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US hospitals are struggling with how to compete and remain viable in an increasingly turbulent and competitive environment. Using Porter’s generic strategies and resource dependence theory, this study examined the relationship between environmental factors and business strategy choice among U.S. hospitals. The study used longitudinal data from 2006 to 2016 of US urban, general acute care hospitals from the American Hospital Association Annual Survey, Medicare cost reports, and Area Health Resource File. Multinomial regression was used to analyze the data. and Discussion: Our findings showed four types of hospital strategy: cost-leadership, differentiation, hybrid, and stuck-in-the-middle. A greater number of physicians (county-level) increases the likelihood of pursuing differentiation and hybrid strategy. On the other hand, a higher older adult population (65 years+) increases the likelihood of pursuing a cost-leadership strategy. Similarly, lower competition and higher Medicare Advantage penetration increases the likelihood of pursuing cost-leadership over hybrid strategy. An increase in the unemployment rate decreases the likelihood of pursuing differentiation and cost-leadership strategies versus the hybrid strategy. Finally, hospitals pursuing a differentiation strategy tended to be larger, teaching, and not-for-profit. The results showed the importance of environmental and organizational factors in predicting the strategy choice of hospitals.

EXECUTIVE SUMMARY Financial distress is a persistent problem in U.S. hospitals, leading them to close at an alarming rate over the past two decades. Given the potential adverse effects of hospital closures on healthcare access and public health, interest is growing in understanding more about the financial health of U.S. hospitals. In this study, we set out to explore the extent to which relevant organizational and environmental factors potentially buffer financially distressed hospitals from closure, and even at the brink of closure, enable some to merge with other hospitals. We tested our hypotheses by first examining how factors such as slack resources, environmental munificence, and environmental complexity affect the likelihood of survival versus closing or merging with other organizations. We then tested how the same factors affect the likelihood of merging relative to closing for financially distressed hospitals that undergo one of these two events. We found that different types of slack resources and environmental forces impact different outcomes. In this article, we discuss the implications of our findings for hospital stakeholders.

Background The aims of this study were to explore to explore the viewpoints of parents of children with Autism Spectrum Disorders (ASD) and professionals regarding the implementation of screening programs for ASD, to explore the challenges of the implementation of a universal screening program for ASD in Iran from their viewpoints, and, to explore their recommendations to overcome the potential challenges. Method This qualitative study was conducted using an inductive content analysis, between June 2018 and December 2018, in East-Azerbaijan province of Iran. Data was collected through in-depth interviews and focus group discussions. The participants were purposively selected among two groups: representatives of health system and representatives of children with ASD. A sample of 32 parents and 30 professionals were recruited in this study. Results Totally, 9 main themes and 23 sub-themes were extracted in three main areas including: viewpoints of the participants about universal screening for ASD, challenges in implementation of the universal screening program, and participants’ recommendations about how to overcome the potential challenges. Main challenges in implementation of the universal screening program included: shortages of ASD screening tools, weakness of the health system, lack of coordination among the ASD service providers, and social and ethical issues. Conclusion The parents and the professionals had different viewpoints about the implementation of ASD universal screening program in Iran. According to the professionals, there is not enough rational to implement ASD screening program for all children. However, the parents believed that universal screening program is inevitable, and it should be implemented in primary health centers during the early child-care visits. The results of this study open up unspoken issues that could help in initiating the screening program not only in Iran but also in other low- and middle-income countries as well.

In this qualitative study, we aimed to explore the challenges of providing services and supports for children with autism spectrum disorders (ASD) and their families from the perceptions of professionals and parents of children with ASD. We classified the results of the study into three key categories including shortcomings in the management of children with ASD; shortcomings of supportive programs and facilities for children with ASD and their families; and organizational challenges in providing services for these children. We analyzed data using the content analysis method. The results showed that there is a wide range of challenges in providing sufficient and high-quality services for children with ASD and empowerment programs for their parents.

Non-Pharmaceutical Public Health Interventions (NPHIs) have been used by different countries to control the spread of the COVID-19. Despite available evidence regarding the effectiveness of NPHSs, there is still no consensus about how policymakers can trust these results. Studies on the effectiveness of NPHSs are single studies conducted in specific communities. Therefore, they cannot individually prove if these interventions have been effective in reducing the spread of the infection and its adverse health outcomes. In this systematic review, we aimed to examine the effects of NPHIs on the COVID-19 case growth rate, death growth rate, Intensive Care Unit (ICU) admission, and reproduction number in countries, where NPHIs have been implemented. We searched relevant electronic databases, including Medline (via PubMed), Scopus, CINAHL, Web of Science, etc. from late December 2019 to February 1, 2021. The key terms were primarily drawn from Medical Subject Heading (MeSh and Emtree), literature review, and opinions of experts. Peer-reviewed quasi-experimental studies were included in the review. The PROSPERO registration number is CRD42020186855. Interventions were NPHIs categorized as lockdown, stay-at-home orders, social distancing, and other interventions (mask-wearing, contact tracing, and school closure). We used PRISMA 2020 guidance for abstracting the data and used Cochrane Effective Practice and Organization of Practice (EPOC) Risk of Bias Tool for quality appraisal of the studies. Hartung-Knapp-Sidik-Jonkman random-effects model was performed. Main outcomes included COVID-19 case growth rate (percentage daily changes), COVID-19 mortality growth rate (percentage daily changes), COVID-19 ICU admission (percentage daily changes), and COVID-19 reproduction number changes. Our search strategies in major databases yielded 12,523 results, which decreased to 7,540 articles after eliminating duplicates. Finally, 35 articles qualified to be included in the systematic review among which 23 studies were included in the meta-analysis. Although studies were from both low-income and high-income countries, the majority of them were from the United States (13 studies) and China (five studies). Results of the meta-analysis showed that adoption of NPHIs has resulted in a 4.68% (95% CI, -6.94 to -2.78) decrease in daily case growth rates, 4.8% (95 CI, -8.34 to -1.40) decrease in daily death growth rates, 1.90 (95% CI, -2.23 to -1.58) decrease in the COVID-19 reproduction number, and 16.5% (95% CI, -19.68 to -13.32) decrease in COVID-19 daily ICU admission. A few studies showed that, early enforcement of lockdown, when the incidence rate is not high, contributed to a shorter duration of lockdown and a lower increase of the case growth rate in the post-lockdown era. The majority of NPHIs had positive effects on restraining the COVID-19 spread. With the problems that remain regarding universal access to vaccines and their effectiveness and considering the drastic impact of the nationwide lockdown and other harsh restrictions on the economy and people’s life, such interventions should be mitigated by adopting other NPHIs such as mass mask-wearing, patient/suspected case isolation strategies, and contact tracing. Studies need to address the impact of NPHIs on the population’s other health problems than COVID-19.

Health inequities vary along social and economic gradients. The COVID-19 pandemic and nursing home infections have highlighted this fact. Using the Centers for Medicare and Medicaid Services’ Nursing Home COVID-19 Public File, Brown University’s LTCFocus, Robert Graham Center’s Social Deprivation Index, and CMS Nursing Home Payroll Based Journal Staffing Data. We examined the relationship between community resource scarcity, as conceptualized by the Social Deprivation Index (SD) and COVID-19 incidence rates in nursing homes. After controlling for interstate differences, organizational enabling factors, as well as, facility-level resident and community-level characteristics, nursing homes located in communities with medium levels of social deprivation had 4.4% more COVID-19 infection rates (Incidence Rate Ratio [IRR] = 1.04; p < 0.05) and communities with high levels of social deprivation had 7.5% higher COVID-19 infection rates (Incidence Rate Ratio [IRR] = 1.07; p < 0.01) as compared to nursing facilities located in areas of low social deprivation. From a policy perspective, nursing homes, that are located in socially deprived communities, may need additional resources, such as, funding for staffing and personal protective equipment in the face of the pandemic. The COVID-19 pandemic has sharpened the focus on healthcare disparities and societal inequalities in the delivery of long-term care.

Background Socioeconomic disparities in health and healthcare are global issues that affect both adults as well as children. Children with exceptional healthcare needs, especially those with developmental impairments, including Autism Spectrum Disorders (ASD), encounter major disparities in access to and quality of health services. However, disparities in the population of children are rarely studied. The main aim of this paper is to study the socioeconomic disparities in children with ASD by examining the association between their Social Determinants of Health (SDH) status and access to and the quality of services. Methods This is a cross-sectional study on 202 children with ASD conducted in 2019 in two provinces including Ardabil and East-Azerbaijan, in the North-West of Iran. A structured, valid questionnaire was used to collect data on demographic, SDH status, quality of services, and access to services in a population of children with ASD aged 2–16-year-old. Around 77% participants were male and the mean age of children was 2 years and 6 months. Structural Equation Modeling (SEM) were used to assess the relationship. Results Based on the results of this study, the overall mean scores of the quality of services, access to services, and SDH status were 61.23 (30.01), 65.91 (21.89), and 29.50 (22.32) out of 100, respectively. All the associations between the quality and access dimensions and quality (B: 0.464–0.704) and access (B: 0.265–0.726) scales were statistically significant (P P = 0.004). Finally, the associations between SDH score with service quality (P = 0.039) and access (P Conclusions There are socioeconomic disparities in the quality of and access to services among children with ASD, who use ASD services, in the North-West of Iran. We recommend health/medical centers, where children are diagnosed with ASD, conducting SDH screening and providing families of low-SDH status with specific information about the quality of and access to services for children with ASD. Additionally, medical universities must have a plan to routinely monitor the quality of and access to services provided for the children with low SDH.

Racial/ethnic disparities in healthcare have been highlighted by the recent COVID-19 pandemic. Using the Centers for Medicare and Medicaid Services' Nursing Home COVID-19 Public File, this study examined the relationship between nursing home racial/ethnic mix and COVID-19 resident mortality. As of October 25, 2020, high minority nursing homes reported 6.5 COVID-19 deaths as compared to 2.6 deaths for nursing homes that had no racial/ethnic minorities. After controlling for interstate differences, facility-level resident characteristics, resource availability, and organizational characteristics, high-minority nursing homes had 61% more COVID-19 deaths [Incidence Rate Ratio (IRR) = 1.61; p < 0.001] as compared to nursing facilities with no minorities. From a policy perspective, nursing homes, that serve primarily minority populations, may need additional resources, such as, funding for staffing and personal protective equipment in the face of the pandemic. The COVID-19 pandemic has sharpened the focus on healthcare disparities and societal inequalities in the delivery of long-term care.

Financial distress is a persistent problem in U.S. hospitals, leading them to close at an alarming rate over the past two decades. Given the potential adverse effects of hospital closures on healthcare access and public health, interest is growing in understanding more about the financial health of U.S. hospitals. In this study, we set out to explore the extent to which relevant organizational and environmental factors potentially buffer financially distressed hospitals from closure, and even at the brink of closure, enable some to merge with other hospitals. We tested our hypotheses by first examining how factors such as slack resources, environmental munificence, and environmental complexity affect the likelihood of survival versus closing or merging with other organizations. We then tested how the same factors affect the likelihood of merging relative to closing for financially distressed hospitals that undergo one of these two events. We found that different types of slack resources and environmental forces impact different outcomes. In this article, we discuss the implications of our findings for hospital stakeholders.

Objective: To review the cost-effectiveness of multifactorial interventions to prevent falls in elderly people. Methods: In this systematic review, the databases including PubMed via MEDLINE, Web of Science, Embase, Scopus, Cochrane Library and Google Scholar (from 1st January 2000 to 30th February) were used. All pre-reviewed articles related to cost-effectiveness analysis of multifactorial interventions to prevent falls in elderly were included in this paper and congresses abstracts were excluded. Descriptive statistics were used for quantitative data and content-analysis method to analyze qualitative data. Results: Out of the 456 articles, 19 were finally included in the study. Eighteen articles were conducted in High-Income Countries (HICs) and 16 were at the community level. Medical visits consultation and education were the most common interventions. Most studies were cost-effectiveness and using the Randomized Control Trial (RCT) methods. A fall of prevention costs ranged from $ 272 to $ 987. Incremental Cost-Effectiveness Ratio (ICER) interventions also ranged from the US $ 120,667 to the US $ 4280.9. Conclusion: The results show that despite the high effectiveness of multifactorial interventions to prevent elderly falls, the cost of the interventions are high and they are not very cost-effective. It would be better to design and implement multifactorial interventions with low cost and high effectiveness that are appropriate for each country.

BackgroundWithout any pharmaceutical intervention and vaccination, the only way to combat Coronavirus Disease 2019 (COVID-19) is to slow down the spread of the disease by adopting non-pharmaceutical public health interventions (PHIs). Patient isolation, lockdown, quarantine, social distancing, changes in health care provision, and mass screening are the most common non-pharmaceutical PHIs to cope with the epidemic. However, there is neither systematic evidence on the effectiveness of non-pharmaceutical PHIs in controlling the COVID-19 nor on how these interventions work in different contexts. Therefore, in this study we will address two main objectives: 1) to assess the effectiveness of the non-pharmaceutical PHIs in controlling the spread of COVID-19 using a systematic review and meta-analyses; 2) to explore why, how, and for whom these interventions work using a realist review.Materials and methodsThis review study has two main phases. In the first phase of this study, we will extract data from two main types of studies including quasi-experimental studies (such as quasi-randomized trials, controlled before-after studies (CBAs) and interrupted time series studies (ITSs)) and observational studies (such as cohort, case-control, and cross-sectional studies), written in the English language. We will explore effectiveness of the non-pharmaceutical PHIs targeted either suppression or mitigation strategies (or a combination of both) in controlling the COVID-19 epidemics in the community level. Effectiveness will be considered as the changes in mortality rate, incidence rate, basic reproduction number rate, morbidity rate, rates of hospitalization, rates of intensive care unit (ICU) hospitalization, and other health outcomes where possible. We will perform random-effects meta-analyses, if possible, using CMA software. In the second phase, we will conduct a realist review to find out how, why, for whom, and in what circumstances the non-pharmaceutical PHIs work. At the realist review, we will identify and explore Context-Mechanism-Outcome configurations to provide a robust explanation on the effectiveness of the interventions in different contexts using Pawson's 5-step realist review template including: "clarify scope; search for evidence; appraise primary studies and extract data; synthesize evidence and draw conclusions; and disseminate, implement and evaluate". Although the steps are presented in a linear manner, in practice, we will follow them in iterative stages to fill any potential overlap.DiscussionThe findings of this research will provide a crucial insight into how and in which context the non-pharmaceutical PHIs work in controlling the spread of COVID-19. Conducting a systematic review and meta-analysis in line with a realist review will allow us to draw a robust conclusion on the effects and the way in which the interventions work. Understanding the role of contextual factors in the effectiveness of non-pharmaceutical PHIs and the mechanism of this process could enable policymakers to implement appropriate policies and manage the COVID-19 epidemics more efficiently.Systematic review registrationCRD42020186855.

Background Successful implementation of pay-for-quality (P4Q) programs mostly depends upon a valid, timely, and reliable data about quality measures generated by providers, and interpreted by payers. The aim of this study was to establish a data reporting method for P4Q program through an action research. Methods Qualitative method was used to align theory with action through a three-cycle action research. The study was conducted in September 15, 2015 to March 15, 2017, in East-Azerbaijan, Iran. The purposeful sampling was used to select participants. The participants included healthcare providers, staff in district health centers (DHC), experts, and managers in the provincial primary health center (PPHC). Data was collected by interviews, focus group discussions, and expert panels. Content analysis was used to synthesize the data. In each step, decisions about data reporting methods were made through a consensus of expert panel members. Results The most important dimensions of data reporting method were data entry and accuracy, data reporting, data analysis and interpretations, the flexibility of method, and training. By establishment of an online data reporting system for the P4Q program, a major improvement was observed in the documentation of performance data, the satisfaction of health care providers and staff (e.g. either in DHCs or PPHC), improvement of the P4Q program and acceptance of the P4Q program by providers. Following the present study, the online system was expanded in Iran’s public health system for data collection and estimating the amount of incentive payments in P4Q program. Moreover, more improvements were achieved by linking the system to EMRs and also, providing automated feedback to providers about their own performance. Conclusions A web-based computerized system with the capability of linking medical record and also its ability to provide feedback to healthcare providers was identified as an appropriate method of data reporting in the P4Q program from the viewpoints of participants in this study. Electronic supplementary material The online version of this article (10.1186/s12913-018-3472-4) contains supplementary material, which is available to authorized users.

Background: Tobacco smoking is one of the most important public health problems that may be prevented. There is limited information about its relationship with communication skills. Findings on the relationships between self-esteem and cigarette/hookah smoking are inconsistent. The aim of this study was to investigate the relationships between cigarette and hookah smoking,self-esteem and communication skills among a representative sample of high school students. Methods: In this cross-sectional study, a sample of 1321 tenth-grade students (14-17 years) was selected through multi-stage proportionally cluster sampling in Tabriz, 2017. The participants completed a self–administered multiple choice questionnaire including questions about cigarette smoking, hookah smoking, self-esteem, and communication skills. Results: After controlling for potential confounders, the results demonstrated that higher score of self-esteem protects students against being in advanced stages of cigarette smoking (odds ratio [OR] = 0.95, 95% CI: 0.92-0.99, P=0.012). However, there was no significant association between self-esteem score and the hookah smoking. Also, there was no significant association between communication skills score and cigarette and hookah smoking. Conclusion: According to our findings, self-esteem was associated with cigarette smoking, but not with hookah smoking. Furthermore, there was no statistically significant association between communication skills score and cigarette and hookah smoking.

Research Objective Racial/ethnic disparities in healthcare have been highlighted by the recent COVID‐19 pandemic. Using the Centers for Medicare and Medicaid Services’ Nursing Home COVID‐19 Public File, we examined the relationship between nursing home racial/ethnic mix and COVID‐19 resident mortality. Additionally, we examined the effects of resident characteristics, market resource availability, and organizational characteristics as it relates to nursing home racial/ethnic disparities in COVID‐19 mortality. Study Design Multivariate regressions were used to model the relationship between COVID‐19 deaths and the proportion of racial/ethnic minority residents (Black and Hispanic residents). Given the over‐dispersion of the count dependent variable (number of COVID‐19 deaths), negative binomial regressions were used. We used four nested sequential models to examine the separate contributions of facility‐level resident characteristics, resource availability, and other organizational characteristics to racial/ethnic disparities in COVID‐19 deaths. In addition, we controlled for size and interstate differences using state fixed effects. Population Studied The study sample consisted of all US nursing homes included in the CMS Nursing Home COVID‐19 Public File, or 15,382 nursing homes, which mirrors the national census of facilities. Principal Findings As of October 25, 2020, high minority nursing homes reported 6.5 COVID‐19 deaths as compared to 2.6 deaths for nursing homes that had no racial/ethnic minorities. After controlling for interstate differences, facility‐level resident characteristics, resource availability, and organizational characteristics, high‐minority nursing homes had 61% more COVID‐19 deaths (Incidence Rate Ratio [IRR] = 1.61; p < 0.001) as compared to nursing facilities with no minorities. Conclusions From a policy perspective, nursing homes, that serve primarily minority populations, may need additional resources, such as, funding for staffing and personal protective equipment in the face of the pandemic. The COVID‐19 pandemic has sharpened the focus on healthcare disparities and societal inequalities in the delivery of long‐term care. Implications for Policy or Practice This study shows the disparate effect that COVID‐19 has had on nursing home mortality based on resident racial/ethnic mix. Even after controlling for interstate differences, facility‐level resident characteristics, resource availability, and organizational characteristics, high‐minority nursing homes had almost three times the probability of having COVID‐19 deaths compared to those with no minorities. These findings highlight the existing and systemic health disparities in nursing homes and the tangible impact it has on racial/ethnic minorities. Death due to COVID‐19 is greater risk for racial/ethnic minorities in nursing homes relative to White residents. Nursing homes that serve larger minority populations may need additional resources to combat this crisis.

Research in the nursing home industry shows more robust knowledge management activities are associated with the adoption of patient-centered, culture change initiatives among high Medicaid nursing homes. These findings are notable because they highlight the important role that knowledge management activities may play for improving quality of care in under-resourced nursing homes. They also raise important questions about the conditions that may support or hinder the use of these activities. Using survey responses from 393 nursing home administrators, we empirically examined whether two components of human resources – staffing levels and HRM practices – are associated with the level of knowledge management activities in high Medicaid census nursing homes. More robust HRM practices were associated with greater levels of knowledge management activities, as well as three separate domains of knowledge management (acquisition, dissemination, and responsiveness). Staffing levels, in contrast, were not significantly associated with the level of knowledge management activities.

Racial/ethnic disparities have been well documented in long-term care literature. As the population ages and becomes more diverse over time, it is essential to identify mechanisms that may eliminate or mitigate racial/ethnic disparities. Culture change is a movement to transition nursing homes to more home-like environments. The literature on culture change initiatives and quality has been mixed, with little to no literature on the use of culture change initiatives in high Medicaid nursing homes and quality. The purpose of this study was to examine how the involvement of culture change initiatives among high Medicaid facilities was associated with nursing home quality. The study relied on both survey and secondary nursing home data for the years 2017-2018. The sample included high Medicaid (85% or higher) nursing homes. The outcome of interest was the overall nursing home star rating obtained from the Nursing Home Compare Five-Star Quality Rating System. The primary independent variable of interest was the years of involvement in culture change initiatives among nursing homes, which was obtained from the nursing home administrator survey. The final model consisted of an ordinal logistic regression with state-level fixed effects. High-Medicaid nursing homes with six or more years in culture change initiatives had higher odds of having a higher star rating, while facilities with one year or less had significantly lower odds of having a higher star rating. Culture change initiatives may require some time to effectively implement, but these initiatives are potential mechanisms to improve quality in high Medicaid nursing homes.

This paper investigates the relationship between organizational culture and financial performance in high-Medicaid Nursing Homes, nursing homes that serve a high proportion of Medicaid residents. A...

Racial/ethnic disparities have been well documented in long-term care literature. Culture change is a movement to transition nursing homes to more home-like environments to improve the quality of care for all residents. The purpose of this study was to examine how the involvement of culture change initiatives among high Medicaid facilities was associated with nursing home quality. The study relied on both survey and secondary nursing home data for the years 2017-2018. The sample included high Medicaid facilities. The final model consisted of an ordinal logistic regression. High-Medicaid nursing homes with six or more years in culture change initiatives had higher odds of having a higher star rating, while facilities with one year or less had significantly lower odds of having a higher star rating. Culture change initiatives may require some time to effectively implement, but these initiatives are potential mechanisms to improve quality in high Medicaid nursing homes.

This study examines the association between leadership styles on resident quality and financial performance in under resourced nursing homes (70% or higher Medicaid census). The Bonoma/Slevin leadership model was used to classify managers into four categories, autocrat, consultative autocrat, consensus manager, and shareholder manager. Survey data from 391 nursing home directors (response rate of 37%) from 2017- 2018, were merged with secondary data from LTCFocus, Area Health Resource File, Medicare Cost Reports, and Nursing Home Compare. Two models were ran to examine the effect of leadership styles on the dependent variable(s) nursing home STAR data (quality) and operating margin (financial performance). The independent variables were composite scores for leadership styles, with autocrat as the reference group. Control variables included organizational (ownership, chain affiliation, size, occupancy, payer mix, staffing, and race/ethnicity), and county factors (Medicare Advantage penetration, per capita income, poverty, education, unemployment, and competition). Multivariate regression was used to model the relationship between leadership styles and nursing home quality and financial performance. The consultative autocrat was associated with lower quality (p < 0.05), while the consensus manager was associated with lower profit margin (p < 0.05), as compared to autocratic leadership. The consultative autocrat, who solicits information from the staff yet still makes all significant decisions, is associated in lower quality; however, a consensus manager, who delegates their authority to the group, is associated with lower financial performance. Under-resourced nursing homes who face dual pressures need to recognize trade-offs of different decision making styles for quality and financial performance.

Introduction: The previous studies have suggested that alteration in oxidative stress and antioxidant defense depends on various factors, such as mode, intensity, frequency and duration of exercise. In this study, we compared the effects of two various durations of resistance exercise (1 month and 4 month) on oxidative stress and antioxidant status in cardiac tissue. Methods: Thirty Wistar male rats divided into 3 groups: control (sedentary), exercise-1 (regular exercise for 1 month) and exercise-2 group (regular exercise for 4 months). After the final to the experiment, the rats were anesthetized, and then blood and heart samples were obtained and used to determine glutathione peroxidase (GPX), superoxide dismutase (SOD), malondialdehyde (MDA) and biochemical estimation. Results: MDA levels between control and exercise-2 groups showed no significant difference, hence, MDA level in exercise-1 group was higher compared to control group (P < .01). The heart GPX activity increased significantly in exercise-2 group regarding other groups (P < .01). The SOD activities of groups were similar. Creatine kinase (CK) and lactate dehydrogenase (LDH) concentrations increased in the exercise-1 compared to the other groups (P < .01). Conclusion: Our results indicate that in heart, the adaptation and alteration in oxidative stress and cell injury level depend on duration of exercise.

There is longstanding interest in identifying ways to support culture change initiatives in nursing homes given their association with a number of desirable outcomes, including fewer health-related...

Background: Non-suicidal self-injury (NSSI) has become one of the serious public health concerns among adolescents. Factors like family and social environment of adolescents may be important determinants of the NSSI. This study aimed to investigate the relationship between family psychological function and perceived social support with the NSSI experience among adolescents. Study design: A cross-sectional study. Methods: Overall, 4216 high school students (15-18 yr old) of Tabriz City, northwestern Iran were selected using multi-stage cluster random sampling method in October and November 2017. Participants completed survey including demographic characteristics, NSSI status, Iranian family psychological function, and perceived social support. After six months, NSSI status was reassessed. The data were analyzed using logistic regression model. Results: 8.5% of the students had NSSI experience. In addition, the weak family psychological function increased the odds of experiencing the NSSI by 13 times compared to the strong psychological function (OR = 13.15, 95% CI: 7.19, 23.80). Besides, the low level of perceived social support increased the odds of experiencing the NSSI by about 7 times compared to the high perception of social support (OR= 6.67, 95% CI: 4.01, 11.11). Conclusion: Low levels of psychological functioning of the families and perception of social support significantly can increase the odds of experiencing the NSSI among adolescents. Therefore, special attention should be paid to these factors in the development of relevant preventive programs in adolescence period.

This study examines whether nursing homes’ (NHs) human resource management (HRM) practices and organizational culture are associated with nursing staff turnover. HRM practices are classified into traditional (employment selection tests, formal performance appraisal systems, and realistic job previews); employee-centered (flexible work hours and job sharing); and high involvement (incentive based/merit pay and self-managing teams). Organizational culture consists of four types: clan culture (friendly working environment); adhocracy culture (dynamic/creative working environment); market culture (results-based organization); and hierarchy culture (formalized/structured work environment). This study used facility survey data from approximately 324 NH administrators (30% response rate) from 2017- 2018, merged with secondary data from LTCFocus, Area Health Resource File, and Medicare Cost Reports. The dependent variables consisted of RN, LPN, and CNA turnover rates (% voluntarily quit), while the independent variables comprised HRM practices and type of organizational culture. Control variables consisted of organizational (ownership, chain affiliation, size, occupancy rate, and payer mix) and county-level factors (Medicare Advantage penetration, income, education, unemployment rate, poverty, and competition). Generalized linear model results show that every unit increase in high-involvement HRM practices is associated with a reduction of 6%, 4%, and 2% in RN, LPN, and CNA turnover rates, respectively. Also compared to hierarchical cultures, nursing homes with a clan culture are associated with a reduction of 62%, 49%, and 33% in RN, LPN, and CNA turnover rates, respectively. HRM practices and organizational cultures that promote employee participation, engagement, and empowerment have the potential to reduce nurse staffing turnover rates among underresourced nursing homes.

Culture change represents an organizational transformational process to become person-centered, through staff and resident empowerment. Culture change initiatives have been associated with fewer health-related deficiency citations and better psychosocial outcomes. Knowledge management, defined as the process of creating or locating knowledge, and managing the dissemination of knowledge within and between organizations, has been shown to be associated with the adoption of innovations such as culture change initiatives. This study examines the relationship between knowledge management activities of high Medicaid census (70% or higher) nursing homes (NHs) and the adoption of culture change initiatives. This study used facility survey data from approximately 324 nursing home administrators (30% response rate) from 2017- 2018, merged with data from LTCFocus, Area Health Resource File, and Medicare Cost Reports. Binary logistic regression models revealed that the probability of adopting a culture change initiative was 0.12 higher for facilities reporting a one-unit higher level of knowledge management activities. Additional interaction analysis revealed that knowledge management activities were associated with a greater likelihood of adopting a culture change initiative for NHs where the director had been in his/her position fewer years. Similarly, higher levels of overall knowledge management activities were significantly associated with greater adoption of culture change initiatives at intermediate levels of nurse retention. Results suggest that knowledge management activities may help high Medicaid NHs acquire and mobilize informational resources in ways that can support the adoption of patient-centered initiatives. These activities may be particularly effective in nursing homes with leadership and nursing staff instability.

This study examines the association between culture change artifacts and financial performance among under-resourced nursing homes (70% or higher Medicaid census). Culture change represents a transformational process to become person-centered, through staff and resident empowerment. Cultural artifacts represent the physical evidences that culture change is occurring. In this study, we focus on the workplace (nurse staffing consistent assignments) and leadership (residents engagement) artifacts to assess the relationship between culture change practices and performance. Survey data came from 387 nursing home directors from 2016- 2018, merged with secondary data from LTCFocus, Area Health Resource File, and Medicare Cost Reports. The dependent variable consisted of the total profit margin (%), while the independent variables comprised composite scores for leadership (0-25) and workplace artifacts (0-15). Control variables included organizational-level (ownership, chain affiliation, size, occupancy rate, and Medicare and Medicaid payer mix), and county-level factors (Medicare Advantage penetration, per capita income, educational level, unemployment rate, poverty level and competition). Multivariate regression was used to model the relationship between cultural change artifacts and financial performance. Workplace artifacts in nursing homes were found to be associated with significantly higher profit margin (β = 0.30, p < 0.05), while leadership artifacts were not. Culture change practices aimed at improving nursing staff consistent assignments are associated with better financial performance. Given increasing nursing home market competition and declining resources for high Medicaid nursing homes, facilities with a greater emphasis on workplace culture may be able to perform better financially among these under-resourced facilities.

This study examines the relationship between organizational culture and financial performance of high Medicaid census (70% or higher) nursing homes (NHs). Based on the Competing Values Framework, there are four types of organizational culture: clan culture (friendly working environment); adhocracy culture (dynamic/creative working environment); market culture (results-based organization); and hierarchy culture (formalized/structured work environment). This study used facility survey data from approximately 324 nursing home administrators (30% response rate) from 2017- 2018, merged with secondary data from LTCFocus, Area Health Resource File, and Medicare Cost Reports. The dependent variable consisted of the operating margin, while the independent variable comprised type of organizational culture. Control variables were organizational (ownership, chain affiliation, size, occupancy rate, and payer mix), and county-level factors (Medicare Advantage penetration, income, education, unemployment rate, poverty, and competition). Multivariable regression was used to model the relationship between organizational culture type and financial performance. Regression results show that compared to a market culture, a hierarchy culture was associated with an 11.8 % lower operating margin, a clan culture with a 10.6% lower operating margin, and a non-dominant culture with 11.4% lower operating margin. Organizational culture is associated with financial performance among high Medicaid facilities, with market cultures outperforming other organizational cultures. Given increasing competition in the nursing home market and declining resources for high Medicaid nursing homes, facilities with a more external orientation and focus on results may be able to perform better financially. Future research should examine the effect of organizational culture on quality of care.

This study examines how organizational and community factors are associated with organizational culture among high Medicaid nursing homes (70% or higher Medicaid census). According to the Competing Values, Framework, there are four types of organizational culture: clan culture (friendly working environment); adhocracy culture (dynamic/creative working environment); market culture (results-based organization); and hierarchy culture (formalized/structured work environment). Survey data from 324 nursing home administrators (30% response rate) from 2017- 2018 were merged with secondary data from LTCFocus, Area Health Resource File, and Medicare Cost Reports. The dependent variable consisted of organizational culture type. The independent variables comprised organizational factors (facility has nurse practitioner/physician assistant (NP/PA), RN/LPN/CNA hours per resident day, RN skill mix, ownership, chain affiliation, size, occupancy rate, and Medicare and Medicaid payer mix) and community factors (Medicare Advantage penetration, per capita income, educational level, unemployment rate, poverty level and competition). Multinomial regression results showed that, compared to facilities with hierarchical cultures, those with a market culture have greater odds of having an NP/PA and higher RN skill mix and LPN intensity, but lower odds for RN intensity, Medicaid payer mix, occupancy rate, and Black residents. Also compared to facilities with hierarchical cultures, those with a clan culture have lower odds for having an NP/PA, beds and occupancy rate, but higher odds of being located in communities with lower unemployment and higher Medicare managed care. In conclusion, different organizational cultures are associated with different staffing patterns, as well as organizational and community factors.

ObjectiveTo evaluate the district health management fellowship training programme in the north-west of Iran.Data sources/study settingThe programme was introduced to build the managerial capacity of district health managers in Iran. Eighty-nine heads of units in the province’s health centre, district health managers and the health deputies of the district health centres in the north-west provinces of Iran had registered for the district health management fellowship training programme in Tabriz in 2015–2016.Study designThis was an educational evaluation study to evaluate training courses to measure participants' reactions and learning and, to a lesser extent, application of training to their job and the organisational impact.Data collection/extraction methodsValid and reliable questionnaires were used to assess learning techniques and views towards the fellowship, and self-assessment of health managers’ knowledge and skills. Also, pretest and post-test examinations were conducted in each course and a portfolio was provided to the trainees to be completed in their work settings.Principal findingsAbout 63% of the participants were medical doctors and 42.3% of them had over 20 years of experience. Learning by practice (scored 18.37 out of 20) and access to publications (17.27) were the most useful methods of training in health planning and management from the participants’ perspective. Moreover, meeting peers from other districts and the academic credibility of teachers were the most important features of the current programme. Based on the managers’ self-assessment, they were most skilful in quality improvement, managing, planning and evaluation of the district. The results of the post-test analysis on data collected from district health managers showed the highest scores in managing the district (77 out of 100) and planning and evaluation (69) of the courses.ConclusionThe results of this study indicated that training courses, methods and improvement in managers' knowledge about the health system and the skills necessary to manage their organisation were acceptable.