Addressing Equity and Social Needs: The New Frontier of Patient Engagement Research

Patient engagement has been a focus of patient-centered care in recent years, encouraging health care organizations to increase efforts to facilitate a patient's ability to participate in health care. At the same time, a growing body of research has examined the impact that social determinants of health (SDOH) have on patient health outcomes. Additionally, health care equity is increasingly becoming a focus of many organizations as they work to ensure that all patients receive equitable care. These three domains - patient engagement, SDOH, and health care equity - can intersect in the implementation of social needs screenings among health care organizations. We present a case study on a two-phase social needs screening implementation project and describe how this process focuses on equity. As health care organizations seek to increase patient engagement, address SDOH, and improve health equity, we highlight the need to move away from a siloed approach and view these efforts as interrelated. By approaching efforts to address these challenges and barriers as the duty of all those involved in the patient care process, there may be larger strides made toward equitable health care.

Promoting informed prostate cancer screening decision-making for African American men in a community-based setting

PURPOSE

Current screening guidelines for prostate cancer (PCa) encourage men to make individual screening decisions after consulting with their primary care provider to weigh the risks and benefits of undergoing prostate specific antigen (PSA) testing, but many men at high risk of PCa diagnosis (notably African American men) are more likely to be uninsured and lack a primary care provider. An academic-community partnership redesigned its community-based screening program to ensure access to services for African American men, incorporating a session with a trained clinical educator in community settings, designed to increase knowledge and promote informed decision-making regarding PSA testing. This study evaluated effects of the intervention on decision-making outcomes.

METHODS

To evaluate program efficacy, 88 men completed pre- and post-test surveys assessing outcomes of interest.

RESULTS

Participants' knowledge, beliefs, attitudes, anxiety levels, and self-efficacy all improved from pre- to post-test at a statistically significant level. Most notably participants' awareness that PCa is often not life-threatening, and watchful waiting is a reasonable treatment option increased after the encounter. More than half of the study sample felt they had received enough knowledge to make an informed decision about whether the PSA test was right for them.

CONCLUSION

Our findings show the program had positive effects on men's ability to make informed decisions about PCa screening and demonstrate that educational outreach programs with an emphasis on informed decision-making can effectively balance screening guidelines with the needs of underserved populations in community settings to improve outcomes.

Access to Health Care in Appalachia: Perception and Reality

INTRODUCTION

Health disparities such as cancer and diabetes are well documented in Appalachia. These disparities contribute to health status, and by many indicators, Appalachian people are less healthy than those who live in other parts of the country. Access to health care is one factor that contributes to health disparities. Access to care is complex and involves both intrinsic and extrinsic aspects, including satisfaction with quality of care. This research sought to compare Appalachian to non-Appalachian communities in terms of perceptions of access to care.

METHODS

We implemented a statewide survey to quantify perceptions of multiple components of access to care, including satisfaction with quality of care. We compared survey results to quantitative data from the County Health Rankings to document consistency with perceptions of access to care. We used chi-square analysis to compare Appalachian with non-Appalachian respondents.

RESULTS

More than 600 people completed the survey. Results of the survey identify significant differences between Appalachian and non-Appalachian residents' perceptions of access to care and their satisfaction with health care. Specifically, Appalachian residents are less satisfied with convenience, information, quality, and courtesy of health care. They perceive providers relying on stereotypes when communicating with patients.

IMPLICATIONS

Examining and documenting perceptions of health care is important because it could lead to improving access by focusing on cultural competency in addition to more resource intensive strategies. Health disparities in Appalachia might be minimized by being more compassionate and understanding of people who live here.

In pursuit of equity: partnering to improve breast and prostate cancer outcomes among African Americans

PURPOSE

Community-based participatory research (CBPR) is a collaborative partnership approach that leverages the strengths of academic-community groups to address local problems. CBPR emphasizes equity (e.g., co-learning, power-sharing, participatory decision-making) among groups to achieve goals and promote sustainability. This study examines group dynamics, and their influence on achieving shared goals, within a CBPR-guided partnership established to improve breast and prostate cancer outcomes among underserved African American communities in St. Louis, Missouri.

METHODS

We conducted in-person, semi-structured interviews with key academic and community informants and surveyed via email community collaborators involved in outreach activities. Interviews were audiotaped, transcribed, and independently coded by two authors using an iterative, open-coding process to identify major themes. Surveys were summarized using similar coding criteria for open-ended responses and descriptive statistics for discrete responses. Using a grounded theory approach, we summarized and compared themes from each data source to identify similarities and differences and triangulated results to generate overarching thematic findings.

RESULTS

Participants described benefits from the partnership (funding; clinical, public health and evaluation expertise; training and networking opportunities) and found beneficial ways to leverage the partners' strengths in collaborating Participants expressed long-term commitment to sustaining the partnership and building capacity to address cancer disparities, but faced challenges related to power-sharing and participatory decision-making.

CONCLUSIONS

Using CBPR to address cancer disparities is an effective approach to capacity-building and achieving shared goals. By evaluating the structures and processes within CBPR collaborations through the lens of equity, partners may identify and address challenges that threaten long-term partnership sustainability.

Development and application of a rubric to compare strategies for improving access to health care in rural communities in the United States

Rural areas are underserved in terms of the availability of and access to health care services. According to Healthy People 2020, access to health care continues to be the most frequently identified rural health priority in the United States.

PURPOSE

The purpose was to develop an efficient approach for standardizing and prioritizing strategies to improve access to health care in rural areas across the United States. The rubric provides a quantitative metric of the effectiveness of each strategy in terms of impact and feasibility and allows community health departments and other access to care groups to compare strategies and facilitate discussion of various strategies' ability to meet the needs of diverse communities.

FRAMEWORK

The Plan, Do, Check, Act (PDCA) cycle was used to create the rubric. The research team constructed a plan for creating a rubric to measure each strategy's impact and feasibility. We checked the rubric by applying it to selected access to care improvement strategies evaluated by the Robert Wood Johnson Foundation (RWJF). Members of a rural community Access to Care Workgroup applied the rubric to several RWJF What Works for Health strategies. The final step was to compare the results of the application phase through facilitated conversations with the goal of determining which strategy or strategies would best meet the needs of the rural community.

DISCUSSION

A rubric is a valuable tool to facilitate assessment and discussion and for assisting community members in determining access to care priorities. After applying the rubric in a community setting, we identified two important tactics: 1) the rubric is best applied to strategies when they are summarized consistently and cohesively; and 2) it is important to involve community stakeholders early in the process of identifying strategies for evaluation. The next step is to apply the rubric to similar strategies in other rural communities to further validate the rubric's effectiveness.

Developing tailored positive parenting messages for a clinic-based communication programme

BACKGROUND

Health care providers fill a central role in the prevention of both child abuse and neglect (CA/N) and unintentional childhood injury. Health communication interventions hold promise for promoting attitudes and behaviours among parents that increase positive parenting practices, which may be linked to decreased rates of intentional and unintentional childhood injuries. This manuscript describes the development of 'RISE Up', an ambulatory clinic-based childhood injury prevention programme that provides tailored, injury prevention print materials to parents of children ages 0-5.

METHODS

Fifteen semi-structured key informant interviews were conducted with clinic healthcare providers and staff to develop communication strategies and materials for caregivers. Cognitive response testing was then conducted with 20 caregivers of the priority population to assess all materials. Interviews were recorded, transcribed and analyzed using thematic coding methods.

RESULTS

Formative research revealed that health care providers and caregivers were very responsive to messages and materials. Health care providers reported that abuse and neglect were particularly relevant to their patients and noted several benefits to implementing the RISE Up programme in a health care setting. Caregivers generally found messages on reducing the risks of injuries, as well as the graphics displayed in the RISE Up programme to be helpful.

CONCLUSIONS

Addressing the common determinants of both intentional and unintentional childhood injury through customized print materials may be a useful component of comprehensive prevention efforts to address childhood injury risk with greater impact. Providers and parents responded favourably to this communication strategy.

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

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