Social ecological approaches to individuals and their contexts: twenty years of health education & behavior health promotion interventions

Determinants of physical activity habit formation: a theory-based qualitative study among young adults

PURPOSE

Engagement in physical activity significantly contributes to reducing the onset and severity of chronic diseases. Nonetheless, establishing habits around this behaviour remains a persistent challenge. This research endeavours to discern the determinants influencing the formation of physical activity habit among young adults in Israel, drawing upon a socio-ecological model.

METHODS

A qualitative approach with phenomenological-hermeneutical method was used. In-depth interviews were carried to cover four levels of the socio-ecological model.

RESULTS

Interviewees were categorized into three subgroups according to their physical activity habit strength: Habitually physically active (n = 8), Variably physically active (n = 11), and physically inactive (n = 6). The content analysis yielded four overarching themes associated with physical activity habit formation. Intrapersonal determinants encompassed personal traits, perceptions and attitudes, perceived benefits, and emotional responses related to physical activity. Interpersonal determinants encompassed social support, modelling support, and peer pressure. Community determinants pertained to social norms, resource availability, and accessibility. Finally, public policy considerations encompassed educational policies as well as workplace policies and cultural influences.

CONCLUSIONS

This study highlights the unique determinants contributing to the formation of physical activity habit. As intrapersonal and interpersonal factors are significant determinants, interventions should focus on these elements in order to promote this behaviour among young adults.

Risk and Protective Factors of Commercial Sexual Exploitation of Children and Adolescents in sub-Saharan Africa: A Systematic Review

Commercial sexual exploitation of children (CSEC) has emerged as a critical child protection and public health concern in recent years. While the phenomenon is prevalent globally, its impact is compounded in sub-Saharan Africa owing to the cultural and socioeconomic challenges that leave many households in the region vulnerable. The present study synthesized existing evidence using the socioecological model as a guiding framework to assess the risk and protective factors associated with CSEC in sub-Saharan Africa. A protocol for the study was published in PROSPERO (CRD42022331832) with pre-specified inclusion and exclusion criteria. Studies were screened and extracted from eight databases: PsycINFO, Scopus, Web of Science, PROQUEST (Social Science Premium), PubMed, CINAHL, EMBASE, and MEDLINE via Ovid. After an initial screening of 4,377 papers, seven studies were found eligible for the final review. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guide for reporting systematic reviews. Included studies were appraised and rated using the Cambridge Quality Checklist and GRADE. Findings revealed risk factors, including adverse childhood experience and victimization, females aged 16 years and older, school dropouts, technology influence, child and parental alcohol use, and separation from caregivers. On the other hand, protective factors such as the number of female adolescents in a household, frequent health screening in schools, children being in school, and high parental monitoring were found to be associated with a lower risk of CSEC. Based on these findings, we recommend that interventions in sub-Saharan Africa adopt a holistic approach that addresses identified risk factors while harnessing protective factors to combat CSEC effectively.

Ecological Momentary Intervention to Replace Sedentary Time With Physical Activity to Improve Executive Function in Midlife and Older Latino Adults: Pilot Randomized Controlled Trial

BACKGROUND

Exercise interventions often improve moderate to vigorous physical activity, but simultaneously increase sedentary time due to a compensatory resting response. A higher level of sedentary time is associated with a lower level of executive function, while increased moderate to vigorous physical activity is associated with improved global cognition and working memory among Latino adults. Latino adults are the fastest-growing minority group in the United States and are at high risk for cognitive decline, spend more time sedentary compared to non-Hispanic populations, and engage in low levels of physical activity. Interventions that are culturally appropriate for Latino adults to replace sedentary time with physical activity are critically needed.

OBJECTIVE

This study aims to develop and test the feasibility and acceptability of an ecological momentary intervention (EMI; delivered in real time) that is individually designed to replace sedentary time with physical activity in Latino adults.

METHODS

This pilot study randomized 39 (n=26, 67% female; mean age 61, SD 5.8 years) community-dwelling, Spanish-speaking Latino adults (1:1 allocation) to either a 6-week EMI program designed to replace sitting time with physical activity (20/39, 51%) or physical activity guidelines education (19/39, 49%). The program was conducted on the web and in Spanish. The intervention was individualized based on individual interview responses. The intervention included the use of a Fitbit activity monitor, weekly didactic phone meetings, interactive tools (SMS text messages), and coach-delivered feedback. Feasibility and acceptability were assessed via study satisfaction (Likert scales), motivation (ecological momentary assessment), retention, and compliance. Sedentary time and physical activity were assessed via 7-day actigraphy. Cognitive performance was assessed via the trail making test part A and B (part B=executive function) and via the National Institutes of Health Toolbox remote cognitive assessment. Statistical analysis included a linear model on change score from baseline, adjusting for age, sex, and education, emphasizing effect size.

RESULTS

Participant satisfaction with EMI was high (9.4/10), with a high degree of motivation to replace sitting time with physical activity (9.8/10). The intervention compliance rate was 79% with low difficulty using the Fitbit (1.7/10). Weekly step count increased in the intervention group by 5543 steps (group difference: d=0.54; P=.05) and sedentary time decreased by a mean 348 (SD 485) minutes (group difference: d=0.47; P=.24) compared to controls, with moderately strong effect sizes. The trail making test part B improved in the intervention group (mean -35.26, SD 60.35 seconds), compared to the control group (mean 7.19, SD 46 seconds; group difference: d=0.74; P=.01). No group differences were observed in other cognitive measures.

CONCLUSIONS

An individualized EMI designed for midlife and older Latino adults has the potential to replace sitting time with physical activity and improve executive functioning. The intervention was feasible and well received with a high degree of satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04507464; https://tinyurl.com/44c4thk5.

Disparities in Delirium across the Continuum of Care and Associations with Social Determinants of Health

Disparities exist in the identification, treatment, and management of delirium. These disparities can be most holistically and comprehensively understood by using a social-ecological model-which acknowledges multilevel impacts including individual, interpersonal, organizational, community, and policy-level factors-as well as a social determinant of health framework, that considers nonmedical factors that influence health outcomes. This narrative review leverages both frameworks to identify and discuss existing literature pertaining to the intersection of these social risk factors and delirium, focusing specifically on disparities due to racial and/or ethnic identity, language ability, and socioeconomic differences. We also look at disparities and the potential role of these social risk factors throughout the continuum of care, including prehospitalization, hospitalization, and posthospitalization factors. Understanding and analyzing the role of these inequities is critical to ensuring better health outcomes for patients at risk of and/or with delirium.

Adherence to treatment in pulmonary tuberculosis: Rodgers' evolutionary concept analysis

Background

Adherence to treatment is essential for the management of pulmonary tuberculosis. Nurses and healthcare professionals play a significant role in promoting adherence behavior among this population. Nevertheless, defining adherence to treatment within this particular population remains complex.

Objective

This study aimed to explore and clarify the concept of adherence to treatment among individuals with pulmonary tuberculosis.

Methods

Rodgers' evolutionary concept analysis was employed in this study. A literature search was conducted in the PubMed and Scopus databases to identify relevant studies published between July 2013 and July 2023.

Results

The attributes of adherence to treatment in pulmonary tuberculosis consist of multiple components: biological, individual, social, health service, and policy-making processes. Antecedents include various patient-related factors as well as factors associated with clinical conditions and patient-health professional engagement. Three consequences of the concept have emerged: enhanced treatment efficacy, increased commitment to tuberculosis treatment adherence, and improved health service quality.

Conclusion

This study provides a comprehensive operational definition of adherence to tuberculosis treatment, including its attributes, antecedents, and consequences. This framework will assist nurses in evaluating adherence more effectively. However, further research into the experiences of individuals adhering to tuberculosis treatment is needed to confirm and enhance these strategies.

Exploring Experiences and Asthma Management Among Middle Eastern Arabic-Speaking Migrants and Refugees with Asthma: A Qualitative Study

Purpose

Effective asthma management relies on individuals' knowledge, inhaler technique, and perceptions of asthma and medications. Investigating barriers and enablers to optimal asthma management is vital. This research pursues a comprehensive understanding of asthma control, asthma-related experiences, perceptions, inhaler technique, and knowledge among Arabic-speaking Middle Eastern migrants and refugees living in Australia. Furthermore, it aims to explore the factors influencing optimal asthma management within this demographic.

Patients and Methods

This study involved interviews with 17 participants, with nine identified as migrants and eight as refugees. All participants were Arabic-speaking Middle Eastern individuals residing in Australia and diagnosed with asthma. Interviews were thematically analysed, and findings were presented following the guidelines of the consolidated criteria for reporting qualitative research (COREQ).

Results

The thematic analysis yielded five key themes: (1) asthma experiences; (2) participant perspectives on asthma; (3) asthma management; (4) asthma health literacy; and (5) strategies to overcome obstacles in asthma management. Some disparities were noted between refugees and migrants in terms of their comprehension and views on asthma, medications use, interactions with healthcare providers, and inhaler technique. Refugees experienced more psychological distress and lacked social support, while migrants were more concerned about long-term medication use and preferred specialised care.

Conclusion

This research addresses a knowledge gap concerning asthma control among Middle Eastern immigrants. It provides insights into their beliefs and medication adherence. It underscores the importance of considering the unique characteristics of Middle Eastern migrants and refugees when delivering healthcare interventions to enhance overall health and medication adherence within these populations. To address these differences, the study recommends tailored education, specialised clinics, and culturally relevant asthma management plans to enhance self-management support for both groups. Future studies should explore the impact of modifying beliefs, attitudes, and knowledge regarding medications and asthma to enhance asthma management within this population.

Social ecological system framework as a decision-making tool for risk mitigation: A superfund site case study

Several studies have reported vapor intrusion (VI) occurring when volatile organic compound (VOC) vapors are transported through subsurface piping systems into building spaces (e.g. conduit VI). Site-specific risk assessment and risk management practices are complicated and evolving for conduit VI, especially at large hazardous waste sites, like Superfund sites, where many stakeholders are involved and have varied interests. Here, we propose a social ecological system (SES) framework as a decision-making tool to inform risk mitigation decisions. We demonstrate the SES framework using field data associated with a Superfund site near San Francisco, California. We evaluate sewer invert elevation and groundwater elevation data, as well as pre- and post- mitigation VOC concentration data within a sewer system. Unexpectedly, the sewer located above the groundwater table was determined to be a potential source of conduit VI risks. The SES framework describes how typical stakeholders associated with the site can affect and be affected by mitigation activities. It informs decisions about mitigation implementation and long-term operation efficacy by considering stakeholder roles and interests. Ultimately, gas siphons were selected as the mitigation technology for the example site. To date, approximately 6 gas siphons have been installed to mitigate conduit VI risks throughout the community. Collectively, our findings advance risk management decisions and highlight key considerations for risk mitigation approaches at hazardous waste sites, including Superfund sites, especially where VI risks are a concern.

Physical activity in adult users of inpatient mental health services: A scoping review

People with severe mental illness engage in considerably less physical activity than those without. They also experience premature mortality of around 10-25 years. A large proportion of these premature deaths are attributed to modifiable behaviours, including physical activity. The inpatient environment provides an opportunity to support people to become more physically active; however, there is limited evidence on which interventions are most successful and what contextual factors affect their delivery. A scoping review was conducted to help understand the extent and type of evidence in this area and identify research gaps. We included studies of physical activity correlates and interventions in adult inpatient mental health services published in peer-reviewed journals. Reviews, meta-analyses, and papers focusing on eating disorder populations were excluded. We searched the MEDLINE, CINAHL, PsycINFO, ASSIA and Web of Science databases for relevant studies published in English. We extracted data on study design, participant characteristics, intervention and control conditions, key findings, and research recommendations. We used a descriptive analytical approach and results are presented in tables and figures. Of 27,286 unique records screened, 210 reports from 182 studies were included. Sixty-one studies reported on correlates of physical activity, and 139 studies reported on physical activity interventions. Most intervention studies used a single-group, pre-post design (40%) and included fewer than 100 participants (86%). Ninety percent of interventions delivered physical activity directly to participants, and 50% included group-based sessions. The duration, type, frequency and intensity of sessions varied. Mental health was the most commonly reported outcome (64%), whereas physical activity was rarely an outcome (13%). Overall, there is a modest but growing body of research on physical activity in adult users of inpatient mental health services. More high-quality trials are needed to advance the field, and future research should target neglected intervention types, outcomes, populations and settings.

An implementation evaluation of a sports-based health intervention for underrepresented middle school youth in Philadelphia

Multicomponent, community-based programs aiming to improve health behaviors in youth are needed but can be challenging to implement. Research is needed to better understand the factors that facilitate and inhibit effective implementation of these programs especially for youth at increased risk of health disparities. This study aimed to identify and explore the implementation determinants and outcomes of a multicomponent health intervention conducted from 2021 to 2022 for middle school students living in underserved communities in Philadelphia, PA, USA. Mixed methods approaches, including self-report surveys and semi-structured qualitative interviews, were administered to 18 members of the implementation staff at the end of the program, including coaches (n = 7), assistant coaches (n = 2), school champions (n = 6), administrative leaders (n = 2), and a school district administrator (n = 1). Survey and interview questions were guided by the Consolidated Framework for Implementation Research (CFIR), and interviews were thematically coded following transcription based on 26 CFIR constructs. Innovation source, evidence strength and quality, cosmopolitanism, and the personal attributes of individuals were key constructs associated with implementation effectiveness. Data revealed three multidimensional themes that highlighted broader challenges influencing implementation: (i) broad consensus, different interpretations, (ii) staffing challenges, and (iii) continuity is key. The need for the program was clearly recognized and overall belief in the purpose of the intervention was strong among key program staff and administration. However, issues including limited engagement with training, staffing turnover, and the rotational programming design hindered implementation. Future projects aiming to implement multicomponent after-school time interventions must ensure a consistent vision among partners and continuity in program delivery.

Change in clusters of lifestyle behaviours from childhood to adolescence: a longitudinal analysis

This study aimed to identify changes in clusters of lifestyle behaviours (physical activity, screen time and diet) between the ages of 7 and 14 years, and to examine socio-demographic determinants of changes. Longitudinal analyses were performed on a sample of 9339 children from the UK Millennium Cohort Study (MCS) who had complete data on behaviours of interest at age 7 (wave 4) and 14 years (wave 6). Joint Correspondence Analysis (JCA) and k-means cluster analysis were used to identify clusters of lifestyle behaviours at both time waves. Multinomial logistic regressions were used to examine the associations between socio-economic variables and changes in cluster membership. Analyses were conducted separately for boys and girls. Clusters of behaviours at age 7 and 14 years were identified as healthy, mixed or unhealthy respectively. Compared to girls, a higher proportion of boys remained in the healthier cluster over time (19.1% vs. 13.1%) or became healthier (26.4% vs. 9.36%). A higher proportion of girls changed to an unhealthier cluster (57.2% vs. 33.9%). Indicators of lower socio-economic status, such as low family income, low parental education, and not living with both parents at age 7 were associated with unhealthier changes in cluster membership. Conclusion Lifestyle behaviours cluster in children and are susceptible to change over a 7-year period, with a high proportion of boys becoming healthier and a higher proportion of girls became unhealthier. Indicators of socio-economic status appear to be important in determining changes in clusters. What is Known: • Poor lifestyle behaviours (i.e. unhealthy dietary habits, low physical activity, and sedentary behaviours) tend to cluster in children and adolescents. What is New: • Lifestyle behaviours cluster in children and are susceptible to changes between childhood and adolescence. Changes occur differently in boys and girls. Indicators of low socio-economic status are associated with unhealthier changes in behavioural clusters.

A scoping review of policies to encourage breastfeeding, healthy eating, and physical activity among rural people and places in the United States

BACKGROUND

Rural U.S. residents experience a disproportionate burden of diet and physical activity (PA) related chronic disease compared to urban residents, due to resource and economic challenges. Diverse policy approaches for chronic disease prevention have been implemented to address barriers to breastfeeding, healthy eating, and PA. Therefore, the purpose of this paper is to describe policy supports for breastfeeding, healthy eating, and/or PA occurring in rural U.S. areas.

METHODS

A scoping review was conducted March-June 2020 to identify policy, systems, and environment change approaches occurring in the rural U.S. for breastfeeding, healthy eating, and PA. Search procedures were guided by the PRISMA-ScR, Arksey and O'Malley's work (2007), and a science librarian. Medline, PubMed, Web of Science, and Agricola were used to identify peer-reviewed research. ProQuest Dissertations and Theses A&I were used to identify dissertation research. Grey literature searches included Google, Google Scholar, government pages, and public health, federal nutrition assistance program, Cooperative Extension Services, and related webpages. Policy results are reported and inclusion criteria were: (1) breastfeeding, healthy eating, and/or PA focus; (2) about policy factors; (3) specific to U.S. rural populations/places; and (4) English language. Outcomes (study/source design, objective(s), methods/measurement, setting, population characteristics, behavioral focus, policy-specific results) were extracted into a standardized Excel document.

RESULTS

Results include 122 total sources: original research, with some sources referencing multiple behaviors, (n = 74 sources: 8 breastfeeding, 41 healthy eating, 42 PA), grey literature (n = 45 sources: 16 breastfeeding, 15 healthy eating, 27 PA), and graduate research (n = 3 sources: 1 breastfeeding, 2 healthy eating, 1 PA). Breastfeeding policy initiatives included policies or programs at hospitals, increasing access to resources, and improving culture or norms at workplaces. Healthy eating policy initiatives included increasing access to healthy foods, reducing financial burden, implementing programs, food assistance programs, and healthy food prescriptions at healthcare facilities. PA policy initiatives focused on Complete Streets, joint or shared use efforts, Safe Routes to Schools, master plans for greenways, trails, and/or transportation, school health plans, and childcare/school standards.

CONCLUSIONS

Results from this scoping review compile and offer commentary on existing policy solutions to improve breastfeeding, healthy eating, and/or PA in the rural U.S.

Physicians' perspectives on COVID-19 vaccinations for children: a qualitative exploration in Ontario, Canada

OBJECTIVES

Parents' decisions to vaccinate their children against COVID-19 are complex and often informed by discussions with primary care physicians. However, little is known about physicians' perspectives on COVID-19 vaccinations for children or their experiences counselling parents in their decision-making. We explored physicians' experiences providing COVID-19 vaccination recommendations to parents and their reflections on the contextual factors that shaped these experiences.

DESIGN

We conducted an interpretive qualitative study using in-depth interviews. We analyzed the data using reflexive thematic analysis and a socioecological framework.

SETTING

This study involved primary care practices associated with The Applied Research Group for Kids (TARGet Kids!) primary care research network in the Greater Toronto Area, Ontario, Canada.

PARTICIPANTS

Participants were 10 primary care physicians, including family physicians, paediatricians and paediatric subspecialists.

RESULTS

Participants discussed elements at the individual level (their identity, role, and knowledge), the interpersonal level (their relationships with families, responsiveness to parents' concerns, and efforts to build trust) and structural level (contextual factors related to the evolving COVID-19 climate, health system pandemic response, and constraints on care delivery) that influenced their experiences providing recommendations to parents. Our findings illustrated that physicians' interactions with families were shaped by a confluence of their own perspectives, their responses to parents' perspectives, and the evolving landscape of the broader pandemic.

CONCLUSIONS

Our study underscores the social and relational nature of vaccination decision-making and highlights the multiple influences on primary care physicians' experiences providing COVID-19 vaccination recommendations to parents. Our findings offer suggestions for future COVID-19 vaccination programmes for children. Delivery of new COVID-19 vaccinations for children may be well suited within primary care offices, where trusting relationships are established, but physicians need support in staying knowledgeable about emerging information, communicating available evidence to parents to inform their decision-making and dedicating time for vaccination counselling.

Transtheoretical model to predict the stages of changes in smoking cessation behavior among adolescents

Introduction

Previous studies on adolescent smoking cessation behavior based on the transtheoretical model have primarily focused on the development of cessation programs. Attempting to quit smoking is a prerequisite for executing smoking cessation. Appropriate methods must be selected based on the characteristics and intentions of individuals to increase smokers' satisfaction and success rates in quitting. Therefore, this study aimed to identify changing processes influencing the stages of change associated with successful smoking cessation among adolescents and examined the related factors. This descriptive study explored a transtheoretical model of different stages of changes in smoking cessation behavior among adolescent smokers.

Methods

The participants included 237 middle and high school students in South Korea. We examined the differences in stages of changes in smoking cessation behaviors based on general characteristics, smoking-related characteristics, smoking cessation change processes (cognitive and behavioral), smoking decisional balance (pros and cons of smoking), and self-efficacy.

Results

The probability of reaching the preparation stage of smoking cessation was significantly lower among participants who did not know their father's educational level than among those who knew their father's educational level. Conversely, this probability was significantly higher among participants whose mothers had a college or higher education level and those who did not know their mother's educational level than in those whose mothers had a high school or lower education level.

Conclusion

These findings indicated that parental education is a significant predictor of the preparation stage of smoking cessation, highlighting the importance of the family environment in facilitating smoking cessation among adolescents. Accordingly, communication and support at home could help reinforce adolescents' determination to quit smoking and make relevant plans. Thus, smoking cessation support should stress the need to enhance communication at home.

Understanding the impact of community-based sun safety interventions on a college campus in Texas

Objective: Examine the impact of a community-based, multi-component sun intervention on the campus of Lee College in Baytown, Texas. Participants: 735 respondents completed the survey as part of a range of campus topics. Methods: Survey data on the program were gathered through an emailed campus-wide survey to better understand the community's perceptions and awareness as well as campaign effectiveness over time. Results: Sun safety self-efficacy and awareness of the importance of sun safety behaviors were high in the community. Students reported a lower level of sun safety self-efficacy than employees. Open-ended responses also offered insight into complex views some community members hold about sun-safety behavior, raising questions about the effectiveness of sunscreen and the need for vitamin D. Conclusions: The paper found high awareness of sun-safe behaviors, high self-efficacy in taking personal action, and appreciation for the institutional effort to care for the community.

A multi-component intervention to reduce bias during family planning visits: qualitative insights on implementation from Burkina Faso, Pakistan and Tanzania

Beyond Bias was an intervention introduced in Burkina Faso, Pakistan and Tanzania, with the aim of reducing health worker bias toward young, unmarried and nulliparous women seeking family planning services. This study used qualitative methods - based on interviews with health workers who participated in the intervention, managers at health facilities that participated in the intervention, and policy and program stakeholders at the national level - to understand implementation experiences with the intervention. The results offer insights for organizations or countries seeking to implement Beyond Bias or similar programs, and point to some other key implementation challenges for multi-component interventions in lower-resource settings. The intervention, developed using a human-centered design approach, was seen as key for successful implementation but there were logistical challenges. The digital intervention was disruptive and distracting to many. In addition, the non-financial rewards intervention was perceived as complex, and some participants expressed feeling discouraged when they did not receive a reward. Beyond Bias did not sufficiently attend to the "outer setting," and this was perceived as a major implementation barrier as it limited individuals' capacity to fully achieve the desired behavior change; for example, space constraints meant that some health facilities could not ensure private services for all clients. There were scalability concerns related to cost, and there is uncertainty whether diversity of contexts (within and across countries) might constrain implementation of Beyond Bias at scale.

Building the African American/Black Community's Capacity to Elucidate Factors for High Smoking Rates in Jackson, MS: Results from Implementing a Community-Led Needs Assessment

INTRODUCTION

Although smoking has decreased dramatically over the last 50 years, reductions are uneven by race and income, specifically in the Southern United States. There is a need for intentional collaboration with communities located where large tobacco disparities exist to make lasting change. Using community-based participatory research principles, we provided intensive capacity building to a community advisory group (CAG) of 14 Jackson, MS, residents to conduct a community-led needs assessment. The aim of the community-led needs assessment was to investigate firsthand why the community smokes and the impacts of smoking-giving the CAG voice and choice to work towards reducing tobacco-related harms and inequities.

METHODS

From October 2020 to September 2021, CAG members conducted thirteen interviews and nine focus groups, reaching 54 residents. We analyzed the data using a thematic and in vivo approach.

RESULTS

Participants reported smoking is used to cope with systemic socio-economic issues (e.g., racism, poverty). Smoking is normalized in the community through continued use, ease of purchase, visibility of tobacco retailers, and lack of conversations or questioning surrounding smoking. Participants felt that peer and family use, addiction, and inaccessible smoking resources were the most influential factors driving smoking behaviors.

CONCLUSION

This community engagement approach empowered residents to design and implement a comprehensive needs assessment resulting in rich data-a needed approach for a community experiencing enduring health inequities. Communities need to be engaged and invested in from the beginning as equal partners to learn, investigate, and develop community-relevant and innovative solutions to address tobacco social norms.

Perspectives on Referral Pathways for Timely Head and Neck Cancer Care

Importance

Timely diagnosis and treatment are of paramount importance for patients with head and neck cancer (HNC) because delays are associated with reduced survival rates and increased recurrence risk. Prompt referral to HNC specialists is crucial for the timeliness of care, yet the factors that affect the referral and triage pathway remain relatively unexplored. Therefore, to identify barriers and facilitators of timely care, it is important to understand the complex journey that patients undertake from the onset of HNC symptoms to referral for diagnosis and treatment.

Objective

To investigate the referral and triage process for patients with HNC and identify barriers to and facilitators of care from the perspectives of patients and health care workers.

Design, Participants, and Setting

This was a qualitative study using semistructured interviews of patients with HNC and health care workers who care for them. Participants were recruited from June 2022 to July 2023 from HNC clinics at 2 tertiary care academic medical centers in Boston, Massachusetts. Data were analyzed from July 2022 to December 2023.

Main Outcomes and Measures

Themes identified from the perspectives of both patients and health care workers on factors that hinder or facilitate the HNC referral and triage process.

Results

In total, 72 participants were interviewed including 42 patients with HNC (median [range] age, 60.5 [19.0-81.0] years; 27 [64%] females) and 30 health care workers (median [range] age, 38.5 [20.0-68.0] years; 23 [77%] females). Using thematic analysis, 4 major themes were identified: the HNC referral and triage pathway is fragmented; primary and dental care are critical for timely referrals; efficient interclinician coordination expedites care; and consistent patient-practitioner engagement alleviates patient fear.

Conclusions and Relevance

These findings describe the complex HNC referral and triage pathway, emphasizing the critical role of initial symptom recognition, primary and dental care, patient information flow, and interclinician and patient-practitioner communication, all of which facilitate prompt HNC referrals.

Knowledge, attitudes, and intentions regarding COVID-19 vaccination in the general population and the effect of different framing messages for a brief video on intentions to get vaccinated among unvaccinated individuals in the United States during July 2021

OBJECTIVE

To identify knowledge, attitudes, and beliefs (KABs) associated with COVID-19 vaccination intentions and assess the impact of vaccine-promoting messages on vaccination intentions.

METHODS

Our nationally representative survey measured KABs of COVID-19 vaccination and incorporated a randomized experiment to assess the impact of different framing messages for a video encouraging vaccination intentions among unvaccinated adults in the US. Multivariable multinomial logistic regression models were fitted to investigate the relationships of KABs, trust in public health authorities (PHAs), and vaccine confidence with vaccination intentions. Difference-in-difference estimation was conducted to assess the impact of framing messages for a video on unvaccinated individuals' vaccination intentions.

RESULTS

We observed that people with increasingly favorable vaccine KABs, trust in PHAs, and vaccine confidence were more likely to be vaccinated or intend to get vaccinated against COVID-19. Difference-in-difference estimates indicated a positive impact of exposure to the video on vaccination intentions while framing messages in some cases appeared to lower vaccination intentions. Associations between the video and vaccination intentions were more pronounced among Black/African American and Hispanic/Latinx populations and Democrats; however, associations did not vary by trust in PHAs or vaccine confidence.

CONCLUSION

Videos that encourage people to get vaccinated may provide an efficient approach to nudge vaccine-hesitant individuals towards getting vaccinated. However, framing messages may negatively impact vaccination intentions and need to be developed carefully.

PRACTICE IMPLICATIONS

This study provides solid experimental evidence for the importance of tailoring message framing to the characteristics and experience of the audience, while cautioning potential negative impacts of framing that does not match its intended audience. Our findings are applicable to health communication strategies on the population level, such as mass media campaigns, and the use of framing for messages to encourage vaccination but may also be informative for healthcare professionals consulting hesitant individuals about COVID-19 vaccinations.

Health Promotion of Early and Sustained Allergenic Food Introduction for the Prevention of Food Allergy

Observational studies and landmark randomized control trials support early and sustained allergenic food introduction in infancy as an effective preventive strategy against food allergy development. Despite a consensus regarding the intended goals of early and sustained allergenic food introduction, there have been myriad policy recommendations among health authorities in how to achieve both individual and population-level health outcomes for food allergy prevention. This clinical management review provides an overview on the data that informs early and sustained allergenic food introduction strategies, suggestions on how to advise allergenic food introduction, principles of prevention programs as they relate to food allergy prevention, and health promotion and systems-level challenges that impede achievement of food allergy prevention goals.

The Social Ecology of Burnout: A framework for research on nurse practitioner burnout

BACKGROUND

The U.S. health system is burdened by rising costs, workforce shortages, and unremitting burnout. Well-being interventions have emerged in response, yet data suggest that the work environment is the problem. Nurse practitioner (NP) burnout is associated with structural and relational factors in the work environment, practice autonomy, and hierarchical leadership.

PURPOSE

We explore the unique social, cultural, and political environment in which NPs work through the lens of social ecology and present the Social Ecology of Burnout (SEB) framework.

METHODS

We review current burnout frameworks in the context of the NP practice environment and discuss the SEB, specifically exploring psychological safety and its influence on burnout.

FINDINGS

Psychological safety, work environment, and policy are presented within the SEB and solutions which empower NPs are considered.

DISCUSSION

Our framework can serve as a guide for future nursing research, practice, and policy.

The Impact of Vacant and Abandoned Property on Health and Well-Being: A Qualitative Inquiry

This qualitative study explored the role of neglected properties and neighborhood environment characteristics on a sample of New Orleans, Louisiana residents' health and well-being, sense of community, sense of safety, and civic engagement. We hypothesized that residents would identify conditions of their neighborhood's physical environment, including neglected properties, as one factor that impacted their health and other aspects of well-being. Seventy-four (N = 74) participants, including women, men, youth, young adults, and community leaders, took part in 11 focus groups (n = 51) and 23 key informant interviews. Thematic content analysis through inductive and deductive coding cycles of interview transcripts revealed five main categories related to urban neighborhood-built and social environments: 1) health and well-being, 2) sense of community, 3) sense of safety, 4) civic engagement, and 5) youth and family violence. Ten themes were developed and included, for example, the role of neighborhoods in delineating access to health-promoting characteristics and resources; the role of neighborhood social networks as crime prevention strategies; resident-led decision-making in neighborhood improvements; the negative impact of neglected properties; and the role of the local government in improving physical infrastructure. These findings affirm that residents were aware of and impacted by the cyclical nature of built environment neglect on health and well-being, community violence, neighborhood cohesion, civic engagement, and youth violence. Participants recommended improving neighborhood conditions to shift resident mindsets about the health of neighborhoods, reduce violence, and improve quality of life.

How researchers can translate health evidence into books for children

The health promotion literature that considers how scientific evidence can be effectively communicated tends to focus on evaluating the effectiveness of communication materials. This has resulted in a knowledge gap regarding effective knowledge translation processes. This study explores the process, reasoning and practices for developing books for children that incorporate evidence-based information to aid understanding of scientific evidence about health and environmental or natural disasters. This study is informed by a systematic review of the literature combined with responses to an email interview with authors of books for children. Nine published studies were included in the systematic review. Twenty-two authors responded to the email survey (25% response rate, following 86 invitations). We report seven key findings to guide the development of health-promoting books for children: (i) understand the needs and expectations of the audience, (ii) articulate the topic and research evidence, (iii) assemble a team with a mix of content knowledge and creative expertise, (iv) format should be chosen to suit the user group and guided by the creative team, (v) early testing with children and their support system is crucial, (vi) develop a dissemination strategy to reach the user group and (vii) engage in reflexivity through evaluation of effectiveness of messaging. The current investigation can guide the process, reasoning and practice of developing books for children that incorporate evidence about health and environmental disasters.

Assigning Responsibility for Depression and Diabetes: Frame Building Factors in Health Coverage

Although frame building is a crucial part of framing in health communication, it is much less understood than media frames or their effects on audiences (i.e. frame setting). To address this research gap, we analyzed the individual, organizational, and external factors of influence contributing to the media's portrayal of responsibility for two major health issues: depression and diabetes. To identify relevant factors, we conducted 23 semi-structured interviews with German journalists who regularly report on these health issues. Our findings indicate that the way in which media coverage portrays responsibilities in depression and diabetes is affected by a variety of factors. These include individual (journalist role perception, journalistic routines, academic background and personal experiences with depression, diabetes-related knowledge, and personal values and beliefs), organizational (editorial lines, space limits, time limitations and payment, and newsroom structures), and external (health news sources, audience interest, newsworthiness, and social norms) factors. Notably, there are differences between depression and diabetes coverage - especially regarding individual factors - confirming that frame building, similar to framing in general, should be examined with regard to specific issues. Nevertheless, some factors that seem important across different topics could be identified.

Effectiveness of community-based diabetes and hypertension prevention and management programmes in Indonesia and Viet Nam: a quasi-experimental study

INTRODUCTION

Non-communicable diseases (NCDs) have surpassed infectious diseases as the leading global cause of death, with the Southeast Asian region experiencing a significant rise in NCD prevalence over the past decades. Despite the escalating burden, screening for NCDs remains at very low levels, resulting in undetected cases, premature mortality and high public healthcare costs. We investigate whether community-based NCD prevention and management programmes are an effective solution.

METHODS

In Indonesia, we compare participants in the community-based NCD screening and management programme Pos Pembinaan Terpadu-Penyakit Tidak Menular with matched non-participants with respect to their uptake of screening activities, health-related behaviour and knowledge and metabolic risk factors. We use statistical matching to redress a possible selection bias (n=1669). In Viet Nam, we compare members of Intergenerational Self-Help Clubs, which were offered similar NCD health services, with members of other community groups, where such services were not offered. We can rely on two waves of data and use a double-difference approach to redress a possible selection bias and to measure the impacts of participation (n=1710). We discuss strengths and weaknesses of the two approaches in Indonesia and Viet Nam.

RESULTS

In Indonesia, participants have significantly higher uptake of screening for hypertension and diabetes (+13% from a control mean of 88% (95% CI 9% to 17%); +93% from a control mean of 48% (95% CI 79% to 108%)). In both countries, participants show a higher knowledge about risk factors, symptoms and complications of NCDs (Indonesia: +0.29 SD (0.13-0.45), Viet Nam: +0.17 SD (0.03-0.30)). Yet, the improved knowledge is only partly reflected in improved health behaviour (Viet Nam: fruit consumption +0.33 SD (0.15-0.51), vegetable consumption +0.27 SD (0.04-0.50)), body mass index (BMI) (Viet Nam: BMI -0.07 SD (-0.13 to -0.00)) or metabolic risk factors (Indonesia: systolic blood pressure: -0.13 SD (-0.26 to -0.00)).

CONCLUSION

Community-based NCD programmes are well suited to increase screening and to transmit health knowledge. Due to their extensive outreach within the community, they can serve as a valuable complement to the screening services provided at the primary healthcare level. Yet, limited coverage, insufficient resources and a high staff turnover remain a problem.

TRIAL REGISTRATION NUMBER

NCT05239572.

Mapping the needs of healthcare workers caring for COVID-19 patients using the socio-ecological framework: a rapid scoping review

Undoubtedly, the mental health of healthcare workers (HCWs) was negatively affected because of caring for patients during the COVID-19 pandemic. However, literature is limited on mapping the challenges and needs of HCWs during COVID-19 pandemic. A widely used framework in public health for mapping evidence includes the socio-ecological models, suggesting behavior can be influenced by individual, interpersonal, organizational, and community factors. The aim of this rapid scoping review was to use the socio-ecological model to map and compile lessons learnt from the literature regarding primarily the challenges and needs and secondly available psychological interventions for HCWs caring for COVID-19 patients. PubMed, CINAHL and Scopus databases were searched, with 21 studies finally included examining challenges and needs of HCWs and 18 studies presenting psychological interventions. Organizational-level challenges and needs such as inadequate staff preparation and supplies of protective equipment, flexible work policies and paid rest periods were the most reported. Individual-level challenges and needs included COVID-19-related fears and reduced mental health, whereas interpersonal-related needs included support provision. Community-level challenges included societal stigma. Certain psychological interventions were found to be promising for HCWs, but these were utilized to address only individual-level challenges and needs. Given that well-being entails an interaction of factors, multi-level interventions addressing multiple socio-ecological levels (interpersonal, organizational, community) and that place HCWs in their social context should be administrated to increase and maintain intervention' effects long-term and possibly aid in better coping with future pandemics.

Physical Activity and Motor Skill Development During Early Childhood: Investigating the Role of Parent Support

PURPOSE

This study examined the relationship between parent physical activity (PA) support and children's motor skill development and PA during early childhood and explored the potential moderating effect of child PA and motor skills on these relationships.

METHODS

Participants (N = 589, 250 girls, meanage = 4.93 [0.59] y) were part of a larger, longitudinal cohort study. Motor skills were assessed using the Movement Assessment Battery for Children-Second Edition. Moderate to vigorous PA (MVPA) was measured using ActiGraph accelerometers. Five items were used to measure parent support frequency (1 = none, 3 = 3-4 times, 5 = daily). Moderation analyses were conducted to examine the moderating effect of MVPA and motor skills on the relationship between parent support and motor skills and MVPA, respectively.

RESULTS

Parent support was significantly related to motor skills (B = 14.45, P = .007), and child MVPA significantly moderated this relationship (B = -0.17, P = .021). The relationship between parent support and child MVPA did not reach significance (B = 2.89, P = .051); however, motor skills had a significant moderating effect (B = -0.08, P = .022).

CONCLUSIONS

These novel findings suggest parent PA support is related to child motor skills and PA during early childhood, but this relationship is context dependent. Child-level characteristics should be considered in future parent PA support research.

Quantifying Overlapping Forms of Malnutrition Across Latin America: A Systematic Literature Review and Meta-Analysis of Prevalence Estimates

Estimating the prevalence of double burden of malnutrition (DBM) is challenging in the Latin American and Caribbean (LAC) region where various DBM typologies (e.g., obesity and stunting) are heterogeneous and estimates are scattered across literature This study aimed to assess the prevalence of DBM typologies in the LAC region. We searched PubMed, Embase, Scopus, and Web of Science to identify studies on the prevalence of DBM published between 1 January, 2000, and 23 January, 2023. Outcomes were the prevalence of the identified DBM typologies at the household, individual, or across life course levels. Random-effect meta-analyses of proportions were used to estimate pooled period prevalence for all outcomes. Heterogeneity was explored using meta-regressions. From 754 records identified, 60 (8%) studies were eligible, with a median of 4379 individuals. Studies reported data from 27 LAC countries collected between 1988 and 2017. Most studies used nationally representative surveys (68%) and scored as low risk of bias (70%). We identified 17 DBM typologies for which 360 estimates were analyzed. The prevalence of the identified DBM typologies ranged between 0% and 24%, with the DBM typology of "adult with overweight and child with anemia" having the highest prevalence (24.3%; 95% CI: 18.8%, 30.2%). The most frequently reported DBM typology was "adult with overweight and child with stunting," with a prevalence of 8.5% (95% CI: 7.7, 9.3). All prevalences carried large heterogeneity (I2>90%), modestly explained by subregions and countries. DBM across the life course could not be estimated owing to insufficient estimates. In conclusion, using available data, our study suggests that the burden of DBM in the LAC region ranges between 0% and 24%. In the most frequent DBM typologies, overweight was a common contributor. Substantial progress can be made in curbing the burden of DBM in the LAC region through strategies addressing excess weight within these population groups. This study was registered at PROSPERO as CRD42023406755.

The HI V O pen Call on I nformed C onsent and E thics in Research (VOICE) for Adolescents and Young Adults: A Digital Crowdsourcing Open Call in Low- and Middle-Income Countries

BACKGROUND

Many adolescents and young adults (AYAs; 10-24 years old) are excluded from HIV research because of social, ethical, and legal challenges with informed consent, resulting in limited AYA-focused data. We use a participatory approach to identify strategies for improving AYA consent processes in HIV research in low- and middle-income countries (LMICs).

METHODS

We conducted a digital crowdsourcing open call for ideas to improve AYA consent to HIV research in LMICs. Crowdsourcing involves engaging a group of people in problem-solving, then sharing emergent solutions. Submissions were evaluated by 3 independent judges using predefined criteria, with exceptional strategies receiving prizes. Demographic data were collected, and textual data were qualitatively analyzed for emergent themes in barriers and facilitators for improving AYA consent in HIV research, guided by a socioecological model.

RESULTS

We received 110 strategies total; 65 were eligible for evaluation, 25 of which were identified as finalists. Fifty-eight participants from 10 LMICs submitted the 65 eligible submissions, of which 30 (52%) were 18 to 24 years old. Thematic analysis identified 10 barriers to AYA consent, including HIV stigma, limited education, and legal/regulatory barriers. Strategies for improving AYA consent processes revealed 7 potential facilitators: enhancing AYA engagement in research, involving parents/guardians, improving education/awareness, improving institutional practices/policy, making research participation more AYA-friendly, enhancing engagement of other key communities of interest, and empowering AYA.

CONCLUSIONS

Diverse communities of interest in LMICs developed compelling strategies to enhance informed consent that may improve AYA inclusion in HIV research. These data will be used to develop practical guidance on improving AYA consent processes.

Population-wide active case finding as a strategy to end TB

Tuberculosis (TB) is the leading infectious cause of morbidity and mortality globally. Despite available tools for preventing, finding, and treating TB, many people with TB remain undiagnosed. In high-incidence settings, TB transmission is ubiquitous within the community, affecting both high-risk groups and the general population. In fact, most people who develop TB come from the general population. To disrupt the chain of transmission that sustains the TB epidemic, we need to find and treat everyone with infectious TB as early as possible, including those with minimal symptoms or subclinical TB who are unlikely to present for care. Important elements of an effective active case-finding strategy include effective social mobilisation and community engagement, using sensitive screening tools that can be used at scale, and embracing population-wide screening in high-incidence ('hot spot') areas. We require a better description of feasible delivery models, 'real-life' impact and cost effectiveness to enable wider implementation.

Farm to Preschool Programs and Its Impact on Children's Dietary Health: Evaluation Through Bronfenbrenner's Socio-Ecological Model

Children's development is shaped by the world around them. According to Bronfenbrenner's theory, children are influenced by direct interactions and the broader environment, which includes family, community, and society. This concept aligns with initiatives like farm-to-preschool programs. These programs forge connections between communities and local food sources, introducing gardening and nutritional education. This approach aligns seamlessly with Bronfenbrenner's theory, creating a multi-layered learning experience and fostering children's healthier eating habits. This review delves into how farm-to-preschool efforts enhance young children's diets through the ecological model evaluation framework, encompassing health, education, economics, and the environment.

Community Health workers United to Reduce Colorectal cancer and cardiovascular disease among people at Higher risk (CHURCH): study protocol for a randomized controlled trial

BACKGROUND

Colorectal cancer (CRC) is the second most lethal cancer in the United States (U.S.) with the highest incidence and mortality rates among African Americans (AAs) compared to other racial groups. Despite these disparities, AAs are the least likely to undergo CRC screening, have precancerous colorectal polyps removed, and have CRC detected at stages early enough for curative excision. In addition, compelling evidence links inflammatory dietary patterns to increased CRC and cardiovascular disease risk. Studies show that AA churches can successfully engage in health promotion activities including those related to cancer control. The current study seeks to leverage church-placed Community Health Workers (CHWs) to increase CRC screening and reduce CRC risk.

DESIGN AND METHODS

We aim to (1) increase guideline concordant CRC screening uptake using church-placed CHWs trained in screening with a validated instrument, Brief Intervention using Motivational Interviewing, and Referral to Treatment (SBIRT); and (2) reduce dietary risk factors (inflammatory dietary patterns) linked to CRC. The latter will be addressed by culturally adapting an existing, web-based lifestyle program called Alive!. Using a Hybrid Type 1 Implementation-Effectiveness cluster randomized design, we will randomize 22 AA churches into either the dual intervention arm (CHW-led SBIRT intervention plus Alive!) or a usual care arm comprised of CRC prevention educational pamphlets and a list of CRC screening sites. We will recruit 440 subjects and evaluate the effects of both arms on screening uptake (colonoscopy, fecal DNA) (primary outcome) and dietary inflammation score (secondary outcome) at 6-month follow-up, and Life Simple7 (LS7)-a cardiovascular disease (CVD) risk score-at 6 months and 1 year (secondary outcome). Finally, guided by a racism-conscious adaptation of the Consolidated Framework for Implementation Research (CFIR), we will conduct a mixed-methods process evaluation with key stakeholders to understand multi-level influences on CRC screening and CVD risk behaviors.

DISCUSSION

Church-placed CHWs are trusted influential connectors between communities and health systems. Studies have shown that these CHWs can successfully implement health prevention protocols in churches, including those related to cancer control, making them potentially important community mediators of CRC screening uptake and CRC/CVD risk reduction.

TRIAL REGISTRATION

NCT05174286; clinicaltrials.gov; August 31st, 2023.

A reduced exposure heated tobacco product was introduced then abruptly taken off United States shelves: results from a tobacco harm reduction natural experiment

BACKGROUND

A heated tobacco product (HTP) authorized for purchase in the United States by the Food and Drug Administration as a reduced harm product was removed from the market after about 2 years of sales. Adults who used the HTP were surveyed to determine the impact of the introduction and removal of the HTP on past and current tobacco behaviors.

METHODS

Adults who were using the HTP before its United States market removal (n = 502) completed a cross-sectional online survey to determine their tobacco use behaviors at three timepoints: prior to HTP initiation, just before HTP market removal, and at the time of the survey which was administered approximately 10 months post-removal. Descriptive statistics summarized outcome variables and paired bivariate testing was used to compare percent change between timepoints. Multivariable logistic regression and general linear models estimated associations of tobacco use behaviors and cigarette consumption.

RESULTS

Overall, significantly fewer adults consumed cigarettes while using HTP than before they tried the product (63.0% vs. 89.9%, p value < 0.0001) and the number of cigarettes consumed per week (CPW) decreased (106.3-39.0, p value < 0.0001). After HTP removal, the percent of adults who consumed cigarettes increased non-significantly (63.0-67.5%, p value = 0.0544) while CPW increased significantly (39.0-76.6 CPW, p value < 0.0001). At the time of the survey, over 25% of the sample continued to use the HTP and 7.2% reported use of no tobacco products. Electronic nicotine delivery system use had increased significantly from the prior period (27.4% increase, p value < 0.0001).

CONCLUSION

This study demonstrates reduction or elimination of combustible cigarette smoking while adults were using HTPs and some increased smoking after market removal, albeit at lower levels. If unable to find satisfying alternatives, adults who smoke and transition to reduced harm products may return to smoking or purchase products illicitly if their preferred products are removed from the regulated market.

Factors Impacting Chinese Older Adults' Intention to Prevent COVID-19 in the Post-COVID-19 Pandemic Era: Survey Study

BACKGROUND

Understanding the factors influencing individuals' health decisions is a dynamic research question. Particularly, after China announced the deregulation of the COVID-19 epidemic, health risks escalated rapidly. The convergence of "no longer controlled" viruses and the infodemic has created a distinctive social period during which multiple factors may have influenced people's decision-making. Among these factors, the precautionary intentions of older individuals, as a susceptible health group, deserve special attention.

OBJECTIVE

This study aims to examine the intention of older adults to engage in preventive behaviors and the influencing factors, including social, media, and individual factors, within the context of the postepidemic era. Drawing upon the structural influence model of communication, this study tests the potential mediating roles of 3 different types of media exposure between cognitive and structural social capital and protective behavior intention, as well as the moderating role of negative emotions between social capital and media exposure.

METHODS

In this study, a web survey was used to collect self-reported quantitative data on social capital, media exposure, negative emotions, and the intention to prevent COVID-19 among older adults aged ≥60 years (N=399) in China.

RESULTS

The results indicate that cognitive social capital significantly influenced protective behavior intention (P<.001), with cell phone exposure playing an additional impactful role (P<.001). By contrast, newspaper and radio exposure and television exposure mediated the influence of structural social capital on protective behavior intention (P<.001). Furthermore, negative emotions played a moderating role in the relationship between cognitive social capital and cell phone exposure (P<.001).

CONCLUSIONS

This study suggests that using tailored communication strategies across various media channels can effectively raise health awareness among older adults dealing with major pandemics in China, considering their diverse social capital characteristics and emotional states.

Managing long COVID symptoms and accessing health services in Brazil: A grounded theory analysis

Background

The worldwide community has shown significant interest in researching the management of Long COVID. However, there is scarce evidence about the daily experiences of people living with Long COVID and their insights into the healthcare services provided to them.

Aims

This study aims to understand the experience of Long COVID sufferers with their symptoms and in accessing health services.

Method

We employed Charmaz's grounded theory methodology, informed by constructivism, and applied the COREQ guidelines for qualitative research. Sixty-six Brazilians living with Long COVID participated in the study. The data was collected using semi-structured telephone interviews and analyzed using a constant comparative process.

Findings

The findings refer firstly to the consequences of persistent Long COVID symptoms. Secondly, they describe how the disease trajectory required Long COVID sufferers to reorganize their routines and develop adaptive strategies. Lastly, they reflect a diverse array of both positive and negative interactions inside the healthcare system conveyed by individuals suffering from Long COVID. These elements converge towards the core category of the study: "The limbo of Long COVID sufferers: between the persistence of symptoms and access to health services".

Conclusions

Long COVID is characterized by its varied nature, including a range of physical and emotional repercussions experienced by individuals. There is a need for enhanced comprehension and discourse about Long COVID across several domains, including the general public, policy-making entities, and healthcare professionals. In this sense, the development of specialized services or the reinforcement of existing services to support long COVID sufferers is imperative.

Using an ecological model of health behaviour to identify factors associated with smoking behaviour among Buddhist novices in Thailand: a cross-sectional digital survey

OBJECTIVE

Buddhist novices reside in Buddhist temples, which are legally designated as smoke-free areas. Nevertheless, similar to other men in their age group, they are susceptible to various risk factors that lead to smoking. This digital survey aimed to examine tobacco smoking and its associated factors among Buddhist novices in Thailand.

DESIGN

A cross-sectional digital survey.

SETTING

88 temple-based schools in Thailand.

PARTICIPANTS

A stratified two-stage cluster sampling method was employed to select 5371 novices. Data were collected between June and August 2022 using self-administered electronic questionnaires.

MEASURE

Descriptive statistics and multivariable logistic regression analysis were used to identify the associated factors.

RESULTS

Overall, 32.8% of the respondents reported they had tried smoking, and the average age of initiation was 12.4 years. In the past 30 days, 25.7% had smoked any tobacco product. Multiple factors following the ecological model of health behaviour were found to be statistically associated with smoking by 37.3%. Among these were intrapersonal-level factors, such as age, living in the southern region and attempted smoking. Two were interpersonal-level factors: the smoking behaviour of close relatives, specifically parents, and their respected monks. Two were institutional-level factors: perceiving that temple-based schools are smoke-free areas and exposure to secondhand smoke. Three factors at the community and policy levels were noticed tobacco advertising at the point of sale, social media and tobacco promotion.

CONCLUSION

The findings of this study support the development of comprehensive intervention programmes that address the multiple factors to prevent Buddhist novices from smoking.

Community Health workers United to Reduce Colorectal cancer and cardiovascular disease among people at Higher risk (CHURCH): study protocol for a randomized controlled trial

Background: Colorectal cancer (CRC) is the second most lethal cancer in the United States (U.S.) with the highest incidence and mortality rates among African Americans (AAs) compared to other racial groups. Despite these disparities, AAs are the least likely to undergo CRC screening, have precancerous colorectal polys removed, and have CRC detected at stages early enough for curative excision. In addition, compelling evidence links inflammatory dietary patterns to increased CRC and cardiovascular disease risk. Studies show that AA churches can successfully engage in health promotion activities including those related to cancer control. The current study seeks to leverage church-placed Community Health Workers (CHWs) to increase CRC screening and reduce CRC risk. Design and Methods: We aim to (1) increase guideline concordant CRC screening uptake using church-placed CHWs trained in screening with a validated instrument, Brief Intervention using Motivational Interviewing, and Referral to Treatment (SBIRT); and (2) reduce dietary risk factors (inflammatory dietary patterns) linked to CRC. The latter will be addressed by culturally adapting an existing, web-based lifestyle program called Alive!. Using a Hybrid Type 1 Implementation-Effectiveness cluster randomized design, we will randomize 22 AA churches into either the dual intervention arm (CHW-led SBIRT intervention plus Alive!) or a usual care arm comprised of CRC prevention educational pamphlets and a list of CRC screening sites. We will recruit 440 subjects and evaluate the effects of both arms on screening uptake (colonoscopy, fecal DNA) (primary outcome) and dietary inflammation score (secondary outcome) at 6-months follow up, and Life Simple7 (LS7) - a cardiovascular disease (CVD) risk score - at 6 months and 1-year (secondary outcome). Finally, guided by a racism-conscious adaptation of the Consolidated Framework for Implementation Research (CFIR), we will conduct a mixed- methods process evaluation with key stakeholders to understand multi-level influences on CRC screening and CVD risk behaviors. Discussion: Church-placed CHWs are trusted influential connectors between communities and health systems. Studies have shown that these CHWs can successfully implement health prevention protocols in churches, including those related to cancer control, making them potentially important community mediators of CRC screening uptake and CRC/CVD risk reduction. Trial registration: NCT05174286.

Equity M&M - Adaptation of the Morbidity and Mortality Conference to Analyze and Confront Structural Inequity in Internal Medicine

BACKGROUND

At morbidity and mortality (M&M) conferences, medical teams review cases for medical education and system improvement. Adverse outcomes are often driven by social inequity, but processes to analyze such outcomes are lacking.

AIM

Adapt quality improvement and patient safety (QIPS) tools in the M&M format to systematically analyze adverse patient outcomes rooted in social and structural determinants of health (SSDH).

SETTING

One-hour conferences conducted in health systems in Seattle, WA, and Dallas, TX.

PARTICIPANTS

Equity M&M conferences were held 11 times, each with approximately 45 participants comprised of internal medicine trainees, faculty, and non-medical staff.

PROGRAM DESCRIPTION

Conferences included a case narrative and counternarrative highlighting SSDH, an equity-framed root cause analysis, and potential interventions.

PROGRAM EVALUATION

Conferences were received well across both institutions. Following conferences, most respondents reported increased identification of opportunities for action towards equity (88.5%) and confidence in discussing equity issues with colleagues (92.3%).

DISCUSSION

Equity M&M conferences are a structured tool for deconstructing and confronting structural inequity that leads to adverse patient outcomes. Evaluations demonstrate educational impact on participants. Anecdotal examples suggest institutional impact. Other health systems could adopt this model for similar advocacy and system improvement.

How the interplay of late retirement, health care, economic insecurity, and electronic social contact affects the mental health amongst older workers?

The delayed retirement initiative has become increasingly emphasised to cope with the population ageing. Based on the social-ecological model, this study explores the interplay of late retirement, health care, economic insecurity, and electronic social contact on mental health of older workers. Using data from the Survey of Health, Ageing and Retirement in Europe (wave 8), results show that the late retirement, health care quality, and electronic social contact are all negatively associated with the mental health problems among older workers. Besides, the influence of health care quality and electronic social contact on mental health problems are buffered by the economic insecurity respectively. It is concluded that more targeted policy response is in need to achieve better health outcomes among older workers.

Interventions to address mealtime support needs in dementia: A scoping review

The decrease in cognitive and physical ability among people with dementia can significantly affect eating performance, resulting in mealtime support needs that could lead to inadequate oral intake, weight loss, malnutrition, and reduced functionality in activities of daily living. This scoping review aimed to identify and summarize available research literature on mealtime interventions for people with dementia, and their impact on older people with dementia living in a residential care setting, care staff, and care context/environment. A scoping review of available research published in English, French, Portuguese, or Spanish, was conducted according to the methodology established by The Joanna Briggs Institute. The search was conducted between November 2022 and February 2023 in the following databases: MEDLINE, Web of Science, Scopus, CINAHL Complete, and SciELO. A total of 275 articles were retrieved, of which 33 studies were selected according to inclusion criteria. The interventions were classified into four general categories: environmental, mealtime assistance, staff training, and multicomponent. Most studies demonstrated effectiveness in increasing oral intake and improving behaviors such as agitation and aggression in people with dementia. The impact of interventions on care staff was linked to greater knowledge and attitudes towards mealtime support needs. There is a lack of reporting on the impact of interventions on the care context/environment. Most interventions examined the effects exclusively on residents, focusing on their oral intake and behavioral patterns, particularly agitation among individuals with dementia. However, it is crucial to conduct studies that evaluate the impact on administrators, to comprehend the viewpoints of various hierarchical levels within an organization regarding challenges associated with mealtime. The findings of this scoping review can support the development of new supportive programs, or strategies to improve mealtime experience with positive impact according to the reality and needs of each person or institution.

Multi-level factors associated with utilization of water, sanitation and hygiene services by mothers in Nepal

BACKGROUND

Providing improved water, sanitation, and hygiene (WASH) at a household level remains one of the major public health challenges in Nepal. Household mothers are likely to have limited access to combined WASH services, this is influenced by individual, and community factors. Individual components of an improved water source, sanitary toilet, fixed place for handwashing, and availability of soap and water were merged into one and called combined WASH. This paper aimed to identify the individual and community factors associated with combined WASH facilities and practices among mothers with children under five years in Nepal.

METHODS

A cross-sectional study was conducted using data from the Nepal Demographic and Health Survey (NDHS), 2016. The weighted sample size of this study was 4887 mothers with children under five years. The independent variables within the mothers included age, education, occupation, and caste/ethnicity in addition to education of the husband, wealth index, exposure to the newspaper, radio and television, residence, ecological zones, provinces, distance and participation in health mother groups were analyzed with the outcome variable of combined WASH. A multi-level mixed effects logistic regression model was used to assess the relationship of explanatory variables with WASH.

RESULTS

At an individual level, a rich wealth index was positively associated with combined WASH (AOR = 6.29; 95%CI: 4.63-8.54). Higher education levels and exposure to television had higher odds of having combined WASH. At the community level, the hill zone, urban residence, and Sudurpashim Provinces were positively associated with combined WASH while Madesh and Karnali Provinces and distance to water source greater than 31 minutes were associated with lower access to combined WASH.

CONCLUSION

Educated and rich household have positive association with combined WASH. It is recommended that both the health and other sectors may be instrumental in improving the combined WASH service for mothers at households.

Views and experiences of young women from a migrant or refugee background regarding the contraceptive implant in Australia

Young people comprise a significant proportion of migrants and refugees in Australia. Many encounter challenges in accessing contraception information and services. This study explored the views and experiences of young women from migrant and/or refugee backgrounds regarding the contraceptive implant and related decision-making. Interviews were conducted with 33 women, aged 15-24, living in New South Wales, Australia, who spoke a language other than English and had some experience of the implant. Three themes were developed from the data as follows: 'Finding your own path': contraception decision-making (in which participants described sex and contraception as being taboo in their community, yet still made independent contraceptive choices); Accessing 'trustworthy' contraception information and navigating services (in which participants consulted online resources and social media for contraception information, and preferred discussions with healthcare providers from outside their community); and Views and experiences of the contraceptive implant (while the implant was described as a 'Western' method, most participants regarded it as an acceptable, convenient, cost-effective, and confidential means of contraception). Decision-making regarding the implant is influenced by many factors which must be considered in health promotion efforts and when providing clinical care. Consideration of more informative health promotion resources, peer education strategies, and healthcare provider training is warranted to support contraception decision-making and choice.

The association between neighborhood social and built environment on loneliness among young adults with cancer

PURPOSE

Young adults with cancer (YAs, aged 18-39) are at increased risk of experiencing loneliness due to their unique challenges of coping with a cancer diagnosis and treatment during young adulthood. Understanding factors that impact loneliness is critical to improving survivorship outcomes for this vulnerable YA population. Neighborhoods are key determinants of health. However, little is known about how such neighborhood characteristics are associated with loneliness among YA survivors.

METHODS

YA survivors (N = 181) drawn from the National Institutes of Health All of Us Research Program completed measures of neighborhood social environment (e.g., shared values), aspects of their neighborhood built environment (e.g., access to transit, recreational activities), and loneliness. Two total scores were calculated with higher scores reflecting higher neighborhood social cohesion and higher neighborhood walkability/bikeability (i.e., built environment). Hierarchical linear regression examined associations between the social and built environment on loneliness.

RESULTS

Higher levels of neighborhood social cohesion (β =  - 0.28, 95% confidence interval (CI) =  - 0.44, - 0.11) and neighborhood walkability/bikeability (β =  - 0.15, 95% CI =  - 0.31, - 0.006) were significantly associated with lower levels of loneliness.

CONCLUSIONS

Findings suggest that living within a cohesive social environment with neighborhood walkability/bikeability to built environment amenities such as green space, grocery stores, and public transportation is protective against loneliness among YA survivors. More longitudinal research is necessary to understand the dynamic changes in loneliness among YA survivors living in diverse social and built environments.

IMPLICATIONS FOR CANCER SURVIVORS

YA survivors may benefit from cultivating neighbor relationships and living within neighborhoods with walkability/bikeability.

Community Health Care Providers' Perspectives on Human Immunodeficiency Virus Pre-Exposure Prophylaxis Use Among Black Women in Eastern Virginia

The most at-risk population among women for human immunodeficiency virus (HIV) diagnosis in the United States are Black women, accounting for 61% of all new HIV cases. Pre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention method for people at risk of HIV acquisition. Although disproportionately affected by HIV, Black women's knowledge, perceived benefits, and uptake of PrEP remain low. The socioecological model (SEM) may be useful for understanding why there is a low uptake of PrEP among Black women. The current study used the SEM to explore provider perspectives on the barriers and facilitators of PrEP uptake among Black women in Eastern Virginia. Semistructured interviews were conducted with a total sample of 15 community health care providers. Barriers of PrEP uptake at the societal (e.g., PrEP advertisements focus on gay men), community/organizational (e.g., time constraints in the workplace), interpersonal (e.g., perceived monogamy), and individual (e.g., unmet basic needs) levels were identified. Providers also identified facilitators of PrEP uptake at the societal (e.g., PrEP advertisements that target women), community/organizational (e.g., PrEP education), interpersonal (e.g., HIV-positive partner), and individual (e.g., PrEP awareness and perceived susceptibility to HIV) levels. These findings highlight unique barriers to accessing and taking PrEP for Black women in the United States, and potential factors that could facilitate PrEP use. Both barriers and facilitators may be important targets for interventions to improve PrEP uptake. Future research focused on improving PrEP uptake among Black women in the United States should consider multi-level interventions that target barriers and facilitators to reduce rates of HIV infections.

Health literacy and pandemic coping in Leisure Time Monitors

INTRODUCTION

Health literacy allows us to make appropriate decisions about our self-care and to use health services appropriately, therefore, it conditions people's health.

OBJECTIVES

The aim of this study was to describe the level of health literacy of leisure time monitors and the influence of self-perception of health in times of pandemic.

STUDY DESIGN

We used a cross-sectional observational design with non-probabilistic purposive sampling among leisure time monitors in the Autonomous Community of Galicia (Spain).

METHOD

For this purpose, the HLS-EU-Q47 questionnaire measuring health literacy and a questionnaire measuring perception of COVID-19 were used.

RESULTS

The results verify that the monitors consider that the pandemic affects their daily life, that it will be a situation that will last for a long time, and they are very worried. The low level of health literacy of the leisure time monitors is also confirmed.

CONCLUSIONS

Therefore, it seems urgent to evaluate the existing training programme and to include health education contents in this programme, given the involvement of leisure time monitors in the training of children and adolescents.

A Social-Ecological Model Exploring Gestational Diabetes Mellitus Screening Practices Among Antenatal Health Care Providers

Gestational diabetes mellitus (GDM) is associated with adverse health outcomes for the pregnant individual and their baby. Screening approaches for GDM have undergone several iterations, introducing variability in practice among healthcare providers. As such, our study aimed to explore the views of antenatal providers regarding their practices of, and counseling experiences on the topic of, GDM screening in Ontario. We conducted a qualitative, grounded theory study. The study population included antenatal providers (midwives, family physicians, and obstetricians) practicing in Hamilton, Ottawa, or Sudbury, Ontario. Semi-structured telephone interviews were conducted and transcribed verbatim. Transcripts were analyzed using inductive coding upon which codes, categories, and themes were developed to generate a theory grounded in the data. Twenty-two participants were interviewed. Using the social-ecological theory, we created a model outlining four contextual levels that shaped the experiences of GDM counseling and screening: Intrapersonal factors included beliefs, knowledge, and skills; interpersonal factors characterized the patient-provider interactions; organizational strengths and challenges shaped collaboration and health services infrastructure; and finally, guidelines and policies were identified as systemic barriers to health care access and delivery. A focus on patient-centered care was a guiding principle for all care providers and permeated all four levels of the model. Patient-centered care and close attention to barriers and facilitators across intrapersonal, interpersonal, organizational, and policy domains can minimize the impact of variations in GDM screening guidelines. Among care providers, there is a desire for additional skill development related to GDM counseling, and for national consensus on optimal screening guidelines.

Perspectives of Certified Nurse-Midwives and Physicians on the Structural and Institutional Barriers that Contribute to the Reproductive Inequities of Black Birthing People in the San Francisco Bay Area

INTRODUCTION

Black birthing people in the United States disproportionately endure inequitable experiences and outcomes during pregnancy and childbirth via structural, interpersonal, and obstetric racism. In this study, the researchers explore provider perspectives of how racism is perpetuated in institutional perinatal and reproductive health care.

METHODS

Critical Race Theory, Reproductive Justice, and midwifery theory were operationalized through secondary thematic analysis of existing qualitative data from the Community Racial Equity and Training Interventions and Evaluation of Current and Future Healthcare Clinicians Study. Twenty-four perinatal providers (certified nurse-midwives [n = 7] and physicians [n = 17]) voluntarily participated in interviews. A comparative approach was used to determine how professional identity and model of care influence physicians' and certified nurse-midwives' perceptions of equity.

RESULTS

Thematic analysis produced 5 themes: racism as a comorbidity, health care systems' inability to address the needs of Black birthing people, health care systems prioritizing providers over patients are failed systems, patients are the experts in the optimal health care model, and benefits of interprofessional teams grounded in Reproductive Justice. Additionally, both physicians and midwives expressed a need for a new care model.

DISCUSSION

With these findings, our team proposes a modification of the midwifery model for application by all provider types that could radically shift the experience and outcomes of perinatal and reproductive health care and reduce mortality. Using a human rights approach to care, a Reproductive Justice-Public Health Critical Race praxis-informed midwifery model may be operationalized by all perinatal and reproductive health care providers. This novel model reflects an iterative process that may offer institutions and providers methods to build on past research supporting midwifery-centered care for improving outcomes for all patients by specifically focusing on improving care of Black birthing people. The implications of this work offer broad application in current clinical practice, quality improvement, research, technology, and patient resources.

Surgical informed consent practices and influencing factors in sub-Saharan Africa: a scoping review of the literature

INTRODUCTION

Current international standards in consent to surgery practices are usually derived from health systems in Western countries, while little attention has been given to other contexts such as sub-Saharan Africa (SSA), despite this region facing the highest burdens of disease amenable to surgery globally. The aim of this study was to examine how the concept of informed consent for surgery is interpreted and applied in the context of SSA, and factors affecting current practices.

METHODS

A systematic search of Medline, Embase and African Journal OnLine databases as well as grey sources was executed in May 2023 to retrieve relevant literature published since 2010 in English language against a set of given criteria. The socioecological framework for health was used for organising and summarising the identified evidence.

RESULTS

A total of 27 papers were included in the review. Findings revealed that consent to surgery practices is generally substandard across SSA and the process is not adequate. Patients' understanding of informed consent is limited, likewise awareness of their rights to decision-making. A range of factors at the individual, interpersonal, institutional and system/societal levels affect the informed consent process.

CONCLUSION

There is a need to find more culturally acceptable and ethical ways to include the participation of patients in the decision-making process for surgical treatment in the SSA and define standards more closely aligned with the local context.

Reach and Capacity of Black Protestant Health Ministries as Sites of Community-Wide Health Promotion: A Qualitative Social Ecological Model Examination

Black communities in the Southeast United States experience a disproportionate burden of illness and disease. To address this inequity, public health practitioners are partnering with Black Protestant churches to deliver health promotion interventions. Yet, the reach of these programs beyond the organizational level of the Social Ecological Model (SEM) is not well defined. Thus, the aim of this study is to understand Black Protestant church leaders' and members' perceptions about the capacity of their ministries to reach into their communities, beyond their congregations, as providers or hosts of health education or promotion interventions. From 20 Black Protestant churches in Atlanta, GA, 92 church leaders and members participated in semi-structured interviews. Grounded theory guided data analysis and a diverse team coded the interviews. Most participating churches had health ministries. Participants saw the boundaries between their churches at the organizational level of the SEM and the broader Black community to be porous. Those who described their "community" as being broader than their congregation also tended to describe community-wide health promotion their church engaged in. They described church-based health fairs as a strategy to promote engagement in their communities. Some participants, particularly those in a health-related profession, discussed visions of how to utilize their church as a site for community-wide health promotion. We suggest these participants may be boundary leaders who can build relationships between public health professionals, pastors, and congregants. Based on the findings, we suggest that church-based health fairs may be effective sites of community-wide health promotion.

The Social and Home Environment: Impacts of Determinants of Health on Atopic Dermatitis, Pathways Toward Solutions, and Unique Considerations for Rural and Remote North American Indigenous Populations

Disparities in environmental and social determinants of health (DOH) are associated with morbidity in atopic dermatitis (AD). The socioecological model (SEM) is a framework that can be applied to better understand how such DOH impacts patients with AD. We include a case scenario of a remote Indigenous patient reflective of real-world situations of living with AD and examine relevant impact, gaps in knowledge, and further research needs. This review highlights a variety of social and environmental exposures as important DOH which must be addressed to achieve optimal management in AD. The "rainbow model" is a modified framework to help illustrate how complex environmental and social forces impact both AD presentation and therapeutic success. However, practical applications and outcome metrics for health promotion are limited. An inter- and transdisciplinary approach is paramount to address the complex challenges associated with AD care, as well as multistakeholder approach integrating culturally-competent equitable health frameworks. This review underscores the importance of expanding the focus of AD management beyond basic science and clinical trials to recognize and address health disparities and to promote optimal health and well-being in patients with AD, and contributes a working approach to mapping the complex interventions and patient-oriented research needed using a focus on remote North American Indigenous patients affected by AD.

Medical students' perception of their 'distance travelled' in medical school applications

INTRODUCTION

Within medical school's holistic review of applicants includes a review of their distance travelled to get to this point in their education. The AAMC defines distance travelled (DT) as, 'any obstacles or hardships you've overcome to get to this point in your education or any life challenges you've faced and conquered'. What medical students consider as their distance travelled has not been explored. The authors sought to identify the factors medical students perceive are important for medical school admissions to consider when assessing someone's 'distance travelled' by asking current medical students to share their DT experiences along with the barriers and facilitators they encountered on their medical school journey.

METHODS

The authors conducted semi-structured interviews with US medical students through purposeful sampling methods. The social-ecological model framework was used to develop questions to elicit participants' experiences that contributed to their distance travelled. Interviews were conducted in 2021 and ranged from 60-75 minutes. Transcribed interviews were qualitatively analysed using interpretive description.

RESULTS

A total of 31 medical students from seven medical schools were included in the study. Overall, participants defined distance travelled as an applicant's hardships (e.g. being the primary caregiver for a family member) and privileges (e.g. having physician parents) they experienced. Three major themes were identified: (1) individual-level characteristics and factors, (2) interpersonal relationships and (3) aspects of the participants' community and society.

DISCUSSION

Our findings show that medical school applicants considered DT to be a valuable component of a holistic medical school admission process. Participants' experiences of DT were varied and complex. Our research suggests that admissions teams for medical schools should incorporate more comprehensive recruitment practices and inclusive methodological frameworks to accurately capture the diversity of identities and experiences of medical school applicants and to consider the factors that shape their journey to medical schools.