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1.
Cancer Med ; 12(14): 15358-15370, 2023 07.
Article in English | MEDLINE | ID: mdl-37403745

ABSTRACT

BACKGROUND: Pediatric Early Warning Systems (PEWS) assist early detection of clinical deterioration in hospitalized children with cancer. Relevant to successful PEWS implementation, the "stages of change" model characterizes stakeholder support for PEWS based on willingness and effort to adopt the new practice. METHODS: At five resource-limited pediatric oncology centers in Latin America, semi-structured interviews were conducted with 71 hospital staff involved in PEWS implementation. Purposive sampling was used to select centers requiring variable time to complete PEWS implementation, with low-barrier centers (3-4 months) and high-barrier centers (10-11 months). Interviews were conducted in Spanish, professionally transcribed, and translated into English. Thematic content analysis explored "stage of change" with constant comparative analysis across stakeholder types and study sites. RESULTS: Participants identified six interventions (training, incentives, participation, evidence, persuasion, and modeling) and two policies (environmental planning and mandates) as effective strategies used by implementation leaders to promote stakeholder progression through stages of change. Key approaches involved presentation of evidence demonstrating PEWS effectiveness, persuasion and incentives addressing specific stakeholder interests, enthusiastic individuals serving as models for others, and policies enforced by hospital directors facilitating habitual PEWS use. Effective engagement targeted hospital directors during early implementation phases to provide programmatic legitimacy for clinical staff. CONCLUSION: This study identifies strategies to promote adoption and maintained use of PEWS, highlighting the importance of tailoring implementation strategies to the motivations of each stakeholder type. These findings can guide efforts to implement PEWS and other evidence-based practices that improve childhood cancer outcomes in resource-limited hospitals.


Subject(s)
Clinical Deterioration , Neoplasms , Child , Humans , Early Detection of Cancer , Medical Oncology , Neoplasms/diagnosis , Neoplasms/therapy , Hospitals
2.
Front Oncol ; 13: 1122355, 2023.
Article in English | MEDLINE | ID: mdl-37207162

ABSTRACT

Background: Pediatric Early Warning Systems (PEWS) aid in identification of deterioration in hospitalized children with cancer but are underutilized in resource-limited settings. Proyecto EVAT is a multicenter quality improvement (QI) collaborative in Latin America to implement PEWS. This study investigates the relationship between hospital characteristics and time required for PEWS implementation. Methods: This convergent mixed-methods study included 23 Proyecto EVAT childhood cancer centers; 5 hospitals representing quick and slow implementers were selected for qualitative analysis. Semi-structured interviews were conducted with 71 stakeholders involved in PEWS implementation. Interviews were recorded, transcribed and translated to English, then coded using a priori and novel codes. Thematic content analysis explored the impact of hospital characteristics and QI experience on time required for PEWS implementation and was supplemented by quantitative analysis exploring the relationship between hospital characteristics and implementation time. Results: In both quantitative and qualitative analysis, material and human resources to support PEWS significantly impacted time to implementation. Lack of resources produced various obstacles that extended time necessary for centers to achieve successful implementation. Hospital characteristics, such as funding structure and type, influenced PEWS implementation time by determining their resource-availability. Prior hospital or implementation leader experience with QI, however, helped facilitate implementation by assisting implementers predict and overcome resource-related challenges. Conclusions: Hospital characteristics impact time required to implement PEWS in resource-limited childhood cancer centers; however, prior QI experience helps anticipate and adapt to resource challenges and more quickly implement PEWS. QI training should be a component of strategies to scale-up use of evidence-based interventions like PEWS in resource-limited settings.

3.
Cancer Med ; 12(10): 11878-11888, 2023 05.
Article in English | MEDLINE | ID: mdl-37022012

ABSTRACT

BACKGROUND: The COVID-19 pandemic impacted healthcare delivery worldwide, including pediatric cancer care, with a disproportionate effect in resource-limited settings. This study evaluates its impact on existing quality improvement (QI) programs. METHODS: We conducted 71 semi-structured interviews of key stakeholders at five resource-limited pediatric oncology centers participating in a collaborative to implement Pediatric Early Warning System (PEWS). Interviews were conducted virtually using a structured interview guide, recorded, transcribed, and translated into English. Two coders developed a codebook of a priori and inductive codes and independently coded all transcripts, achieving a kappa of 0.8-0.9. Thematic analysis explored the impact of the pandemic on PEWS. RESULTS: All hospitals reported limitations in material resources, reduction in staffing, and impacts on patient care due to the pandemic. However, the impact on PEWS varied across centers. Identified factors that promoted or limited ongoing PEWS use included the availability of material resources needed for PEWS, staff turnover, PEWS training for staff, and the willingness of staff and hospital leaders to prioritize PEWS. Consequently, some hospitals were able to sustain PEWS; others halted or reduced PEWS use to prioritize other work. Similarly, the pandemic delayed plans at all hospitals to expand PEWS to other units. Several participants were hopeful for future expansion of PEWS post-pandemic. CONCLUSION: The COVID-19 pandemic created challenges for sustainability and scale of PEWS, an ongoing QI program, in these resource-limited pediatric oncology centers. Several factors mitigated these challenges and promoted ongoing PEWS use. These results can guide strategies to sustain effective QI interventions during future health crises.


Subject(s)
COVID-19 , Neoplasms , Child , Humans , Pandemics , COVID-19/epidemiology , Delivery of Health Care , Hospitals , Neoplasms/epidemiology , Neoplasms/therapy
4.
Int J Obes (Lond) ; 47(7): 644-650, 2023 07.
Article in English | MEDLINE | ID: mdl-37085587

ABSTRACT

BACKGROUND/OBJECTIVES: Childhood overweight and obesity have a well-established negative impact on children's health. Overweight and obesity might also negatively impact children's academic performance, but existing literature on this association is inconclusive. This study uses a longitudinal design in a large, diverse elementary school sample to rigorously test the association between longitudinal weight status and academic achievement. Analyses also investigate modification by sex, race/ethnicity, and cardiorespiratory fitness (CRF). SUBJECTS/METHODS: In a large suburban school district in the United States, 4936 Grade 4 students were recruited. Demographic, course grade, and standardized test data were collected from school records for Grades 3-5, and body mass index and CRF were assessed each year. Students wore accelerometers during the school day for up to 15 days across three semesters (Grade 4 Fall and Spring, Grade 5 Fall) to objectively measure physical activity. Multiple imputation addressed missing data and multilevel analyses controlled for student demographics and clustering within schools. RESULTS: Unadjusted multilevel models found small negative associations between persistent obesity and course grades and standardized test scores, but these associations largely disappeared when controlling for demographic characteristics. Residual associations for math and writing course grades were attenuated when controlling for CRF, though some marginal negative associations for math and writing remained for students who developed obesity during follow-up. There was also evidence of marginal negative associations with course grades for students who developed overweight/obesity. There was no evidence of modification by sex or race/ethnicity. CONCLUSIONS: Results suggest very small associations between weight status and academic achievement that were largely explained by sociodemographic factors and CRF. Evidence of an association between weight status and achievement was stronger among students who developed overweight/obesity. Interventions promoting healthy weight and high CRF remain critical for schools given the link between student health and achievement.


Subject(s)
Academic Success , Pediatric Obesity , Child , Humans , United States/epidemiology , Overweight/epidemiology , Educational Status , Pediatric Obesity/epidemiology , Body Mass Index , Schools
5.
Front Oncol ; 12: 1018224, 2022.
Article in English | MEDLINE | ID: mdl-36313665

ABSTRACT

Background: Pediatric Early Warning Systems (PEWS) reduce clinical deterioration, improve interdisciplinary communication, and provide cost savings; however, little is known about how these impacts are achieved or related. This study evaluates the multi-level impacts of PEWS in resource-limited pediatric oncology centers. Methods: We conducted 71 semi-structured interviews including physicians (45%), nurses (45%), and administrators (10%) from 5 resource-limited pediatric oncology centers in 4 Latin American countries. Interviews were conducted in Spanish, transcribed, and translated into English. A code book was developed using a priori and inductively derived codes. Transcripts were independently coded by 2 coders, achieving a kappa of 0.8-0.9. Thematic content analysis explored perceived impacts of PEWS at the level of the patient, clinician, healthcare team, and institution. Results: PEWS improved the quality of attention for patients, reducing morbidity and mortality. Clinicians felt more knowledgeable, confident, and empowered providing patient care, resulting in greater job satisfaction. PEWS affected team dynamics by improving interdisciplinary (ward and intensive care unit) and interprofessional (physicians and nurses) relationships and communication. This ultimately led to institutional culture change with emphasis on patient safety, collaboration with other centers, and receipt of institutional awards. Together, these impacts led to hospital-wide support of ongoing PEWS use. Conclusions: In resource-limited hospitals, PEWS use results in multi-level positive impacts on patients, clinicians, teams, and institutions, creating a feedback loop that further supports ongoing PEWS use. These findings can guide advocacy for PEWS to various stakeholders, improve PEWS effectiveness, and inform assessment of other interventions to improve childhood cancer outcomes.

6.
Int J Behav Nutr Phys Act ; 19(1): 110, 2022 08 30.
Article in English | MEDLINE | ID: mdl-36042515

ABSTRACT

BACKGROUND: Many children do not engage in sufficient physical activity, and schools provide a unique venue for children to reach their recommended 60 daily minutes of moderate-to-vigorous physical activity (MVPA). Prior research examining effects of MVPA on academic achievement is inconclusive, and few studies have investigated potential moderators of this relationship. This study examined whether student-level characteristics (gender, race/ethnicity, free/reduced-price lunch status) and school-level characteristics (proportion of students qualifying for free/reduced-price lunch, physical activity environment and opportunities) moderate the relationship between MVPA and academic achievement. METHODS: In a large, diverse metropolitan public school district in Georgia, 4,936 students in Grade 4 were recruited from 40 elementary schools. Students wore accelerometers to measure school-day MVPA for a total of 15 days across three semesters (fall 2018, spring 2019, fall 2019). Academic achievement data, including course marks (grades) for math, reading, spelling, and standardized test scores in writing, math, reading, and Lexile (reading assessment), were collected at baseline (Grade 3, ages 8-9) and at follow-up in Grade 4 (ages 9-10). Standardized test scores were not measured in Grade 5 (ages 10-11) due to COVID-19-related disruptions. Multilevel modeling assessed whether student-level and/or school-level characteristics were moderators in the cross-sectional and longitudinal MVPA-academic achievement relationship. RESULTS: Cross sectional analyses indicated that the MVPA and AA relationship was moderated only by student Hispanic ethnicity for Grade 4 fall spelling marks (ß = -0.159 p < 0.001). The relationship for Grade 4 fall spelling marks was also moderated by school physical activity opportunities (ß = -0.128 (p < 0.001). Longitudinally, there was no significant moderation of the MVPA-academic achievement. A relationship by student gender, free/reduced-price lunch status, race/ethnicity; nor for school-level factors including proportion of students qualifying for free/reduced-price lunch, physical activity environment, and physical activity opportunities. CONCLUSIONS: Overall, our results did not suggest that student- or school-level characteristics moderate the MVPA-academic achievement relationship. While statistically significant results were observed for certain outcomes, practical differences were negligible. In this population, school-based MVPA does not appear to differently affect academic performance based on student gender, race/ethnicity, free/reduced-price lunch, nor school characteristics. TRIAL REGISTRATION: This study was registered with the National Institutes of Health (NIH) ClinicalTrials.gov system, with ID NCT03765047 . Registered 05 December 2018-Retrospectively registered.


Subject(s)
Academic Success , COVID-19 , Child , Cross-Sectional Studies , Exercise , Humans , Students
7.
Int J Behav Nutr Phys Act ; 19(1): 90, 2022 07 23.
Article in English | MEDLINE | ID: mdl-35870926

ABSTRACT

BACKGROUND: It is recommended that school-aged children accrue 30 minutes of daily moderate-to-vigorous physical activity (MVPA) in school. Current literature is inconclusive about the long-term associations between school-based physical activity and academic achievement. In this study, we use a large sample and longitudinal design to rigorously evaluate whether school-day MVPA is associated with academic achievement. METHODS: In a diverse suburban public school district, 4936 Grade 4 students were recruited in 40 elementary schools. Students wore accelerometers to measure school-day MVPA for 15 days across three semesters. Academic performance data was collected across Grade 3 fall to Grade 5 spring, including teacher-assigned grades and standardized test scores. Multilevel modeling was conducted controlling for student demographics and school characteristics. RESULTS: Cross-sectional analyses found small negative associations in Grade 4. Grade 4 full-year mean daily school-day MVPA had ß = --0.066, ß = --0.063, ß = --0.066, and ß = --0.058 associations (p <  0.001) with Grade 4 math, reading, spelling, and writing grades respectively, and Grade 4 full-year mean daily school-day MVPA had ß = --0.206 and ß = --0.283 (p <  0.001) associations with Grade 4 math and English Language Arts (ELA) standardized test scores respectively out of approximately 500 points. Longitudinal analyses found no significant associations between Grade 4 full-year mean daily school-day MVPA and Grade 5 Fall course grades. Results also indicated small negative associations for students attaining 30+ minutes of daily school-day MVPA compared to those attaining less than 15 minutes, but only in Grade 4 Fall cross-sectional analyses where teacher-assigned reading, spelling, and writing grades were - 1.666, - 1.638, and - 1.993 points lower respectively (p <  0.001). CONCLUSION: The cross-sectional findings, while statistically significant in a negative direction, have a negligible association when translated practically. For example, even if students attained twice the recommended amount of school-day MVPA - which would constitute an approximately 300% increase from current levels - results suggest that grades would only decrease by 2 points on a 100-point scale. Furthermore, longitudinal analyses suggest school-day MVPA does not have a predictive association with course grades or standardized test scores. Findings suggest school-based MVPA implemented in accordance with recommendations does not meaningfully detract from academic progress. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03765047. Registered 05 December 2018 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03765047.


Subject(s)
Academic Success , Child , Cross-Sectional Studies , Exercise , Humans , Schools , Students
8.
JAMA Netw Open ; 5(3): e221547, 2022 03 01.
Article in English | MEDLINE | ID: mdl-35262714

ABSTRACT

Importance: Pediatric early warning systems (PEWS) aid with early identification of clinical deterioration and improve outcomes in children with cancer hospitalized in resource-limited settings; however, there may be barriers to implementation. Objective: To evaluate stakeholder-reported barriers and enablers to PEWS implementation in resource-limited hospitals. Design, Setting, and Participants: In this qualitative study, semistructured stakeholder interviews were conducted at 5 resource-limited pediatric oncology centers in 4 countries in Latin America. Hospitals participating in a multicenter collaborative to implement PEWS were purposefully sampled based on time required for implementation (fast vs slow), and stakeholders interviewed included physicians, nurses, and administrators, involved in PEWS implementation. An interview guide was developed using the Consolidated Framework for Implementation Research (CFIR). Interviews were conducted virtually in Spanish, audiorecorded, and professionally transcribed and translated into English. A codebook was developed a priori using the CFIR and supplemented with codes inductively derived from transcript review. Two coders independently analyzed all transcripts, achieving a κ of 0.8 to 0.9. The study was conducted from June 1 to August 31, 2020. Main Outcomes and Measures: Thematic analysis was conducted based on CFIR domains (inner setting, characteristics of individuals, outer setting, intervention characteristics, and implementation process) to identify barriers and enablers to PEWS implementation. Results: Seventy-one staff involved in PEWS implementation were interviewed, including 32 physicians (45%), 32 nurses (45%), and 7 administrators (10%). Of these, 50 were women (70%). Components of the 5 CFIR domains were mentioned by participants as barriers and enablers to PEWS implementation at both fast- and slow-implementing centers. Participants emphasized barriers at the level of the clinical staff, hospital, external factors, and PEWS intervention. These barriers included staff resistance to change, inadequate resources, components of health systems, and the perceived origin and complexity of PEWS. At all centers, most barriers were successfully converted to enablers during the implementation process through targeted strategies, such as early stakeholder engagement and adaptation, including adapting PEWS to better fit the local context and changing the hospital setting to support ongoing use of PEWS. Conclusions and Relevance: To date, this is the first multicenter, multinational study describing barriers and enablers to PEWS implementation in resource-limited settings. Findings suggest that many barriers are not immutable and can be converted to enablers during the implementation process. This work can serve as a guide for clinicians looking to implement evidence-based interventions to reduce global disparities in patient outcomes.


Subject(s)
Clinical Deterioration , Neoplasms , Child , Female , Hospitalization , Hospitals , Humans , Male , Medical Oncology
9.
Front Health Serv ; 2: 1004805, 2022.
Article in English | MEDLINE | ID: mdl-36925775

ABSTRACT

Background: Sustainability, or continued use of evidence-based interventions for long-term patient benefit, is the least studied aspect of implementation science. In this study, we evaluate sustainability of a Pediatric Early Warning System (PEWS), an evidence-based intervention to improve early identification of clinical deterioration in hospitalized children, in low-resource settings using the Clinical Capacity for Sustainability Framework (CCS). Methods: We conducted a secondary analysis of a qualitative study to identify barriers and enablers to PEWS implementation. Semi-structured interviews with PEWS implementation leaders and hospital directors at 5 Latin American pediatric oncology centers sustaining PEWS were conducted virtually in Spanish from June to August 2020. Interviews were recorded, professionally transcribed, and translated into English. Exploratory thematic content analysis yielded staff perceptions on PEWS sustainability. Coded segments were analyzed to identify participant perception about the current state and importance of sustaining PEWS, as well as sustainability successes and challenges. Identified sustainability determinants were mapped to the CCS to evaluate its applicability. Results: We interviewed 71 staff including physicians (45%), nurses (45%), and administrators (10%). Participants emphasized the importance of sustaining PEWS for continued patient benefits. Identified sustainability determinants included supportive leadership encouraging ongoing interest in PEWS, beneficial patient outcomes enhancing perceived value of PEWS, integrating PEWS into the routine of patient care, ongoing staff turnover creating training challenges, adequate material resources to promote PEWS use, and the COVID-19 pandemic. While most identified factors mapped to the CCS, COVID-19 emerged as an additional external sustainability challenge. Together, these challenges resulted in multiple impacts on PEWS sustainment, ranging from a small reduction in PEWS quality to complete disruption of PEWS use and subsequent loss of benefits to patients. Participants described several innovative strategies to address identified challenges and promote PEWS sustainability. Conclusion: This study describes clinician perspectives on sustainable implementation of evidence-based interventions in low-resource settings, including sustainability determinants and potential sustainability strategies. Identified factors mapped well to the CCS, however, external factors, such as the COVID pandemic, may additionally impact sustainability. This work highlights an urgent need for theoretically-driven, empirically-informed strategies to support sustainable implementation of evidence-based interventions in settings of all resource-levels.

10.
AIDS Care ; 30(11): 1341-1350, 2018 11.
Article in English | MEDLINE | ID: mdl-29843518

ABSTRACT

In Peru, HIV is concentrated among men who have sex with men (MSM) and transgender women (TGW). Between June 2015 and August 2016, 591 HIV-positive MSM and TGW were recruited at five clinical care sites in Lima, Peru. We found that 82.4% of the participants had achieved viral suppression (VS; VL < 200) and 73.6% had achieved maximal viral suppression (MVS; VL < 50). Multivariable modeling indicated that patients reporting transportation as a barrier to HIV care were less likely to achieve VS (aOR = 0.47; 95% CI = 0.30-0.75) and MVS (aOR = 0.56; 95% CI = 0.37-0.84). Alcohol use disorders were negatively associated with MVS (aOR = 0.62; 95% CI = 0.30-0.75) and age was positively associated with achieving MVS (aOR = 1.29; 95% CI = 1.04-1.59). These findings underscore the need for more accessible HIV care with integrated behavioral health services in Lima, Peru.


Subject(s)
HIV Infections/virology , Homosexuality, Male , Transgender Persons , Viral Load , Adult , Female , Humans , Male , Middle Aged , Peru
11.
LGBT Health ; 5(8): 477-483, 2018.
Article in English | MEDLINE | ID: mdl-30874476

ABSTRACT

PURPOSE: Globally, transgender women (TGW) experience a high burden of adverse health outcomes, including a high prevalence of HIV and sexually transmitted infections (STIs) as well as psychiatric disorders and substance use disorders. To address gaps in HIV research in Peru focused specifically on TGW, this study presents characteristics of a sample of HIV-positive TGW and identifies factors associated with viral suppression. METHODS: Between June 2015 and August 2016, 50 HIV-positive TGW were recruited in Lima, Peru. Multivariable logistic regression was used to identify factors associated with viral suppression (<200 copies/mL) among the TGW. RESULTS: Among TGW, 85% achieved viral suppression. Approximately half (54%) reported anal sex with more than five partners in the past 6 months, 38% reported sex work, 68% had not disclosed their HIV status to one or more of their partners, and 38% reported condomless sex with their last partner. The prevalence of alcohol use disorders was high (54%), and 38% reported use of drugs in the past year. Moderate-to-severe drug use significantly reduced odds of achieving viral suppression (adjusted odds ratio 0.69; 95% confidence interval: 0.48-0.98). CONCLUSION: Our findings highlight the need for integrated treatment for substance disorders in HIV care to increase the viral suppression rate among TGW in Lima, Peru.


Subject(s)
Anti-HIV Agents/therapeutic use , HIV Infections/drug therapy , Transgender Persons/statistics & numerical data , Viral Load/statistics & numerical data , Adult , Cross-Sectional Studies , Female , HIV Infections/epidemiology , Health Services Accessibility , Health Services Needs and Demand , Humans , Male , Peru/epidemiology , Risk Factors , Substance-Related Disorders/epidemiology , Treatment Outcome
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