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Introduction Strategies are needed to increase implementation of evidence-based tobacco dependence treatment (TDT) in health care systems in low-and middle-income countries (LMICs). Aims and Methods We conducted a two-arm cluster randomized controlled trial to compare the effectiveness of two strategies for implementing TDT guidelines in community health centers (n = 26) in Vietnam. Arm 1 included training and a tool kit (eg, reminder system) to promote and support delivery of the 4As (Ask about tobacco use, Advise to quit, Assess readiness, Assist with brief counseling) (Arm 1). Arm 2 included Arm 1 components plus a system to refer smokers to a community health worker (CHW) for more intensive counseling (4As + R). Provider surveys were conducted at baseline, 6 months, and 12 months to assess the hypothesized effect of the strategies on provider and organizational-level factors. The primary outcome was provider adoption of the 4As. Results Adoption of the 4As increased significantly across both study arms (all p < .001). Perceived organizational priority for TDT, compatibility with current workflow, and provider attitudes, norms, and self-efficacy related to TDT also improved significantly across both arms. In Arm 2 sites, 41% of smokers were referred to a CHW for additional counseling. Conclusions The study demonstrated the effectiveness of a multicomponent and multilevel strategy (ie, provider and system) for implementing evidence-based TDT in the Vietnam public health system. Combining provider-delivered brief counseling with opportunities for more in-depth counseling offered by a trained CHW may optimize outcomes and offers a potentially scalable model for increasing access to TDT in health care systems like Vietnam. Implications Improving implementation of evidence-based TDT guidelines is a necessary step toward reducing the growing burden of noncommunicable diseases and premature death in LMICs. The findings provide new evidence on the effectiveness of multilevel strategies for adapting and implementing TDT into routine care in Vietnam and offer a potentially scalable model for meeting Framework Convention on Tobacco Control Article 14 goals in other LMICs with comparable public health systems. The study also demonstrates that combining provider-delivered brief counseling with referral to a CHW for more in-depth counseling and support can optimize access to evidence-based treatment for tobacco use. Clinical trials number: NCT01967654.

Introduction: Cervical cancer is the second leading cause of cancer death among women in the Dominican Republic, and high rates persist despite existing Pap smear screening programs. The purpose of this study was to explore Dominican women’s knowledge and attitudes regarding human papillomavirus (HPV) and cervical cancer, cervical cancer screening practices, and perceived barriers and facilitators to early detection of cervical cancer. Method: Six focus groups ( N = 64) were conducted in Spanish in urban, suburban, and rural locations, in private and public school settings, community and workplace settings, in or near Santo Domingo, as part of a larger study on barriers and facilitators to HPV vaccine implementation. Audio recordings were transcribed verbatim and translated from Spanish to English. Qualitative data analysis used inductive and deductive approaches. Results: Knowledge regarding HPV and cervical cancer varied across groups, but all agreed there was significant stigma and fear regarding HPV. Most women reported having Pap screening at least yearly. Follow-up of abnormal Pap testing was less consistent, with cost and uncertainty about provider recommendations identified as barriers. Discussion: Broader examination of provider-level and health system barriers and facilitators to cervical cancer prevention in the Dominican Republic is essential, in order to inform interventions to improve the effectiveness of cervical cancer screening and treatment programs and reduce preventable deaths.

Background Effective strategies are needed to increase implementation and sustainability of evidence-based tobacco dependence treatment (TDT) in public health systems in low- and middle-income countries (LMICs). Our two-arm cluster randomized controlled trial (VQuit) found that a multicomponent implementation strategy was effective in increasing provider adherence to TDT guidelines in commune health center (CHCs) in Vietnam. In this paper, we present findings from a post-implementation qualitative assessment of factors influencing effective implementation and program sustainability. Methods We conducted semi-structured qualitative interviews (n = 52) with 13 CHC medical directors (i.e., physicians), 25 CHC health care providers (e.g., nurses), and 14 village health workers (VHWs) in 13 study sites. Interviews were transcribed and translated into English. Two qualitative researchers used both deductive (guided by the Consolidated Framework for Implementation Research) and inductive approaches to analysis. Results Facilitators of effective implementing of TDT included training and point-of-service tools (e.g., desktop chart with prompts for offering brief counseling) that increased knowledge and self-efficacy, patient demand for TDT, and a referral system, available in arm 2, which reduced the provider burden by shifting more intensive cessation counseling to a trained VHW. The primary challenges to sustainability were competing priorities that are driven by the Ministry of Health and may result in fewer resources for TDT compared with other health programs. However, providers and VHWs suggested several options for adapting the intervention and implementation strategies to address challenges and increasing engagement of local government committees and other sectors to sustain gains. Conclusion Our findings offer insights into how a multicomponent implementation strategy influenced changes in the delivery of evidence-based TDT. In addition, the results illustrate the dynamic interplay between barriers and facilitators for sustaining TDT at the policy and community/practice level, particularly in the context of centralized public health systems like Vietnam’s. Sustaining gains in practice improvement and clinical outcomes will require strategies that include ongoing engagement with policymakers and other stakeholders at the national and local level, and planning for adaptations and subsequent resource allocations in order to meet the World Health Organization’s goals promoting access to effective treatment for all tobacco users. Trial registration NCT02564653, registered September 2015

Introduction: Waterpipe use is a significant health concern in low- and middle-income countries like Viet Nam, yet there is a lack of research on factors that may influence use and self-efficacy to quit among adults.Aims: This study examined the relationship between social norms related to waterpipe use and self-efficacy to quit among male waterpipe smokers in Viet Nam.Methods: A cross-sectional survey was conducted with 214 adult male waterpipe smokers enrolled in a large cluster–randomised controlled trial conducted in a rural province in Viet Nam. Associations between social norms related to waterpipe smoking and the participants’ confidence to quit waterpipes were assessed using hierarchical regression models to account for differences among study sites and other covariates.Results: Self-efficacy to quit smoking was positively associated with immediate family members’ not minding participants smoking and with extended family's encouragement to quit smoking.Conclusions: The findings suggest the need for a more comprehensive understanding of the functions and characteristics of the social context of waterpipe smoking, including the social networks of waterpipe smokers, to inform effective cessation interventions for waterpipe smokers.

Globally, the scope and frequency of natural disasters- particularly climate-related disasters-are increasing, and the human impact of these events is widening. Since 2000, climate-related disasters have increased 44% from the 1994-2000 average (Centre for Research on the Epidemiology of Disasters, 2015). Large-scale natural disasters are by their very nature extremely disruptive, overwhelming a community's infrastructure and severely impacting access to essential public health and medical services. The emergency response goals in a natural disaster are twofold: to continue to maintain provision of the public health services, and to provide acute response to the public health needs created by the disaster. Natural, weather-related disasters such as hurricanes provide considerable forewarning of the event and enable preparedness planning.During these catastrophic events, significant burdens are imposed on those individuals engaged in the delivery of essential public health and medical services, such as nurses, who must balance professional obligations along with the demands of their personal life, such as family needs (Adams & Berry, 2012; Qureshi et al, 2005). Experiencing a disaster can have both short- and longterm effects. A growing body of research is documenting that emergency response and healthcare workers are at increased risk for developing mental health conditions, such as post-traumatic stress disorder, depression, and anxiety (Benedek, Fullerton, & Ursan, 2007). Given the nature of their work, nurses are at particular risk for compassion fatigue, burnout, and psychological trauma (Johal, 2015; Qureshi et al., 2005).When Superstorm Sandy hit the New York-New Jersey coastline in October 2012, the vulnerability and interdependence of area hospitals and healthcare workers were revealed. Severe flooding from the storm surges forced an evacuation of New York University Langone Medical Center (NYULMC), a 725-bed tertiary care facility in New York City, during the height of the storm, and subsequently an extended shutdown, along with other area hospitals in the flood zone, of essential healthcare facilities. Superstorm Sandy was the second storm to result in the evacuation of NYULMC within a 14-month period. Even though weather-related disasters can provide for considerable forewarning and an opportunity for predisaster planning, the psychosocial toll on nurses working in such rapidly changing circumstances can be considerable.The primary aim of this study was to assess nurses' experiences and the challenges they faced during Superstorm Sandy in order to identify how nurses can be supported to function effectively before, during, and after a weather-related disaster. The study was approved by the NYULMC School of Medicine Institutional Review Board.MethodsStudy DesignIn order to develop a more complete understanding of the NYULMC nurses' experiences during this event and to contextualize the data (Miles & Huberman, 1994), we implemented a sequential mixed-methods study consisting of in-depth qualitative interviews with a purposive sample of the hospital nurses followed by a quantitative Internet survey of the hospital nursing staffemployed at the time of the evacuation and deployment.Qualitative InterviewsSample and recruitment. We recruited a purposive sample of 20 nurses reflecting the diversity of practice areas, nursing experience, and organizational role in the disaster. Nurses were contacted by the research team via text, e-mail, or phone and invited to participate in a 60-min semistructured interview to explore their Superstorm Sandy experiences. Sixteen of the 20 nurses sampled agreed to participate and completed an interview (response rate 80%); 12 of the participants held staffnurse positions, and 4 had management positions. The interviews were conducted by experienced qualitative interviewers in a private setting from April to June 2013. Participants were assured that no individual identifiers would be collected. …

Purpose Weather-related disasters have increased dramatically in recent years. In 2012, severe flooding as a result of Hurricane Sandy necessitated the mid-storm patient evacuation of New York University Langone Medical Center. The purpose of this study was to explore, from the nurses’ perspective, what the challenges and resources were to carrying out their responsibilities, and what the implications are for nursing education and preparation for disaster. Design This mixed-methods study included qualitative interviews with a purposive sample of nurses and an online survey of nurses who participated in the evacuation. Methods The interviews explored prior disaster experience and training, communication, personal experience during the evacuation, and lessons learned. The cross-sectional survey assessed social demographic factors, nursing education and experience, as well as potential challenges and resources in carrying out their disaster roles. Findings Qualitative interviews provided important contextual information about the specific challenges nurses experienced and their ability to respond effectively. Survey data identified important resources that helped nurses to carry out their roles, including support from coworkers, providing support to others, personal resourcefulness, and leadership. Nurses experienced considerable challenges in responding to this disaster due to limited prior disaster experience, training, and education, but drew on their personal resourcefulness, support from colleagues, and leadership to adapt to those challenges. Conclusions Disaster preparedness education in schools of nursing and practice settings should include more hands-on disaster preparation exercises, more “low-tech” options to address power loss, and specific policies on nurses’ disaster roles. Clinical Relevance Nurses play a critical role in responding to disasters. Learning from their disaster experience can inform approaches to nursing education and preparation.

BACKGROUND: Tobacco use continues to be the leading cause of preventable death worldwide. OBJECTIVE: To assess perceived tobacco educational preparation of undergraduate and graduate nurses in a large urban university. DESIGN: A cross-sectional web-based survey of all nursing students in an urban college of nursing was conducted to assess perceived tobacco educational content, skills, and self-efficacy for cessation counseling with patients who smoke cigarettes and use alternative tobacco products (e.g., hookah and e-cigarettes). RESULTS: Participants reported the most education about health effects of tobacco use (67%), and less than 6% reported education about alternative tobacco products. While the majority of nurses agreed that advising patients to quit is a priority, less than 40% reported receiving sufficient training in cessation counseling. CONCLUSIONS: There continues to be a compelling need articulated by leaders in tobacco policy and research over the past decade for a more vigorous response by nurses to the tobacco epidemic.

Having an experienced and trained healthcare workforce available during public health emergencies, such as the COVID-19 pandemic, is critical. While all healthcare workers are at risk of contracting COVID-19, older workers are at increased risk of serious or fatal illness. This investigation explores the front-line experiences and perspectives of registered nurses (RNs) at a major New York City medical center during the COVID-19 pandemic, focusing on two age cohorts: older (50+) and younger (20-49) RNs. An anonymous internet-based survey was sent to all RN’s employed at the center. Data collection was initiated in May 2020, following the initial surge in NYC’s COVID-19 related hospitalizations and deaths; 1,483 surveys were completed. This investigation found that in comparison to younger RNs (n=1,067), older RNs’ (n=416) psychosocial well-being was significantly better -- fewer depression, anxiety, and PTSD symptoms (p

PURPOSE Effective strategies are needed to increase the implementation and sustainability of evidence-based tobacco dependence treatment (TDT) in public health systems in low- and middle-income countries. Our cluster randomized controlled trial (VQuit) found that a multicomponent implementation strategy was effective in increasing provider adherence to TDT guidelines in community health centers (CHCs) in Vietnam. In this paper, we present findings from a postimplementation qualitative assessment of factors that influence implementation effectiveness and program sustainability. METHODS We conducted semistructured qualitative interviews (N = 52) with 13 CHC medical directors (ie, physicians), 25 CHC health care providers, and 14 village health workers (VHWs) in 13 study sites. Interviews were transcribed and translated into English. RESULTS Facilitators of implementation effectiveness included training that increased confidence and skill, satisfaction with point-of-service tools, increasing patient demand for TDT, and, for the intervention arm, the value of a VHW referral system that reduced provider burden. The primary challenge to sustainability is the competing priorities driven by the Vietnam Ministry of Health, which may result in fewer resources for TDT compared with other health programs. However, providers and VHWs described several options for adapting the implementation strategies to address challenges and increase the engagement of local government committees and other sectors to sustain gains. CONCLUSION Our findings offer insight into how a multicomponent implementation strategy influenced changes in the delivery of evidence-based TDT. In addition, these results illustrate the dynamic interplay between barriers to and facilitators of sustaining TDT at the policy and community/practice level, particularly in the context of centralized public health systems, like that of Vietnam. Sustaining gains in practice improvement and clinical outcomes will require strategies that include ongoing engagement with policymakers and other stakeholders at the national and local level, as well as planning for adaptations and subsequent resource allocations, to meet Article 14 goals.

Background Community health workers (in Vietnam referred as village health workers - VHWs) have potential to play a key role in expanding access to evidence-based tobacco use treatment. VHWs can help smokers quit by asking patients about tobacco use, advising them to quit, and offering cessation assistance (3As). We are conducting a NIH funded cluster randomized controlled trial comparing two strategies for implementing tobacco use treatment guidelines (TUTG) in commune health centers (CHCs) in Vietnam: brief provider counseling + self-help materials (BC) vs. BC + 3 sessions of in person counseling delivered by a VHW. This paper presents data on the effect of the intervention on VHWs' practice patterns and attitudes towards TUTG. Methods We examined changes in adherence to TUTG before and 12 months after the intervention with 89 VHWs working in 13 CHCs in Vietnam. Adherence to each of the 3As was measured using a 5-point likert scale: from 1-none (did not ask any patients in past month if they smoke), to 5-all or most of patients. Response scales of questions measuring attitudes and self-efficacy range from 1-strongly disagree to 4-strongly agree. Factor analysis was used to form two scales measuring attitudes and self-efficacy. Results The mean adherence level to each of the TUTG increased significantly: Asking about tobacco use increased from 1.79±0.57 to 2.61±0.96; advising to quit from 1.93±0.60 to 2.90±1.11; assisting from 1.53±0.62 to 2.65±1.19. Perceived barriers to treating tobacco use decreased significantly. Self-efficacy and attitudes towards TUTG improved significantly. Increased adherence to TUTG was associated with positive attitudes towards TUTG. Conclusions The implementation strategies were effective in improving VHWs' adherence to TUTG. Extending VHWs' role to include smoking cessation could offer a sustainable supporting resource for tobacco smokers who wish to quit.

Nurses and other healthcare providers play key roles in screening and smoking cessation for their patients. However, studies have shown that providers who themselves smoke are less likely to assess and counsel their patients about smoking cessation (Braun et al. 2004; Sarna, Brown, Lillington, Wewers, & Brecht, 2000; Ulbricht et al., 2008). A report analyzing data from the U.S. National Tobacco Use Supplement comparing smoking rates in healthcare professionals from 2003 to 2010- 2011 demonstrated continued declines among physicians to 1% and registered nurses to 7% (Sarna, Bialous, Nandy, Antonio, & Yang, 2014). These rates are significantly lower than the general population rate of 18.1%. Healthcare providers as a group have among the lowest rates of smoking in the United States. An international review of tobacco smoking among nurses revealed an overall pattern of smoking reduction since the 1970s, with higher rates in some developing countries. However, there were considerable inconsistencies in developed countries, with some reporting rates significantly higher than those in the United States. Asian countries generally had lower rates for female nurses, who are culturally less inclined to smoke (Smith & Leggat, 2007).Though rates of cigarette smoking in the United States have declined dramatically over the past several decades, the Centers for Disease Control and Prevention (CDC) recently warned that the rise in use of alternative tobacco products (ATPs) may undercut the success of efforts to decrease cigarette consumption (CDC, 2012a). For example, recent studies of U.S. college and university students have showen that 40% to 54% have used ATPs during their lifetimes (Cobb, Ward, Maziak, Shihadeh, & Eissenberg, 2010; Primack et al., 2008; Rahman, Chang, Hadgu, Salinas-Miranda, & Corvin, 2014). Little is known about use of these products by healthcare providers. Reports of ATP use among international medical students have found rates of up to 20% (Nawaz, et al. 2007; Senkubuge, Ayo-Yusuf, Louwagie, & Okuyemi, 2012). A recent study conducted with medical students in an urban U.S. medical center found that about 4% reported current cigarette use, 4.8% currently used ATPs, and 51.7% reported lifetime use of ATPs. Students in the study consistently estimated cigarettes to be more harmful that ATPs despite the absence of research evidence comparing the two (Zhou et al., 2015). No studies of nurses' use of ATPs have been published to date.The most common ATPs used today are hookahs, electronic cigarettes (e-cigarettes), cigars, and cigarillos. Hookah, also known as waterpipe and narghile, is an alternative nicotine delivery system to cigarettes in which shisha (tobacco or nontobacco combustible materials) is smoked. The shisha is heated in a bowl of charcoal that is ignited to create smoke. Smoke from the bowl is drawn through a tube that passes through a water jar that cools and humidifies the smoke (American Lung Association, 2007). In contrast, e-cigarettes, which resemble tobacco cigarettes, do not contain any tobacco but do deliver nicotine that has been vaporized electronically to simulate tobacco smoke (Caponnetto, Campagna, Papale, Rosso, & Polosa, 2012). Smokeless tobacco, also called chewing and spit tobacco, is a less commonly used ATP. Bidis and kreteks are small rolled cigarettes containing tobacco, cloves, and sometimes flavors. While the prevalence of bidi and kretek use in the United States is low compared to other ATPs, they contain more nicotine, tar, and carbon monoxide than conventional cigarettes and are therefore more injurious to the health of smokers (Watson, Polzin, Calafat, & Ashley, 2003).The health effects of all ATPs are understudied. A systematic review of 24 studies conducted by Akl and colleagues (2010) concluded that hookah smoking was associated with increased risks for lung cancer, respiratory disease, and low birth weight. These studies, however, had some methodological limitations, and more rigorous studies are needed. …

Purpose: Pap smear screening programs have been ineffective in reducing cervical cancer mortality in most Latin American and Caribbean countries, in part due to low screening rates. The purpose of this review was to analyze recent studies to identify demographic, social, and cultural factors influencing women’s participation in Pap screening programs in Latin America and the Caribbean. Design/Method: For this integrative review, cervical cancer screening in Latin America and the Caribbean was searched using PubMed, CINAHL, EMBASE, and PsycINFO databases. Findings/Results: Demographic barriers to screening were socioeconomic status, education, race/ethnicity, and geography. Social barriers included lack of uniformity in screening guidelines, lack of knowledge regarding cervical cancer, and lack of preventive culture. Cultural barriers were fear/embarrassment and gender roles. Conclusions: There are multilevel barriers to Pap smear utilization among women in Latin America and the Caribbean. Implications for Practice: Findings highlight a need for health system engagement, promotion of preventive care, and community-generated educational programs and solutions.

The purpose of this study was to explore current tobacco use treatment (TUT) practice patterns, and attitudes and beliefs among Village Health Workers (VHWs) about expanding their role to include delivering smoking cessation interventions and the perceived barriers. We conducted a survey of 449 VHWs from 26 communes in Thai Nguyen province, Vietnam. We assessed TUT practice patterns including asking about tobacco use, advising smokers to quit, offering assistance (3As) and attitudes, self-efficacy, and norms related to TUT. Seventy two per cent of VHWs reported asking patients if they use tobacco, 78.6% offered advice to quit, and 41.4% offered cessation assistance to few or more patients in the past month. Self-efficacy was low, with 53.2% agreeing that they did not have the skills to counsel patients about smoking cessation. The most commonly reported barriers to offering TUT were a lack of training and perceived lack of patient interest. Greater awareness of their commune health centre's smoke-free policy and higher levels of self-efficacy were associated with screening and offering cessation assistance. VHWs support an expanded role in tobacco cessation, but require additional resources and training to increase their self-efficacy and skills to provide effective treatment.

Weather-related disasters have increased dramatically in recent years. In 2012, severe flooding as a result of Hurricane Sandy necessitated the mid-storm patient evacuation of New York University Langone Medical Center. The purpose of this study was to explore, from the nurses' perspective, what the challenges and resources were to carrying out their responsibilities, and what the implications are for nursing education and preparation for disaster.This mixed-methods study included qualitative interviews with a purposive sample of nurses and an online survey of nurses who participated in the evacuation.The interviews explored prior disaster experience and training, communication, personal experience during the evacuation, and lessons learned. The cross-sectional survey assessed social demographic factors, nursing education and experience, as well as potential challenges and resources in carrying out their disaster roles.Qualitative interviews provided important contextual information about the specific challenges nurses experienced and their ability to respond effectively. Survey data identified important resources that helped nurses to carry out their roles, including support from coworkers, providing support to others, personal resourcefulness, and leadership. Nurses experienced considerable challenges in responding to this disaster due to limited prior disaster experience, training, and education, but drew on their personal resourcefulness, support from colleagues, and leadership to adapt to those challenges.Disaster preparedness education in schools of nursing and practice settings should include more hands-on disaster preparation exercises, more "low-tech" options to address power loss, and specific policies on nurses' disaster roles.Nurses play a critical role in responding to disasters. Learning from their disaster experience can inform approaches to nursing education and preparation.

Superstorm Sandy forced the evacuation and extended shutdown of New York University Langone Medical Center. This investigation explored how nurses were impacted by the disasters and how they can best be supported in their nursing responsibilities.Sequential mixed methods were used to explore the psychosocial issues nurses experienced throughout the course of this natural disaster and its lingering aftermath.In-depth interviews were conducted from April to June 2013 with a subsample of nurses who participated in the evacuation deployment (n = 16). An anonymous, Internet-based cross-sectional survey sent to all registered nurses employed at the hospital at the time of the storm explored storm impact and recovery. Between July and September 2013, 528 surveys were completed.The qualitative data revealed challenges in balancing professional obligations and personal concerns. Accounts described dealing in the immediate recovery period with unexpected job changes and resultant work uncertainty. The storm's lingering aftermath did not signify restoration of their predisaster lifestyle for some, but necessitated coping with this massive storm's long-lasting impact on their personal lives and communal loss.Nurses working under the rapidly changing, uncontrolled, and potentially dangerous circumstances of a weather-related disaster are also experiencing concerns about their families' welfare and worries about personal loss. These multiple issues increase the psychosocial toll on nurses during a disaster response and impending recovery.Awareness of concerns and competing demands nurses experience in a disaster and aftermath can inform education and services to enable nurses to perform their critical functions while minimizing risk to patients and themselves.

On October 29, 2012, a 12-ft storm surge generated by Hurricane Sandy necessitated evacuation and temporary closure of three New York City hospitals including NYU Langone Medical Center (NYULMC). NYULMC nurses participated in the evacuation, and 71 % were subsequently deployed to area hospitals to address patient surge for periods from a few days up to 2 months when NYULMC reopened. This mixed methods study explored nurses' experience in the immediate disaster and the subsequent deployment. More than 50 % of deployed nurse participants reported the experience to be extremely or very stressful. Deployed nurses encountered practice challenges related to working in an unfamiliar environment, limited orientation, legal concerns about clinical assignments. They experienced psychosocial challenges associated with the intense experience of the evacuation, uncertainty about future employment, and the increased demands of managing the deployment. Findings provide data to inform national and regional policies to support nurses in future deployments.

Background Services to treat tobacco dependence are not readily available to smokers in low-middle income countries (LMICs) where smoking prevalence remains high. We are conducting a cluster randomized controlled trial comparing the effectiveness of two strategies for implementing tobacco use treatment guidelines in 26 community health centers (CHCs) in Viet Nam. Guided by the Consolidated Framework for Implementation Research (CFIR), prior to implementing the trial, we conducted formative research to (1) identify factors that may influence guideline implementation and (2) inform further modifications to the intervention that may be necessary to translate a model of care delivery from a high-income country (HIC) to the local context of a LMIC. Methods We conducted semi-structured qualitative interviews with CHC medical directors, health care providers, and village health workers (VHWs) in eight CHCs (n = 40). Interviews were transcribed verbatim and translated into English. Two qualitative researchers used both deductive (CFIR theory driven) and inductive (open coding) approaches to analysis developed codes and themes relevant to the aims of this study. Results The interviews explored four out of five CFIR domains (i.e., intervention characteristics, outer setting, inner setting, and individual characteristics) that were relevant to the analysis. Potential facilitators of the intervention included the relative advantage of the intervention compared with current practice (intervention characteristics), awareness of the burden of tobacco use in the population (outer setting), tension for change due to a lack of training and need for skill building and leadership engagement (inner setting), and a strong sense of collective efficacy to provide tobacco cessation services (individual characteristics). Potential barriers included the perception that the intervention was more complex (intervention characteristic) and not necessarily compatible (inner setting) with current workflows and staffing historically designed to address infectious disease prevention and control rather than chronic disease prevention and competing priorities that are determined by the MOH (outer setting). Conclusions In this study, CFIR provided a valuable framework for evaluating factors that may influence implementation of a systems-level intervention for tobacco control in a LMIC and understand what adaptations may be needed to translate a model of care delivery from a HIC to a LMIC. Trial registration NCT02564653. Registered September 2015

Understanding the sexual risk behaviors of youths living with HIV/AIDS is critical to secondary prevention of HIV. As part of a larger qualitative study of youths living with HIV, in-depth interviews were conducted with 27 African American and Latino, HIV-infected young men who have sex with men, aged 16–24 years, living in New York City. The study explored the role of substance use, the social-sexual-environmental, and psychological contexts in which sexual risk behaviors occurred. Since learning of their HIV infection, the majority of participants had reduced their risky sexual behaviors; however, a subset (26%) of participants continued to have unprotected sex, in most cases with multiple partners. Substance use, the social environmental context of the sexual encounter, the psychological impact of HIV on sexual behavior, and partner characteristics were associated with high-risk sexual behaviors in this group. Among high-risk participants, factors associated with risky sexual behaviors clustered, with 57% reporting two or more factors. More intensive interventions are needed for this subset of youths living with HIV, including assessment and treatment for substance use and mental health issues, strategies for stress reduction, and partner interventions.

Using qualitative data, this article explored the circumstances leading to HIV testing among 59 HIV-infected adolescents recruited from New York City HIV clinics. Results showed differences between the heterosexual women and the gay and bisexual men. Most of the young women were tested during routine health care or self-initiated tests, and most were asymptomatic when they tested positive. Their testing decisions were sometimes based on assessments of their boyfriends' risk behaviors rather than their own. Many young men were experiencing symptoms of illness when they tested positive, and about half of them recognized their symptoms as related to HIV and sought tests. Some young men expressed fear of learning about positive test results, which delayed their testing, and some providers did not initially recommend HIV testing for young men who presented with symptoms. The article concludes that consideration of these gender and sexual orientation-related concerns can facilitate HIV testing among adolescents.

The authors evaluate the effectiveness of the small media campaign in raising community awareness about the importance of going for a health check up. Data were collected over time from 535 respondents ages 15-30 years using cross-sectional surveys in two low-income, predominantly African-American communities in New York city. Regression analyses indicated campaign material recognition at 15 months was significantly higher in the intervention community relative to the comparison community. There were no significant changes in social norms, attitudes, or beliefs. Media campaigns aimed at adolescents and young adults on a community-wide level are an effective means of gaining material recognition. Editors' Strategic Implications: This research illustrates the effect of a public health media campaign on awareness, but it also serves as a reminder to public health officials that awareness is not necessarily sufficient to promote attitudinal or behavioral health changes.

Objectives. We examined the mechanisms by which living in a disadvantaged minority community influences smoking and illegal cigarette sale and purchasing behaviors after a large cigarette tax increase. Methods. Data were collected from 14 focus groups (n=104) that were conducted during the spring of 2003 among Blacks aged 18 years and older living in New York City. Results. A large tax increase led to what focus group participants described as a pervasive illegal cigarette market in a low-income minority community. Perceived pro-smoking community norms, a stressful social and economic environment, and the availability of illegal cigarettes worked together to reinforce smoking and undermine cessation. Conclusions. Although interest in quitting was high, bootleggers created an environment in which reduced-price cigarettes were easier to access than cessation services. This activity continues to undermine the public health goals of the tax increase.

The purpose of the study was to assess nursing students' knowledge, beliefs, behaviors, and social norms regarding use of alternative tobacco products (ATPs).This anonymous online survey was conducted with all students enrolled in a college of nursing. The survey utilized measures from several national tobacco studies to assess knowledge and beliefs about ATPs (hookahs, cigars or cigarillos, bidis, kreteks, smokeless tobacco, electronic cigarettes) compared to cigarettes, health effects of ATPs, personal use of ATPs, and social norms. Data were analyzed in SPSS 22.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics and frequencies were performed for basic sociodemographic data. Paired samples t tests were performed to determine differences for scaled measures.Nursing students demonstrated very low levels of knowledge about ATPs and their health consequences, despite high rates of ATP personal use. About 76% of participants reported use of one or more ATPs once or more in their lifetimes. A greater proportion of students had used hookahs or waterpipes (39.6%) compared to cigarettes (32.7%).Nurses' lack of knowledge about the emerging use and health threats associated with ATPs may undermine their ability to provide appropriate tobacco cessation counseling. Research is needed to identify gaps in nurses' education regarding tobacco cessation counseling and to develop new counseling approaches specific to use of ATPs.Nurses play critical roles in counseling their patients for tobacco cessation. Further research and education about the risks presented by ATPs are critical to reducing excess tobacco-related mortality.

Background: Persons who have been infected with chlamydia or gonorrhea (CT/GC) are at elevated risk for reinfection. The cost-effectiveness of interventions designed to encourage public sexually transmitted disease (STD) clinic patients to return for rescreening has not been well-evaluated. Goal: The goal of this study was to conduct a program- and societal-perspective cost-effectiveness analysis of five interventions designed to encourage public STD clinic patients infected with CT/GC to return for rescreening 3 months after initial treatment. Study: Researchers at two STD clinics collected cost data for the five interventions. These were combined with study data on return rates and CT/GC positivity rates among returning patients to compare the cost-effectiveness of the interventions. Results: The cost per patient counseled with a brief recommendation to return, followed by a telephone reminder after 3 months, was higher than two interventions: a brief recommendation to return with no reminder and a $20 incentive, received on return. However, the brief recommendation with a telephone reminder yielded the highest return rate (33%) and was the least costly in terms of cost per infection treated ($622 program, $813 societal). In-depth motivational counseling that helped clients identify risk factors and provided reasons for returning was more costly than a phone reminder alone and was not more effective. Conclusions: Phone reminders are more cost-effective than motivational counseling and improve return rates over a brief recommendation given at the time of initial treatment.

Objectives. We evaluated the effectiveness of an intervention designed to increase preventive health care seeking among adolescents. Methods. Adolescents and young adults aged 12 to 21 years, recruited from community-based organizations in 2 different communities, were randomized into either a 3-session intervention or a control condition. We estimated outcomes from 3-month follow-up data using logistic and ordinary least squares regression. Results. Female intervention participants were significantly more likely than female control participants to have scheduled a health care appointment (odds ratio [OR]=3.04), undergone a checkup (OR=2.87), and discussed with friends or family members the importance of undergoing a checkup (OR=4.5). There were no differences between male intervention and male control participants in terms of outcomes. Conclusions. This theory-driven, community-based group intervention significantly increased preventive health care seeking among female adolescents. Further research is needed, however, to identify interventions that will produce successful outcomes among male adolescents.

Background: Individuals who use sexually transmitted disease (STD) clinics are at high risk for hepatitis B virus (HBV). While HBV vaccine is frequently offered to clients in this setting, reported vaccination rates are low. More information is needed about HBV vaccine knowledge, attitudes, beliefs, and behavior among high risk populations. The current study assesses these issues at an urban STD clinic. Methods: A survey assessing knowledge, attitudes, and beliefs concerning HBV vaccine was administered to individuals seeking services at an STD clinic before seeing the physician. Immediately after the clinical visit these individuals were interviewed and asked whether they had accepted vaccination and their reasons for acceptance or rejection. Results: Fifty percent of unvaccinated study subjects elected to receive an HBV vaccine dose at the current visit. Significant predictors in a multiple logistic regression model for choosing to be vaccinated were: having a vaccinated acquaintance, perceived risk of disease, perceived healthfulness of vaccine, and clinician's recommendation. Knowledge regarding hepatitis B risks and outcomes was not related to vaccine choices. Patients expressed concern about vaccine safety and provider motivation. Conclusions: The role of acquaintances and the physician are central to the decision to be vaccinated, as are risk perception and familiarity with the vaccine. Mistrust of the medical establishment and of vaccines is a barrier to acceptance of HBV vaccine.

Studies over the last decade have demonstrated the effectiveness of public health interventions based on social and behavioral science theory for many health problems. Little is known about the extent to which health departments are currently utilizing these theories. This study assesses the application of social and behavioral science to programs in the New York City Department of Health (NYCDOH). Structured open-ended interviews were conducted with executive and program management staff of the health department. Respondents were asked about the application of social and behavioral sciences within their programs, and about the benefits and barriers to increasing the use of such approaches. Themes related to the aims of the study were identified, a detailed coding manual developed, narrative data were coded independently by two investigators (kappa.85), and data analyzed. Interviews were conducted with 61 eligible individuals (response rate 88%). The most common applications of social and behavioral science were individual-level behavior change to prevent HIV transmission and community-level interventions utilizing community organizing models and/or media interventions for health promotion and disease prevention. There are generally positive attitudes about the benefits of utilizing these sciences; however, there are also reservations about expanded use because of resource constraints. While NYCDOH has successfully applied social and behavioral sciences in some areas of practice, many areas use them minimally or not at all. Increasing use will require additional resources. Partnerships with academic institutions can bring additional social and behavioral science resources to health departments and benefit researchers understanding of the health department environment.

Background Despite high smoking rates, cessation services are largely unavailable in Vietnam. This study explored attitudes and beliefs of community health workers (CHWs) towards expanding their role to include delivering tobacco use treatment (TUT), and potential barriers and facilitators associated with implementing a strategy in which health centers would refer patients to CHWs for cessation services. Methods We conducted four focus groups with 29 CHWs recruited from four district community health centers (CHCs) in Hanoi, Vietnam. Results Participants supported expanding their role saying that it fit well with their current responsibilities. They further endorsed the feasibility of serving as a referral resource for providers in local CHCs expressing the belief that CHWs were “more suitable than their clinical colleagues” to offer cessation assistance. The most frequently cited barrier to routinely offering cessation services was that despite enacting a National Tobacco Control Action plan, cessation is not one of the national prevention priorities. As a result, CHWs have not been “assigned” to help smokers quit by the Ministry of Health. Additional barriers included lack of training and time constraints. Conclusion Focus groups suggest that implementing a systems-level intervention that allows providers to refer smokers to CHWs is a promising model for extending the treatment of tobacco use beyond primary care settings and increasing access to smoking cessation services in Vietnam. There is a need to test the cost-effectiveness of this and other strategies for implementing TUT guidelines to support and inform national tobacco control policies in Vietnam and other low-and middle-income countries. Electronic supplementary material The online version of this article (doi:10.1186/s12913-014-0606-1) contains supplementary material, which is available to authorized users.

Adolescents may come from family settings that heighten their vulnerability to early sexual initiation, promiscuity and sexual exploitation. To illuminate how this may occur, we present a set of five representative cases of HIV-infected females from a sample of 26 adolescent and young adult HIV-infected females (ages 16–24) enrolled in a study about the adaptive challenges people their age faced living with the disease. Study participants were recruited from five New York City adolescent HIV clinics that provided comprehensive specialty medical and supportive ancillary social services to adolescents and young adults with HIV. Study participants completed a battery of standardizes measures, using ACASI, and participated in a semi-structured in-depth interview. Using the qualitative interview data, we illustrate how early life and family circumstances including neglectful or dysfunctional parenting (e.g., low parental supervision), sexual abuse, and unstable housing placed these young women on a risk trajectory for HIV infection.

Purpose The study evaluates the implementation of a United Nations Children's Fund (UNICEF)/WHO Baby-Friendly Hospital Initiative (BFHI) in a large urban hospital in New York City that serves primarily poor, minority women. Study design and methods A descriptive qualitative evaluation study that included focus groups, key informant interviews, and observations of the clinical environment was conducted using a community-based participatory research approach with healthcare providers. Results Findings revealed strengths and challenges in the implementation process at the system, provider, and patient levels. Strategies for enhancing program implementation and outcomes include expansion of provider education, development of additional patient interventions, enhancement of environmental structural supports, and continuation and expansion of program evaluation activities. Clinical implications Evaluation of program implementation at multiple levels of the organization in collaboration with providers is critical to understanding program outcomes.

The frequently asymptomatic nature and high incidence of severe complications of sexually transmitted diseases (STD) calls for targeted efforts to identify those at greatest risk. Earlier studies have shown inconsistencies regarding STD evaluation by primary care clinicians and physicians. However, the literature regarding the consistency of practice patterns regarding elicitation of sexual history is limited. We examined practice patterns for the elicitation of sexual history among providers across seven sites nationwide.As part of a multisite study to encourage health seeking for populations specifically at risk for gonorrhea (GC) and other STDs, semistructured interviews that included questions regarding sexual history elicitation were conducted with 208 service providers in a total of 121 publicly and privately funded clinics, managed care organizations (MCOs), hospital clinics, community- and school-based clinics in Denver, New York, Los Angeles, Birmingham, St. Louis, Indianapolis, and Prince Georges County, MD.Among the providers interviewed, practice patterns for the elicitation of sexual history were inconsistent. Sexual histories were described as routine (i.e., solicited from every client regardless of reason for visit) in 57% of sites. Providers most frequently asked clients their number of sex partners (57%), their contraceptive history (55%), and STD history (34%). Client discomfort among 46% and provider discomfort among 13% was cited as barriers to the elicitation of sexual history. A quarter (26%) of providers agreed that the elicitation of sexual history can be fostered by improved provider communication skills and 16% agreed increasing training and experience for providers is needed.These findings suggest that interventions with providers to standardize sexual history elicitation can help to reduce barriers to prevention, diagnosis, and treatment of STD.

Couples confronted with HIV infection face significant challenges. Little is known about the impact of HIV on heterosexual couples who account for the vast majority of cases worldwide and an increasing proportion of cases in the USA, especially among women. In this study, analysis of data collected on HIV-discordant couples participating in a ten-week support group revealed four major groups of issues: (1) dealing with the emotional and sexual impact on the relationship; (2) confronting reproductive decisions; (3) planning for the future of children and the surviving partner; and (4) disclosure of the HIV infection to friends and family. These findings have implications for the design of interventions to enhance adaptation to HIV for discordant couples.

The development of effective behavioral interventions is critical to controlling the HIV epidemic. Although heterosexual transmission accounts for a growing proportion of new infections in the United States, little is known about factors that influence sexual behavior in HIV-discordant heterosexual couples. The objective of this study was to examine the reproductive behaviors of HIV-discordant heterosexual couples. Data were obtained on 71 discordant couples enrolled in a study of HIV heterosexual transmission. Results showed that women in such couples have pregnancy rates similar to those of women of reproductive age in the general population. One seroconversion occurred as a result of pregnancy attempt. These results suggest the need for educational efforts directed at HIV-discordant heterosexual couples.

dolescents and young adults ages 15 to 24 yearsconstitute half of all new cases of HIV worldwide(Joint United Nations Programme on HIV/AIDS,2009). In the United States in 2009, more than8,000 new cases of HIV were diagnosed in youthages 13 to 24 years (Centers for Disease Controland Prevention, 2011). Further, at the end of 2009,16,743 cumulative cases of HIV were reportedamong New York City youth ages 13 to 24 years(New York City Department of Health and MentalHygiene, 2011).Adherence to HIV medications and adherence toHIV primary care appointments are necessary forgood health in this population. Quarterly medicalappointments are recommended to monitor CD

Some individuals remain uninfected with human immunodeficiency virus type-1 (HIV-1) despite multiple high-risk sexual exposures. We studied a cohort of 25 subjects with histories of multiple high-risk sexual exposures to HIV-1 and found that their CD8+ lymphocytes had greater anti-HIV-1 activity than did CD8+ lymphocytes from nonexposed controls. Further studies indicated that their purified CD4+ lymphocytes were less susceptible to infection with multiple primary isolates of HIV-1 than were CD4+ lymphocytes from the nonexposed controls. This relative resistance to HIV-1 infection did not extend to T-cell line-adapted strains, was restricted by the envelope glycoprotein, was not explained by the cell surface density of CD4 molecules, but was associated with the activity of the C-C chemokines RANTES, MIP-1alpha, and MIP-1beta. This relative resistance of CD4+ lymphocytes may contribute to protection from HIV-1 in multiply exposed persons.

Background More than 1 million individuals in the U.S. are infected with HIV; approximately 20% of whom do not know they are infected. Early diagnosis of HIV infection results in earlier access to treatment and reductions in HIV transmission. In 2006, the CDC recommended that health care providers offer routine HIV screening to all adolescent and adult patients, regardless of community seroprevalence or patient lifestyle. Dental providers are uniquely positioned to implement these recommendations using rapid oral fluid HIV screening technology. However, thus far, uptake into dental practice has been very limited. Methods The study utilized a qualitative descriptive approach with convenience samples of dental faculty and students. Six in-depth one-on-one interviews were conducted with dental faculty and three focus groups were conducted with fifteen dental students. Results Results were fairly consistent and indicated relatively high levels of acceptability. Barriers and facilitators of oral fluid HIV screening were identified in four primary areas: scope of practice/practice enhancement, skills/knowledge/training, patient service/patient reactions and logistical issues. Conclusions Oral fluid HIV screening was described as having benefits for patients, dental practitioners and the public good. Many of the barriers to implementation that were identified in the study could be addressed through training and interdisciplinary collaborations.

The need for oral health services among patients with HIV, especially those in advanced stages of disease and those who smoke, has been well documented. Patients receiving HIV-related home care services provide an opportunity for assessment of oral health and smoking cessation needs; however, the majority of home care providers lack formal training to provide these services, thus interprofessional collaborations may be of value. This study assessed the oral health and smoking cessation practices of a random sample of 81 HIV home care providers. Results showed very favorable attitudes toward providing these services with some differences across disciplines. More than 70% of nurses would like to receive additional training in comprehensive oral health assessment by dental professionals. The study provides evidence for the potential of expanding these services for patients with HIV through interprofessional collaboration, in particular with nurses and dentists.

Background: Process evaluation of community-academic partnership function and fidelity to principles of community-based participatory research (CBPR) is essential to achievement of intermediate and long term partnership goals. Objectives: This article describes the evaluation of B Free CEED, a community-academic partnership created to address hepatitis health disparities in Asian American and Pacific Islander (API) communities. Methods: A mixed methods approach with an online survey and qualitative key informant interviews was conducted with all partnership members at baseline and follow-up, 18 months later. Results: Survey findings showed stability over time, with some consistent differences in community and academic perspectives. Academic members were somewhat more satisfied with the partnership functioning. Key informant interviews provided contextual data key to further defining partnership functioning. Conclusions: Conducting ongoing partnership evaluations is necessary to reassess and align processes and protocols to enhance partnership functioning and strengthen group cohesion.

Since 9/11, federal funds directed toward public health departments for training in disaster preparedness have dramatically increased, resulting in changing expectations of public health workers’ roles in emergency response. This article explores the public health emergency responder role through data collected as part of an oral history conducted with the 3 health departments that responded to Hurricane Katrina in Mississippi and Louisiana. The data reveals a significant change in public health emergency response capacity as a result of federal funding. The role is still evolving, and many challenges remain, in particular, a clear articulation of the public health role in emergency response, the integration of the public health and emergency responder cultures, identification of the scope of training needs and strategies to maintain new public health emergency response skills, and closer collaboration with emergency response agencies.

Survival among perinatally infected children and youth with HIV has been greatly extended since the advent of highly active antiretroviral therapies. Yet, adherence to HIV medication regimens is suboptimal and decreases as children reach adolescence. This paper reports on a qualitative study examining psychosocial factors associated with adherence among perinatally infected youth ages 10-16 years. The study was based on in-depth interviews with a sample of 30 caregivers participating in a comprehensive health care program in New York City serving families with HIV. A subsample comprising 14 caregivers of children ages 10 and above is the focus of this paper. The analysis identified a number of themes associated with the psychosocial context of managing adherence among older children. Maintaining adherence was an ongoing challenge and strategies evolved as children matured. Regimen fatigue and resistance to taking the medications were major challenges to maintaining adherence among the oldest children. In other cases, caregivers developed a kind of partnership with their child for administering the medications. Disclosure to the child of his or her HIV status was used as a strategy to promote adherence but seemed to be effective only under certain circumstances. Social support appeared to have an indirect influence on adherence, primarily by providing caregivers with temporary help when needed. Health care professionals were an important source of disclosure and adherence support for parents. The study illustrates the interplay of maturational issues with other contextual psychosocial factors as influences on adherence among older children and adolescents.

We thank Callaghan et al. for sharing their innovative strategy for assessing illicit cigarette sales among psychiatric patients. Their findings are an important addition to the growing literature on the potential burden of cigarette tax increases on marginalized smokers. This issue is not isolated to one low-income community in New York City. Rather, it has broader implications for a range of high-risk groups, including psychiatric patients and substance abusers. There is a need to consider the ethical dilemmas posed by certain tobacco control policies—in this case, tax policy—to ensure that the tobacco control community is responsive to the needs of the most at-risk populations.1 As Fox so aptly notes, “through the increased use of ethics in tobacco control, the public health community may be better positioned to claim the high road as the protector of the public’s interests.”2(p1)

The development of a structured psychoeducational support group model for blood donors who tested positive for human immunodeficiency virus Type I antibody is described. Salient group therapy techniques and educational content are discussed, issues of group structure are identified, and the need for support of clinicians is highlighted.

Developing community capacity to improve health is a cornerstone of community-based public health. The concept of community capacity reflects numerous facets and dimensions of community life and can have different meanings in different contexts. This paper explores how members of one community identify and interpret key aspects of their community’s capacity to limit the availability and use of tobacco products. Particular attention is given to examining the interrelationship between various dimensions of community capacity in order to better understand the processes by which communities are able to mobilize for social change. The study is based on qualitative analysis of 19 in-depth interviews with key informants representing a variety of community sectors in Harlem, New York City. Findings indicate that the community is viewed as rich in human and social resources. A strong sense of community identity and connectedness underlies this reserve and serves as a catalyst for action.

This report presents data on computer access, Internet use, and factors associated with health information seeking on the Internet among a sample of youths aged 15 to 30 years in New York City. Findings from street intercept surveys indicate substantial computer access at home (62%) and frequent (everyday or a few times a week) Internet use (66%). Fifty-five percent of the sample reported seeking health information on the Internet, which was associated with positive beliefs about getting a health checkup and frequent Internet use.

Individual behavior and social contexts are critical determinants of health. We surveyed commissioners or their designees in 22 departments of health serving US cities of at least 500,000 people to examine their use of scientific approaches to influence individual behavior and social contexts. Each department used behavioral or social science in its work, but only four departments were judged to have integrated these approaches throughout their operations, using both centralized and decentralized structures. Degree of integration was unrelated to collaboration with universities or communities but was related to use of explicit theories. Behavioral and social sciences were employed most frequently in the areas of HIV/AIDS and maternal and child health and in the service of changing individual behavior rather than larger contexts, although across departments many health problems and approaches were involved. Commissioners generally found the approaches valuable, but articulated barriers to more widespread adoption.

Objective: To assess the relation between health literacy and receipt of a screening test for gonorrhoea in the past year. Methods: Study design was multisite, cross sectional survey of subjects enrolled from clinics, from community based organisations, and by street intercept. Data were obtained using face to face interview. The dependent variable was self reported receipt of a test for gonorrhoea in the past year. Health literacy was measured by the Rapid Estimate of Adult Literacy in Medicine (REALM), recoded to represent 8th grade or lower reading or 9th grade and higher reading level. Statistical analyses were adjusted to account for selection bias in literacy assessment. Results: 54% of the sample reported at least one gonorrhoea test in the previous year. 65% of the sample read at a 9th grade level or higher. REALM score was moderately correlated with the respondent's years of education. After adjustment for missing REALM data, past suspicion of gonorrhoea, self inspection for gonorrhoea, self efficacy for care seeking, REALM score of 9th grade reading level or higher, and younger age were independently associated with gonorrhoea testing in the previous year. For the average respondent, REALM reading grade level of 9th grade or higher is associated with a 10% increase in the probability of having a gonorrhoea test in the past year. Conclusions: Low literacy appears to pose a barrier to care for sexually transmitted infections such as gonorrhoea.