Stressors and Silver Linings during COVID-19: Implications for Supporting Families with Young Children in a Post-Pandemic World

OBJECTIVES

To better understand impacts of the COVID-19 pandemic and resulting economic and social disruptions on families, we analyzed qualitative data capturing perspectives from parents of young children.

METHODS

This study analyzes interviews of parents of children aged 1-3.5 years at enrollment, recruited from four primary care systems serving mainly lower-income Hispanic families in Los Angeles, California. Interviews were conducted over 15 months beginning September 2020. Analyses focused on the open-ended question: Please describe in your own words how the COVID-19 pandemic has affected you and your family. We used iterative, multi-step processes to identify emergent qualitative themes.

RESULTS

A total of 460 parent responses were collected and coded. Key themes and subthemes were tested for interrater reliability, with Kappa ranging from 0.74 to 0.91. Thematic analysis revealed two groups of responses, one emphasizing stress and one emphasizing "silver linings." Parents cited a range of stressors, from fear of COVID-19 to social isolation. Those emphasizing "silver linings" also referenced formal or informal supports - especially government/community assistance programs and childcare access - that enabled stronger family ties and positive lifestyle modifications.

CONCLUSIONS FOR PRACTICE

Experiences of families with young children during COVID-19 were not uniform. Economic stability and reliable childcare may be critical mediators of family stress. Results affirm that the pandemic's impacts were distributed through channels largely built on, and possibly exacerbating, existing disparities. For lower-income families with young children, funding for public and private programs that target economic stability and childcare assistance may merit prioritization in future socio-economic disruptions.

Application of a user experience design approach for an EHR-based clinical decision support system

Objective

We applied a user experience (UX) design approach to clinical decision support (CDS) tool development for the specific use case of pediatric asthma. Our objective was to understand physicians' workflows, decision-making processes, barriers (ie, pain points), and facilitators to increase usability of the tool.

Materials and methods

We used a mixed-methods approach with semi-structured interviews and surveys. The coded interviews were synthesized into physician-user journey maps (ie, visualization of a process to accomplish goals) and personas (ie, user types). Interviews were conducted via video. We developed physician journey maps and user personas informed by their goals, systems interactions, and experiences with pediatric asthma management.

Results

The physician end-user personas identified were: efficiency, relationship, and learning. Features of a potential asthma CDS tool sought varied by physician practice type and persona. It was important to the physician end-user that the asthma CDS tool demonstrate value by lowering workflow friction (ie, difficulty or obstacles), improving the environment surrounding physicians and patients, and using it as a teaching tool. Customizability versus standardization were important considerations for uptake.

Discussion

Different values and motivations of physicians influence their use and interaction with the EHR and CDS tools. These different perspectives can be captured by applying a UX design approach to the development process. For example, with the importance of customizability, one approach may be to build a core module with variations depending on end-user preference.

Conclusion

A UX approach can drive design to help understand physician-users and meet their needs; ultimately with the goal of increased uptake.

Personal legacy and treatment choices for serious illness: a scoping review

BACKGROUND

Legacy-how one hopes to be remembered after death-is an unexplored and important dimension of decision-making for people facing serious illness.

OBJECTIVES

We conducted a scoping review to answer the following research questions: (1) How do people making treatment choices conceive of legacy? and (2) What treatment choices do people make with legacy in mind?

ELIGIBILITY CRITERIA

Participants included people facing serious illness who discussed how they wanted to be remembered after their own death, or how they hoped to impact others, as they made treatment choices. Studies in English published between 1990 and 2022 were included.

SOURCES OF EVIDENCE

We conducted searches in electronic databases including Medline/PubMed, CINAHL, PsycInfo, SocialWork, AnthropologyPlus, Web of Science, ProQuest and EMBASE databases.

DATA SYNTHESIS

We used an electronic screening tool to screen abstracts and review full-text articles suitable for inclusion. We analysed included articles using Atlas.ti. We constructed tables and narratively synthesised the findings.

RESULTS

We identified three major intersecting legacy goals that influence choices people facing serious illness make about their treatment and health behaviours, and the types of choices people make with legacy in mind. The three legacy goals are: remembrance of the individual self, remembrance of the social self and impact on others' well-being.

CONCLUSIONS

We identify the importance of legacy to patient treatment choices. Understanding for whom this construct is important, what types of legacy goals people hold and how those goals impact treatment choices is necessary to provide patient-centred whole-person care to people facing serious illness.

Moving upstream: healthcare partnerships addressing social determinants of health through community wealth building

BACKGROUND

Healthcare-based interventions addressing social needs such as food and housing generally fail to impact the upstream wealth and power inequities underlying those needs. However, a small number of US healthcare organizations have begun addressing these upstream inequities by partnering with community wealth building initiatives. These initiatives include community land trusts, resident-owned communities, and worker cooperatives, which provide local residents ownership and control over their housing and workplaces. While these partnerships represent a novel, upstream approach to the social determinants of health, no research has yet evaluated them.

METHODS

To assess the current state and key aspects of healthcare-community wealth building partnerships, we conducted a multiple case study analysis using semi-structured interviews with thirty-eight key informants across ten partnerships identified through the Healthcare Anchor Network. To analyze the interviews, we used a two-stage coding process. First, we coded responses based on the phase of the intervention to which they corresponded: motivation, initiation, implementation, or evaluation. Then we assessed responses within each aspect for common themes and variation on salient topics.

RESULTS

Partnerships were generally motivated by a combination of community needs, such as affordable housing and living wage jobs, and health system interests, such as workforce housing and supply chain resilience. Initiating projects required identifying external partners, educating leadership, and utilizing risk mitigation strategies to obtain health system buy-in. Implementation took various forms, with healthcare organizations providing financial capital in the form of grants and loans, social capital in the form of convening funders and other stakeholders, and/or capacity building support in the form of strategic planning or technical assistance resources. To evaluate projects, healthcare organizations used more process and community-level metrics rather than metrics based on individual health outcomes or returns on investment. Based on best practices from each partnership phase, we provide a roadmap for healthcare organizations to develop effective community wealth building partnerships.

CONCLUSIONS

Assessing healthcare partnerships with community wealth building organizations yields key strategies healthcare organizations can use to develop more effective partnerships to address the upstream causes of poor health.

Experiences of Sleep Problems Among Older Korean Immigrants

Despite poor sleep among older adults, little is known about the sleep habits of older immigrants living in the United States. The current pragmatic qualitative descriptive study explored sleep among older Korean immigrants, using a focus group with six participants and individual phone interviews with 22 Korean immigrants aged ≥60 years. Transcripts were coded to identify underlying themes. Several thematic categories were identified under six domains: daytime function, getting ready for bed, falling asleep, awakenings during sleep, going back to sleep, and seeking advice from peers. Unhealthy sleep behaviors were found during daytime and bedtime, particularly among those who were retired/unemployed or living alone. Seeking advice from peers was common but none of the advice helped participants sleep. Sleep education programs in Korean-speaking communities can be used to target those who are socially isolated and may benefit older Korean immigrants with sleep difficulties. [Research in Gerontological Nursing, xx(x), xx-xx.].

Beyond housing: Understanding community integration among homeless-experienced veteran families in the United States

Community integration is important to address among homeless-experienced individuals. Little is known about helping veteran families (families with a parent who is a veteran) integrate into the community after homelessness. We sought to understand the experiences of community integration among homeless-experienced veteran families. We used a two-stage, community-partnered approach. First, we analysed 16 interviews with homeless-experienced veteran parents (parents who served in the military; n = 9) living in permanent housing and providers of homeless services (n = 7), conducted from February to September 2016, for themes of community integration. Second, we developed a workgroup of nine homeless-experienced veteran parents living in a permanent housing facility, who met four times from December 2016 to July 2017 to further understand community integration. We audio-recorded, transcribed and analysed the interviews and workgroups for community integration themes. For the analysis, we developed community integration categories based on interactions outside of the household and built a codebook describing each topic. We used the codebook to code the individual interviews and parent workgroup sessions after concluding that the workgroup and interview topics were consistent. Findings were shared with the workgroup. We describe our findings across three stages of community integration: (a) first housed, (b) adjusting to housing and the community, and (c) housing maintenance and community integration. We found that parents tended to isolate after transitioning into permanent housing. After this, families encountered new challenges and were guarded about losing housing. One facilitator to community integration was connecting through children to other parents and community institutions (e.g. schools). Although parents felt safe around other veterans, many felt judged by non-veterans. Parents and providers reported a need for resources and advocacy after obtaining housing. We share implications for improving community integration among homeless-experienced veteran families, including providing resources after obtaining housing, involving schools in facilitating social connections, and combating stigma.

Comparing the Recruitment of Research Participants With Chronic Low Back Pain Using Amazon Mechanical Turk With the Recruitment of Patients From Chiropractic Clinics: A Quasi-Experimental Study

OBJECTIVE

The purpose of this study was to compare the crowdsourcing platform Amazon Mechanical Turk (MTurk) with in-person recruitment and web-based surveys as a method to (1) recruit study participants and (2) obtain low-cost data quickly from chiropractic patients with chronic low back pain in the United States.

METHODS

In this 2-arm quasi-experimental study, we used in-person clinical sampling and web-based surveys from a separate study (RAND sample, n = 1677, data collected October 2016 to January 2017) compared with MTurk (n = 310, data collected November 2016) as a sampling and data collection tool. We gathered patient-reported health outcomes and other characteristics of adults with chronic low back pain receiving chiropractic care. Parametric and nonparametric tests were run. We assessed statistical and practical differences based on P values and effect sizes, respectively.

RESULTS

Compared with the RAND sample, the MTurk sample was statistically significantly younger (mean age 35.4 years, SD 9.7 vs 48.9, SD 14.8), made less money (24% vs 17% reported less than $30,000 annual income), and reported worst mental health than the RAND sample. Other differences were that the MTurk sample had more men (37% vs 29%), fewer White patients (87% vs 92%), more Hispanic patients (9% vs 5%), fewer people with a college degree (59% vs 68%), and patients were more likely to be working full time (62% vs 58%). The MTurk sample was more likely to have chronic low back pain (78% vs 66%) that differed in pain frequency and duration. The MTurk sample had less disability and better global health scores. In terms of efficiency, the surveys cost $2.50 per participant in incentives for the MTurk sample. Survey development took 2 weeks and data collection took 1 month.

CONCLUSION

Our results suggest that there may be differences between crowdsourcing and a clinic-based sample. These differences range from small to medium on demographics and self-reported health. The low incentive costs and rapid data collection of MTurk makes it an economically viable method of collecting data from chiropractic patients with low back pain. Further research is needed to explore the utility of MTurk for recruiting clinical samples, such as comparisons to nationally representative samples.

Barriers and Facilitators to Implementation of Health System Interventions Aiming to Welcome and Protect Immigrant Patients: a Qualitative Study

BACKGROUND

At the same time that federal policymakers have enforced restrictive immigration policies, healthcare systems across the USA are developing, and have implemented, interventions aimed at addressing immigration-related stressors faced by immigrant communities. Yet, little is known about the contextual determinants that influence their implementation success. Using the Consolidated Framework for Implementation Research (CFIR), this study identifies factors enabling or challenging the implementation of interventions aimed at mitigating immigration-related stressors in the healthcare context.

METHODS

We used a qualitative research design to conduct 38 semi-structured interviews with stakeholders involved in implementation of interventions at 25 healthcare facilities across 5 states with the highest undocumented immigrant populations (California, Texas, New York, Florida, and Illinois). Interviews were conducted from May through August 2018. Constant comparative analysis was used to identify barrier and facilitator themes. Deductive coding was thereafter used to categorize themes according to CFIR domain.

RESULTS

Barriers to implementation included perceptions of legal complexity and challenges to adopting such systemic strategies. Facilitators included a national policy climate that had brought immigrant health to the forefront, allowing for leveraging momentum towards institutional change; communication among healthcare personnel; existing community partnerships with immigrant rights and service organizations; and a shared sense of mission centering health equity. Local variation in immigration-related policies (e.g., local law agencies enforcing federal immigration laws) and heterogeneity of local immigrant communities also impacted implementation. Champions and informal leaders were integral to institutional efforts but not sufficient for sustainability. Perceived urgency to act superseded evaluation considerations, with all interventions in initial phases of implementation. Future iterations and evaluations of these interventions are needed to establish best practices and implementation determinants.

CONCLUSION

This is the first systematic study describing implementation determinants of immigration-related interventions across health systems. Identifying these determinants provides guidance to other healthcare organizations to effectively strategize and ensure implementation success.

Deficits in Advance Care Planning for Patients With Decompensated Cirrhosis at Liver Transplant Centers

IMPORTANCE

The burden of end-of-life care for patients with cirrhosis is increasing in the US, and most of these patients, many of whom are not candidates for liver transplant, die in institutions receiving aggressive care. Advance care planning (ACP) has been associated with improved end-of-life outcomes for patients with other chronic illnesses, but it has not been well-characterized in patients with decompensated cirrhosis.

OBJECTIVE

To describe the experience of ACP in patients with decompensated cirrhosis at liver transplant centers.

DESIGN, SETTING, AND PARTICIPANTS

For this multicenter qualitative study, face-to-face semistructured interviews were conducted between July 1, 2017, and May 30, 2018, with clinicians and patients with decompensated cirrhosis at 3 high-volume transplant centers in California. Patient participants were adults and had a diagnosis of cirrhosis, at least 1 portal hypertension-related complication, and current or previous Model for End-Stage Liver Disease with sodium score of 15 or higher. Clinician participants were health care professionals who provided care during the illness trajectory.

MAIN OUTCOMES AND MEASURES

Experiences with ACP reported by patients and clinicians. Participants were asked about the context, behaviors, thoughts, and decisions concerning elements of ACP, such as prognosis, health care preferences, values and goals, surrogate decision-making, and documentation.

RESULTS

The study included 42 patients (mean [SD] age, 58.2 [11.2] years; 28 men [67%]) and 46 clinicians (13 hepatologists [28%], 11 transplant coordinators [24%], 9 hepatobiliary surgeons [20%], 6 social workers [13%], 5 hepatology nurse practitioners [11%], and 2 critical care physicians [4%]). Five themes that represent the experiences of ACP were identified: (1) most patient consideration of values, goals, and preferences occurred outside outpatient visits; (2) optimistic attitudes from transplant teams hindered the discussions about dying; (3) clinicians primarily discussed death as a strategy for encouraging behavioral change; (4) transplant teams avoided discussing nonaggressive treatment options with patients; and (5) surrogate decision makers were unprepared for end-of-life decision-making.

CONCLUSIONS AND RELEVANCE

This study found that, despite a guarded prognosis, patients with decompensated cirrhosis had inadequate ACP throughout the trajectory of illness until the end of life. This finding may explain excessively aggressive life-sustaining treatment that patients receive at the end of life.

Associations of Self-Reported Sleep Quality with Demographic and Other Characteristics in Older Korean Immigrants

Poor sleep is common among older adults, affecting a wide range of health outcomes. However, little is known about sleep issues among older Korean immigrants, the fastest growing Asian American subgroup in the United States. We aimed to explore multiple factors associated with sleep among this group. We analyzed cross-sectional survey data from 43 older immigrants living in two large Korean communities in Southern California. Perceived sleep quality was significantly associated with gender, living arrangement, employment status, mental health, and sleep-related beliefs (all p-values < 0.05). Living with someone and being employed for wages were significantly uniquely associated with better sleep quality, accounting for demographic and health-related factors (R² = 51.8%, adjusted R² = 38.7%, p = 0.002). These findings suggest a potential role of sociocultural factors on sleep. Further studies are needed to confirm these findings and to inform a sleep intervention program tailored to the characteristics of older Korean immigrants.

Experiences With Chiropractic Care for Patients With Low Back or Neck Pain

Background

Musculoskeletal disorders are the second leading cause of disability worldwide.

Objective

Examine experiences of chiropractic patients in the United States with chronic low back or neck pain.

Method

Observational study of 1853 chronic low back pain and neck pain patients (74% female) who completed an online questionnaire at the 3-month follow-up that included Consumer Assessment of Healthcare Providers and Systems (CAHPS) items assessing their experiences with care.

Results

We found similar reports of communication for the chiropractic sample and patients in the 2016 CAHPS National Database, but 85% in the database versus 79% in the chiropractic sample gave the most positive response to the time spent with provider item. More patients in the CAHPS database rated their provider at the top of the scale (8 percentage points). More chiropractic patients reported always getting answers to questions the same day (16 percentage points) and always being seen within 15 minutes of their appointment time (29 percentage points).

Conclusions

The positive experiences of patients with chronic back and neck pain are supportive of their use of chiropractic care.

Assessment of Perspectives on Health Care System Efforts to Mitigate Perceived Risks Among Immigrants in the United States: A Qualitative Study

IMPORTANCE

Increases in the enforcement of immigration policies, deportations, and rhetoric critical of immigration during and after the 2016 US presidential election have been associated with a decrease in health-seeking behaviors and an increase in adverse health outcomes among immigrants. Efforts to address the health care needs of immigrants after the 2016 presidential election have centered on individual-level patient-practitioner strategies or federal- and state-level policy changes. However, these approaches have not captured the role of health care systems and the range of health care facilities encompassed within them.

OBJECTIVE

To characterize policies and actions implemented by health care facilities to address immigration status-related stressors.

DESIGN, SETTING, AND PARTICIPANTS

This exploratory qualitative study involved semistructured interviews in a purposive sample of health care facilities across 5 states (California, Texas, New York, Florida, and Illinois) with the largest populations of individuals with undocumented immigration status. Data from media sources and informational interviews with local immigration advocacy leaders were used to identify health care facilities that had implemented welcoming policies and strategies. Stakeholders, including administrators, frontline clinicians involved in policy implementation, and senior executive leaders, were interviewed. Interviews were conducted between May 1 and August 9, 2018, and were recorded, transcribed, and coded using constant comparative analysis. Data analysis was performed from June 29, 2018, to February 5, 2019.

MAIN OUTCOMES AND MEASURES

Stakeholder perspectives on the range, scope and content of policies and actions implemented to address immigration-related stressors at health care facilities.

RESULTS

A total of 38 in-depth interviews were conducted spanning 25 health care facilities in 5 states; these facilities included 13 federally qualified health centers, 7 academic or private hospitals, and 5 public institutions. Interviewees described policies and actions that mitigated one or more of the following perceived risks: (1) risk of exposure to immigration enforcement personnel at or near facilities, (2) risk of immigration status-related information disclosure, (3) risk associated with patient-level stressors, (4) risk associated with practitioner-level stressors, and (5) coordination of risk mitigation. Most personnel at health care facilities emphasized that their policies and actions fit within a larger mission and history of addressing the social needs of diverse patients and mitigating risks for patients.

CONCLUSIONS AND RELEVANCE

Health care facilities can implement both active and reactive measures to address perceived immigration-associated risks among patients and practitioners. Population health and immigration policies are at the forefront of current policy debates. An understanding of the ways in which health care facilities can serve to mitigate perceived risks among their patients and employees can be one step toward optimizing health care for immigrants.

How care decisions are made among interdisciplinary providers caring for critically injured patients: A qualitative study

BACKGROUND

Injury is the leading cause of death in people under 45 years of age in the United States; however, how care decisions occur in critical injury is poorly understood. This exploratory study sought to generate hypotheses about how care decisions are made among interdisciplinary providers caring for patients who have been critically injured.

METHODS

This was a qualitative study conducted at two intensive care units in a level 1 trauma center in an urban, teaching, safety-net hospital. Semistructured interviews consisted of case scenarios with competing clinical priorities presented to 25 interdisciplinary providers, elucidating how decisions are approached. Responses were recorded, transcribed, and coded. Thematic analysis was conducted to discover central themes. Category formulation and sorting was done for data reduction and thematic structuring of the data. The range and central tendency of these themes are reported.

RESULTS

The central theme for how care decisions are made among interdisciplinary providers was through the distribution of shared responsibility. The distribution of shared responsibility depended on interdisciplinary communication to navigate the two subthemes of time and roles. Time had to be navigated carefully, because it was both an opportunity for data acquisition and consensus building but also a pressure to decisively progress care. Roles were distinct but interchangeable and consisted of experts, actualizers, and questioners.

CONCLUSION

Care decisions are made in the context of shared responsibility among interdisciplinary providers. Interdisciplinary communication is a means of establishing roles and navigating time to distribute shared responsibility among interdisciplinary providers.

Youth Growing Up in Families Experiencing Parental Substance Use Disorders and Homelessness: A High-Risk Population

Objectives: We sought to understand the stressors, the parent-child relationship and family processes, and experiences with services among families experiencing parental substance use disorders (SUDs) and homelessness. Methods: We conducted a total of 41 in-depth semistructured interviews with parents with a history of SUDs and homelessness (n = 16) and housing support staff (n = 25) from May 2017 until January 2018. Participants were recruited from transitional housing facilities across the Los Angeles metropolitan area, which served families experiencing homelessness and parental SUDs. The interviews were audio-recorded, transcribed, and themes coded with Dedoose. Results: We found a high burden of trauma and guilt among parents, and a fear of SUD disclosure. We found challenges with family processes important for SUD prevention, including communication, discussion of substance use, and family and youth goal setting. We also discovered unique stressors related to navigating housing and services within the community. Conclusion: Our findings demonstrate the need for a family-based SUD-preventive intervention for youth growing up in families with parental SUDs and experiencing homelessness, to address the heightened SUD risk. In addition, findings from our study can inform clinical and housing services for this important population.

The impact of patient preferences and costs on the appropriateness of spinal manipulation and mobilization for chronic low back pain and chronic neck pain

BACKGROUND

Although the delivery of appropriate healthcare is an important goal, the definition of what constitutes appropriate care is not always agreed upon. The RAND/UCLA Appropriateness Method is one of the most well-known and used approaches to define care appropriateness from the clinical perspective-i.e., that the expected effectiveness of a treatment exceeds its expected risks. However, patient preferences (the patient perspective) and costs (the healthcare system perspective) are also important determinants of appropriateness and should be considered.

METHODS

We examined the impact of including information on patient preferences and cost on expert panel ratings of clinical appropriateness for spinal mobilization and manipulation for chronic low back pain and chronic neck pain.

RESULTS

The majority of panelists thought patient preferences were important to consider in determining appropriateness and that their inclusion could change ratings, and half thought the same about cost. However, few actually changed their appropriateness ratings based on the information presented on patient preferences regarding the use of these therapies and their costs. This could be because the panel received information on average patient preferences for spinal mobilization and manipulation whereas some panelists commented that appropriateness should be determined based on the preferences of individual patients. Also, because these therapies are not expensive, their ratings may not be cost sensitive. The panelists also generally agreed that preferences and costs would only impact their ratings if the therapies were considered clinically appropriate.

CONCLUSIONS

This study found that the information presented on patient preferences and costs for spinal mobilization and manipulation had little impact on the rated appropriateness of these therapies for chronic low back pain and chronic neck pain. Although it was generally agreed that patient preferences and costs were important to the appropriateness of M/M for CLBP and CNP, it seems that what would be most important were the preferences of the individual patient, not patients in general, and large cost differentials.

Prevalence and Characteristics of Chronic Spinal Pain Patients with Different Hopes (Treatment Goals) for Ongoing Chiropractic Care

Objectives: The treatment goals of patients successfully using ongoing provider-based care for chronic spinal pain can help inform health policy related to this care. Design: Multinomial logistical hierarchical linear models were used to examine the characteristics of patients with different treatment goals for their ongoing care. Settings/Location: Observational data from a large national sample of patients from 125 chiropractic clinics clustered in 6 U.S. regions. Subjects: Patients with nonwork-injury-related nonspecific chronic low-back pain (CLBP) and chronic neck pain (CNP). Interventions: All were receiving ongoing chiropractic care. Outcome measures: Primary outcomes were patient endorsement of one of four goals for their treatment. Explanatory variables included pain characteristics, pain beliefs, goals for mobility/flexibility, demographics, and other psychological variables. Results: Across our sample of 1614 patients (885 with CLBP and 729 with CNP) just under one-third endorsed a treatment goal of having their pain go away permanently (cure). The rest had goals of preventing their pain from coming back (22% CLBP, 16% CNP); preventing their pain from getting worse (14% CLBP, 12% CNP); or temporarily relieving their pain (31% CLBP, 41% CNP). In univariate analysis across these goals, patients differed significantly on almost all variables. In the multinomial logistic models, a goal of cure was associated with shorter pain duration and more belief in a medical cure; a goal of preventing pain from coming back was associated with lower pain levels; and those with goals of preventing their pain from getting worse or temporarily relieving pain were similar, including in having their pain longer. Conclusions: Although much of health policy follows a curative model, the majority of these CLBP and CNP patients have goals of pain management (using ongoing care) rather than "cure" (care with a specific end) for their chiropractic care. This information could be useful in crafting policy for patients facing provider-based nonpharmacologic care for chronic pain.

Feasibility of a combined strategy of HPV vaccination and screening in Mexico: the FASTER-Tlalpan study experience

There has been a noticeable shift in discussions about cervical cancer, moving from prevention to elimination. Interventions such as FASTER, human papillomavirus (HPV) vaccination and HPV screening are innovative intervention strategies which can be utilized to begin a path to elimination. To explore the feasibility of the FASTER strategy, an evaluation was carried out in eight primary health-care centers within the Tlalpan Health-Jurisdiction of Mexico City between March 2017 and August 2018. A mixed methods approach was used to evaluate three components: infrastructure, patient acceptability, and health-care professionals' perceptions. This included checklists of requirements for the infrastructure rollout of FASTER and interviews with women and health-care professionals. Nearly all (93%) of the 3,474 women aged 25-45 years accepted HPV vaccination as part of a combined vaccination and screening program. The main reason for acceptance was prevention, while having doubts about the vaccine's benefits was the main reason for refusal. Most of the 24 health-care professionals had a positive opinion toward HPV vaccination and identified the need to increase dissemination, inform the population clearly and concisely and currently extend the age range for vaccination. The evaluation of eight primary health-care centers showed they had the necessary infrastructure for the development of a joint HPV prevention strategy, but many centers required improvements to become more efficient. Together these findings suggest that although HPV vaccine acceptance was high, there is the need to increase education and awareness among potential vaccine recipients and health-care professionals to implement the FASTER strategy.

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 5: Using Patient Records: Selection, Protection, and Abstraction

OBJECTIVES

The purpose of this paper is to describe the 4-step process (consent, selection, protection, and abstraction) of acquiring a large sample of chiropractic patient records from multiple practices and subsequent data abstraction.

METHODS

From April 2017 to December 2017, RAND acquired patient records from 99 chiropractic practices across the United States. The records included patients enrolled in a survey e-study (prospective sample) and a random sample of all clinic patients (retrospective sample) with chronic back or neck pain. Clinic staff were trained to collect the sample, scan, and transfer the records. We designed an online data collection tool for abstraction. Protocols were instituted to protect patient confidentiality. Doctors of chiropractic were selected and trained as abstractors, and a system was established to monitor data collection.

RESULTS

In compliance with data protection protocols, 3603 patient records were scanned, including 1475 in the prospective sample and 2128 in the random sample. A total of 1716 patients (prospective sample) consented to having their records scanned, but only 1475 could be retrieved. Of records scanned, 19% were unusable owing to illegibility, no care during the period of interest, or poor scanning. The abstractor interrater reliability for appropriateness of care decisions was fair to moderate (κ .38-.48).

CONCLUSION

The acquisition, handling, and abstraction of a large sample of chiropractic records was a complex task with challenges that necessitated adapting planned approaches. Of the records abstracted, many revealed incomplete provider documentation regarding the details of and rationale for care. Better documentation and more standardized record keeping would facilitate future research using patient records.

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions: Part I

OBJECTIVES

The purpose of this article is to report on the Center of Excellence for Research on Complementary and Alternative Medicine at RAND Corporation. The overall project examined the appropriateness of chiropractic spinal manipulation and mobilization for chronic low back pain and chronic cervical pain using the RAND and University of California Los Angeles Appropriateness Method, including patient preferences and costs, to acknowledge the importance of patient-centered care in clinical decision-making.

METHODS

This article is a narrative summary of the overall project and its inter-related components (ie, 4 Research Project Grants and 2 centers), including the Data Collection Core, whose activities and learning will be the subject of a following series of methods articles.

RESULTS

The project team faced many challenges in accomplishing data collection goals. The processes we developed to overcome barriers may be of use to other researchers and for practitioners who may want to participate in such studies in complementary and integrative health, which previously was known as complementary and alternative medicine.

CONCLUSION

For this large, complex, successful project, we gathered online survey data, collected charts, and abstracted chart data from thousands of chiropractic patients. The present article delineates the challenges and lessons that were learned during this project so that others may gain from the authors' experience. This information may be of use to future research that collects data from independent practitioners and their patients because it provides what is needed to be successful in such studies and may encourage participation.

Characteristics of Chiropractic Patients Being Treated for Chronic Low Back and Neck Pain

OBJECTIVES

Chronic low back pain (CLBP) and chronic neck pain (CNP) are the most common types of chronic pain, and chiropractic spinal manipulation is a common nonpharmacologic treatment. This study presents the characteristics of a large United States sample of chiropractic patients with CLBP and CNP.

METHODS

Data were collected from chiropractic patients using multistage systematic stratified sampling with 4 sampling levels: regions and states, sites (ie, metropolitan areas), providers and clinics, and patients. The sites and regions were San Diego, California; Tampa, Florida; Minneapolis, Minnesota; Seneca Falls and Upstate New York; Portland, Oregon; and Dallas, Texas. Data were collected from patients through an iPad-based prescreening questionnaire in the clinic and emailed links to full screening and baseline online questionnaires. The goal was 20 providers or clinics and 7 patients with CLBP and 7 with CNP from each clinic.

RESULTS

We had 6342 patients at 125 clinics complete the prescreening questionnaire, 3333 patients start the full screening questionnaire, and 2024 eligible patients completed the baseline questionnaire: 518 with CLBP only, 347 with CNP only, and 1159 with both. In general, most of this sample were highly-educated, non-Hispanic, white females with at least partial insurance coverage for chiropractic care who have been in pain and using chiropractic care for years. Over 90% reported high satisfaction with their care, few used narcotics, and avoiding surgery was the most important reason they chose chiropractic care.

CONCLUSIONS

Given the prevalence of CLBP and CNP, the need to find effective nonpharmacologic alternatives for chronic pain, and the satisfaction these patients found with their care, further study of these patients is worthwhile.

Fostering a Commitment to Quality: Best Practices in Safety-net Hospitals

In 2007, the Martin Luther King, Jr.-Harbor Hospital (MLK-Harbor), which served a large safety-net population in South Los Angeles, closed due to quality challenges. Shortly thereafter, an agreement was made to establish a new hospital, Martin Luther King, Jr. Community Hospital (MLKCH), to serve the unmet needs of the community. To assist the newly appointed MLKCH Board of Directors in building a culture of quality, we conducted a series of interviews with five high-performing hospital systems. In this report, we describe our findings. The hospitals we interviewed achieved a culture of quality by: 1) developing guiding principles that foster quality; 2) hiring and retaining personnel who are stewards of quality; 3) promoting efficient resource utilization; 4) developing a well-organized quality improvement infrastructure; and 5) cultivating integrated, patient-centric care. The institutions highlighted in this report provide important lessons for MLKCH and other safety-net institutions.

Data-driven decision-making tools to improve public resource allocation for care and prevention of HIV/AIDS

Public health agencies face difficult decisions when allocating scarce resources to control the spread of HIV/AIDS. Decisions are often made with few local empirical data. We demonstrated the use of the robust decision making approach in Los Angeles County, an approach that is data driven and allows decision makers to compare the performance of various intervention strategies across thousands of simulated future scenarios. We found that the prevailing strategy of emphasizing behavioral risk reduction interventions was unlikely to achieve the policy goals of the national HIV/AIDS strategy. Of the alternative strategies we examined, those that invested most heavily in interventions to initiate antiretroviral treatment and support treatment adherence were the most likely to achieve policy objectives. By employing similar methods, other public health agencies can identify robust strategies and invest in interventions more likely to achieve HIV/AIDS policy goals.

Care Transitions to and from the National Intrepid Center of Excellence (NICoE) for Service Members with Traumatic Brain Injury

Improvised explosive devices (IEDs) have been one of the leading causes of death and injury among U.S. troops. Those who survive an IED blast or other injuries may be left with a traumatic brain injury (TBI) and attendant or co-occurring psychological symptoms. In response to the need for specialized services for these populations, the U.S. Department of Defense (DoD) established the National Intrepid Center of Excellence (NICoE) in Bethesda, Maryland, in 2010. The NICoE's success in fulfilling its mission is impacted by its relationships with home station providers, patients, and their families. The RAND Corporation was asked to evaluate these relationships and provide recommendations for strengthening the NICoE's efforts to communicate with these groups to improve patients' TBI care. Through surveys, site visits, and interviews with NICoE staff, home station providers, service members who have received care at the NICoE, and the families of these patients, RAND's evaluation examined the interactions between the NICoE and the providers responsible for referring patients and implementing treatment plans.

Improving Health Care for the Future Uninsured in Los Angeles County: A Community-Partnered Dialogue

OBJECTIVE

To understand the health care access issues faced by Los Angeles (LA) County's uninsured and residually uninsured after implementation of the Affordable Care Act (ACA) and to identify potential solutions using a community-partnered dialogue.

DESIGN

Qualitative study using a community-partnered participatory research framework.

SETTING

Community forum breakout discussion.

DISCUSSANTS

Representatives from LA County health care agencies, community health care provider organizations, local community advocacy and service organizations including uninsured individuals, and the county school district.

MAIN OUTCOME MEASURES

Key structural and overarching value themes identified through community-partnered pile sort, c-coefficients measuring overlap between themes.

RESULTS

Five overarching value themes were identified - knowledge, trust, quality, partnership, and solutions. Lack of knowledge and misinformation were identified as barriers to successful enrollment of the eligible uninsured and providing health care to undocumented individuals. Discussants noted dissatisfaction with the quality of traditional sources of health care and a broken cycle of trust and disengagement. They also described inherent trust by the uninsured in "outsider" community-based providers not related to quality.

CONCLUSIONS

Improving health care for the residually uninsured after ACA implementation will require addressing dissatisfaction in safety-net providers, disseminating knowledge and providing health care through trusted nontraditional sources, and using effective and trusted partnerships between community and health care agencies with mutual respect. Community-academic partnerships can be a trusted conduit to discuss issues related to the health care of vulnerable populations.

Risk evaluations and condom use decisions of homeless youth: a multi-level qualitative investigation

Background

Homeless youth are at higher risk for sexually transmitted infections and unwanted pregnancy than non-homeless youth. However, little is known about how they evaluate risk within the context of their sexual relationships. It is important to understand homeless youths' condom use decisions in light of their sexual relationships because condom use decisions are influenced by relationship dynamics in addition to individual attitudes and event circumstances. It is also important to understand how relationship level factors, sexual event circumstances, and individual characteristics compare and intersect.

Methods

To explore these issues, we conducted semi-structured interviews with 37 homeless youth in Los Angeles County in 2011 concerning their recent sexual relationships and analyzed the data using systematic methods of team-based qualitative data analysis.

Results

We identified themes of risk-related evaluations and decisions at the relationship/partner, event, and individual level. We also identified three different risk profiles that emerged from analyzing how different levels of risk intersected across individual respondents. The three profiles included 1) Risk Takers, who consistently engage in risk and have low concern about consequences of risk behavior, 2) Risk Avoiders, who consistently show high concern about protection and consistently avoid risk, and 3) Risk Reactors, those who are inconsistent in their concerns about risk and protection and mainly take risks in reaction to relationship and event circumstances.

Conclusions

Interventions targeting homeless youth should reflect multiple levels of risk behavior and evaluation in order to address the diversity of risk profiles. Relationship/partner-, event-, and individual-level factors are all important but have different levels of importance for different homeless youth. Interventions should be tailored to address the most important factor contributing to homeless youth reproductive needs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1419-9) contains supplementary material, which is available to authorized users.

Understanding Condom Use Decision Making Among Homeless Youth Using Event-Level Data

This is one of the first qualitative event-based studies to understand the various mechanisms through which multiple factors influence condom use decision making among homeless youth. Event-level interviews that explore characteristics of the environment surrounding sexual events were conducted with 29 youth who were asked to describe two recent sexual encounters. In thematic analyses of data across events, reasons that youth gave for engaging in unprotected sex included the expectation of having sex and use of alternative methods of protection against pregnancy. Other nonevent factors that influenced condom use decision making were related to attributes of the partnership (e.g., testing, trust and love, and assessments of risk) and attributes of the youth (e.g., perceptions of diseases, concerns over pregnancy, and discomfort using condoms). Additional event analyses conducted within the same individuals found that decision making was influenced by multiple interacting factors, with different pathways operating for event and nonevent factors. Future interventions should consider taking a multilevel and individualized approach that focuses on event-based determinants of risky sex in this population.

A Program Manager's Guide for Program Improvement in Ongoing Psychological Health and Traumatic Brain Injury Programs

Between 2001 and 2011, the U.S. Department of Defense has implemented numerous programs to support service members and their families in coping with the stressors from a decade of the longstanding conflicts in Iraq and Afghanistan. These programs, which address both psychological health and traumatic brain injury (TBI), number in the hundreds and vary in their size, scope, and target population. To ensure that resources are wisely invested and maximize the benefits of such programs, RAND developed a tool to help assess program performance, consider options for improvement, implement solutions, then assess whether the changes worked, with the intention of helping those responsible for managing or implementing programs to conduct assessments of how well the program is performing and to implement solutions for improving performance. Specifically, the tool is intended to provide practical guidance in program improvement and continuous quality improvement for all programs.

Value for Money in Donor HIV Funding

Countries with the highest burden of human immunodeficiency virus (HIV) disease are heavily reliant on donor funding from such sources as the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria for their HIV programs. In recent years, commitments from these organizations have flattened while demand for HIV/AIDS care continues to rise. To meet the continued need for more HIV services in developing countries, existing resources need to be better leveraged, i.e., to provide improved value for the money. This article examines options for improving value for money in HIV funding by using a case study that focuses on the two largest funders, PEPFAR and the Global Fund, with funding for antiretroviral therapy (ART) as its leading example. The authors' assessment of available input and output data suggests that current spending allocations across direct and indirect services are not based on increasing value for money. The authors recommend that expenditure data for PEPFAR be made available to the public in a transparent fashion on an annual basis in a usable format and that the Global Fund make its data accessible for each program funded. They find that program output indicators to track indirect services are incomplete and need to be further developed. The trade-off between providing current services and providing future ones needs to be stated clearly, and funding decisions made accordingly. Finally, given projections that funding for HIV will likely not increase, particularly for low-income countries facing the highest HIV burden, an explicit emphasis on improving value for money by finding ways to better leverage existing monies is imperative.

Negotiation Strategies for Antiretroviral Drug Purchasers in the United States

Antiretroviral treatment has transformed HIV from a death sentence to a chronic condition, allowing people with HIV to live longer and healthier lives. However, they face significant barriers to accessing and affording life-saving-but expensive-antiretroviral (ARV) medications. These barriers are particularly severe for low-income patients, and they disproportionately affect racial and ethnic minorities. High ARV prices create pressure for government insurers to contain costs either by rationing care or by restricting eligibility for public programs. Limited funding, coupled with a growing demand for HIV care and treatment, is likely to make programmatic decisions about who is covered become more difficult over time. Therefore, it is important to identify options for reducing the cost of providing ARVs to allow more people to receive treatment. This study examines a variety of options for negotiating lower ARV procurement costs in U.S. markets. A case-study approach is used to assess options that different stakeholders could use in negotiating ARV price discounts with drug manufacturers given the regulatory and market constraints that exist in the United States.

Substance use and other risk factors for unprotected sex: results from an event-based study of homeless youth

This study used an event-based approach to understand condom use in a probability sample of 309 homeless youth recruited from service and street sites in Los Angeles County. Condom use was significantly less likely when hard drug use preceded sex, the relationship was serious, the partners talked about "pulling out", or sex occurred in a non-private place (and marginally less likely when heavier drinking preceded sex, or the partnership was monogamous or abusive). Condom use was significantly more likely when the youth held positive condom attitudes or were concerned about pregnancy, the partners talked about condom use, and the partners met up by chance. This study extends previous work by simultaneously examining a broad range of individual, relationship, and contexual factors that may play a role in condom use. Results identify a number of actionable targets for programs aimed at reducing HIV/STI transmission and pregnancy risk among homeless youth.

Provider barriers and facilitators to screening for intimate partner violence in Bogotá, Colombia

We conducted interviews with 27 health care personnel in Bogotá, Colombia, to examine provider barriers and facilitators to screening for intimate partner violence (IPV). We used systematic qualitative analysis to identify the range and consistency of beliefs. We found that respondents did not routinely screen for IPV. Providers listed numerous barriers to screening. Ways to improve screening included increased clinician training, installing systematic IPV screening, providing patient education, and implementing health care setting interventions. Improving the care for IPV survivors will involve translating health care personnel preferred solutions into more systematic IPV screening interventions.

Sex and relationships on the street: how homeless men judge partner risk on Skid Row

Homeless men in the U.S. represent a large and growing population, and have elevated rates of HIV/AIDS and sexual risk behaviors, including unprotected sex with women. We conducted qualitative interviews (n = 30) with homeless men using shelters and meal lines in downtown Los Angeles (Skid Row) to better understand how such men view the risks of sexual encounters with female partners. Men living on Skid Row perceived multiple risks, including HIV and unwanted pregnancy as well as emotional trauma, loss of resources, exacerbation of drug addiction, and physical attack. Respondents described using visual and behavioral cues, social reputation, geographical location, feelings of trust, perceived relationship seriousness, and medically inaccurate "folk" beliefs to judge whether partners were risky and/or condom use was warranted. Medically inaccurate beliefs suggest the potential utility of evidence-based interventions to change such beliefs. We also consider implications for relationships on the street and housing interventions.

Association of childhood abuse with homeless women's social networks

OBJECTIVE

Childhood abuse has been linked to negative sequelae for women later in life including drug and alcohol use and violence as victim or perpetrator and may also affect the development of women's social networks. Childhood abuse is prevalent among at-risk populations of women (such as the homeless) and thus may have a stronger impact on their social networks. We conducted a study to: (a) develop a typology of sheltered homeless women's social networks; (b) determine whether childhood abuse was associated with the social networks of sheltered homeless women; and (c) determine whether those associations remained after accounting for past-year substance abuse and recent intimate partner abuse.

METHODS

A probability sample of 428 homeless women from temporary shelter settings in Los Angeles County completed a personal network survey that provided respondent information as well as information about their network members' demographics and level of interaction with each other. Cluster analyses identified groups of women who shared specific social network characteristics. Multinomial logistic regressions revealed variables associated with group membership.

RESULTS

We identified three groups of women with differing social network characteristics: low-risk networks, densely connected risky networks (dense, risky), and sparsely connected risky networks (sparse, risky). Multinomial logistic regressions indicated that membership in the sparse, risky network group, when compared to the low-risk group, was associated with history of childhood physical abuse (but not sexual or emotional abuse). Recent drug abuse was associated with membership in both risky network groups; however, the association of childhood physical abuse with sparse, risky network group membership remained.

CONCLUSIONS

Although these findings support theories proposing that the experience of childhood abuse can shape women's social networks, they suggest that it may be childhood physical abuse that has the most impact among homeless women.

PRACTICAL IMPLICATIONS

The effects of childhood physical abuse should be more actively investigated in clinical settings, especially those frequented by homeless women, particularly with respect to the formation of social networks in social contexts that may expose these women to greater risks.

Assessment of food offerings and marketing strategies in the food-service venues at California Children's Hospitals

OBJECTIVE

Marketing strategies and food offerings in hospital cafeterias can impact dietary choices. Using a survey adapted to assess food environments, the purpose of this study was to assess the food environment available to patients, staff, and visitors at the food-service venues in all 14 California children's hospitals.

METHODS

We modified a widely-used tool to create the Nutritional Environment Measures Survey for Cafeterias (NEMS-C) by partnering with a hospital wellness committee. The NEMS-C summarizes the number of healthy items offered, whether calorie labeling is present, if there is signage promoting healthy or unhealthy foods, pricing structure, and the presence of unhealthy combination meals. The range of possible scores is zero (unhealthy) to 37 (healthy). We directly observed the food-service venues at all 14 tertiary care children's hospitals in California and scored them.

RESULTS

Inter-rater reliability showed 89% agreement on the assessed items. For the 14 hospitals, the mean score was 19.1 (SD = 4.2; range, 13-30). Analysis revealed that nearly all hospitals offered diet drinks, low-fat milk, and fruit. Fewer than one-third had nutrition information at the point of purchase and 30% had signs promoting healthy eating. Most venues displayed high calorie impulse items such as cookies and ice cream at the registers. Seven percent (7%) of the 384 entrees served were classified as healthy according to NEMS criteria.

CONCLUSIONS

Most children's hospitals' food venues received a mid-range score, demonstrating there is considerable room for improvement. Many inexpensive options are underused, such as providing nutritional information, incorporating signage that promotes healthy choices, and not presenting unhealthy impulse items at the register.

Social networks of PLHA in Uganda: implications for mobilizing PLHA as agents for prevention

The objective of this study was to describe the social networks of people living with HIV/AIDS (PLHA) and explore the implications social network characteristics might have for mobilizing PLHA as prevention agents. Thirty-nine PLHA attending an HIV clinic in Kampala, Uganda provided information on themselves and on 20 network members. Based on these data, descriptive statistics for social network composition and structure were calculated. Research questions relating these network characteristics to treatment-related variables such as time since diagnosis, ART status, and time on ART were investigated. Analyses reveal that, in general, network members know the PLHA's status, are trusted, provide advice and support, and are well-connected to each other. Network features (e.g., proportion of individuals who know the PLHA's status) are related to the previously mentioned treatment variables. Findings suggest that PLHA surround themselves with a social context that enables PLHA to feel fairly protected and supported if they choose to discuss HIV and prevention. With respect to treatment, those on ART may be better prepared to act as prevention advocates.

Patients' and caregivers' experiences of the impact of Parkinson's disease on health status

BACKGROUND: Parkinson's disease (PD) is a neurodegenerative disease that significantly affects patients' quality of life. The myriad complexities of the disease, including its nonmotor manifestations, are beginning to be more fully appreciated, particularly in regard to the emotional and social effects of PD. Considering that both motor and nonmotor manifestations of PD significantly influence the health outcomes and conditions of patients, and their health-related quality of life (HRQOL), we collected qualitative data from patients with PD, as well as caregivers of persons with PD having cognitive impairment, to assess their perceptions of the impact of PD on HRQOL. METHODS: We conducted eight focus groups and five one-on-one interviews in English and in Spanish between March 2007 and February 2008. Three of the focus groups were conducted with a total of 15 caregivers; the remaining focus groups and all interviews were conducted with 48 PD patients. Study participants were asked about the challenges that PD patients may experience, particularly pertaining to physical functioning, the impact of PD on their emotional status, and social functioning. RESULTS: Based on analysis of the transcripts, we identified seven overarching domains or themes that reflect patients' perspectives on living with PD, ie, physical functioning, social and role functioning, emotional impact, fears and uncertainty about the future, stigma and other feelings about PD, coping mechanisms, and benefits of having PD. CONCLUSION: We underscore the salient aspects regarding the physical effects of PD along with its nonphysical ramifications, offering perspectives into the experience of PD and suggestions on how PD patients and their caregivers may cope with the disease.

Strengthening families of children with developmental concerns: parent perceptions of developmental screening and services in Head Start

OBJECTIVE

The authors investigated perceptions of parents with children in the Head Start program about the processes of detection and intervention for developmental concerns.

DESIGN

Descriptive, qualitative study.

SETTING

A large, urban Head Start agency, operating 14 centers and annually serving more than 1200 predominantly Latino children. During 2008-2009, a collaborative partnership with academicians from UCLA was created to evaluate their model of developmental screening and referrals. PARTICIPANTS AND PROCEDURES: We conducted 5 focus groups with a total of 30 parents of Head Start children with developmental concerns. Parents were asked about where they go for information when they have concerns, how they perceived the developmental screening process and services, and how children and families have changed after being in the Head Start program. Focus groups were recorded, transcribed and translated into English, then coded in ATLAS.ti using the domains above and sorted into themes for analysis.

RESULTS

Parents perceived the screening process as both diagnostically and therapeutically important, with multiple benefits ranging from closer parent-teacher relationships to improved parenting and understanding of developmental interventions. Families focused their discussion on the importance of social-emotional and behavioral development, with school readiness and improved expressive language as important but secondary outcomes.

CONCLUSIONS

For families of children with developmental and behavioral risks or concerns, a structured developmental screening process in a preschool setting, such as that provided by Head Start, may serve as a vital gateway for identifying and addressing concerns and promoting social-emotional learning, parent engagement, language development and school readiness.

Parents' disclosure of their HIV infection to their children in the context of the family

We interviewed 33 HIV-infected parents from the HIV Cost and Services Utilization Study (HCSUS), 27 of their minor children, 19 adult children, and 15 caregivers about the process of children learning that their parents were HIV positive. We summarize the retrospective descriptions of parents' disclosure of their HIV status to their children, from the perspective of multiple family members. We analyzed transcripts of these interviews with systematic qualitative methods. Both parents and children reported unplanned disclosure experiences with positive and negative outcomes. Parents sometimes reported that disclosure was not as negative as they feared. However, within-household analysis showed disagreement between parents and children from the same household regarding disclosure outcomes. These findings suggest that disclosure should be addressed within a family context to facilitate communication and children's coping. Parents should consider negative and positive outcomes, unplanned disclosure and children's capacity to adapt after disclosure when deciding whether to disclose.

Unprotected sex of homeless women living in Los Angeles county: an investigation of the multiple levels of risk

This research uses multi-level modeling to investigate the context of unprotected sex of homeless women. Based on interviews with 429 randomly selected women living in temporary shelter settings in Los Angeles, this project investigates multiple levels of influence on unprotected sex with particular partners. Previous studies have investigated condom use of homeless women primarily at the individual level. This project investigates unprotected sex at the level of the partnership, the individual woman, and her social network. Homeless women who believe in the efficacy of condoms to prevent HIV infection, believe that they have low susceptibility to HIV and have a greater proportion of their non-sex partner social network ties with whom they speak about HIV are less likely to engage in unprotected sex. Women are more likely to engage in risky sexual behavior in relationships in which they have high commitment to their partner and experience physical violence.

School site visits for community-based participatory research on healthy eating

BACKGROUND

School nutrition policies are gaining support as a means of addressing childhood obesity. Community-based participatory research (CBPR) offers an approach for academic and community partners to collaborate to translate obesity-related school policies into practice. Site visits, in which trained observers visit settings to collect multilevel data (e.g., observation, qualitative interviews), may complement other methods that inform health promotion efforts. This paper demonstrates the utility of site visits in the development of an intervention to implement obesity-related policies in Los Angeles Unified School District (LAUSD) middle schools.

METHODS

In 2006, trained observers visited four LAUSD middle schools. Observers mapped cafeteria layout; observed food/beverage offerings, student consumption, waste patterns, and duration of cafeteria lines; spoke with school staff and students; and collected relevant documents. Data were examined for common themes and patterns.

RESULTS

Food and beverages sold in study schools met LAUSD nutritional guidelines, and nearly all observed students had time to eat most or all of their meal. Some LAUSD policies were not implemented, including posting nutritional information for cafeteria food, marketing school meals to improve student participation in the National School Lunch Program, and serving a variety of fruits and vegetables. Cafeteria understaffing and costs were obstacles to policy implementation.

CONCLUSIONS

Site visits were a valuable methodology for evaluating the implementation of school district obesity-related policies and contributed to the development of a CBPR intervention to translate school food policies into practice. Future CBPR studies may consider site visits in their toolbox of formative research methods.

Risk and resilience in Latinos: a community-based participatory research study

BACKGROUND

Latino youth in low-income households have a higher likelihood of poor educational and health outcomes than their peers. Protective factors, such as parental support, improve chances of success for youth. A community-academic partnership used community-based participatory research principles to examine perceptions of resilience among Latino young people in low-income households.

METHODS

Semi-structured qualitative interviews were conducted in 2007 with Latino young people living in an urban low-income housing complex (n=20); their parents (n=10); and representatives from local community-based organizations (n=8) to explore their definitions of youth "success," and barriers to and facilitators of success. Interviews were audiotaped, transcribed, coded, and analyzed using content-analysis and grounded theory in 2007.

RESULTS

Participants identified self, family, and community factors as potential sources of support. Parents appeared to de-emphasize community resources, expressing that success resulted primarily from a child's individual desire, bolstered by family support. All stakeholder groups perceived peers more as potential barriers to achieving success than as potential sources of support.

CONCLUSIONS

These findings raise the possibility that in this community, low-income Latino parents' beliefs about community resources may act as a barrier to seeking assistance outside the family. Results also suggest that Latino youth recognize the benefits of interacting with adults outside the family and are accepting of help from the community. Resilience promotion programs in this population may benefit from engaging parents and community members in addition to young people. Parent-focused programs could explore parental beliefs about youth success, and youth programs could engage adult community members to generate positive interactions and messages.

Using community-based participatory research to identify potential interventions to overcome barriers to adolescents' healthy eating and physical activity

Using a community-based participatory research approach, we explored adolescent, parent, and community stakeholder perspectives on barriers to healthy eating and physical activity, and intervention ideas to address adolescent obesity. We conducted 14 adolescent focus groups (n = 119), 8 parent focus groups (n = 63), and 28 interviews with community members (i.e., local experts knowledgeable about youth nutrition and physical activity). Participants described ecological and psychosocial barriers in neighborhoods (e.g., lack of accessible nutritious food), in schools (e.g., poor quality of physical education), at home (e.g., sedentary lifestyle), and at the individual level (e.g., lack of nutrition knowledge). Participants proposed interventions such as nutrition classes for families, addition of healthy school food options that appeal to students, and non-competitive physical education activities. Participants supported health education delivered by students. Findings demonstrate that community-based participatory research is useful for revealing potentially feasible interventions that are acceptable to community members.

A contrast between mothers' assessments of child malnutrition and physical anthropometry in rural Mexico: a mixed methods community study

OBJECTIVE

To compare mothers' assessments of nutritional status with anthropometric measures and gain further insights into mothers' reasons for their judgment.

DESIGN

Each mother was asked to assess the nutritional status of her child and 2 other children and to compare all 3. Rates for "hits" and "misses" between mothers' assessment and physical anthropometry were analyzed using the binomial test. The rationale for the mothers' assessments was explored through open-ended questions.

SETTING

A rural clinic in an indigenous area of Mexico.

PARTICIPANTS

31 mothers of children 1-5 years of age.

MAIN OUTCOME MEASURES

Physical anthropometry and mothers' assessments.

RESULTS

A significant proportion (P <or= .01) of mothers matched the anthropometry on weight for age and weight for height but not on height for age; only when assessing their own child, and when comparing weight for age of their own child with the first child used for comparison. Mothers based their assessment on the child's physical appearance, energy, eating behavior, and on their own performance as caregivers.

CONCLUSIONS AND IMPLICATIONS

Mothers' assessments were better than mere guesses. Their understanding of children's nutritional status in particular and health in general should be used to design more effective and sustainable communication messages, properly combining mothers' and health providers' constructs. It is also important to find ways to make mothers recognize stunting as a nutrition-related problem.

Technical assistance as a prevention capacity-building tool: a demonstration using the getting to outcomes framework

Demands on community-based prevention programs for performance accountability and positive outcomes are ever increasing in the face of constrained resources. Relatively little is known about how technical assistance (TA) should be structured to benefit community-based organizations and to lead to better outcomes. In this study, data from multiple sources were used to describe an effective TA model designed to improve the capacity of community-based organizations to plan, implement, and evaluate prevention programming. This article is the first of its kind to provide detailed analyses of the TA delivered to community-based organizations to build substance abuse prevention capacity. The results of this study describe the range of TA services provided and the importance of two-way communication between the TA provider and recipient. TA recipients reported high satisfaction and an improved understanding of targeted TA activities. However, achieving these benefits requires significant program staff time, and not all skills were successfully transferred. Results from this study suggest how TA may be structured to be effective in supporting quality prevention programming in community settings.

Characteristics of the original patient navigation programs to reduce disparities in the diagnosis and treatment of breast cancer

BACKGROUND

Patient navigation is an intervention developed to reduce disparities in cancer care that is being widely replicated and receiving considerable support for demonstration projects and research to test its effectiveness. In the current study, the authors present an in-depth descriptive analysis of the original patient navigation programs to inform current and future program development.

METHODS

A qualitative multistakeholder case study using interviews and site visits of the first patient navigation site and 2 sites subsequently developed by the leadership of the original site were evaluated.

RESULTS

At these sites, patient navigation is a system, as opposed to a person, comprised primarily of navigators and directors that work together to remove barriers and facilitate access in a well-defined course of care; navigators were from the community or were culturally similar to the patient population served but were also paid employees of the clinical care site with detailed knowledge of the clinical course patients must traverse to complete care plans. Directors had administrative authority over the clinical facility and social capital across institutions, and communicated regularly and openly with navigators to implement system level changes to remove barriers to care. Contextual factors such as policies supporting breast cancer care also influenced the implementation of these programs.

CONCLUSIONS

The first patient navigation programs combined community and culturally sensitive care-coordination with aspects of disease management programs to reduce racial, ethnic, and poverty-driven disparities in care. Future efforts to replicate and evaluate patient navigation should take into account these unique aspects of the original patient navigation programs.

Experiences of social stigma and implications for healthcare among a diverse population of HIV positive adults

Stigma profoundly affects the lives of people with HIV/AIDS. Fear of being identified as having HIV or AIDS may discourage a person from getting tested, from accessing medical services and medications, and from disclosing their HIV status to family and friends. In the present study, we use focus groups to identify the most salient domains of stigma and the coping strategies that may be common to a group of diverse, low-income women and men living with HIV in Los Angeles, CA (n = 48). We also explore the impact of stigma on health and healthcare among HIV positive persons in our sample. Results indicate that the most salient domains of stigma include: blame and stereotypes of HIV, fear of contagion, disclosure of a stigmatized role, and renegotiating social contracts. We use the analysis to develop a framework where stigma is viewed as a social process composed of the struggle for both internal change (self-acceptance) and reintegration into the community. We discuss implications of HIV-related stigma for the mental and physical health of HIV-positive women and men and suggestions for possible interventions to address stigma in the healthcare setting.

Variations in provider conceptions of integrative medicine

Consumers often turn to complementary and alternative medicine (CAM) and use it concurrently with conventional medicine to treat illnesses and promote wellness. However, prior studies demonstrate that these two paradigms are often not combined effectively. Consumers often do not tell physicians about CAM treatments or CAM practitioners about conventional treatments that they are using. This can lead to inefficient care and/or adverse interactions. There is also a lack of consensus about the structure and practice of integrative medicine among the various types of practitioners. This qualitative study aimed to identify key domains and develop a conceptual model of integrative medicine at the provider level, using a grounded theory approach. Purposive sampling was used to select 50 practitioners, including acupuncturists, chiropractors, internists/family practitioners, and physician acupuncturists in private practice and at academic medical centers in Los Angeles. We conducted semi-structured, in-depth interviews with practitioners and then identified core statements that describe practitioners' attitudes and behaviors toward integrative medicine. Core statements were free pile sorted to ascertain key domains of integrative medicine. Four key domains of integrative medicine were identified at the provider level: attitudes, knowledge, referral, and practice. Provider age, training, and practice setting also emerged as important factors in determining clinicians' "orientation" toward integrative medicine. "Dual-trained" practitioners, such as physician acupuncturists, exemplified clinicians with a greater orientation toward integrative medicine. They advocated an open-minded perspective about other healing traditions, promoting co-management with and making referrals to practitioners of other paradigms, and treating patients with both CAM and conventional healing modalities.

A Self-Report Measure of Clinicians' Orientation toward Integrative Medicine

OBJECTIVE

Patients in the U.S. often turn to complementary and alternative medicine (CAM) and may use it concurrently with conventional medicine to treat illness and promote wellness. However, clinicians vary in their openness to the merging of treatment paradigms. Because integration of CAM with conventional medicine can have important implications for health care, we developed a survey instrument to assess clinicians' orientation toward integrative medicine.

STUDY SETTING

A convenience sample of 294 acupuncturists, chiropractors, primary care physicians, and physician acupuncturists in academic and community settings in California.

DATA COLLECTION METHODS

We used a qualitative analysis of structured interviews to develop a conceptual model of integrative medicine at the provider level. Based on this conceptual model, we developed a 30-item survey (IM-30) to assess five domains of clinicians' orientation toward integrative medicine: openness, readiness to refer, learning from alternate paradigms, patient-centered care, and safety of integration.

PRINCIPAL FINDINGS

Two hundred and two clinicians (69 percent response rate) returned the survey. The internal consistency reliability for the 30-item total scale and the five subscales ranged from 0.71 to 0.90. Item-scale correlations for the five subscales were higher for the hypothesized subscale than other subscales 75 percent or more of the time. Construct validity was supported by the association of the IM-30 total scale score (0-100 possible range, with a higher score indicative of greater orientation toward integrative medicine) with hypothesized constructs: physician acupuncturists scored higher than physicians (71 versus 50, p<.001), dual-trained practitioners scored higher than single-trained practitioners (71 versus 62, p<.001), and practitioners' self-perceived "integrativeness" was significantly correlated (r=0.60, p<.001) with the IM-30 total score.

CONCLUSION

This study provides support for the reliability and validity of the IM-30 as a measure of clinicians' orientation toward integrative medicine. The IM-30 survey, which we estimate as requiring 5 minutes to complete, can be administered to both conventional and CAM clinicians.