Engaging Community-Academic Partnerships: A Case Study of the Influence of Social Drivers of Health on Equitable Transitions of Cancer Care in the United States

Enduring community-academic partnerships are essential for expediting the successful dissemination and implementation of promising interventions and programs, particularly for complex public health issues such as cancer prevention and control. The purpose of this case study was to understand the combined voices of a diverse group of stakeholders to outline the essential factors needed to translate research into sustainable cancer care within communities. System dynamics group model building was used to develop system maps of the factors impacting equitable access to cancer care services among three stakeholder groups (Group A: survivors and family members, n = 20; Group B: providers and administrators in community agencies/organizations, n = 40; Group C: administrators from a cancer institute, academic universities, foundations, and healthcare facilities that coordinate care, n = 25) in central Texas, USA. The lead researcher identified factors involved in transitions of care and their linkages with each other. The analysis of this work displays these connections visually. These models represent the ripple effect of factors influencing the transition of care for stakeholders who are invested in cancer care outcomes. All three groups identified medical mistrust, a culturally sensitive and diverse provider workforce, and care coordination as three essential factors (i.e., themes). Group A also identified caregiver navigation. The groups varied in their emphasis on upstream vs. downstream social drivers of health, with Group B emphasizing the former and Group C emphasizing the latter. To achieve cancer care equity, all stakeholder groups agreed on the importance of addressing the impact of social drivers as critical gaps. Eliminating or reducing these impacts allows each stakeholder group to work more efficiently and effectively to improve cancer care for patients.

Racial disparity in ART adherence is closed in states with high social trust: Results from the Medical Monitoring Project (MMP), 2015

Racial/ethnic disparities persist in antiretroviral therapy (ART) adherence and viral suppression. We examined associations between state-level social trust and individual-level ART adherence and viral suppression and assessed whether these relationships varied by race/ethnicity. The Medical Monitoring Project (MMP) annually reports nationally representative estimates of the behavioral and clinical characteristics of HIV-positive adults in primary care. A total of 3298 adults diagnosed with HIV between 2015 and 2016 from 16 US states were included. We used weighted logistic regression to model the association between state-level social trust, race/ethnicity (Non-Hispanic Black, White, and Hispanic/Latino), and cross-product interactions with ART adherence (a binary measure derived from three self-reported questions), and viral suppression (a binary measure corresponding to plasma HIV RNA < 200 copies/ml). Social trust was the percentage of people in each state who agreed that most people in their neighborhood could be trusted. A high level of social trust was associated with a higher likelihood of ART adherence (PR [prevalence ratio] = 1.17; 95% confidence interval [CI]: 1.05-1.30). In covariate-adjusted analyses, the association between state-level social trust and individual-level ART adherence significantly varied by race/ethnicity (Wald χ2  F = 9.8 [df = 4], p = 0.044). Social trust was positively associated with ART, but the effect was smaller for Blacks than for Whites (PR = 0.66; 95% CI: 0.57-0.82) in states with the lowest social trust. Black-White differences were closed and no longer significant above mean social trust (PP [predicted probability] = 0.50 vs. 0.53, at two standard deviations). Racial/ethnic disparities in ART adherence were closed among individuals living in states with high social trust. Understanding the mechanisms that promote social trust among neighbors may have downstream impacts on reducing disparities in ART adherence among people with HIV (PWH).

Paediatric alternative payment models: emerging elements

PURPOSE OF REVIEW

The aim of this study was to summarize emerging elements of paediatric alternative payment models (APMs), identify strategies to address barriers in implementing paediatric APMs and share policy approaches.

RECENT FINDINGS

The unique health needs of children and adolescents must be considered as paediatric value-based care and APMs are developed. The longer time period for achieving cost savings, relatively few existing model tests and challenges with cross-sector data-sharing and pooled financing are barriers to the adoption of paediatric APMs. The Integrated Care for Kids (InCK) model and some state-based efforts are testing whether an integrated service delivery model combined with paediatric APMs can reduce expenditures and improve care and outcomes. However, the relative paucity of models makes it difficult to identify the most effective strategies and overall impact of paediatric APMs.

SUMMARY

Emerging paediatric APMs include the following key elements: developmentally appropriate approaches, paediatric-specific quality and cost measures, a focus on primary care, special considerations for children with complex healthcare needs and cross-sector integration of data, workforce and financing. A variety of strategies, rooted in cross-sector partnerships, can be pursued to address implementation barriers and ultimately support paediatric care transformation.

No Prescription, No Problem! A Mixed-Methods Study of Antimicrobial Stewardship Relating to Working Equines in Drug Retail Outlets of Northern India

Multidrug resistance (MDR) is already occurring among some equids in India. Donkeys and mules are a mobile species moving between regions and international borders, often populating areas of India where private community pharmacies, or medical stores, are the primary healthcare provider for both humans and animals. This article highlights how the capacities of drug retail outlet workers might affect their antibiotic dispensing practices, particularly in relation to donkeys and mules, in order to consider how this might impact the development of antimicrobial resistance (AMR) on a wider scale. A mixed-methods approach was implemented using patient simulation method (n = 28), semi-structured interviews (SSIs) (n = 23), focus group discussions (FGDs) with veterinary practitioners and non-governmental organisation animal health workers (n = 2 FGDs), and participant observation. Fewer than 48 per cent of drug retail outlet workers admitted to having had any formal training in pharmaceuticals at all, while 78 per cent reported having no formal training in animal-related pharmaceuticals. Moreover, 35 per cent of all participants sold antibiotics without a prescription, unprompted and without specifically being asked for antibiotics. Of the antibiotics dispensed, only 21 per cent were correctly dispensed for the symptoms presented, and all dosages dispensed were incorrect (underdosed). Furthermore, 43 per cent of drug retail outlet workers interviewed believe that some antibiotics can be legally dispensed without a prescription. Equine owners in northern India are frequently being sold antibiotics without a prescription and, in most cases, with incorrect diagnoses, treatment choice, and dosage. A substantial gap in capacities exists amongst Drug Retail Outlet (DRO) workers, with few being sufficiently qualified or trained to dispense antibiotics to animal owners. The study highlights the need for further training of private DRO workers as well as knowledge extension and awareness training for both DRO workers and animal owners regarding antimicrobial resistance and its potential impact upon livelihoods. It also illustrates the need to identify a balance whereby greater enforcement of regulation at all levels is implemented, while at the same time maintaining sufficient access to medicine for rural populations.

Prevalence and social drivers of HIV among married and cohabitating heterosexual adults in south-eastern Tanzania: analysis of adult health community cohort data

Background

In sub-Saharan Africa, the prevalence of HIV among married and cohabiting couples is substantial. Information about the underlying social drivers of HIV transmission in couples is critical for the development of structural approaches to HIV prevention, but not readily available. We explored the association between social drivers, practices, and HIV status among stable couples in Ifakara, Tanzania.

Design

Using a cross-sectional design, we analyzed data from a sample of 3,988 married or cohabiting individuals, aged 15 years and older from the MZIMA adult health community cohort study of 2013. Sociodemographic factors (sex, income, age, and education), gender norms (perceived acceptability for a wife to ask her partner to use a condom when she knows he is HIV positive), marriage characteristics (being in a monogamous or a polygamous marriage, being remarried), sexual behavior practices (lifetime number of sexual partners and concurrent sexual partners), health system factors (ever used voluntary HIV counseling and testing), and lifestyle patterns (alcohol use) were used to explore the odds of being HIV positive, with 95% confidence intervals.

Results

Prevalence of HIV/AIDS was 6.7% (5.9% males and 7.1% females). Gender norms, that is, perception that a woman is not justified to ask her husband to use a condom even when she knows he has a disease (adjusted odds ratio AOR=1.51, 95% CI 1.06–2.17), marital characteristics, that is, being remarried (AOR=1.49, 95% CI 1.08–2.04), and sexual behavior characteristics, that is, lifetime number of sexual partners (2–4: AOR=1.47, 95% CI 1.02–2.11; 5+: AOR=1.61, 95% CI 1.05–2.47) were the main independent predictors of HIV prevalence.

Conclusions

Among married or cohabiting individuals, the key social drivers/practices that appeared to make people more vulnerable for HIV are gender norms, marriage characteristics (being remarried), and sexual behavior practices (lifetime number of sexual partners). Married and cohabiting couples are an important target group for HIV prevention efforts in Tanzania. In addition to individual interventions, structural interventions are needed to address the gender norms, remarriage, and sexual practices that shape differential vulnerability to HIV in stable couples.

Structural approaches for prevention of sexually transmitted HIV in general populations: definitions and an operational approach

Introduction

Although biomedical HIV prevention efforts have seen a number of recent promising developments, behavioural interventions have often been described as failing. However, clear lessons have been identified from past efforts, including the need to address influential social, economic and legal structures; to tailor efforts to local contexts; and to address multiple influencing factors in combination. Despite these insights, there remains a pervasive strategy to try to achieve sexual behaviour change through single, decontextualized, interventions or sets of activities. With current calls for structural approaches to HIV as part of combination HIV prevention, though, there is a unique opportunity to define a structural approach to HIV prevention as one which moves beyond these past limitations and better incorporates our knowledge of the social world and the lessons from past efforts.

Discussion

A range of interlinked concepts require delineation and definition within the broad concept of a structural approach to HIV. This includes distinguishing between “structural factors,” which can be seen as any number of elements (other than knowledge) which influence risk and vulnerability, and “structural drivers,” which should be reserved for situations where an empirically established relationship to a target group is known. Operationalizing structural approaches similarly can take different paths, either working to alter structural drivers or alternatively working to build individual and community resilience to infection. A “structural diagnostic approach” is further defined as the process one undertakes to develop structural intervention strategies tailored to target groups.

Conclusions

For three decades, the HIV prevention community has struggled to reduce the spread of HIV through sexual risk behaviours with limited success, but equally with limited engagement with the lessons that have been learned about the social realities shaping patterns of sexual practices. Future HIV prevention efforts must address the multiple factors influencing risk and vulnerability, and they must do so in ways tailored to particular settings. Clarity on the concepts, terminology and approaches that can allow structural HIV prevention efforts to achieve this is therefore essential to improve the (social) science of HIV prevention.

Evaluating social outcomes of HIV/AIDS interventions: a critical assessment of contemporary indicator frameworks

Introduction

Contemporary HIV-related theory and policy emphasize the importance of addressing the social drivers of HIV risk and vulnerability for a long-term response. Consequently, increasing attention is being given to social and structural interventions, and to social outcomes of HIV interventions. Appropriate indicators for social outcomes are needed in order to institutionalize the commitment to addressing social outcomes. This paper critically assesses the current state of social indicators within international HIV/AIDS monitoring and evaluation frameworks.

Methods

We analyzed the indicator frameworks of six international organizations involved in efforts to improve and synchronize the monitoring and evaluation of the HIV/AIDS response. Our analysis classifies the 328 unique indicators according to what they measure and assesses the degree to which they offer comprehensive measurement across three dimensions: domains of the social context, levels of change and organizational capacity.

Results and discussion

The majority of indicators focus on individual-level (clinical and behavioural) interventions and outcomes, neglecting structural interventions, community interventions and social outcomes (e.g. stigma reduction; community capacity building; policy-maker sensitization). The main tool used to address social aspects of HIV/AIDS is the disaggregation of data by social group. This raises three main limitations. Indicator frameworks do not provide comprehensive coverage of the diverse social drivers of the epidemic, particularly neglecting criminalization, stigma, discrimination and gender norms. There is a dearth of indicators for evaluating the social impacts of HIV interventions. Indicators of organizational capacity focus on capacity to effectively deliver and manage clinical services, neglecting capacity to respond appropriately and sustainably to complex social contexts.

Conclusions

Current indicator frameworks cannot adequately assess the social outcomes of HIV interventions. This limits knowledge about social drivers and inhibits the institutionalization of social approaches within the HIV/AIDS response. We conclude that indicator frameworks should expand to offer a more comprehensive range of social indicators for monitoring and evaluation and to include indicators of organizational capacity to tackle social drivers. While such expansion poses challenges for standardization and coordination, we argue that the complexity of interventions producing social outcomes necessitates capacity for flexibility and local tailoring in monitoring and evaluation.