Addressing Mental Health and Stress in Medicaid-Insured Pregnant Women Using a Nurse-Community Health Worker Home Visiting Team

Neighborhood Racialized Economic Polarization, Home Visiting Coverage, and Adverse Birth Outcomes in a Medicaid-eligible Population

BACKGROUND

Residential polarization shaped by racial segregation and concentrations of wealth (hereafter neighborhood racialized economic polarization) results in both highly deprived and highly privileged neighborhoods. Numerous studies have found a negative relationship between neighborhood racialized economic polarization and birth outcomes. We investigated whether community-informed home visiting programs achieve high rates of service coverage in highly deprived neighborhoods and can attenuate the deleterious effect of neighborhood polarization on birth outcomes.

METHODS

We used 2016-2019 data from Michigan's statewide database that links birth records, Medicaid claims, and program participation (N = 211,412). We evaluated whether 1) home visiting programs achieved high rates of service coverage in highly deprived neighborhoods, 2) participation in home visiting may help to mitigate the negative relationship between neighborhood polarization and birth outcomes, and 3) the reductions in preterm birth and low birthweight were larger among Black birthing individuals. Data were examined using multilevel generalized linear models and mediation analysis.

RESULTS

The statewide home visiting program achieved higher rates of coverage in the most deprived neighborhoods (21.0% statewide, 28.3% in the most deprived vs. 10.4% in the most privileged neighborhoods). For all, home visiting participation was associated with a decrease in the relationship between neighborhood polarization and preterm birth by 6.8% (mean indirect effect, -0.008; 95% confidence interval, -0.011 to -0.005), and by 5.2% (mean indirect effect, -0.013; 95% confidence interval, -0.017 to -0.009) for low birthweight, adjusting for individual-level risk factors. The decrease was larger among Black individuals.

CONCLUSIONS

A statewide Medicaid-sponsored home visiting program achieved high rates of service coverage in highly deprived neighborhoods. Program participation may help to mitigate the negative relationship between neighborhood polarization and birth outcomes, and more so among Black individuals. Continued support for home visiting services is required to better engage birthing individuals in neighborhoods with concentrated deprivation and to decrease disparities.

A systematic review of screening for perinatal depression and anxiety in community-based settings

Screening for perinatal depression and anxiety in community-based maternal and child health settings may help close the detection and treatment gap among women at higher risk for these conditions. We aim to review perinatal depression and anxiety screening tools, timing, and follow-up processes for positive screens in community-based settings. We conducted a systematic review of the literature to identify papers describing screening and interventions for perinatal depression and anxiety in community-based settings. We identified 49 papers describing 47 studies of perinatal depression or anxiety screening in community-based settings. The Edinburgh Postnatal Depression Scale (EPDS) was the most frequently used screening tool. Referral and referral tracking for those who screened positive for symptoms were inadequately described. Types of training and technical assistance provided for screening varied widely. It is feasible and acceptable to screen for perinatal depression in community settings, but there is a need for systematic research examining which screening tools to use, the ideal frequency of screening, and referral completion rates. There is a lack of information regarding perinatal anxiety screening and a lack of uniformity in training regarding screening in community-based settings. Future studies should compare the efficacy of screening in community-based settings to screening in healthcare settings.

Organizational Readiness for Community Health Worker Workforce Integration Among Medicaid Contracted Health Plans and Provider Networks: An Arizona Case Study

Understanding and building organizational capacity for system change and the integration of the Community Health Worker (CHW) workforce within the health scare sector requires a supportive organizational culture among sector leaders and providers. The aim of this mixed-methods study was to assess organizational readiness for CHW workforce integration into Arizona Medicaid health systems and care teams. This collaborative effort was in direct response to emergent state and national CHW workforce policy opportunities, and the shifting health care landscape in Arizona – which merged behavior and physical health. Specifically, and in collaboration with a broad-based, statewide CHW workforce coalition, led by the CHW professional association, we assessed 245 licensed health care professionals with experience working with CHWs and 16 Medicaid-contracted health plan leadership. Our goal was to generate a baseline understanding of the knowledge, attitudes and beliefs these stakeholders held about the integration of CHWs into systems and teams. Our findings demonstrate a high level of organizational readiness and action toward integration of CHWs within the Arizona health care system and care teams. CHWs have emerged as a health care workforce able to enhance the patient experience of care, improve population health, reduce cost of care, and improve the experience of providing care among clinicians and staff.

Increasing culturally responsive care and mental health equity with indigenous community mental health workers

There are 600 diverse American Indian/Alaska Native communities that represent strong and resilient nations throughout Indian Country. However, a history of genocidal practices, cultural assaults, and continuing oppression contribute to high rates of mental health and substance use disorders. Underresourced mental health care and numerous barriers to services maintain these disparities. Indigenous community mental health workers hold local understandings of history, culture, and traditional views of health and wellness and may reduce barriers to care while promoting tribal health and economic self-determination and sovereignty. The combination of Native community mental health workers alongside a growing workforce of Indigenous mental health professionals may create an ideal system in which tribal communities are empowered to restore balance and overall wellness, aligning with Native worldviews and healing traditions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Medicaid member perspectives on innovation in prenatal care delivery: A call to action from pregnant people using unscheduled care

BACKGROUND

Low-income women using prenatal care have shared concerns as well as unique needs not met by traditional prenatal care. Our objective was to explore user ideas on addressing unmet needs driving unscheduled care utilization and use findings to inform interventions to improve perinatal outcomes.

METHODS

We performed a secondary analysis of qualitative interviews among purposively sampled, Medicaid-insured pregnant women with varied degrees of unscheduled care utilization. Interviews explored barriers and facilitators of health and ideas for improvement in care delivery, with a focus on the potential role of community health workers and social support. We extracted material on participants' perceived gaps and ideas, used modified grounded theory to develop general and subset themes by study group, and then mapped themes to potential intervention features.

RESULTS

We identified intervention targets in three thematic domains: social support, care delivery, and access, noting sub-group differences. Participants with four or more unscheduled visits during pregnancy ("Group 1") wanted individualized help navigating resources, coaching, and peer support, while participants with a first unscheduled care visit after 36 weeks of pregnancy ("Group 2) wanted these services to be optional. Group 1 participants wanted flexible appointments, less wait time, discharge education and improved communication with providers, while Group 2 participants sought stable insurance coverage.

CONCLUSIONS

Findings suggest acceptable approaches to improve social support, care delivery, and access via stratified, targeted interventions.

IMPLICATIONS

Targeted interventions to improve prenatal care that incorporate user ideas and address unique unmet needs of specific subgroups may improve perinatal outcomes.

LEVEL OF EVIDENCE

III.

Two decades of interventions in New York State to reduce maternal mortality: a systematic review

Objective: To perform a systematic review of interventions to reduce maternal mortality in New York.Study design: We conducted a systematic review of literature published between 2000 and January 2019 reporting interventions to reduce maternal mortality in New York using PubMed and search terms: pregnancy-related death or maternal mortality OR maternal death AND New York. Eight hundred and ninety-three articles were reviewed by title, content, and focus on New York interventions or policies. Ten met inclusion criteria. A second review of the Safe Motherhood Initiative (SMI) identified an additional six articles.Results: Nine articles described hospital-based initiatives; one described a community-based initiative. No prospective randomized controlled trials in a nonsimulated setting were identified. Several articles described SMI bundles; one tested simulated checklist implementation. Three presented results of bundle implementation but did not significantly impact measured maternal mortality and/or morbidity. The single community-based initiative provided doulas to low-income women, yielding significantly lower rates of preterm birth and low birthweight, but no difference in cesarean deliveries compared to other women in the community.Conclusion: Current hospital-based interventions have not reduced maternal mortality in New York. The single community-based intervention identified reduced adverse birth outcomes. Continued concern about maternal mortality in New York suggests community-based approaches should be considered to affect change in conjunction with longer term hospital-based interventions.

Psychometric Properties of the Multidimensional Scale of Perceived Social Support in Greek Nurses

BACKGROUND

Psychosocial well-being in the workplace may increase retention of oncology nurses, while a lack of social support has been a predictor of occupational stress in nurses.

PURPOSE

To further explore this phenomenon by examining the psychometric properties of the Multidimensional Scale of Perceived Social Support in Greek nurses working in oncology and mental health settings.

METHODS

A cross-sectional design was used. The sample consisted of 150 nurses (70 oncology nurses and 80 mental health nurses) from the area of greater Athens who joined the study. The scale was translated to Greek using the "forward-backward" procedure. The Multidimensional Scale of Perceived Social Support's internal consistency reliability (Cronbach's α), stability (intraclass correlation coefficient), factor structure (factor analysis), and convergent validity (correlation with Ways of Coping Questionnaire) were examined.

RESULTS

A three-factor (significant others, family, and friends) model was confirmed. The subscales representing the three factors demonstrated excellent internal consistency reliability (Cronbach's αs > .90) and stability intraclass correlation coefficient (>.90).

CONCLUSIONS

The measure is reliable and valid, and it can be used to assess nurses' social support; the results of such an assessment could be helpful when selecting strategies for assisting nurses.

Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations: A Systematic Review

This systematic review evaluates efforts to date to involve community health workers (CHWs) in delivering evidence-based mental health interventions to underserved communities in the United States and in low- and middle-income countries. Forty-three articles (39 trials) were reviewed to characterize the background characteristics of CHW, their role in intervention delivery, the types of interventions they delivered, and the implementation supports they received. The majority of trials found that CHW-delivered interventions led to symptom reduction. Training CHWs to support the delivery of evidence-based practices may help to address mental health disparities. Areas for future research as well as clinical and policy implications are discussed.

Lay Health Worker Involvement in Evidence-Based Treatment Delivery: A Conceptual Model to Address Disparities in Care

Mobilizing lay health workers (LHWs) to deliver evidence-based treatments (EBTs) is a workforce strategy to address mental health disparities in underserved communities. LHWs can be leveraged to support access to EBTs in a variety of ways, from conducting outreach for EBTs delivered by professional providers to serving as the primary treatment providers. This critical review provides an overview of how LHW-supported or -delivered EBTs have been leveraged in low-, middle-, and high-income countries (HICs). We propose a conceptual model for LHWs to address drivers of service disparities, which relate to the overall supply of the EBTs provided and the demand for these treatments. The review provides illustrative case examples that demonstrate how LHWs have been leveraged globally and domestically to increase access to mental health services. It also discusses challenges and recommendations regarding implementing LHW-supported or -delivered EBTs.

Achieving IHI's Triple Aim by Utilizing Core Health Program With Community Health Workers in Rural Communities

Utilizing a nurse/community health worker team model, a Midwest institution's community health care division developed a 12-month managed care program for underserved individuals diagnosed with heart failure and/or diabetes. A study of 277 patients was conducted to determine whether this model could be utilized in rural settings. The program was evaluated using the Institute for Healthcare Improvement's Triple Aim criteria; HEDIS measures and other health indicators quantified each patient's performance. Study participants showed improved outcomes and a reduction in the total cost of care. Hospital admissions decreased (203.4 inpatient days were saved), and the return-on-investment value realized was 1.37 for emergency department and inpatient visits in the rural communities.

PTSD and Depression Among Museum Workers After the March 18 Bardo Museum Terrorist Attack

On March 18, 2015, two gunmen attacked the Bardo museum in Tunis, Tunisia, killing 23 foreign tourists. We assessed PTSD and depression symptoms 4-6 weeks after the event among museum workers, in relation to sociodemographic factors and social support, and we analysed the determinants and predictor factors of PTSD and depression symptoms among the participants. Our findings indicated that 68.6% of the respondents had posttraumatic stress symptoms above the cutoff point (IER-S scores >33), and 40.6% reported severe levels of depressive symptoms (DASS-depression scores >20). Male and female participants did not significantly differ in terms of their symptom severities. Low social support was the best predictor of PTSD and depression symptoms. Our results suggest that interventions designed to reinforce ties within social networks may be particularly helpful for victims in the aftermath of a terrorist attack.

Perspectives of Low Socioeconomic Status Mothers of Premature Infants

BACKGROUND AND OBJECTIVES

Transitioning premature infants from the NICU to home is a high-risk period with potential for compromised care. Parental stress is high, and families of low socioeconomic status may face additional challenges. Home visiting programs have been used to help this transition, with mixed success. We sought to understand the experiences of at-risk families during this transition to inform interventions.

METHODS

Mothers of infants born at <35 weeks' gestation, meeting low socioeconomic status criteria, were interviewed by telephone 30 days after discharge to assess caregiver experiences of discharge and perceptions of home visitors (HVs). We generated salient themes by using grounded theory and the constant comparative method. Interviews were conducted until thematic saturation was achieved.

RESULTS

Twenty-seven mothers completed interviews. Eighty-five percent were black, and 81% had Medicaid insurance. Concern about infants' health and fragility was the primary theme identified, with mothers reporting substantial stress going from a highly monitored NICU to an unmonitored home. Issues with trust and informational consistency were mentioned frequently and could threaten mothers' willingness to engage with providers. Strong family networks and determination compensated for limited economic resources, although many felt isolated. Mothers appreciated HVs' ability to address infant health but preferred nurses over lay health workers.

CONCLUSIONS

Low-income mothers experience significant anxiety about the transition from the NICU to home. Families value HVs who are trustworthy and have relevant medical knowledge about prematurity. Interventions to improve transition would benefit by incorporating parental input and facilitating trust and consistency in communication.

Task-Sharing Approaches to Improve Mental Health Care in Rural and Other Low-Resource Settings: A Systematic Review

PURPOSE

Rural areas persistently face a shortage of mental health specialists. Task shifting, or task sharing, is an approach in global mental health that may help address unmet mental health needs in rural and other low-resource areas. This review focuses on task-shifting approaches and highlights future directions for research in this area.

METHODS

Systematic review on task sharing of mental health care in rural areas of high-income countries included: (1) PubMed, (2) gray literature for innovations not yet published in peer-reviewed journals, and (3) outreach to experts for additional articles. We included English language articles published before August 31, 2013, on interventions sharing mental health care tasks across a team in rural settings. We excluded literature: (1) from low- and middle-income countries, (2) involving direct transfer of care to another provider, and (3) describing clinical guidelines and shared decision-making tools.

FINDINGS

The review identified approaches to task sharing focused mainly on community health workers and primary care providers. Technology was identified as a way to leverage mental health specialists to support care across settings both within primary care and out in the community. The review also highlighted how provider education, supervision, and partnerships with local communities can support task sharing. Challenges, such as confidentiality, are often not addressed in the literature.

CONCLUSIONS

Approaches to task sharing may improve reach and effectiveness of mental health care in rural and other low-resource settings, though important questions remain. We recommend promising research directions to address these questions.

Translating an Evidence-Based Injury Prevention Program for Implementation in a Home Visitation Setting

Safe N' Sound (SNS), a computer-based childhood injury prevention program, provides individually tailored information to parents about their child's injury risks with specific behavioral recommendations. We translated SNS for implementation in a home visitation organization in order to increase its capacity to effectively address injury prevention and decrease the burden of injury experienced by high-need families. The aim of this study was to identify behavioral and organizational barriers and facilitators to translating and implementing SNS in a home visitation setting. Nurse home visitors (NHVs) participated in semistructured interviews that examined perceptions of program implementation, intervention characteristics, individual characteristics of NHVs, and recommendations for improving implementation. The utility of the program for promoting injury prevention systematically and its alignment with the organization's mission were facilitators of successful implementation. Barriers included NHVs' concerns about overburdening clients and missed educational opportunities related to injury risks not addressed by the program and delayed delivery of educational reports. Findings illustrate the dynamic interactions of intervention characteristics with organizational and individual factors and suggest that customizing implementation to organizational capacity and specific needs may better support successful program implementation in home visitation settings.

Translation and Cultural Adaptation of the Multidimensional Scale of Perceived Social Support for Greece

Recently, there is a surge of interest in the use of the Multidimensional Scale of Perceived Social Support (MSPSS) to measure perceived social support across cultures. The objective of this study was to translate and make the cultural adaptation of the Greek version of the MSPSS. The study counted with a sample of 10 patients diagnosed with multiple sclerosis. The process involved the following steps of translation back translation and semantic evaluation. The former revealed good acceptance of the translated version of the instrument, which participants considered having items of easy understanding. After completing the process of validation in the country, the instrument will become available to Greek researchers to measure social support, as well as to compare results from Greece to that of other cultures in which the instrument has already been validated.

Community health workers and the Patient Protection and Affordable Care Act: an opportunity for a research, advocacy, and policy agenda

Community health workers (CHWs), who have been shown to be effective in multiple roles in the provision of culturally appropriate health care in a variety of settings, have the potential to be important members of an interdisciplinary health care team. Recent efforts have started to explore how best to integrate CHWs into the health system. However, to date, there has been limited policy guidance, support, or evidence on how best to achieve this on a larger scale. The Patient Protection and Affordable Care Act (ACA), through several provisions, provides a unique opportunity to create a unified framework for workforce integration and wider utilization of CHWs. This review identifies four major opportunities to further the research, advocacy, and policy agenda for CHWs.

The Respecting the Circle of Life trial for American Indian adolescents: rationale, design, methods, and baseline characteristics

This paper describes the rationale, design, methods, and baseline results of a randomized controlled trial to evaluate the impact of an adapted evidence-based intervention (EBI), "Respecting the Circle of Life" (RCL) to reduce behavioral risks for HIV/AIDS among American Indian (AI) adolescents. A participatory approach shaped intervention adaptation and study design. A total of 267 participants (aged 13-19) were randomized by peer groups of the same sex to receive the RCL intervention or a control condition. Self-report assessments were administered at four intervals. The sample was predominately female (57%), had low HIV knowledge prevention scores, early sexual initiation (mean 14.6 years), and 56% reported intention to use a condom at next sex. Baseline characteristics were evenly distributed between groups with the exception of age and extrinsic reward scores. This is the first rigorous evaluation of an adapted EBI for HIV/AIDS prevention among AI adolescents, an at-risk and understudied population.

Enhancing the care navigation model: potential roles for health sciences librarians

This study analyzed the overlap between roles and activities that health care navigators perform and competencies identified by the Medical Library Association’s (MLA’s) educational policy statement.Roles and activities that health care navigators perform were gleaned from published literature. Once common roles and activities that health care navigators perform were identified, MLA competencies were mapped against those roles and activities to identify areas of overlap. The greatest extent of correspondence occurred in patient empowerment and support. Further research is warranted to determine the extent to which health sciences librarians might assume responsibility for roles and activities that health care navigators perform

Stress: pregnancy considerations

Stress-induced pregnancy complications represent a significant cause of maternal and perinatal morbidity and mortality due to preterm labor, low-birth-weight babies, pregnancy-induced hypertension, and neuropsychological developmental delays of affected offspring. Psychosocial factors such as socioeconomic status, work status, marital status, level of education, access to prenatal care, substance abuse, ethnicity, cultural background, and quality of relationships with partners and parents have been identified as determinants of stress during pregnancy. The biopsychosocial model of health and disease aptly explains the interactions of these psychosocial factors in the genesis of stress-induced pregnancy complications. Prenatal screening and intervention for relevant biopsychosocial risk factors may be useful in preventing stress-related perinatal complications.

TARGET AUDIENCE

Obstetricians and gynecologists, family physicians.

LEARNING OBJECTIVES

After completing this CME activity, physicians should be better able to describe how stress is manifested biologically, discuss stress and its impact from the biopsychosocial model of health and disease, recognize how stress may lead to pregnancy complications such as preterm labor, preeclampsia, and low-birth-weight infants, explain how stress may impact the neuropsychological development of children whose mothers experienced perinatal stress, and demonstrate how prenatal screening and appropriate interventions may reduce perinatal stress and associated pregnancy complications.

Infant health effects of a nurse-community health worker home visitation programme: a randomized controlled trial

BACKGROUND

  Home visiting is supported as a way to improve child health and development. Home visiting has been usually provided by nurses or community health workers (CHWs). Few studies compared the child health advantages of a nurse-CHW team approach over nurse prenatal and postnatal home visiting.

METHODS

  A randomized trial was conducted with Medicaid-insured pregnant women in Kent County, Michigan. Pregnant women were assigned to a team intervention including nurse-CHW home visitation, or standard community care (CC) including nurse home visitation. Morbidity was assessed in 530 infants over their first 12 months of life from medical claims and reported by the mother.

RESULTS

  There were no differences in overall child health between the nurse-CHW intervention and the CC arm over the first year of life. There were fewer mother-reported asthma/wheezing/croup diagnostics in the team intervention group among infants whose mothers have low psychosocial resources (13% vs. 27%, P = 0.01; adjusted OR = 0.4, P = 0.01). There were no differences in diagnosed asthma/wheezing/croup documented by medical claims. There were no differences in immunizations, hospitalizations and ear infections.

CONCLUSIONS

  There was no strong evidence that infant health was improved by the addition of CHWs to a programme of CC that included nurse home visitation. Targeting such interventions at common health problems of infancy and childhood or at diagnosed chronic conditions may prove more successful.

Maternal perceptions of help from home visits by nurse-community health worker teams

We used data from a home visiting trial to examine low-income women's perceptions of services received from nurses (the community care [CC] group) and from a nurse-community health worker (CHW) team. More mothers in the nurse-CHW group than in the CC group reported receiving help in all of the categories assessed. For both groups, assistance with health education ranked highest among the types of assistance received. A higher percentage of women in the nurse-CHW group than the CC group reported that they received psychosocial help.

Home visits during pregnancy and after birth for women with an alcohol or drug problem

BACKGROUND

One potential method of improving outcome for pregnant or postpartum women with a drug or alcohol problem is with home visits.

OBJECTIVES

To determine the effects of home visits during pregnancy and/or after birth for women with a drug or alcohol problem.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), CENTRAL (The Cochrane Library 2011, Issue 4 of 4), MEDLINE (1966 to 30 November 2011), EMBASE (1980 to 30 November 2011), CINAHL (1982 to 30 November 2011) and PsycINFO (1974 to 30 November 2011) supplemented by searches of citations from previous reviews and trials and contact with experts.

SELECTION CRITERIA

Studies using random or quasi-random allocation of pregnant or postpartum women with a drug or alcohol problem to home visits. Trials enrolling high-risk women of whom more than 50% were reported to use drugs or alcohol were also eligible.

DATA COLLECTION AND ANALYSIS

Review authors performed assessments of trials independently. We performed statistical analyses using fixed-effect and random-effects models where appropriate.

MAIN RESULTS

Seven studies (reporting 803 mother-infant pairs) compared home visits mostly after birth with no home visits. Visitors included community health nurses, paediatric nurses, trained counsellors, paraprofessional advocates, midwives and lay African-American women. Several studies had significant methodological limitations. There was no significant difference in continued illicit drug use (three studies, 384 women; risk ratio (RR) 1.05, 95% confidence interval (CI) 0.89 to 1.24), continued alcohol use (three studies, 379 women; RR 1.18, 95% CI 0.96 to 1.46), failure to enrol in a drug treatment program (two studies, 211 women; RR 0.45, 95% CI 0.10 to 1.94), not breastfeeding at six months (two studies, 260 infants; RR 0.95, 95% CI 0.83 to 1.10), incomplete six-month infant vaccination schedule (two studies, 260 infants; RR 1.09, 95% CI 0.91 to 1.32), the Bayley Mental Development Index (three studies, 199 infants; mean difference 2.89, 95% CI -1.17 to 6.95) or Psychomotor Index (MD 3.14, 95% CI -0.03 to 6.32), child behavioural problems (RR 0.46, 95% CI 0.21 to 1.01), infants not in care of biological mother (two studies, 254 infants; RR 0.83, 95% CI 0.50 to 1.39), non-accidental injury and non-voluntary foster care (two studies, 254 infants; RR 0.16, 95% CI 0.02 to 1.23) or infant death (three studies, 288 infants; RR 0.70, 95% CI 0.12 to 4.16). Individual studies reported a significant reduction in involvement with child protective services (RR 0.38, 95% CI 0.20 to 0.74) and failure to use postpartum contraception (RR 0.41, 95% CI 0.20 to 0.82).

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend the routine use of home visits for pregnant or postpartum women with a drug or alcohol problem. Further large, high-quality trials are needed.

Study protocol: a randomized controlled trial of patient navigation-activation to reduce cancer health disparities

Background

Cancer health disparities affecting low-income and minority patients are well documented. Root-causes are multifactorial, including diagnostic and treatment delays, social and financial barriers, and poor communication. Patient navigation and communication coaching (activation) are potential interventions to address disparities in cancer treatment. The purpose of this clinical trial is to test the effectiveness of an intervention combining patient navigation and activation to improve cancer treatment.

Methods/Design

The Rochester Patient Navigation Research Program (PNRP) is a National Cancer Institute-sponsored, patient-level randomized trial (RCT) of patient navigation and activation, targeting newly-diagnosed breast and colorectal cancer patients in Rochester, NY. The goal of the program is to decrease cancer health disparities by addressing barriers to receipt of cancer care and promoting patient self-efficacy. The intervention uses trained, paraprofessional patient navigators recruited from the target community, and a detailed training and supervisory program. Recruited patients are randomly assigned to receive either usual care (except for baseline and follow-up questionnaires and interviews) or intervention. The intervention patients receive tailored assistance from their patient navigators, including phone calls, in-person meetings, and behind-the-scenes coordination of care. A total of 344 patients have been recruited. Outcomes measured at three month intervals include timeliness of care, patient adherence, patient satisfaction, quality of life, self-efficacy, health literacy, and cancer knowledge.

Discussion

This unique intervention combining patient navigation and patient activation is designed to address the multifactorial problem of cancer health disparities. If successful, this study will affect the design and implementation of patient navigation programs.

Trials Registration

clinicaltrials.gov identifier NCT00496678

Alleviating perinatal depressive symptoms and stress: a nurse-community health worker randomized trial

To determine whether a Nurse-Community Health Worker (CHW) home visiting team, in the context of a Medicaid enhanced prenatal/postnatal services (EPS), would demonstrate greater reduction of depressive symptoms and stress and improvement of psychosocial resources (mastery, self-esteem, social support) when compared with usual Community Care (CC) that includes Medicaid EPS delivered by professionals. Greatest program benefits were expected for women who reported low psychosocial resources, high stress, or both at the time of enrollment. Medicaid eligible pregnant women (N = 613) were randomly assigned to either usual CC or the Nurse-CHW team. Mixed effects regression was used to analyze up to five prenatal and postnatal psychosocial assessments. Compared to usual CC, assignment to the Nurse-CHW team resulted in significantly fewer depressive symptoms, and as hypothesized, reductions in depressive symptoms were most pronounced for women with low psychosocial resources, high stress, or both high stress and low resources. Outcomes for mastery and stress approached statistical significance, with the women in the Nurse-CHW group reporting less stress and greater mastery. Women in the Nurse-CHW group with low psychosocial resources reported significantly less perceived stress than women in usual CC. No differences between the groups were found for self-esteem and social support. A Nurse-CHW team approach to EPS demonstrated advantage for alleviating depressive symptoms in Medicaid eligible women compared to CC, especially for women at higher risk.

Fixed effects, random effects and GEE: what are the differences?

For analyses of longitudinal repeated-measures data, statistical methods include the random effects model, fixed effects model and the method of generalized estimating equations. We examine the assumptions that underlie these approaches to assessing covariate effects on the mean of a continuous, dichotomous or count outcome. Access to statistical software to implement these models has led to widespread application in numerous disciplines. However, careful consideration should be paid to their critical assumptions to ascertain which model might be appropriate in a given setting. To illustrate similarities and differences that might exist in empirical results, we use a study that assessed depressive symptoms in low-income pregnant women using a structured instrument with up to five assessments that spanned the pre-natal and post-natal periods. Understanding the conceptual differences between the methods is important in their proper application even though empirically they might not differ substantively. The choice of model in specific applications would depend on the relevant questions being addressed, which in turn informs the type of design and data collection that would be relevant.

A systematic review of home-based interventions to prevent and treat postpartum depression

This systematic review evaluated randomized controlled trials assessing home-based psychological interventions to prevent and treat postpartum depression (PPD). Six studies meeting inclusion criteria were identified, five assessing treatments for PPD and one assessing a preventive intervention for PPD. Interventions used cognitive behavioral, psychodynamic, and non-directive counseling approaches. Of the six studies reviewed, four reported statistically significant treatment effects on PPD following the intervention. Each of the three types of psychological interventions were shown to reduce levels of maternal depression. Recommendations for future development and evaluation of home-based psychological interventions for PPD are discussed. These include identification of mediators and moderators of intervention efficacy, exploring strategies for prevention of PPD, and targeting high-risk groups.