Examining healthcare transition experiences among youth living with HIV in Atlanta, Georgia, USA: a longitudinal qualitative study

INTRODUCTION

Virtually all youth living with HIV in paediatric/adolescent care must eventually transition to adult-oriented HIV care settings. To date, there is limited evidence examining the perspectives of youth living with HIV longitudinally through the healthcare transition process. The objective of our study was to examine attitudes and experiences of youth living with HIV regarding healthcare transition, including potential change in attitudes and experiences over time.

METHODS

We conducted a longitudinal qualitative interview study within a large, comprehensive HIV care centre in Atlanta, Georgia, USA between August 2016 and October 2019.We interviewed 28 youth living with HIV as part of a longitudinal observational cohort study of youth undergoing healthcare transition. We conducted qualitative interviews both immediately prior to, and one year following the transition from paediatric to adult-oriented care.

RESULTS

Six distinct themes emerged from interviews conducted with youth living with HIV pre-transition: (1) reluctance to transition; (2) paediatric spaces as welcoming, and adult spaces as unwelcoming; (3) varying levels of preparation for transition; and (4) expectation of autonomy in the adult clinic. Analysis of post-transition interviews with the same youth demonstrated: (1) inconsistencies in the transition experience; (2) fear and anxiety about transition quelled by experience; (3) varying reactions to newfound autonomy and (4) communication as the most valuable facilitator of successful transition.

CONCLUSIONS

This study's longitudinal perspective on the healthcare transition experience yields insights that can be incorporated into programming targeting this critically important population. Although our study was conducted in a USA-based clinic with co-located paediatric and adult care services, many of our findings are likely to have relevance in other settings as well. Interventions aiming to improve HIV care engagement through transition should seek to enhance patient-provider communication in both paediatric and adult clinics, improve preparation of patients in paediatric clinics and ease patients gradually into autonomous disease management.

State Laws Matter When It Comes to District Policymaking Relative to the Whole School, Whole Community, Whole Child Framework

BACKGROUND

The Whole School, Whole Community, Whole Child (WSCC) framework supports the "whole child" across 10 domains. This study assessed state law and district policy WSCC coverage.

METHODS

Primary legal research was used to compile relevant district policies and state laws for a stratified random sample of 368 public school districts across 20 states for school year 2017-18. Policies/laws were evaluated on 79 items across the WSCC domains (range: 3-14 items/domain). Multivariable regressions examined the relationship between state laws and district policies, controlling for district characteristics, and weighted to account for the sample design and non-response.

RESULTS

On average, district policies and state laws addressed 53% and 60% of the 79 items, respectively. State law predicted district policy WSCC attention across items (coeff. = 0.26, 95% CI = 0.14, 0.38) and 4 domains: physical activity (coeff. = 0.57, 95% CI = 0.29, 0.86); health services (coeff. = 0.50, 95% CI = 0.39, 0.62); social and emotional climate (coeff. = 0.34, 95% CI = 0.23, 0.45); and family engagement (coeff. = 0.41, 95% CI = 0.28, 0.54). State law was associated with lower district-level coverage in 3 domains (health education; counseling, psychological, and social services; and community involvement).

CONCLUSIONS

Although WSCC implementation is locally-driven, states have an active role to play in setting a policy "floor" for guiding district WSCC attention.

Every School Healthy: Creating Local Impact Through National Efforts

BACKGROUND

Whole school, whole community, whole child (WSCC) approaches to education address contexts beyond school that influence young people's academic and life outcomes. These recommended approaches demand mobilization of an array of actors, but such mobilization is challenging. Little research has explored strategies for convening national experts to support local communities.

METHODS

This paper presents a case narrative of Every School Healthy (ESH), a grant-funded effort to support organizations/school districts in 6 communities building WSCC initiatives by engaging national youth development organizations as expert advisors to ESH and communities. A thematic analysis of the narrative yielded 3 key learnings.

RESULTS

Three themes emerged as key learnings regarding implementation of national-local initiatives: (1) baseline assessment of local communities should be conducted to identify opportunities for maximizing strengths; (2) national organizations must be flexible with the expertise they bring to the initiative; (3) national organizations should prioritize community-cultivated solutions and meet communities where they are.

CONCLUSIONS

The 3 themes presented in this case narrative offer insights for effectively mobilizing national organizations to support healthy, equitable school environments at the local level.

From Consultation to Shared Decision-Making: Youth Engagement Strategies for Promoting School and Community Wellbeing

BACKGROUND

The benefits of youth engagement are well documented. In this paper, we examine youth engagement in America's Promise Alliance's Every School Healthy initiative, a part of the Robert Wood Johnson Foundation's Together for Healthy and Successful Schools Initiative (THSS).

METHODS

Six community acceleration sites were selected through a competitive grant-making process. Sites were required to describe youth engagement strategies. A case study design was employed to examine how sites conceptualize youth engagement as well as youth engagement strategies employed across 6 sites. Data sources included observations, team member debriefs, and document review.

RESULTS

There was variation in how youth engagement and youth voice are conceptualized in educational settings, and readiness for youth engagement. Sites actively solicited and implemented youth engagement resources and strategies.

CONCLUSIONS

By failing to engage young people, well-intentioned adults miss important opportunities. Youth engagement presents an exciting opportunity for school leaders, policymakers, and program planners to gain a deeper understanding of the factors that influence individual and community health and wellbeing and, in turn, helps them to develop responsive policies and programs.

Community-Based System Dynamics for Mobilizing Communities to Advance School Health

BACKGROUND

Frameworks such as the WSCC model provide evidence-based guidance for addressing school health at the school, district, and regional level. However, frameworks do not implement themselves; they require the mobilization and collaboration of stakeholders within communities and an understanding of the unique resources and barriers within each context. Furthermore, addressing school health presents a complex systems problem.

METHODS

Community-based system dynamics (CBSD) is a participatory approach for engaging communities in understanding and changing complex systems. We used a descriptive multiple case study design to evaluate how and why CBSD was used as a tool for stakeholders to engage with the complexity of school health.

RESULTS

We analyzed 3 cases to understand how these methods were used to enhance collaboration, analysis, and community action at multiple levels, including in 2 school districts, with a city-wide stakeholder committee, and with a group of high school students.

CONCLUSIONS

Community-based system dynamics presents a promising approach for building shared language and ownership among stakeholders, tailoring to local community contexts, and mobilizing stakeholders for action based on new system insights. We close with a discussion of unique opportunities and challenges of expanding the use of CBSD in the field of school health.

Prospective associations, longitudinal patterns of childhood socioeconomic status, and white matter organization in adulthood

The association between childhood socioeconomic status (SES) and brain development is an emerging area of research. The primary focus to date has been on SES and variations in gray matter structure with much less known about the relation between childhood SES and white matter structure. Using a longitudinal study of SES, with measures of income-to-needs ratio (INR) at age 9, 13, 17, and 24, we examined the prospective relationship between childhood SES (age 9 INR) and white matter organization in adulthood using diffusion tensor imaging. We also examined how changes in INR from childhood through young adulthood are associated with white matter organization in adult using a latent growth mixture model. Using tract-based spatial statistics (TBSS) we found that there is a significant prospective positive association between childhood INR and white matter organization in the bilateral uncinate fasciculus, bilateral cingulum bundle, bilateral superior longitudinal fasciculus, and corpus callosum (p < .05, FWE corrected). The probability that an individual was in the high-increasing INR profile across development compared with the low-increasing INR profile was positively associated with white matter organization in the bilateral uncinate fasciculus, left cingulum, and bilateral superior longitudinal fasciculus. The results of the current study have potential implications for interventions given that early childhood poverty may have long-lasting associations with white matter structure. Furthermore, trajectories of socioeconomic status during childhood are important-with individuals that belong to the latent profile that had high increases in INR having greater regional white matter organization in adulthood.

Differences in HIV risk and healthcare engagement factors in Filipinx transgender women and cisgender men who have sex with men who reported being HIV negative, HIV positive or HIV unknown

INTRODUCTION

Understanding HIV risk and healthcare engagement of at-risk individuals by HIV status is vital to informing HIV programmes in settings where the HIV epidemic is rapidly expanding like the Philippines. This study examined differences in HIV risk and healthcare engagement factors among Filipinx transgender women and cisgender men who have sex with men (trans-WSM and cis-MSM respectively) who self-reported being HIV negative, HIV positive or HIV unknown.

METHODS

Between 2018 and 2019, we conducted Project #ParaSaAtin, an online cross-sectional survey that examined the structural, social and behavioural factors impacting HIV services among Filipinx trans-WSM and cis-MSM (n = 318). We performed multinomial regression procedures to determine factors associated with HIV status (with HIV-negative referent). Co-variates included participant demographics, experiences of social marginalization, HIV risk, healthcare engagement and alcohol and substance problems.

RESULTS

Self-reported HIV status of the sample was as follows: 38% HIV negative, 34% HIV positive and 28% HIV unknown. Relative to HIV-negative respondents, HIV-positive respondents were more likely to be older (25- to 29-year-old adjusted risk ratio [aRRR]=5.08, 95% Confidence Interval [95% CI] = 1.88 to 13.72; 30- to 34-year-old aRRR = 4.11, 95% CI = 1.34 to 12.58; and 35 + years old aRRR = 8.13, 95% CI = 2.40 to 27.54, vs. 18 to 25 years old respectively), to live in Manila (aRRR = 5.89, 95% CI = 2.20 to 15.72), exhibit hazardous drinking (aRRR = 2.87, 95% CI = 1.37 to 6.00) and problematic drug use (aRRR = 2.90, 95% CI = 1.21 to 7.13). HIV-positive respondents were less likely to identify as straight (aRRR = 0.13, 95% CI = 0.02 to 0.72), and were more likely to avoid HIV services due to lack of anti-lesbian, gay, bisexual and transgender (LGBT) discrimination policies (aRRR = 0.37, 95% CI = 0.14 to 0.90). Relative to HIV-negative respondents, HIV-unknown respondents were less educated (some college aRRR = 0.10, 95% CI = 0.02 to 0.37, beyond college aRRR = 0.31, 95% CI = 0.09 to 0.99, vs. high school or below respectively), had lower HIV knowledge (aRRR = 0.30, 95% CI = 0.20 to 0.71), and were less communicative about safer sex (ARR = 0.29, 95% CI = 0.09 to 0.92). Moreover, HIV-unknown respondents were also more likely to have avoided HIV services due to cost (aRRR = 4.46, 95% CI = 1.73 to 11.52).

CONCLUSIONS

This study highlights differences in HIV risks and healthcare engagement by HIV status. These findings show different barriers exist per HIV status group, and underscore the need to address Filipinx trans-WSM and cis-MSM's poor engagement in HIV services in the Philippines.

Hidden talents in harsh conditions? A preregistered study of memory and reasoning about social dominance

Although growing up in stressful conditions can undermine mental abilities, people in harsh environments may develop intact, or even enhanced, social and cognitive abilities for solving problems in high-adversity contexts (i.e. 'hidden talents'). We examine whether childhood and current exposure to violence are associated with memory (number of learning rounds needed to memorize relations between items) and reasoning performance (accuracy in deducing a novel relation) on transitive inference tasks involving both violence-relevant and violence-neutral social information (social dominance vs. chronological age). We hypothesized that individuals who had more exposure to violence would perform better than individuals with less exposure on the social dominance task. We tested this hypothesis in a preregistered study in 100 Dutch college students and 99 Dutch community participants. We found that more exposure to violence was associated with lower overall memory performance, but not with reasoning performance. However, the main effects of current (but not childhood) exposure to violence on memory were qualified by significant interaction effects. More current exposure to neighborhood violence was associated with worse memory for age relations, but not with memory for dominance relations. By contrast, more current personal involvement in violence was associated with better memory for dominance relations, but not with memory for age relations. These results suggest incomplete transfer of learning and memory abilities across contents. This pattern of results, which supports a combination of deficits and 'hidden talents,' is striking in relation to the broader developmental literature, which has nearly exclusively reported deficits in people from harsh conditions. A video abstract of this article can be viewed at: https://youtu.be/e4ePmSzZsuc.

Association of a national insurer's reference-based pricing program and choice of imaging facility, spending, and utilization

OBJECTIVE

To examine the association of a national insurer's reference-based pricing (RBP), program for outpatient advanced imaging-a benefit design to encourage patients to choose lower-price facilities.

DATA SOURCE/STUDY SETTING

Administrative and medical claims data for three self-insured employers that introduced RBP and a comparison group without RBP.

STUDY DESIGN

Difference-in-difference comparison of pre-RBP (2014) and post-RBP (2015-6) care between intervention and comparison groups.

DATA COLLECTION/EXTRACTION METHOD

We identified 137 680 imaging procedures (4602 intervention group; 133 078 comparison group) in 2014-2016.

PRINCIPAL FINDINGS

In the first post-RBP year (2015), there was no change in choice of facility; by the second year, RBP-exposed enrollees were 21.9 pp (95% CI: 18.5, 25.3) more likely to choose a lower-priced facility and net prices were $101.05 (95% CI: -$130.65, -$71.46), a difference of 8.1 percent lower. RBP was associated with higher patient out-of-pocket spending in the first post-RBP year ($31.82; 95% CI: $10.91, $52.73). There was no change in utilization, and higher-priced providers did not lower prices in the postperiod. Net savings represented 0.3 percent of outpatient spending.

CONCLUSIONS

Reference-based pricing for advanced imaging was associated with a shift to lower-priced facilities, but net impact on outpatient spending was modest. Patients paid increased out-of-pocket costs, though the amount declined after the first year of the program.

Equity First: Conceptualizing a Normative Framework to Assess the Role of Preemption in Public Health

Policy Points Preemption is a legal doctrine whereby a higher level of government may limit or even eliminate the power of a lower level of government to regulate a certain issue. Some state legislatures are using preemption with increasing regularity to thwart local policies that have the potential to reduce health inequities. Despite recent trends, preemption is not inherently adversarial to public health, equity, or good governance but rather reflects its wielder's goals and values. Existing frameworks for assessing preemption fail to reconcile its potential to both advance and hinder health equity. An equity-first preemption framework can facilitate case-by-case assessments of whether preemption is likely to worsen inequities or whether it is an appropriate response to address existing inequities. Robust empirical evidence is needed to develop and operationalize such a framework.

CONTEXT

Due to the inequitable distribution of various social determinants of health, disparities in health and well-being are tied to where an individual lives. In the United States, a zip code often better predicts a person's health than their genetic code. As communities seek to redress these inequities, many find that, due to state preemption, their zip code also dictates their ability to pursue more equitable laws through local government action. Preemption is a legal doctrine whereby a higher level of government may limit or even eliminate the power of a lower level of government to regulate a certain issue.

METHODS

We conducted a literature review to survey existing scholarship about the effects of preemption on public health and health equity using online databases such as PubMed, WestLaw, and Google Scholar. We also cohosted a series of cross-sector, interdisciplinary research convenings with preemption, public health, and equity experts. Based on our findings, this article reviews the role of law and policy in the genesis of health inequities and highlights how preemption has both created and alleviated such inequities. We demonstrate how a normative framework rooted in redressing health inequities can advance a more just approach to preemption and outline a research agenda to support future action.

FINDINGS

Law and policy have been central to creating health inequities, and while those same tools can promote health equity, some state legislatures are using preemption with increasing regularity to thwart local policies that may improve health and equity. Nevertheless, preemption is not inherently adversarial to public health, equity, or good governance. Preemptive federal civil rights laws, for example, have countered government-sanctioned discrimination. However, existing frameworks for assessing preemption fail to reconcile its potential to both advance and hinder health equity.

CONCLUSIONS

Shortcomings in existing preemption frameworks demonstrate the need for new approaches to elevate equity as a central consideration in assessing preemption. We propose the development of an equity-first preemption framework to establish evidence-based criteria for assessing when preemption will enhance or inhibit equity and a research agenda for developing the evidence necessary to inform and operationalize the framework. An equity-first reconceptualization of preemption can help ensure that local governments remain places of innovation while allowing states and the federal government to block local actions that are likely to create or perpetuate inequities.

Isolated Voices: Perspectives of Teachers, School Nurses, and Administrators Regarding Implementation of Sexual Health Education Policy

BACKGROUND

Comprehensive sexual health education (SHE) reduces risky sexual behavior and increases protective behavior in adolescents. It is important to understand how professionals responsible for implementing SHE policy interpret state and local policy and what influences their commitment to formal SHE policy implementation.

METHODS

This descriptive study explored content and delivery of SHE policy in a rural, southwestern state with high levels of poverty, unintended adolescent pregnancy, and sexually transmitted infections. The social ecological model (SEM) was used to better understand levels of influence on the implementation of SHE policy.

RESULTS

We conducted telephone surveys with 38 teachers, 63 nurses, and 21 administrators in public secondary schools. There was substantial local variability in the scope and content of SHE curricula. Respondents identified significant barriers to the delivery of SHE content and minimal evaluation of whether educational objectives were met. Based on participant responses, community and organizational SEM levels had the greatest influence on SHE policy implementation, although examples of all SEM levels were identified.

CONCLUSIONS

Given perceived challenges regarding subject matter, successful SHE implementation at the local level requires committed stakeholders working in concert at the school and community levels, backed by strong policy commitment at the state level.

Issues Relevant to Population Health in Political Advertising in the United States, 2011-2012 and 2015-2016

Policy Points Political advertising can influence which issues are public policy priorities. Population health-relevant issues were frequently referenced in televised political advertising in the 2011-2012 and 2015-2016 US election cycles, with about one-fourth of all ads aired mentioning traditional public health and health policy topics and more than half referencing broader determinants of population health. The volume of population health-relevant issues referenced in political ads varied by geography, political office, political party, and election cycle. Ads referencing broader determinants of population health (such as employment, education, or gender equality) rarely tied these determinants directly to health outcomes.

CONTEXT

Political discourse is one way that policymakers and candidates for public office discuss societal problems, propose solutions, and articulate actionable policies that might improve population health. Yet we know little about how politicians define and discuss issues relevant to population health in their major source of electoral communication, campaign advertisements. This study examined the prevalence of references to population health-relevant issues conveyed in campaign advertising for political office at all levels of government in the United States in 2011-2012 and 2015-2016. Understanding advertising as part of the political discourse on topics of relevance to population health yields insights about political agenda-setting and can inform efforts to shape opinion.

METHODS

We conducted a content analysis of all English-language, candidate-related campaign advertisements aired on local broadcast, national network, and national cable television in the 2011-2012 and 2015-2016 election cycles (3,980,457 and 3,767,477 airings, respectively). We analyzed the volume of coverage in these ads about issues relevant to population health, including narrowly defined public health issues as well as a broad range of other social, economic, and environmental factors that affect population health.

FINDINGS

Across both election cycles and all electoral races, 26% of campaign advertising discussed issues relevant for the narrowly defined conceptualization of public health and 57% discussed issues pertinent to topics within the more expansive population health conceptualization. There was substantial variation in population health-related content in ads across election cycles, by level of political office, political party, and geographic area. Geographic variation indicates that where a person lives affects their potential exposure to political communication about various health-related topics.

CONCLUSIONS

Political campaign ads in the United States frequently referenced population health-relevant content at all levels of government, although the ads rarely connected population health-relevant issues to health. Variation in volume and content of these references likely shaped public opinion and the public will to address population health-related policy.

Mutations in spliceosome genes and therapeutic opportunities in myeloid malignancies

Since the discovery of RNA splicing more than 40 years ago, our comprehension of the molecular events orchestrating constitutive and alternative splicing has greatly improved. Dysregulation of pre-mRNA splicing has been observed in many human diseases including neurodegenerative diseases and cancer. The recent identification of frequent somatic mutations in core components of the spliceosome in myeloid malignancies and functional analysis using model systems has advanced our knowledge of how splicing alterations contribute to disease pathogenesis. In this review, we summarize our current understanding on the mechanisms of how mutant splicing factors impact splicing and the resulting functional and pathophysiological consequences. We also review recent advances to develop novel therapeutic approaches targeting splicing catalysis and splicing regulatory proteins, and discuss emerging technologies using oligonucleotide-based therapies to modulate pathogenically spliced isoforms.