Telehealth uptake among middle-aged and older Americans during COVID-19: chronic conditions, social media communication, and race/ethnicity

OBJECTIVES

This study investigated whether and to what extent constructs of the protection motivation theory of health (PMT)-threat appraisal (perceived vulnerability/severity) and coping appraisal (response efficacy and self-efficacy)-are related to telehealth engagement during the COVID-19 pandemic, and how these associations differ by race/ethnicity among middle-aged and older Americans.

METHODS

Data were from the 2020 Health and Retirement Study. Multivariable ordinary least-squares regression analyses were computed adjusting for health and sociodemographic factors.

RESULTS

Some PMT constructs are useful in understanding telehealth uptake. Perceived vulnerability/severity, particularly comorbidity (b = 0.13, 95% confidence interval (CI) [0.11, 0.15], p < 0.001), and response efficacy, particularly participation in communication via social media (b = 0.24, 95% CI [0.21, 0.27], p < 0.001), were significantly and positively associated with higher telehealth uptake during the COVID-19 pandemic among middle-aged and older Americans. Non-Hispanic Black adults were more likely to engage in telehealth during the pandemic than their non-Hispanic White counterparts (b = 0.20, 95% CI [0.12, 0.28], p < 0.001). Multiple moderation analyses revealed the significant association between comorbidity and telehealth uptake was similar across racial/ethnic groups, whereas the significant association between social media communication and telehealth uptake varied by race/ethnicity. Specifically, the association was significantly less pronounced for Hispanic adults (b = -0.11, 95% CI [-0.19, -0.04], p < 0.01) and non-Hispanic Asian/other races adults (b = -0.13, 95% CI [-0.26, -0.01], p < 0.05) than it was for their non-Hispanic White counterparts.

CONCLUSION

Results suggest the potential of using social media and telehealth to narrow health disparities, particularly serving as a bridge for members of underserved communities to telehealth uptake.

Reconsidering Community-Engaged Research Through a Syndemic Theoretical Framework: Lessons from COVID-19

BACKGROUND

Community-engaged research is a well-established approach to tackling health disparities in communities of color. However, the devastation caused by coronavirus disease 2019 (COVID-19) calls for a reexamination of the practice of community-engaged research. Syndemic framework characterizes the clustering and synergistic interactions between two or more diseases amid an underlay of social and environmental threats. This framework has been used to explain the disproportionately higher rates of COVID-19 in communities of color and may have utility in guiding future community-engaged research.

OBJECTIVES

This article describes the process by which a syndemic framework was used to generate discussions on lessons learned from COVID-19 and describes the ensuing collaborative writing process that emerged from this discourse.

METHODS

This article was developed by the Community Engagement Working Group (CEWG) of the Jackson Heart Study, a community-based epidemiologic study focused on cardiovascular disease among African Americans in the Jackson, Mississippi Metropolitan Area. By drawing upon a syndemic framework and lessons from COVID-19, the CEWG identified gaps and opportunities to enhance community-engaged research.

CONCLUSIONS

Using syndemic framework as a starting point, the CEWG identified the following as aspects of community-engaged research that may warrant further consideration: 1) the need to examine multiple dimensions and assets of a community, 2) the need to view communities through an intersectionality lens, 3) the need to acknowledge the impact of historical and current trauma on the community, and 4) the need to provide support to community-engaged researchers who may be members of minoritized groups themselves and therefore, experience similar trauma.

Targeting Hypertension: Working with Rural Barbershops to Identify Hypertension and Encourage Treatment

INTRODUCTION

Cardiovascular disease (CVD), accounting for one in every four U.S. deaths, has had a devastating impact on Mississippi's African American population. Seeking innovative mitigation models, this study assesses CVD prevalence and reach via barbershops to rural Mississippi African Americans.

METHODS

Data was collected from barbershop clientele who consented to be screened and contacted for referral to clinical care if blood pressure was found to be elevated.

RESULTS

Most participants were African American (97.7%, n=2,756) and male (54.4%). Descriptive findings revealed more than one-third of participants (34.2%) had elevated blood pressure at screening. Factoring in those with hypertension in control, we found lower rates of hypertension in the male population (males 51.4% vs. females 57.8%), a sharp contrast to national rates.

CONCLUSION

Evaluation findings suggest CVD prevalence in rural Mississippi is comparatively high but that barbershop partners were able to successfully reach and screen the target population.

The Living Donor Navigator Program Provides Support Tools for Caregivers

INTRODUCTION

The Living Donor Navigator (LDN) program is one of several initiatives designed to help transplant candidates identify living donors with the help of a friend or family member advocate to speak on their behalf. More than half of advocates in the LDN program were the spouse or parent of the candidate and served in a caregiving role. Caregivers for patients awaiting transplantation have reported poorer quality of life than the general population, suggesting more support is needed for this vulnerable group. The purpose of this study was to understand whether the LDN program met the needs of advocates who were also caregivers for the transplant candidate.

METHODS

We performed a supplementary secondary qualitative analysis of a parent study conducted December 2017-January 2018 with 9 advocates who participated in the LDN program. Transcripts were reanalyzed from focus group discussions, concentrating on comments about caregiving or made by caregivers. Using manual coding and reflexive thematic analysis, we identified broad codes and major themes.

FINDINGS

Our re-analysis revealed one theme overlapping with our previous analysis (Support) and 2 new themes specific to caregiver advocates: Quality of Life and Fear. Caregivers agreed that the LDN program equipped them with tools to address these areas and best serve their simultaneous caregiver/advocate roles.

DISCUSSION

These analyses demonstrated that those who served as advocate and caregiver derived a benefit from the LDN program but had distinct needs from other advocates. These findings can inform continued refinement of the program and expansion to support needs of caregiver.

The Mississippi Delta Health Collaborative Medication Therapy Management Model: Public Health and Pharmacy Working Together to Improve Population Health in the Mississippi Delta

Introduction

The Mississippi Delta has high rates of chronic disease and is known for its poor health outcomes and health disparities. The University of Mississippi School of Pharmacy (UMSOP) and the Mississippi State Department of Health partnered in 2009 through the Mississippi Delta Health Collaborative to reduce health disparities and improve clinical outcomes by expanding the UMSOP’s evidence-based medication therapy management (MTM) initiative, focused in Mississippi’s 18-county Delta region, to federally qualified health centers (FQHCs) in 4 of those counties.

Methods

Between January 2009 and August 2018, the MTM initiative targeted FQHC patients aged 18 years or older with a diagnosis of diabetes, hypertension, and/or dyslipidemia. Pharmacists initially met face-to-face with patients to review all medications, provide education about chronic diseases, identify and resolve drug therapy problems, and take appropriate actions to help improve the effectiveness of medication therapies. Clinical parameters evaluated were systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, and hemoglobin A_1c (HbA_1c).

Results

The analysis included 335 patients with hypertension (n = 287), dyslipidemia (n = 131), and/or diabetes (n = 331). Significant mean reductions occurred in the following metrics: SBP (7.1 mm Hg), DBP (6.3 mm Hg), LDL cholesterol (24.9 mg/dL), triglycerides (45.5 mg/dL), total cholesterol (37.7 mg/dL), and HbA_1c (1.6% [baseline ≥6%] and 1.9% [baseline ≥9%]).

Conclusion

Despite the cultural and environmental disadvantages present in the Mississippi Delta, the integrated MTM treatment program demonstrated significant health improvements across 3 chronic diseases: hypertension, dyslipidemia, and diabetes. This model demonstrates that a partnership between public health and pharmacy is a successful and innovative approach to care.

Transitional Care Home Visits Among Underserved Patients With Heart Failure

Heart failure (HF), a global public health problem affecting 26 million people worldwide, significantly impacts quality of life. The prevalence of depression associated with HF is 3 times higher than that of the general population. Evidence, though, supports the use of transitional care as a method to enhance functional status and improve rates of depression in patients with HF. This article discusses the findings of a quality improvement project that evaluated health outcomes in underserved patients with HF who participated in a transitional care home visitation program. The visitation program exemplifies the role of leadership in facilitating transitions across the health care continuum. The 2-year retrospective review included 79 participants with HF. Comparisons of outcomes were made over 6 months. Although not statistically significant, clinically significant differences in health outcomes were observed in participants who received a home visit >14 days compared with ≤14 days after hospital discharge. A home visitation program for underserved patients with HF offers opportunities to enhance care across the continuum. Ongoing evaluation of the existing home visitation program is indicated over time with the goal of offering leaders data to enhance patient and family-centered transitional care coordination.

A Qualitative Assessment of the Living Donor Navigator Program to Identify Core Competencies and Promising Practices for Implementation

Introduction:

The best strategy to increase awareness of and access to living kidney donation remains unknown. To build upon the existing strategies, we developed the Living Donor Navigator program, combining advocacy training of patient advocates with enhanced health-care systems training of patient navigators to address potential living donor concerns during the evaluation process. Herein, we describe a systematic assessment of the delivery and content of the program through focus group discussion.

Methods:

We conducted focus groups with 9 advocate participants in the Living Donor Navigator program to identify knowledge, skills, and abilities needed for both advocates and navigators. We focused on 2 organizational levels: (1) the participant level or the advocacy training of the advocates and (2) the programmatic level or the support role provided by the navigators and administration of the program.

Findings:

From 4 common themes (communication, education, support, and commitment), we identified several core competencies and promising practices, at both the participant and programmatic levels. These themes highlighted the potential for several improvements of program content and delivery, the importance of cultural sensitivity among the Living Donor navigators, and the opportunity for informal caregiver support and accountability provided by the program.

Discussion:

These competencies and promising practices represent actionable strategies for content refinement, optimal training of advocates, and engagement of potential living donors through the Living Donor Navigator program. These findings may also assist with program implementation at other transplant centers in the future.

Moving Career Development Upstream: Evaluation of a Course for Internal Medicine Trainees Contemplating Career Pathways in Academic Medicine

OBJECTIVES

Despite training in academic medical centers, many residents and fellows lack an understanding of the different career paths in academic medicine. Without this fundamental knowledge, choosing an academic career pathway and transitioning to junior faculty is challenging. We started the Pathways in Academic Medicine course ("Pathways") to introduce residents and fellows to the wide array of academic career pathways and to expose them to the concepts and resources needed to transition successfully from trainee to junior faculty.

RESULTS

Sixty-nine medicine residents and fellows participated in Pathways programming. Surveys and focus groups revealed high satisfaction with the course sessions. Trainees indicated that Pathways helped them to envision an academic career, clarified the steps needed to pursue an academic career, and normalized common challenges.

CONCLUSIONS

Pathways is an important educational innovation that gives participants experiences to jumpstart successful careers in academic medicine. We hope that our program will serve as an example for other institutions interested in improving the trainee-to-faculty transition.

Integration of Authentic Leadership Lens for Building High Performing Interprofessional Collaborative Practice Teams

Interprofessional collaborative practice (IPCP) models facilitate collaboration and teamwork across the health care continuum. Success of high performing IPCP teams is dependent on compassionate, authentic leaders who invest in helping their teams thrive amidst complexity. This article presents the integration of an authentic leadership lens for building high performing IPCP teams. Using their experience with implementation of an innovative IPCP model to improve health outcomes for an underserved patient population in the southeastern United States, the authors share targeted strategies using an authentic leadership lens to develop high performing teams. Data collected for 3 years reflect positive team performance outcomes related to collaboration and teamwork, which contributed to enhanced access to care, exceptional patient experience, improved physical and mental health outcomes, reduced hospital readmissions, and decreased cost of care. An innovative IPCP model of care is an effective approach to improve health outcomes and care transitions. However, it may not be fully successful if health care professionals practicing within these models cannot collaborate effectively or maintain personal well-being. The value of using an authentic leadership lens to guide IPCP team development cannot be underestimated.

Community-Based Participatory Research-Speed Dating: An Innovative Model for Fostering Collaborations Between Community Leaders and Academic Researchers

Developing meaningful community-based participatory relationships between researchers and the community can be challenging. The overall success of a community-based participatory relationship should be predicated on commitment and respect from empowered stakeholders. Prior to developing the technique discussed in this article, we hypothesized that the process of fostering relationships between researchers and the community was much like a social relationship: It has to develop organically and cannot be forced. To address this challenge, we developed a community-based participatory research-speed dating technique to foster relationships based on common interests, which we call CBPR-SD. This article describes the logistics of implementing CBPR-SD to foster scholarly collaborations. As part of a federally funded community-based research project, the speed dating technique was implemented for 10 researchers and 11 community leaders with a goal of developing scholarly collaborative groups who will submit applications for community-based research grants. In the end, four collaborative groups developed through CBPR-SD, three (75%) successfully submitted grant applications to fund pilot studies addressing obesity-related disparities in rural communities. Our preliminary findings suggest that CBPR-SD is a successful tool for promoting productive scholarly relationships between researchers and community leaders.

Impact of elective versus required medical school research experiences on career outcomes

Many US medical schools have added a scholarly or research requirement as a potential intervention to increase the number of medical students choosing to become academic physicians and physician scientists. We designed a retrospective qualitative survey study to evaluate the impact of medical school research at the University of Alabama at Birmingham (UAB) on career choices. A survey tool was developed consisting of 74 possible questions with built-in skip patterns to customize the survey to each participant. The survey was administered using the web-based program Qualtrics to UAB School of Medicine alumni graduating between 2000 and 2014. Alumni were contacted 3 times at 2-week intervals during the year 2015, resulting in 168 completed surveys (11.5% response rate). MD/PhD graduates were excluded from the study. Most respondents completed elective research, typically for reasons relating to career advancement. 24 per cent said medical school research increased their desire for research involvement in the future, a response that positively correlated with mentorship level and publication success. Although completion of medical school research was positively correlated with current research involvement, the strongest predictor for a physician scientist career was pre-existing passion for research (p=0.008). In contrast, students motivated primarily by curricular requirement were less likely to pursue additional research opportunities. Positive medical school research experiences were associated with increased postgraduate research in our study. However, we also identified a strong relationship between current research activity and passion for research, which may predate medical school.

Refining and validating a conceptual model of Clinical Nurse Leader integrated care delivery

AIMS

To empirically validate a conceptual model of Clinical Nurse Leader integrated care delivery.

BACKGROUND

There is limited evidence of frontline care delivery models that consistently achieve quality patient outcomes. Clinical Nurse Leader integrated care delivery is a promising nursing model with a growing record of success. However, theoretical clarity is necessary to generate causal evidence of effectiveness.

DESIGN

Sequential mixed methods.

METHODS

A preliminary Clinical Nurse Leader practice model was refined and survey items developed to correspond with model domains, using focus groups and a Delphi process with a multi-professional expert panel. The survey was administered in 2015 to clinicians and administrators involved in Clinical Nurse Leader initiatives. Confirmatory factor analysis and structural equation modelling were used to validate the measurement and model structure.

RESULTS

Final sample n = 518. The model incorporates 13 components organized into five conceptual domains: 'Readiness for Clinical Nurse Leader integrated care delivery'; 'Structuring Clinical Nurse Leader integrated care delivery'; 'Clinical Nurse Leader Practice: Continuous Clinical Leadership'; 'Outcomes of Clinical Nurse Leader integrated care delivery'; and 'Value'. Sample data had good fit with specified model and two-level measurement structure. All hypothesized pathways were significant, with strong coefficients suggesting good fit between theorized and observed path relationships.

CONCLUSIONS

The validated model articulates an explanatory pathway of Clinical Nurse Leader integrated care delivery, including Clinical Nurse Leader practices that result in improved care dynamics and patient outcomes. The validated model provides a basis for testing in practice to generate evidence that can be deployed across the healthcare spectrum.

Bringing Community and Academic Scholars Together to Facilitate and Conduct Authentic Community Based Participatory Research: Project UNITED

Cultural competency, trust, and research literacy can affect the planning and implementation of sustainable community-based participatory research (CBPR). The purpose of this manuscript is to highlight: (1) the development of a CBPR pilot grant request for application; and (2) a comprehensive program supporting CBPR obesity-related grant proposals facilitated by activities designed to promote scholarly collaborations between academic researchers and the community. After a competitive application process, academic researchers and non-academic community leaders were selected to participate in activities where the final culminating project was the submission of a collaborative obesity-related CBPR grant application. Teams were comprised of a mix of academic researchers and non-academic community leaders, and each team submitted an application addressing obesity-disparities among rural predominantly African American communities in the US Deep South. Among four collaborative teams, three (75%) successfully submitted a grant application to fund an intervention addressing rural and minority obesity disparities. Among the three submitted grant applications, one was successfully funded by an internal CBPR grant, and another was funded by an institutional seed funding grant. Preliminary findings suggest that the collaborative activities were successful in developing productive scholarly relationships between researchers and community leaders. Future research will seek to understand the full-context of our findings.

Evaluating Policy, Systems, and Environmental Change Interventions: Lessons Learned From CDC's Prevention Research Centers

Introduction

The field of public health is increasingly implementing initiatives intended to make policies, systems, and environments (PSEs) more supportive of healthy behaviors, even though the evidence for many of these strategies is only emerging. Our objective was 3-fold: 1) to describe evaluations of PSE-change programs in which the evaluators followed the steps of the Centers for Disease Control and Prevention’s (CDC’s) Framework for Program Evaluation in Public Health, 2) to share the resulting lessons learned, and 3) to assist future evaluators of PSE-change programs with their evaluation design decisions.

Methods

Seven Prevention Research Centers (PRCs) applied CDC’s framework to evaluate their own PSE-change initiatives. The PRCs followed each step of the framework: 1) engage stakeholders, 2) describe program, 3) focus evaluation design, 4) gather credible evidence, 5) justify conclusions, and 6) ensure use and share lessons learned.

Results

Evaluation stakeholders represented a range of sectors, including public health departments, partner organizations, and community members. Public health departments were the primary stakeholders for 4 of the 7 evaluations. Four PRCs used logic models to describe the initiatives being evaluated. Their evaluations typically included both process and outcome questions and used mixed methods. Evaluation findings most commonly focused on contextual factors influencing change (process) and the adoption or implementation of PSE-change strategies (outcome). Evaluators shared lessons learned through various channels to reach local stakeholders and broader public health audiences.

Conclusion

Framework for Program Evaluation in Public Health is applicable to evaluations of PSE-change initiatives. Using this framework to guide such evaluations builds practice-based evidence for strategies that are increasingly being used to promote healthful behaviors.

Developing Common Metrics for the Clinical and Translational Science Awards (CTSAs): Lessons Learned

The National Institutes of Health (NIH) Roadmap for Medical Research initiative, funded by the NIH Common Fund and offered through the Clinical and Translational Science Award (CTSA) program, developed more than 60 unique models for achieving the NIH goal of accelerating discoveries toward better public health. The variety of these models enabled participating academic centers to experiment with different approaches to fit their research environment. A central challenge related to the diversity of approaches is the ability to determine the success and contribution of each model. This paper describes the effort by the Evaluation Key Function Committee to develop and test a methodology for identifying a set of common metrics to assess the efficiency of clinical research processes and for pilot testing these processes for collecting and analyzing metrics. The project involved more than one-fourth of all CTSAs and resulted in useful information regarding the challenges in developing common metrics, the complexity and costs of acquiring data for the metrics, and limitations on the utility of the metrics in assessing clinical research performance. The results of this process led to the identification of lessons learned and recommendations for development and use of common metrics to evaluate the CTSA effort.

Orchestrating energy for shifting busyness to strategic work

This department highlights change management strategies that may be successful in strategically planning and executing organizational change initiatives. In this article, the authors discuss the elements of busy work and offers strategies for shifting to focused, strategic work. A useful energy preservation framework is introduced to promote vitality that drives engagement, productivity, and innovation.

A Regional Public Health Field Placement Program

Beginning in 2010, the U.S. Department of Health and Human Services, Health Resources and Services Administration, made provisions in its Public Health Training Center cooperative agreements for field placements. This article describes best practices and lessons learned establishing and managing the South Central Public Health Partnership’s Interns and Mentors Program for ACTion (IMPACT) Field Placement Program, which was initially funded through the Centers for Disease Control and Prevention’s Centers for Public Health Preparedness Cooperative agreement in 2002. The IMPACT program is based on a six-step process that has been developed and refined over its 10-year history: (a) identifying field placement opportunities, (b) marketing field experience opportunities to students, (c) selecting students seeking field experience opportunities, (d) placing students with practice partners, students with practice partners, (e) evaluating student progress toward field experience objectives, and (f) evaluating the program. This article describes the program’s structure and processes, delineates the roles of its academic and practice partners, discusses evidence of its effectiveness, and describes lessons learned from its decade-long history. Hopefully, this information will facilitate the establishment, management and evaluation of internship and field placement programs in other Public Health Training Centers and academic public health programs.

Understanding quality: a guide for developers and consumers of public health emergency preparedness trainings

The work described in this article represents two years of collaboration among 32 evaluators from 23 schools of public health involved in the Centers for Disease Control and Prevention's Centers for Public Health Preparedness program. Evaluators in public health emergency preparedness (PHEP) training were tasked with identifying what constitutes quality in PHEP training and providing guidance to practitioners in selecting training packages. The results of their deliberations included development and selection of guidelines for a high-quality course, a justification of the guidelines, and a Training Selection System (TSS) to assist in analyzing extant trainings. In this article, we present the TSS (along with explanatory notes for each of its sections), preliminary feedback from practitioners, and a discussion of next steps.