A systems model of clinical preventive care: an analysis of factors influencing patient and physician

Pediatric practice experiences with second dose influenza vaccination: An AAP Pediatric Research in Office Settings (PROS) Study

OBJECTIVES

Explore pediatric staff experiences administering the second influenza vaccine dose.

STUDY DESIGN

Qualitative focus groups/interviews.

METHODS

As part of the National Institutes of Health-funded Flu2Text randomized control trial of text message reminders for second influenza vaccine dose, we conducted seven focus groups and four individual interviews (n = 39 participants total) with clinicians and staff from participating practices from the American Academy of Pediatrics' Pediatric Research in Office Settings (PROS) Network. Of 37 participating practices, 10 were selected through stratified sampling of practices with highest (n = 5) and lowest (n = 5) randomized controlled trial effect sizes. A semi-structured discussion guide included questions that addressed parental, practice, and health system barriers/facilitators to second influenza vaccine dose administration. Using the Systems Model of Clinical Preventive Care as a conceptual framework, two investigators independently coded transcripts (Κ = 0.86, high agreement) with NVivo 12 Plus. Coding inconsistencies were resolved by consensus.

RESULTS

Clinicians/staff reported that administering the second influenza vaccine dose in a season was more complex than other childhood vaccines. They highlighted parental uncertainty about the need for the second dose and the difficulty and inconvenience of bringing children back to the office as important barriers. Caregiver-staff relationships were perceived as helpful in getting children vaccinated with their second dose and vaccine reminders were seen as important cues-to-action.

CONCLUSIONS

Ensuring receipt of two doses of the influenza vaccine in a given season presents unique challenges. Themes identified provide a framework for understanding opportunities to bolster second dose receipt, including explaining why two doses are needed, offering flexible hours for vaccination, and sending vaccine reminders.

Primary Care Providers' Experiences Recommending and Performing Cervical Cancer Screening for Women with Intellectual Disabilities: A Qualitative Study

Women with intellectual and developmental disabilities (I/DD) are less likely to receive cervical cancer screening (CCS) relative to women without disabilities. Primary care providers (PCPs) play key roles in recommending CCS. The purpose of this study was to identify factors PCPs consider when recommending and performing CCS for women with I/DD. Using a qualitative approach, in-depth semi-structured interviews (N = 13) were conducted with majority family medicine-trained PCPs. Through inductive data analysis, it was found that most PCPs reported recommending CCS; however, follow-through for performing CCS varied. PCPs attempted to align their CCS recommendations with national guidelines and provided counseling and education to families and patients about CCS while taking an individualized risk-benefit approach. Despite most PCPs reporting a lack of knowledge or training related to providing I/DD-specific care, PCPs attempted to draw upon experiences with similar populations to recommend and perform CCS. There is an opportunity to improve knowledge of PCPs related to performing CCS for women with I/DD.

Development of an internet-based intervention to improve health professionals' counseling skills around adolescent weight management in Indonesia

BACKGROUND

Obesity is a growing public health and clinical concern, worldwide. In many countries, including Indonesia, health professionals lack the capacity to promote behavior change around obesity prevention and management, especially with adolescents for whom a wider set of communication skills are required. This study describes the theoretical basis, approach to development of content, use and satisfaction of an internet-based educational intervention designed to improve the quality of health professional weight management counseling with adolescents in Indonesia.

METHODS

This study is part of an exploratory sequential mixed methods design which was undertaken from 2020 to 2022. Following a needs analysis, an internet-based training resource was developed, informed by constructive alignment theory and active learning principles. Using both synchronous and asynchronous approaches over a four-week pilot study, a weekly interactive session was held online, using multifaceted training materials housed on a website (https://ramahremaja.id). The training resource was then tested in a two-arm study involving health professionals from 17 of 34 provinces across Indonesia.

RESULTS

Sixty-four primary health professionals were recruited for the two-arm study. The completion rate for reviewing all materials and assignments on the website was 72% and the online meeting participation rate was 78%. Participants were highly positive about the clarity of the training material and the appropriateness of the delivery methods. The main challenges related to poor internet literacy and interrupted internet connectivity.

CONCLUSION

Designed to support weight management in adolescents, this internet-based training program shows potential for enhancing Indonesian health professional behavior-change counseling skills.

Active Ingredients of Interventions Improving Smoking Cessation Support by Dutch Primary Care Providers: A Systematic Review

The objective was to assess active ingredients, change mechanisms, and fidelity in interventions aiming to increase the quality of smoking cessation care in the Dutch primary healthcare setting. We conducted a systematic review searching five scientific databases on August 2nd, 2019, updated on October 28th, 2021. We included effect data of behavioural interventions aiming at improving the provision of smoking cessation support by Dutch primary care providers to their patients. We excluded studies published before 2000 and those without a behavioural support intervention for primary care providers targeting smoking cessation in their patients. We found 1939 articles and included 15 distinct interventions in the review. We provided an overview of study characteristics, intervention effects, fidelity, active ingredients and change mechanisms using the Behaviour Change Techniques (BCT) Taxonomy and Mechanisms of Action (MoAs) protocols. Interventions seemed more effective when including a face-to-face component, using active learning strategies and providing a tool to help follow the guidelines in practice (e.g., physical cards with information). BCTs, MoAs, and fidelity were overall poorly reported on. To support the application of smoking cessation practices in Dutch primary care, we recommend implementation of face-to-face training programs incorporating active skill training elements combined with practical tools.

Perceptions of Facilitators and Barriers to Smoking Cessation Among Patients and Providers in a Cancer Center: A Single Institution Qualitative Exploratory Study

PURPOSE

Cancer patients who remain tobacco users have poorer outcomes, including increased mortality and decreased treatment tolerance; however, cessation post-diagnosis is challenging. Our formative research explored cessation-related perspectives among patients and staff at one National Cancer Institute-designated cancer center, to inform improving cessation services within oncology care.

METHODS

Using a descriptive phenomenological approach, a purposive sample of current cancer patients (n = 13) and cancer center physicians and cessation program staff (n = 9) were recruited to complete one-on-one audio-recorded in-depth qualitative interviews, to explore experiences providing or receiving cessation support, and perspectives on patients' readiness and needs regarding cessation. Thematic coding utilized Green's predisposing, enabling, and reinforcing framework to identify factors having positive, negative, or mixed impact on delivery of best-practices cessation services (ie, 5As) and patient cessation success.

RESULTS

Patients identified cancer diagnosis as a wake-up call, existing health problems, persistent healthcare providers, cost of cigarettes, and societal disapproval of smoking as factors facilitating quitting. Futility of quitting after a cancer diagnosis, cost and logistics of program participation, clinician time constraints, and lifetime addiction made quitting harder. Family, friends, stigma and motivation, and pharmacotherapies played mixed roles. Patients felt survivor-focused cessation programs, including stress management, could better enable quitting. Provider-anticipated problems with implementing cessation counseling included so-called "therapeutic nihilism" (ie, pessimism regarding cessation post-diagnosis), lack of training and standardized approaches, and time and documentation burden. Clinicians saw both policies and peer clinician "champions" as potentially increasing prioritization of cessation within oncology.

CONCLUSIONS

Findings highlight unmet needs for patients and providers regarding provision of effective cessation care. Despite survival benefit, cessation is still not standard within cancer care. Our results show that many patients would benefit from standardized programs where they are routinely asked about cessation. Providers would benefit from both structural enhancements and professional education to ensure that evidence-based cessation services tailored to cancer patients, are offered throughout treatment and survivorship.

Examining the Association between Polish Migrant Status and Health Preferences Using a Novel Application of a Smaller Design EQ-5D-5L Valuation Study

INTRODUCTION

Migrants have different utilisation of healthcare services and health-related behaviours than host populations. A potential factor that may contribute to the notable differences in healthcare use and health-related behaviours between migrants and host populations is how these groups value health. Those who place a high value on health have greater healthcare-seeking practices than those who do not.

OBJECTIVE

The aim of this study was to examine how Polish migrants and native Irish differ in health state utility valuations using a novel application of a smaller design EQ-5D-5L valuation study.

METHODS

This study uses health preferences as a predictor of how one values health. We examined the EQ-5D-5L health preferences of 119 Polish migrants and 123 native Irish, both residing full-time in Ireland. To do so, we used a novel application of a smaller design EQ-5D-5L valuation study that consisted of 30 health states and a targeted sampling strategy coupled with a Bayesian statistical nonparametric model. We collected data from June 2018 to September 2019.

RESULTS

Our results highlight that Polish migrants and native Irish differ in their health preferences for and valuation of severe health states. Polish migrants place meaningfully higher utility valuations of 0.1 or more on the three most severe health states compared with the native Irish.

CONCLUSION

This study can provide an understanding of a potential new factor underpinning some of the disparities in healthcare utilisation and health-related behaviours among migrants and host populations in Europe. This study also provides proof of principle for using a smaller design EQ-5D-5L valuation study to explore differences in health preferences among other minority subgroups, which can otherwise be hard to uncover when using the secondary analysis of national EQ-5D-5L valuation studies.

Health preferences and preventive care utilisation: How EQ-5D-5L health preferences may affect uptake

Despite the economic and health benefits of preventive care being well established, the uptake of many cost-effective preventive services remains lower than desired in many cases, especially among specific sub-populations. The value an individual places on health can influence their uptake of preventive care. One way to capture the value an individual places on health and future health status is to examine their health preferences. This study used a novel use of EQ-5D-5L health preferences to determine if health preferences are associated with the uptake of a range of preventive care services, including a cancer screening, blood pressure check, cholesterol check, blood test and urine test. We collected EQ-5D-5L composite time trade-off data in 2018/2019 on 242 respondents residing in Ireland. We estimated an initial tobit model to predict an individual’s health preference to capture health preferences as a regressor. We then estimated a bivariate probit model to examine the uptake of each preventive service and GP use. Each model controlled for health preferences, education, sex, type of health coverage, self-reported health, employment status, age and marital status. Health preferences are a significant determinant of all five preventive services while controlling for other covariates. The results shows that the higher an individual values good health, the more likely they are to avail of preventive care. Health preferences can be noted as a potential determinant of preventive care use that could guide policy responses seeking to increase demand-side factors for preventive care uptake.

Strategies to increase uptake of maternal pertussis vaccination

INTRODUCTION

Pertussis is a highly contagious respiratory disease that results in disproportionate morbidity and mortality in infants who have yet to receive the primary diphtheria-tetanus-pertussis vaccine series. In the preceding decades numerous countries began to pursue either prenatal vaccination of pregnant women or postpartum vaccination of caregivers to protect infants. Despite proven benefit, maternal uptake of pertussis vaccine continues to remain suboptimal.

AREAS COVERED

Many studies have been conducted to address the suboptimal uptake of maternal pertussis vaccination. This systematic review was undertaken to systematically identify those studies, highlight the most successful strategies and find the knowledge gaps that need to be filled over the coming years to improve vaccine uptake. Twenty-five studies were identified from six different databases.

EXPERT OPINION

Five different interventions were shown to be successful in promoting uptake of pertussis vaccination: (1) standing orders, (2) opt-in orders, (3) provider education, (4) on-site vaccination and (5) interactive patient education. Three major knowledge gaps were also identified that need to be filled over the coming years: (1) lack of studies in low- and middle-income countries, (2) lack of studies targeting midwives and/or home birth and (3) lack of studies on the process of vaccine communication.

Systematic reviews as a "lens of evidence": Determinants of participation in breast cancer screening

OBJECTIVE

To assess the determinants of the participation rate in breast cancer screening programs by conducting a systematic review of reviews.

METHODS

We conducted a systematic search in PubMed via Medline, Scopus, Embase, and Cochrane identifying the literature up to April 2019. Out of 2258 revealed unique abstracts, we included 31 reviews, from which 25 were considered as systematic. We applied the Walsh & McPhee Systems Model of Clinical Preventive Care to systematize the determinants of screening participation.

RESULTS

The reviews, mainly in high-income settings, reported a wide range for breast cancer screening participation rate: 16-90%. The determinants of breast cancer screening participation were simple low-cost interventions such as invitation letters, basic information on screening, multiple reminders, fixed appointments, prompts from healthcare professionals, and healthcare organizational factors (e.g. close proximity to screening facility). More complex interventions (such as face-to-face counselling or home visits), mass media or improved access to transport should not be encouraged by policy makers unless other information appears. The repeated participation in mammography screening was consistently high, above 62%. Previous positive experience with screening influenced the repeated participation in screening programs. The reviews were inconsistent in the use of terminology related to breast cancer screening participation, which may have contributed to the heterogeneity in the reported outcomes.

CONCLUSIONS

This study shows that consistent findings of systematic reviews bring more certainty into the conclusions on the effects of simple invitation techniques, fixed appointments and prompts, as well as healthcare organizational factors on promoting participation rate in screening mammography.

Breast Cancer Screening Practices in a Tertiary Care Center in the State of Qatar: A Cross-Sectional Survey

Introduction

Breast cancer is the most common cancer in females. In Qatar, mortality related to breast cancer came in third after lung cancer and leukemia. In this study, we aim to comprehensively evaluate the rate of internal medicine residents and faculty compliance with breast cancer screening in Hamad Medical Corporation (Doha, Qatar), as well as to identify barriers and facilitators that could potentially augment changes to enhance physician-led cancer screening.

Methods

A cross-sectional web-based survey was distributed among internal medicine physicians between December 2018 and March 2019 at a tertiary medical centre. It focused on the knowledge, attitude, and practice of physicians regarding breast cancer screening guidelines and explored potential barriers and proposed solutions. Chi-square and t-test statistics were used to draw conclusions where appropriate.

Results

A total of 158 physicians responded to the survey, with a response rate of 61%. 75.9% were postgraduate trainees. Around three-quarters of the physicians mentioned that they would recommend breast cancer screening for their age-appropriate average-risk patients. There was a statistically significant difference between the trainees, consultants, and specialists regarding the modality of choice, where the majority of the trainees opted mammogram every 2 or 3 years while 44.4% of the consultants indicated yearly self-breast exam (p<0.001). The percentage of survey participants who rarely to never offer breast cancer screening in the outpatient settings was 37.8%. Unclear pathway (40%) and lack of time in clinic/ward rounds (26.5%) were the major reported barriers for cancer screening.

Conclusion

In the current era of personalized medicine, physicians should be more oriented to local guidelines to provide optimal care to their patients. While the attitude towards breast cancer screening is positive, the overall compliance with the national recommendations is sub-optimal. Further initiatives and intervention programs are required to promote the breast cancer screening in Qatar.

Perspectives of family physicians towards access to lung cancer screening for individuals living with low income - a qualitative study

BACKGROUND

Individuals living with low income are less likely to participate in lung cancer screening (LCS) with low-dose computed tomography. Family physicians (FPs) are typically responsible for referring eligible patients to LCS; therefore, we sought to understand their perspectives on access to lung cancer screening for individuals living with low income in order to improve equity in access to LCS.

METHODS

A theory-informed thematic analysis was conducted using data collected from 11 semi-structured interviews with FPs recruited from three primary care sites in downtown Toronto. Data was coded using the Systems Model of Clinical Preventative Care as a framework and interpretation was guided by the synergies of oppression analytical lens.

RESULTS

Four overarching themes describe FP perspectives on access to LCS for individuals living with low income: the degree of social disadvantage that influences lung cancer risk and opportunities to access care; the clinical encounter, where there is often a mismatch between the complex health needs of low income individuals and structure of health care appointments; the need for equity-oriented health care, illustrated by the neglect of structural origins of health risk and the benefits of a trauma-informed approach; and finally, the multiprong strategies that will be needed in order to improve equity in health outcomes.

CONCLUSION

An equity-oriented and interdisciplinary team based approach to care will be needed in order to improve access to LCS, and attention must be given to the upstream determinants of lung cancer in order to reduce lung cancer risk.

Factors affecting pregnant women's decisions regarding prenatal pertussis vaccination: A decision-making study in the nationwide Prenatal Pertussis Immunization Program in Taiwan

OBJECTIVE

To examine the factors affecting pregnant women's decisions to accept or decline the prenatal pertussis (Tdap) vaccination in Taiwan.

MATERIALS AND METHODS

We conducted a cross-sectional survey, recruiting pregnant women who had received prenatal care from eight maternity hospitals between January and December 2018. We examined the participants' demographic characteristics, perceptions of pertussis disease risk and vaccination effectiveness, beliefs regarding vaccine information, physician recommendation, and other potential factors affecting decision-making regarding prenatal vaccination.

RESULTS

The complete survey response rate among eligible women was 78%. Among the participants, 74% accepted and 26% declined prenatal Tdap vaccination. Most women accepted Tdap during pregnancy because of perceived severity of pertussis in their infants, perceived effectiveness of the prenatal Tdap in preventing neonatal pertussis, and perceived safety of the prenatal Tdap vaccine for the fetus, as well as a provider's recommendation, which was the factor strongly associated with actual Tdap reception. Most of the participants who accepted Tdap vaccination during pregnancy and who believed that the Tdap vaccine could protect their infants from pertussis reported the receiving sufficient information to make an informed decision and trust in the information. By contrast, a large proportion of the participants who declined Tdap and who did not want to experience possible fetal side effects of Tdap reported not getting sufficient information to make an informed decision and a lack of trust in the information.

CONCLUSION

Developing a comprehensive strategy involving government policy, the health care system, public media, health professionals, and pregnant women to launch a successful campaign may improve the nationwide acceptance of the prenatal pertussis vaccination.

Knowledge, Attitude and Practice of Physicians Regarding Screening of Colorectal Cancer in Qatar: A Cross-Sectional Survey

PURPOSE

The aim of this study was to evaluate the rate of internal medicine residents' and faculties' (specialists and consultants) compliance to colorectal cancer screening in Hamad Medical Corporation (Doha, Qatar) and to identify barriers as well as facilitators that will assist in drawing up changes that would enhance physician-related cancer screening.

METHODS

A cross-sectional web-based survey was distributed among internal medicine physicians at three component hospitals of Hamad Medical Corporation (HMC); focusing on knowledge and practice of colorectal cancer screening, its barriers and facilitators. Chi-square and t-test statistics were used to draw conclusions where appropriate.

RESULTS

The response rate for the survey was 91% and over 75% of the survey respondents were post-graduate trainees. The majority (90.6%) of the physicians (n=144) mentioned that they would recommend colorectal cancer screening for their asymptomatic patients, though trainees tend to choose the correct modality of screening compared to the consultants, 86.21% vs 40.74%. Only 43.4% of the survey participants always to usually recommend screening to their patients in their clinics while only 29.4% do so for their inpatients. Even though there was no statistically significant difference among the frequency of outpatient colorectal cancer screening among trainees, specialists or consultants (p=0.628), there was a clear increase in the reported referrals as the training years or the years of experience increases (p=0.049 for trainees and p=0.009 for faculty). Unclear pathway was reported as the main obstacle to outpatient cancer screening by 30.2% (n= 48) and 54% (n=87) pointed out that an easy and clear pathway for cancer screening would facilitate the same.

CONCLUSION

While the attitude towards colorectal cancer screening is positive, the actual practice of recommendation is sub-optimal. Further initiatives are required to facilitate awareness and compliance to colorectal cancer screening.

A systematic review of practice-, provider-, and patient-level determinants impacting Asian-Americans' human papillomavirus vaccine intention and uptake

INTRODUCTION

Asian-Americans have been documented to have low human papillomavirus (HPV) vaccine initiation and completion. No research has attempted to examine underlying mechanisms of HPV vaccine uptake disparities among Asian-Americans. Using the P3 (practice, provider, and patient) model, this study aimed to identify practice-, provider-, and patient-level determinants of Asian-Americans' HPV vaccine intention and uptake.

METHODS

We conducted a systematic review of published literature regarding practice-, provider- and patient-level determinants of vaccine intention (e.g., intention, willingness, or acceptability) and uptake (e.g., initiation or completion). Eligible studies were those presenting empirical/original data, focusing on Asian populations in the U.S., including outcomes related to HPV vaccine intention and uptake, and analyzing data on factors associated with these outcomes separately for Asian groups.

RESULTS

Twenty-six studies (19 quantitative and 7 qualitative studies) were included in the review. Most commonly studied subgroups were Koreans (n = 9), Chinese (n = 6), and Cambodians (n = 5). Studies showed varied prevalence across subgroups (intention: 23.4%-72%; initiation: 14%-67%; completion: 9%-63%). Only 3 studies included measurements of practice-level determinants (language services, insurance policy). Twelve studies measured provider-level determinants (most commonly documented: HPV vaccine recommendation). All studies measured patient-level determinants (most commonly documented: HPV and HPV vaccine knowledge, perceived safety, perceived susceptibility, and perceived relationship between HPV vaccine and sexual activity).

CONCLUSIONS

Existing research on determinants of HPV vaccine intention and uptake among Asian-Americans currently lacks measurements of practice-level constructs and perspectives of clinic staff and providers, which are needed to guide system-level interventions and provider training. Data regarding patient-level determinants suggest that interventions for Asian-American populations can focus on providing educational information in culturally-appropriate manners, leveraging familial influences, and attending to access-related or cultural beliefs about HPV vaccine. Interventions should take into account varied vaccine intention and uptake prevalence in different Asian subgroups.

A Longitudinal Analysis of Patient-Level Factors Associated with Pap Test Uptake Among Chinese American Women

The purpose of this study was to longitudinally examine patient-level factors associated with Pap test uptake among middle-aged Chinese American women. The study analyzed data from 498 Chinese American women (1326 person-time-waves) who participated in the Study of Women's Health Across the Nation (SWAN) Series. Generalized estimating equation (GEE) was used to longitudinally examine patient-level factors associated with Pap test uptake over the 7-year period. Of the 1326 person-time-waves, 61% had a Pap test and 39% did not. Higher amounts of time spent by female healthcare providers for female health needs (e^b = 3.35, p < 0.01), having a female healthcare provider for female health needs (e^b = 3.36, p < 0.01),, and a history of cancer (e^b = 6.05, p < 0.01) or fibroids (e^b = 1.66, p < 0.01) were positively associated with Pap test uptake among Chinese American women, whereas not having a primary care provider (e^b = 0.27, p < 0.05) and not having time to go to the doctor (e^b = 0.31, p < 0.05) were negatively associated with Pap test uptake. Health education and health promotion messaging that accentuates the benefits of access to primary care providers and allocation of time to attend to health needs may bolster Chinese American women's acceptability and uptake of routine Pap testing for cervical cancer prevention. If health education and health promotion efforts are not developed, suboptimal rates of Pap testing will widen the disparity gap and contribute to Chinese American women's increased risk of cervical cancer morbidity and mortality in the coming years.

A Qualitative Study of Barriers and Facilitators to Adherence to Secondary Prevention Medications Among French Patients Suffering from Stroke and Transient Ischemic Attack

PURPOSE

Secondary prevention medications (SPM) reduce the risk of ischemic stroke (IS) and transient ischemic attack (TIA) recurrence. However, approximately one-third of patients are estimated to be non-adherent. This qualitative study aimed to explore barriers and facilitators to adherence to SPM after IS or TIA.

PATIENTS AND METHODS

Thirty-six face-to-face semi-structured interviews were conducted with 14 TIA patients and 22 IS patients who self-administered their treatment 12 months after IS/TIA. A thematic analysis was performed.

RESULTS

Major facilitators to good adherence to SPM were the fear of stroke recurrence and the high level of trust in the prescribing physician. Barriers included a perceived lack and/or inappropriate timing of information about SPM, practical difficulties of taking some SPM (eg, inadequate packaging) and of implementing routines into their daily life.

CONCLUSION

Information on SPM is inadequate in terms of quantity and timing both during the acute IS/TIA period and over the long term. Providing more tailor-made information at an opportune moment, in particular by promoting discussion with their general practitioner (GP) throughout the course of illness and recovery, is essential to ensure that patients are not left alone in the decision-making process regarding adherence to SPM.

Toward targeting inflammasomes: insights into their regulation and activation

Inflammasomes are multi-component signaling complexes critical to the initiation of pyroptotic cell death in response to invading pathogens and cellular damage. A number of innate immune receptors have been reported to serve as inflammasome sensors. Activation of these sensors leads to the proteolytic activation of caspase-1, a proinflammatory caspase responsible for the cleavage of proinflammatory cytokines interleukin-1β and interleukin-18 and the effector of pyroptotic cell death, gasdermin D. Though crucial to the innate immune response to infection, dysregulation of inflammasome activation can lead to the development of inflammatory diseases, neurodegeneration, and cancer. Therefore, clinical interest in the modulation of inflammasome activation is swiftly growing. As such, it is imperative to develop a mechanistic understanding of the regulation of these complexes. In this review, we divide the regulation of inflammasome activation into three parts. We discuss the transcriptional regulation of inflammasome components and related proteins, the post-translational mechanisms of inflammasome activation, and advances in the understanding of the structural basis of inflammasome activation.

PreView: a Randomized Trial of a Multi-site Intervention in Diverse Primary Care to Increase Rates of Age-Appropriate Cancer Screening

BACKGROUND

Women aged 50-70 should receive breast, cervical (until age 65), and colorectal cancer (CRC) screening; men aged 50-70 should receive CRC screening and should discuss prostate cancer screening (PSA). PreView, an interactive, individually tailored Video Doctor Plus Provider Alert Intervention, adresses all cancers for which average risk 50-70-year-old individuals are due for screening or screening discussion.

METHODS

We conducted a randomized controlled trial in 6 clinical sites. Participants were randomized to PreView or a video about healthy lifestyle. Intervention group participants completed PreView before their appointment and their clinicians received a "Provider Alert." Primary outcomes were receipt of mammography, Pap tests (with or without HPV testing), CRC screening (FIT in last year or colonoscopy in last 10 years), and PSA screening discussion. Additional outcomes included breast, cervical, and CRC screening discussion.

RESULTS

A total of 508 individuals participated, 257 in the control group and 251 in the intervention group. Screening rates were relatively high at baseline. Compared with baseline screening rates, there was no significant increase in mammography or Pap smear screening, and a nonsignificant increase (18% vs 12%) in CRC screening. Intervention participants reported a higher rate of PSA discussion than did control participants (58% vs 36%: P < 0.01). Similar increases were seen in discussions about mammography, cervical cancer, and CRC screening.

CONCLUSION

In clinics with relatively high overall screening rates at baseline, PreView did not result in significant increases in breast, cervical, or CRC screening. PreView led to an increase in PSA screening discussion. Clinician-patient discussion of all cancer screenings significantly increased, suggesting that interventions like PreView may be most useful when discussion of the pros and cons of screening is recommended and/or with patients reluctant to undergo screening. Future research should investigate PreView's impact on those who are hesitant or reluctant to undergo screening.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02264782.

Using Chart-Stimulated Recall to Identify Barriers and Facilitators to Routine HIV Testing Among Pediatric Primary Care Providers

PURPOSE

Adolescents account for one in five new HIV infections in the U.S. Yet, only 25% of sexually active adolescents report HIV testing, and testing rates have not improved over time. In this study, the primary aim was to identify barriers and facilitators to routine HIV testing in the pediatric primary care setting.

METHODS

Practices within a large pediatric network were stratified by higher and lower rates of HIV testing. Providers were purposively sampled across practices, and chart-stimulated recall was used to explore HIV testing knowledge and practices by having providers review actual adolescent well visit records. Interviews were audio-recorded and transcribed. Qualitative content analysis identified categories of barriers and facilitators to HIV testing among higher and lower performing sites.

RESULTS

Of participants (n = 31), 52% were from higher performing clinics, and 48% from lower performing clinics, and mean number of years in practice was 16.9 (standard deviation 10.8). Provider-identified barriers at lower-performing sites included lack of knowledge of testing guidelines, inadequate sexual risk assessment, concerns about damaging patient/caregiver relationships, and competing priorities, whereas both high- and low-performing cites reported concerns about confidentiality. Identified facilitators at higher performing sites included availability of on-site resources (Title X funding; laboratory).

CONCLUSIONS

Several distinct barriers and facilitators to routine HIV screening were identified at lower and higher performing sites. These findings can inform the development of multilevel interventions to improve HIV testing rates in pediatric primary care.

Calidad percibida en el servicio del sistema público de salud de Bogotá

Objetivo Conocer el nivel de satisfacción de los usuarios en relación con los servicios prestados por las entidades del sector público de salud de BogotáMétodo Estudio descriptivo de corte trasversal, en el cual se indagó a 12 573 usuarios y pacientes de 196 puntos de atención de las subredes de servicios de salud, la entidad administradora de planes de beneficios (Capital Salud EPS) y la entidad rectora del sistema de salud en Bogotá, acerca de aspectos relacionados con la calidad y satisfacción percibidas. Se diseñaron tres instrumentos con calificación entre 1 y 5, en los que puntajes de 4 y 5 representaron satisfacción.Resultados Se presentan en cinco categorías: 1. El resultado global de desempeño del sistema, entendido como la confianza que genera y el posicionamiento del mismo; 2. Si hay mejoras en la gestión en relación con el año anterior; 3. El nivel de adherencia a los tratamientos; 4. La intención de colaborar con el sistema, y; 5. La experiencia vivencial integral, como la suma de las interacciones durante el proceso de atención. Aunque se encuentran niveles de satisfacción aceptables, se identifican diversas oportunidades de mejoramiento.Discusión Se analiza la importancia y validez del estudio, se postulan algunas acciones de mejora y se recomienda la implementación sistemática de este tipo de estudios.

Factors Associated with Adherence to Preventive Breast Cancer Screenings among Middle-aged African American Women

Medical and other health professionals recommend biyearly screening for breast cancer for women 40-74 years of age. However, the breast cancer screening rate of African American women aged 45 and up is lower than that of other ethnicities. The present study intended to identify factors impacting African American women's participation in breast cancer screening. This study is a longitudinal secondary data analysis of 3,911 African American participants of the Study of Women's Health Across the Nation. By using Systems Model of Clinical Preventive Care, multinomial logistic regression was applied to explore the likelihood of having breast cancer screenings (breast exam and/or mammogram) associating with predisposing factors, enabling factors, referencing factors, and situational factors. Participants with older age, with higher education, having a healthcare provider for female health, in far distance, and with a cancer(s) were significantly more likely to adhere to the recommendations of breast cancer screenings. However, participants who did not have time to visit doctors, did not trust the physicians, and who smoked regularly were significantly less likely to adhere to the recommendations of breast cancer screenings. Implications for policy and practice are discussed.

A qualitative study on the educational needs of young people with chronic conditions transitioning from pediatric to adult care

OBJECTIVES

Although patient education is recommended to facilitate the transition from pediatric to adult care, a consensus has not been reached for a particular model. The specific skills needed for the transition to help in facilitating the life plans and health of young people are still poorly understood. This study explored the educational needs of young people with diverse chronic conditions during their transition from pediatric to adult care.

METHODS

Qualitative semi-structured interviews were conducted with 17 young people with chronic conditions. A thematic analysis was conducted to examine the data.

RESULTS

Five themes emerged from the data, identified through the following core topics: learning how to have a new role, learning how to adopt a new lifestyle, learning how to use a new health care service, maintaining a dual relationship with pediatric and adult care, and having experience sharing with peers.

CONCLUSION

A shift in perspective takes place when the transition is examined through the words of young people themselves. To them, moving from pediatric to adult care is not viewed as the heart of the process. It is instead a change among other changes. In order to encourage a transition in which the needs of young people are met, educational measures could focus on the acquisition of broad skills, while also being person-centered.

Association between patient-reported HIV status and provider recommendation for screening in an opportunistic cervical Cancer screening setting in Jos, Nigeria

BACKGROUND

Cervical cancer screening (CCS) is an important health service intervention for prevention of morbidity and mortality from invasive cervical cancer. The role of provider recommendation and referral is critical in utilization of this services particularly in settings where screening is largely opportunistic. We sought to understand how patient-reported human immunodeficiency virus (HIV) infection status is associated with provider referral in an opportunistic screening setting.

METHODS

We performed a cross-sectional analysis of data on a sample of women who had received a CCS at the "Operation Stop" cervical cancer (OSCC) screening service in Jos, Nigeria over a 10-year time period (2006-2016). We used the de-identified records of women who had their first CCS to analyze the association between patient-reported HIV and likelihood of provider-referral at first CCS. We performed descriptive statistics with relevant test of association using Student t-test (t-test) for continuous variables and Pearson chi square or Fisher exact test where applicable for categorical variables. We also used a bivariable and multivariable logistic regression models to estimate the independent association of patient-reported HIV on provider referral. All statistical tests were performed using STATA version 14.1, College Station, Texas, USA. Level of statistical significance was set at 0.05.

RESULTS

During the 10-year period, 14,088 women had their first CCS. The reported HIV prevalence in the population was 5.0%; 95% CI: 4.6, 5.4 (703/14,088). The median age of women who were screened was 37 years (IQR; 30-45). Women who were HIV infected received more referrals from providers compared to women who were HIV uninfected (68.7% versus 49.2%), p-value < 0.001. Similarly, we found an independent effect of patient-reported HIV infection on the likelihood for provider-referral in the screened sample (aOR = 2.35; 95% CI: 1.95, 2.82).

CONCLUSION

Our analysis supports the design of health systems that facilitates providers' engagement and provision of necessary counseling for CCS in the course of routine clinical care. The practice of offering recommendation and referrals for CCS to women at high risk of cervical cancer, such as HIV infected women should be supported.

Perspectives on Providing And Receiving Preventive Health Care From Primary Care Providers and Their Patients With Mental Illnesses

PURPOSE

Individuals with mental illnesses have higher morbidity rates and reduced life expectancy compared to the general population. Understanding how patients and providers perceive the need for prevention, as well as the barriers and beliefs that may contribute to insufficient care, are important for improving service delivery tailored to this population.

DESIGN

Cross-sectional; mixed methods.

SETTING

An integrated health system and a network of federally qualified health centers and safety net clinics.

PARTICIPANTS

Interviews (n = 30) and surveys (n = 249) with primary care providers. Interviews (n = 158) and surveys (n = 160) with patients diagnosed with schizophrenia, bipolar, anxiety, or major depressive disorders.

MEASURES

Semi-structured interviews and surveys.

ANALYSIS

Thematic analysis for qualitative data; frequencies for quantitative data.

RESULTS

More than half (n = 131, 53%) of clinicians believed patients with mental illnesses care less about preventive care than the general population, yet 88% (n = 139) of patients reported interest in improving health. Most providers (n = 216, 88%) lacked confidence that patients with mental illnesses would follow preventive recommendations; 82% (n = 129) of patients reported they would try to change lifestyles if their doctor recommended. Clinicians explained that their perception of patients' chaotic lives and lack of interest in preventive care contributed to their fatalistic attitudes on care delivery to this population. Clinicians and patients agreed on substantial need for additional support for behavior changes. Clinicians reported providing informational support by keeping messages simple; patients reported a desire for more detailed information on reasons to complete preventive care. Patients also detailed the need for assistive and tangible support to manage behavioral health changes.

CONCLUSIONS

Our results suggest a few clinical changes could help patients complete preventive care recommendations and improve health behaviors: improving clinician-patient collaboration on realistic goal setting, increasing visit time or utilizing behavioral health consultants that bridge primary and specialty mental health care, and increasing educational and tangible patient support services.

Practice-, Provider-, and Patient-level interventions to improve preventive care: Development of the P3 Model

For adequate provision of preventive services, there is an interplay between activities at the healthcare practice, healthcare provider, and patient levels of the clinical encounter. Commonly used health promotion and behavior theoretical models address some of these three levels, but none fully account for all three. Building off of key components of many existing theoretical models, including the Health Belief Model, Theory of Planned Behavior/Theory of Reasoned Action, Social Cognitive Theory, Social Ecological Model, and the Systems Model of Clinical Preventive Care, we describe the development of the P3 (Practice-, Provider-, and Patient-level) Model for preventive care interventions. The P3 Model accounts for all three levels of the clinical encounter, and the factors that impact these levels, concurrently. This yields a model for preventive care that is applicable and adaptable to different settings, and that provides a framework for the development, implementation, and evaluation of preventive care promotion interventions. The applicability of the P3 Model is shown through two exemplar preventive care programs – immunization and colorectal cancer screening. The P3 Model allows interventions to be developed and evaluated in a modular approach, to allow more practical refinement and optimization of the intervention.

Clinician perspectives on strategies to improve patient maternal immunization acceptability in obstetrics and gynecology practice settings

Pregnancy is an ideal time to communicate with women about vaccines for themselves and their infants, yet maternal immunization rates remain suboptimal. This study aimed to identify clinic, provider, and staff-related attributes and facilitators to be utilized for a comprehensive vaccine intervention in ob-gyn clinical settings. We conducted in-depth interviews with 24 providers, both healthcare providers (e.g., physicians, nurse practitioners, midwives) and practice managers, from urban and suburban ob-gyn practices in Georgia and Colorado about their immunization attitudes, practices, and patient experiences. Qualitative analyses included Pearson correlation tests to evaluate patterns and relationships within the data to determine themes. Six major themes emerged: 1) strong provider "buy in" for maternal immunization; 2) the supporting role of clinical/interpersonal cues for vaccine promotion; 3) varying provider-patient communication approaches and its influence on maternal and pediatric uptake; 4) an urgent need for a designated office immunization champion; 5) reimbursement and practice implementation challenges; and 6) region differences in attitudes and values toward maternal immunization. Although providers expressed strong support for maternal immunization practices and offered environmental cues for vaccine promotion, practices often lacked a designated, structured role for an immunization champion equipped to manage delicate conversations with patients. The findings reflect needs for immunization champion identification, training, and support, along with best practices guidelines to improve coordination of vaccine promotion and delivery efforts in ob-gyn provider offices. Additionally, provider training on communication approaches to enhance acceptance and uptake of maternal vaccines is warranted.

Assessment of recent HIV testing among older adults in the United States

Older adults are the fastest growing segment of people living with HIV, and unfortunately many are unaware of their HIV status. Many providers are reluctant to ask older adults about their sexual histories, evaluate their risk factors, and test for HIV, and older adults have low perception of HIV risk. Using data from the 2013 to 2014 National Health and Nutrition Examination Survey, this study assessed the prevalence of recent HIV testing among older adults in the United States (n = 1,056) and identified predictors and barriers to recent HIV testing. The prevalence of recent HIV testing was 28%. Recent HIV testing was associated positively with male gender, education level, having public insurance, having same sex sexual behavior, African, and Hispanic ethnicity, whereas age, income-to-poverty ratio, and Asian ethnicity were associated negatively with recent HIV testing. Public health social workers are advised that targeted HIV testing for Asian, economically disadvantaged, female older adults is needed to increase HIV awareness and detection and to decrease late diagnosis of HIV. Provided public insurance was identified as a predictor of recent HIV testing, facilitating economically disadvantaged older adults' eligibility for public insurance that will likely improve access to HIV testing services and increase HIV testing rates.

Effects of Medicare Coverage of a "Welcome-to-Medicare" Visit on Use of Preventive Services among New Medicare Enrollees

In January 2005, Medicare began covering a one-time initial preventive physical examination (IPPE), also called a “Welcome-to-Medicare” visit, during a beneficiary's first 6 months under Part B. This paper examines the effects of offering Medicare IPPE coverage on the use of mammograms, breast self-exams, Pap smears, prostate cancer screenings, cholesterol screenings, and flu vaccines among beneficiaries new to Part B. We adopt a difference-in-difference estimator and estimate a set of multivariate logit models to quantify the effects of introducing Medicare IPPE coverage on the use of preventive services. Models are estimated separately for men and women. Data for the analysis come from the 1996–2008 Health and Retirement Study. Among both men and women, having coverage for a one-time IPPE under Medicare had no effects on the utilization of any of the preventive services listed above. In this study, we find that offering coverage for a one-time IPPE under Medicare was insufficient to spur greater use of preventive services among new Medicare beneficiaries. These findings are important and suggest that policy-makers may need to consider other approaches to increase the use of recommended preventive services.

Tailoring Lay Health Worker Interventions for Diverse Cultures: Lessons Learned from Vietnamese and Latina Communities

Indigenous lay health workers are presumed to be effective communicators in their communities due to their cultural competence. Lay health worker programs in Vietnamese and Latino communities show the influence of each community's culture and structure on the intervention designs and recruitment and training of lay health workers. To promote cancer screening. Vietnamese lay health workers conducted educational sessions in neighborhoods, while Latina lay health workers served as networkers and media role models. The studies demonstrated ways to build upon cultural strengths of the community and to tailor interventions to meet community expectations and needs. The authors conclude that ongoing responsiveness to both cultural norms and structural conditions in the community is the sine qua non of successful community programs.

Pathways to Early Cancer Detection for Vietnamese Women: Suc Khoe La Vang! (Health is Gold!)

To promote breast and cervical screening among Vietnamese women, a neighborhood-based intervention was developed that included small-group education, distribution of Vietnamese-language educational materials, and health fairs. The rationale for these modes of intervention is described. A pretest/posttest controlled trial is used to evaluate the intervention. San Francisco, California, is the experimental community; Sacramento, California, is the comparison community. The study hypothesizes that postintervention measurements of screening rates will reflect significantly greater increases among women in the experimental community than in the comparison community. This article reports results from the 1992 baseline household survey of 306 Vietnamese women in San Francisco and of 339 Vietnamese women in Sacramento. There were no significant differences in screening rates between the two communities. Only 50-54% of women had received routine checkups; 44-55%, mammograms; 40-45%, clinical breast examinations; 40-46%, Pap smear tests; and 58-65%, pelvic examinations.

Pathways to Early Cancer Detection in the Multiethnic Population of the San Francisco Bay Area

The Pathways project studied the relationship of race/ethnicity, socioeconomic status, and culture to breast and cervical cancer screening. A multidisciplinary, multicultural team of investigators assessed the knowledge, attitudes, and practices of women from five race/ethnic groups (N = 4,228) and their barriers to screening utilization. A planning framework guided the development of interventions and analyses of the similarities and differences in screening behaviors across race/ethnic groups. Baseline data for women ages 18 to 74 years showed that levels of screening were higher than national averages for Latina, white, and black women but lower for Chinese and Vietnamese women. Analyses revealed the importance of education and insurance in obtaining recommended screening regardless of race/ethnicity. However, race, ethnicity, and culture are important to the tailoring of effective interventions.

Perceptions of influenza vaccination during pregnancy in Korean women of childbearing age

The rate of maternal influenza vaccination in Korea is much lower than the general population. We evaluated the influenza vaccination rate during pregnancy and assessed women's perceptions of the influenza vaccine. One thousand women of childbearing age were surveyed from April through May 2014, using a questionnaire about vaccination history, general understanding of influenza vaccination and that examined factors that influence decisions about influenza vaccination. We also conducted an intervention to evaluate potential improvement in vaccination behavior. The influenza vaccination rate during pregnancy was 37.3%. The common reasons listed in support of vaccination included the perception of the risk of influenza infection, recommendations from health care providers, and belief in the effectiveness of the influenza vaccine. The most common reasons for not vaccinating included concern about harmful effects and the lack of recommendation from health care providers. Based on the results of the questionnaire and intervention, it is important to provide accurate information and for health care providers to recommend the influenza vaccine to pregnant women. It is also necessary for the government to encourage women to receive the influenza vaccination as a healthcare policy.

The Utility of Systems Models of Stress and Coping for Applied Research

Contemporary conceptual models of stress and coping are intricate systems formulations that depict adaptation as a dynamic, interactional process. The inherent complexity of these models presents conceptual and methodological challenges that make testing a complete model difficult. This article makes the case for a more microanalytic strategy for applied coping research that, by centering attention and available resources on selected high-frequency, high-stress problems, permits more conceptually sophisticated and clinically informative analyses. In this context, the prevailing conceptual models have heuristic value for organizing the holistic study of adaptational processes. The utility of the proposed strategy for the development of problem-specific systems models is illustrated using the example of treatment-induced sterility from research on cancer adaptation.

Integrating Prenatal-Postnatal Smoking Interventions into Usual Care in a Health Maintenance Organization

Consistent with the increasing national emphasis on providing health promotion in clinical care settings, Stop Smoking for OuR Kids (STORK), a research-derived, prenatal-postnatal smoking cessation intervention, was implemented throughout prenatal clinics, inpatient postpartum services, and pediatric clinics of Kaiser Permanente Northwest. Process data collected during the project rollout and maintenance to monitor the clinical practices of clinicians and staff members, patient responses to the intervention, and penetration of the intervention into the health maintenance organization priority population of prenatal smokers highlighted barriers to intervention delivery. These barriers fell into three categories related to the smoking intervention design, clinicians and staff members, and the organization. By monitoring the intervention implementation process, such problems were identified early. This allowed for implementing strategies to overcome many of these barriers and to assess their effectiveness. Keys to implementation success included simplifying the intervention activities, considering stakeholder needs, and providing tangible organizational resources and goals.

Physician Recommendation for Colorectal Cancer Screening by Race, Ethnicity, and Health Insurance Status Among Men and Women in the United States, 2000

In this study, the authors examined whether men and women in the United States had received a physician recommendation to get a colorectal cancer screening test, by race, ethnicity, and health insurance status using data from the 2000 National Health Interview Survey. Among men and women who had had a doctor visit in the past year but who had not had a recent fecal occult blood test, about 94.6% (95% CI 94.0-95.2) reported that their doctor had not recommended the test in the past year. African Americans, Hispanics, and American Indians/Alaska Natives were less likely to report receiving a recommendation for endoscopy compared to Whites.

Preventive Care Quality of Medicare Accountable Care Organizations: Associations of Organizational Characteristics With Performance

BACKGROUND

Accountable Care Organizations (ACOs) are a delivery and payment model aiming to coordinate care, control costs, and improve quality. Medicare ACOs are responsible for 8 measures of preventive care quality.

OBJECTIVES

To create composite measures of preventive care quality and examine associations of ACO characteristics with performance.

DESIGN

This is a cross-sectional study of Medicare Shared Savings Program and Pioneer participants. We linked quality performance to descriptive data from the National Survey of ACOs. We created composite measures using exploratory factor analysis, and used regression to assess associations with organizational characteristics.

RESULTS

Of 252 eligible ACOs, 246 reported on preventive care quality, 177 of which completed the survey (response rate=72%). In their first year, ACOs lagged behind PPO performance on the majority of comparable measures. We identified 2 underlying factors among 8 measures and created composites for each: disease prevention, driven by vaccines and cancer screenings, and wellness screening, driven by annual health screenings. Participation in the Advanced Payment Model, having fewer specialists, and having more Medicare ACO beneficiaries per primary care provider were associated with significantly better performance on both composites. Better performance on disease prevention was also associated with inclusion of a hospital, greater electronic health record capabilities, a larger primary care workforce, and fewer minority beneficiaries.

CONCLUSIONS

ACO preventive care quality performance is related to provider composition and benefitted by upfront investment. Vaccine and cancer screening quality performance is more dependent on organizational structure and characteristics than performance on annual wellness screenings, likely due to greater complexity in eligibility determination and service administration.

Effectiveness of Lay Health Worker Outreach in Reducing Disparities in Colorectal Cancer Screening in Vietnamese Americans

OBJECTIVES

We conducted a cluster randomized controlled study of a lay health worker (LHW) intervention to increase colorectal cancer (CRC) screening rates among Vietnamese Americans, who typically have lower rates than do non-Hispanic Whites.

METHODS

We randomized 64 LHWs to 2 arms. Each LHW recruited 10 male or female participants who had never had CRC screening (fecal occult blood test, sigmoidoscopy, or colonoscopy). Intervention LHWs led 2 educational sessions on CRC screening. Control LHWs led 2 sessions on healthy eating and physical activity. The main outcome was self-reported receipt of any CRC screening at 6 months after the intervention. We conducted the study from 2008 to 2013 in Santa Clara County, California.

RESULTS

A greater proportion of intervention participants (56%) than control participants (19%) reported receiving CRC screening (P < .001). When controlling for demographic characteristics, the intervention odds ratio was 5.45 (95% confidence interval = 3.02, 9.82). There was no difference in intervention effect by participant gender.

CONCLUSIONS

LHW outreach was effective in increasing CRC screening in Vietnamese Americans. Randomized controlled trials are needed to test the effectiveness of LHW outreach for other populations and other health outcomes.

[Preventive health care and health promotion: Which models for supporting the evolution of clinical practice in primary health care?]

OBJECTIVES

Published operating models about preventive health care and health promotion in primary care were sought with the aim of (1) compiling a functional inventory; and (2) to formulate working hypotheses for the improvement of clinical practice towards more efficiency and more equity.

METHODS

Narrative literature review, using keywords related to the various prevention classes, health promotion, primary care, practice models and health care delivery. The diversity of models led to a multi-criteria analysis.

RESULTS

Twelve models were selected. Their characteristics were unevenly distributed. The models, whose authors announce that they apply to prevention, mainly describe approaches that focus on individuals within physician-patient relationship, and take into account practice organization. Some socio-ecological and systems models illustrate health promotion: educational practice, group- or population-based targets, community environment and social determinants of health. There is little room for patients in elaborating the models, as they have little role in health care systems. The definitions of prevention, health promotion and patient education greatly differ from one model to another.

DISCUSSION

Little is known about practical implementation of the models; assessment data are scarce. Some elements valued by health promotion could be integrated to health care: empowerment of citizens, addressing community environment; increased involvement in local health professionals' networks; integration of individual and collective approaches within the same health care facilities to address simultaneously individual customization, efficiency and equity objectives. These developments may call for adaptation in vocational training and continuous professional development: communication skills, awareness to public health concepts, and early and longitudinal exposure to community-based learning experiences for students.

Understanding pregnant women's attitudes and behavior toward influenza and pertussis vaccination

Internationally, pregnant and postpartum women have been the focus of influenza and pertussis immunization campaigns, with differing levels of vaccine acceptance. We used semistructured interviews to explore pregnant women's perspectives on influenza vaccination during pregnancy and postpartum pertussis vaccination. Many women saw pregnancy as a busy time filled with advice on what they "should" and "should not" do to ensure the health of their fetus, and vaccinating themselves was regarded as just one of these tasks needing consideration. Women were more concerned about potential risks to their infants' health before their own. They saw influenza as a disease affecting the mother, whereas they viewed pertussis as a threat to the baby and therefore comparatively more risky. They were thus more likely to intend to vaccinate against pertussis to protect their infant. Framing of vaccination information toward protection of the baby might help increase vaccine uptake among pregnant women.

Physicians' knowledge, beliefs, and use of race and human genetic variation: new measures and insights

BACKGROUND

Understanding physician perspectives on the intersection of race and genomics in clinical decision making is critical as personalized medicine and genomics become more integrated in health care services. There is a paucity of literature in the United States of America (USA) and globally regarding how health care providers understand and use information about race, ethnicity and genetic variation in their clinical decision making. This paper describes the development of three scales related to addressing this gap in the literature: the Bonham and Sellers Genetic Variation Knowledge Assessment Index--GKAI, Health Professionals Beliefs about Race-HPBR, and Racial Attributes in Clinical Evaluation-RACE scales.

METHODS

A cross-sectional, web survey of a national random sample of general internists in the USA (N = 787) was conducted. Confirmatory factor analysis was used to assess the construct validity of the scales. Scale items were developed through focus groups, cognitive interviews, expert advisory panels, and exploratory factor analysis of pilot data.

RESULTS

GKAI was measured as a count of correct answers (Mean = 3.28 SD = 1.17). HPBR yielded two domains: beliefs about race as a biological phenomenon (HPBR-BD, alpha = .69, 4 items) and beliefs about the clinical value of race and genetic variation for understanding risk for disease (HPBR-CD alpha = .61, 3 items). RACE yielded one factor (alpha = .86, 7 items).

CONCLUSIONS

GKAI is a timely knowledge scale that can be used to assess health professional knowledge of race and human genetic variation. HPBR is a promising new tool for assessing health professionals' beliefs about the role of race and its relationship with human genetic variation in clinical practice. RACE offers a valid and reliable tool for assessing explicit use of racial attributes in clinical decision making.

Weight's up? Predictors of weight-related communication during primary care visits with overweight adolescents

OBJECTIVE

Physicians' use of Motivational Interviewing (MI) techniques when discussing weight with adolescent patients is unknown.

METHODS

We coded audio-recorded encounters between 49 primary care physicians and 180 overweight adolescent patients. During weight discussions, we used the MITI 3.0 to assess: Empathy, MI Spirit, open-ended questions, reflections, MI consistent behaviors (e.g., praising) and MI inconsistent behaviors (e.g., confronting). We examined associations of patient and physician characteristics with (1) MI techniques, (2) time discussing weight, and (3) encounter time.

RESULTS

Physicians used more MI consistent techniques with female patients (p=0.06) and with heavier patients (p=0.02). Physicians with prior MI training also used more MI consistent techniques (p=0.04) and asked more open-ended questions (p=0.05). Pediatricians had a higher MI Spirit score than family physicians (p=0.03). Older patient age was associated with physicians spending less time discussing weight-related topics (p=0.04) and higher BMI percentile was associated with physicians spending more time discussing weight-related topics (p=0.01). Increased use of MI inconsistent techniques was associated with longer encounters (p=0.02).

CONCLUSION

Physicians' weight discussions vary based on adolescent and physician characteristics. Importantly, not using MI lengthened encounter time.

PRACTICE IMPLICATIONS

Physicians might consider using MI techniques more and attempt to use these equally with all adolescents.

Colon polyp model use for educating about colorectal cancer screening in the Iowa Research Network

Providing a model of a colon segment with an adenomatous polyp and cancer can help to educate patients about the adenoma to carcinoma sequence and how this sequence can be interrupted with appropriate testing. The purpose of this study was to assess the use of a three-dimensional colon model with polyps and cancer provided to family physicians or nurses in some Iowa Research Network family physician offices. Colon models were provided to 117 family medicine healthcare providers interested in colorectal cancer screening. Using a mailed survey and follow-up telephone calls to non-responders, 81 (69%) questionnaires were returned. Thirty-six (44%) of the respondents reported they had used the model, 33 (41%) reported they used the model for a mean 16% of their patients in a month's time, 31 (38%) reported using the model to teach patients about the colon and polyps prior to a colonoscopy. Other model use described by respondents included educating staff to promote patient willingness for colonoscopies, demonstrating the need for colon cancer screening, and teaching patients about annual fecal occult blood tests. Respondents agreed that anatomical models are helpful for patient education, the design of the colon model was good, and that it facilitated demonstration of colon polyps. Possible recommendations for an office-wide adoption of an anatomical model would be an in-service for all employees and a standard location for finding the model.

Factors associated with the intention to recommend pertussis vaccination for postpartum women: a survey in Taiwan of obstetrician-gynecologists' knowledge, beliefs, and attitudes

OBJECTIVE

To examine obstetrician-gynecologists' knowledge, beliefs, and attitudes associated with the intention to recommend adult tetanus, reduced diphtheria, and acellular pertussis (Tdap) vaccination to postpartum women.

MATERIALS AND METHODS

A survey instrument was mailed to a total of 2686 members of the Taiwan Association of Obstetrics and Gynecology to assess provider demographic characteristics, occupational information, pertussis knowledge, and beliefs and attitudes about vaccination. The intention to recommend pertussis vaccination to postpartum women was evaluated. Trend chi-square statistics and multivariate logistic models were used to determine variables that were significantly associated with intention to recommend vaccination.

RESULTS

Of the 676 surveys returned (25.2%), 510 participants were active in obstetric practice. A statistically significant difference was found in mean ± SD knowledge scores for pertussis disease and pertussis vaccination between obstetrician-gynecologists who intended to recommend and those who did not intend to recommend postpartum Tdap vaccination (disease: 2.99 ± 2.2 vs. 2.31 ± 1.9, respectively, p < .001; vaccination: 2.64 ± 2.2 vs. 1.36 ± 1.8, respectively, p < .001). Obstetrician-gynecologists who were in favor of postpartum Tdap vaccination were more likely to: (1) rate the change in pertussis incidence among adults as increased; (2) rate pertussis disease among newborn infants as highly severe; (3) rate pertussis as highly contagious; and (4) understand the current recommendation of important organizations for protecting infants against pertussis.

CONCLUSION

Our study of obstetrician-gynecologists' attitudes and intentions concerning postpartum Tdap vaccination may be useful in guiding the design of effective perinatal Tdap immunization programs nationwide.

Primary care physicians' prevention counseling with patients with multiple morbidity

The prevalence of multiple health conditions, or multiple morbidity (MM), is increasing. Providing medical care for adults with MM presents challenges, including balancing disease management with prevention. We conducted in-depth semistructured interviews with 12 primary care physicians to explore their perspectives on prevention counseling among patients with MM. Participants described the complex relationship between disease management and prevention, highlighted the importance of patient motivation, and discussed various strategies to promote receptivity to prevention recommendations. The perceived potential benefits of prevention recommendations encouraged physicians to persist with such counseling, despite challenges presented by visit time constraints, reimbursement procedures, and concerns over futility. Physicians recommended the development of alternate care delivery and reimbursement models to overcome challenges of the existing health care system and to meet the prevention needs of patients with MM. We explore the implications of these findings for maximizing the health and quality of life of adults with MM.

Influenza immunization in pregnancy: overcoming patient and health care provider barriers

Seasonal influenza imparts disproportionate morbidity and death to pregnant women. Immunization against influenza is the most effective intervention to mitigate the burden of influenza disease during pregnancy; nevertheless, immunization rates remain suboptimal in this patient population. Therefore, there is a clear need for strategies to optimize influenza vaccination among pregnant women. We reviewed potential patient and health care provider barriers to influenza immunization and propose effective strategies for overcoming them.