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Moore R, Callaghan-Koru J, Vincenzo JL, Patton SK, Spear MJ, Riklon S, Alik E, Padilla Ramos A, Takamaru S, McElfish PA, Curran GM. External relationships as implementation determinants in community-engaged, equity-focused COVID-19 vaccination events. FRONTIERS IN HEALTH SERVICES 2024; 4:1338622. [PMID: 38533190 PMCID: PMC10964718 DOI: 10.3389/frhs.2024.1338622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/21/2024] [Indexed: 03/28/2024]
Abstract
Background While relationships and connectedness among organizations have been included in implementation theories, models, and frameworks, the increased attention to health equity in implementation science raises the urgency of understanding the role of relationships external to the implementing organization. This paper addresses this gap through an exploration of the role of external relationships in community-based, equity-focused interventions. Methods This study focuses on an equity-focused, community-based COVID-19 vaccination intervention in Arkansas, drawing upon long-term community-engaged relationships among University of Arkansas for Medical Sciences and the Hispanic and Marshallese Islander communities. We used an exploratory qualitative descriptive design to examine barriers and facilitators to implementation of COVID-19 vaccination events analyzing in-depth qualitative interviews with implementation team members (n = 17). Results All participants described pre-existing relationships among the implementing organization, partner organizations, and communities as a key implementation determinant for this equity-focused program. At the inter-organizational level, external relationships included formal connections and informal relationships among staff (e.g., communication channels from prior partnerships). At the individual level, strong external relationships with the community were facilitators leveraging long-term engagement, community familiarity, and staff from the communities of focus. Strong external relationships facilitated program reach in underserved communities through three mechanisms: (1) reduced time required to establish functional working relationships among partners; (2) accessibility and cultural congruence of health services; and (3) increased trust among community members. Barriers to implementation also existed in external relationships, but had less influence than facilitators. Conclusions Achieving health equity in implementation science requires greater understanding of external relationships as implementation determinants. This exploratory study makes a significant contribution to the literature by describing the types of external relationships that facilitate equitable implementation and identifying the mechanisms through which they may work. We argue that approaches to community engagement drawn from community-engaged research approaches may be useful, as these processes require investment in building/maintaining formal and informal organizational and interpersonal relationships. Further research is needed to understand connections among external relationships and other implementation determinants.
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Affiliation(s)
- Ramey Moore
- Office of Community Health and Research, College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, AR, United States
| | - Jennifer Callaghan-Koru
- Office of Community Health and Research, College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, AR, United States
| | - Jennifer L. Vincenzo
- Geriatrics, College of Health Professions, University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, United States
| | - Susan K. Patton
- Nursing, College of Education and Health Professions, University of Arkansas, Fayetteville, AR, United States
| | - Marissa J. Spear
- Office of Community Health and Research, University of Arkansas for Medical Sciences Northwest, Springdale, AR, United States
| | - Sheldon Riklon
- Department of Family Medicine, Family Medicine Residency Training Program, College of Medicine, University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, United States
| | - Eldon Alik
- Consulate General of Arkansas, Republic of the Marshall Islands, Springdale, AR, United States
| | - Alan Padilla Ramos
- Department of Family Medicine, Family Medicine Residency Training Program, College of Medicine, University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, United States
| | | | - Pearl A. McElfish
- Office of Community Health and Research, College of Medicine, University of Arkansas for Medical Sciences Northwest, Springdale, AR, United States
| | - Geoffrey M. Curran
- Department of Pharmacy Practice, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
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Leon N, Xu H. Implementation considerations for non-communicable disease-related integration in primary health care: a rapid review of qualitative evidence. BMC Health Serv Res 2023; 23:169. [PMID: 36803143 PMCID: PMC9938355 DOI: 10.1186/s12913-023-09151-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 02/03/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Integrated delivery of primary health care (PHC) services is a health reform recommended for achieving ambitious targets of the Sustainable Development Goals and Universal Health Coverage, responding to growing challenges of managing non-communicable and multimorbidity. However, more evidence is needed on effective implementation of PHC integration in different country settings. OBJECTIVE This rapid review synthesized qualitative evidence on implementation factors affecting integration of non-communicable disease (NCD) into PHC, from the perspective of implementers. The review contributes evidence to inform the World Health Organizations' guidance on integration of NCD control and prevention to strengthen health systems. METHOD The review was guided by standard methods for conducting rapid systematic reviews. Data analysis was guided by the SURE and WHO health system building blocks frameworks. We used Confidence in the Evidence of Reviews of Qualitative Research (GRADE-CERQual) to assess the confidence of the main findings. RESULTS The review identified 81 records eligible for inclusion, from 595 records screened. We sampled 20 studies for analysis (including 3 from expert recommendations). Studies covered a wide range of countries (27 countries from 6 continents), the majority from low-and middle-income countries (LMICs), with a diverse set of NCD-related PHC integration combinations and implementation strategies. The main findings were categorised into three overarching themes and several sub-themes. These are, A: Policy alignment and governance, B: Health systems readiness, intervention compatibility and leadership, and C: Human resource management, development, and support. The three overarching findings were assessed as each having a moderate level of confidence. CONCLUSION The review findings present insights on how health workers responses may be shaped by the complex interaction of individual, social, and organizational factors that may be specific to the context of the intervention, the importance of cross-cutting influences such as policy alignment, supportive leadership and health systems constraints, knowledge that can inform the development of future implementation strategies and implementation research.
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Affiliation(s)
- N. Leon
- Independent Public Health Researcher, Charlottesville, VA USA ,grid.40263.330000 0004 1936 9094Department of Epidemiology, Brown University School of Public Health, Providence, RI USA ,grid.415021.30000 0000 9155 0024South African Medical Research Council, Cape Town, South Africa
| | - H. Xu
- grid.3575.40000000121633745Department of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland
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Daniels SI, Cheng H, Gray C, Kim B, Stave CD, Midboe AM. A scoping review of implementation of health-focused interventions in vulnerable populations. Transl Behav Med 2022; 12:935-944. [DOI: 10.1093/tbm/ibac025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Abstract
Vulnerable populations face significant challenges in getting the healthcare they need. A growing body of implementation science literature has examined factors, including facilitators and barriers, relevant to accessing healthcare in these populations. The purpose of this scoping review was to identify themes relevant for improving implementation of healthcare practices and programs for vulnerable populations. This scoping review relied on the methodological framework set forth by Arksey and O’Malley, and the Consolidated Framework for Implementation Research (CFIR) to evaluate and structure our findings. A framework analytic approach was used to code studies. Of the five CFIR Domains, the Inner Setting and Outer Setting were the most frequently examined in the 81 studies included. Themes that were pertinent to each domain are as follows—Inner Setting: organizational culture, leadership engagement, and integration of the intervention; Outer Setting: networks, external policies, and patients’ needs and resources; Characteristics of the Individual: knowledge and beliefs about the intervention, self-efficacy, as well as stigma (i.e., other attributes); Intervention Characteristics: complexities with staffing, cost, and adaptations; and Process: staff and patient engagement, planning, and ongoing reflection and evaluation. Key themes, including barriers and facilitators, are highlighted here as relevant to implementation of practices for vulnerable populations. These findings can inform tailoring of implementation strategies and health policies for vulnerable populations, thereby supporting more equitable healthcare.
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Affiliation(s)
- Sarah I Daniels
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System , Menlo Park, CA 94025 , USA
| | - Hannah Cheng
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System , Menlo Park, CA 94025 , USA
| | - Caroline Gray
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System , Menlo Park, CA 94025 , USA
| | - Bo Kim
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System , Boston, MA 02114 , USA
- Department of Psychiatry, Harvard Medical School , Boston, MA 02115 , USA
| | | | - Amanda M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System , Menlo Park, CA 94025 , USA
- Stanford University School of Medicine , Stanford, CA 94305 , USA
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4
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van Heerden J, Hendricks M, Poole J, Büchner A, Naidu G, du Plessis J, van Emmenes B, van Zyl A, Uys R, Johani J, Hadley GP, Harrison D, Rowe B, Bassingthwaighte M, Moonsamy N, Kruger M. The implementation of a national paediatric oncology protocol for neuroblastoma in South Africa. Cancer Causes Control 2021; 32:725-737. [PMID: 33881651 PMCID: PMC8058747 DOI: 10.1007/s10552-021-01424-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/23/2021] [Indexed: 11/25/2022]
Abstract
Purpose The aim of the World Health Organization-International Paediatric Oncology Society is to improve childhood cancer survival in low- and middle-income countries to 60% by 2030. This can be achieved using standardised evidence-based national treatment protocols for common childhood cancers. The aim of the study was to describe the development and implementation of the SACCSG NB-2017 neuroblastoma (NB) treatment protocol as part of the treatment harmonisation process of the South African Children’s Cancer Study Group. Methods The Consolidated Framework for Implementation Research was used to identify factors that could influence the implementation of the national NB protocol as a health care intervention. The evaluation was done according to five interactive domains for implementation: intervention characteristics, inner setting, outer setting, individual or team characteristics and the implementation process. Results The protocol was developed over 26 months by 26 physicians involved in childhood cancer management. The process included an organisational phase, a resource identification phase, a development phase and a research ethics approval phase. Challenges included nationalised inertia, variable research ethical approval procedures with delays and uncoordinated clinical trial implementation. Conclusion The implementation of the national NB protocol demonstrated the complexity of the implementation of a national childhood cancer treatment protocol. However, standardised paediatric cancer treatment protocols based on local expertise and resources in limited settings are feasible. Supplementary Information The online version contains supplementary material available at 10.1007/s10552-021-01424-2.
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Affiliation(s)
- Jaques van Heerden
- Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa. .,Paediatric Haematology and Oncology, Department of Paediatrics, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Antwerp, Belgium.
| | - Marc Hendricks
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Paediatric Haematology and Oncology Service, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Janet Poole
- Faculty of Health Sciences, Division of Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, University of the Witwatersrand, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Ané Büchner
- Paediatric Haematology and Oncology, Department of Paediatrics, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Gita Naidu
- Faculty of Health Sciences, Division of Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Jan du Plessis
- Division of Paediatric Haematology and Oncology, Department of Paediatrics, Faculty of Health Sciences, Universitas Hospital, University of the Free State, Bloemfontein, South Africa
| | - Barry van Emmenes
- Division of Paediatric Haematology and Oncology Hospital, Department of Paediatrics, Frere Hospital, East London, South Africa
| | - Anel van Zyl
- Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Ronelle Uys
- Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Johani Johani
- Paediatric Haematology Oncology, Department of Paediatrics and Child Health, Port Elizabeth Provincial Hospital, Walter Sisulu University, Port Elizabeth, South Africa
| | - G P Hadley
- Department of Paediatric Surgery, Faculty of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Derek Harrison
- Faculty of Health Sciences, Department of Paediatric Surgery, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Biance Rowe
- Faculty of Health Sciences, Division of Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Mairi Bassingthwaighte
- Faculty of Health Sciences, Division of Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Nicolene Moonsamy
- Department of Paediatric Haematology and Oncology, Faculty of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Inkosi Albert Luthuli Academic Hospital, Durban, South Africa
| | - Mariana Kruger
- Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
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Means AR, Kemp CG, Gwayi-Chore MC, Gimbel S, Soi C, Sherr K, Wagenaar BH, Wasserheit JN, Weiner BJ. Evaluating and optimizing the consolidated framework for implementation research (CFIR) for use in low- and middle-income countries: a systematic review. Implement Sci 2020; 15:17. [PMID: 32164692 PMCID: PMC7069199 DOI: 10.1186/s13012-020-0977-0] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/27/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The Consolidated Framework for Implementation Research (CFIR) is a determinants framework that may require adaptation or contextualization to fit the needs of implementation scientists in low- and middle-income countries (LMICs). The purpose of this review is to characterize how the CFIR has been applied in LMIC contexts, to evaluate the utility of specific constructs to global implementation science research, and to identify opportunities to refine the CFIR to optimize utility in LMIC settings. METHODS A systematic literature review was performed to evaluate the use of the CFIR in LMICs. Citation searches were conducted in Medline, CINAHL, PsycINFO, CINAHL, SCOPUS, and Web of Science. Data abstraction included study location, study design, phase of implementation, manner of implementation (ex., data analysis), domains and constructs used, and justifications for use, among other variables. A standardized questionnaire was sent to the corresponding authors of included studies to determine which CFIR domains and constructs authors found to be compatible with use in LMICs and to solicit feedback regarding ways in which CFIR performance could be improved for use in LMICs. RESULTS Our database search yielded 504 articles, of which 34 met final inclusion criteria. The studies took place across 21 countries and focused on 18 different health topics. The studies primarily used qualitative study designs (68%). Over half (59%) of the studies applied the CFIR at study endline, primarily to guide data analysis or to contextualize study findings. Nineteen (59%) of the contacted authors participated in the survey. Authors unanimously identified culture and engaging as compatible with use in global implementation research. Only two constructs, patient needs and resources and individual stages of change were commonly identified as incompatible with use. Author feedback centered on team level influences on implementation, as well as systems characteristics, such as health system architecture. We propose a "Characteristics of Systems" domain and eleven novel constructs be added to the CFIR to increase its compatibility for use in LMICs. CONCLUSIONS These additions provide global implementation science practitioners opportunities to account for systems-level determinants operating independently of the implementing organization. Newly proposed constructs require further reliability and validity assessments. TRIAL REGISTRATION PROSPERO, CRD42018095762.
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Affiliation(s)
| | | | | | - Sarah Gimbel
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Child, Family and Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Caroline Soi
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Industrial & Systems Engineering, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Bradley H Wagenaar
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Judith N Wasserheit
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, Washington, USA
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Samuels TA, Murphy MM, Unwin N. Validating the self-reported annual monitoring grid for the 2007 Caribbean Community Declaration of Port-of-Spain on noncommunicable diseases. Rev Panam Salud Publica 2019; 42:e189. [PMID: 31093216 PMCID: PMC6386129 DOI: 10.26633/rpsp.2018.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/30/2018] [Indexed: 11/27/2022] Open
Abstract
Objectives In 2007, the Caribbean Community (CARICOM) convened the world's first-ever heads of government summit on noncommunicable diseases (NCDs) and issued the landmark Declaration of Port-of-Spain: Uniting to Stop the Epidemic of Chronic NCDs. Since then, ministry of health (MoH) focal points in each country have self-reported annually on their NCD efforts, using a 26-indicator grid created to assess implementation of the Declaration. Our objective was to assess the validity of those grid responses, as compared to information from in-depth interviews and document reviews. Methods Seven national case studies on policy responses to the Declaration were undertaken in 2015. In-depth, semistructured interviews were conducted with stakeholders from multiple sectors, including the MoH. Policy documents were also identified and reviewed. The results from the 2015 case studies were compared to the 2014 MoH focal point grid responses. Kappa statistics evaluated chance agreement. Results The information from the grid and from the case studies agreed closely. Out of a total of 182 indicators (26 each for seven countries), there was a lack of agreement on just 9 (4.9%). All the differences were between policy statements and implementation. Except for physical activity, kappa statistics indicated that agreement was good to excellent for all the clusters of the grid and for the grid as a whole, but with wide confidence intervals. Conclusions In general, the monitoring grid accurately assessed the national situation, but with a possible tendency to overstate performance in some areas. These findings contributed to the design of a new, 50-indicator monitoring grid in 2016. Alongside these improvements, CARICOM countries face a substantial burden from having to complete many other required NCD reports, mainly for the Pan American Health Organization and the World Health Organization.
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Affiliation(s)
- T Alafia Samuels
- George Alleyne Chronic Disease Research Centre, Caribbean Institute for Health Research, University of the West Indies, Bridgetown, Barbados
| | - Madhuvanti M Murphy
- Faculty of Medical Sciences, Cave Hill campus, University of the West Indies, Bridgetown, Barbados
| | - Nigel Unwin
- MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
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Hawley NL, Suss R, Cash HL, Aitaoto N, Samoa R, Ayers B, McElfish P. Diabetes Prevention and Care Programs in the US-Affiliated Pacific Islands: Challenges, Innovation, and Recommendations for Effective Scale-Up. Curr Diab Rep 2019; 19:24. [PMID: 30919169 DOI: 10.1007/s11892-019-1139-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW This review describes some of the unique challenges faced by the US-Affiliated Pacific Islands (USAPIs) in addressing diabetes prevention and care and presents innovative population-level strategies that have been employed to address them. RECENT FINDINGS Challenges include an unhealthy food environment and a strained health care infrastructure, both compounded by geography. Innovations in addressing these challenges include attempts to modify the food environment, a focus on early life prevention, and task shifting among the health workforce. Many of the successful interventions share a focus on culture, community, and capacity building. Although the USAPIs are uniquely challenged by environmental, structural, and health system barriers, there have been a number of innovative and successful strategies employed that highlight the resilience of these island nations in addressing their current disease burden when provided with the opportunity and resources to do so. Health policies to protect, support, and promote diabetes prevention and care are essential and may be informed by the interventions described.
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Affiliation(s)
- Nicola L Hawley
- Department of Chronic Disease Epidemiology, Yale School of Public Health, 60 College Street, New Haven, CT, 06510, USA.
| | - Rachel Suss
- Yale College, Yale University, New Haven, CT, USA
| | - Haley L Cash
- Regional Epidemiology Unit, Pacific Island Health Officers' Association, Honolulu, HI, USA
| | - Nia Aitaoto
- Department of Nutrition and Integrative Physiology, College of Health, University of Utah, Salt Lake City, UT, USA
| | - Raynald Samoa
- Department of Diabetes, Endocrinology and Metabolism, City of Hope Hospital, Los Angeles, CA, USA
| | - Britni Ayers
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Pearl McElfish
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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