without specific prompting from interviewers, every participant raised concerns about their school food environments, which they commonly found to be unhealthy and unappealing. Participants' responses reflected four themes: (1) mixed reviews regarding the healthfulness of school vending machines, (2) lunch from home versus lunch from school, (3) factors that influenced food choice at school, and (4) critiques of school food environments. Students embraced the photo-elicitation approach as a way to convey their concerns and to suggest opportunities for improvements. School nurses, who are trusted by students and school personnel, are well-positioned to solicit student input and advocate for healthier school food environments.

Perceptions of Health Care Executives on Leadership Development Skills for Residents After Participating in a Longitudinal Mentorship Program

Despite the fact that physicians are being asked to lead and enact change to improve a myriad of quality of care measures, there is little focus on leadership skills development during their training. One strategy to address this gap is to focus on trainees during graduate medical education, specifically those residents aspiring to careers as physician leaders in quality. The authors designed a leadership curriculum for self-selected residents who are pursuing a certificate in health care leadership in quality. Residents were surveyed and focus groups were conducted with health system executives who participated in the curriculum as part of an evaluation designed to inform improvements in the program and to provide guidance to others who direct physician leadership training programs. The findings support the need to invest in young physician leaders who are focused on quality with the ultimate goal of improving population health in the ever-changing health care environment.

Experiences with skin and soft tissue infections among people who inject drugs in Philadelphia: A qualitative study

OBJECTIVES

To understand how people who inject drugs (PWID) experience skin and soft tissue infections (SSTI) and make decisions to seek or delay medical treatment.

METHODS

We conducted semi-structured, in-depth interviews in 2015 with 19 PWID at a syringe exchange program in Philadelphia. We analyzed the data using standard qualitative techniques.

RESULTS

PWID described adequate knowledge about SSTI, although they could not always implement knowledge about SSTI prevention due to environmental constraints. Participants reported different experiences with incident SSTI. Some sought immediate medical care at initial presentation. Most, however, waited to seek care. Previous positive and negative healthcare experiences, both in general -including stigma and withdrawal- and specific to SSTI, influenced this decision. Among those who delayed medical care, some reported self-treatment, including increased drug use for pain control, and lancing and draining their own wounds.

CONCLUSION

Reducing the incidence of SSTI and promoting earlier treatment are important public health priorities. Both require ongoing attention and improvements to the environments in which PWID inject and receive care.

Internet and Social Media Access Among Youth Experiencing Homelessness: Mixed-Methods Study

Background

Youth experiencing homelessness are at a risk for a variety of adverse outcomes. Given the widespread use of the internet and social media, these new technologies may be used to address their needs and for outreach purposes. However, little is known about how this group uses these resources.

Objective

This study investigated how homeless adolescents use these technologies for general and health-related purposes, whether the scope of their use changes with housing status, and their interest in a website dedicated to youth experiencing homelessness.

Methods

A convenience sample of youth aged 18 to 21 years was recruited from a youth-specific homeless shelter. All participants completed a 47-item survey, with 10 individuals completing a semistructured interview. Descriptive statistics, exact testing, logistic regression, and generalized estimating equation modeling was performed for quantitative data analysis. Interviews were transcribed verbatim, and NVivo 10 (QSR International) was employed to facilitate double coding and thematic analysis.

Results

A total of 87 participants completed the survey with a mean age of 19.4 (SD 1.1) years. While experiencing homelessness, 56% (49/87) accessed the internet at least once a day, with 86% (75/87) accessing once a week. Access to a smartphone was associated with a 3.03 greater odds of accessing the internet and was the most frequently used device (66% of participants, 57/87). While experiencing homelessness, subjects reported a 68% decreased odds in internet access frequency (odds ratio [OR] 0.32, P<.001), 75% decreased odds in spending greater amounts of time on the internet (OR 0.25, P<.001), and an 87% decreased odds of social media use (OR 0.13, P=.01). Ten participants completed the semistructured interview. Several themes were identified, including (1) changes in internet behaviors while experiencing homelessness, (2) health status as a major concern and reason for Internet use, and (3) interest in a website dedicated to youth experiencing homelessness. While experiencing homelessness, participants indicated their behaviors were more goal-oriented and less focused on leisure or entertainment activities.

Conclusions

While homeless youth experience changes in the frequency, amount of time, and specific uses of the internet and social media, study participants were able to access the internet regularly. The internet was used to search health-related topics. Given the importance of smartphones in accessing the internet, mobile-optimized websites may be an effective method for reaching this group.

County Jail or Psychiatric Hospital? Ethical Challenges in Correctional Mental Health Care

Approximately 20% of the roughly 2.5 million individuals incarcerated in the United States have a serious mental illness (SMI). As a result of their illnesses, these individuals are often more likely to commit a crime, end up incarcerated, and languish in correctional settings without appropriate treatment. The objective of the present study was to investigate how correctional facility personnel reconcile the ethical challenges that arise when housing and treating individuals with SMI. Four focus groups and one group interview were conducted with employees ( n = 24) including nurses, clinicians, correctional officers, administrators, and sergeants at a county jail in Pennsylvania. Results show that jail employees felt there are too many inmates with SMI in jail who would benefit from more comprehensive treatment elsewhere; however, given limited resources, employees felt they were doing the best they can. These findings can inform mental health management and policy in a correctional setting.

"My bitterness is deeper than the ocean": understanding internalized stigma from the perspectives of persons with schizophrenia and their family caregivers

Background

It is estimated that 8 million of the Chinese adult population had a diagnosis of schizophrenia. Stigma associated with mental illness, which is pervasive in the Chinese cultural context, impacts both persons with schizophrenia and their family caregivers. However, a review of the literature found a dearth of research that explored internalized stigma from the perspectives of both patients and their caregivers.

Methods

We integrated data from standardized scales and narratives from semi-structured interviews obtained from eight family-dyads. Interview narratives about stigma were analyzed using directed content analysis and compared with responses from Chinese versions of the Internalized Stigma of Mental Illness Scale and Affiliated Stigma Scale. Scores from the two scales and number of text fragments were compared to identify consistency of responses using the two methods. Profiles from three family-dyads were analyzed to highlight the interactive aspect of stigma in a dyadic relationship.

Results

Our analyses suggested that persons with schizophrenia and their caregivers both internalized negative valuation from their social networks and reduced engagement in the community. Participants with schizophrenia expressed a sense of shame and inferiority, spoke about being a burden to their family, and expressed self-disappointment as a result of having a psychiatric diagnosis. Caregivers expressed high level of emotional distress because of mental illness in the family. Family dyads varied in the extent that internalized stigma were experienced by patients and caregivers.

Conclusions

Family plays a central role in caring for persons with mental illness in China. Given the increasingly community-based nature of mental health services delivery, understanding internalized stigma as a family unit is important to guide the development of cultural-informed treatments. This pilot study provides a method that can be used to collect data that take into consideration the cultural nuances of Chinese societies.

Electronic supplementary material

The online version of this article (10.1186/s13033-018-0192-4) contains supplementary material, which is available to authorized users.

'That's when I struggle' … Exploring challenges faced by care givers of children with tuberculosis in Botswana

SETTING

Government-funded public health clinics in and around Gaborone, Botswana.

OBJECTIVE

To explore the challenges faced by care givers of children on treatment for tuberculosis (TB) to inform a more child-friendly approach to Botswana's National TB Programme (NTP) strategy.

DESIGN

Qualitative study using 28 in-depth interviews with care givers of children receiving anti-tuberculosis treatment.

RESULTS

Care givers identified five main challenges: long delays in their child's diagnosis, difficulty attending clinic for daily treatment, difficulty administering TB medications, stock-outs of TB medications leading to treatment interruptions, and inadequate TB education. Care givers prioritized these same five areas to improve the overall management of their child's TB.

CONCLUSION

Our findings suggest that despite accessing care through an NTP that adheres to World Health Organization guidelines, care givers for children on treatment in Botswana continue to encounter significant challenges. While each of these represents a potential threat to successful treatment, they can be addressed with relatively small systematic and programmatic adjustments. These results will inform the next version of the Botswana NTP guidelines towards a more child- and care giver-centered approach.

The Association Between Pregnancy Intention and Breastfeeding

BACKGROUND

Although breastfeeding is associated with proven benefits to both mother and child, there are many factors that influence a mother's decision to breastfeed. Pregnancy intentionality at the time of conception is associated with postpartum maternal behavior including breastfeeding. Research aim: We sought to understand how maternal and paternal pregnancy intentions were associated with breastfeeding initiation and duration in a nationally representative sample.

METHODS

We used a cross-sectional, retrospective study of the CDC National Survey of Family Growth data to examine the link between pregnancy intentionality and breastfeeding initiation and duration among women ages 15 to 44 years.

RESULTS

We found that whereas the mother's intention to have a child was a factor in how long she breastfed, the paternal intention to have a child predicted whether the mother breastfed at all. Additionally, Hispanic mothers were most likely to breastfeed and breastfed the longest of any other group. Age and education were also positive predictors of ever breastfeeding.

CONCLUSION

Understanding the father's and mother's attitudes toward the pregnancy and influence on breastfeeding intention is important for intervention planning.

Perceptions about supervised injection facilities among people who inject drugs in Philadelphia

BACKGROUND

People who inject drugs (PWID) are at high risk for infectious diseases, skin and soft tissue infections, and overdose. However, these harms are all avoidable when sterile injection equipment, hygienic places to inject, and medical care are accessible. Unfortunately, many PWID in the U.S lack these resources. The most vulnerable are forced to inject in public spaces, where individual risks are high and communal harms are sometimes many. Supervised Injection Facilities (SIFs) are an established intervention for reducing these harms. Despite positive experiences in other countries, little research explores how PWID in the U.S. perceive the value of such facilities.

METHODS

We conducted a freelisting exercise with PWID (n=42) and healthcare providers (n=20) at a syringe exchange program (SEP) that provides comprehensive clinical and social services in Philadelphia to inform in-depth semi-structured interviews with PWID (n=19) at the same location.

RESULTS

Participants expressed support for a potential SIF as a valuable public health intervention. They suggested that an SIF would improve PWID health while reducing the public disorder associated with injecting drugs in public. The latter was especially important to participants without stable housing, whose decision to inject furtively in secluded places was often motivated by desire not to upset community members, and particularly children. These participants acknowledged that such seclusion elevated the risk of fatal overdose. Despite similarly positive perceptions about an SIF, participants with stable housing reported that they would prefer to continue injecting at home.

CONCLUSION

Results both confirm and extend prior research about PWID and SIFs. Participants expressed support for SIFs as in prior survey research in the U.S. and in other countries. Facility location and housing status were identified as important determinants of facility use. Results extend prior research by illuminating PWID perceptions in the U.S. including motivations grounded in concern for public order.

Lessons from the field: the conduct of randomized controlled trials in Botswana

Background

The conduct of randomized controlled trials (RCTs) in low-resource settings may present unique financial, logistic, and process-related challenges. Middle-income countries that have comparable disease burdens to low-income countries, but greater availability of resources, may be conducive settings for RCTs. Indeed, the country of Botswana is experiencing a rapid increase in the conduct of RCTs. Our objective was to explore the experiences of individuals conducting RCTs in Botswana to gain an understanding of the challenges and adaptive strategies to their work.

Methods

We conducted in-depth interviews with 14 national and international individuals working on RCTs in Botswana. Participants included principal investigators, research coordinators, lab technicians, research assistants, and other healthcare professionals. Interviews were audiotaped, transcribed verbatim, and coded for thematic analysis.

Results

Five primary themes were identified: ethics board relationships (including delays in the process); research staff management (including staff attrition and career development); study recruitment and retention (including the use of reimbursements); resource availability (including challenges accessing laboratory equipment); and capacity-building (including issues of exporting locally sourced samples). These themes were explored to discuss key challenges and adaptive strategies.

Conclusions

This study offers a first-hand account of individuals engaged in conducting RCTs in Botswana, a nation that is experiencing a rapid increase in research activities. Findings provide a foundational understanding for researchers in Botswana and trial managers in similar settings when planning RCTs so that the conduct of research does not outpace the ability to manage, support, and regulate it.

Adverse events in veterans affairs inpatient psychiatric units: Staff perspectives on contributing and protective factors

OBJECTIVES

This study sought to identify risk factors and protective factors in hospital-based mental health settings in the Veterans Health Administration (VHA), with the goal of informing interventions to improve care of persons with serious mental illness.

METHODS

Twenty key informants from a stratified sample of 7 VHA inpatient psychiatric units were interviewed to gain their insights on causes of patient safety events and the factors that constrain or facilitate patient safety efforts.

RESULTS

Respondents identified threats to patient safety at the system-, provider-, and patient-levels. Protective factors that, when in place, made patient safety events less likely to occur included: promoting a culture of safety; advocating for patient-centeredness; and engaging administrators and organizational leadership to champion these changes.

CONCLUSIONS

Findings highlight the impact of systems-level policies and procedures on safety in inpatient mental health care. Engaging all stakeholders, including patients, in patient safety efforts and establishing a culture of safety will help improve the quality of inpatient psychiatric care. Successful implementation of changes require the knowledge of local experts most closely involved in patient care, as well as support and buy-in from organizational leadership.

Understanding potential uptake of a proposed mHealth program to support caregiver home management of childhood illness in a resource-poor setting: a qualitative evaluation

BACKGROUND

Extensive uptake of mobile phones offers an unprecedented opportunity to improve global healthcare delivery, especially among underserved populations. Mobile health (mHealth) has been increasingly recognized as a promising approach to addressing challenges in global maternal-child health and may play an important role in accelerating progress towards improved outcomes. However, more evidence guiding development of mHealth interventions is needed. The current study explores factors that may support or hinder adoption and use of a proposed mHealth intervention to improve caregiver home management of common childhood illnesses in order to shape program development.

METHODS

Elicitation interviews were conducted with a convenience sample of 25 mothers recruited from a larger cluster-randomized survey sample in the Cono Norte region of Arequipa, Peru. Interview data were analyzed in Spanish to preserve important cultural nuances.

RESULTS

Thematic analysis revealed potential facilitators of and barriers to uptake of the proposed mHealth program. Potential facilitators of caregiver participation include opportunity to engage in two-way communication with healthcare providers, development of instrumental and support knowledge to care for sick children, and healthcare challenges faced in a resource-poor community. Potential barriers include preference for in-person healthcare visits, program cost, text messaging abilities, and concern around program legitimacy.

CONCLUSIONS

This study underscores the potential for mHealth to improve global healthcare delivery in the area of maternal-child health. It demonstrates that mHealth interventions can meet the needs of vulnerable populations by offering novel approaches to promoting evidence-based care. This in-depth understanding of factors that may influence participation and use of this proposed mHealth program will help shape development of the intervention in this community.

Cohort study of early literacy and childbearing over the reproductive lifecourse

INTRODUCTION

Literacy is linked to a range of health outcomes, but its association with reproductive health in high-income countries is not well understood. We assessed the relationship between early-life literacy and childbearing across the reproductive lifecourse in the USA.

STUDY DESIGN

A prospective cohort design was employed to assess early-life literacy and subsequent childbearing, using data from the National Longitudinal Survey of Youth 1979. The US youth aged 14-22 years in 1979, including 6283 women, were surveyed annually through 1994 and biannually thereafter. Literacy was assessed in 1980 using the Armed Services Vocational Aptitude Battery Reading Grade Level (RGL). Cumulative childbearing and grand multiparity (≥5 births) were assessed in 2010. Summary statistics, χ², Kruskal-Wallis, test for trend and logistic regression, were used.

RESULTS

Of 6283 women enrolled, 4025 (64%) had complete data and were included in the analyses. In 1980, these women were on average 18 years old and in 2010 they were 45. Median cumulative parity decreased for each RGL and ranged from 3.0 (<5th grade) to 2.0 (>12th grade) (p=0.001). Adjusting for race/ethnicity, poverty status, whether a woman had had a child in 1980, and age in 1980, odds of grand multiparity were 1.9 (95% CI 1.1 to 3.5) and 1.8 (95% CI 1.0 to 3.3), greater among women with <5th or 5-6th grade literacy compared with those ≥12th literacy.

DISCUSSION

In the USA, early-life literacy is associated with total parity over a woman's lifecourse. Literacy is a powerful social determinant of reproductive health in this high-income nation just as it has been shown to be in low-income nations.