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Background: Despite disproportionate rates of mental ill-health compared with non-Indigenous populations, few programs have been tailored to the unique health, social, and cultural needs and preferences of young Aboriginal and Torres Strait Islander males. This paper describes the process of culturally adapting the US-based Young Black Men, Masculinities, and Mental Health (YBMen) Project to suit the needs, preferences, culture, and circumstances of Aboriginal and Torres Strait Islander males aged 16–25 years in the Northern Territory, Australia. YBMen is an evidence-based social media-based education and support program designed to promote mental health, expand understandings of gender and cultural identities, and enhance social support in college-aged Black men. Methods: Our adaptation followed an Extended Stages of Cultural Adaptation model. First, we established a rationale for adaptation that included assessing the appropriateness of YBMen's core components for the target population. We then investigated important and appropriate models to underpin the adapted program and conducted a non-linear, iterative process of gathering information from key sources, including young Aboriginal and Torres Strait Islander males, to inform program curriculum and delivery. Results: To maintain program fidelity, we retained the core curriculum components of mental health, healthy masculinities, and social connection and kept the small cohort, private social media group delivery but developed two models: 'online only' (the original online delivery format) and 'hybrid in-person/online' (combining online delivery with weekly in-person group sessions). Adaptations made included using an overarching Aboriginal and Torres Strait Islander social and emotional wellbeing framework and socio-cultural strengths-based approach; inclusion of modules on health and wellbeing, positive Indigenous masculinities, and respectful relationships; use of Indigenous designs and colours; and prominent placement of images of Aboriginal and Torres Strait Islander male sportspeople, musicians, activists, and local role models. Conclusions: This process resulted in a culturally responsive mental health, masculinities, and social support health promotion program for young Aboriginal and Torres Strait Islander males. Next steps will involve pilot testing to investigate the adapted program's acceptability and feasibility and inform further refinement. Keywords: Aboriginal, Torres Strait Islander, Indigenous, Australia, male, cultural adaptation, social media, mental health, masculinities, social support. [ABSTRACT FROM AUTHOR]

Background: This study involved a scoping review to explore factors influencing dental hygienist demand and supply in high-income countries. Methods: A six-stage scoping review was conducted with separate search strategies tailored to four databases (MEDLINE, CINAHL, Google Scholar, and Google) plus a targeted scan of dental hygienist organization websites. This yielded 2,117 unique citations, leading to 148 articles included in the review. Results: Nearly half of the articles (47%) focused on the United States, with 11% on Canada. Most articles (91%) were in English, alongside 13 in Korean and one in French. Journal articles comprised 62% of the publications, followed by reports/working papers (11%) and websites (11%). Other types included conference abstracts, policy briefs, and presentation slides. Content-wise, 47% were original research, with analysis articles (14%), commentaries (11%), and reviews (8%) also present. The articles were coded into three main categories: workforce characteristics/projections, factor-specific analyses, and workforce opportunities. The articles on workforce characteristics covered demographic, geographic, and employment aspects of dental hygienists, along with projections for supply and demand using simulation modelling and geospatial analyses. Factor-specific articles investigated the (1) working environment, (2) policy/regulatory/training environment, (3) job/career satisfaction and related human resource issues, and (4) scope of practice. The third key category of articles highlighted opportunities for expanding the workforce through alternative models in different sectors/settings (e.g., public health, primary care, long-term care, hospitals, mobile outreach, and non-clinical roles including research, education and leadership) and for a range of vulnerable or underserved populations (e.g., geriatric and pediatric populations, persons with disabilities, those living in rural/remote areas, Indigenous peoples, and incarcerated people). Conclusions: This review provides a comprehensive documentation of the current state of the dental hygienist workforce, compiling factors affecting demand and supply, and highlighting opportunities for the dental hygienist workforce in Canada and other high-income countries. The findings offer a foundation for future research, highlighting the need for more focused and rigorous reviews and underscoring the necessity of high-quality studies to verify the effectiveness of various interventions and policies. This is crucial to address dental hygienist workforce challenges and ensure the sustainability and effectiveness of oral health care delivery. [ABSTRACT FROM AUTHOR]

Background: Since the early 90s, patient navigation programs were introduced in the United States to address inequitable access to cancer care. Programs have since expanded internationally and in scope. The goals of patient navigation programs are to: a) link patients and families to primary care services, specialist care, and community-based health and social services (CBHSS); b) provide more holistic patient-centred care; and, c) identify and resolve patient barriers to care. This paper fills a gap in knowledge to reveal what is known about motivators and factors influencing implementation and maintenance of patient navigation programs in primary care that link patients to CBHSS. It also reports on outcomes from these studies to help identify gaps in research that can inform future studies.Methods: This scoping literature review involved: i) electronic database searches; ii) a web site search; iii) a search of reference lists from literature reviews; and, iv) author follow up. It included papers from Canada, the United States, the United Kingdom, Australia, New Zealand, and/or Western Europe published between January 1990 and June 2013 if they discussed navigators or navigation programs in primary care settings that linked patients to CBHSS.Results: Of 34 papers, most originated in the United States (n = 29) while the remainder were from the United Kingdom, Canada and Australia. Motivators for initiating navigation programs were to: a) improve delivery of health and social care services; b) support and manage specific health needs or specific population needs, and; c) improve quality of life and wellbeing of patients. Eleven factors were found to influence implementation and maintenance of these patient navigation programs. These factors closely aligned with the Diffusion of Innovation in Service Organizations model, thus providing a theoretical foundation to support them. Various positive outcomes were reported for patients, providers and navigators, as well as the health and social care system, although they need to be considered with caution since the majority of studies were descriptive.Conclusions: This study contributes new knowledge that can inform the initiation and maintenance of primary care patient navigation programs that link patients with CBHSS. It also provides directions for future research. [ABSTRACT FROM AUTHOR]

Objective: Although medication abortion has become more common in high-income countries, the procedure has not yet met early expectations for widening access to abortion. High-quality evidence can serve as a catalyst for changes in policy and practice. To direct research priorities, it is important to understand where quality evidence is concentrated and where gaps remain. High-income countries have developed a body of evidence that may have implications for the future of medication abortion. This literature review assesses the characteristics and quality of published studies on medication abortion conducted in the last 10 years in high-income countries and indicates future areas for research to advance policy and practice, and broaden access. Study design: A structured search for literature resulted in 207 included studies. A framework based upon the World Health Organization definition of sub-tasks for medication abortion was developed to categorize research by recognized stages of the medication abortion process. Using an iterative and inductive approach, additional sub-themes were created under each of these categories. Established quality assessment frameworks were drawn upon to gauge the internal and external validity of the included research. Results: Studies in the US and the UK have dominated research on MA in high-income countries. The political and social contexts of these countries will have shaped of this body of research. The past decade of research has focused largely on clinical aspects of medication abortion. Conclusion: Researchers should consider refocusing energies toward testing service delivery approaches demonstrating promise and prioritizing research that has broader generalizability and relevance outside of narrow clinical contexts. Plain English summary: Although medication abortion is more commonly available worldwide, it is not being used as often as people thought it would be, particularly in high income countries. In order to encourage changes in policy and practice that would allow greater use, we need good quality evidence. If we can understand where we do not have enough research and where we have good amounts of research, we can determine where to invest energies in further studies. Many high-income countries have produced research on medication abortion that could influence policy and practice in similarly resourced contexts. I conducted a literature review to be able to understand the type and quality of research on medication abortion conducted in high-income countries in the past 10 years. I conducted the review in an organized way to make sure that the papers reviewed discussed studies that I thought would be important for answering this question. The literature review found 207 papers. Each of these papers were reviewed and organized them by theme. I also used existing methods to determinine the quality of each study. Most of the research came from the US and the UK. Furthermore, most of the research conducted in the past 10 years was focused on clinical studies of medication abortion. In future studies, researchers should focus more on new ways of providing medication abortion to women that offers greater access. Also, the studies should be designed so that the results have meaning for a broader group of people or situations beyond where the study was done. [ABSTRACT FROM AUTHOR]

Background: Those whose lives are most directly impacted by health care—patients, caregivers, and frontline staff—are ideally situated to improve patient health care services and care quality. Despite a proliferation of literature on both Patient and Public Involvement (PPI) and clinical quality improvement (QI), concrete strategies regarding how to involve patients remain elusive. Aim: Research suggests catalyst films, comprised of rigorously-analyzed interview data from diverse patients about their experiences with health and health care ("catalyst films") are a promising way to bring actionable patient feedback to QI. To date, such films have been crafted primarily by researchers. This project aimed to inform the science of engagement through analyzing how deliberate PPI informed the process of creating catalyst films. Methods: PPI methods included: research team norming activities through a project charter and role delineation process; key informant interviews; participant-ambassador videotaped interviews; clinician and research focus groups; and inclusion of advisors on the research team. Content studied for the analysis presented here included team meeting notes, interview and focus group transcripts, and documentation from a facilitated discussion about team processes. These data were analyzed to determine the impact of our PPI process. Member checking verified themes and lessons learned. Results: PPI shaped team deliberations and final products in substantial ways, including: what material to include in catalyst films and the tone they should convey; multiple issues regarding representation; and our collective understanding of how catalyst films could be used in the United States. Specific discussions addressed: how to include the optimal mix of interview segments that describe experiences with those that more directly point towards care improvement strategies; and how to balance positive and negative feedback from patients about experiences with care. Team process issues included ensuring equity in involvement despite team members having differing and sometimes multiple roles that complicated power dynamics and processes. Conclusions: Multiple forms and degrees of PPI resulted in significant influence on catalyst films and companion materials. Our project thus provides proof of concept for PPI in creation of video products for QI which have traditionally been crafted by researchers. The model we developed, and document in this paper, can be adapted by others creating research-derived video products. Our findings can also inform future research on how co-designing catalyst films enhances their value for QI and the application of co-designed catalyst film use in QI. Lastly, it can guide those engaged in QI and medical education in their selection of film products focused on patient experiences. Plain English Summary: Involving patients in care improvement efforts is valuable for improving the quality and safety of health care services because patients offer unique insights and are directly impacted by the system. Involving patients in these efforts can also inform better patient and family experiences. Studies have shown that using video interviews highlighting good and bad patient experiences in healthcare is one of the promising way to include a wider range of patient narratives and feedback in care improvement. Videos used in these situations are now called catalyst films, formerly known as trigger films. This paper describes how catalyst films are similar to and distinct from other film products used in research and improvement projects. It examines a process for equitably engaging a team of many different stakeholders—patients, providers, and researchers—to select video excerpts from existing research-based patient experience interviews to create catalyst films. It describes methods used to ensure robust input from all team members, so that all perspectives influence the catalyst films. The study concluded that patient and public involvement had significant impact on both the research process and the final products created. Our findings can equip those making or selecting films for use in improving health and social care to ensure films are patient informed. The paper concludes by offering limitations and recommendations for future research to advance the fields of patient and public involvement and quality improvement. [ABSTRACT FROM AUTHOR]

Introduction: Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research. Methods: A literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported. Results: Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level. Discussion and implications: We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities. [ABSTRACT FROM AUTHOR]

Background: In 2010, the first comprehensive National HIV/AIDS Strategy for the United States was released and included three goals: (1) reducing the number of people who become infected with HIV, (2) increasing access to care and improving health outcomes for people living with HIV, and (3) reducing HIV-related health disparities and health inequities. In 2013, as part of its effort to help address the National HIV/AIDS Strategy, the National Institute on Drug Abuse (NIDA) funded a type 2 effectiveness-implementation hybrid trial titled the Substance Abuse Treatment to HIV Care (SAT2HIV) Project. Aim 1 of the SAT2HIV Project tests the effectiveness of a motivational interviewing-based brief intervention (MIBI) for substance use as an adjunct to usual care within AIDS Service Organizations (ASOs) as part of its MIBI Experiment. Aim 2 of the SAT2HIV Project tests the effectiveness of implementation and sustainment facilitation (ISF) as an adjunct to the Addiction Technology Transfer Center (ATTC) model for training staff in motivational interviewing as part of its ISF Experiment. The current paper describes the study protocol for the ISF Experiment. Methods: As part of a multisite randomized controlled trial, individuals with comorbid HIV/AIDS and problematic substance use are randomized to receive either the ASOs'; usual care (control condition) or usual care plus a MIBI for substance use (experimental condition) delivered by trained ASO case-management staff. Primary outcome measures are reductions in days of primary substance use, number of substance-related problems, times engaging in risky behaviors, days of non-adherence to HIV medications, and increases in substance use treatment. As part of this paper, we describe the trial protocol in accordance with the Standard Protocol Items: Recommendations for Interventional Trials guidelines. Discussion: If successfully able to implement MIBI as an effective adjunct to usual care, the current trial may have a significant impact on increasing the capacity of ASOs to address problematic substance use among individuals living with HIV/AIDS. Reducing the prevalence of problematic substance use among individuals living with HIV/AIDS within the United States may lead to significant improvements on key performance measures (i.e., the HIV Care Continuum and the 90-90-90 target). [ABSTRACT FROM AUTHOR]

Background: The goal of Lean Enterprise Transformation (LET) is to go beyond simply using Lean tools and instead embed Lean principles and practices in the system so that it becomes a fundamental, collective mindset of the entire enterprise. The Veterans Engineering Resource Center (VERC) launched the Veterans Affairs (VA) LET pilot program to improve quality, safety, and the Veteran's experience. A national evaluation will examine the pilot program sites' implementation processes, outcomes and impacts, and abilities to improve LET adoption and sustainment. This paper describes the evaluation design for the VA LET national evaluation and describes development of a conceptual framework to evaluate LET specifically in healthcare settings.Methods: A targeted literature review of Lean evaluation frameworks was performed to inform the development of the conceptual framework. Key domains were identified by a multidisciplinary expert group and then validated with key stakeholders. The national evaluation design will examine LET implementation using qualitative, survey, and quantitative methods at ten VA facilities. Qualitative data include site visits, interviews, and field observation notes. Survey data include an employee engagement survey to be administered to front-line staff at all pilot sites. Quantitative data include site-level quality improvement metrics collected by the Veterans Services Support Center. Qualitative, quantitative, and mixed-methods analyses will be conducted to examine implementation of LET strategic initiatives and variations in implementation success across sites.Discussion: This national evaluation of a large-scale LET implementation effort will provide insights helpful to other systems interested in embarking on a Lean journey. Additionally, we created a multi-faceted conceptual framework to capture the specific features of a Lean healthcare organization. This framework will guide this evaluation and may be useful as an assessment tool for other organizations interested in implementing Lean principles at an enterprise level. [ABSTRACT FROM AUTHOR]

Background: Racism in the healthcare system has become a burgeoning focus in health policy-making and research. Existing research has shown both interpersonal and structural forms of racism limiting access to quality healthcare for racialised healthcare users. Nevertheless, little is known about the specifics of racism in the inpatient sector, specifically hospitals and rehabilitation facilities. The aim of this scoping review is therefore to map the evidence on racial discrimination experienced by people receiving treatment in inpatient settings (hospitals and rehabilitation facilities) or their caregivers in high-income countries, focusing specifically on whether intersectional axes of discrimination have been taken into account when describing these experiences. Methods: Based on the conceptual framework developed by Arksey and O'Malley, this scoping review surveyed existing research on racism and racial discrimination in inpatient care in high-income countries published between 2013 and 2023. The software Rayyan was used to support the screening process while MAXQDA was used for thematic coding. Results: Forty-seven articles were included in this review. Specifics of the inpatient sector included different hospitalisation, admission and referral rates within and across hospitals; the threat of racial discrimination from other healthcare users; and the spatial segregation of healthcare users according to ethnic, religious or racialised criteria. While most articles described some interactions between race and other social categories in the sample composition, the framework of intersectionality was rarely considered explicitly during analysis. Discussion: While the USA continue to predominate in discussions, other high-income countries including Canada, Australia and the UK also examine racism in their own healthcare systems. Absent from the literature are studies from a wider range of European countries as well as of racialised and disadvantaged groups other than refugees or recent immigrants. Research in this area would also benefit from an engagement with approaches to intersectionality in public health to produce a more nuanced understanding of the interactions of racism with other axes of discrimination. As inpatient care exhibits a range of specific structures, future research and policy-making ought to consider these specifics to develop targeted interventions, including training for non-clinical staff and robust, transparent and accessible complaint procedures. [ABSTRACT FROM AUTHOR]

Background: The rates of diabetes and prediabetes in the USA are growing, significantly impacting the quality and length of life of those diagnosed and financially burdening society. Premature death and disability can be prevented through implementation of evidence-based programs and policies (EBPPs). Local health departments (LHDs) are uniquely positioned to implement diabetes control EBPPs because of their knowledge of, and focus on, community-level needs, contexts, and resources. There is a significant gap, however, between known diabetes control EBPPs and actual diabetes control activities conducted by LHDs. The purpose of this study is to determine how best to support the use of evidence-based public health for diabetes (and related chronic diseases) control among local-level public health practitioners.Methods/design: This paper describes the methods for a two-phase study with a stepped-wedge cluster randomized trial that will evaluate dissemination strategies to increase the uptake of public health knowledge and EBPPs for diabetes control among LHDs. Phase 1 includes development of measures to assess practitioner views on and organizational supports for evidence-based public health, data collection using a national online survey of LHD chronic disease practitioners, and a needs assessment of factors influencing the uptake of diabetes control EBPPs among LHDs within one state in the USA. Phase 2 involves conducting a stepped-wedge cluster randomized trial to assess effectiveness of dissemination strategies with local-level practitioners at LHDs to enhance capacity and organizational support for evidence-based diabetes prevention and control. Twelve LHDs will be selected and randomly assigned to one of the three groups that cross over from usual practice to receive the intervention (dissemination) strategies at 8-month intervals; the intervention duration for groups ranges from 8 to 24 months. Intervention (dissemination) strategies may include multi-day in-person workshops, electronic information exchange methods, technical assistance through a knowledge broker, and organizational changes to support evidence-based public health approaches. Evaluation methods comprise surveys at baseline and the three crossover time points, abstraction of local-level diabetes and chronic disease control program plans and progress reports, and social network analysis to understand the relationships and contextual issues that influence EBPP adoption.Trial Registration: ClinicalTrial.gov, NCT03211832. [ABSTRACT FROM AUTHOR]

Background: Engaging patients and community members in healthcare implementation, research and evaluation has become more popular over the past two decades. Despite the growing interest in patient engagement, there is scant evidence of its impact and importance. Boot Camp Translation (BCT) is one evidence-based method of engaging communities in research. The purpose of this report is to describe the uptake by primary care practices of cardiovascular disease prevention materials produced through four different local community engagement efforts using BCT. Methods: EvidenceNOW Southwest (ENSW) was a randomized trial to increase cardiovascular disease (CVD) prevention in primary care practices. Because of its study design, Four BCTs were conducted, and the materials created were made available to participating practices in the "enhanced" study arm. As a result, ENSW offered one of the first opportunities to explore the impact of the BCT method by describing the uptake by primary care practices of health messages and materials created locally using the BCT process. Analysis compared uptake of locally translated BCT products vs. all other products among practices based on geography, type of practice, and local BCT. Results: Within the enhanced arm of the study that included BCT, 69 urban and 13 rural practices participated with 9 being federally qualified community health centers, 14 hospital owned and 59 clinician owned. Sixty-three practices had 5 or fewer clinicians. Two hundred and ten separate orders for materials were placed by 43 of the 82 practices. While practices ordered a wide variety of BCT products, they were more likely to order materials developed by their local BCT. Conclusions: In this study, patients and community members generated common and unique messages and materials for cardiovascular disease prevention relevant to their regional and community culture. Primary care practices preferred the materials created in their region. The greater uptake of locally created materials over non-local materials supports the use of patient engagement methods such as BCT to increase the implementation and delivery of guideline-based care. Yes, patient and community engagement matters. Trial registration and IRB: Trial registration was prospectively registered on July 31, 2015 at ClinicalTrials.gov (NCT02515578, protocol identifier 15–0403). The project was approved by the Colorado Multiple Institutional Review Board and the University of New Mexico Human Research Protections Office. [ABSTRACT FROM AUTHOR]

Background: Medical diaspora options, including the engagement of expatriate physicians in development efforts within their home country, are being called for to reverse the effects of brain drain from developing countries. This paper presents the results of a study exploring the potential contributions for the Sudanese Medial Diaspora Options to the healthcare delivery system (HCDS) in Sudan, focusing on the options of temporal and permanent returns and the likely obstacles faced in their implementation.Methods: This was a cross-sectional study using a mixed methods design including quantitative and qualitative approaches. For the quantitative approach, the study, which focused on the possible contribution of the diaspora to healthcare delivery in Sudan, was based on an online survey using random purposive and snowballing sampling techniques involving 153 Sudanese physicians working in Saudi Arabia and other Gulf States, the United Kingdom, the Republic of Ireland, and the United States of America. The qualitative approach involved in-depth interviews with returnee physicians and key informants in Sudan, focusing on the return experiences, the barriers for return, and the options to improve future contributions.Results: Despite contributions of the Sudanese medical diaspora being of a small scale considering the size of the phenomenon, as well as infrequent and not appropriately organized, their inputs to academia and the links built with overseas institutions and specialist clinical services were nevertheless remarkable. The main barrier to temporal return was inappropriate organization by the local counterparts, while those for permanent return of physicians were poor work environment, insufficient financial payment, unsecured accommodation, and offspring education. The study identified short-term return as a feasible option considering the country's current conditions. Proper coordination mechanisms for short-term returns and facilitation of permanent return through stakeholders' collaboration were proposed to improve diaspora contributions.Conclusions: The potentials of Sudanese medial diaspora contributions to the HCDS in Sudan are promising. Short-term contributions were observed as the best option for the current country situation. Creation of a coordinating body from within the healthcare sector in Sudan to effectively coordinate diaspora contributions is recommended. [ABSTRACT FROM AUTHOR]

Background: There is increased interest in the capacity of US immigrants to contribute to their homelands via entrepreneurship and philanthropy. However, there has been little research examining how immigrant physicians may support health systems and what factors facilitate or raise barriers to increased support.Methods: This study used an observational design with paper questionnaire and interview components. Our sample was drawn from attendees of a 2011 conference for US Based Nigerian physicians; respondents who were not US residents, physicians, and of Nigerian birth or parentage were excluded from further analysis. Respondents were randomly selected to complete a follow-up interview with separate scripts for those having made past financial contributions or medical service trips to support Nigerian healthcare (Group A) and those who had done neither (Group B). Survey results were analyzed using Fischer exact tests and interviews were coded in pairs using thematic content analysis.Results: Seventy-five of 156 (48 %) individuals who attended the conference met inclusion criteria and completed the survey, and 13 follow-up interviews were completed. In surveys, 65 % percent of respondents indicated a donation to an agency providing healthcare in Nigeria the previous year, 57 % indicated having gone on medical service trips in the prior 10 years and 45 % indicated it was "very likely" or "likely" that they would return to Nigeria to practice medicine. In interviews, respondents tended to favor gifts in kind and financial gifts as modes of contribution, with medical education facilities as the most popular target. Personal connections, often forged in medical school, tended to facilitate contributions. Individuals desiring to return permanently focused on their potential impact and worried about health system under-preparedness; those not desiring permanent return centered on how safety, financial security and health systems issues presented barriers.Conclusions: This study demonstrates several mechanisms by which health systems may benefit from expatriate engagement. Greater identification of reliable local partners for diaspora, deeper collaboration with those partners and a focus on sustainable interventions might improve the quantity and impact of contributions. Ethnic medical associations have a unique role in organizing and facilitating diaspora response. Public-private partnerships may help diaspora negotiate the challenges of repatriation. [ABSTRACT FROM AUTHOR]

Background: There is growing concern that short-term experiences in global health experiences (STEGH), undertaken by healthcare providers, trainees, and volunteers from high income countries in lower and middle income countries, risk harming the community by creating a parallel system of care separate from established community development efforts. At the same time, the inclusion of non-traditional actors in health planning has been the basis of the development of many Healthy Community Partnerships (HCP) being rolled out in Canada and the United States. These partnerships aim to bring all stakeholders with a role to play in health to the table to align efforts, goals and programs towards broad community health goals.Results: This methodology paper reports on the process used in La Romana, Dominican Republic, in applying a modified HCP framework. This project succeeded at bringing visiting STEGH organizations into a coalition with key community partners and supported attempts to embed the work of STEGH within longer-term, established development plans.Conclusions: In presenting the work and process and lessons learned, the hope is that other communities that encounter significant investment from STEGH groups, and will gain the same benefits that were seen in La Romana with regards to improved information exchange, increased cross-communication between silos, and the integration of STEGH into the work of community partners. [ABSTRACT FROM AUTHOR]

Background: Health care organizations need to be responsive to the needs of increasingly diverse patient populations. We compared the contents of six publicly available approaches to organizational responsiveness to diversity. The central questions addressed in this paper are: what are the most consistently recommended issues for health care organizations to address in order to be responsive to the needs of diverse groups that differ from the majority population? How much consensus is there between various approaches?Methods: We purposively sampled six approaches from the US, Australia and Europe and used qualitative textual analysis to categorize the content of each approach into domains (conceptually distinct topic areas) and, within each domain, into dimensions (operationalizations). The resulting classification framework was used for comparative analysis of the content of the six approaches.Results: We identified seven domains that were represented in most or all approaches: organizational commitment, empirical evidence on inequalities and needs, a competent and diverse workforce, ensuring access for all users, ensuring responsiveness in care provision, fostering patient and community participation, and actively promoting responsiveness. Variations in the operationalization of these domains related to different scopes, contexts and types of diversity. For example, approaches that focus on ethnic diversity mostly provide recommendations to handle cultural and language differences; approaches that take an intersectional approach and broaden their target population to vulnerable groups in a more general sense also pay attention to factors such as socio-economic status and gender.Conclusions: Despite differences in labeling, there is a broad consensus about what health care organizations need to do in order to be responsive to patient diversity. This opens the way to full scale implementation of organizational responsiveness in healthcare and structured evaluation of its effectiveness in improving patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: The objective of this paper is to demonstrate the utility of the CFIR framework for evaluating broad-scale change by discussing the challenges to be addressed when planning the assessment of broad-scale change and the solutions developed by the evaluation team to address those challenges. The evaluation of implementation of Patient-centered Care and Cultural Transformation (PCC&CT) within the Department of Veterans Affairs (VA) will be used as a demonstrative example. Patient-Centered Care (PCC) is personalized health care that considers a patient's circumstances and goals. The Department of Veterans Affairs (VA) is working towards implementing PCC throughout its healthcare system, comprised of multiple interventions with a singular long-term goal of cultural transformation, however little is known about the factors influencing its implementation. This paper discusses the issues that arose using CFIR to qualitatively assess the factors influencing implementation of cultural transformation. Results: Application of CFIR to this broad-scale evaluation revealed three strategies recommended for use in evaluating implementation of broad-scale change: (1) the need for adapted definitions for CFIR constructs (especially due to new application to broad-scale change), (2) the use of a mixed deductive-inductive approach with thematic coding to capture emergent themes not encompassed by CFIR, and (3) its use for expedited analysis and synthesis for rapid delivery of findings to operational partners. This paper is among the first to describe use of CFIR to guide the evaluation of a broad-scale transformation, as opposed to discrete interventions. The processes and strategies described in this paper provide a detailed example and structured approach that can be utilized and expanded upon by others evaluating implementation of broad-scale evaluations. Although CFIR was the framework selected for this evaluation, the strategies described in this paper including: use of adapted definitions, use of mixed deductive-inductive approach, and the approach for expedited analysis and synthesis can be transferred and tested with other frameworks. [ABSTRACT FROM AUTHOR]

Background: In 2007, the National Cancer Institute (NCI) launched the NCI Community Cancer Centers Program (NCCCP) as a public-private partnership with community hospitals with a goal of advancing cancer care and research. In order to leverage federal dollars in a time of limited resources, matching funds from each participating hospital were required. The purpose of this paper is to examine hospitals' level of and rationale for co-investment in this partnership, and whether there is an association between hospitals' co-investment and achievement of strategic goals.Methods: Analysis using a comparative case study and micro-cost data was conducted as part of a comprehensive evaluation of the NCCCP pilot to determine the level of co-investment made in support of NCI's goals. In-person or telephone interviews with key informants were conducted at 10 participating hospital and system sites during the first and final years of implementation. Micro-cost data were collected annually from each site from 2007 to 2010. Self-reported data from each awardee are presented on patient volume and physician counts, while secondary data are used to examine the local Medicare market share.Results: The rationale expressed by interviewees for participation in a public-private partnership with NCI included expectations of increased market share, higher patient volumes, and enhanced opportunities for cancer physician recruitment as a result of affiliation with the NCI. On average, hospitals invested resources into the NCCCP at a level exceeding $3 for every $1 of federal funds. Six sites experienced a statistically significant change in their Medicare market share. Cancer patient volume increased by as much as one-third from Year 1 to Year 3 for eight of the sites. Nine sites reported an increase in key cancer physician recruitment.Conclusions: Demonstrated investments in cancer care and research were associated with increases in cancer patient volume and perhaps in recruitment of key cancer physicians, but not in increased Medicare market share. Although the results reflect a small sample of hospitals, findings suggest that hospital executives believe there to be a strategic case for a public-private partnership as demonstrated through the NCCCP, which leveraged federal funds to support mutual goals for advancing cancer care and research. [ABSTRACT FROM AUTHOR]

Background: By examining 2013 County Health Rankings and Roadmaps data from the University of Wisconsin and the Robert Wood Johnson Foundation, this paper seeks to add to the available literature on health variances between United States residents living in rural and non-rural areas. We believe this is the first study to use the Rankings data to measure rural and urban health differences across the United States and therefore highlights the national need to address shortfalls in rural healthcare and overall health. The data indicates that U.S. residents living in rural counties are generally in poorer health than their urban counterparts.Methods: We used 2013 County Health Rankings data to evaluate differences across the six domains of interest (mortality, morbidity, health behaviors, clinical care, social and economic factors, and physical environment) for rural and non-rural U.S. counties. This is a cross-sectional study employing chi-square analysis and logit regression.Results: We found that residents living in rural U.S. counties are more likely to have poorer health outcomes along a variety of measurements that comprise the County Health Rankings' indexed domains of health quality. These populations have statistically significantly (p ≤ 0.05) lower scores in such areas as health behavior, morbidity factors, clinical care, and the physical environment. We attribute the differences to a variety of factors including limitations in infrastructure, socioeconomic differences, insurance coverage deficiencies, and higher rates of traffic fatalities and accidents.Discussions: The largest differences between rural and non-rural counties were in the indexed domains of mortality and clinical care.Conclusions: Our analysis revealed differences in health outcomes in the County Health Rankings' indexed domains between rural and non-rural U.S. counties. We also describe limitations and offer commentary on the need for more uniform measurements in the classification of the terms rural and non-rural. These results can influence practitioners and policy makers in guiding future research and when deciding on funding allocation. [ABSTRACT FROM AUTHOR]

Background The UK medical graduates of 2008 and 2009 were among the first to experience a fully implemented, new, UK training programme, called the Foundation Training Programme, for junior doctors. We report doctors' views of the first Foundation year, based on comments made as part of a questionnaire survey covering career choices, plans, and experiences. Methods Postal and email based questionnaires about career intentions, destinations and views were sent in 2009 and 2010 to all UK medical graduates of 2008 and 2009. This paper is a qualitative study of 'free-text' comments made by first-year doctors when invited to comment, if they wished, on any aspect of their work, education, training, and future. Results The response rate to the surveys was 48% (6220/12952); and 1616 doctors volunteered comments. Of these, 61% wrote about their first year of training, 35% about the working conditions they had experienced, 33% about how well their medical school had prepared them for work, 29% about their future career, 25% about support from peers and colleagues, 22% about working in medicine, and 15% about lifestyle issues. When concerns were expressed, they were commonly about the balance between service provision, administrative work, and training and education, with the latter often suffering when it conflicted with the needs of medical service provision. They also wrote that the quality of a training post often depended on the commitment of an individual senior doctor. Service support from seniors was variable and some respondents complained of a lack of team work and team ethic. Excessive hours and the lack of time for reflection and career planning before choices about the future had to be made were also mentioned. Some doctors wrote that their views were not sought by their hospital and that NHS management structures did not lend themselves to efficiency. UK graduates from non-UK homes felt insecure about their future career prospects in the UK. There were positive comments about opportunities to train flexibly. Conclusions Although reported problems should be considered in the wider context, in which the majority held favourable overall views, many who commented had been disappointed by aspects of their first year of work. We hope that the concerns raised by our respondents will prompt trainers, locally, to determine, by interaction with junior staff, whether or not these are concerns in their own training programme. [ABSTRACT FROM AUTHOR]

Background: One practice in healthcare implementation is patient engagement in quality improvement and systems redesign. Implementers in healthcare systems include clinical leadership, middle managers, quality improvement personnel, and others facilitating changes or adoption of new interventions. Patients provide input into different aspects of health research. However, there is little attention to involve patients in implementing interventions, especially in the United States (U.S.), and this might be essential to reduce inequities. Implementers need clear strategies to overcome challenges, and might be able to learn from countries outside the U.S. Methods: We wanted to understand existing work about how patients are being included in implementation activities in real world U.S. healthcare settings. We conducted an environmental scan of three data sources: webinars, published articles, and interviews with implementers who engaged patients in implementation activities in U.S. healthcare settings. We extracted, categorized, and triangulated from data sources the key activities, recurring challenges, and promising solutions using a coding template. Results: We found 27 examples of patient engagement in U.S. healthcare implementation across four webinars, 11 published articles, and seven interviews, mostly arranging patient engagement through groups and arranging processes for patients that changed how engaged they were able to be. Participants rarely specified if they were engaging a population experiencing healthcare inequities. Participants described eight recurring challenges; the two most frequently identified were: (1) recruiting patients representative of those served in the healthcare system; and (2) ensuring processes for equitable communication among all. We matched recurring challenges to promising solutions, such as logistic solutions on how to arrange meetings to enhance engagement or training in inclusivity and power-sharing. Conclusion: We clarified how some U.S. implementers are engaging patients in healthcare implementation activities using less and more intensive engagement. It was unclear whether reducing inequities was a goal. Patient engagement in redesigning U.S. healthcare service delivery appears similar to or less intense than in countries with more robust infrastructure for this, such as Canada and the United Kingdom. Challenges were common across jurisdictions, including retaining patients in the design/delivery of implementation activities. Implementers in any region can learn from those in other places. [ABSTRACT FROM AUTHOR]

Background: Reduced funding to public health care systems during economic downturns is a common phenomenon around the world. The effect of health care cost on family members of the patients has not been established. This paper aims to explore the relationship between affordability of health care and vulnerability of family members to distress levels. Methods: Data of a total of 262,843 participants were obtained from 17 waves (1997-2013) of the United States National Health Interview Survey. Multinomial logistic regression was used to investigate psychological distress level as a result of having family members who experienced unmet medical needs due to cost. Results: Among participants without family members who experienced unmet needs for medical care due to cost, risks of having 'moderate' (score of 5-12) or 'serious' (score of 13 or above) level of psychological distress were 1.0% and 11.5%, respectively. Risks of having 'moderate' or 'serious' level of psychological distress were 3.1% and 23.4%, respectively among participants with family members who experienced unmet needs. The adjusted relative risk ratio of 'moderate' and 'serious', as compared to 'normal' level of psychological distress, were 1.58 (95% confidence interval: 1. 47-1.69) and 2.09 (95% confidence interval: 1.78-2.45) if one's family members experienced unmet medical needs. Conclusions: Unmet medical needs due to cost increases risk of distress levels experienced by family members. Careful planning and adequate funding to public health care system could be implemented to prevent any unnecessary detrimental effect on mental health among family members of the unwell and any further increment of the prevalence of mental illnesses. This recommendation aligns with the World Health Organization Mental Health Action Plan 2013-2020. [ABSTRACT FROM AUTHOR]

Background: Our aims were to examine themes of the most difficult or distressing events reported by healthcare workers during the first wave of COVID-19 pandemic in two US health care systems in order to identify common themes and then to relate them to both behavioral theory and measures of anxiety and depression. Methods: We conducted a cross-sectional survey of nurses and physicians during the early phases of the COVID-19 pandemic in the US. An emailed recruitment letter was sent, with about half choosing to supply open-ended responses relevant to thematic analysis. We measured symptoms of anxiety and depression separately, captured demographics, and asked two open-ended questions regarding events that were the most difficult or stressful, and reinforced pride. We reported descriptive statistics and coded thematic categories for their continuum "pride" and "distress" the factors related to fostering well-being according to the Self-Determination Theory. Results: Themes that emerged from these narratives were congruent with prediction of Self-Determination theory that autonomy-supportive experiences will foster pride, while autonomy-thwarting experiences will cause distress. Those who reported distressful events were more anxious and depressed compared to those who did not. Among those who reported incidences that reinforced pride in the profession, depression was rarer compared to those who did not. These trends were evident after allowing for medical history and other covariates in logistic regressions. Conclusion: Causal claims from our analysis should be made with caution due to the cross-sectional research design. Understanding perceptions of the pandemic by nurses and physicians may help identify and manage sources of distress, and suggest means of mitigating the risk of mental health distress through autonomy-supportive policies. [ABSTRACT FROM AUTHOR]

Background: Electronic health records (EHRs) have become a mandated part of delivering health care in the United States. The purpose of this study is to report patient volume before and after the transition to EHR in an academic outpatient ophthalmology practice.Methods: Review of patient visits per half-day and number of support staff for established faculty ophthalmologists between July and October for five consecutive years beginning the year before EHR implementation.Results: Eight physicians met inclusion criteria for the study. The number of patient visits was lower in each year after EHR adoption compared to baseline p ≤ 0.027). Patient volume per provider was reduced an average of 16.9% over the 4 years (range 15.3-18.5%), and during the final year studied, no provider had returned to the pre-EHR number of patients per clinic session. Support staffing was unchanged (p > 0.2).Conclusions: Adoption of EHR was associated with a significantly reduced number of patient visits per clinic session in an academic setting in which support staffing remained stable. Maintaining clinic volume and access in similar settings may require use of additional staffing. [ABSTRACT FROM AUTHOR]

Background: When doctors have honest conversations with patients about their illness and involve them in decisions about their care, patients express greater satisfaction with care and lowered anxiety and depression. The Serious Illness Care Programme (the Programme), originally developed in the United States (U.S), promotes meaningful, realistic and focused conversations about patient's wishes, fears and worries for the future with their illness. The Serious Illness Conversation Guide (the guide) provides a framework to structure these conversations. The aim of this paper is to present findings from a study to examine the 'face validity', acceptability and relevance of the Guide for use within the United Kingdom (UK) health care setting.Methods: A multi-stage approach was undertaken, using three separate techniques: 1. Nominal Group Technique with clinician 'expert groups' to review the Serious Illness Conversation Guide: 14 'experts' in Oncology, Palliative Care and Communication Skills; 2. Cognitive Interviews with 6 patient and public representatives, using the 'think aloud technique'; to explore the cognitive processes involved in answering the questions in the guide, including appropriateness of language, question wording and format 3. Final stakeholder review and consensus.Results: Nominal Group Technique Unanimous agreement the conversation guide could provide a useful support to clinicians. Amendments are required but should be informed directly from the cognitive interviews. Training highlighted as key to underpin the use of the guide. Cognitive interviews The 'holistic' attention to the person as a whole was valued rather than a narrow focus on their disease. Some concern was raised regarding the 'formality' of some wording however and suggestions for amendments were made. Final stakeholder review Stakeholders agreed amendments to 5/13 prompts and unanimously agreed the UK guide should be implemented as a part of the pilot implementation of the Serious Illness Care Programme UK.Conclusion: Use of the guide has the potential to benefit patients, facilitating a 'person-centred' approach to these important conversations, and providing a framework to promote shared decision making and care planning. Further research is ongoing, to understand the impact of these conversations on patients, families and clinicians and on concordance of care delivery with expressed patient wishes. [ABSTRACT FROM AUTHOR]

Background: In 2006, the British government launched 'Improving Access to Psychological Therapies' (IAPT), a low intensity cognitive behaviour therapy intervention (LiCBT) designed to manage people with symptoms of anxiety and depression in the community. The evidence of the effectiveness of IAPT has been demonstrated in multiple studies from the UK, USA, Australia and other countries. MindStep™ is the first adaptation of IAPT in Australia, delivered completely by telephone, targeting people with a recent history of a hospital admission for mental illnesses within the private health system. This paper reports on the outcome of the first 17 months of MindStep™ implemented across Australia from March 2016. Methods: This prospective observational study investigated the MindStep™ program in a cohort of clients with a recent hospitalisation for mental illnesses. The study used quantitative methods to compare pre-post treatment clinical measures (N = 680) using Patient Health Questionnaire (PHQ-9) and the Generalised Anxiety Disorder (GAD-7). This study also included in-depth interviews with participants (N = 14) and coaches (N = 4) to determine the feasibility and acceptability of the program. Results: Of the 867 clients referred to MindStep™, 757 had initial assessments by phone making an enrolment rate of 87.3%. Following assessment, 680 commenced treatment and of them, 427 (62.7%) completed treatment. According to 'per-protocol' analysis (N = 427), there was a large effect size for post-treatment PHQ-9 (d = 1.03) and GAD-7 (d = 0.99) scores; reliable recovery rate was 62% (95% CI: 57–68%). For intent-to-treat analysis using multiple imputation (N = 680), effect sizes were also large for pre-post treatment change: PHQ-9 (d = 0.78) and GAD-7 (d = 0.76). The reliable recovery rate was 49% (95% CI: 45–54%). Qualitative findings supported these claims where participants were positive about MindStep™ and found the telephone delivery and use of mental health coaches highly acceptable. Conclusions: MindStep™ has demonstrated encouraging outcomes that suggest LiCBT can be successfully delivered to people with a history of hospital admissions for anxiety and depressive disorders and achieve target recovery rates of > 50%. Other promising evaluation findings indicate the MindStep™ option is acceptable, feasible and safe within the stepped models of mental health care delivery in Australia. [ABSTRACT FROM AUTHOR]

Background: The relationship between healthcare service accessibility in the community and incarceration is an important, yet not widely understood, phenomenon. Community behavioral health and the criminal legal systems are treated separately, which creates a competing demand to confront mass incarceration and expand available services. As a result, the relationship between behavioral health services, demographics and community factors, and incarceration rate has not been well addressed. Understanding potential drivers of incarceration, including access to community-based services, is necessary to reduce entry into the legal system and decrease recidivism. This study identifies county-level demographic, socioeconomic, healthcare services availability/accessibility, and criminal legal characteristics that predict per capita jail population across the U.S. More than 10 million individuals pass through U.S. jails each year, increasing the urgency of addressing this challenge.Methods: The selection of variables for our model proceeded in stages. The study commenced by identifying potential descriptors and then using machine learning techniques to select non-collinear variables to predict county jail population per capita. Beta regression was then applied to nationally available data from all 3,141 U.S. counties to identify factors predicting county jail population size. Data sources include the Vera Institute's incarceration database, Robert Wood Johnson Foundation's County Health Rankings and Roadmaps, Uniform Crime Report, and the U.S. Census.Results: Fewer per capita psychiatrists (z-score = -2.16; p = .031), lower percent of drug treatment paid by Medicaid (-3.66; p < .001), higher per capita healthcare costs (5.71; p < .001), higher number of physically unhealthy days in a month (8.6; p < .001), lower high school graduation rate (-4.05; p < .001), smaller county size (-2.66, p = .008; -2.71, p = .007; medium and large versus small counties, respectively), and more police officers per capita (8.74; p < .001) were associated with higher per capita jail population. Controlling for other factors, violent crime rate did not predict incarceration rate.Conclusions: Counties with smaller populations, larger percentages of individuals that did not graduate high school, that have more health-related issues, and provide fewer community treatment services are more likely to have higher jail population per capita. Increasing access to services, including mental health providers, and improving the affordability of drug treatment and healthcare may help reduce incarceration rates. [ABSTRACT FROM AUTHOR]

Background: Ethiopia's government and civil society have driven crosscutting initiatives in the last 15 years to improve sexual and reproductive health outcomes, including passing a 2005 abortion law that facilitated reduced rates of maternal death due to unsafe abortion. However, both the government and nongovernmental organizations have relied on external funding for sexual and reproductive health and rights, particularly from the U.S. government, which has been Ethiopia's largest global health donor. This article explores how the implementation and expansion of the 2017–2021 U.S. foreign policy "Protecting Life in Global Health Assistance," also known as the Global Gag Rule—which attached itself to a nongovernmental organization's funding—impacted sexual and reproductive health and rights, including safe abortion care, in Ethiopia. Methods: This article is based on research conducted by PAI staff in Ethiopia in 2018 with follow-up in 2019. PAI held in-depth semistructured interviews with representatives of 30 organizations in Ethiopia's capital, Addis Ababa. Among these groups were U.S.-based and non-U.S. nongovernmental organizations, including community-based organizations, non-U.S. government donors, and Ethiopian government officials. Results: Nongovernmental organizations have been essential to sexual and reproductive health service provision and advocacy in Ethiopia. Because of the sector's reliance on U.S. global health assistance, these organizations; their activities; and, consequently, the wider health system were negatively impacted by the Global Gag Rule. Certain vulnerable groups, particularly adolescents and youth, have traditionally relied on the private sector for sexual and reproductive health services. PAI's research demonstrates that U.S. policy disrupted activities and service delivery, threatened the closure of private clinics, stalled mobile outreach, and impacted safe abortion training of health personnel. Additionally, the Global Gag Rule dismantled partnerships, affected non-U.S. government donors' investments, and caused confusion that limited activities permissible under the policy. Conclusions: The Trump administration's Global Gag Rule forced non-U.S. organizations to choose between providing comprehensive care or losing U.S. global health assistance, ultimately impacting populations in need of services. Ethiopia provides a clear example of how the Global Gag Rule can threaten a country's domestic health agenda by targeting nongovernmental organizations that are vital to health service delivery and safe abortion care. Plain language summary: In 2005, Ethiopia's government, health advocates, and service providers secured a more liberal abortion law that has been instrumental in reducing maternal deaths due to unsafe abortion. However, these fragile gains are vulnerable because the in-country sexual and reproductive health sector has relied heavily on external funding. The U.S. government has been an important development partner to Ethiopia for global health and, in particular, reproductive health and family planning. As a result, the Global Gag Rule, reimposed and expanded by the Trump administration in 2017, impacted sexual and reproductive health and rights in Ethiopia. U.S. agencies and departments attached this policy to U.S. global health assistance for nongovernmental organizations that were critical partners in service delivery and advocacy. In a country like Ethiopia with a progressive environment for sexual and reproductive health, including safe abortion care, it remains important to examine the impacts of the Global Gag Rule, despite being rescinded in January 2021 by the Biden administration, as the policy has still not yet been permanently repealed and could be reinstated by future administrations. PAI's research sought to document the impacts of the expanded Global Gag Rule on sexual and reproductive health in Ethiopia, with a focus on safe abortion care. Study participants reported that nongovernmental organizations serving rural populations, adolescents and youth, sex workers, and people living with HIV/AIDS were impacted by the loss of U.S. government funding due to noncompliance with the policy. Organizations that chose to comply with the policy were forced to stop critical activities like training on safe abortion care. Outcomes also included self-censorship out of fear of the policy and dismantled partnerships between compliant and noncompliant organizations. [ABSTRACT FROM AUTHOR]

Background: Indigenous peoples in developed countries have reduced life expectancies, particularly from chronic diseases. The lack of access to and take up of palliative care services of Indigenous peoples is an ongoing concern. Objectives: To examine and learn from published studies on provision of culturally safe palliative care service delivery to Indigenous people in Australia, New Zealand (NZ), Canada and the United States of America (USA); and to compare Indigenous peoples' preferences, needs, opportunities and barriers to palliative care. Methods: A comprehensive search of multiple databases was undertaken. Articles were included if they were published in English from 2000 onwards and related to palliative care service delivery for Indigenous populations; papers could use quantitative or qualitative approaches. Common themes were identified using thematic synthesis. Studies were evaluated using Daly's hierarchy of evidence-for-practice in qualitative research. Results: Of 522 articles screened, 39 were eligible for inclusion. Despite diversity in Indigenous peoples' experiences across countries, some commonalities were noted in the preferences for palliative care of Indigenous people: to die close to or at home; involvement of family; and the integration of cultural practices. Barriers identified included inaccessibility, affordability, lack of awareness of services, perceptions of palliative care, and inappropriate services. Identified models attempted to address these gaps by adopting the following strategies: community engagement and ownership; flexibility in approach; continuing education and training; a whole-of-service approach; and local partnerships among multiple agencies. Better engagement with Indigenous clients, an increase in number of palliative care patients, improved outcomes, and understanding about palliative care by patients and their families were identified as positive achievements. Conclusions: The results provide a comprehensive overview of identified effective practices with regards to palliative care delivered to Indigenous populations to guide future program developments in this field. Further research is required to explore the palliative care needs and experiences of Indigenous people living in urban areas. [ABSTRACT FROM AUTHOR]

Background: Operating room (OR) crises are high-acuity events requiring rapid, coordinated management. Medical judgment and decision-making can be compromised in stressful situations, and clinicians may not experience a crisis for many years. A cognitive aid (e.g., checklist) for the most common types of crises in the OR may improve management during unexpected and rare events. While implementation strategies for innovations such as cognitive aids for routine use are becoming better understood, cognitive aids that are rarely used are not yet well understood. We examined organizational context and implementation process factors influencing the use of cognitive aids for OR crises.Methods: We conducted a cross-sectional study using a Web-based survey of individuals who had downloaded OR cognitive aids from the websites of Ariadne Labs or Stanford University between January 2013 and January 2016. In this paper, we report on the experience of 368 respondents from US hospitals and ambulatory surgical centers. We analyzed the relationship of more successful implementation (measured as reported regular cognitive aid use during applicable clinical events) with organizational context and with participation in a multi-step implementation process. We used multivariable logistic regression to identify significant predictors of reported, regular OR cognitive aid use during OR crises.Results: In the multivariable logistic regression, small facility size was associated with a fourfold increase in the odds of a facility reporting more successful implementation (p = 0.0092). Completing more implementation steps was also significantly associated with more successful implementation; each implementation step completed was associated with just over 50% higher odds of more successful implementation (p ≤ 0.0001). More successful implementation was associated with leadership support (p < 0.0001) and dedicated time to train staff (p = 0.0189). Less successful implementation was associated with resistance among clinical providers to using cognitive aids (p < 0.0001), absence of an implementation champion (p = 0.0126), and unsatisfactory content or design of the cognitive aid (p = 0.0112).Conclusions: Successful implementation of cognitive aids in ORs was associated with a supportive organizational context and following a multi-step implementation process. Building strong organizational support and following a well-planned multi-step implementation process will likely increase the use of OR cognitive aids during intraoperative crises, which may improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: In the United States, home-based primary care (HBPC) is increasingly proposed as a means of enabling frail elders to remain at home for as long as possible, while still receiving needed medical care. However, there are relatively few studies of either the medical outcome effects or cost benefits of HBPC. In this paper, we examine medical cost and mortality outcomes for enrollees in the HBPC program offered by Spectrum Health/Priority Health (SH/PH), a not-for-profit integrated health care/health insurance system located in Grand Rapids, MI, USA.Methods: We perform a concurrent matched cohort study. SH/PH HBPC enrollees during 2012-2014 are matched for prior costs, age, sex and comorbidities against controls selected from unenrolled insurance plan members. Twelve and twenty four-month medical costs are compared between HBPC participants and matched controls, overall and conditional on mortality status. Mortality rates of HBPC participants are studied on their own and in comparison to controls.Results: At 12 and 24 months, in comparison to matched controls HBPC participants show higher ($2933) and lower ($8620) costs respectively. Relative costs and savings of HBPC participants are a function of short term increased costs upon entry into the program (enrollees who survive the first year cost $5866 more than controls); substantial savings at end-of-life (approximately $37,037 in savings relative to controls are realized); and the overall mortality of HBPC participants (mean residual lifespan is 37.75 months from the time of enrollment). We project the present value of lifetime medical cost savings due to enrollment in the HBPC program to be at least $14,336.Conclusions: The SH/PC HBPC program reduces healthcare costs while enabling frail elders to remain at home. Reduction in costs is obtained at end-of-life and is offset with a smaller initial increase in costs upon enrollment. [ABSTRACT FROM AUTHOR]

Background: People who inject drugs (PWID) constitute 60% of the approximately 5 million people in the U.S. infected with hepatitis C virus (HCV). Treatment of PWID is complex due to addiction, mental illness, poverty, homelessness, lack of positive social support, poor adherence-related skills, low motivation and knowledge, and poor access to and trust in the health care system. New direct-acting antiviral medications are available for HCV with high cure rates and few side effects. The life expectancy and economic benefits of new HCV treatments will not be realized unless we determine optimal models of care for the majority of HCV-infected patients. The purpose of this study is to evaluate the effectiveness of directly observed therapy and group treatment compared with self-administered individual treatment in a large, urban opioid agonist therapy clinic setting in the Bronx, New York.Methods/design: In this randomized controlled trial 150 PWID with chronic HCV were recruited from opioid agonist treatment (OAT) clinics and randomized to one of three models of onsite HCV treatment in OAT: 1) modified directly observed therapy; 2) group treatment; or 3) control - self-administered individual treatment. Participants were age 18 or older, HCV genotype 1, English or Spanish speaking, treatment naïve (or treatment experienced after 12/3/14), willing to receive HCV treatment onsite, receiving methadone or buprenorphine at the medication window at least once per week, and able to provide informed consent. Outcomes of interest include adherence (as measured by self-report and electronic blister packs), HCV treatment completion, sustained virologic response, drug resistance, and cost-effectiveness.Discussion: This paper describes the design and rationale of a randomized controlled trial comparing three models of care for HCV therapy delivered in an opioid agonist treatment program. Our trial will be critical to rigorously identify models of care that result in high adherence and cure rates. Use of blister pack technology will help us determine the role of adherence in successful cure of HCV. Moreover, the trial methodology outlined here can serve as a template for the development of future programs and studies among HCV-infected drug users receiving opioid agonist therapy, as well as the cost-effectiveness of such programs.Trial Registration: This trial was registered with ClinicalTrials.gov ( NCT01857245 ). Trial registration was obtained prospectively on May 20th, 2013. [ABSTRACT FROM AUTHOR]

Background: Expansion of healthcare insurance coverage to bariatric surgeries has led to an increased demand from patients for post-bariatric contouring surgeries. This study examined the relationship between the use of contouring procedures on post-bariatric surgery patients, clinical need and sociodemographic factors.Methods: Data were extracted from the Healthcare Cost and Utilization Project (HCUP) Nationwide Ambulatory Surgery Sample (NASS) regarding hospital-owned ambulatory surgical centres in the US. Episodes without missing values relating to patients, 18 years old or above were the primary unit of analysis. Episodes were excluded if the field regarding expected payer was reported as "no charge." The primary outcome was the likelihood of panniculectomy, abdominoplasty, and mastopexy among post-bariatric surgery patients; and the degree to which uptake of these types of contouring surgery were associated with age, gender, median households' income, expected payer, patient's location, and comorbidity.Results: A total of 66,368 weighted episodes of care received by patients who had had bariatric surgery were extracted (54,684 female [82.4%]; mean age, 51.3 [SD, 12.1]; 6219 episodes had contouring surgeries [9.37%]). Panniculectomy was the most common post-bariatric contouring procedure (3.68%). Uptake of post-bariatric contouring procedures was associated with age, sex, payment type, area-based measures of median household income, and patient location. Compared to Medicare insured patients, the odds of receiving contouring surgery among self-payers were 1.82 (95% CI, 1.47 to 2.26) for panniculectomy, 14.79 (95% CI, 12.19 to 17.93) for abdominoplasty and 47.97 (95% CI, 32.76 to 70.24) for mastopexy. Rank order of comorbidity profiles also differed between insured and self-paying recipients of contouring surgery.Conclusions: Insurance status of bariatric surgery patients and their sex were strongly associated with receipt of a range of contouring procedures. Self-payments were associated with a doubling of the odds of having panniculectomy and an increase in the odds to approximately 14 times for abdominoplasty and 48 times for mastopexy. Thus, access to contouring surgery by post-bariatric patients may be disproportionately dependent on personal preference supported by ability to pay rather than clinical need. Further research is needed to examine the impact of contouring or delayed/denied contouring on health status. [ABSTRACT FROM AUTHOR]

Background: A woman and girl centred, rights-based approach to health care is critical to achieving sexual and reproductive health. However, women with female genital mutilation in high-income countries have been found to receive sub-optimal care. This study examined documents guiding clinicians in health and community service settings in English-speaking high-income countries to identify approaches to ensure quality women and girl-centred care for those with or at risk of female genital mutilation. Method: We undertook a scoping review using the integrative model of patient-centredness to identify principles, enablers, and activities to facilitate woman and girl-centred care interactions. We developed an inclusion criterion to identify documents such as guidance statements and tools and technical guidelines, procedural documents and clinical practice guidelines. We searched the databases and websites of health professional associations, ministries of health, hospitals, national, state and local government and non-government organisations working in female genital mutilation in the United Kingdom, Ireland, Canada, The United States, New Zealand, and Australia. The Appraisal of Guidelines for Research and Evaluation tool was used to appraise screened documents. Findings: One-hundred and twenty-four documents were included in this scoping review; 88 were developed in the United Kingdom, 20 in Australia, nine in the United States, three in Canada, two in New Zealand and two in Ireland. The focus of documents from the United Kingdom on multi-professional safeguarding (62), while those retrieved from Australia, Canada, Ireland, New Zealand and the US focused on clinical practice. Twelve percent of the included documents contained references to all principles of patient-centred care, and only one document spoke to all principles, enablers and activities. Conclusion: This study demonstrates the need to improve the female genital mutilation-related guidance provided to professionals to care for and protect women and girls. Professionals need to involve women and girls with or at risk of female genital mutilation in the co-design of guidelines and tools and evaluation of them and the co-production of health care. Plain Language Summary: High-quality health care for women and girls should be provided by health workers who are respectful and caring. Health workers should also work with others as a team and help women and girls make their own decisions about their health care. This approach is called patient-centred care. Female genital mutilation (FGM) is a cultural practice associated with poor health outcomes. Women who have experienced FGM have not always received quality health care. We studied the guidance and tools to help health workers provide care to women and girls with or at risk of FGM. This study aimed to understand how health workers are supported to provide woman and girl-centred health care in these documents. We searched for these documents on the websites of health professional associations, government health departments and organisations working in FGM in the United Kingdom, Ireland, Canada, The United States, New Zealand, and Australia. The documents were analysed using a tool that described all the important areas needed to provide patient-centred health care. Of the 124 documents, we found that only 12% contained information about all aspects of patient-centred care. Only one document had details about all the areas that are part of patient-centred care. This study shows that we need to improve the FGM-related guidance provided to health workers to care for and protect women and girls. There is a need for health workers to involve women and girls with or at risk of FGM in designing guidelines and tools and evaluating them to these documents best fit their needs. [ABSTRACT FROM AUTHOR]

Background: Decomposing health care spending by disease, type of care, age, and sex can lead to a better understanding of the drivers of health care spending. But the lack of diagnostic coding in outpatient care often precludes a decomposition by disease. Yet, health insurance claims data hold a variety of diagnostic clues that may be used to identify diseases.Methods: In this study, we decompose total outpatient care spending in Switzerland by age, sex, service type, and 42 exhaustive and mutually exclusive diseases according to the Global Burden of Disease classification. Using data of a large health insurance provider, we identify diseases based on diagnostic clues. These clues include type of medication, inpatient treatment, physician specialization, and disease specific outpatient treatments and examinations. We determine disease-specific spending by direct (clues-based) and indirect (regression-based) spending assignment.Results: Our results suggest a high precision of disease identification for many diseases. Overall, 81% of outpatient spending can be assigned to diseases, mostly based on indirect assignment using regression. Outpatient spending is highest for musculoskeletal disorders (19.2%), followed by mental and substance use disorders (12.0%), sense organ diseases (8.7%) and cardiovascular diseases (8.6%). Neoplasms account for 7.3% of outpatient spending.Conclusions: Our study shows the potential of health insurance claims data in identifying diseases when no diagnostic coding is available. These disease-specific spending estimates may inform Swiss health policies in cost containment and priority setting. [ABSTRACT FROM AUTHOR]

Clinical pharmacists have advanced training that enables them to manage medication therapy, including prescribing, titrating, and discontinuing medications, in order to achieve therapeutic goals. In some countries, such as the United States, advances in training, responsibility, legal frameworks, and public acceptance of new roles have proceeded in parallel to expand the scope and contribution of clinical pharmacists over several decades. In this manuscript, we detail seven discrete key parameters of professional advancement for clinical pharmacists, corresponding to the seven areas in which they must advance in order to contribute fully to delivering high-quality medical care. For each key parameter, we briefly summarize the progress made in the United States to date, as well as goals for future progress. We then compare this to the development of the analogous key parameter in Israel. We found that on some key parameters, the development of clinical pharmacy in Israel lags behind the United States. This manuscript can provide a roadmap for the future advancement of clinical pharmacy in Israel, toward its full realization as a profession that can contribute to delivering high-quality medical care. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to identify the range of ways that safety net hospitals (SNHs) have been empirically operationalized in the literature and determine the extent to which patterns could be identified in the use of empirical definitions of SNHs.Methods: We conducted a PRISMA guided systematic review of studies published between 2009 and 2018 and analyzed 22 articles that met the inclusion criteria of hospital-level analyses with a clear SNH definition.Results: Eleven unique SNH definitions were identified, and there were no obvious patterns in the use of a definition category (Medicaid caseload, DSH payment status, uncompensated care, facility characteristics, patient care mix) by the journal type where the article appeared, dataset used, or the year of publication.Conclusions: Overall, there is broad variability in the conceptualization of, and variables used to define, SNHs. Our work advances the field toward the development of standards in measuring, operationalizing, and conceptualizing SNHs across research and policy questions. [ABSTRACT FROM AUTHOR]

Background: Patient-Centered Medical Home (PCMH) adoption is an important strategy to help improve primary care quality within Health Resources and Service Administration (HRSA) community health centers (CHC), but evidence of its effect thus far remains mixed. A limitation of previous evaluations has been the inability to account for the proportion of CHC delivery sites that are designated medical homes.Methods: Retrospective cross-sectional study using HRSA Uniform Data System (UDS) and certification files from the National Committee for Quality Assurance (NCQA) and the Joint Commission (JC). Datasets were linked through geocoding and an approximate string-matching algorithm. Predicted probability scores were regressed onto 11 clinical performance measures using 10% increments in site-level designation using beta logistic regression.Results: The geocoding and approximate string-matching algorithm identified 2615 of the 6851 (41.8%) delivery sites included in the analyses as having been designated through the NCQA and/or JC. In total, 74.7% (n = 777) of the 1039 CHCs that met the inclusion criteria for the analysis managed at least one NCQA- and/or JC-designated site. A proportional increase in site-level designation showed a positive association with adherence scores for the majority of all indicators, but primarily among CHCs that designated at least 50% of its delivery sites. Once this threshold was achieved, there was a stepwise percentage point increase in adherence scores, ranging from 1.9 to 11.8% improvement, depending on the measure.Conclusion: Geocoding and approximate string-matching techniques offer a more reliable and nuanced approach for monitoring the association between site-level PCMH designation and clinical performance within HRSA's CHC delivery sites. Our findings suggest that transformation does in fact matter, but that it may not appear until half of the delivery sites become designated. There also appears to be a continued stepwise increase in adherence scores once this threshold is achieved. [ABSTRACT FROM AUTHOR]

Background: A new movement towards improved postpartum care calls for restructuring how that care is provided. As professional guidelines evolve, understanding how providers prioritize and practice postpartum care can offer insights about elements of care that may be currently performed more routinely than providers deem a priority to do so, as well as those that may warrant more routine practice.Methods: We surveyed 600 randomly-sampled U.S. postpartum care providers about their priorities for and the frequency with which specific elements of care are provided, as well as the feasibility of remote delivery of postpartum care provision (i.e., telemedicine).Results: The survey response rate was 43% across medical specialties. Providers reported an average of only 24.4 ± 11.7 min available to spend on the postpartum visit. Certain types of postpartum care were highly prioritized and routinely performed, such as depression screening. Yet, there were also noted discrepancies between prioritized and performed care, revealing competing demands on providers' time. For example, pelvic exams were performed more often than similarly prioritized care, whereas screening for intimate partner violence and substance use were performed less often than similarly-prioritized care. Certain types of care were identified as important that are not explicitly addressed by national practice guidelines (e.g. transitioning to parenthood). Approximately 25% of respondents regarded telemedicine as a feasible remote care delivery alternative to much of the care currently provided in-person.Conclusions: The time providers have available to offer comprehensive postpartum care is constrained. Understanding how certain elements of care may be competing with one another at a single postpartum visit highlights those elements of care, which may be currently underperformed, as well as those elements of care that may warrant evaluation for future inclusion in standard care. For some providers experiencing time constraints, complementary remote care represents a potentially viable approach to implementing recommendations for transitioning the traditional visit to a more frequent, ongoing postpartum care process. In calling for a new approach to postpartum care delivery, professional organizations should consider the practices and priorities of their constituency as they revise guidelines and shape future research about the value of specific postpartum services. [ABSTRACT FROM AUTHOR]

Background: Mobile health clinics serve an important role in the health care system, providing care to some of the most vulnerable populations. Mobile Health Map is the only comprehensive database of mobile clinics in the United States. Members of this collaborative research network and learning community supply information about their location, services, target populations, and costs. They also have access to tools to measure, improve, and communicate their impact. Methods: We analyzed data from 811 clinics that participated in Mobile Health Map between 2007 and 2017 to describe the demographics of the clients these clinics serve, the services they provide, and mobile clinics' affiliated institutions and funding sources. Results: Mobile clinics provide a median number of 3491 visits annually. More than half of their clients are women (55%) and racial/ethnic minorities (59%). Of the 146 clinics that reported insurance data, 41% of clients were uninsured while 44% had some form of public insurance. The most common service models were primary care (41%) and prevention (47%). With regards to organizational affiliations, they vary from independent (33%) to university affiliated (24%), while some (29%) are part of a hospital or health care system. Most mobile clinics receive some financial support from philanthropy (52%), while slightly less than half (45%) receive federal funds. Conclusion: Mobile health care delivery is an innovative model of health services delivery that provides a wide variety of services to vulnerable populations. The clinics vary in service mix, patient demographics, and relationships with the fixed health system. Although access to care has increased in recent years through the Affordable Care Act, barriers continue to persist, particularly among populations living in resource-limited areas. Mobile clinics can improve access by serving as a vital link between the community and clinical facilities. Additional work is needed to advance availability of this important resource. [ABSTRACT FROM AUTHOR]

Background: Cancer control programs have added patient navigation to improve effectiveness in underserved populations, but research has yielded mixed results about their impact on patient satisfaction. This study focuses on three related research questions in a U.S. state cancer screening program before and after a redesign that added patient navigators and services for chronic illness: Did patient diversity increase; Did satisfaction levels improve; Did socioeconomic characteristics or perceived barriers explain improved satisfaction.Methods: Representative statewide patient samples were surveyed by phone both before and after the program design. Measures included satisfaction with overall health care and specific services, as well as experience of eleven barriers to accessing health care and self-reported health and sociodemographic characteristics. Multiple regression analysis is used to identify independent effects.Results: After the program redesign, the percentage of Hispanic and African American patients increased by more than 200% and satisfaction with overall health care quality rose significantly, but satisfaction with the program and with primary program staff declined. Sociodemographic characteristics explained the apparent program effects on overall satisfaction, but perceived barriers did not. Further analysis indicates that patients being seen for cancer risk were more satisfied if they had a patient navigator.Conclusions: Health care access can be improved and patient diversity increased in public health programs by adding patient navigators and delivering more holistic care. Effects on patient satisfaction vary with patient health needs, with those being seen for chronic illness likely to be less satisfied with their health care than those being seen for cancer risk. It is important to use appropriate comparison groups when evaluating the effect of program changes on patient satisfaction and to consider establishing appropriate satisfaction benchmarks for patients being seen for chronic illness. [ABSTRACT FROM AUTHOR]

Background: Health policy in Australia positions Aboriginal and Torres Strait Islander Health Workers (AHWs) as central to improving Aboriginal and Torres Strait Islander peoples' health, with high expectations of their contribution to closing the gap between Indigenous and non-Indigenous health outcomes. Understanding how AHWs' governance and accountability relationships influence their ability to address such health inequities has policy, programme and ethical significance. We sought to map the evidence of AHWs' experiences of accountability in the Australian health system. Methods: We followed an adapted qualitative systematic review process to map evidence on accountability relations in the published literature. We sought empirical studies or first-person accounts describing AHWs' experiences of working in government or Aboriginal community-controlled services anywhere in Australia. Findings were organised according to van Belle and Mayhew's four dimensions of accountability – social, political, provider and organisational. Results: Of 27 included studies, none had a primary focus on AHW governance or AHWs' accountability relationships. Nonetheless, selected articles provided some insight into AHWs' experiences of accountability across van Belle and Mayhew's four dimensions. In the social dimension, AHWs' sense of connection and belonging to community was reflected in the importance placed on AHWs' cultural brokerage and advocacy functions. But social and cultural obligations overlapped and sometimes clashed with organisational and provider-related accountabilities. AHWs described having to straddle cultural obligations (e.g. related to gender, age and kinship) alongside the expectations of non-Indigenous colleagues and supervisors which were underpinned by 'Western' models of clinical governance and management. Lack of role-clarity stemming from weakly constituted (state-based) career structures was linked to a system-wide misunderstanding of AHWs' roles and responsibilities – particularly the cultural components – acting as a barrier to AHWs working to their full capacity for the benefit of patients, broader society and their own professional satisfaction. Conclusions: In literature spanning different geographies, service domains and several decades, this review found evidence of complexity in AHWs' accountability relationships that both affects individual and team performance. However, theoretically informed and systematic investigation of accountability relationships and related issues, including the power dynamics that underpin AHW governance and performance in often diverse settings, remains limited and more work in this area is required. [ABSTRACT FROM AUTHOR]

Background: Approximately 20% of community-dwelling older adults discharged from the emergency department (ED) return to an ED within 30 days, an occurrence partially resulting from poor care transitions. Prior published interventions to improve the ED-to-home transition have either lacked feasibility or effectiveness. The Care Transitions Intervention (CTI) has been validated to decrease rehospitalization among patients transitioning from the hospital to the home but has never been tested for patients transitioning from the ED to the home. Paramedics, traditionally involved only in emergency care, are well-positioned to deliver the CTI, but have never been previously evaluated in this role.Methods: This single-blinded randomized controlled trial tests whether the paramedic-delivered ED-to-home CTI reduces community-dwelling older adults' ED revisits in the 30 days after an index visit. We are prospectively recruiting patients aged≥ 60 years at 3 EDs in Rochester, NY and Madison, WI to enroll 2400 patient subjects. Subjects are randomized into control and treatment groups, with the latter receiving the adapted CTI. The intervention consists of the paramedic performing one home visit and up to three follow-up phone calls. During these interactions, the paramedic follows the CTI approach by coaching patients toward their goals, with a focus on their personal health record, medication management, red flags, and primary care follow-up. We follow patient participants for 30 days. All receive a survey during the index ED visit to capture baseline demographic and health information and two telephone-based surveys to assess process objectives and outcomes. We also perform a medical record review. The primary outcome is the odds of ED revisit within 30 days after discharge from the index ED visit.Discussion: This is the first study to test whether the CTI, applied to the ED-to-home transition and delivered by community paramedics, can decrease the rate at which older adults revisit an ED. Outcomes from this research will help address a major emergency care challenge by supporting older adults in the transition from the ED to home, thereby improving health outcomes for this population and reducing potentially avoidable ED visits.Trial Registration: ClinicalTrials.gov Registration: NCT02520661 . Trial registration date: August 13, 2015. [ABSTRACT FROM AUTHOR]

Background: The biopsychosocial model is a comprehensive approach emphasizing holistic medical care. However, medical curricula that incorporate narrative reflective writing and group dynamic discussion of psychosocial issues among patients and their family members in reflective dialogue groups are currently underutilized. The aim of this study was to determine psychosocial issues among patients and their family members through medical students' reflective dialogue groups. Methods: This study was completed as part of a pediatric clerkship. Fifty medical students were rotated to the department of Pediatrics. They completed a narrative writing assignment concerning patients' psychosocial issues and participated in a reflective group discussion during the rotation. The recordings of the six reflective group sessions were transcribed for thematic analysis. A six-step theme generation process was conducted in the first reading stage of all transcripts by four researchers. Subsequently, initial codes were generated and potential themes sought before possible themes were reviewed and thematic maps generated. Names for each theme were defined and a scholarly report of the analysis was presented through a consensus-based approach. Results: A total of 108 psychosocial issues were coded and categorized as the following six main themes: medical communication, the intricate medical ecological system, role and function of a family, development of medical professionalism, ethical dilemmas, and various patient perspectives from diverse cultural backgrounds. All these themes underlie the complexity of clinical encounters. Conclusions: Clinical care is an extremely complex interactive ecological network involving human behavior, family, and public health care systems. The discovery of psychosocial problems by medical students as narrators in this study illustrates that medical care should focus not only on illnesses but also patients' psychosocial narratives. [ABSTRACT FROM AUTHOR]

Background: Strategies are central to the National Institutes of Health's definition of implementation research as "the study of strategies to integrate evidence-based interventions into specific settings." Multiple scholars have proposed lists of the strategies used in implementation research and practice, which they increasingly are classifying under the single term "implementation strategies." We contend that classifying all strategies under a single term leads to confusion, impedes synthesis across studies, and limits advancement of the full range of strategies of importance to implementation. To address this concern, we offer a system for classifying implementation strategies that builds on Proctor and colleagues' (2013) reporting guidelines, which recommend that authors not only name and define their implementation strategies but also specify who enacted the strategy (i.e., the actor) and the level and determinants that were targeted (i.e., the action targets).Main Body: We build on Wandersman and colleagues' Interactive Systems Framework to distinguish strategies based on whether they are enacted by actors functioning as part of a Delivery, Support, or Synthesis and Translation System. We build on Damschroder and colleague's Consolidated Framework for Implementation Research to distinguish the levels that strategies target (intervention, inner setting, outer setting, individual, and process). We then draw on numerous resources to identify determinants, which are conceptualized as modifiable factors that prevent or enable the adoption and implementation of evidence-based interventions. Identifying actors and targets resulted in five conceptually distinct classes of implementation strategies: dissemination, implementation process, integration, capacity-building, and scale-up. In our descriptions of each class, we identify the level of the Interactive System Framework at which the strategy is enacted (actors), level and determinants targeted (action targets), and outcomes used to assess strategy effectiveness. We illustrate how each class would apply to efforts to improve colorectal cancer screening rates in Federally Qualified Health Centers.Conclusions: Structuring strategies into classes will aid reporting of implementation research findings, alignment of strategies with relevant theories, synthesis of findings across studies, and identification of potential gaps in current strategy listings. Organizing strategies into classes also will assist users in locating the strategies that best match their needs. [ABSTRACT FROM AUTHOR]

Background: Sexual violence is widespread, yet relatively few survivors receive healthcare or complete treatment. In low and middle-income countries, community health workers (CHWs) have the potential to provide support services to large numbers of survivors. The aim of this review was to document the role of CHWs in sexual violence services. We aimed to: 1) describe existing models of CHWs services including characteristics of CHWs, services delivered and populations served; 2) explore acceptability of CHWs' services to survivors and feasibility of delivering such services; and 3) document the benefits and challenges of CHW-provided sexual violence services. Methods: Quantitative and qualitative studies reporting on CHWs and other community-level paraprofessional volunteer services for sexual violence were eligible for inclusion. CHWs and sexual violence were defined according to WHO criteria. The review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Quality of included studies was assessed using two quality assessment tools for quantitative, and, the methodology checklist by the National Institute for Health and Clinical Excellence for qualitative studies. Data were extracted and analysed separately for quantitative and qualitative studies and results integrated using a framework approach. Results: Seven studies conducted in six countries (Democratic Republic of Congo, Rwanda, Burma, United States of America, Scotland, Israel) met the inclusion criteria. Different models of care had diverse CHWs roles including awareness creation, identifying, educating and building relationships with survivors, psychosocial support and follow up. Although sociocultural factors may influence CHWs' performance and willingness of survivors to use their services, studies often did not report on CHWs characteristics. Few studies assessed acceptability of CHWs' to survivors or feasibility of delivery of services. However, participants mentioned a range of benefits including decreased incidence of violence, CHWs being trusted, approachable, non-judgmental and compassionate. Challenges identified were high workload, confidentiality issues and community norms influencing performance. Conclusions: There is a dearth of research on CHWs services for sexual violence. Findings suggest that involving CHWs may be beneficial, but potential challenges and harms related to CHW-provided services exist. No different models of CHW-provided care have been robustly evaluated for effects on patient outcomes. Further research to establish survivors' views on these services, and, their effectiveness is desperately needed. [ABSTRACT FROM AUTHOR]

Background: The collaborative care model is an evidence-based practice for treatment of depression in which designated care managers provide clinical services, often by telephone. However, the collaborative care model is infrequently adopted in the Department of Veterans Affairs (VA). Almost all VA medical centers have adopted a co-located or embedded approach to integrating mental health care for primary care patients. Some VA medical centers have also adopted a telephone-based collaborative care model where depression care managers support patient education, patient activation, and monitoring of adherence and progress over time. This study evaluated two research questions: (1) What does a dedicated care manager offer in addition to an embedded-only model? (2) What are the barriers to implementing a dedicated depression care manager?Methods: This study involved 15 qualitative, multi-disciplinary, key informant interviews at two VA medical centers where reimbursement options were the same- both with embedded mental health staff, but one with a depression care manager. Participant interviews were recorded and transcribed. Thematic analysis was used to identify descriptive and analytical themes.Results: Findings suggested that some of the core functions of depression care management are provided as part of embedded-only mental health care. However, formal structural attention to care management may improve the reliability of care management functions, in particular monitoring of progress over time. Barriers to optimal implementation were identified at both sites. Themes from the care management site included finding assertive care managers to hire, cross-discipline integration and collaboration, and primary care provider burden. Themes from interviews at the embedded site included difficulty getting care management on leaders' agendas amidst competing priorities and logistics (staffing and space).Conclusions: Providers and administrators see depression care management as a valuable healthcare service that improves patient care. Barriers to implementation may be addressed by team-building interventions to improve cross-discipline integration and communication. Findings from this study are limited in scope to the VA healthcare system. Future investigation of whether alternative barriers exist in implementation of depression care management programs in non-VA hospital systems, where reimbursement rates may be a more prominent concern, would be valuable. [ABSTRACT FROM AUTHOR]

Background: Valuations of health state descriptors such as EQ-5D or SF6D have been conducted in different countries. There is a scope to make use of the results in one country as informative priors to help with the analysis of a study in another, for this to enable better estimation to be obtained in the new country than analyzing its data separately.Methods: Data from 2 EQ-5D valuation studies were analyzed using the time trade-off technique, where values for 42 health states were devised from representative samples of the UK and US populations. A Bayesian non-parametric approach has been applied to predict the health utilities of the US population, where the UK results were used as informative priors in the model to improve their estimation.Results: The findings showed that employing additional information from the UK data helped in the production of US utility estimates much more precisely than would have been possible using the US study data alone.Conclusion: It is very plausible that this method would serve useful in countries where the conduction of large evaluation studies is not very feasible. [ABSTRACT FROM AUTHOR]

Background: Self-rated health (SRH) is widely used to measure subjective health. Yet it is unclear what underlies health ratings, with implications for understanding the validity of SRH overall and across sociodemographic characteristics. We analyze participants' explanations of how they formulated their SRH answer in addition to which health factors they considered and examine group differences in these processes.Methods: Cognitive interviews were conducted with 64 participants in a convenience quota sample crossing dimensions of race/ethnicity (white, Latino, black, American Indian), gender, age, and education. Participants rated their health then described their thoughts when answering SRH. We coded participants' answers in an inductive, iterative, and systematic process from interview transcripts, developing analytic categories (i.e., themes) and subdimensions within. We examined whether the presence of each dimension of an analytic category varied across sociodemographic groups.Results: Our qualitative analysis led to the identification and classification of various subdimensions of the following analytic categories: types of health factors mentioned, valence of health factors, temporality of health factors, conditional health statements, and descriptions and definitions of health. We found differences across groups in some types of health factors mentioned-corresponding, conflicting, or novel with respect to prior research. Furthermore, we also documented various processes through which respondents integrate seemingly disparate health factors to formulate an answer through valence and conditional health statements. Finally, we found some evidence of sociodemographic group differences with respect to types of health factors mentioned, valence of health factors, and conditional health statements, highlighting avenues for future research.Conclusion: This study provides a description of how participants rate their general health status and highlights potential differences in these processes across sociodemographic groups, helping to provide a more comprehensive understanding of how SRH functions as a measure of health. [ABSTRACT FROM AUTHOR]

Background: The clinical research enterprise is not producing the evidence decision makers arguably need in a timely and cost effective manner; research currently involves the use of labor-intensive parallel systems that are separate from clinical care. The emergence of pragmatic clinical trials (PCTs) poses a possible solution: these large-scale trials are embedded within routine clinical care and often involve cluster randomization of hospitals, clinics, primary care providers, etc. Interventions can be implemented by health system personnel through usual communication channels and quality improvement infrastructure, and data collected as part of routine clinical care. However, experience with these trials is nascent and best practices regarding design operational, analytic, and reporting methodologies are undeveloped.Methods: To strengthen the national capacity to implement cost-effective, large-scale PCTs, the Common Fund of the National Institutes of Health created the Health Care Systems Research Collaboratory (Collaboratory) to support the design, execution, and dissemination of a series of demonstration projects using a pragmatic research design.Results: In this article, we will describe the Collaboratory, highlight some of the challenges encountered and solutions developed thus far, and discuss remaining barriers and opportunities for large-scale evidence generation using PCTs.Conclusion: A planning phase is critical, and even with careful planning, new challenges arise during execution; comparisons between arms can be complicated by unanticipated changes. Early and ongoing engagement with both health care system leaders and front-line clinicians is critical for success. There is also marked uncertainty when applying existing ethical and regulatory frameworks to PCTS, and using existing electronic health records for data capture adds complexity. [ABSTRACT FROM AUTHOR]

Background: Incorporating behavioral health care into patient centered medical homes is critical for improving patient health and care quality while reducing costs. Despite documented effectiveness of behavioral health integration (BHI) in primary care settings, implementation is limited outside of large health systems. We conducted a survey of BHI in primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a four-year multi-payer initiative of the Centers for Medicare and Medicaid Services (CMS). We sought to explore associations between practice characteristics and the extent of BHI to illuminate possible factors influencing successful implementation.Method: We fielded a survey that addressed six substantive domains (integrated space, training, access, communication and coordination, treatment planning, and available resources) and five behavioral health conditions (depression, anxiety, pain, alcohol use disorder, and cognitive function). Descriptive statistics compared BHI survey respondents to all CPC practices, documented the availability of behavioral health providers, and primary care and behavioral health provider communication. Bivariate relationships compared provider and practice characteristics and domain scores.Results: One hundred sixty-one of 188 eligible primary care practices completed the survey (86% response rate). Scores indicated basic to good baseline implementation of BHI in all domains, with lowest scores on communication and coordination and highest scores for depression. Higher scores were associated with: having any behavioral health provider, multispecialty practice, patient-centered medical home designation, and having any communication between behavioral health and primary care providers.Conclusions: This study provides useful data on opportunities and challenges of scaling BHI integration linked to primary care transformation. Payment reform models such as CPC can assist in BHI promotion and development. [ABSTRACT FROM AUTHOR]