Social determinants and participation in fecal occult blood test based colorectal cancer screening: A qualitative systematic review and meta-synthesis

ISSUE ADDRESSED

Colorectal cancer (CRC) screening through fecal occult blood testing (FOBT) has saved thousands of lives globally with multiple countries adopting comprehensive population wide screening programs. Participation rates in FOBT based CRC screening for the socially and economically disadvantaged remains low. The aim of this systematic review is to explore empirical evidence that will guide targeted interventions to improve participation rates within priority populations.

METHODS

PubMed, Embase, Scopus, Cinahl and PsycInfo were systematically searched from inception to 22 June 2022. Eligible studies contained qualitative evidence identifying barriers to FOBT based CRC screening for populations impacted by the social determinants of health. An inductive thematic synthesis approach was applied using grounded theory methodology, to explore descriptive themes and interpret these into higher order analytical constructs and theories.

RESULTS

A total of 8,501 publications were identified and screened. A total of 48 studies from 10 countries were eligible for inclusion, representing 2,232 subjects. Coding within included studies resulted in 30 key descriptive themes with a thematic frequency greater than 10%. Coded themes applied to four overarching, interconnected barriers driving inequality for priority populations: social, behavioural, economic and technical/interfaces. SO WHAT?: This study has highlighted the need for stronger patient/provider relationships to mitigate barriers to FOBT screening participation for diverse groups. Findings can assist health professionals and policy makers address the systemic exclusion of priority populations in cancer screening by moving beyond the responsibility of the individual to a focus on addressing the information asymmetry driving low value perceptions.

Automated Reminders Enhance Mailed Fecal Immunochemical Test Completion Among Veterans: a Randomized Controlled Trial

BACKGROUND

The Veterans Affairs (VHA) is working to establish a population-based colorectal cancer screening program for average-risk patients using mailed fecal immunochemical testing (FIT). However, low response rates to mailed FIT may hinder success. Key features of mailed FIT programs, including the use of reminders, differ among various national programs, with limited evidence among veterans.

OBJECTIVE

We sought to test whether using reminders, either via telephone call or text message, was effective in improving mailed FIT response rates.

DESIGN

We conducted a prospective, randomized quality improvement trial ( ClinicalTrials.gov NCT05012007). Veterans who had not returned a FIT within 2 weeks of receiving the kit were randomized to one of three groups: (1) control (no reminder); (2) an automated telephone call reminder; or (3) an automated text message reminder.

PARTICIPANTS

A total of 2658 veterans enrolled at VA Puget Sound Health Care System who were aged 45-75 and had an average risk of colorectal cancer.

INTERVENTIONS

A single automated telephone call or text message reminder prompting veterans to return the FIT kit.

MAIN MEASURES

Our primary outcome was FIT return at 90 days and our secondary outcome was FIT return at 180 days.

KEY RESULTS

Participant average age was 62 years, 88% were men, and 66% White. At 90 days, both the phone and text reminder interventions had higher FIT return rates compared to control (intention-to-treat results (ITT): control 28%, phone 39%, text 38%; p<0.001). At 180 days, FIT kit return remained higher in the reminder interventions (ITT: control 32%, phone 42%, text 40%; p<0.001).

CONCLUSIONS

Automated reminders increased colorectal cancer screening completion among average-risk veterans. An automated phone call or text message was equally effective. VHA facilities seeking to implement a mailed FIT program should consider using phone or text reminders, depending on available resources.

One Step Closer to Safer: Counseling Outcomes from American Academy of Pediatrics Firearm Safe Storage Education Training

OBJECTIVE

To assess pre and postself-reported counseling outcomes for Safer: Storing Firearms Prevents Harm, an American Academy of Pediatrics universal firearm safe storage counseling training for pediatric clinicians providing health maintenance in outpatient settings.

STUDY DESIGN

Safer was developed by a national multidisciplinary committee of firearm injury prevention experts with input from firearm-owning families and launched in June 2021. Pediatric clinicians completed baseline and 1-month posttraining surveys after signing up for the Pedialink course from February through June 2022. Primary outcomes included self-reported measures of counseling self-efficacy and frequency. Wilcoxon matched-pairs signed-rank tests compared outcome distributions at baseline and follow-up. Two adjusted, multilevel mixed-effects regression models were conducted.

RESULTS

Of 230 clinicians who completed baseline surveys, 146 (64%) completed 1-month postsurveys. Regional representation included Southeast = 67 (46%), Northeast = 24 (16%), Midwest = 21 (14%), Pacific = 15 (10%), Southwest = 11 (8%), and Rocky Mountain = 8 (5%). At follow-up, there was significant improvement in both the distribution of self-efficacy (median [first Quartile-third Quartile = 50 [20-70] at baseline and 80 [60-85] at follow-up; P < .001) and self-reported counseling frequency (median [first Quartile-third Quartile] = 10 [0-50] at baseline and 50 [10-80] at follow-up; P < .001). Adjusted regression model results suggested that self-efficacy significantly improved from baseline to follow-up (time coefficient 25.3; 95% CI = [21.0, 29.5]; P < .001) as did counseling frequency (time coefficient 13.6; 95% CI = [9.2, 18.0]; P < .001).

CONCLUSIONS

Significant improvement in self-reported counseling self-efficacy and frequency was demonstrated 1 month following Safer training.

A Scoping Review of the Clinical Evidence for the Health Benefits of Culinary Doses of Herbs and Spices for the Prevention and Treatment of Metabolic Syndrome

Metabolic syndrome (MetS) is a growing global health problem. Evidence suggests that diets rich in phytochemical-containing herbs and spices can contribute to reducing the risk of chronic diseases. This review assesses the scope of evidence supporting the use of herbs and spices in the diet for the prevention or treatment of MetS and its associated health conditions. A search of the PubMed, Scopus and Google Scholar databases was carried out to assess the available clinical evidence for culinary doses of commonly used herbs and spices. Trials that were measuring health factors related to metabolic disorders in healthy individuals, or the health of individuals with MetS or associated diseases, were included. Out of a total of 1738 papers identified, there were 142 relevant studies on black pepper, chilli, cardamom, cinnamon, coriander, cumin, fennel, fenugreek, garlic, ginger, nigella seed, rosemary, sage and turmeric. No relevant research was found for cloves, mint, oregano, parsley or thyme. Cinnamon, fenugreek and ginger were the herbs/spices with the most published trials on them and that showed promise for glycaemic control. Cardamom appears to have potential to reduce inflammatory markers, and cinnamon, ginger and turmeric to reduce blood lipids. Patients with type 2 diabetes were the population most likely to be included in studies, but the preventative benefits of herbs/spices in healthy populations were also investigated, particularly for chilli, ginger and cinnamon. There is evidence for the beneficial effect of culinary doses of many common herbs/spices in the prevention and treatment of MetS and associated disorders.

A Postcard Primer Prior to Mailed Fecal Immunochemical Test Among Veterans: a Randomized Controlled Trial

BACKGROUND

Mailed fecal immunochemical testing (FIT) programs are increasingly utilized for population-based colorectal cancer (CRC) screening. Advanced notifications (primers) are one behavioral designed feature of many mailed FIT programs, but few have tested this feature among Veterans.

OBJECTIVE

To determine if an advanced notification, a primer postcard, increases completion of FIT among Veterans.

DESIGN

This is a prospective, randomized quality improvement trial to evaluate a postcard primer prior to a mailed FIT versus mailed FIT alone.

PARTICIPANTS

A total of 2404 Veterans enrolled for care at a large VA site that were due for average-risk CRC screening.

INTERVENTION

A written postcard sent 2 weeks in advance of a mailed FIT kit that contained information on CRC screening and completing a FIT.

MAIN MEASURES

Our primary outcome was FIT completion at 90 days, and our secondary outcome was FIT completion at 180 days.

KEY RESULTS

Overall, unadjusted mailed FIT return rates were similar among control vs. primer arms at 90 days (27% vs. 29%, p = 0.11). Our adjusted analysis found a primer postcard did not increase FIT completion compared to mailed FIT alone (OR 1.14 (0.94, 1.37)).

CONCLUSIONS

Though primers are often a standard part of mailed FIT programs, we did not find an increase in FIT completion with mailed postcard primers among Veterans. Given the overall low mailed FIT return rates, testing different ways to improve return rates is essential to improving CRC screening.

Changes in opioid treatment programs and harm reduction provider services during the COVID-19 pandemic: Findings from 10 states

Harm reduction and opioid treatment programs (OTPs) modified service delivery based on rapid changes to state and federal regulations during the COVID-19 pandemic. There is little evidence on how these regulations changed the delivery of medication for opioid use disorder and harm reduction services and whether certain regulations should be made permanent. This study explores how harm reduction OTPs across the United States leveraged changes in regulations and responded to impacts of COVID-19 to continue providing services and perspectives on future legislation that regulates their practice and practice sites. The COVID Harm Reduction and Treatment programs Survey study administered a survey that included closed-ended and free-response questions to 22 sites between August 2020 and January 2021. Program demographics and responses to survey items pertaining to site and service modifications were tabulated and proportions reported. A qualitative descriptive method was used to analyze free-response questions. All (100%) surveyed providers reported the need to modify their services. The majority (68%) reported an increase or no change in client volume; 68% reported increases in naloxone services and 77% reported increases in syringe services programs. Qualitative themes included (a) flexibility in reaching clients due to regulatory changes, (b) benefits and drawbacks of telehealth, and (c) increased vulnerabilities of their clients during the pandemic. Despite difficulties during the COVID-19 pandemic, harm reduction and OTP sites found that regulatory changes provided flexibility in service delivery and that they were better able to serve their clients. Future policies should bolster these sites to continue to provide low-barrier and high-quality services. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Barriers and Facilitators to Cardiovascular Disease Prevention Following Hypertensive Disorders of Pregnancy in Primary Care: Cross-Sectional Surveys

Women with a history of hypertensive disorders of pregnancy (HDP) have an increased risk of cardiovascular disease (CVD). Guidelines recommend that women diagnosed with HDP should be advised of their increased CVD risk, have regular blood pressure monitoring by their general practitioner (GP), and adopt healthy lifestyle behaviours. However, within Australia, the current practice in primary health care is unknown. The aim of this study was to describe current practices, barriers, and facilitators to the provision of CVD preventative services for women after HDP in the primary care setting and to identify potential strategies to support GPs in providing recommended care. Separate cross-sectional online surveys were undertaken with 35 GPs and 105 women with a history of HDP. Surveys included both closed- and open-ended questions. Closed-ended questions were analysed using basic descriptive statistics, and open-ended questions were themed and tallied. The survey of GPs revealed that GPs are more likely to assess traditional CVD risk markers than lifestyle risk factors or HDP history. GPs identified a lack of resources and skills as barriers to providing CVD preventative care post-HDP. The survey with women after HDP revealed that women with a history of HDP are more likely to be assessed for blood pressure than lifestyle CVD risk factors, and that the women's barriers to obtaining care included difficulty obtaining an appointment and time required for attending appointments. Strategies to improve CVD preventative care were consistent between surveys, where 70% of GPs and 59% of women chose 'increasing women's awareness of increased CVD risk' and 67% of GPs and 55% of women chose 'improving communication between hospitals and primary care' as their preferred strategies. While the findings suggest that women with a history of HDP are receiving advice consistent with guidelines for traditional CVD risk markers, such as blood pressure, they are less likely to receive CVD preventative care for lifestyle or female-specific CVD risk factors.

Evaluation of a 13-Month-Old Anemic Child With Gushing Gums

While it is common practice for adults to brush their teeth twice a day and instill in their children the importance of setting hygiene routines centered around brushing their teeth, infants and toddlers are often overlooked. Infants begin teething around four to seven months of age; during this period of tooth eruption, their gums are highly susceptible to bacterial build-up, causing problems long before oral hygiene comes to mind. We describe a case of a 13-month-old child presenting with bleeding gums and worsening anemia. After blood tests, iron supplementation, and a referral to a pediatric hematologist-oncologist out of concern for a potential bleeding disorder, this patient was diagnosed with normochromic, normocytic anemia caused by bleeding due to infectious gingivitis. After the completion of antibiotic therapy and changes to the patient's routine to incorporate appropriate oral hygiene, the anemia resolved. Generally benign, gingivitis induced by plaque biofilm can advance to more severe forms of periodontal disease, leading to receding gums and abscesses, thus reinforcing the importance of promoting adequate oral hygiene in all ages regardless of dentition. Additionally, educating primary-care providers on pediatric gingivitis allows for the inclusion of this diagnosis on differentials, limiting extensive blood tests and specialist appointments.

Women over 50 who use alcohol and their engagement with primary and preventative health services: a narrative review using a systematic approach

BACKGROUND

Women who are over 50 years are drinking alcohol in higher quantities and more frequently than in previous decades. Good engagement with primary care is crucial for women's physical and psychological health, particularly if they use alcohol. However, there is little known about the alcohol use of women over 50 and their use of primary care.

METHODS

A systematic search was conducted on six databases; CINAHL, Medline, PsycINFO, Academic Search Complete, EMBASE and Web of Science to identify literature on primary health care engagement of women 50 years and older (50+) who use alcohol. Titles and abstracts were reviewed and full texts were independently reviewed by two researchers. A narrative review, critical appraisal and synthesis of the eligible studies produced common themes and key findings.

RESULTS

After excluding 3822 articles, 13 articles were deemed eligible for the review. For this age group (50+), findings were: 1) women who drink heavily were less likely than men to attend General Practitioners (GPs), moderate drinkers were more likely than abstainers to attend mammogram screening, 2) GPs were less likely to ask questions or discuss alcohol with women than with men, 3) GPs offered less advice on alcohol to women than to men, and 4) less women than men received alcohol screening from their GP.

DISCUSSION

While women 50+ are drinking more, their alcohol use is underreported and insufficiently provided for in primary health. As women's life expectancy increases, improved GP engagement will benefit women's health and reduce future healthcare costs.

Yoga for Preventive Health: A Holistic Approach

Yoga has been prevalent for over 5000 years; it originated in India and has become an essential lifestyle ingredient for achieving optimal health. The goal of this article in lifestyle modification is to increase awareness about the benefits of yoga and how its practice can reduce the overall risk of chronic diseases. Yoga has been proven to be therapeutic for enhancing immunity and support management of chronic diseases such as cardiovascular, respiratory, endocrine disorders, obesity, cancer, and metabolic syndrome. Yoga techniques called asanas, such as pranayama for breathing regulation and dhyana for meditation, boost innate immune response, interrupt inflammation, and thereby prevent the manifestation of chronic diseases. Yoga also provides symptomatic relief for chronic arthritis by increasing joint flexibility and microcirculation. Yoga and meditation regulate neurotransmitters, neuropeptides, hormones, and cytokines that mediate interactions between the central nervous system and the immune system. These techniques reduce the psychological and physiological effects of chronic stress. Serotonin, oxytocin, and melatonin released directly due to practicing yoga have been shown to better manage anxiety and fear, especially during the pandemic. We believe the current trends of chronic disease management will become more effective with the implementation of lifestyle changes using yoga.

Developmental origins of health and disease: knowledge, attitude and practice of obstetrics & gynecology residents, pediatric residents, and medical students

Developmental Origin of Health and Disease (DOHaD) explains how the health of the mother influences the offspring's risk of non-communicable diseases in later life. However, this remains underutilized in clinical practice. This study aimed to investigate the knowledge, attitude, and practice (KAP) of medical students, Obstetrics and Gynecology (O&G) and Pediatrics residents, toward DOHaD, identify potential barriers to DOHaD counseling, and translate DOHaD concepts into clinical practice. This cross-sectional study was conducted with a multi-section digital questionnaire, rated on a five-point Likert scale (1-5), with a higher score indicating better KAP. The scores between groups were compared using ANOVA. A total of 117 participants, comprising medical students (n = 75, 64.1 percent), O&G (n = 33, 28.2 percent) and Pediatric residents (n = 9, 7.7 percent), completed the questionnaire. The mean scores for the "Knowledge," "Attitude" and "Practice" sections were 3.73 (standard deviation 0.82), 4.27 (0.59) and 3.03 (0.52), respectively. O&G residents scored higher for the "Practice" section than Pediatric residents (mean scores 3.17 vs. 2.16; p = .048). Overall, the participants demonstrated good knowledge and attitude, but poor practice toward DOHaD. Thus, there is a need to improve education and training for health care professionals, develop a structured implementation framework, and provide a transdisciplinary care continuum for mother and child.

Factors Associated with Annual Vision Screening in Diabetic Adults: Analysis of the 2019 National Health Interview Survey

Purpose

To determine the association(s) between receiving an annual eye exam and various economic, social, and geographic factors assessed in the 2019 National Health Interview Survey (NHIS) among adults with diabetes.

Patients and Methods

Data from adults 18 years of age and older relevant to self-reported non-gestational diabetes diagnosis and eye exam within the last 12 months were extracted from the 2019 NHIS dataset. A multivariate logistic regression model was used to determine associations between receiving an eye exam in the preceding 12 months and various economic, insurance-related, geographic, and social factors. Outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI).

Results

Among diabetic adults in the US, receiving an eye exam within the last 12 months was significantly associated with female sex (OR 1.29; 95% CI 1.05-1.58), residence in the Midwestern United States (OR 1.39; 95% CI 1.01-1.92), use of Veteran's Health Administration healthcare (OR 2.15; 95% CI 1.34-3.44), having a usual place to go for healthcare (OR 3.89; 95% CI 2.16-7.01), and the use of Private, Medicare Advantage, or other insurance (OR 3.66; 95% CI 2.42-5.53), use of Medicare only excluding Medicare Advantage (OR 3.18; 95% CI 1.95-5.30), dual eligibility for Medicare and Medicaid (OR 3.88; 95% CI 2.21-6.79), and use of Medicaid and other public health insurance (OR 3.04; 95% CI 1.89-4.88) compared to those without insurance. An educational attainment of less than high school (OR 0.66; 95% CI 0.48-0.92), and an educational attainment of high school or GED without any college (OR 0.62; 95% CI 0.47-0.81) reduced the odds of having an annual eye exam.

Conclusion

Economic, social, and geographic factors are associated with diabetic adults receiving an annual eye exam.

Steering Straight: Adapting suicide risk safety planning as a prevention-focused self-management resource for the Australian farming community

OBJECTIVE

This paper draws on the principles of suicide risk safety planning to co-design a farming community resource for preventing and managing risks to mental health.

SETTING

This project was undertaken in the Great South Coast Region of Victoria, Australia.

PARTICIPANTS

A working group (n = 6-8) from the Victorian farming community contributed to the iterative co-design and co-production of Steering Straight: My plan to keep on track. Twenty-four members of the farming community pilot tested Steering Straight.

DESIGN

Co-design to develop, pilot and refine the resource with working group and target farming community.

RESULTS

Steering Straight was viewed positively by the farming community as a tool that prompts prioritising well-being; encourages reflection, planning and concrete steps towards taking action; helps set and meet personal goals; is simple and practical; and identifies pathways to support. Most participants (94%) completed Steering Straight on their own, taking approximately 15-30 min to create their personalised plan. Questions most likely to be filled in related to recognising personal signs of deteriorating well-being and listing and planning enjoyable activities. A majority of participants (67%) kept a hard copy of their Steering Straight plan on hand to refer back to, while 78% expressed a preference for a digital version.

CONCLUSION

The co-design and co-production process resulted in a tailored prevention-focused resource that was accepted and valued by the farming community.

Integrated Health Maintenance Reminders for Improved HPV Vaccine Administration: Toward Improvements in Completion Disparities

OBJECTIVE

To evaluate the effect of a health maintenance reminder (HMR) on human papillomavirus (HPV) vaccine administration and completion across different age, insurance, and race cohorts.

STUDY DESIGN

Retrospective pre-post analysis.

SETTING

Academic primary care.

METHODS

Patients aged 9 to 26 who had initiated the HPV vaccine series from 2016 to 2021 were analyzed, based on current age-based standards. The cohort was divided based on vaccine uptake before and after the implementation of the HMR program in February 2020. The multivariate analysis estimated the odds of vaccine completion based on sociodemographic factors, and variable interactions were investigated to determine independent associations between sociodemographic factors and HMR implementation.

RESULTS

There were 7654 individual patients (mean age was 15.8 years; 46.7 were males; and 50.7% were white). HPV vaccine completion rates increased post-HMR implementation by 59.2% (37% pre-, and 58.9% post-HMR; p < .001) in the entire cohort. Overall, black patients (adjusted odds ratio [aOR] = 0.68; 95% confidence interval [CI]: 0.60, 0.70) and patients ≥18 years (aOR = 0.13; 95% CI: 0.11, 0.15) were significantly less likely to complete their vaccine series; however, this improved significantly following HMR in these groups (p < .001). Post-HMR, race, and insurance status were not independently associated with disparate vaccine completion rates, however, age was, and patients ≤14 or younger had higher odds of vaccine completion (aOR = 3.54; 95% CI: 2.91, 4.32).

CONCLUSION

The implementation of an HMR was associated with increased HPV vaccine uptake across age and race groups in this single-institution study. Future research should explore barriers to implementing HMRs in different healthcare settings.

"So, if she wasn't aware of it, then how would everybody else out there be aware of it?"-Key Stakeholder Perspectives on the Initial Implementation of Self-Collection in Australia's Cervical Screening Program: A Qualitative Study

BACKGROUND

In December 2017, the Australian National Cervical Screening Program transitioned from 2-yearly cytology-based to 5-yearly human papillomavirus (HPV)-based cervical screening, including a vaginal self-collection option. Until July 2022, this option was restricted to under- or never-screened people aged 30 years and older who refused a speculum exam. We investigated the perspectives and experiences of stakeholders involved in, or affected by, the initial implementation of the restricted self-collection pathway.

METHODS

Semi-structured interviews were conducted with 49 stakeholders as part of the STakeholder Opinions of Renewal Implementation and Experiences Study. All interviews were audio recorded and transcribed. Data were thematically analysed and coded to the Conceptual Framework for Implementation Outcomes.

RESULTS

Stakeholders viewed the introduction of self-collection as an exciting opportunity to provide under-screened people with an alternative to a speculum examination. Adoption in clinical practice, however, was impacted by a lack of clear communication and promotion to providers, and the limited number of laboratories accredited to process self-collected samples. Primary care providers tasked with communicating and offering self-collection described confusion about the availability, participant eligibility, pathology processes, and clinical management processes for self-collection. Regulatory delay in developing an agreed protocol to approve laboratory processing of self-collected swabs, and consequently initially having one laboratory nationally accredited to process samples, led to missed opportunities and misinformation regarding the pathway's availability.

CONCLUSIONS

Whilst the introduction of self-collection was welcomed, clear communication from Government regarding setbacks in implementation and how to overcome these in practice were needed. As Australia moves to a policy of providing everyone eligible for screening the choice of self-collection, wider promotion to providers and eligible people, clarity around pathology processes and the scaling up of test availability, as well as timely education and communication of clinical management practice guidelines, are needed to ensure smoother program delivery in the future. Other countries implementing self-collection policies can learn from the implementation challenges faced by Australia.

Study protocol of "From Science 2 School"-prevalence of sports and physical exercise linked to omnivorous, vegetarian and vegan, diets among Austrian secondary schools

The increasing prevalence of unhealthy lifestyle choices contribute to almost all chronic conditions negatively affecting individual and public health. As the most beneficial preventative solution, a healthy lifestyle focusing on the dual approach of physical activity (PA) and a healthful diet is highly recommended. Considering the growing number of people interested in sustainable, plant-based diets, it seems crucial to analyze lifestyle behaviors with a special focus on diet type to delve deeper into the unenthusiastic health status among young populations. Therefore, this multidisciplinary study aims to survey and scale health behaviors with a special focus on the prevalence of traditional and vegetarian diets in connection with PA levels among Austrian pupils (10-19 years), teachers and principals in secondary education levels I and II. Following a cross-sectional design, sociodemographic and school-related data along with a complete profile of lifestyle behaviors, including detailed information regarding diet, PA, sports & exercise, and other health-related behaviors, were collected using online-based questionnaires. A total number of 8,845 children/adolescents (~1.2% of the eligible 771,525 Austrian secondary school pupils) and 1,350 adults (~1.5% of total eligible 89,243 Austrian teachers/principals) participated in the study. As this is the first investigation to explore the prevalence of veganism/vegetarianism amongst a large group of pupils, the present study will add an important contribution to overcome the lack of knowledge on PA, sports & exercise linked to healthy alternative diets. With a sustainable healthy lifestyle, a healthy transition from childhood to adulthood occurs, which can result in growing healthier functioning generations at all social levels. As a study protocol, the present article is intended to present comprehensive details of the study design, objectives, and the associated analytical procedures of the "From Science 2 School" study.

Emergency Department Visits Before Sudden Unexpected Infant Death: A Touchpoint for Unsafe Sleep Reduction

OBJECTIVES

Unsafe sleep remains a leading cause of preventable sudden unexpected infant death (SUID). Infants frequently visit emergency departments (EDs), but the frequency of visits before SUID is unknown. The objective of this study was to determine how often SUID infants visited a pediatric ED or urgent care (UC) before death.

METHODS

We performed a retrospective study of infant deaths in the county of a large, academic pediatric institution. We linked institutional records with coroner reports and death scene investigations. We excluded deaths associated with childbirth, prematurity, injury, or underlying medical condition. We characterized all SUID infants, focusing on unsafe sleep factors detailed in the medical record and scene reports. The main outcome was ED/UC visit(s) before the visit for SUID.

RESULTS

Seventy-three of 122 infant deaths met inclusion criteria for SUID over 76 months (April 2014-July 2020). Median age at death was 87 days (IQR 58, 137); 68 (93%) died before 6 months-of-age. Twenty infants (27%) had an ED/UC visit before SUID; mean visits for these infants were 1.7 (SD 0.8). Median days between the last ED/UC visit and SUID was 39; five infants visited the ED/UC within 2 weeks of SUID. Most visits were for minor medical conditions. All 73 SUID infants had at least one unsafe sleep factor; 88% had ≥2 and 56% ≥3.

CONCLUSIONS

Many SUID infants visited a pediatric ED/UC before death, and unsafe sleep factors were found in every case. Early infancy ED/UC visits may present an opportunity for targeted prevention efforts.

Impact of establishing a Geriatrics Workforce Enhancement Program clinic on preventive health and Medicare Annual Wellness Visits

We established a Geriatrics Workforce Enhancement Program (GWEP) clinic to enhance resident training on comprehensive preventive care and chronic disease management, and to increase the number of older patients who received Medicare Annual Wellness Visit (AWV) preventive services. A total of 1,104 patients were tracked at baseline and during the intervention period. Patients were grouped into two categories: Adult (aged 55-64) and Senior (aged 65+). Clinical quality measures were monitored by electronic health record and tracked through monthly reports at baseline (May 2018) and during the intervention period (July 2018-June 2019). In the Senior group, the proportion of patients receiving the Medicare AWV increased after GWEP began (p <.001). Additionally, the Senior group showed significant improvements in the frequency of body mass index assessments (p = .04), colorectal cancer screenings (p < .001), advance directive documentation (p < .001), cognitive screenings (p < .001), and pneumococcal vaccinations (p < .001). In the Adult group, a trending increase was seen in influenza vaccinations (p = .06). Curricular innovations including the establishment of a GWEP clinic in our residency outpatient center, development of new educational materials, and use of a nurse coordinator resulted in significant improvements in the percentage of older adults who received the Medicare AWV benefit and preventive health performance metrics.

Participation in Physical Education Classes and Health-Related Behaviours among Adolescents from 67 Countries

The present study sought to examine the associations between participation in physical education (PE) classes and a range of health-related behaviours among adolescents. Secondary analysis of self-reported data from the Global Student Health Survey, collected between 2010 and 2017 from 222,121 adolescents (N = 117,914 girls; 49.0%; aged 13–17 years) from 67 countries and five world regions, was carried out. Participation in PE classes (0, 1–2, ≥3 days/week) was the independent variable. Physical activity (PA); sedentary behaviour (SB); active travel to school; fruit, vegetables, and alcohol consumption; and smoking; as well as adopting ≥5 of these healthy behaviours; were the dependent variables. Complex samples logistic regressions were performed to explore the associations between participation in PE classes and health-related behaviours. The results revealed that 18.2% of adolescents did not take part in PE classes. A total of 56.7% and 25.1% of adolescents reported participating in PE classes on 1–2 and ≥3 days/week, respectively. Only 26.8% of adolescents adopted ≥5 healthy behaviours. Participation in PE classes was positively associated with PA, active travel, fruit consumption, and vegetable consumption (only for ≥3 days/week), but was negatively associated with meeting SB recommendations, and with not smoking (only for girls and ≥3 days/week). Overall, PE participation was positively associated with adopting ≥5 healthy behaviours, with favourable results found for those who attended more PE classes. The findings revealed a positive association between participation in PE classes and a range of health-related behaviours among adolescents. This suggests that, worldwide, quality PE should be delivered at least 3 days per week up to daily to promote healthy lifestyles among adolescents.

Which Children Use School-Based Health Services as a Primary Source of Care?

BACKGROUND

School-based health centers (SBHCs) offer primary and preventive health care for children and adolescents. Using nationally representative data, we aimed to examine which child and family characteristics are associated with using school-based health care providers as the primary source of health care, and whether care received from these providers met the criteria for a medical home.

METHODS

Using data from the 2016-2018 National Survey of Children's Health (NSCH), we analyzed children's usual source of care (school-based provider, doctor's office or clinic, other location, or none), and whether they received care meeting medical home criteria.

RESULTS

Based on a sample of 64,710 children, 0.5% identified school-based providers as their primary source of health care. Children who were older, uninsured, or living in the Northeast were significantly more likely to report school-based providers as their usual source of care. Children whose usual source of care was a school-based provider were less likely to receive care meeting medical home criteria than children who usually received care at a doctor's office.

CONCLUSIONS

While SBHCs improve access to care, our findings indicate potential challenges with establishing a medical home for children who usually receive health care from a school-based provider.

An Exploration of the Value of Elective Health Checks in UK Zoo-Housed Gibbons

Elective health checks form an important part of the preventative healthcare of many zoo-housed animals. These procedures are not without risk or financial expenditure, meaning careful cost-benefit analysis is required when determining the frequency and intensity with which they are implemented. This study evaluated the value of elective health checks (n = 74) carried out on 33 gibbons at a single UK zoological collection from 2011 to 2018. Data were categorised by health check type, animal age, clinical findings and outcome. Univariable binary logistic regression and multivariable modelling were used to identify factors associated with the likelihood of actionable (clinically significant) outcomes. In total, 51.35% of all elective health checks resulted in an actionable outcome. Elderly heath checks had 13.64 times greater odds of an actionable outcome and 34 times greater odds of a significant radiographic finding, when compared to routine (non-elderly) health checks. Our findings suggest that 75% wild longevity is a suitable threshold for identifying elderly captive gibbons and increasing health check frequency. Whilst further work is needed to ascertain whether these findings can be extrapolated to other collections and/or species, this study demonstrates how the analysis of clinical data can aid in the implementation of an effective and evidence-based preventative healthcare plan.

A mixed-method analysis of screening for Strongyloides stercoralis prior to immunosuppression: A problem of limited bandwidth?

BACKGROUND

Guidelines recommend screening for strongyloidiasis prior to immunosuppression in those at epidemiological risk, as hyperinfection following immunosuppression is often fatal. The uptake of this recommendation is unknown, and we aimed to explore this in our setting.

AIMS

Determine the proportion of adult patients at epidemiological risk for strongyloidiasis who were screened prior to immunosuppression at the Royal Melbourne Hospital, Explore the factors that influenced clinicians' decision to screen for strongyloidiasis prior to immunosuppression.

METHODS

This study used a mixed-methods approach. First, a 12-month (1 January 2018 to 1 January 2019) retrospective observational study was used to quantify the proportion of those at epidemiological risk who were screened prior to immunosuppression, while also identifying variables that were positively or negatively associated with screening. Second, clinicians from relevant specialties were recruited for focus group sessions to explore factors that influenced their decision to screen according to an interpretivist framework.

RESULTS

230 newly immunosuppressed patients at epidemiological risk of strongyloidiasis were identified, of whom 87 (37.8%) were screened prior to immunosuppression. In multivariate analysis, older patients, outpatients and people from non-English speaking backgrounds were significantly less likely to be screened. In focus groups, a number of barriers and enablers to screening were identified. Notably, clinicians reported that a major barrier was the cognitive load required to clinically reason about this uncommon disease, in addition to other priorities.

CONCLUSION

We identified many missed opportunities to screen patients at risk of hyperinfection, particularly those most vulnerable. To improve screening, this study highlights the importance of reducing cognitive load by using decision-support tools, which may facilitate screening in vulnerable patients and in time-constrained settings. This article is protected by copyright. All rights reserved.

Health screening and preventative health care in refugee women: A qualitative analysis

Background: Regular health screening provides opportunities for early detection and effective treatment of disease. There is underutilisation of health services by migrants from culturally and linguistically diverse backgrounds, particularly refugees in Australia. Aim: To explore the beliefs, understandings, and use of health and healthcare screening services among African refugee women living in Australia. Design/Method: Qualitative secondary analysis. Method: Oral narratives derived from two primary qualitative datasets of Sub-Saharan women in New South Wales, Australia, underwent secondary thematic analysis. Findings: Twenty-two of the forty-two women had refugee status on migrating to Australia. Thematic findings reflection of misinformation, low health literacy, and health screening as not a priority. Conclusions: There is an urgent need to develop innovative strategies to engage refugee migrant women in health screening by provision of culturally meaningful health information. Relevance to clinical practice: Including refugee women's suggestions for information to be provided by health services may improve attitudes towards screening and preventative health care.

Health promotion and preventive health care service guidelines for the care of people with spina bifida

Individuals with Spina Bifida (SB) have unique lifelong medical and social needs. Thus, when considering how to promote health and offer preventive care, providers must adapt general healthcare screening and counseling recommendations to their patients' physical and cognitive impairments along with discerning how to monitor secondary or chronic conditions common to the population. This article provides an update on the health promotion and preventive health care guidelines developed as part of the Spina Bifida Association's fourth edition of the Guidelines for the Care of People with Spina Bifida. The guidelines highlight accommodations needed to promote general preventive health, common secondary/chronic conditions such as obesity, metabolic syndrome, hypertension, musculoskeletal pain, and considerations for preventing acute care utilization for the SB population throughout the lifespan. Further research is needed to understand the effectiveness of preventive care interventions in promoting positive health outcomes and mitigating potentially preventable acute care utilization.

Are formal self-care interventions for healthy people effective? A systematic review of the evidence

Introduction

Preventative interventions are shown to be effective in reducing 40% of the mortality due to unhealthy behaviours and lifestyles. Health-promoting self-care has been recognised as a promising strategy in preventative health. However, self-care research is being done around the self-management of chronic illnesses and the promotion of self-care practices among healthy populations has been overlooked by many healthcare systems.

Method

The study methodology was a systematic review with a narrative synthesis. The search was done through seven academic databases, reference tracking of selected articles and grey literature. The scoping, selection, screening and quality assessments of the articles were reviewed independently by two reviewers.

Results

Sixteen studies met the inclusion criteria. Self-care behaviour, health-promotive lifestyle changes and medical care utilisation were some of the main outcomes evaluated in the studies. Positive effects were seen in increasing self-care and health-promotive behaviours in most interventions although limited or mixed impact was seen in health attitudes, beliefs and utilisation of medical services. Most studies were from high income settings with low-quality study designs. The complexity of the word ‘self-care’ and inconsistencies in the terminology used in health-promotive self-care were significant highlights of the study.

Conclusion

Health-promoting preventative self-care interventions show promise in increasing the well-being of healthy people. However, the methodological drawbacks limit the generalisability of the findings. As the demand for self-care interventions increases, the lack of a formal globally accepted definition and framework and complexity of behaviour change are key limitations to consider moving forward.

Health disparities and chronic disease associated with anemia in free clinics: A retrospective study of uninsured patients in Tampa Bay

Objectives: The objective of this study was to assess the diagnosis and management of anemic patients in free clinics around the Tampa Bay area.Methods: In this retrospective study we extracted data including demographics, chronic diseases, and laboratory values from medical charts of uninsured patients seen in 9 free clinics from January 2016 through December 2017 in the Tampa Bay area, FL, USA. Multiple logistic regression analysis was used to assess relationships between socioeconomic variables and a documented history of anemia.Results: From two years of documented data, 6971 patients were included, of which 367 (5%) had a documented diagnosis of anemia. Most were women (315, 86%), and the median age was 41 years (6-91). Among the 367 patients with anemia,191 (52%) patients had an unspecified type of anemia, 144 (39%) were diagnosed with IDA, 16 (4%) with anemia of chronic disease, and the remaining were other uncommon causes. Only 67% (97/144) of IDA patients had documented iron replacement. Colonoscopies were documented in only 32 (9%) of all patients with anemia, and in 23 (16%) IDA patients. Several chronic diseases were statistically associated and comorbid with a diagnosis of anemia.Conclusions: Uninsured patients with IDA are prescribed iron and undergo colonoscopies at sub-optimal rates. Increasing resources, awareness, and education of providers in these settings could lead to improved treatment practices and decrease the risk of morbidity and mortality.

Long-Term Impact of a Culturally Tailored Patient Navigation Program on Disparities in Breast Cancer Screening in Refugee Women After the Program's End

Purpose: To examine the long-term effects of a patient navigation (PN) program for mammography screening tailored to refugee women and to assess screening utilization among these women after PN ended.

Methods: We assessed the proportion of patients completing mammography screening during the prior 2 years during 2012–2016 for refugee women who had previously received PN compared with that of English-speaking women cared for at the same health center during the same period, both overall and stratifying by age. We used logistic regression to compare screening completion between refugees and English speakers, adjusting for age, race, insurance status, number of clinic visits, and clustering by primary care physician and to test trends in screening over time.

Results: In 2012, the year when the funding for PN ceased, among 126 refugee women eligible for breast cancer screening, mammography screening rates were significantly higher among refugees (90.5%, 95% confidence interval [CI]: 83.5–94.7%) than among English speakers (81.9%, 95% CI: 76.2–86.5%, p=0.006). By 2016, screening rates decreased among refugee women (76.5%, 95% CI: 61.6–86.9%, p=0.023) but were not statistically significantly different from those among English-speaking women (80.5%, 95% CI: 74.4–85.3%, p=0.460). Screening prevalence for refugee women remained above the pre-PN program screening levels, and considerably so in women <50 years.

Conclusion: The culturally and language-tailored PN program for refugee women appeared to have persistent effects, with refugee women maintaining similar levels of mammography screening to English-speaking patients 5 years after the PN program's end.

Cardiovascular disease as a leading cause of death: how are pharmacists getting involved?

Cardiovascular diseases (CVDs) are a leading cause of death globally. This article explores the evidence surrounding community pharmacist interventions to reduce cardiovascular events and related mortality and to improve the management of CVD risk factors. We summarize a range of systematic reviews and leading randomized controlled trials and provide critical appraisal. Major observations are that very few trials directly measure clinical outcomes, potentially owing to a range of challenges in this regard. By contrast, there is an extensive, high-quality evidence to suggest that improvements can be achieved for key CVD risk factors such as hypertension, dyslipidemia, tobacco use, and elevated hemoglobin A1c. The heterogeneity of interventions tested and considerable variation of the context under which implementation occurred suggest that caution is warranted in the interpretation of meta-analyses. It is highly important to generate evidence for pharmacist interventions in developing countries where a majority of the global CVD burden will be experienced in the near future. A growing capacity for clinical registry trials and data linkage might allow future research to collect clinical outcomes data more often.

Web-Based Health Intervention for Young People Who Have a Parent with a Mental Illness: Delphi Study Among Potential Future Users

BACKGROUND

Young people who have a parent with a mental illness face elevated risks to their mental health and well-being. However, they may not have access to appropriate interventions. Web-based interventions may reach and meet the needs of this at-risk group, yet their preferences regarding the features of this medium are unknown.

OBJECTIVE

This study sought to determine the utility of a Web-based intervention to meet the needs of young people who have a parent with a mental illness and their perspectives regarding the types of features of such a website.

METHODS

A systematic, 2-round Delphi study was employed to solicit the views of 282 young people aged 16 to 21 years (Round 1, n=14; Round 2, n=268) from urban and regional settings in Australia who self-reported that their parent has a mental illness. "Regional" was used to refer to nonurban participants in the study. After ascertaining whether a Web-based intervention was warranted, Web-based intervention features were identified, including how the site might be facilitated, topics, duration and frequency, and the nature of the professional contact. The extent to which young people agreed on the importance of these factors was assessed. Differences and similarities across gender and location were investigated. A mixed method analytic framework was employed using thematic analysis as well as 2-way between-groups analysis of covariance (ANCOVA) controlling for age and chi-square test of independence analysis.

RESULTS

Both rounds highlighted a strong preference for a Web-based intervention. Consensus was reached for a professionally monitored site, young people and professionals having equal input into the weekly facilitated sessions (eg, sharing the lead role in discussions or deciding on relevant session content), unlimited time access, 1-hour, open discussion, weekly sessions over 6 weeks, psychoeducation about mental illness, and considerations for the management of safety violations. There were significant main effects of location type and several of the preferred features for a Web-based intervention for young people who have a parent with a mental illness. However, effect sizes were small to moderate, limiting practical application.

CONCLUSIONS

Young people aged 16 to 21 years indicated a need for a professionally monitored, psychoeducational, Web-based intervention, with input from professional facilitators and other young people who have a parent with a mental illness, in addition to recommendations to external resources. These findings may inform the development of future Web-based interventions for this highly vulnerable group.

Hepatitis C Screening: The Downstream Dissemination of Evolving Guidelines in a Resident Continuity Clinic

Background

In 2012, the Centers for Disease Control and Prevention (CDC) published guidelines supporting one-time screening for hepatitis C (HCV) in all persons born between 1945 and 1965. It is estimated that 75% of adults infected with HCV fall within this cohort. Furthermore, it is projected that this preventative health intervention would lead to the diagnosis of 800,000 unknown cases and the prevention of 120,000 deaths.

Objectives

The primary objectives are to measure adherence to HCV screening in a continuity practice staffed by internal medicine residents and attending physicians and to measure the effect of educational interventions to enhance HCV screening. The secondary objectives include finding whether insurance or provider status affects adherence to HCV screening.

Methods

In 2015, we performed a retrospective chart review of asymptomatic patients born between 1945 and 1965 to estimate the rate of HCV screening. In order to meet inclusion criteria, the patients must have had an HCV status that was unknown and must have been seen by a primary care provider ≥ 2 times between January 1 and December 31, 2013. The data extracted included whether HCV testing was ordered, whether testing was performed primarily for screening purposes, demographic information, insurance status, number of clinic visits, and whether the primary provider was a resident or attending physician. Subsequently, in 2016 we implemented an educational intervention aimed at improving these rates. Afterwards, we repeated the chart review to determine if screening rates had improved.

Results

Out of 294 patients reviewed pre-intervention, 200 patients were eligible for inclusion, of which 17 (8.5%) patients were offered screening for HCV, of which 13 (76.5%) patients completed testing. Following an educational intervention, 484 patients were reviewed and 100 patients were included, of which 34 (34%) patients were screened. Compared to a pre-intervention screening rate of 8.5%, post-intervention screening had improved to 34%, a 300% increase (p<0.001).

Conclusions

Educational interventions are feasible and can lead to significant improvements in clinical practice enabling for the rapid dissemination of evolving guidelines.

Preventative care for patients with inflammatory bowel disease in the Veterans Health Administration

Patients with inflammatory bowel disease (IBD) have underlying immune dysregulation. Immunosuppressive medications put them at risk of infection. This study assessed rates of recommended vaccinations and preventative screening in patients with IBD.Nationwide data on patients diagnosed with IBD in the Veterans Health Administration (VHA) October 2004 to September 2014 were extracted. Variation in vaccination, screenings, and risk of death by demographic factors (age group, gender) were estimated in bivariate and multivariable analyses.During the 10-year study period, 62,002 patients were treated for IBD. Nonmelanoma skin cancer was found in 2.6%, and these patients more commonly accessed dermatology clinic (22.5% vs 15.2%; chi-square = 66.6; df = 1; P < 0.0001). In total, 15% received DEXA scans, especially women (34.7% vs 13.2% men; chi-square = 1415.5; df = 1; P < 0.0001). Eye manifestations were noted in 38.3% yet only 31% were referred to ophthalmology. Abnormal Pap smears were found for 15% of women <65 (compared to 5% among normal patient populations); 34% had no record of Pap smear in VHA data. Vaccination rates were modest: pneumococcal 39%; TDAP 23%; hepatitis B 3%; varicella and PPD <0.5%. In an adjusted logistic regression model, 5-year mortality was lower among those using primary care prior to IBD diagnosis (odds ratio [OR] = 0.61; 95% CI 0.55-0.68).Despite the current IBD guidelines, vaccination and preventative screening rates were unacceptably low among patients diagnosed with IBD. Interventions such as education and increased awareness may be needed to improve these rates.

Aboriginal involvement in caring-for-country: an economic case study in primary preventative health

OBJECTIVE

Firstly, to demonstrate the involvement of Aboriginal people in caring-for-country as a case study of how appropriately targeted non-medical primary preventative health strategies can be a cost-effective approach to addressing chronic disease among Indigenous people. Secondly, to demonstrate the use of an analogous approach in addressing the global chronic disease pandemic.

METHOD

A review of prior biomedical and economic research based on the involvement of Aboriginal people in caring-for-country is used to: (a) exemplifying the cost effectiveness of a non-medical preventative health intervention; and (b) the process by which such an approach might be applied across a broader context.

RESULTS

The presented results demonstrate one non-medical primary preventative health approach to addressing the health burden affecting Indigenous peoples.

CONCLUSIONS

The suggested steps in optimising the cost effectiveness of such an approach demonstrate how it could be applied in addressing the global chronic disease pandemic.

Obesity and Healthcare Avoidance: A Systematic Review

This review addresses the issue of health care avoidance and obesity. English language journal articles published between 1990 and 2012 that addressed the review question; “is being overweight or obese an unrecognized factor in healthcare avoidance?” were located using major databases. A modified JADAD scoring system was then used to assess papers. Ten papers were identified which directly addressed the review question. A positive relationship exists between obesity and healthcare avoidance. The major contributory factors were being female, have a diagnosed mental health problem and perceived or actual bias and discrimination by health professionals. The review also highlights the importance of the relationship between healthcare professionals and their patients, and the physical environment in which interactions occur as these may contribute to avoidance behaviors. Concern about obesity is rising and while there has been much discussion about strategies to reduce obesity this review highlights the need for thinking more broadly about the way in which overweight and obese individuals interact with preventative health strategies.

Genomics and personalised whole-of-life healthcare

Genome sequencing has the potential for stratified cancer treatment and improved diagnostics for rare disorders. However, sequencing needs to be utilised in risk stratification on a population scale to deepen the impact on the health system by addressing common diseases, where individual genomic variants have variable penetrance and minor impact. As the accuracy of genomic risk predictors is bounded by heritability, environmental factors such as diet, lifestyle, and microbiome have to be considered. Large-scale, longitudinal research programmes need to study the intrinsic properties between both genetics and environment to unravel their risk contribution. During this discovery process, frameworks need to be established to counteract unrealistic expectations. Sufficient scientific evidence is needed to interpret sources of uncertainty and inform decision making for clinical management and personal health.

Social and self-reflective use of a Web-based personally controlled health management system

Background

Personally controlled health management systems (PCHMSs) contain a bundle of features to help patients and consumers manage their health. However, it is unclear how consumers actually use a PCHMS in their everyday settings.

Objective

To conduct an empirical analysis of how consumers used the social (forum and poll) and self-reflective (diary and personal health record [PHR]) features of a Web-based PCHMS designed to support their physical and emotional well-being.

Methods

A single-group pre/post-test online prospective study was conducted to measure use of a Web-based PCHMS for physical and emotional well-being needs during a university academic semester. The PCHMS integrated an untethered PHR with social forums, polls, a diary, and online messaging links with a health service provider. Well-being journeys additionally provided information to encourage engagement with clinicians and health services. A total of 1985 students and staff aged 18 and above with access to the Internet were recruited online, of which 709 were eligible for analysis. Participants’ self-reported well-being, health status, health service utilization, and help-seeking behaviors were compared using chi-square, McNemar’s test, and Student’s t test. Social networks were constructed to examine the online forum communication patterns among consumers and clinicians.

Results

The two PCHMS features that were used most frequently and considered most useful and engaging were the social features (ie, the poll and forum). More than 30% (213/709) of participants who sought well-being assistance during the study indicated that other people had influenced their decision to seek help (54.4%, 386/709 sought assistance for physical well-being; 31.7%, 225/709 for emotional well-being). Although the prevalence of using a self-reflective feature (diary or PHR) was not as high (diary: 8.6%, 61/709; PHR: 15.0%, 106/709), the proportion of participants who visited a health care professional during the study was more than 20% greater in the group that did use a self-reflective feature (diary: P=.03; PHR: P<.001).

Conclusions

There was variation in the degree to which consumers used social and self-reflective PCHMS features but both were significantly associated with increased help-seeking behaviors and health service utilization. A PCHMS should combine both self-reflective as well as socially driven components to most effectively influence consumers’ help-seeking behaviors.

Which bundles of features in a Web-based personally controlled health management system are associated with consumer help-seeking behaviors for physical and emotional well-being?

BACKGROUND

Personally controlled health management systems (PCHMS), which include a personal health record (PHR), health management tools, and consumer resources, represent the next stage in consumer eHealth systems. It is still unclear, however, what features contribute to an engaging and efficacious PCHMS.

OBJECTIVE

To identify features in a Web-based PCHMS that are associated with consumer utilization of primary care and counselling services, and help-seeking rates for physical and emotional well-being concerns.

METHODS

A one-group pre/posttest online prospective study was conducted on a university campus to measure use of a PCHMS for physical and emotional well-being needs during a university academic semester (July to November 2011). The PCHMS integrated an untethered personal health record (PHR) with well-being journeys, social forums, polls, diaries, and online messaging links with a health service provider, where journeys provide information for consumer participants to engage with clinicians and health services in an actionable way. 1985 students and staff aged 18 and above with access to the Internet were recruited online. Logistic regression, the Pearson product-moment correlation coefficient, and chi-square analyses were used to associate participants' help-seeking behaviors and health service utilization with PCHMS usage among the 709 participants eligible for analysis.

RESULTS

A dose-response association was detected between the number of times a user logged into the PCHMS and the number of visits to a health care professional (P=.01), to the university counselling service (P=.03), and help-seeking rates (formal or informal) for emotional well-being matters (P=.03). No significant association was detected between participant pre-study characteristics or well-being ratings at different PCHMS login frequencies. Health service utilization was strongly correlated with use of a bundle of features including: online appointment booking (primary care: OR 1.74, 95% CI 1.01-3.00; counselling: OR 6.04, 95% CI 2.30-15.85), personal health record (health care professional: OR 2.82, 95% CI 1.63-4.89), the poll (health care professional: OR 1.47, 95% CI 1.02-2.12), and diary (counselling: OR 4.92, 95% CI 1.40-17.35). Help-seeking for physical well-being matters was only correlated with use of the personal health record (OR 1.73, 95% CI 1.18-2.53). Help-seeking for emotional well-being concerns (including visits to the university counselling service) was correlated with a bundle comprising the poll (formal or informal help-seeking: OR 1.03, 95% CI 1.00-1.05), diary (counselling: OR 4.92, 95% CI 1.40-17.35), and online appointment booking (counselling: OR 6.04, 95% CI 2.30-15.85).

CONCLUSIONS

Frequent usage of a PCHMS was significantly associated with increased consumer health service utilization and help-seeking rates for emotional health matters in a university sample. Different bundles of PCHMS features were associated with physical and emotional well-being matters. PCHMS appears to be a promising mechanism to engage consumers in help-seeking or health service utilization for physical and emotional well-being matters.