Examining self-efficacy and COVID-19 disease prevention behaviors among socially vulnerable populations.

Social vulnerabilities are associated with higher COVID-19 disease morbidity and mortality. Primary forms of COVID-19 disease prevention aside from vaccination, are health behaviors including masking, hand washing, social distancing, and staying home when one is sick. Understanding the self-efficacy of these behaviors in vulnerable populations can inform health interventions to improve COVID-19 disease outcomes. A repeated cross-sectional study with three waves (Wave 1 = pilot, Wave 2, n = 1258, Wave 3, n = 477) was conducted using an online survey. This analysis only included Wave 2 and Wave 3. The study targeted Yakima County, WA, USA, an area with pronounced social, environmental, and health disparities. Measures included demographic, household, and self-efficacy constructs. Binary logistic regression was used to determine which demographic and household factors were related to constructs of self-efficacy. An independent t-test was performed to determine if there were significant differences between population levels of self-efficacy over time (Wave 2 vs. Wave 3). Household size, identifying as Hispanic/Latino, and measures of socioeconomic status were significantly related to various self-efficacy beliefs about COVID-19 disease prevention behaviors and the ability to protect oneself from COVID-19 disease in general. Self-efficacy increased for each measure between Wave 2 and Wave 3 (p < 0.001). Socially vulnerable groups continue to experience disparate health outcomes in the face of COVID-19 disease. Future studies should examine ways to increase self-efficacy among populations that are experiencing lower levels as self-efficacy is a significant factor related to health outcomes.

Pregnancy and Childbirth Expectations During COVID-19 in a Convenience Sample of Women in the United States.

The COVID-19 pandemic has transformed the health care landscape and shifted individuals' expectations for and interactions with essential health services, including pregnancy-related care. This study explores alterations to individuals' pregnancy and childbirth decisions during an infectious disease pandemic. A convenience sample of 380 pregnant individuals with an expected delivery date between April and December 2020 consented to enroll and complete an online questionnaire on their pregnancy and childbirth expectations during the COVID-19 pandemic; a subset of respondents (n = 18) participated in semi-structured phone interviews. Survey data were analyzed quantitatively while interview data were analyzed using a thematic content analysis until a consensus on key themes was achieved. Respondents reported substantial stressors related to shifting policies of health care facilities and rapidly changing information about COVID-19 disease risks. As a result, respondents considered modifying their prenatal and childbirth plans, including the location of their birth (25%), health care provider (19%), and delivery mode (13%). These findings illuminate the concerns and choices pregnant individuals face during the COVID-19 pandemic and offer recommendations to engage in compassionate, supportive, and person-centered care during a time of unprecedented risk and uncertainty.

One Key Question®: First Things First in Reproductive Health.

Objectives Preconceptional health care is increasingly recognized as important to promotion of healthy birth outcomes. Preconceptional care offers an opportunity to influence pregnancy timing and intent and mother's health status prior to conception, all predictors of individual outcomes and of inequality in birth outcomes based on race, ethnicity and class. Methods One Key Question, a promising practice developed in Oregon which is now attracting national interest, provides an entry point into preconceptional care by calling on providers to screen for pregnancy intent in well woman and chronic disease care for women of reproductive age. For women who choose not to become pregnant or are not definitive in their pregnancy intent, One Key Question provides an opportunity for provision of or referral to counseling and contraceptive care. Results Adoption of One Key Question and preconceptional care as standard practices will require important shifts in medical practice challenging the longstanding schism between well woman care generally and reproductive care in particular. Adoption will also require shifts in cultural norms which define the onset of pregnancy as the appropriate starting point for attention to infant health. Conclusions for Practice This commentary reviews the case for preconceptional care, presents the rationale for One Key Question as a strategy for linking primary care to preconceptional and/or contraceptive care for women, outlines what is entailed in implementation of One Key Question in a health care setting, and suggests ways to build community support for preconceptional health.

Provider Perspective on Integrative Medicine for Pediatric Sickle Cell Disease-related Pain.

OBJECTIVE: Integrative medicine (IM) approaches are sometimes used to manage sickle cell disease (SCD)-related pain. The purpose of this research is to (1) understand provider perspective towards the use of IM for pain in children with SCD at a large urban children's hospital and (2) provide recommendations on how to better promote IM for children and adolescents with SCD. METHODS: After approval from the institutional review board, a qualitative case study approach was used with criterion-type purposeful sampling to select providers from the division of hematology to adequately inform the study. Semistructured interviews were completed using audiotape to facilitate transcription. NVivo 10 analytic software (QSR International Pty Ltd, Doncaster, Victoria, Australia) was used to organize data into themes to answer the study questions. RESULTS: Ten provider interviews were completed. Attitudes were generally positive, and most providers felt that IM is generally helpful. All providers reported that they do not optimally use integrative therapies for children with SCD. The barriers uncovered focused on lack of process for integration of IM, specifically that IM resources seem transient and based on short-term funding. Provider attitude towards CAM is generally positive, but provider comfort level is highly variable. No providers are completely comfortable with their knowledge base about IM, and increased knowledge is desired. CONCLUSIONS: Creation of protocols and processes to incorporate IM into management plans for patients with SCD could help to promote its use. Education of providers about utility and efficacy of IM for SCD-related pain and about existing resources would aid in promotion of IM for children with SCD.

Privacy and Confidentiality Practices In Adolescent Family Planning Care At Federally Qualified Health Centers.

CONTEXT: The confidentiality of family planning services remains a high priority to adolescents, but barriers to implementing confidentiality and privacy practices exist in settings designed for teenagers who are medically underserved, including federally qualified health centers (FQHCs). METHODS: A sample of 423 FQHCs surveyed in 2011 provided information on their use of five selected privacy and confidentiality practices, which were examined separately and combined into an index. Regression modeling was used to assess whether various state policies and organizational characteristics were associated with FQHCs' scores on the index. In-depth case studies of six FQHCs were conducted to provide additional contextual information. RESULTS: Among FQHCs reporting on confidentiality, most reported providing written or verbal information regarding adolescents' rights to confidential care (81%) and limiting access to family planning and medical records to protect adolescents' confidentiality (84%). Far fewer reported maintaining separate medical records for family planning (10%), using a security block on electronic medical records to prevent disclosures (43%) or using separate contact information for communications regarding family planning services (50%). Index scores were higher among FQHCs that received Title X funding than among those that did not (coefficient, 0.70) and among FQHCs with the largest patient volumes than among those with the smallest caseloads (0.43). Case studies highlighted how a lack of guidelines and providers' confusion over relevant laws present a challenge in offering confidential care to adolescents. CONCLUSIONS: The organizational practices used to ensure adolescent family planning confidentiality in FQHCs are varied across organizations.

Quality and Cost of Diabetes Mellitus Care in Community Health Centers in the United States.

OBJECTIVE: To examine variations in the quality and cost of care provided to patients with diabetes mellitus by Community Health Centers (CHCs) compared to other primary care settings. RESEARCH DESIGN AND METHODS: We used data from the 2005-2008 Medical Expenditure Panel Survey (N = 2,108). We used two dependent variables: quality of care and ambulatory care expenditures. Our primary independent variable was whether the respondent received care in a Community Health Centers (CHCs) or not. We estimated logistic regression models to determine the probability of quality of care, and used generalized linear models with log link and gamma distribution to predict expenditures for CHC users compared to non-users of CHCs, conditional on patients with positive expenditures. RESULTS: Results showed that variations of quality between CHC users and non-CHC users were not statistically significant. Patients with diabetes mellitus who used CHCs saved payers and individuals approximately $1,656 in ambulatory care costs compared to non-users of CHCs. CONCLUSIONS: These findings suggest an opportunity for policymakers to control costs for diabetes mellitus patients without having a negative impact on quality of care.

The Role of Federally Qualified Health Centers in Delivering Family Planning Services to Adolescents.

PURPOSE: The purpose of this article was to examine the role of community health centers (CHCs) in providing comprehensive family planning services to adolescents, looking at the range of services offered and factors associated with provision of these services. METHODS: This study employed a mixed methods approach comprising a national survey of CHCs and six in-depth case studies of health centers to examine the organization and delivery of family planning services. We developed an adolescent family planning index comprising nine family planning services specifically tailored to adolescents. We analyzed the influence of state-level family planning policies, funding for adolescents, and organizational characteristics on the provision of these services in CHCs. The case studies identified barriers to the provision of family planning to adolescent patients. RESULTS: The survey found substantial variation in the provision of family planning services at CHCs, with a mean of 6.33 out of a maximum score of 13 on the family planning adolescent services index. Title X funding and location within a favorable state policy environment were significantly associated with higher scores on the family planning adolescent services index (p value < .001 and .002, respectively). Case studies revealed barriers to adolescent family planning, including lack of funding, lack of knowledge, and limitations on school-based clinical services. CONCLUSIONS: CHCs have the opportunity to play a significant role in providing high-quality family planning to low-income, medically underserved adolescents. Additional funding, resources, and a favorable policy climate would further improve CHCs' ability to serve the family planning needs of this special patient population.

The organization and delivery of family planning services in community health centers.

BACKGROUND: Family planning and related reproductive health services are essential primary care services for women. Access is limited for women with low incomes and those living in medically underserved areas. Little information is available on how federally funded health centers organize and provide family planning services. METHODS: This was a mixed methods study of the organization and delivery of family planning services in federally funded health centers across the United States. A national survey was developed and administered (n = 423) and in-depth case studies were conducted of nine health centers to obtain detailed information on their approach to family planning. FINDINGS: Study findings indicate that health centers utilize a variety of organizational models and staffing arrangements to deliver family planning services. Health centers' family planning offerings are organized in one of two ways, either a separate service with specific providers and clinic times or fully integrated with primary care. Health centers experience difficulties in providing a full range of family planning services. MAJOR CHALLENGES: Major challenges include funding limitations; hiring obstetricians/gynecologists, counselors, and advanced practice clinicians; and connecting patients to specialized services not offered by the health center. CONCLUSIONS: Health centers play an integral role in delivering primary care and family planning services to women in medically underserved communities. Improving the accessibility and comprehensiveness of family planning services will require a combination of additional direct funding, technical assistance, and policies that emphasize how health centers can incorporate quality family planning as a fundamental element of primary care.

Identifying key patient demographics and organizational factors that contribute to health center participation in research.

Federally Qualified Health Centers are well positioned for translational research given their diverse patient population, unique characteristics, and community knowledge. This was the first national survey that assessed their research activities. Those with research experience were more likely to be urban and Health Care for the Homeless grantees and had more patients, minority patients, and physicians relative to nonphysician providers, enabling services providers, Medicaid revenues per Medicaid patient, and total revenues per patient than health centers with no experience and no future interest in research. Only enabling services providers to patient ratios and total patients remained significant after controlling for other factors.

Engaging Community Health Centers (CHCs) in research partnerships: the role of prior research experience on perceived needs and challenges.

Despite community health centers' substantial role in local communities and in the broader safety-net healthcare system, very limited research has been conducted on community health center research experience, infrastructure, or needs from a national perspective. A national survey of 386 community health centers was conducted in 2011 and 2012 to assess research engagement among community health centers and their perceived needs, barriers, challenges, and facilitators with respect to their involvement in public health and health services research. This paper analyzes the differences between health centers that currently conduct or participate in research and health centers that have no prior research experience to determine whether prior research experience is indicative of different perceived challenges and research needs in community health center settings.

Accessibility of long-acting reversible contraceptives (LARCs) in Federally Qualified Health Centers (FQHCs).

OBJECTIVE(S): This study examines the on-site availability of long-acting reversible contraception (LARC) methods, defined here as intrauterine devices and contraceptive implants, at Federally Qualified Health Centers (FQHCs). We also describe factors associated with on-site availability and specific challenges and barriers to providing on-site access to LARC as reported by FQHCs. STUDY DESIGN: An original survey of 423 FQHC organizations was fielded in 2011. RESULTS: Over two thirds of FQHCs offer on-site availability of intrauterine devices yet only 36% of FQHCs report that they offer on-site contraceptive implants. Larger FQHCs and FQHCs receiving Title X Family Planning program funding are more likely to provide on-site access to LARC methods. Other organizational and patient characteristics are associated with the on-site availability of LARC methods, though this relationship varies by the type of method. The most commonly reported barriers to providing on-site access to LARC methods are related to the cost of stocking or supplying the drug and/or device, the perceived lack of staffing and training, and the unique needs of special populations. CONCLUSION: Our findings indicate that patients seeking care in small FQHC organizations, FQHCs with limited dedicated family planning funding and FQHCs located in rural areas may have fewer choices and limited access to LARC methods on-site. IMPLICATIONS: Despite the presumed widespread coverage of contraceptives for women as a result of provisions in the Affordable Care Act, there is a limited understanding of how FQHCs may redesign their practices to provide on-site availability of LARC methods. This study sheds light on the current state of practice and challenges related to providing LARC methods in FQHC settings.

Scope of family planning services available in Federally Qualified Health Centers.

OBJECTIVES: Federally Qualified Health Centers (FQHCs) are a major and growing source of primary care for low-income women of reproductive age; however, only limited knowledge exists on the scope of family planning care they provide and the mechanisms for delivery of these essential reproductive health services, including family planning. In this paper, we report on the scope of services provided at FQHCs including on-site provision, prescription only and referral options for the range of contraceptive methods. STUDY DESIGN: An original survey of 423 FQHC organizations was fielded in 2011. RESULTS: Virtually all FQHCs reported that they provide at least one contraceptive method (99.8%) at one or more clinical sites. A large majority (87%) of FQHCs report that their largest primary care site prescribes oral contraceptives plus one additional method category of contraception, with oral contraception and injectables being the most commonly available methods. Substantial variation is seen among other methods such as intrauterine devices (IUDs), contraceptive implants, the patch, vaginal ring and barrier methods. For all method categories, Title-X-funded sites are more likely to provide the method, though, even in these sites, IUDs and implants are much less likely to be provided than other methods. CONCLUSION: There is clearly wide variability in the delivery of family planning services at FQHCs in terms of methods available, level of counseling, and provision of services on-site or through prescription or referral. Barriers to provision likely include cost to patients and/or additional training to providers for some methods, such as IUDs and implants, but these barriers should not limit on-site availability of inexpensive methods such as oral contraceptives. IMPLICATIONS: With the expansion of contraceptive coverage under private insurance as part of preventive health services for women, along with expanded coverage for the currently uninsured, and the growth of FQHCs as the source of care for women of reproductive age, it is critical that women seeking family planning services at FQHCs have access to a wide range of contraceptive options. Our study both highlights the essential role of FQHCs in providing family planning services and also identifies remaining gaps in the provision of contraception in FQHC settings.

Team-based care: a critical element of primary care practice transformation.

The purpose of this study was to gain an in-depth understanding of how primary care practices in the United States are transforming their practice to deliver patient-centered care. The study used qualitative research methods to conduct case studies of small primary care practices in the state of Virginia. The research team collected data from practices using in-depth interviews, structured telephone questionnaires, observation, and document review. Team-based care stood out as the most critical method used to successfully transform practices to provide patient-centered care. This article presents 3 team-based care models that were utilized by the practices in this study.